Lecture 3 Antepartum and Postpartum Period PDF

Antenatal and postnatal care  Diagnoses of pregnancy : Pregnancy is a physiological state. The importance of the correct diagnosis of pregnancy is essential. Pregnancy occurs when a sperm fertilizes an egg after it’s released from the ovary during ovulation. The fertilized egg then...

Antenatal and postnatal care  Diagnoses of pregnancy : Pregnancy is a physiological state. The importance of the correct diagnosis of pregnancy is essential. Pregnancy occurs when a sperm fertilizes an egg after it’s released from the ovary during ovulation. The fertilized egg then travels down into the uterus, where implantation occurs. A successful implantation results in pregnancy. The endocrinological, physiological and anatomical alterations gives symptoms and signs that provide evidence that pregnancy exists. These symptoms and signs are classified into 3 groups: presumptive evidence probable signs positive signs of pregnancy  Presumptive Evidence of Pregnancy: Presumptive evidence of pregnancy is based on subjective symptoms and signs include: -nausea with or without vomiting; -disturbances in urination; -fatigue and the perception of fetal movement. The presumptive signs of pregnancy include: cessation of menses anatomical changes in the breasts discoloration of the vaginal mucosa increased skin pigmentation development of abdominal striae.  Signs of pregnancy: [Cessation of menses ] In a healthy women who has experienced spontaneous, cyclic, predictable menstruation, the abrupt cessation of menses is highly suggestive. There is variation in the length of the ovarian cycle among women. It is not until 10 days or more after the time of expected onset of the menstrual period. The absence of menses is a reliable indication of pregnancy. When a second menstrual period is missed the probability of pregnancy is high. Cessation of menstruation is an early indication of pregnancy. Gestation may begin without prior menstruation in a girl in whom menarche has not occurred. Nursing mothers who do not menstruate during lactation sometimes ovulate and conceive. Rarely women who believe they recently passed the menopause will ovulate again and may become pregnant. Uterine bleeding somewhat suggestive of menstruation, occurs occasionally after conception.  Generally the anatomical changes in the breast that accompany pregnancy are characteristic in primiparas. They are less obvious in multiparas whose breasts may contain a small amount of milky material. Changes in the breast similar to those women with prolactin- secreting pituitary tumors and in ones taking drugs induce hyperprolactinemia. During pregnancy the vaginal mucosa frequently appears dark bluish or purplish-red and congested which is the Chadwick sign. Increased skin pigmentation and appearance of abdominal striae are common but not diagnostic of pregnancy. These signs may be absent during pregnancy , conversely. These signs may be associated with the ingestion of estrogen- progestin contraceptives. Probable Evidence of Pregnancy: The probable signs of pregnancy include : enlargement of the abdomen, changes in the shape, size and consistency of the uterine, anatomical changes in the cervix, Braxton Hicks contraction( sporadic contractions and relaxation of the uterine muscle), ballottement, physical outlining of the fetus and positive results of endocrine tests for the presence of hCG in urine or cerum. Endocrine Tests of Pregnancy. The presence of chorionic gonadotropin (hCG) in maternal plasma and its excretion in urine provides the basis for the endocrine tests for pregnancy. This hormone can be identified in body fluids of immunoassay or bioassay techniques.  Detection of Chorionic Gonadotropin: One constituent of the fetal-induced maternal recognition of pregnancy system arises in the production of the glycoprotein hormone , hCG. The production of hCG by fetal trophoblast is important because hCG acts to rescue the corpus luteum, the principal site of progesterone formation in the first 6-8 weeks of pregnancy by preventing its involution. The detection of hCG in biological fluids in urine or serum of the woman is tasted by the most common test of pregnancy.  Levels of hCG in pregnancy: hCG is produces in placenta exclusively by syncytiotrophoblast , not by cytotrophoblasts. The synthesis of hCG constitutes an important function of the differentiated trophoblast. The production of hCG in trophoblasts begins in very early pregnancy, almost certainly on the day of implantation. The levels of hCG in maternal plasma and urine rise very rapidly. With a sensitive test as a radioimmunoassay using antibodies directed against the β-subunit of hCG, pregnancy hormone can be demonstrated in maternal plasma or urine by 8-9 days after ovulation.  