Postpartum

Question 1

Describe postpartum anatomic and physiologic changes:

Uterus

Answer 1

• Involution - reduction of size of uterine cells. Starts at 2 days post birth → finished by about 10 – 14 days
  
  • Uterus weighs 1000 g at birth → 500 g at 1 week after → 300 g at 2 weeks → approximately 100 g at 4 weeks
  • Uterus at/slightly above umbilicus immediately after birth → below pubic symphysis by 14 days
    
    • firmly contracted, consistency/size of softball
• Afterpains - contractions strongest first 3 days post birth.
  
  • Worse in parous women, multiple gestation and with breastfeeding (oxytocin)
  • Important for hemostasis (ligates bleeding vessels at placenta site)
  • Can lie prone or use NSAIDS (ie ibuprofen 600 mg q 6)

Question 2

Describe postpartum anatomic and physiologic changes:

Cervix

(vaginal delivery)

Answer 2

• Healing begins within hours after birth
  
  • Begins to remodel as uterus contracts and pulls it back into normal position (shortens/thickens/epithelial remodeling)
• Nearly closed by 1 week
• Almost back to pre-pregnant size/shape by 6 weeks.
• Os looks more like a transverse slit

Question 3

Describe postpartum anatomic and physiologic changes:

Lochia

Answer 3

• Vaginal discharge resulting from the sloughing of decidual tissue and debris
• Lochia rubra – vaginal discharge (debris from placenta, membranes, lanugo, vernix, and decidual tissue ). May have dime-sized clots and fleshy odor. Lasts about 3 days
• Lochia serosa – paler version of lochia rubra, begins as uterus regenerates endometrium and remodel placental site. Can smell bad. Lasts 7 – 10 days (median 22-27 days) and transitions to linea alba
• Lochia alba – pink, yellow, or white discharge. Lasts up to 4 weeks

***May see a sudden, transient increase in bleeding around day 7 - 14 post partum → sloughing of eschar over area of previous placental attachment. Self-limiting (a few hours)

Question 4

Describe postpartum anatomic and physiologic changes:

Endocrine changes

(estrogen, progesterone, thyroid, prolactin, FSH, ADH)

Answer 4

• Estrogen and progesterone drop
  
  • Estradiol to 2% of pregnant levels by 24 hours
  • Estrogen withdrawl → rapid diuresis
  • Progesterone to nonpregnant levels by 24-48 hours → removal of fluid from tissues and return of vascular tone
  • Estrogen to almost prepregnant levels by 7 days
• Thyroid regresses and BMR is normal by 7 days
  
  • T3/T4 normal by 4 weeks
• Non-lactating
  
  • Prolactin - normal range within 3 weeks
  • Estrogen levels start rising within 2 weeks
  • Ovulation - mean 70 - 75 days (early as 27)
• Lactating
  
  • Prolactin - elevated x 6 weeks
  • Ovulation - mean 6 months
• FSH same regardless of lactation
• Increased antidiuretic hormone (ADH) immediately post partum → increased water/Na retention → mild 3rd spacing/pedal edema. Resolves 4-7 days.

Question 5

Describe postpartum anatomic and physiologic changes:

Vagina/Labia/Perineum

Answer 5

• Labial/perineal edema usually resolved by 3-4 days. Lacerations take days to weeks to heal
• Immediately post partum - slack vagina and no rugae
  
  • Rugae appear by 3 weeks (less prominent than prepregnant).
• Vaginal epithelium starts to proliferate at 4 weeks, completed by 6 weeks and tone nearly restored (but never fully recovers).
  
