Essential Postpartum Care Guide: Risks, Treatments, and More

School

Brooklyn College, CUNY**We aren't endorsed by this school

Course

MEDICINE PA1

Subject

Nursing

Date

Dec 12, 2024

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Uploaded by israt095

Postpartum Care EOR Study Guide Endometritis-Infection of the uterine endometrium. Etiology- Usually, mixed vaginal flora ChlamydiaGonorrhea Risk Factors- C section is #1 risk factor Prolonged rupture of membranes >24 hours D&C Postpartum Diagnosis- Fever Tachycardia Abdominal pain Uterine tenderness after C-section Treatment- Post C-section- Clindamycin + gentamicin Post Vaginal Delivery- Ampicillin + gentamicin Prophylaxis- 1stgeneration cephalosporins during C-sectionPerineal Laceration-Tear of the skin or soft tissue structures: MC obstetric injury and affects 85% of women postpartum. First Degree- Perineal skin and vaginal mucosa Second Degree-Injury to the perineal body Third Degree-Through the external anal sphincter Fourth Degree-Injury through the rectal mucosa Treatment- 3rdand 4thdegree usually require surgical repair For 1stand 2nddegree, let heal naturally with observation Episiotomy- Surgical incision of the perineum performed during the second stage of labor to increase the diameter of the pelvic outlet to prevent 3rdand 4thdegree laceration. Indications- Fetal distress Complications-Vaginal bleeding, pain, infections Types-oMidline- Vertical. Easier to repair but may extend into the anus. oMediolateral-Done at an angle, 2.5 cm away from anus. More difficult to repair but less risk of extension into the anus. oLateral-Incision extends laterally. May injure the Bartholin’s ducts.

oJ-shaped- Begins midline and directed laterally to avoid anal sphincters Puerperium Care- Postpartum period lasts 6 weeks- the period of adjustment following delivery. Immediate puerperium- First 24 hours Early puerperium-First week Remote puerperium-6 weeks Lochia- Postpartum vaginal discharge. Lochia Rubra- Menses-like bleeding for the first 7 days Lochia Serosa-Lighter discharge with less blood Lochia albia-Whitish discharge persisting for weeks Ovarian Function-Average time is 45 days to ovulation if not lactating and 189 (6 months) if lactating. Uterine Involution- At the end of the first postpartum week, will have decreased to the size of 12 weeks gestation Returns to normal size by 6 weeks Cervical, Vagina, and Pelvic Changes- Cervix is dilated to 1 cm after the first week Vagina returns to antepartum condition by the 3rdweek Hospital Management- Skin to skin contact Reliever perineal pain with ice packs, TylenolEncourage ambulation Avoid breast stimulation if do not plan to breastfeed

Lactation consultationBreast Feeding CI- HIV, untreated TB, chemo, radiation, drug use Nipple Care-Wash with water after feeding and air dry 15-20 minsImmunizations- Rubella if not immune Tdap if >2 years since last booster Rhogam if Rh+ infant Bowel/Bladder Function-Common to not have a BM for 1-2 days Periureteral edema can cause transitory urinary retention Bladder capacity is increasedProteinuria 1-2 after delivery is common Pregnancy causes 50% increase in GFR, this will go back to normal Creatinine clearance returns to normal after 8 weeks Monitor urinary output and cath if necessary Contraception-Progestin only minipill may be initiated at 3-6 weeks if breastfeedingShould not be on combo pill while breastfeeding Can insert IUD at 4-6 weeks Tubal ligation may be performed at the time of C-sectionSexual Activity- Coitus can resume once the patient is comfortable Risk of hemorrhage or infection before 2 weeks Median time to resume intercourse is 6 weeks May need vaginal lubricant Diet- Protein rich foods, veggies, high fluid intake500 calories per day more than they consumed non-pregnant Hospital Stay-48 hours for vaginal 96 for C-sectionShortened Stay Criteria-oNo feveroNormal vitals oLochia amount and color are appropriate oAbsence of abnormal physical, lab, or emotional findings oMother able to perform ADL and care for newborn Postpartum Depression- Major depression 2 weeks-12 months postpartum

Postpartum Blues- Occurs 2-4 days postpartum and resolves within 10 days. General anhedonia, fatigue, depressed mood. Will not have thoughts of harming self or baby. Is self-limited. Postpartum Depression-2 weeks-12 months postpartum. May have thoughts of harmingbaby and may need antidepressants. SSRIs are first line. Postpartum Visit- 4-6 weeks after Ask about breastfeeding Return of menstruation Contraception and coital activity Interaction with newborn Assess for postpartum depression. Postpartum Hemorrhage-4% prevalence. Primary- Within 24 hours of delivery Secondary-Up to 12 weeks after delivery Criteria- 1.10% drop in hematocrit 2.Need for transfusion 3.Signs and symptoms of blood loss/hypovolemia ACOG Criteria- Cumulative blood loss >1000 mL or bleeding associated with hypovolemia within 24 hours of the birth process. Etiology-Uterine atony is MCCRetained placenta Genital tract trauma Hematomas Ruptured uterus DICSymptoms- Uterine Atony- Boggy uterus, cervix open, uterus will contract when massaged Retained Placenta- Remaining tissue prevents contractions and causes bleeding and possibly atony 4Uterine Rupture- Often at the site of previous C-section Hypovolemic Shock- oTachycardia oPale/clammy skin oDecreased capillary refill oHypotension Symptoms of Blood Loss- 10-15% BL- Generally tolerated without symptoms

20% BL-Tachycardia, tachypnea, delated capillary refill, orthostatic changes, and narrowed pulse pressure >30% BL-Hypotension, severe tachycardia, and tachypnea 40-50% BL- Oliguria, shock, coma, death Initial Management- Determine etiology and source of bleeding ASAP2 large bore IV access Rapid crystalloid infusions Blood transfusion Treatment-Uterine Atony- oImmediate bimanual massage oAdminister uterotonicsOxytocin- First line uterotonic Methylergonovine Acetate- Causes uterine contractions within minutes. Given IM because IV can cause HTN crisis. CI- Hypertensive disorders Misoprostol- Dinoprostone- Rectal suppository Methyl Prostaglandin F- Given IM Carboprost- CI in maternal asthma oSurgical Treatment- Uterine compression sutures Retained Placenta- Carefully inspect the placenta to detect any missing cotyledons. If suspected, insert two fingers in the cervix and take out the retained tissue. Can also use curettage with suction. Uterine Rupture- Surgical repair is required, may need hysterectomy Prevention- Obtain baseline coagulation studies and platelet count, type and screen, baseline hematocrit Avoid excessive traction on the umbilical cord Be conservative with use of the forceps and vacuum Inspect placenta for complete removal Active management of the third stage of labor Remove all clots in uterus and vagina