POSTPARTUM

Definitions
Postpartum
Period from delivery of the placenta & membranes until the involution of uterus is complete, usually 6 weeks post delivery

Involution
The return of the uterus to normal size after childbirth

Subinvolution
Incomplete return of the uterus to normal size after childbirth

Physiologic and Physical Changes

A review

Cardiovascular system changes

Hypervolemia during pregnancy allows woman to withstand blood loss at delivery
Cardiac output remains elevated for 48 postdelivery Cardiac output decreases to normal levels by 24 weeks postdelivery

As the body rids itself of the excess plasma volume its accumulated during pregnancy, 2 things occur:
Diuresis Diaphoresis

Plasma fibrinogen (coagulation/clots) increases during pregnancy Plasminogen (lysis of clots) does not mobility Therefore, higher risk for thrombus formation

Gastrointestinal System
Bowel tone remains sluggish for the first few days Restricted food/fluids in labor Perineal trauma/hemorrhoids
Result could be constipation

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Urinary system
Trauma during delivery could cause swelling of the urinary meatus Decreased sensation of having to void could cause urinary retention/stasis could lead to a UTI Urinary retention/bladder distention a primary cause of excessive bleeding
Displaced uterus results in inability of uterus to contract (atony)

Musculoskeletal system
Levels of hormone relaxin decrease, causing pelvis to return to prepregnant position = hip/joint pain
Abdominal muscles weak/flabby
Diastasis recti

Integumentary system
Decrease in melanocyte-stimulating hormone causes a decrease or disappearance of chloasma or linea nigra
Striae gravidarum fade to silvery lines, but dont completely go away!

Neurologic system
Investigate headache!
Could be secondary to regional anesthesia.report to anesthesiologist Could be due to development or worsening of PIH/preeclampsia, especially if accompanied by blurred vision/ photophobia/abdominal pain

Breast Changes
If breastfeeding, improper baby positioning may result in redness, blisters, cracked and bleeding nipples

Breast Engorgement
Breastfeeding or bottlefeeding

Thrush

Uterine involution
Immediately after delivery uterus is midway between symphysis and umbilicus Then rises to the umbilicus where it remains for about 24 hours Then gradually descends ( 1 cm/dayor one fingerbreath fb per day) Document in terms of umbilicus (U, U-2, etc.) Usually not palpable by day 10

Assessing Uterus
Have pt. void Feel fundal height related to umbilicus
If fundus is displaced to side may be full bladder

Should feel firm, not overly tender Pain/infection or full of blood Massage and check amount of lochia
Dont over massageoverstimulation can cause atony!

Assessing Uterus
Palpating fundus of uterus during the fourth stage of labor

Assessing Uterus
Assessment of involution of uterus after childbirth 2 days after childbirth (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, Calif.)

Assessing Uterus
Assessment of involution of uterus after childbirth 4 days after childbirth (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, Calif.)

Vagina and Perineum

Introitus stretched and gaping Hemorrhoids and edema by 2-3 days as circulation and movement Episiotomy/perineal discomfort most marked 2-3 days PP, greatly improved by 4-7 days By 6 weeks pelvic floor has regained tone, sutures are absorbed, perineum is healed

Lochia

Vessels at the placental site become thrombosed and slough into lochia (uterine discharge of the puerperium)

Normal progression
Rubra (red): from delivery to 2-3 days PP Serosa (pink/brown):median duration is 22 days, but can still be present at 6 weeks exam Alba (white/yellow): follows serosa

Variations in lochia

Common to have 1-2 hours of bright red flow when eschar sloughs Red lochia after 2 weeks subinvolution/retained placenta
Subinvolution
Slower rate of involution Can be from retained products/placental fragments, clots, atony, infection

Lochia
Lochia should not exceed moderate amount 4-8 pads/day

If heavy bleeding or large clots may need to prescribe methergine po

Scant: 1 inch in 1 hr. Light: < 4 inch stain 1 hr. Moderate: < 6 inch 1 hr. Heavy: Saturated pad in 1 hr.

Episiotomy
Perineum may be swollen May have lacerations or episiotomy
Observe for: REEDA
redness edema ecchymosis/bruising discharge approximation

Emotion
Baby Blues Postpartum Depression Postpartum Psychosis Postpartum Panic Disorder Postpartum Obsessive-Compulsive Disorder

Psychological Changes

Labile emotions following birth

Range from mild forms of feeling sad with frequent crying to full blown psychosis

Physiologic bases
Rapid hormone shifts as body returns to nonpregnant state Fatigue

Discomfort

Psychological bases
Sense of physical loss that may result in a mild grief reaction
Loss of center stage Feelings of insecurity

Levels
Blues 1-10 days after birthweepy
Depression lasts at least 2 weekstense, irritable, sleeplessness, sees infant as demanding, feels inept at mothering

Psychosis rare, within 3 weeks pp; bipolar or major depression

Endocrine system
Placental hormones decline
Estrogen, progesterone, HCG

If not breastfeeding, pituitary hormone prolactin disappears in about 2 weeks.

Ovulation and menstruation

Non-breastfeeding: usually resume periods within 7-9 weeks post delivery Breastfeeding (6 or more times/day): usually resume periods by 12 weeks post delivery

Ovulation usually occurs BEFORE menses resumes.dont rely on breastfeeding for contraception!