  • Drop in progesterone helps impove tone

Question 6

Describe postpartum anatomic and physiologic changes:

Cardiovascular

Answer 6

• Estrogen withdrawal → rapid diuresis x 48 hours → return to normal Hct and plasma levels
• Progesterone decreased → improved vascular tone and water removal from tissues
  
  • takes up to 6 weeks to get to prepregnancy levels (vessel diameter/flow) → increased risk for clots
• CO - elevated 1 hour after birth x 2 days → usually back to prepregnant in 1 week
• BP - slightly elevated x 4 days after birth
• Coagulation increased significantly x 2 days → elevated x 2 weeks

Question 7

Describe postpartum anatomic and physiologic changes:

Renal

Answer 7

• Progesterone falls → renal dilation resolves
• Transient bladder control issues due to stress of labor
• GFR returns to normal by 8 weeks
• Medications with renal dosage adjustments for pregnancy need to be reassessed at 4 - 6 weeks

Question 8

Describe postpartum anatomic and physiologic changes:

Immune system

Answer 8

• Immune system suppressed during pregnancy rebounds quickly after delivery
• May see “flare-ups” of autoimmune disease and latent infections with inflammatory reactions.
  
  • Inflammatory reactions → clinical symptoms.
  • Examples: autoimmune thyroiditis, multiple sclerosis, and lupus erythematosus

Question 9

Describe postpartum anatomic and physiologic changes:

GI changes

Answer 9

• Progesterone decrease → improved heartburn/reflux.
• Constipation may persist due to fear of pain or immobilization after surgery
• Fasting blood sugars return to normal by 48 hours and are stable by 6 weeks

Question 10

Define: telogen effluvium

Answer 10

• More rapid hair turnover is seen for up to 3 months after birth
• As a greater percentage of hair begins to undergo the growth phase, more hair falls out with combing and brushing.
• Loss of hair in diffuse, not balding, pattern
• Reassure patient its transient

Question 11

Components of early (2 week) post-partum visit

vs 6 week post-partum

Answer 11

NUTSHELL

• 2 weeks: assess involution process, psych/physical adaptations
• 6 weeks: assess involution complete, continuing psych adjustment, family planning

DETAILED

Subjective:

• Physical and emotional adjustment
• Birth experience
• Family adaptation
• Infant feeding
• Exercise/activity/Rest/sleep
• Diet/Fluids/Constipation/hemorrhoids
• Lochia/Perineal comfort/
• Sexuality/Resumption of intercourse/Contraception
• At two week visit include: Afterbirth pains and Diuresis/diaphoresis

Objective:

• Vital signs/Weight
• Heart/lungs
• Breasts
• Uterus/Perineum/bleeding prn
• CVAT
• Extremities/edema
• Postpartum depression screening

Plan:

• Teaching: Family adaptation, Maternal role attainment, Infant feeding, Normal involution, Exercise/activity, Rest/sleep, Diet/fluids, Birth control, Warning signs, Resumption of menses (at 6 week)
• Follow-up at 6 weeks/annual and prn
• Consult, collaborate, refer prn

Question 12

Post partum blues

Answer 12

• 80% of women, often appears within 1st week after birth
• Etiology unknown, associated with: fatigue, decreased support, hormonal changes, social isolation, marital/relationship conflict
• Common sx: crying, anxiety, overly fatigued, sleep difficulty, appetite changes, mood swings, conflicted feelings about birth experience
• Symptoms > 2 weeks → evaluate for postpartum depression

Question 13

“Taking in” vs “Taking hold” phases of post partum adjustment

Answer 13

• Taking in - reviews labor and birth and clarifies experience for new parent/family and allows to go to next phase
• Taking hold - parent assumes task of parenting, care of baby and self, along with attention to family and support network

Question 14

Define: bonding

Answer 14

• the emotional tie pregnant person develops with the unborn baby and later the newborn
• Also occurs with other important family members and baby
• Develops over time
• Powerful source of ongoing care activities
• Affected by a number of factors: parent’s perceptions of their own abilities, childhood experiences

Question 15

Family adjustment

Answer 15

• Lots of differnt types of families today…structure affects function
• Healthy newborn should not be seperated from family at birth
• Parents often interact differently with baby and baby’s reaction shapes responses
• Sibling adjustment affected by variety of factors:
  
  • NOT age (according to Jordan)
    