Positive signs of pregnancy: Three positive signs of pregnancy are- Identification of fetal heart action separately and distinctly from the pregnant. Perception of active fetal movements by an examiner, Recognition of the embryo and fetus at any time in pregnancy by sonographic techniques or fetus radiographically in the latter half of pregnancy.  Identification of fetal heart action: Observing the pulsation of fetal heart assures the diagnosis of pregnancy. Fetal heart’s contractions can be identified by auscultation with a special fetoscope by use of the Doppler principle with ultrasound and by of sonogrphy. The fetus heartbeat can be detected by auscultation with a stethoscope by 17 weeks gestation , on nonobese women. Generally the fetal heart rate at this stage of gestation and beyond ranges from 120-160 beats per minute. It is heard as double sound resembling the tick of a watch under a pillow. To establish the diagnosis of pregnancy is not sufficient merely/ just to hear the fetal heart , it must be different from the maternal pulse. During much of pregnancy the fetus moves freely in the amnionic fluid where the fetal heart sounds can be heard best as the positions of the fetus changes. https://www.youtube.com/watch?v=BWiLPGErVF0  Upon auscultation of the abdomen of the pregnant woman in the later months of pregnancy, the examiner may often hear sounds other than those produced by fetal heart action which are : 1. the funic / umbilical cord soufflé, 2. the uterine soufflé, 3. sounds resulting from movement of the fetus, 4. the maternal pulse , 5. the gurgling of gas in the intestines of the pregnant woman.  Perception of Fetal Movements: The positive sign of pregnancy is the detection of movements of fetus by the examiner. After 20 weeks’ gestation, active fetal movements can be felt, at indeterminate intervals, by placing the examination hand on the woman’s abdomen. These movements vary in intensity from a faint flutter early in pregnancy to brisk motions at a later period that are sometimes visible and palpable. Sometimes somewhat similar sensations may be produced by contractions of the intestines or the muscles of the abdominal wall of the pregnant woman.  Up to 12 weeks, the crown-rump length is predictive of gestational age within 4 days. In early identification of normal pregnancy the findings of sonographpy may permit the identification of gestation. When the embryo is dead there is a blighted ovum and an abortion will ultimately. The characteristic features of blighted ovum are: 1. loss of definition of the gestational sac, 2. an unusually small gestational sac, 3. the absence of echoes emanating from the fetus after 8 weeks’ gestation.  Vaginal Sonography in Early Pregnancy: Ultrasonic scanning , using a vaginal probe provides a number of methodological advantages for selected diagnostic purposes in obstetrics and gynecology. A gestational sac in the uterine cavity - 2mm small in diameter can be identified. This shows a time about 16 days after ovulation or 10 days after implantation. Visualization of the chorionic cavity is possible by 2 weeks after conception. The yolk sac at 3 weeks and cardiac activity is readily recognized at 4 postconceptional weeks by vaginal sonography. The findings of sonography almost always provide more information than those of radiographpy without the risks of irradiation.  Ante-partum period  Care provided for the pregnant woman prior to delivery. The prenatal or ante-partum course often influences the outcome of the pregnancy. During this time patient is encouraged to maintain healthy practices and abstain from practices that are harmful for the pregnancy.Regular visits at specific intervals are important to screen patient and fetus for abnormal medical conditions that may develop. To determine the health status of mother and fetus To determine gestational age To initiate plan for obstetrical care depending on risks To lower maternal /paternal morbidity To enhance pregnancy , childbirth experience for patient / family  We have some definitions they are: Gestational age (GA): The time of pregnancy counting from the first day of the last menstrual period (LMP) Developmental age: The time of pregnancy counting from fertilization First trimester : 0-13 weeks Second trimester : 14-27 weeks Third trimester : 28weeks to birth Embryo: Fertilization -8 weeks Fetus : 10 weeks till birth Previable: < 24 weeks Preterm: 22-37weeks Term :37-42weeks  