Care of the Post Partum Patient

1
Care of the Post Partum Patient

• Walter Eisenhauer MMSc, PA-C

2
Physiology of the Puerperium

• Anatomic changes
• Uterus
• Lochia-name given to blood and other necrotic
  debris shed from the uterus
• Uterus does not scar- tissue replaced by new
  growth from the basal endometrium
• Proliferative endometrium persists for about six
  weeks and first menses normally anovulatory

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Physiology of the Puerperium

• Cervix
• Returns to normal within hours of delivery
• Transverse slit like external os persists due to
  laceration
• Vaginal and perineal tears may remain inflamed
  for several days but rapidly heal
• Vagina appears normal in 6 weeks in non lactating
  women
• Breast feeding women are hypoestrogenic resulting
  in vaginal mucosa being pale and smooth (causes
  dryness friction dysparunia)

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Physiology of the Puerperium

• Breasts
• Decline in Estrogen and Progesterone result in
  breast engorgement by day 3

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Physiology of the Puerperium

• Cardiovascular changes
• Changes of pregnancy reversed over three weeks
• Marked increase stroke volume immediately post
  partum
• 500-1000ml blood loss in normal delivery

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Physiology of the Puerperium

• Leukocytosis of labor persists for several days
• Reduces the value of leukocyte count to determine
  infection
• Serial counts may still be useful to follow
  infection

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Physiology of the Puerperium

• Weight changes
• 5-6 kg weight loss expected at delivery
• Additional 3-4 kg over the next two weeks due to
  diuresis loss of extracellular fluid
• GFR returns to normal within several days

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Complications of Puerperium

• Blood loss infection most common complicating
  1-5 of pregnancies
• Blood loss
• Weigh bed clothes and pads for semi-quantitative
  method of determining blood loss
• VS- Q 15 minutes for 1 hour, Q 30 minutes for two
  hours then q4hours for the first day
• Failure to identify early post partum hemorrhage
  remains leading cause of maternal mortality

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Complications of Puerperium

• Blood loss
• Early post partum hemorrhage
• Most common cause uterine Atony
• Normal uterine blood flow 500 ml/min
• If effective contraction of myometrium does not
  occur significant blood loss can occur
• Risk factors include
• Use of oxytocin during labor
• High parity
• Distended uterus

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Complications of Puerperium

• Uterine Atony (Contd)
• Treatment
• Uterine compression
• Oxytocics
• Early suckling causes endogenous release of
  oxytocin
• Oxytocin IV/IM 10 units
• Methylergonovine
• Methyl prostoglandin F

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Complications of Puerperium

• Retained products of conception
• Causes early post partum hemorrhage
• Requires manual exploration of the uterus
• May require anesthesia and curettage

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Complications of Puerperium

• Lacerations
• Repair immediately
• Uterine rupture
• Abdominal exploration and repair

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Complications of Puerperium

• Blood replacement based on estimated loss
• Alterations in vitals signs may occur as late
  finding (Do not wait for hypotension to occur)
• R/O DIC by acquiring appropriate coagulation
  studies (split fibrin products etc)

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Complications of Puerperium

• Placenta Accreta Uterine Inversion
• Uncommon
• Accreta is when incomplete placental separation
  occurs
• Requires immediate hysterectomy
• Uterine inversion requires immediate reduction
• Hematomas

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Complications of Puerperium

• Infections
• Endomyometritis
• Foul smelling lochia and tender uterus within
  first few days post partum
• Increased risk with c-section, PROM, Multiple
  exams during labor, long labor
• Polymicrobial including anaerobes (Ecoli,
  Gardnerella, Peptostreptococcus)
• Treat with Gentamycin/Clindomycin (Gold
  Standard), extended spectrum penicillin or
  cephalosporin

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Complications of Puerperium

• Fever
• UTI/Pyelonephritis
• DVT/Thrombophlebitis
• Milk fever (Lasts lt 24 hours)
• Drug reaction
• Perineal infection(Day five)
• Pulmonary Atelectasis (48 hours)
• Mastitis (2-3 weeks post partum)