    • Newborn mimicry for attention common
    • Depends on developmental milestones
  • family culture, size setting, support network
  • parental competance, relationship with each other
• Providers should reframe as period of adjustment rather than rivalry

Question 16

Define: maternal role attainment

Answer 16

• historic concept used to describe process a mother goes through to attain a new role
• Influenced by culture, experience with being parented, physical condition, socioeconomic status, readiness for life event, and attitude
• Starts in prengnacy and continues through birth of baby and subsequent children
• Not a 1 time event, but a lifelong transformation

Question 17

Describe signs, symptoms and management strategies for:

Fever

Answer 17

• Aka puerperal fever
• Temperature > 100.4° F (38° C)
• Potential causes: often genital tract infection, also breast engorgement, dehydration, pyelonephritis, or respiratory illness
  
  • Fever rarely > 24 hours for breast engorgement or dehydration and is < 39°C
  • Rarely DVT can cause elevated temp
  • C/S < 24 hours and temp > 39° C → group A strep
• Management → investigate for infection

Question 18

Resumption of menses

Answer 18

• Important to know lochial flow patterns to determine if bleeding/spotting is lochia or resumption of menses
• Different if bottle or breast feeding (even if breast was only for short time)
  
  • Bottle: within 4-6 weeks after birth
  • Breast: varies 2 - 18 months after birth
• ***Can ovulate before 1st menses*** - crucial for contraceptive counseling

Question 19

Physical Exam:

Breast

Answer 19

• Breast - recommended due to increase cancer found during pregnancy/lactation
• Not breastfeeding - expect engorgement 2-4 days postpartum, may take several weeks for prolactin to decrease
  
  • Wear form-fitting bra even at night
  • Cold compresess
  • NSAIDS
  • Avoid breast stimulation of any kind
• Breastfeeding: look for breast/nipple redness/breakdown
• Follow-up, collaboration, or referral for any abnormal finding/persistent areas of concern

Question 20

Physical Exam:

Abdomen

Answer 20

• Route of birth important
• Cesarean - incision inspection for signs of infection (warmth, redness, drainage) or wound dehiscence
• Involution assessment: compare level of fundus to # days post partum
  
  • Expect 1 fingerbreadth of descent per day from umbilicus to pubic symphysis
  • Should be pelvic organ by 2 weeks
  • ***Make sure bladder is empty***
  • Further investigation if exam isn’t as expected
  • Fundus should be firm (contracted)
• Diastasis recti - expected finding, degree depends on parity, multiple gestation, abdominal condition before pregnancy
  
  • Patient lies supine → place examining fingers midline on abdomen → ask patient to tighten abs and put chin to chest → measure gap in fingerbreadths

Question 21

Physical exam:

Perineum

Answer 21

• Inspection of episiotomy or laceration at 2 weeks and 6 weeks
• Should be healed by 2-3 weeks, can take months if tearing extensive
  
  • Well-healed: faint, pinkish line where tissue is approximated
  • Infection: redness, edema, purulent exudate, fever
• Granulation tissue → can use silver nitrate

Question 22

Physical exam:

Vaginal and uterine

Answer 22

• Bruises, lacerations, edema expected after vaginal birth
• Tone returns with decreased edema
• Ruggae return 3 - 4 weeks post partum
• Vaginal exam not necessary at 2 weeks unless concerning symptoms
• If uterus is larger than expected → subinvolution → investigate cause
• Saturating > 1 pad/hour → exam to investigate cause
• 6 weeks: speculum exam
  
  • Cultures/pap as indicated
  • Examine internal tissues
  • Assess uterine size, palpate ovaries, assess muscle tone
  • Assess for cystocele or rectocele

Question 23

Physical Exam:

Rectal

Answer 23

• As needed for hemorrhoid evaluation
• Indicated after 3rd or 4th degree laceration
  
  • Assess healing, integrity, tone of internal and external sphincters
• Reports of fecal incontinence → assess rectovaginal wall