Terminology of Reproductive History: The mother’s pregnancy history is described in terms of gravidity (G) and parity (P) gravida indicates the number of times a female is or has been pregnant, regardless of the pregnancy outcome. A current pregnancy, if any, is included in this count. A multiple pregnancy (e.g., twins, triplets, etc.) is counted as 1. Parity, or "para", indicates the number of births (including live births and stillbirths) where pregnancies reached viable gestational age. A multiple pregnancy (e.g., twins, triplets, etc.) carried to viable gestational age is still counted as 1 A woman that is gravida 3, para 1201 (G3P1201)- means she was pregnant 3 times,has one term birth, two preterm births , no abortions and has one live child Frequency of Obstetric Visits < 28 weeks: every month 28-36 weeks : every 2-3 weeks 36-41 weeks: once per week 41-42 weeks: every 2-3 days for fetal testing 42 weeks or more : plan for delivery  First Visit: History Biographical: age, race , occupation , marital status Obstetrical: gravidity , parity, prior labor / deliveries (vaginal / cesareans) , complications, infant status , birth weight Menstrual : Last menstrual period(LMP) ,menstrual irregularities Contraceptive use: What type and when was it last used? Medical: Asthma, diabetes , hypertension, thyroid disease, cardiac disease , medications , smoking, alcohol, recreational drugs Family history: Multiple gestations, diabetes , hypertension, bleeding disorders, hereditary disorders, mental retardation, anesthetic problems  Physical Exam: Vitals: Blood pressure (BP), weight, height, temperature, heart rate Head , neck, heart, lungs, back Pelvic: External genitalia: Bartholin’s gland, condyloma , herpes and other lesions Vagina: Discharge, inflammation Cervix: Polyps, growths Uterus: Masses, irregularities and size compared to gestational age Adnexa : Masses Clinical pelvimetry: Following are dimensions of a gynecoid pelvis shape: Pelvic inlet: Diagonal conjugate > 12.5 cm. This is the distance between the inferior border of symphysis pubis to sacral promontory Mid-pelvis: Ischial spines blunt > 10 cm Pelvic outlet : Inter-tuberous diameter > 8 cm, pubic arch > 9 cm degrees  History : Need to ask each patient the following at each subsequent visit: Presence of fetal movement Vaginal bleeding Leakage of fluid Contractions /abdominal pain Preeclampsia symptoms: - Headache -Visual disturbances -Right upper quadrant pain  Physical Exam: After thorough initial exam, each subsequent exam must record four findings: BP Urine dip for protein , glucose, leukocytes Fundal height Fetal heart rate  Fundal Height : As the fetus grows, the leading edge of the uterus or the fundus grows superiorly in the abdomen, toward the maternal head. Fundal height (in cm) roughly corresponds to gestational age ( measured in weeks) Uterus at level of pubic symphysis: 12 weeks Uterus between pubic symphysis and umbilicus : 16 weeks Uterus at the level of umbilicus : 20-22 weeks Uterine height correlates to weeks gestation : 20-36 weeks Fundal height (cm) should correlate to gestational age (weeks) ± 3. If not, consider inaccurate dating (which is the most common), or molar pregnancy. After approximately 36 weeks gestation, the fundal height may not correspond to the gestational age due to the fetal descent into the pelvis healthcare provider measures fundal height at each prenatal appointment beginning at about 20 weeks in pregnancy. This is the approximate time when fundal height and gestational age begin matching each other.  The index of symphysis-fundal height and abdominal circumference (ISFHAC) combines SFH and AC, which are used to evaluate foetal birth weight, and this index has great potential for use in predicting macrosomia in normal pregnancies (NPs) and GDM pregnancies.  When the mother is diagnosed with a medical condition that can affect the fetus, or when the fetus is diagnosed with a condition that may result in a poor outcome, several tests can be used to monitor the health of the fetus. They include fetal movement counts, non-stress test (NST), contraction stress test (CST) , biophysical profile (BPP), the modified BPP and (mBPP ), Doppler ultrasonography. In general they are performed in T3 , but may be done earlier. These taste asses for chronic uteroplacental insufficiency and cannot predict acute events. The choice and frequency of testing depends on indication, gestational age, medical condition and experience of the practitioner.  