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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)
- Tone (atony) – most common cause.
- 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.