Question 24

Physical Exam

Leg

Answer 24

• Do at 2 and 6 week visits
• Look for varicosities and DVT symptoms
  
  • Cord-like vessel, warmth over area, edema, complaints of pain/tenderness → referral
  • Homan’s sign could be + or -
• Normal leg edema should be disappated by 2 weeks

Question 25

Post partum depression

Answer 25

* Occurs in 10 - 20% of pregnancies, varies in severity * Can 1st appear as post partum blues that persists, or even during pregnacy * Commonly occurs around 4 weeks, but can appear anytime during 1st year (or longer) * Symptoms mimic postpartum blues but include extremes of appetite and sleep disturbances + more severe symptoms (ie suicide ideations) * Risk factors: * Highest risk: previous or present dx of depressive or anxiety disorder * Personal or family hx of mental health disorder * Social factors like isolation * Edinburgh Postnatal Depression Scale * Validated _screening_ tool * Patient can complete in exam room while waiting for provider * May assist someone who is reluctant to disclose negative feelings * Other screening tools: Postpartum Depression Screening Scale (PDSS), Center for Epidemiological StudiesDepression Scale (CED-D), Patient Health Questionnaire (PHQ-9), and Beck Depression Inventory (BDI)

Question 26

Post-traumatic stress disorder (as it relates to labor/birth experience)

Answer 26

* Prevalence 1.5% - 5.6% * Extreme fear and helplessness when exposed to the same or similar environment where the trauma occurred. * May be plagued by recurring thoughts and dreams * May have relationship discord and attachment concerns. * Some births may be psychologically traumatic regarless of physical outcome * Provider role: encourage birth debriefing/counseling and reflection. * Opportunity for the patient to describe her experience, discuss her feelings, define occurrences, and obtain validation. * Opportunity for the healthcare provider to correct misinformation/understanding about the birth event and to help the patient reframe her narrative to assist in the integration of what she had hoped would happen with what really happened. * PTSD has also been linked to postpartum mood and anxiety disorders.

Question 27

Describe signs, symptoms and management strategies for: Uterine Infection

Answer 27

* One of the most common puerperal infections * Often referred to as endometritis, but other areas of uterus can be infected, ie myometrium (endomyometritis), parametrium (endoparametritis) * 1-2% post vaginal, up to 27% post c-section * Clinical presentation: * Fever (chills if severe) * General malaise * Abdonimal pain with uterine tenderness on bimanual * Lochia with or without foul odor * Subinvolution * Differentials: pyelonephritis, pneumonia, appendicitis * Managment: * Exam, CBC, blood cultures, aerobic uterine culture, U/A and urine culture, CXR or U/S if indicated * Mild cases: oral antibiotics * Consult MD if post-cesarean * Moderate-severe: hospitalization with IV antibiotics (obvious MD consult) * usually see improvement in 48 - 72 hours * D/C home once no fever/symptoms for 24 hours off antibiotics

Question 28

Most common reasons for post partum readmission: (regardless of method of delivery)

Answer 28

* Uterine or wound infection * Hypertension

Question 29

Describe signs, symptoms and management strategies for: Wound Infection

Answer 29

* Often in cesarean incision or perineal laceration * _Abdominal_: * **Clinical presentation**: localized edema, induration, and erythema, often with exudates and occasionally fever. * **Management**: wound care, antibiotic treatment, and drainage (prn). * Reclosure of dehiscence vs healing by secondary intention - depends on size, drainage, and other wound characteristics * Culture is rarely necessary for treatment. * Common pathogens include Staph aureus, strep, and both an/aerobic bacilli. * _Perineal_: * **Clinical presentation**: localized edema, erythema, and exudates. * **Management**: similar to other wound infections * Drainage, removal of sutures, and debridement of the infected area. * Cellulitis → broadspectrum antimicrobials * Most heal without needing additional sutures. * Sutures breakdown for a 3rd or 4th° → repair after infection gone. * Use prophylactic antimicrobials initially to reduce infection rates. * Persistent fever, tachycardia, pain, and tenderness, despite several days of tx → assess for complications such as pelvic abscess, septic pelvic thrombophlebitis, and septic shock (severe cases)

