Care of the Post Partum Patient

Walter Eisenhauer MMSc, PA-C

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
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)
Physiology of the Puerperium

 Breasts
– Decline in Estrogen and Progesterone result in
breast engorgement by day 3
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
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
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
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
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
Complications of Puerperium

 Uterine Atony (Cont’d)

» Treatment
 Uterine compression
 Oxytocics
– Early suckling causes endogenous release of oxytocin
– Oxytocin IV/IM 10 units
– Methylergonovine
– Methyl prostoglandin F
Complications of Puerperium

 Retained products of conception

– Causes early post partum hemorrhage
– Requires manual exploration of the uterus
– May require anesthesia and curettage
Complications of Puerperium

 Lacerations
– Repair immediately
 Uterine rupture
– Abdominal exploration and repair
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)
Complications of Puerperium

 Placenta Accreta & Uterine Inversion

– Uncommon
– Accreta is when incomplete placental
separation occurs
– Requires immediate hysterectomy
– Uterine inversion requires immediate reduction
 Hematomas
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
Complications of Puerperium

 Fever
– UTI/Pyelonephritis
– DVT/Thrombophlebitis
– “Milk fever” (Lasts < 24 hours)
– Drug reaction
– Perineal infection(Day five)
– Pulmonary Atelectasis (48 hours)
– Mastitis (2-3 weeks post partum)
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
Analgesics

 Acetaminophen
 Aspirin
 NSAIDs
 Codeine- complicated by high incidence of
constipation & light headedness
 Afterpains especially problematic during
suckling due to oxytocin release
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
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 female
20
Discharge Instructions

 Review infant care

– feeding
– diapering
– Follow up visits
– Colic
– Infant care and needs
 Resuming sexual intercourse
Discharge Instructions

 Maternal follow up instructions

 Perineal care
– sits baths
– green water
– breast care
 Post partum blues/depression
 Support services due to early discharge
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.
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.
Breast Problems During
Lactation

 Mastitis
– S/S
– Organisms
– Rx
 Obstructed ducts
– S/S
– Rx
 Other
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
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
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
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
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
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
Post Partum Psychiatric
Syndromes

 Marce Society Classifications

(International Organization for the
understanding, prevention, & treatment of
mental illness related to childbearing)
– Psychotic
– Nonpsychotic
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
Post Partum Psychiatric
Syndromes

 Two distinct clinical syndromes exist

– Post partum psychosis
– Post partum depression
Post Partum Psychiatric
Syndromes

 Epidemiology
– Post partum psychosis
» 1:500
» Risk for previously affected 1:3
– Non psychotic depression
» 1:10-15
» Risk of previously affected 1:2
» In patients with history of mood disorder and
previous post partum depression ~ 100%
Post Partum Psychiatric
Syndromes

 Post partum blues affects 50-80%

– due to lack of major symptoms not classified as
a disorder
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
Post Partum Psychiatric
Syndromes

 Androgens
– Testosterone & Androstenedione produced by
ovaries
– Cyclic variation of these hormones absent
during pregnancy and lactation
– Androgen Masculogenic and depressogenic
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
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
Sheehan’s 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
Sheehan’s 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
Sheehan’s 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
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
Predisposing Factors

 Primiparous women
 Women with personal or family history of
mood disorders
 Previous history of Postpartum
depression/psychosis
 Perinatal death
Postpartum Mood Syndromes+
Frequency(all Clinical Course
deliveries Features

Maternity blues 50-80% Crying 3-10 days

Irritability postpartum
Euphoria

Postpartum 10-15% Melancholia 80% have onset

depression Neurasthenia within six weeks
Insomnia ( stage postpartum (not
4 sleep before third
postpartum day)
Duration: 6-9 months

Postpartum 0.1% 90% mood Acute onset within

psychosis disorders two weeks
40% mania postpartum
Core Good prognosis
schizophrenic Duration: 2-3
symptoms months
absent
Delirium,
confusion
Treatment

 Depression
– SSRI’s
» Prozac, Paxil, Zoloft
– Agitated symptoms
» Tricyclics, tetracyclics
– ? Role of estrogen patches/Progestin injections
– Consider possibility of Sheehan’s syndrome
– Consider Prophylaxis
– ECT in refractory cases
Treatment

 Psychosis
– Antipsychotics- Haldol, Perphenapine,
Loxitane in Small doses