Postpartum Care

Question 1

Postpartum

Answer 1

Postpartum: delivery through 6 weeks
“4th trimester”
AKA “puerperium”, from the Greek “puerperos”, meaning “to bear young”
Puerperal = postpartal
Key task: involution

Question 2

Involution

Answer 2

Uterus returns to its normal position, shape, size

Position: pelvic organ

Shape: upside-down pear

Size: fruit-basket pear

Question 3

Uterus Decreases in Size

Answer 3

1. Uterine contractions
2. Autolysis
   - Catabolic process
   - Muscle fibers get smaller
   - Protein from myometrial cells reabsorbed

Question 4

Endometrial Changes

Answer 4

1. Uterine contractions decrease placental site to ½ predelivery size
2. Blood loss controlled
   - Compression of blood vessels that supply decidual sinuses
   - Compression of sinuses themselves
   - Clot formation in vessels that supply **decidua - endometrium **

Question 5

WBCs

Answer 5

Infiltrate placental site, blood vessels, and surrounding tissues
Necrosis begins
3 weeks total for decidual necrosis/regeneration
+
3 weeks for placental site necrosis/regeneration

Question 6

Lochia (Postdelivery Flow)

Answer 6

After delivery, almost entirely blood
As sinuses compressed, clots form, less blood
Forms
1. Rubra (red)
2. Serosa (pink)
3. Alba (yellowish-white)

Question 7

Lochia Rubra: 2-3 Days

Answer 7

Blood + mucus + decidual particles + cellular debris from placental site
Endometrial cavity sterile initially, then bacterial growth + WBCs contribute to lochia

Question 8

Lochia Serosa: At 3-4 Days

Answer 8

L_ess oozing blood, more watery (serous)
Pinkish-tan color_
Involution of placental site continues: blood decreases, WBC + cellular debris
predominate

Question 9

Lochia Alba: By Day 10

Answer 9

Yellowish-white to white in color
Gone by end of 3rd PP week or brownish mucoid discharge few days

Question 10

Peripad Assessment (1 Hour)

Answer 10

Scant; Light; Moderate; Heavy saturated

Question 11

PPH (Postpartum Hemorrhage)

Answer 11

Early PPH
Within first 24 hours

Uterine atony #1 ( uterus without tone, not contracting) , also genital tract lacerations and retained placenta
Late PPH
After first 24 hours

Retained placenta

Question 12

Fundal Height

Answer 12

Fundus ( top portion of the uterus ) - at or below the level of umbilicus

Empty bladder - two-handed approach - palpate the abdoemn gently feeling for the top of the uterus while the other hand is placed on the lower segment of the uterus to stabilize it.

* By the 10th day PP, uterus is no longer palpable abdominally

if it is palpable - subinvolution due to retained placenta

Question 13

Fundal Characteristics

Answer 13

Should be firm, in the midline

Reference position to the umbilicus
FF U/0 (at the level of umbilicus) , FF U/1 (1 cm below) , etc. !!!!!!
FF ( fundus firm) 1/U ( 1 cm above) , FF 2/U ( 2 cm above) , etc.

Question 14

Boggy Uterus

Answer 14

Uterus not firm? Massage & reassess.
Support base of uterus
 Massage fundus straight down towards patient’s spine
Note passage of clots, retained placenta, pieces of amniotic sac

Question 15

Full Bladder

Answer 15

Too high? Over to right side? Probably full bladder. Have patient void & reassess.

Question 16

Medications: Promote Uterine Tone

Answer 16

1. Pitocin (oxytocin)
   10 units (1 ml) IM
   Vastus lateralis or directly into myometrium if C/S patient
   Up to 30 units (3 ml) into 1000 cc bag of an electrolyte solution
   Titrate rate to keep uterus firm, bleeding minimal
   2. Methergine (methylergonovine)
   O.2 mg IM or IV
   Note patient’s BP before administering
   IV carries more risk of complications (HPN, CVA)

Question 17

Bimanual Compression

Answer 17

Used for severe cases of uterine atony
Combined with use of oxytocic medications
1 hand in vagina; other on abdomen

Question 18

Bakri Tamponade Balloon

Answer 18

Into uterus - fill with saline - leave - direct pressure on wound - stop bleeding

Question 19

Afterpains

Answer 19

Primipara: uterus contracts & stays contracted
Multipara: intermittent uterine contractions
Worse with breastfeeding (oxytocin) !!! - lets milk down + uterus contractions

Problems maintaining contraction

• Uterus overdistended
• Clots or retained placenta
• Use of pitocin during labor

Question 20

Cervix

Answer 20

Cx & lower uterine segment thin & collapsed; poor tone
Cx soft, edematous, many small lacerations
External os gradually closes & thickens