Postpartum Rounds
Examine chart for:
Time of delivery Type of delivery Episiotomy/lacerations Complications Infant feeding method Labs
Blood type CBC Rubella

BUBBLE HE
B= Breasts U= Uterus B= Bladder B= Bowels L= Lochia E= Episiotomy H= Homans E= Emotions Alsoassess heart and lungs!

Postpartum Rounds
Discharge instructions
Report symptoms of infection Continue prenatal vitamins and iron If CBC low (< 10, if not on iron, can add it) Pain (especially if multigravida or 3rd or 4th degree lacerations
Choice of pain meds (Motrin 800 mg works well) Nupercainal ointment/Tucks for hemorrhoids

Contraceptive choice?
Can get Depo Provera before leaving hospital Can start on OCPs after delivery
Progesterone only/mini pill if BF (immediately) Combined OCPs if bottle feeding (3 weeks)

Postpartum Office Visit

Ask about her delivery

Her feelings about it

Any complications?

Postpartum Office Visit

General state of mother and family
How is she coping with the baby
Mood Appetite Exercise activities Rest/sleep

Involvement and interest of father Reactions of siblings to new baby

Postpartum Office Visit

Ask about the baby
Problems at birth? Problems now? How is feeding going?

Postpartum Office Visit

Ask her about:
Fever, vaginal bleeding, cramping, discharge, episiotomy pain, breast soreness or discharge, swelling, headaches, urinary symptoms, and bowel movements
Medications currently taking Contraception method desired

Postpartum Office Visit

Physical exam
VS HEENT (as indicated) Heart and Lungs Thyroid Breast exam (review BSE) Abdomen diastasis, softness Extremities dont forget homans Perineum inspection Pelvic exam, including pap smear
Note lochia Uterine size should be normal size and nontender GC & Chlamydia culture if desires IUD

Postpartum Office Visit

Labs
Thyroid studies, if enlarged 1 hr GTT if had gestational diabetes

Medications
Prenatal vitamins if breastfeeding OCPs if desired

Postpartum Woman at Risk

Postpartum Hemorrhage
Definition: > 500 ml blood loss during the first 24 hours postpartum (vaginal birth) May occur
immediately after delivery during the early postpartum period may be late postpartum hemorrhage which occurs up to a month after delivery

Endometritis
Caused by bacteria that normally inhabit the vagina and cervix
E. coli, Staphylococcus, Group B streptococcus

Process of delivery causes vagina to change from acidic environment to alkaline, which encourages bacterial growth

Symptoms
Fever Chills Malaise Anorexia Feels like she has the flu Abdominal pain Uterine tenderness Purulent, foulsmelling lochia Tachycardia subinvolution

Risk Factors
History of previous infections Colonization of lower genital tract pathogens Cesarean delivery Trauma (I.e. vacuum delivery) Prolonged ROM Prolonged labor Multiple vaginal exams/internal monitors Catherization Retained placental fragments Hemorrhage Poor general health/hygiene Poor nutritional status Low SES

Treatment
Antibiotics: Cipro, Doxycycline, Metronidazole, Zithromax, Erythromycin Rest Increase fluids

Mastitis
Inflammation usually due to Staphylococcus Aureus Due to:
Poor drainage of milk Tight clothing Missed feedings Milk stasis Lowered maternal defenses

Symptoms
Feels flu-like Fatigue Myalgia Fever (100.4 F or higher) Chills malaise Headache Localized area of redness/inflammation

Treatment of Mastitis
Bedrest Increased fluids Frequent feeding of infant/empty milk ducts Supportive bra Local application of heat Analgesics Antibiotics Dicloxicillin/Ampicillin/Amoxicillin/Augmentin/ Keflex

Thrush
Nystatin suspension Gentian violet Keep nipples clean and dry

Urinary Tract Infection

Overdistention of bladder Decreased bladder sensitivity Increased bladder capacity Trauma, edema Catheterization Bacturia during pregnancy

Cystitis (Lower Urinary Tract)

E-coli usual organism Ascending infection from urethra to bladder to kidneys Get clean catch urine specimen Bacterial concentration > 100,000 colonies per milliliter/sensitivity Antibiotics/sulfonamides Peri-care Increase fluids/ (3 liters)

References
Lesnewski, R., & Prine, L. (2006). Initiating hormonal contraception. American Family Physician, 74 , 105-12. http://www.searo.who.int/LinkFiles/Pregna ncy_Childbirth_e.pdf

SOAP Note Practice

Hospital Note
S: Ready to go home. Breastfeeding is going well. Having some afterbirth pains. + BM O: VSS.
Breasts soft, nontender; nipples intact Heart: RR Lungs clear bilaterally Fundus firm, U-2; abdomen soft Lochia Rubra/serosa; scant Episiotomy intact without redness or exudate Voiding qs

A: Stable
Afterbirth pains

P: Discharge home
Discharge instructions reviewed Motrin 800 mg po Q 8 hrs prn

6 Weeks PP Exam
S: Feeling well; breastfeeding without difficulty; siblings adjusting well to new infant. Voiding without difficulty and having regular BMs. Has not resumed intercourse but desires OCPs. O:
Thyroid: WNL Heart: RR Lungs: CTAB Abdomen: no diastasis; soft Back: straight; no CVAT Extremities: no swelling; - Homans Perineum: healed; no lesions Uterus: small; anteverted No adnexal masses Cervix: transverse os; closed; no exudate

A: P:

normal pp exam Contraceptive needs BSE reviewed Micronor 1 po q day, #3, RF X3 OK to begin exercise F/U in one year or prn