Fetal Movement Counts: Fetal movement counts or kick counts may be performed at home by the patient in order to monitor the baby’s health. The patient should select a time at which the fetus usually is active usually after a meal. The level of activity differs for each baby, and most have sleep cycles of 20-40 min. We have several ways to assess fetal movements: Ask the patient to record daily how long it takes the fetus to make 10 movements. For most, this is usually achieved in about 2hr; however this is variable Alternatively, ask the patient to record the number of fetal movements in an hour tree times per week. A baseline is established in this way For both of these strategies, a physician should be contracted if there is a change from the normal pattern or number of movements recorded  Screening for congenital abnormalities: Screening for fetal abnormalities can include testing during the first and second trimesters, and the tests can be noninvasive or invasive. Commonly used techniques maternal serum screen ultrasound amniocentesis chorionic villus sampling (CVS) cordocentesis. Ultrasound (US) Standard US performed for: Fetal number Presentation Fetal viability Gestational age assessment Amniotic fluid volume Fetal biometry Fetal anatomic survey Placental location Limited -goal-directed US: -Presentation -Placental location intrapartum -Adjust to invasive procedures -Fetal Doppler -Biophysical profile  Nutritional needs of the pregnant woman Proper nutritional habits are important for every woman; this is especially true for those who are pregnant. More energy need and specific vitamins are required by the mother to supply the appropriate nutrients essential to the normal development of the fetus. Without proper dietary control , certain common deficiencies and complications in both mother and baby may occur.  Diet The average woman must consume an additional 300 kcal/day beyond baseline needs and an additional 500 kcal/ day when breast- feeding High protein (70-5 g/day) , low simple carbohydrates and fats, high fiber More dietary folate is required to prevent NTDs. Ideal if started 3 months before pregnancy If previous child with NTD, need folic acid 4 mg/day, starting 4 weeks prior to conception and through T1  Minerals 30 mg elemental iron per day is recommended in T2 and T3. The total amount of iron needed for pregnancy is -1 g. The recommended dietary allowance (RDA) for calcium is up to 1200mg/day ( in pregnancy ) and may be met adequately with diet alone The RDA for zinc is high from 15 to 20mg/day Vegetarians Lacto-over-vegetarians in general have no nutritional deficiencies , except possibly iron and zinc Vegans must consume sufficient quantities of vegetable proteins to provide all essential amino acids that are normally found in animal protein. Supplementation of zinc, vitamin B12 and iron if necessary  Nausea and vomiting (N&V) Recurrent N&V in T1 occurs in50% of pregnancies If severe can result in dehydration, electrolyte imbalance and malnutrition Management of mild cases includes: Avoidance of fatty or spicy foods Eating small, frequent meals Inhaling peppermint oil vapors Drinking ginger teas Management of severe cases includes: IV fluids (usually with dextrose-containing fluid) Discontinuation of vitamin / mineral supplements until symptoms subside Antihistamines Promethazine Metoklopramide Intravenous droperidol Heartburn Occurs in 30% of pregnancies Etiology: Normal relaxation of lower esophageal sphincter. Mechanical forces Treatment: Elimination of spicy /acidic food Small, frequent meals Decreasing amount of liquid consumed with each meal Limiting food and liquid intake a few hours prior to bedtime Sleeping with head elevated on pillows Utilizing liquid forms of antacid and H2-receptor inhibitors Constipation Management : Increasing intake of high-fiber foods Increasing liquids Use of psyllium-containing products (Metamucil ) Avoid enemas , and laxative Varicosities particularly in lower extremities and vulva Can cause chronic pain and superficial thrombophlebities Management : Avoidance of garments that constrict at the knee and upper leg Use of support stocking Rise periods of rest with elevation of the lower extremities Hemorrhoids - Varicosities of the rectal veins are common in pregnancy Management: Cool sits baths Stoll softeners Increase fluid and fiber intake to prevent constipation Hemorrhoidal ointment to decrease swelling, itching and discomfort Topical anesthetic spray or steroid cream for the severe pain of thrombosed hemorrhoids  Leg cramps Occur in 50% of pregnant women , typically at night and in T3 Most commonly occur in the calves Massage and stretching of the affected muscle groups is recommended Backache Typically progressive in