Postpartum issues

1. Postpartum issues Dr AnjumQazi MD Emory Family Medicine

2. “Baby is out. Lots of questions to answer doc ”

3. Introduction • The postpartum period is an exciting, dynamic time in a woman's life, and the family physician plays an important role in promoting a smooth transition through this period.

4. What is postpartum period ? The postpartum period begins one hour after delivery of the placenta and generally lasts six weeks. After this period, the new mother is in a nonpregnant physiologic state, and lactation-if occurring-is usually well established. The World Health Organization (WHO) points out that although there is no official definition, the traditional six-week duration is consistent with the 40-day period commonly observed in many countries. WHO also recommends a schedule of postpartum care for mother and child. Oversight of four general categories (i.e., medical complications, breastfeeding, postpartum depression, and sexuality and contraception) is vital to a mother's healthy recovery and her baby's healthy start.

7. Q ) What is Lochia ?

8. Answer • Superficial layers of the endometrial decidua that are shed through the vagina during the first 3 postpartum weeks. • L.Rubra -> L.Serosa -> L.Alba

9. Medical issues 1) Women with heavy, persistent postpartum bleeding should be evaluated for what complications ?

10. DD Retained placenta, Uterine atony (rapid or protracted labor, chorioamnionitis, medications) Laceration Hematoma, or coagulation disorders (e.g., disseminated intravascular coagulopathy, von Willebrand's disease).

11. 2) Postpartum fever PP Day 0 – atelectasis. 10 times more common in caesarean. Risk factors- G. Anesthesia with incisional pain Cigarette smoking PE- Mild fever with mild rales/crackers Rx Pulmonary exercises/ambulation/deep breathing

12. PP Day 1-2 – UTI. Risk factors- Multiple cath, multiple vag. Exams, indwelling caths PE- High fever, CVAT, +ve UA Rx ABx

13. PP Day 2-3 – Endometritis. Most common cause of PP fever Risk factors- Chorioamnioninits, emergency C-section, PROM PE- Tender uterus, fever, abdominal pain, foul smelling lochia. Rx Clinda and Genta

14. PP Day 4-5 – Wound infection Risk factors- PROM PE- Persistent spiking fever despite ABx, wound erythema, drainage Rx ABx and drainage

15. PP Day 5-6 – septic thombophlebitis. All above normal then think about this. Risk factors- PROM, prolonged labor, emergency C-section PE- Persistent wide fever swings (picket fence fever) Rx IV heparin for 7-10 days

16. PP Day 7-21 – infectious mastitis Risk factors- Lactational nipple trauma PE- Fever, Breast tenderness, edema etc Rx Early mastitis usually can be managed by improving milk removal through increased nursing and expression of milk (manually or via breast pump). If the mastitis is secondary to a bacterial infection and does not improve within 12 to 24 hours If initial presentation is severe, antibiotics are indicated (e.g., 500 mg dicloxacillin [Dynapen] or cephalexin [Keflex] four times daily for seven to 10 days). Breast abscesses usually require incision and drainage.

17. What urinary tract changes to expect • Hypotonic bladder – Intrapartum bladder trauma can result in increased post void residual volume. (more than 250 ml) • Urinary incontinence – Risk factors – higher prepregnancy body mass index, parity, smoking, longer duration of breast feeding, vaginal delivery, use of forceps.

18. GI Tract Changes • Constipation – decreased GI tract motility because of perineal pain and fluid mobilization • Hemorrhoids – Prolonged second stage pushing can exaggerate pre-existing hemorrhoids

19. Breast feeding • Beneficial for the baby and the mother • WHO recommends 4-6 months of breast feeding and initially 8 or more feedings per 24 hours • Takes practice and persistence on part of the mother (ask the residents )

20. Questions frequently asked • Is my baby getting enough ? • Why is my baby not latching ? • Why are my breasts tender etc ?

