Postpartum Care 2025 PDF

LABOR INDUCTION Oxytocin Cervical Ripening Amniotomy Membrane Manipulation C-section TOLAC VBAC 21  Labor Induction* Stimulation of uterine contractions before labor begins on its own Aim - to achieve a vaginal birth Ind...

LABOR INDUCTION Oxytocin Cervical Ripening Amniotomy Membrane Manipulation C-section TOLAC VBAC 21  Labor Induction* Stimulation of uterine contractions before labor begins on its own Aim - to achieve a vaginal birth Indications Concern for maternal or fetal health Is increasingly being used for convenience or to accommodate busy schedules Labor should not be induced if the cervix is not well prepared (softened & partially effaced) 22 Labor Induction Used with Contraindications Post term pregnancy Previous C-section or uterine surgery PPROM* Active genital herpes infection Chorioamnionitis Placenta previa Fetal growth restriction Umbilical cord prolapse Oligohydramnios Transverse fetal lie Gestational diabetes Hypertensive disorders of pregnancy Abruptio placenta Certain medical conditions 23 Labor Induction Aim – to cause cervical ripening (softening, effacement & dilation that occur before active labor) Methods Oxytocin infusion Prostaglandin analogs Dinoprostone (Prepidil, Cervidil) – gel or intravaginal insert Misoprostol (Cytotec) - po Cervical balloon Membrane stripping Amniotomy 24  Not on Exam ! X Induction Favorable (“ripe”) cervix: 2-3 cm open, 80+ % effaced, soft, anterior Unfavorable cervix: cervix is firm, long, or closed 25 Induction – Favorable Cervix Oxytocin (Pitocin, Syntocinon)* - drug of choice for labor induction with a favorable cervix Continuous IV infiltration at low doses to stimulate contractions Complications Uterine hyperstimulation Hypertonicity Maternal fluid overload 26 Induction - Unfavorable Cervix Prostaglandins markedly enhance success misoprostol (Cytotec) 25 mcg intravag every 3-6 hrs dinoprostone (Cervidil); insert is left in place until active labor begins, OR for 12 hrs 27 Labor Induction - Unfavorable Cervix Transcervical balloon (catheter) Foley catheter balloons are used to mechanically dilate the cervix Small rubber tubing is placed through the cervix. A balloon inside the tubing is inflated, just inside the inner edge of the cervix Catheter is left in place until it’s extruded or for up to 12 hrs 28 Labor Induction Membrane stripping Sweeping (stripping) the membranes - pressing the amniotic sac off the cervix w/o breaking it GBS* swab must be negative > 38 wks pregnant Cervix must be open enough to permit this May stimulate the release of oxytocin from the pituitary gland, helping to initiate contractions 29  GBS – normal flora in vagina &/or rectum of approx 25% of all healthy, adult women GBS Women testing positive are said to be “colonized” (Group B GBS can pass to the baby during birth Strep Approx 1 in every 2,000 babies born in US CDC recommends routine infection) screening for vaginal Strep B in all pregnant women Btwn wks 35 – 37 Both the vagina & rectum are swabbed 30  Indicators of higher risk of delivering a baby with GBS: Preterm labor or ROM before 37 wks ROM 18 hrs or more before delivery GBS Fever during labor Previous baby with GBS UTI caused by GBS while pregnant Rx: PCN IV during delivery 31  Risks to infants can occur within hrs of delivery: Sepsis, pneumonia, meningitis – MCC of neonatal sepsis Respiratory problems GBS Heart & BP instability GI & kidney problems Rx: Abx during labor and birth help prevent early onset GBS* po PCN, Keflex or ampicillin 32 Labor Induction Amniotomy/Artificial Rupture of Membranes (AROM) AKA: “breaking the water” Note clarity of fluid & presence of meconium Monitor FHR before & immediately after procedure # risk of umbilical cord prolapse 33  34 Labor and Delivery u Management: u Pain Management/ Anesthesia u VS every 15 - 30 mins u Non-pharmacologic approaches u Continuous fetal monitoring in high risk pregnancy or following u Epidural block administration of