pregnancy (30-50%) Management : 1.Minimizing time standing 2.Wearing a support belt over the lower abdomen 3. Acetaminophen for pain as needed 4. Exercises to increase back strength 5.Supportive shoes and avoidance of high heels 6. Gentle back massage Sexual intercourse There are no restrictions during the normal pregnancy Nipple stimulation, vaginal penetration and orgasm may cause release of oxytocin and prostaglandins, resulting in uterine contractions Contraindications: 1.Ruptured membranes 2. Placenta previa 3. Preterm labor  Employment Work activities that raises risk of falls / trauma should be avoided Exposure to toxins / chemicals should be avoided Travel The best time to travel is in T2. Past possible complications of miscarriage in T1 and not yet encountered risk of preterm labor of T3 If prolonged sitting is involved, the patient should attempt to stretch her lower extremities and walk for 10 min. every 2 hr. This is to avoid DVTs The patient should bring copy of her medical record Wear seat belt when riding in car Airplane travel in pressurized cabin presents no additional risk to the pregnant woman (if uncomplicated pregnancy). Air travel is not recommended after 35 weeks In underdeveloped areas or when traveling abroad, the usual precautions regarding ingestion of unpurified water and raw food should be taken. Appropriate vaccines should be given  Immunizations General principles: Delay vaccines until after the first trimester to avoid potential teratogenicity Risk from vaccines is generally small. Always consider whether risk of the disease is worse than the risk of the vaccine Live vaccines are not given in pregnancy Viral vaccines may be safely given to the children of pregnant women Immune globulins are safe in pregnancy and are recommended for women exposed to measles, hepatitis A and B, tetanus, varicella (chickenpox) and rabies  While many physiologic changes in pregnancy are uncomfortable , most are nonemergent. There are , however some situations when a pregnant woman should contact her obstetrician immediately : Vaginal bleeding Leakage of fluid from the vagina Rhythmic abdominal cramping or back pain more than 6 hour that does not improve with hydration and lying supine Progressive and prolonged abdominal pain Fever and chills Dysuria or abnormally cloudy urine (indicative of a urinary tract infection ) Prolonged vomiting with inability to hold down liquids or solids for more than 24 hr. Progressive , severe headache, visual changes or generalized edema (preeclamptic symptoms) Seizure (eclampsia) Pronounced decrease in frequency or intensity of fetal movements  The puerperium The puerperium (postpartum) is the period of confinement between birth and 6 weeks after delivery. During this time the reproductive tract returns anatomically to a normal nonpregnant state.  Uterus Involution of the Uterine Corpus : Immediately after delivery, the fundus of the contracted uterus is slightly below the umbilicus. After the first 2 days postpartum , the uterus begins to shrink in size. Within weeks, the uterus has descended into the cavity of the true pelvis. The contraction of the uterus immediately after delivery is critical for the achievement of hemostasis. “Afterpains” due to uterine contraction are common and may require analgesia. They typically decreases in intensity by the third postpartum day. Within 2-3 days postpartum, the remaining deciduas becomes differentiated into two layers: superficial layer becomes necrotic, sloughs off as vaginal discharge = lochia Basal layer (adjacent to the myometrium) becomes new endometrium Type Description When Observed Lochia rubra Red due to blood in the Days 1-3 lochia Lochia serosa More pale in color Days 4-10 Lochia alba White to yellow-white due day 11 and more to leukocytes and reduced fluid content Changes in Uterine Vessels Large blood vessels are obliterated by hyaline changes and replaced by new , smaller vessels Cervix The external os of the cervix contracts slowly and has narrowed by the end of the first week. The multiparous cervix takes on a characteristic fish mouth appearance As a result of childbirth , the cervical epithelium undergoes much remodeling. Approximately 50% of women with high- grade cervical dysplasia will show regression after a vaginal delivery due to the remodeling of the cervix Vagina Gradually diminishes in size, but rarely returns to nulliparous dimensions: Rugae reappear by the third week The rugae become obliterated after repeated childbirth and menopause Peritoneum and Abdominal Wall The broad ligament and round ligament slowly relax to the nonpregnant state The