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Complications of Puerperium

• Infection
• Maternal temperature best indicator of post
  partum infection
• Monitor Q6 hours for first twenty four and have
  patient report chills, temperature post
  hospitalization
• Inspect episiotomy site regularly for infection
• Monitor for return of bowel/bladder function
  

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Analgesics

• Acetaminophen
• Aspirin
• NSAIDs
• Codeine- complicated by high incidence of
  constipation light headedness
• Afterpains especially problematic during suckling
  due to oxytocin release

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Immunizations

• Puerperium is ideal time to administer rubella
  vaccine for those found non immune
• Rh- women with Rh baby should receive
  appropriate amounts of Rh immune globulin

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Contraception

• Ovulation may occur by week six
• Sexual intercourse often resumed by week
  two-three
• Oral contraceptives may be started 1-2 weeks post
  partum in non lactating female20

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Discharge Instructions

• Review infant care
• feeding
• diapering
• Follow up visits
• Colic
• Infant care and needs
• Resuming sexual intercourse

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Discharge Instructions

• Maternal follow up instructions
• Perineal care
• sits baths
• green water
• breast care
• Post partum blues/depression
• Support services due to early discharge

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Medications Breast Feeding

• Drugs and breast milk. Drugs concentrated in
  breast milk tend to be weak bases (such as
  metronidazole, antihistamines, erythromycin, or
  antipsychotics and antidepressants).
• Drugs absolutely contraindicated in breast
  feeding. Chemotherapeutic or cytotoxic agents,
  all drugs used recreationally (including alcohol
  and nicotine), radioactive nuclear medicine
  tracers, lithium carbonate, chloramphenicol,
  phenylbutazone, atropine, thiouracil, iodides,
  ergotamine and derivatives, and mercurials.

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Medications Breast Feeding

• Drugs to strongly avoid or consider bottle
  feeding.
• Antipsychotics, antidepressants, metronidazole,
  tetracycline, sulfonamides, diazepam,
  salicylates, corticosteroids ,phenytoin,
  phenobarbital, or warfarin.
• Drugs safe to use in normal doses.
  Acetaminophen, insulin, diuretics, digoxin,
  beta-blockers, penicillins, cephalosporins,
  erythromycin, birth control pills, OTC cold
  preparations, and narcotic analgesics (short term
  in normal doses).
• Lactation-suppressing drugs.
• Levodopa, anticholinergics, bromocriptine,
  trazodone, and large-dose estradiol birth control
  pills.

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Breast Problems During Lactation

• Mastitis
• S/S
• Organisms
• Rx
• Obstructed ducts
• S/S
• Rx
• Other

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Examples of Post Partum Orders

• Pitocin 10 units IM
• Bedrest
• Vital signs Q15 minutes for 1 hour, Q 1hour x 4,
  Then QID if stable
• Consider NPO for 1-2 hours
• Ice packs to perineum

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Examples of Post Partum Orders

• Ambulate as tolerated when stable (caution check
  for orthostatic hypotension)
• Diet- as appropriate
• Tucks to perineum prn
• Sitz baths QID
• IV- discontinue when VS stable and uterine
  bleeding is normal

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Examples of Post Partum Orders

• Urethral catherization if unable to void in 6-8
  hours
• Breast binder if not nursing
• CBC post partum day 2
• Medications
• Continue prenatal vitamins
• FeSO4
• Acetaminophen 650 mg Q4h prn/Ibuprofen

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Examples of Post Partum Orders

• Bowels
• Ducosate sodium 100 mg BID MOM- 30 ml PO QD PRN
• Follow up
• Post partum check 4-6 weeks
• Newborn checkup 1-2 weeks

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Post Partum Psychiatric Syndromes

• Underrecognized
• Undertreated
• Underresearched
• First recognized with publication of DSM IV
  because they were not felt to have
  distinguishable features from other psychiatric
  disorders
• Most classified as mood disorder subsets

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Post Partum Psychiatric Syndromes

• According to DSM must occur within four weeks of
  delivery
• Most do begin within this time frame howevever
• Post partum depression may be of insidious onset
  beginning 3-4 months post partum