analgesia/ u Spinal anesthesia (single anesthetic injection) u NPO (ice chips allowed) u Combined spinal-epidural u Local block u General anesthesia  35 Pain Management u Epidural Block u Spinal anesthesia u Local anesthetic plus opioid u Administered into the u Administered into the epidural subarachnoid space space using continuous IV u Combined spinal-epidural infusion pumps u Epidural catheter may be activated if delivery has not occurred before intrathecal dose wears off  36 Pain Management u Local Block u Bilat pudendal nerve blocks u A supplement for epidural analgesia u General Anesthesia u Used with complications (ie: shoulder dystocia) u If epidural or spinal is not in place, general anesthesia may be necessary POSTPARTUM DR S RYAN CARE OBSTETRICS SPRING 2025  ¡ Postpartum Care ¡ Neonate TOPICS ¡ Maternal ¡ Anxiety and Depression 2 OBJECTIVES ¡ Provide postpartum education for the new mother and her newborn. ¡ Understand the care provided for the first 24 hrs of a newborn infant’s life. ¡ Identify psychological complications that may develop in the postpartum period and collaborate with other health care specialists as needed. 3  4 POSTPARTUM (PP) CARE POSTPARTUM CARE - EVALUATION OF PLACENTA ¡ Placental is spontaneously delivered ¡ Examine to make sure it’s intact ¡ Incomplete delivery of the placenta can lead to PP hemorrhage, infection, DIC, or sepsis 5 POSTPARTUM CARE - EVALUATION OF PLACENTA ¡ Examine umbilical cord ¡ 2 arteries, 1 vein 6 MATERNAL CARE ¡ Evaluate maternal blood loss ¡ Palpate uterine fundus for firmness or atony ¡ Inspect & repair lacerations 7  ¡ Palpate the uterus to assess tone ¡ IV oxytocin (Pitocin) - ensures uterine contraction & involution MATERNAL ¡ Involution – return of uterus to its CARE nonpregnant state ¡ Begins immediately after expulsion of placenta as smooth muscle of the uterus contracts ¡ Uterus returns to normal size within 4 - 6 wks PP 8  ¡ Perineal pads are applied ¡ Amount of blood, mother’s BP are monitored closely for several hrs post delivery to assess blood loss MATERNAL CARE ¡ PP hemorrhage - common cause of maternal death within 24 hrs of delivery ¡ Early – first 24 hrs PP ¡ Delayed – occurs 25 hrs – 8 wk PP 9 INVOLUTION ¡ Within 12 hrs, fundus can rise to approx 1 cm above the umbilicus. ¡ At 24 hrs after birth, uterus is about same size as it was at 20 wks gestation. Fundus descends 1 - 2 cm every 24 hrs. ¡ PP day 6, fundus located halfway btwn the umbilicus & symphysis pubis. ¡ Uterus should not be palpable after 2 wks, Should return to its no-pregnant location by 6 wks PP into specifics Won't go 10  Wipe mucus from nose and mouth, suctioning unnecessary APGAR score at 1 & 5 minutes NEONATE Clamp and cut cord CARE Keep baby dry & warm PE VS, height, weight, measure head circumference Temp, HR, RR, core & peripheral color, level of alertness, tone & activity are monitored at delivery & every 30 min until these are stable for at least 2 hrs Skin to skin contact (Kangaroo Care) Incubators for preemies Won't ask 11 APGAR Score  Ilotycin* – antibiotic ung is placed in newborn’s eyes to prevent neonatal conjunctivitis (ophthalmia neonatorum) NEONATE CARE Prevents blindness Effective against*: Chlamydia Gonorrhea E. coli 12 13 KANGAROO CARE 14 KANGAROO CARE ¡ “The hug that changed medicine” ¡ https://www.yout ube.com/watch?v =0YwT_Gx49os 15 BREASTFEEDING ¡ Should be initiated as soon as possible after delivery ¡ Demand feeding is recommended, respond to hunger cues ¡ 8-12 feedings/24 hrs ¡ Alternate breasts ¡ Avoid artificial nipples ¡ Infant needs to “latch on” 16 BREASTFEEDING Colostrum: small amounts, first few days; slowly replaced by milk Nipple care Wash with water. air dry after each feeding Lanolin or A&D ointment if nipples are tender Lactation specialist 17  Recommended exclusively for 6 mos* Benefits: Decreased ear infections/ URIs Decreased allergies Improved maternal-child attachment BREASTFEEDING Oxytocin released from suckling accelerates