postpartum and lactation

Question 1

postpartum is traditionally defined as…

Answer 1

the first 6 weeks post-birth

Question 2

early postpartum normal vs abnormal
-mood
-temperature
-pulse

Answer 2

NORMAL: tired but happy, Temp between 98.6-100.4, pulse 65-80, RR 12-16, between 90/60 - 140/90, nipples may be sore from nursing but not painful, diastasis recti expected; MILD urinary burning/retention/incontinence common in first 2 days; perineum mildly swollen and bruised, lochia decreasing each day

ABNORMAL: unhappy, dissatisfied, temp > 100.4, pulse > 80, RR < 12 (narcotic overuse, atelectasis, pneumonia), RR > 16 (anxiety, pain) , less than 90/60 evaluate for hypotension causes (blood loss, medication reaction), if > 140/90 evaluate for pp hypertensive disorder, palpitations/chest pain, SOB, painful/cracked/bleeding nipples, BMs return 2-3 days postpartum, N/V, distended abdomen, constipated, dysuria, distended bladder; malodorous lochia, presence of hematoma, deep blue or purple hemorrhoid; unilateral leg pain/calf tenderness

Question 3

T/F there is a transient increase in BP of as much as 5% in the first 4 days after delivery

Answer 3

TRUE

Question 4

when are nipples/breast experiencing the most fullness/filling

Answer 4

3-5 days after delivery

Question 5

Fundus in the postpartum period should be…

Answer 5

firm and midline

Question 6

uterus involution process
-3 steps

Answer 6

-the uterus is returning to the pre-pregnant state!
1. contraction of the uterus
2. autolysis of myometrial cells
3. regeneration of the epithelium

**results from reduction in cell SIZE, not reduction in cell number

Question 7

location of uterus is determined with respect to umbilicus
-descends about ____ cm per day
-“fundus at U-1” denotes…
-immediately after delivery, the uterus contracts to the size of a _____ and is located….. but then 12 hours postdelivery the fundus is located at…

Answer 7

-1 cm per day
-that the fundus is 1 cm below the umbilicus
-should always be midline
-grapefruit; immediately after delivery fundus is located halfway between umbilicus and symphysis pubis but then 12 hours postdelivery is at the level of the umbilicus

Question 8

a fundus that is displaced to the side may indicate…

Answer 8

a distended bladder or sub-involution

Question 9

by two weeks the fundus is…

Answer 9

no longer palpated abdominally

Question 10

by 6 weeks, the fundus…

Answer 10

returns to slightly larger than pre-pregnant size

Question 11

Lochia
-three stages: rubra, serosa, alba
-what days pp? what is the color? d/c make up?

Answer 11

-the breakdown of myometrial placental bed, eschar, and decidual cells

1. RUBRA: first 3-7 days; red or red brown with fleshy odor; d/c contains superficial layer of decidua that has sloughed off the uterus
2. SEROSA: from day 14 to 21 pp, pinkish-brown color; serous to serosanguinous secretion; d/c contains blood, cervical mucus, erythrocytes, leukocytes, decidual tissue
3. ALBA: until cessation of flow in about 4-6 weeks pp; yellowish to white discharge, flow increases with additional activity initially bu decreases progressively over the puerperium

Question 12

the cervix
-immediately pp
-by day 7:
-by 4 weeks
-in multiparous

Answer 12

-immediately pp: edematous, dilated 3-4 cm and bruised; may have lacerations
-by day 7: dilation down to 1 cm
-by 4 weeks: cervix no longer dilated
-in multiparous: never returns to pre pregnant appearance; somewhat wider with transverse opening, “fish mouth”

Question 13

vagina
-by 3-4 weeks
-by 6-10 weeks pp

Answer 13

3-4 weeks: rugae returns, edema vascularity and bruising decrease

6-10 weeks: vaginal epithelium returns

**in pp period there is decreased lubrication, can lead to painful intercourse (Esp in lactating women)

Question 14

when should perineum skin appear well healed?

Answer 14

by day 7 with only linear scarring at 6 weeks and ALWAYS well approximated

Question 15

how many hours after birth does engorgement occur?

