Post-partum Care ARouzi
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Transcript of Post-partum Care ARouzi
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Physiology of the PuerperiumPhysiology of the Puerperium
Anatomic changesAnatomic changes
UterusUterus
LochiaLochia--name given to blood and other necroticname given to blood and other necrotic
debris shed from the uterusdebris shed from the uterus
Uterus does not scarUterus does not scar-- tissue replaced by new growthtissue replaced by new growth
from the basal endometriumfrom the basal endometrium
Proliferative endometrium persists for about sixProliferative endometrium persists for about six
weeks and first menses normally anovulatoryweeks and first menses normally anovulatory
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Physiology of the PuerperiumPhysiology of the Puerperium
CervixCervix
Returns to normal within hours of deliveryReturns to normal within hours of delivery
Transverse slit like external os persists due to lacerationTransverse slit like external os persists due to laceration
Vaginal and perineal tears may remain inflamed for severalVaginal and perineal tears may remain inflamed for several
days but rapidly healdays but rapidly heal
Vagina appears normal in 6 weeks in non lactating womenVagina appears normal in 6 weeks in non lactating women
Breast feeding women are hypoestrogenic resulting inBreast feeding women are hypoestrogenic resulting invaginal mucosa being pale and smooth (causes dryness &vaginal mucosa being pale and smooth (causes dryness &
friction dysparunia)friction dysparunia)
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Physiology of the PuerperiumPhysiology of the Puerperium
BreastsBreasts
Decline in Estrogen and Progesterone result inDecline in Estrogen and Progesterone result in
breast engorgement by day 3breast engorgement by day 3
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Physiology of the PuerperiumPhysiology of the Puerperium
Cardiovascular changesCardiovascular changes
Changes of pregnancy reversed over threeChanges of pregnancy reversed over three
weeksweeks
Marked increase stroke volume immediatelyMarked increase stroke volume immediately
post partumpost partum
500500--1000ml blood loss in normal delivery1000ml blood loss in normal delivery
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Physiology of the PuerperiumPhysiology of the Puerperium
LeukocytosisLeukocytosis of labor persists for severalof labor persists for several
daysdays
Reduces the value of leukocyte count toReduces the value of leukocyte count to
determine infectiondetermine infection
Serial counts may still be useful to followSerial counts may still be useful to follow
infectioninfection
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Physiology of the PuerperiumPhysiology of the Puerperium
Weight changesWeight changes
55--6 kg weight loss expected at delivery6 kg weight loss expected at delivery
Additional 3Additional 3--4 kg over the next two weeks due4 kg over the next two weeks due
to diuresis & loss of extracellular fluidto diuresis & loss of extracellular fluid
GFR returns to normal within several daysGFR returns to normal within several days
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Complications of PuerperiumComplications of Puerperium
Blood loss & infection most commonBlood loss & infection most common
complicating 1complicating 1--5% of pregnancies5% of pregnancies
Blood lossBlood loss
Weigh bed clothes and pads for semiWeigh bed clothes and pads for semi--quantitativequantitative
method of determining blood lossmethod of determining blood loss
VSVS-- Q 15 minutes for 1 hour, Q 30 minutes forQ 15 minutes for 1 hour, Q 30 minutes for
two hours then q4hours for the first daytwo hours then q4hours for the first day
Failure to identify early post partum hemorrhageFailure to identify early post partum hemorrhage
remains leading cause of maternal mortalityremains leading cause of maternal mortality
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Complications of PuerperiumComplications of Puerperium
Blood lossBlood loss
Early post partum hemorrhageEarly post partum hemorrhage
Most common cause uterine AtonyMost common cause uterine Atony
Normal uterine blood flow 500 ml/minNormal uterine blood flow 500 ml/min
If effective contraction of myometrium does notIf effective contraction of myometrium does notoccur significant blood loss can occuroccur significant blood loss can occur
Risk factors include:Risk factors include: Use of oxytocin during laborUse of oxytocin during labor
High parityHigh parity
Distended uterusDistended uterus
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Complications of PuerperiumComplications of Puerperium
Uterine Atony (Contd)Uterine Atony (Contd)
TreatmentTreatment
Uterine compressionUterine compression
OxytocicsOxytocics
Early suckling causes endogenous release of oxytocinEarly suckling causes endogenous release of oxytocin
Oxytocin IV/IM 10 unitsOxytocin IV/IM 10 units
MethylergonovineMethylergonovine
Methyl prostoglandin FMethyl prostoglandin F
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Complications of PuerperiumComplications of Puerperium
Retained products of conceptionRetained products of conception
Causes early post partum hemorrhageCauses early post partum hemorrhage
Requires manual exploration of the uterusRequires manual exploration of the uterus
May require anesthesia and curettageMay require anesthesia and curettage
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Complications of PuerperiumComplications of Puerperium
