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Care of the Post Partum Patient

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Increased risk with c-section, PROM, Multiple exams during labor, & long labor ... this claim- sleep disorders, hypotension, weight changes, hair/skin changes ... – PowerPoint PPT presentation

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Title: 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

3
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)

4
Physiology of the Puerperium
  • Breasts
  • Decline in Estrogen and Progesterone result in
    breast engorgement by day 3

5
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

6
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

7
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

8
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

9
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

10
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

11
Complications of Puerperium
  • Retained products of conception
  • Causes early post partum hemorrhage
  • Requires manual exploration of the uterus
  • May require anesthesia and curettage

12
Complications of Puerperium
  • Lacerations
  • Repair immediately
  • Uterine rupture
  • Abdominal exploration and repair

13
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)

14
Complications of Puerperium
  • Placenta Accreta Uterine Inversion
  • Uncommon
  • Accreta is when incomplete placental separation
    occurs
  • Requires immediate hysterectomy
  • Uterine inversion requires immediate reduction
  • Hematomas

15
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

16
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)

17
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

18
Analgesics
  • Acetaminophen
  • Aspirin
  • NSAIDs
  • Codeine- complicated by high incidence of
    constipation light headedness
  • Afterpains especially problematic during suckling
    due to oxytocin release

19
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

20
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

21
Discharge Instructions
  • Review infant care
  • feeding
  • diapering
  • Follow up visits
  • Colic
  • Infant care and needs
  • Resuming sexual intercourse

22
Discharge Instructions
  • Maternal follow up instructions
  • Perineal care
  • sits baths
  • green water
  • breast care
  • Post partum blues/depression
  • Support services due to early discharge

23
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.

24
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.

25
Breast Problems During Lactation
  • Mastitis
  • S/S
  • Organisms
  • Rx
  • Obstructed ducts
  • S/S
  • Rx
  • Other

26
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

27
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

28
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

29
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

30
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

31
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

32
Post Partum Psychiatric Syndromes
  • Marce Society Classifications (International
    Organization for the understanding, prevention,
    treatment of mental illness related to
    childbearing)
  • Psychotic
  • Nonpsychotic

33
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

34
Post Partum Psychiatric Syndromes
  • Two distinct clinical syndromes exist
  • Post partum psychosis
  • Post partum depression

35
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

36
Post Partum Psychiatric Syndromes
  • Post partum blues affects 50-80
  • due to lack of major symptoms not classified as a
    disorder

37
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

38
Post Partum Psychiatric Syndromes
  • Androgens
  • Testosterone Androstenedione produced by
    ovaries
  • Cyclic variation of these hormones absent during
    pregnancy and lactation
  • Androgen Masculogenic and depressogenic

39
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

40
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

41
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

42
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

43
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

44
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

45
Predisposing Factors
  • Primiparous women
  • Women with personal or family history of mood
    disorders
  • Previous history of Postpartum depression/psychosi
    s
  • Perinatal death

46
Postpartum Mood Syndromes
47
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

48
Treatment
  • Psychosis
  • Antipsychotics- Haldol, Perphenapine, Loxitane in
    Small doses
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