FM Postpartum Care

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FM Postpartum Care

Post partum = 6 to 12 weeks after.

  • Stay in hospital 1-2 days after vaginal delivery, 3-4 days after c-section.
  • May have urinary difficulties – infection, incontinence, retention
  • Postpartum fever → suspect endometritis (polymicrobial infection of uterus, usually ascended from vagina), but can also be UTI or wound infection, thromboembolic disease, or mastitis

Normal Sequences

  • Immediately after:
    • – uterine contractions to compress blood vessels, can give IV oxytocin during or after 3rd stage to aid.
    • Early breastfeeding also helps.
    • Usually returns to normal size by 6 weeks.
  • Vaginal discharge:
    • Bleeding for hours after delivery, then decreases → brown or blood-tinged lochia (RBCs, decidual cells, fibrinous products) for a week → yellow or white lochia for 3-6 weeks.
  • Breastfeeding:
    • – colostrum = yellow/clear w/ lots of antibodies, milk comes 2nd to 4th day after delivery.
    • Sore nipples: manage w/ position changes, alternating sides, lanolin
    • CI’s to breastfeeding:
      • HIV, active Hep B (chronic Hep B and C are okay), breast reduction w/ nipple translation.

Uterine Hemorrhage

  • Uterine hemorrhage – early is w/in 24 hours, late is 24 hrs to 6 weeks. Most often caused by the 4 T’s.
    • Tone (atony) – most common cause.
      • Risks = prolonged labor, prolonged use of oxytocin, large baby, grand multipara (5+ previous babies)
    • Trauma,
    • Tissue (retained placenta or membranes)
    • Thrombin (coagulopathy)
  • Management of uterine hemorrhage:
    • ABC’s first! Manage hypovolemia by placing large bore IV(s) and giving a bolus of NS. Then address source.
    • Start IV oxytocin and bimanual uterine massage.
    • Move to methylergonovine – but contraindicated in patients with hypertension! Can increase BP.
    • Third, try to increase uterine tone with prostaglandin F2 (hemabate) injection (contraindicated in asthma) or misoprostol rectally or orally.

Sex and Fertility

Return to sex & fertility. Most women start having sex again by 3 months. Can place IUD at 6 weeks. Refit diaphragms and cervical caps at 6 weeks.

  • Not breastfeeding: Wait 3 weeks to start OCP. Resume menstruation by 3rd month.
  • Breastfeeding – anovulation can last much longer, 98% contraception protection for 6 months if exclusively breast feeding. Wait 6 weeks to start depo shots or OCP – use progestin-only pills to avoid interfering w/ lactation.

Mood Issues

  • 30-70% have Baby Blues – tearful, emotional, sad. Starts in week 1 and resolves in week 2.
  • 10-20% have post partum depression – onset of depression w/in one year of birth. Symptoms and treatment are the same as in major depression. High recurrence rate in subsequent pregnancies. Higher risk if previous history of depression.
    • SSRIs are safe w/ breastfeeding
  • 1 in 1000 have post partum psychosis – manic or delusional behaviors present within a few days to a few weeks, should be hospitalized. High risk of suicide and infanticide.

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