LacerationsLacerations
Repair immediatelyRepair immediately
Uterine ruptureUterine rupture
Abdominal exploration and repairAbdominal exploration and repair
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Complications of PuerperiumComplications of Puerperium
Blood replacement based on estimated lossBlood replacement based on estimated loss
Alterations in vitals signs may occur as lateAlterations in vitals signs may occur as late
finding (Do not wait for hypotension tofinding (Do not wait for hypotension to
occur)occur)
R/O DIC by acquiring appropriateR/O DIC by acquiring appropriate
coagulation studies (split fibrin productscoagulation studies (split fibrin productsetc)etc)
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Complications of PuerperiumComplications of Puerperium
Placenta Accreta & Uterine InversionPlacenta Accreta & Uterine Inversion
UncommonUncommon
Accreta is when incomplete placentalAccreta is when incomplete placental
separation occursseparation occurs
Requires immediate hysterectomyRequires immediate hysterectomy
Uterine inversion requires immediate reductionUterine inversion requires immediate reduction
HematomasHematomas
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Complications of PuerperiumComplications of Puerperium
InfectionsInfections
EndomyometritisEndomyometritis
Foul smelling lochia and tender uterus within first fewFoul smelling lochia and tender uterus within first fewdays post partumdays post partum
Increased risk with cIncreased risk with c--section, PROM, Multiple exams duringsection, PROM, Multiple exams during
labor, & long laborlabor, & long labor
Polymicrobial including anaerobes (Ecoli, Gardnerella,Polymicrobial including anaerobes (Ecoli, Gardnerella,
Peptostreptococcus)Peptostreptococcus)
Treat with Gentamycin/Clindomycin (Gold Standard),Treat with Gentamycin/Clindomycin (Gold Standard),
extended spectrum penicillin or cephalosporinextended spectrum penicillin or cephalosporin
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Complications of PuerperiumComplications of Puerperium
FeverFever
UTI/PyelonephritisUTI/Pyelonephritis
DVT/ThrombophlebitisDVT/Thrombophlebitis
Milk fever (Lasts < 24 hours)Milk fever (Lasts < 24 hours)
Drug reactionDrug reaction
Perineal infection(
Day five)Perineal infection(
Day five) Pulmonary Atelectasis (48 hours)Pulmonary Atelectasis (48 hours)
Mastitis (2Mastitis (2--3 weeks post partum)3 weeks post partum)
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Complications of PuerperiumComplications of Puerperium
InfectionInfection
Maternal temperature best indicator of postMaternal temperature best indicator of post
partum infectionpartum infection
Monitor Q6 hours for first twenty four and haveMonitor Q6 hours for first twenty four and have
patient report chills, temperature post hospitalizationpatient report chills, temperature post hospitalization
Inspect episiotomy site regularly for infectionInspect episiotomy site regularly for infection
Monitor for return of bowel/bladder functionMonitor for return of bowel/bladder function
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AnalgesicsAnalgesics
AcetaminophenAcetaminophen
AspirinAspirin
NSAIDsNSAIDs
CodeineCodeine-- complicated by high incidence ofcomplicated by high incidence of
constipation & light headednessconstipation & light headedness
Afterpains especially problematic duringAfterpains especially problematic during
suckling due to oxytocin releasesuckling due to oxytocin release
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ImmunizationsImmunizations
Puerperium is ideal time to administerPuerperium is ideal time to administer
rubella vaccine for those found non immunerubella vaccine for those found non immune
RhRh-- women with Rh+ baby should receivewomen with Rh+ baby should receive
appropriate amounts of Rh immune globulinappropriate amounts of Rh immune globulin
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ContraceptionContraception
Ovulation may occur by week sixOvulation may occur by week six
Sexual intercourse often resumed by weekSexual intercourse often resumed by week
twotwo--threethree
Oral contraceptives may be started 1Oral contraceptives may be started 1--22
weeks post partum in non lactatingweeks post partum in non lactating
femalefemale2020
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Discharge InstructionsDischarge Instructions
Review infant careReview infant care
feedingfeeding
diaperingdiapering
Follow up visitsFollow up visits
ColicColic
Infant care and needsInfant care and needs
Resuming sexual intercourseResuming sexual intercourse
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Discharge InstructionsDischarge Instructions
Maternal follow up instructionsMaternal follow up instructions
Perineal carePerineal care
sits bathssits baths
green watergreen water
breast carebreast care
Post partum blues/depressionPost partum blues/depression
Support services due to early dischargeSupport services due to early discharge
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Medications & Breast FeedingMedications & Breast Feeding
Drugs and breast milk.Drugs and breast milk. Drugs concentrated inDrugs concentrated inbreast milk tend to be weak bases (such as metronidazole,breast milk tend to be weak bases (such as metronidazole,
antihistamines, erythromycin, or antipsychotics andantihistamines, erythromycin, or antipsychotics andantidepressants).antidepressants).
Drugs absolutely contraindicated in breast feeding.Drugs absolutely contraindicated in breast feeding.