abdominal wall is soft and flabby due to the prolonged distention and rupture of the skin’s elastic fibers; it resumes pre-pregnancy appearance in several weeks. However the silver striae persist Urinary Tract The puerperal bladder has an increased capacity and is relatively insensitive to intravesical fluid pressure. Hence, over distention , incomplete bladder emptying and excessive residual urine are common and can result in a urinary tract infection (UTI) Between day 2 and 5 postpartum , “puerperal dieresis” typically occurs to reverse the rise in extracellular water associated with normal pregnancy Dilated renal pelves return to their pre-pregnant state 2-8 weeks postpartum  Hematology /Circulation Leukocytosis occurs during and after labor(up to 30.000 /µL) During the first few postpartum days, the hemoglobin and hematocrit fluctuate moderately from levels just prior to labor Plasma fibrinogen and erythrocyte sedimentation rate may remain elevated for ≥ 48 hours postpartum due to low blood flow to the uterus (much smaller) and increased systemic intravascular volume By 1 week postpartum, the blood volume has returned to the patient’s non-pregnant range Body Weight Most women approach their pre-pregnancy weight 6 month after delivery but still retain approximately 1.4 kg of excess weight  Routine postpartum care Immediately after labor : First hour Take blood pressure (BP) and heart rate (HR) at least every 15 min Monitor the amount of vaginal bleeding Palpate the fundus to ensure adequate contraction. If the uterus is relaxed, it should be massaged through the abdominal wall until it remains contracted. Massaging the uterus leads to increased release of oxytocin which helps promote uterine contraction First Several Hours Early Ambulation Women are out of bed (OOB) within a few hours after delivery. Advantages include: Reduced frequency of puerperal venous thrombosis and pulmonary embolism Low bladder complications Less frequent constipation Care of the Vulva The patient should be taught to cleanse and wipe the vulva from front to back (toward the anus)  If Episiotomy / Laceration Repair An ice pack should be applied for the first several hours to reduce edema and pain At 24 hr postpartum, moist heat (eg, via warm sitz baths) can decrease local discomfort The episiotomy incision is typically well healed and asymptomatic by week 3 of the puerperium Bladder Function Ensure that the postpartum woman has voided within 4-6 hr of delivery. If not: This indicates further voiding trouble to follow An indwelling catheter may be necessary Bladder sensation and capability to empty may be diminished due to anesthesia Consider a hematoma of the genital tract as a possible etiology The First Few Days Bowel Function Lack of a bowel movement may be due to a cleansing enema administered prior to delivery. Encourage early ambulation and feeding to decrease the possibility of constipation. Ask the patient about flatus If Fourth-Degree Laceration Fecal incontinence may result, even with correct surgical repair, due to injury to the innervations of the pelvic floor musculature. Keep the patient on a stool softener and a low residue diet to avoid straining and decrease risk of fistula formation. Avoid enemas or suppositories which can disrupt the repair  Discomfort /Pain Management During the first few days of the puerperium, pain may result from : After pains: Contractions of the uterus as it involutes. Treat with non-steroidal anti-inflammatory drugs (NSAIDs) Episiotomy /laceration pain: May require a narcotic medication, but NSAIDs or plain acetaminophen can help Breast engorgement: Well-fitted with bras, NSAIDs Post spinal puncture headache : Positional headache that is worse when upright improved when lying down. Caffeine may help. Occasionally , patient may need a blood patch (performed by an anesthesiologist) Constipation: Treat with stool softeners over 2-3 weeks. May discontinue iron supplementation because it may cause constipation Urinary retention: May need intermittent bladder catheterizations. Evaluate the patient for causes and treat accordingly Abdominal Wall Relaxation Exercise may be initiated any time after vaginal delivery and after abdominal discomfort has diminished after cesarean delivery Diet There are no dietary restrictions /requirement for women who have delivered virginally. Two hours postpartum, the mother should be permitted to eat and drink. Those with an uncomplicated CD can be given clear liquids and regular diet as tolerated Continue iron supplementation for a minimum of 3 month postpartum  Pelvic infection Pelvic infection are asending