21. Signs your baby is getting enough breast milk • Breasts feel full before feeding and softer afterwards • Baby is feeding every 2-3 hours, at least 8 times in a day • Usually feeds for 10 mins or more • Appears satisfied and no longer hungry after feeds • At least 1 wet diaper the first day and 3 on days 2-3 and more on 4-5. At least 6 diapers after 6 days with a clear colorless urine

22. Latching • Early referral to a lactation service or feeding clinic should be considered if the mother is discouraged or struggling or if infant nutrition is a concern • Women who return to work can best maintain breastfeeding if they plan for the challenges of this transition by learning how to use a breast pump and properly store milk. (again ASK THE RESIDENTS  )

23. Evaluation should begin with a breastfeeding history (i.e., frequency and duration of feeds; nipple problems such as cracking, pain, and bleeding; and mastitis symptoms such as redness, warmth, pain, fever, and malaise) • During the physical examination, the physician should ensure proper positioning and attachment of the infant during breastfeeding and assess for nipple problems and engorgement with erythema, tenderness, and induration. • Physicians should also encourage the patient to increase the frequency and duration of feedings for maximal milk production, and should suggest that the mother use nipple shields, creams, and topical breast milk for nipple problems.

24. Early mastitis – Rx : improving milk removal through increased nursing and expression of milk (manually or via breast pump). • If the mastitis is secondary to a bacterial infection and does not improve within 12 to 24 hours, or if initial presentation is severe, antibiotics are indicated (e.g., 500 mg dicloxacillin [Dynapen] or cephalexin [Keflex] four times daily for seven to 10 days). • Breast abscesses usually require incision and drainage.

25. Psychosocial Problems • A) Bonding • B) Blues • C) Depression • D) Psychosis • Thirty to 70 percent of women experience the “blues,” sadness, and emotional instability with onset in the first week postpartum and resolution by 10 days • The blues generally is considered a physiologic phenomenon triggered by hormonal changes and augmented by sleep deprivation, nutritional deficiencies, and the stress of new motherhood.

26. Bonding • Case : SVD of a 1900 gm male in ICU at 31 weeks. Mom shows no interest in the baby. Risk is increased if contact with the baby is limited / poor social support. Rx psychosocial evaluation and support.

27. Blues • Mom cares for the baby but is crying “I don’t know how to take care of my baby” • Thirty to 70 percent of women experience the “blues,” sadness, and emotional instability with onset in the first week postpartum and resolution by 10 days • The blues generally is considered a physiologic phenomenon triggered by hormonal changes and augmented by sleep deprivation, nutritional deficiencies, and the stress of new motherhood.

28. PP Depression • CASE : Mom does not get out of bed and does not care for self and baby • Postpartum depression is one of the most common complications after childbirth (500,000 cases occur in the United States per year, accounting for 13 percent of postpartum women) • According to the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), postpartum depression has its onset within four weeks postpartum, although studies often define onset up to three months postpartum • Risk 1) Hormonal changes 2) stressful life events 3) History of depression • The mother’s education level, the child’s sex, breastfeeding, mode of delivery, and an unplanned pregnancy are not risk factors • Symptoms similar to non PPD (remember SIGECAPS)

30. Sexuality and Contraception • Libido and sexuality are common concerns during the postpartum period • Libido may decrease after delivery, possibly because of decreased estrogen levels • Breastfeeding can delay the return to intercourse, possibly because estrogen levels remain low in these women • Breastfeeding or not, postpartum women have unique contraceptive needs. • Although evidence suggests a delay in resumption of ovulation in breastfeeding women, contraception should be addressed before the traditional six-week postpartum office visit to prevent unintended closely spaced pregnancies

31. Lactational Amenorrhea • For this method to be effective, • the woman must be breastfeeding exclusively on demand • be amenorrheic • have an infant younger than six months

32. Both breastfeeding and nonbreastfeeding women can use • barrier contraceptives • intrauterine devices (IUDs; copper-releasing [ParaGard] • hormone-releasing [Mirena]) • progestin-only contraception. Diaphragms and cervical caps must be refitted, usually six weeks after delivery

33. Imp Points to rememeber • Combination estrogen-progestin contraceptives (e.g., oral pills, the patch [Ortho Evra], the vaginal ring [NuvaRing]) interfere with breast milk production • The American College of Obstetricians and Gynecologists (ACOG) says that progestin-only contraceptives are the best hormonal contraceptive choice for breastfeeding women • ACOG also recommends that women wait at least six weeks before starting combination hormonal contraceptives but acknowledges that this may depend on the clinical situation • Nonbreastfeeding women should wait three weeks before starting estrogen-containing contraceptives because of the increased risk of thromboembolism

34. WAKE UP !