Chemotherapeutic or cytotoxic agents, all drugs used recreationallyChemotherapeutic or cytotoxic agents, all drugs used recreationally
(including alcohol and nicotine), radioactive nuclear medicine tracers,(including alcohol and nicotine), radioactive nuclear medicine tracers,
lithium carbonate, chloramphenicol, phenylbutazone, atropine,lithium carbonate, chloramphenicol, phenylbutazone, atropine,
thiouracil, iodides, ergotamine and derivatives, and mercurialsthiouracil, iodides, ergotamine and derivatives, and mercurials..
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Medications & Breast FeedingMedications & Breast Feeding
Drugs to strongly avoid or consider bottle feeding.Drugs to strongly avoid or consider bottle feeding.
Antipsychotics, antidepressants, metronidazole, tetracycline,Antipsychotics, antidepressants, metronidazole, tetracycline,sulfonamides, diazepam, salicylates, corticosteroids ,phenytoin,sulfonamides, diazepam, salicylates, corticosteroids ,phenytoin,
phenobarbital, or warfarinphenobarbital, or warfarin..Drugs safe to use in normal doses.Drugs safe to use in normal doses. Acetaminophen, insulin, diuretics,Acetaminophen, insulin, diuretics,digoxin, betadigoxin, beta--blockers, penicillins, cephalosporins, erythromycin, birth controlblockers, penicillins, cephalosporins, erythromycin, birth controlpills, OTC cold preparations, and narcotic analgesics (short term in normalpills, OTC cold preparations, and narcotic analgesics (short term in normal
doses).doses).
LactationLactation--suppressing drugs.suppressing drugs.
Levodopa, anticholinergics, bromocriptine, trazodone, and largeLevodopa, anticholinergics, bromocriptine, trazodone, and large--dosedoseestradiol birth control pills.estradiol birth control pills.
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Breast Problems DuringBreast Problems During
LactationLactation
MastitisMastitis
S/SS/S
OrganismsOrganisms RxRx
Obstructed ductsObstructed ducts
S/SS/S RxRx
OtherOther
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Examples of Post Partum OrdersExamples of Post Partum Orders
Pitocin 10 units IMPitocin 10 units IM
BedrestBedrest
Vital signs Q15 minutes for 1 hour, QVital signs Q15 minutes for 1 hour, Q
1hour x 4, Then QID if stable1hour x 4, Then QID if stable
Consider NPO for 1Consider NPO for 1--2 hours2 hours
Ice packs to perineumIce packs to perineum
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Examples of Post Partum OrdersExamples of Post Partum Orders
Ambulate as tolerated when stable (cautionAmbulate as tolerated when stable (caution
check for orthostatic hypotension)check for orthostatic hypotension)
DietDiet-- as appropriateas appropriate
Tucks to perineum prnTucks to perineum prn
Sitz baths QIDSitz baths QID
IVIV-- discontinue when VS stable and uterinediscontinue when VS stable and uterine
bleeding is normalbleeding is normal
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Examples of Post Partum OrdersExamples of Post Partum Orders
Urethral catherization if unable to void in 6Urethral catherization if unable to void in 6--8 hours8 hours
Breast binder if not nursingBreast binder if not nursing CBC post partum day 2CBC post partum day 2
MedicationsMedications
Continue prenatal vitaminsContinue prenatal vitamins FeSOFeSO44 Acetaminophen 650 mg Q4h prn/IbuprofenAcetaminophen 650 mg Q4h prn/Ibuprofen
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Examples of Post Partum OrdersExamples of Post Partum Orders
BowelsBowels
Ducosate sodium 100 mg BID;MOMDucosate sodium 100 mg BID;MOM-- 30 ml30 ml
PO QD PRNPO QD PRN
Follow upFollow up
Post partum check 4Post partum check 4--6 weeks6 weeks
Newborn checkup 1Newborn checkup 1--2 weeks2 weeks
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Post Partum PsychiatricPost Partum Psychiatric
SyndromesSyndromes
UnderrecognizedUnderrecognized
UndertreatedUndertreated
UnderresearchedUnderresearched
First recognized with publication ofDSM IVFirst recognized with publication ofDSM IV
because they were not felt to havebecause they were not felt to have
distinguishable features from other psychiatricdistinguishable features from other psychiatricdisordersdisorders
Most classified as mood disorder subsetsMost classified as mood disorder subsets
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Post Partum PsychiatricPost Partum Psychiatric
SyndromesSyndromes
EpidemiologyEpidemiology
Post partum psychosisPost partum psychosis
1:5001:500
Risk for previously affected 1:3Risk for previously affected 1:3
Non psychotic depressionNon psychotic depression
1:101:10--1515 Risk of previously affected 1:2Risk of previously affected 1:2
In patients with history of mood disorder andIn patients with history of mood disorder and
previous post partum depression ~ 100%previous post partum depression ~ 100%
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Post Partum PsychiatricPost Partum Psychiatric
SyndromesSyndromes
Post partum blues affects 50Post partum blues affects 50--80%80%
due to lack of major symptoms not classified asdue to lack of major symptoms not classified as
a disordera disorder
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