infections.The bacteria responsible for pelvic infections are those that normally reside in the bowel and colonize the perineum,vagina and cervix. Risk Factors Prolonged rupture of membranes > 18 hr Prolonged second stage Cesarean delivery /uterine manipulation Colonization of the lower genital tract with certain microorganisms (ie, group B streptococci [GBS], C trachomatis, M hominis, and Gardnerella vaginalis) Premature labor Frequent vaginal exams Foreign body Diabetes Diagnosis Fever > 100.4ºF (38 º C) Soft , tender uterus Lochia has a foul odor Leukocytosis (WBC > 10.000 /µL), (remember physiologi leukosytosis; look for trends) Identify source of infection (urinalysis , culture of lochia) Management Broad-spectrum antibiotics Types of Postpartum infections Endometritis (Metritis, Endomyometirtis) A postpartum uterine infecton involving the deciduas , myometrim, and parametrial tissue More common after cesarean delivery than vaginal delivery. Hypoxic tissue and foreign body (suture) with cesarean delivery are ideal for infections Typically develops postpartum day 2-3 treat with IV antibiotics until patient is afebrile for 24-48 hr GBS colonization increases risk of endometritis  Urinary Tract Infection Caused by catheterization , birth trauma, conduction anesthesia, and frequent pelvic examinations Presents with dysuria, frequency, urgency and low-grade fever Rule out pyelonephritis (cost vertebral angle tenderness, pyuria, hematuria) Obtain a urinalysis and urinary culture (E coli is isolated in 75% of postpartum women) Treat with appropriate antibiotics  surgical site infection - Superficial SSI: Involves skin and subcutaneous tissue -Deep SSI: Involves fascia and muscle Diagnosis: Fever, wound erythema and persistent tenderness, purulent drainage Management : Obtain Gram stain and cultures from wound material Wound should be drained, irrigated and debrided Antibiotics should be given along with : 1. Superficial SSI: Wet-to-dry packing placed. Consider closure of incision when wound healthy 2. Deep SSI: May need debridement in the operating room under anesthesia. Consider necrotizing fasciitis Episiotomy Infection Look for pain at the episiotomy site, disruption of the wound, and a necrotic membrane over the wound Rule out the presence of a rectovaginal fistula with a careful rectovaginal exam Open , clean and debride the wound to promote granulation tissue formation Sitz baths are recommended Reassess for possible closure after granulation tissue has appeared Discharge from hospital Vaginal Delivery One to two days postdelivery, if no complications. Return to the office at 4-6 weeks for postpartum exam Cesarean Delivery Two or three days postdelivery if no compilations. Return to the office in 2 weeks to check the incision and 4-6 weeks for postpartum exam Discharge Instructions The patient should call the doctor or go to hospital if she develops: Fever > 100.4 F (37 Celsius ) Excessive vaginal bleeding - soaking a pad an hour. Suspicious for retained placenta Lower extremity pain and /or swelling. Suspicious for DVT Shortness of breath: Suspicious for pulmonary embolus (PE) Chest pain Coitus in Postpartum After 6 weeks , coitus may be resumed based on patient’s desire and comfort. A vaginal lubricant prior to coitus may improve comfort Dangers of premature intercourse : 1. Pain due to continued uterine involution and healing of lacerations / episiotomy scars raised likelihood of hemorrhage and infection Do not wait until first menses to begin contraception; ovulation may come before first menses Contraception is essential after the first menses unless a subsequent pregnancy is desired Lactational Amenorrhea Method of Contraception Lactational amenorrhea involves exclusive breast-feeding to prevent ovulation. It can be used as a contraceptive method. It is 98% effective for up to 6 months if: The mother is not menstruating The mother is nursing >2-3 times per night, and more than every 4 hr. during the day without other supplementation The baby is milk 2. Fat: Milk > coloctrum 3. Carbs: Milk > colostrums Colostrum is gradually converted to mature milk by 4 weeks postpartum. Subsequent lactation is primarily controlled by the repetitive stimulus of nursing and the presence of prolactin  Benefits Uterine involution: Nursing accelerates uterine involution (increases oxytocin) Immunity : Colostrum and breast milk contain secretory lgA antibodies against Escherichia coli and other potential infection Milk contains memory T cells, which allows the fetus to benefit from maternal immunologic experience Colostrum contains interleukin-6, which stimulates