Question 30

Describe signs, symptoms and management strategies for: Delayed postpartum hemorrhage

Answer 30

* Occurs after 24 hours and until 12 weeks postpartum * Prevalence 1-2% * Screen for vWD if occurs 2-5 days post birth * Management: * Uterotonic agents or curretage * Ergonovine, methylergonovine, oxytocin, or a prostaglandin analog * Consider U/S for retained placental fragments but not always accurate and retained frags dont usually cause hemorrhage *

Question 31

Describe signs, symptoms and management strategies for: Subinvolution

Answer 31

* _Differential diagnosis_: retained placental fragments, uterine infection, or excessive maternal activity prohibiting proper recovery. * Clinical presentation: * Irregular bleeding (can be profuse) * Abdominal and bimanual exam → enlarged and often boggy uterus. * Management * * R/o retained placental fragments and infection * Methylergonovine (0.2 mg PO q 4 hrs) x 24– 48 hrs * Encourage rest, proper nutrition, fluid intake, and help at home * Follow-up in 1– 2 wks

Question 32

Describe signs, symptoms and management strategies for: Thrombophlebitis (SVT, DVT, PE)

Answer 32

* Incidence 1 in 1000-2000 womem * _Risk factors_: hypercoagulability, venous stasis, and inflammation from venous trauma caused by distension during pregnancy (Virchow's triad) * _Superficial thrombophlebitis (SVT)_: * Presents with increased leg pain, localized edema, erythema, and warmth over the thrombotic site. * Exam → enlarged, hard, cord-like structure. * Management: support stockings, NSAIDS, leg rest, and elevation. * Deep vein thrombosis (DVT) * Mimics SVT (leg pain/inflammation), but usually abrupt onset with increased pain with mvmnt or standing. * Homan’s sign (calf pain elicited with foot dorsiflexion) could also be muscle strain from childbirth and absence of Homan’s does not r/o DVT. * Edema may be more generalized over leg/thigh * Differential diagnosis includes SVT, trauma, ruptured Baker’s cyst, muscle strain, vasculitis, or lymphedema. * Management: * Physician referral for management * Venous ultrasonography with or without a color Doppler, labs like D-dimer * Anticoagulant therapy, bed rest with leg elevation, and analgesia. * Support stockings should be worn up when ambulation resumes.

Question 33

Identify appropriate time periods for initiating different contraceptive methods

Answer 33

* COCs * Contraindicated for everyone x 21 days * Contraindicated if risk for VTE x 42 days * Contraindicated if breastfeeding x 30 days * May interfer with milk production * Watch out if risk for VTE → still 42 days * POPs * Start anytime (no concerns with clotting or breastfeeding) * DMPA * Can be given immediately, milk production not affected, not associated with PPD * IUDs * May be done post-placental (within 10 minutes is best, but higher expulsion rate 20% (lower in cesarean vs vaginal) * Contraindicated if postpartum sepsis * Implant * Can be placed immediately - milk production not affected * Diaphragm * Wait to fit until 6 weeks

Question 34

CDC MEC conditions for increased risk of post partum VTE (no COC's for \_\_\_\_days?)

Answer 34

* \> 35 yrs * Previous VTE * Thrombophilia * Immobility * Transfusion at delivery * Peripartum cardiomyopathy * BMI \> 30 * Postpartum hemorrhage * Post cesarean * Preeclampsia * Smoking No COC's for first 42 days

Question 35

7 W's of Febrile Morbitity in Postpartum Period

Answer 35

1. Wound (infection) 2. Womb (endometritis) 3. Water (UTI/pyelo) 4. Weaning (mastitis) 5. Wind (PE) 6. Walking, not (thrombophlebitis) 7. Wonder drug (example: misoprostol)