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Post Partum Psychiatric Syndromes

• Marce Society Classifications (International
  Organization for the understanding, prevention,
  treatment of mental illness related to
  childbearing)
• Psychotic
• Nonpsychotic

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Post Partum Psychiatric Syndromes

• Louis Victor Marce 1858
• Wide variety of symptoms
• Was certain of organic etiology
• Sympathie Morbid
• Wrote and died 1/4 century before outlines of the
  endocrine system were described
• Treated with traditional psychotherapy during
  20th century with almost no research being done

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Post Partum Psychiatric Syndromes

• Two distinct clinical syndromes exist
• Post partum psychosis
• Post partum depression

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Post Partum Psychiatric Syndromes

• Epidemiology
• Post partum psychosis
• 1500
• Risk for previously affected 13
• Non psychotic depression
• 110-15
• Risk of previously affected 12
• In patients with history of mood disorder and
  previous post partum depression 100

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Post Partum Psychiatric Syndromes

• Post partum blues affects 50-80
• due to lack of major symptoms not classified as a
  disorder

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Post Partum Psychiatric Syndromes

• Etiology
• Hormonal
• Estradiol
• Marked elevation during pregnancy
• Abrupt decline after parturition
• Studies fail to reveal consistent correlation
  between estradiol levels and depression or
  psychosis
• Progesterone
• Theory of progesterone deficiency
• Controlled studies using progesterone
  prophylactically fail to show efficacy
• Progesterone depressogenic

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Post Partum Psychiatric Syndromes

• Androgens
• Testosterone Androstenedione produced by
  ovaries
• Cyclic variation of these hormones absent during
  pregnancy and lactation
• Androgen Masculogenic and depressogenic

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Post Partum Psychiatric Syndromes

• Cortisol
• Precipitous fall of estrogen and progesterone in
  the post Partum period initiate a cascade of
  events
• Serum cortisol elevated during last trimester
• Pituitary hormones markedly decreased during post
  Partum period

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Post Partum Psychiatric Syndromes

• Cortisol
• psychosis may be due to deficit below cortical
  neuronal tolerance
• extreme anxiety symptoms may be a result of
  stimulation of autonomic centers in the
  hypothalamus by continuous discharge of cortisol
  sensitive structures
• Sx substantiate this claim- sleep disorders,
  hypotension, weight changes, hair/skin changes
• Limited studies show success in using prednisilone

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Sheehans Syndrome

• 1967 Howard Sheehan described postpartum necrosis
  of the anterior pituitary
• blood loss during pregnancy followed by
  circulatory collapse of the pituitary
• causes array of multiglandular disorders
• causes agitation, hallucinations, delusions,
  depression

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Sheehans Syndrome

• Hypothesis is that some degree of tissue necrosis
  occurs causing temporary deficits of pituitary
  hormones
• High hormonal levels during last trimester
• Hormonal levels fall off rapidly after delivery
  but remain above baseline levels until day three
• Blues, psychosis, or depressive sx can/will occur
  anytime after day three

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Sheehans Syndrome

• Thyroxine
• Thyroid levels also above normal during last
  trimester the fall off precipitously
• Reaches pre pregnancy level on average three
  weeks after delivery
• Marked individual variation
• 10 of women have post partum hypothyroidism

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Psychosocial Factors

• Disruption of previous lifestyle
• History of previous infertility may be a risk
  factor
• Lack of extended family
• Need for perfectionism by mother thwarted by baby
• Narcissistic loss if independent self

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Predisposing Factors

• Primiparous women
• Women with personal or family history of mood
  disorders
• Previous history of Postpartum depression/psychosi
  s
• Perinatal death

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Postpartum Mood Syndromes
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Treatment

• Depression
• SSRIs
• Prozac, Paxil, Zoloft
• Agitated symptoms
• Tricyclics, tetracyclics
• ? Role of estrogen patches/Progestin injections
• Consider possibility of Sheehans syndrome
• Consider Prophylaxis
• ECT in refractory cases

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Treatment

• Psychosis
• Antipsychotics- Haldol, Perphenapine, Loxitane in
  Small doses