and rising in breast milk mononuclear cells Nutrients: All proteins are absorbed by babies and all essential and nonessential amino acids available Gastrointestinal (GI) maturation: Milk contains epidermal growth factor, which may promote growth and maturation of the intestinal mucosa  Breast engorgement is common on days 2-4 postpartum: 1. Often painful 2.Often accompanied by transient temperature elevation 3. Often present in non-breast-feeding women Suckling stimulates the neurohypophysis to secrete oxytocin in pulsatile fashion, causing contraction of myopethelial cells and small milk ducts, which leads to milk expression. Women who do not want to breast-feed should wear a well-fitting brassiere, breast binder, or “sport bra”. Pharmacologic therapy with bromocriptine is not recommended due to its associations with strokes, myocardial infarction, seizures and psychiatric disturbances.  Breast Fever Breast engorgement is a result of milk collecting in the breast. Occurs within 2-4 days of delivery. Seldom persists for > 24 hrs Presents with bilateral painful , firm, globally swollen breasts Rule out other causes of postpartum fever Treat with supportive bra, 24 hr. demand feedings, ice packs Mastitis is an infection of the breast. It affects 1-2% of postpartum women. Approximately 10 % of women with mastitis develop breast abscess 1. Caused by: - Staphylococcus aureus from the infant’s nasopharunx (40%). More likely to cause an abscess - Staphylococcus coagulase negative , Streptococcus viridians (60%) 2. Presents approximately 4 weeks postpartum with fever , chills 3. Focal area of erythema and induration. No fluctuance 4. Culture milk to identify the organism 5. Treat with antib. for 7-10 days. Continue breast-feeding. Resolves Mastitis  Contraindications to Breast-Feeding Mothers with the following infections: HIV infection Breast lesions from active herpes simplex virus Tuberculosis (active , untreated ) Breast- feeding not contraindicated : Cytomegalovirus (CMV): Both the virus and antibodies are present in breast milk Hepatitis B virus (HBV): If the infant receives hepatitis B immune globulin Hepatitis C: 4% risk of transmission same for breast- and bottle -fed infants  Medications: Mothers ingesting the following contraindicated medications (not an exhaustive list): -Bromocriptine -Cyclophosphamide -Cyclosporine - Doxorubicin -Ergotamine -Lithium -Methotrexate -Extrogen-containing oral contraceptives (OCPs)  Drug abuse: Mothers who abuse the following drugs should not breast-feed: Amphetamines Cocaine Heroine Marijuana Nicotine Phencyclidine Ethanol Radiotherapy : Mothers undergoing radiotherapy with the following should not breast-feed: -Gallium -Indium -Iodine -Radiocative sodium - Technetium  Postpartum psychiatric disorders Maternity /Postpartum Blues A self-limited , mild mood disturbance due to biochemical factors and psychological stress: Affects 50% of women Begins within 3-6 days after parturition May persist for up to 10 days May be related to progesterone withdrawal Sympotms : Similar to depression but milder  Treatment: Supportive-acknowledgment of the mother’s feelings and reassurance Monitor for the development of more severe symptoms (ie, postpartum depression or psychosis) Postpartum Depression Similar to minor and major depression that can occur at any time: Classified as “postpartum depression “ if it begins within 3-6 months after childbirth Eight to fifteen percent of postpartum women develop postpartum depression within 2-3 months Up to 70 % recurrence Symptoms: are the same as major depression  Natural Course : Gradual improvement over the 6-month postpartum period The mother may remain symptomatic for months to years Treatment -Pharmacologic intervention is typically required : 1. Antidepressants 2.Anxiolytic agents 3. Electroconvulsive therapy - Mother should be comanaged with a psychiatrist (ie, for psychotherapy to focus on any maternal fears or concerns ) Treatment -Pharmacologic intervention is typically required : 1. Antidepressants 2.Anxiolytic agents 3. Electroconvulsive therapy -  Mother should be comanaged with a psychiatrist (ie, for psychotherapy to focus on any maternal fears or concerns ) Course - Variable and depends on the type of underlying illness; often 6 months Treatment : Psychiatric care Pharmacologic therapy Hospitalization (in most cases) Postpartum thyroid dysfunction Postpartum thyroiditis is a transient lymphocytic thyroiditis in 5-10% of women during the first year after childbirth. The two clinical phases of postpartum thyroiditis are thyrotosicosis and hypothyroidism. Thank you Questions ??