Question 21

Vagina

Answer 21

1. Damage to soft tissues & support structures
   - Small tears in fascia & musculature
2. Vagina: smooth, swollen, poor tone
   - Tone restored, but rarely like nullipara’s
   - Rugae reappear after 3 weeks; many not as thick as before
   - Estrogen deficiency by 3-4 weeks = atrophy of epithelial cells (vaginal tissue)
   - Poor lubrication, vasocongestion, sexual response
   - Estrogen normal level 6-10 weeks - no intercoarse until 6 weeks post

Question 22

Introitus ( vaginal opening )

Answer 22

Red & swollen, especially if episiotomy or lacerations
Heals by 2 weeks PP if no infections or hematomas
Free of perineal pain
**Extensive lacerations or poor repair = relaxed perineal floor - urine and fecal incontinence **

Question 23

Layers of Tissue in Perineum

Answer 23

Degrees

1st: perineal skin + subcutaneous layer
2nd: addition of perineal muscles
3rd: addition of rectal sphincter
4th: addition of rectal mucosa
Episiotomies cut through 2nd degree
Lacerations (tears) usually 1st & 2nd degree
Periurethral lacerations

                              Episiotomies

                    - Midline (median)
                     - Mediolateral

                                   Right or left

Question 24

Pericare (Perineal Care)

Answer 24

1. Ice packs x 24 hours - reduce swelling ( 20 min on ; 20 min off)
2. Sitz baths ( 2/ day , 10 min ) - warmth brings blood flow to the area - WBC ( healing) + RBC
3. Peribottle
4. Topical lidocaine ( allergic to novocaine)
   Sprays
   Foams
   Creams
5. Tucks (witch hazel) pads

Question 25

Special Considerations: 3rd & 4th Degree Lacerations

Answer 25

Nothing per rectum Edema Bruising Emphasize dietary changes Increase fluids Increase intake of fruits/vegetables Encourage ambulation Stool softeners Laxatives \* occur with midline episiotomie

Question 26

REEDA Scale

Answer 26

Redness Edema Eccyhmosis Discharge Approximation \* Blue+black dime or smaller - ice for an hour; bigger - call doctor - hematoma - up to 1000 cc blood loss

Question 27

Fallopian Tubes

Answer 27

Respond to low **estrogen** level Transient, non-bacterial inflammation by PPD #4 Gone once estrogen levels are restored to normal

Question 28

Hormonal Changes

Answer 28

Decreased estrogen & progesterone reactivates hypothalamic-pituitary-ovarian feedback cycle FSH & LH rise gradually Lower level than normal menstrual cycle Breastfeeding governs if normal ovarian function, ovulation, menstruation returns

Question 29

Bottlefeeding or Breastfeeding \< 28 Days

Answer 29

FSH & estrogen levels rise to follicular phase concentration by 3rd week PP Menses can occur 6-8 weeks PP Menses before 6 weeks usually anovulatory Initial ovulation usually about 10 weeks PP By 12 weeks PP, 70% have first menses

Question 30

Breastfeeding

Answer 30

Associated with delayed ovulation  Menses return more gradually 12 weeks PP: 45% have menses 36 weeks PP: 55-75% have menses First 1-2 cycles usually anovulatory Unclear why delay in menses: possible influence of prolactin

Question 31

Puerperal Morbidity: 1-8%

Answer 31

 Morbid temperature: **_38 degrees Celsius (100.4 F) or greater, after the first 24 hours PP, on any 2 consecutive days out of the first 10 PP days_** 1. Endometritis 2. UTI 3. Thrombophlebitis 4. Mastitis

Question 32

Endometritis

Answer 32

 More common in C/S Lower abdominal pain Foul-smelling lochia Treated with oral antibiotics for mild cases; IV for moderate/severe cases Use of **broad-spectrum** antibiotics Rapid response to medications typically

Question 33

UTI

Answer 33

Same S/S of any UTI (urgency, frequency, dysuria) Also flank pain if **pyelonephritis** (CVA tenderness) Usually from bowel contaminants Often were **catheterized** during labor Diagnose with **urine C/S** (straight cath.) Treat with antibiotics

Question 34

Thrombophlebitis

Answer 34

Blood is **hypercoagulable** due to increased clotting factors Venous stasis also a factor Many patients have varicose veins  May have + Homan’s Sign Red streaks on leg Warmth, edema of leg Treated with heat, elevation, NSAIDs, anticoagulants

Question 35

Mastitis

Answer 35

Frequently unilateral Tender, engorged, erythematous breast Malaise (feel “flu-like”) Usually due to **S. aureus** Treatment: antibiotics, rest, fluids, Tylenol, empty affected breast q3h, ice, breast support Can develop into breast abscess (surgical drainage)