involution of the uterus Contraindications: HIV Chemotherapy Meds – lithium, tetracycline, bromocriptine, methotrexate Illegal drug use 18 MATERNAL CARE Postpartum Changes Puerperium: 6 - 8 wk period after birth Uterus returns to normal size by 4 – 6 wks Lochia: heavy x 2-3 days, lasts for several wks Lochia rubra – menses like bleeding Lochia serosa – less blood Lochia alba – whitish discharge 19 PP CHANGES ¡ Cervix: os appears slit-like ¡ Average time to ovulation ¡ 45 days in non-lactating women ¡ 189 days in lactating women ¡ Abd wall ¡ Striae gravidarum ¡ Diastasis recti – separation of the rectus muscles & facia 20 PP CARE Hospital Stay 48 hrs after vaginal delivery 96 hrs after C-section PP Complications Infection – 5% of pts Postpartum hemorrhage – 1% of pts Ambulation: encouraged ASAP 21 PP CARE Ice packs Analgesia Breast engorgement Supportive bra Discourage manual expression of milk if mother doesn’t want to breastfeed Blocked milk duct Complications Mastitis Breast abscess 22  ¡ Perineal Care ¡ Oral analgesics (NSAIDS) POSTPARTUM ¡ Ice packs CARE ¡ Topical anesthetics ¡ Sitz baths 24 hrs after delivery 23  ¡ Contraception ¡ Combined OCs may inhibit milk supply ¡ Progestin only preparations are “safe” for breastfeeding POSTPARTUM ¡ Begin at 6 wks if breastfeeding exclusively CARE ¡ Begin at 3 wks if not breastfeeding exclusively ¡ Begin at 3 wks if not breast feeding ¡ IUD 4-6 wks postpartum 24 PP CARE Sexual activity Can resume as soon as pt is comfortable External lubrication prn Initiate contraception prior to intercourse Weight loss 2 lbs per month will not affect lactation 25 PP ANXIETY & DEPRESSION ¡ PP “blues” ¡ Affects 70-80% of women ¡ Feeling of sadness come and go ¡ Abates within 1-2 weeks ¡ PP depression ¡ 10% of women ¡ Sadness/anxiety interfere with daily activities ¡ Sx last wks - mos 26  ¡ Postpartum Psychosis ¡ Occurs 1–4 wks after childbirth ¡ 0.1- 0.2% of pts ¡ An overt presentation of bipolar PP ANXIETY & disorder that coincides with hormonal shifts that occur after DEPRESSION delivery ¡ Pt develops frank psychosis, cognitive impairment, & grossly disorganized behavior that represent a complete change from previous functioning ¡ Lacks insight 27 PP DEPRESSION ¡ Rx: * ¡ SSRI - fluoxetine and sertraline ¡ SNRI - venlafaxine Not on exam ¡ Zuranolone - a neuroactive steroid gamma-aminobutyric acid (GABA) A receptor positive X modulator, X ¡ The first oral medication indicated to treat postpartum depression in adults ¡ ACOG recommends consideration of zuranolone in the PP period (ie, within 12 mos postpartum) for depression that has onset in the third trimester or within 4 weeks postpartum. X X ¡ Brexanolone (Zulresso) is the first drug approved by the U.S. Food and Drug Administration specifically for postpartum depression in adult women. ¡ Consists of a 60-hour in-hospital intravenous infusion and may not be readily accessible. 28 PP ANXIETY & DEPRESSION ¡ Can lead to devastating consequences in which the safety & well-being of the mother & her baby are jeopardized ¡ Careful and repeated assessment of the mothers’ symptoms, safety, and functional capacity is imperative ¡ Refer for inpatient care 29 METRITIS AKA: endomyometritis, endometritis, metritis with cellulitis Infection of uterine cavity & adjacent tissue Ascending infection from lower genital tract MC infection after C-section Polymicrobial, anaerobic predominance S&S: Fever (post-op day 1 or 2) Uterine tenderness 30  ¡ Rx: ¡ IV Abx until pt is asx & afebrile x24 hrs ¡ clindamycin + gentamicin every 8 hrs METRITIS ¡ Oral Abx after successful parenteral treatment is not required ¡ Abx prophylaxis for C-sections: ¡ IV Cefazolin or ampicillin 31 PP FOLLOW UP Usually at 6 wks ¡ Discuss: ¡ PE: ¡ Breastfeeding ¡ Bimanual exam - check for ¡ Return of menses involution of the uterus ¡ Sexual activity/contraception ¡ Pap smear at this time may show ¡ Return to work atypical cells (repeat in 3 mos) ¡ Mental state 32 QUESTIONS? 33