Answer 15

72 hours/3 days
-milk production starts in upper-outer glands, filling then occurs medially and inferiorly
-distention and stasis of vascular and lymphatic circulation cause engorgement as the ducts, lobules, alveoli fill with milk

Question 15

“let down reflex” or milk ejection reflex develops within…

Answer 15

the first 1-2 weeks

Question 15

how much does cardiac output increase within first couple hours post-delivery

Answer 15

60-80%

Question 15

over first 48 hours, as diuresis occurs, plasma volume decreases, causing cardiac output to normalize within

Answer 15

2 weeks

Question 16

renal system changes in the pp period
-diuresis
-bladder tone

Answer 16

-diuresis occurs within first 5 days
-bladder can be hypotonic and edematous immediately after birth; resolves within 24 hours

Question 17

caloric intake should be at least….

Answer 17

1800 kcal/day

Question 18

recommended weight loss after first month post-delivery is

Answer 18

4.5 lb/month

Question 19

ALT and AST levels return to pre pregnant values within

Answer 19

2 weeks

Question 20

T/F diastasis recti is found in 75-80% of women

Answer 20

TRUE!
these women are at risk for back pain in future pregnancies; striae also common

Question 21

breastfeeding women
-resumption of menses variable… but generally:
1. ovulation returns ____ days after weaning
2. first menses
3. mean time to ovulation

Answer 21

-lactation secretes prolactin and oxytocin; prolactin suppresses estrogen halting menstruation and ovulation

1. ovulation returns 14-30 days after weaning
2. first menses 14 days later
3. mean time to ovulation is 190 days

Question 22

NON breastfeeding women -prolactin levels -hormonal shifts stimulate ovulation how many weeks pp? -first menses within how many weeks pp?

Answer 22

-prolactin levels fall -hormonal shifts stimulate ovulation to begin about 3-4 weeks pp -first period 6-8 weeks pp; 70% by 12 weeks

Question 23

what should Rh women be screened with in the pp period?

Answer 23

the Kleihauer-Betke screen (tests for fetal blood in maternal circulation)

Question 24

Immunizations in the PP period 1. RhoGAM 2. Rubella 3. Varicella 4. Influenza 5. HPV 6. Tdap

Answer 24

1. RhoGAM: give within 72 hours of birth if mother Rh status is negative and infant is + 2. Rubella: offer prior to d/c if nonimmune 3. Varicella: offer prior to d/c with second dose given 6-8 weeks after; PP patients should be counseled to avoid pregnancy for 4 weeks after last dose (at second pp visit) 4. Influenza: offer 5. HPV: women ages 9-26 who have not completer primary series should receive three doses at 0, 2, 6 months; if series started prior to pregnancy, series can be completed pp without repeating the initial dose HPV vaccines SHOULD be given to breastfeeding women 26 years and younger who have not previously been vaccinated 6. Tdap: offer if did not receive in pregnancy

Question 25

Postpartal discomforts -involution pain (increases with...(2)) ^non pharm relief

Answer 25

-likely to increase with each subsequent birth -increases with lactation NON pharm: empty badder and bowels, change positions, apply heat Pharm: acetaminophen, ibuprofen

Question 26

Breast engorgement (for breastfeeding individuals) -education on how to avoid this

Answer 26

-breastfeed early and often, correct positioning, proper latch -express small amount of milk manually before each feeding to soften areola -breast pump also works, but avoid excessive pumping (increases breastmilk production/worsens engorgement) -supportive bra -warm compress or warm shower right before feeding

Question 27

breast engorgement advice for moms that are bottle feeding

Answer 27

tight bra, ice packs, analgesics, cold cabbage leaves

Question 28

perineal pain should be evaluated by REEDA -treatments?

Answer 28

Redness Edema Ecchymosis Discharge Approximation Topical meds/treatments -witch hazel pads -dibucain, benzocaine -ice packs first 24 hours, size baths after 24 hours -topical anesthetics

Question 29

risk factors for constipation

Answer 29

1. lack of ambulation in labor and pp 2. decreased intestinal peristalsis r/t anesthesia 3. narcotic use for pain relief -increase fluids, fiber, stool softener, ambulate, laxatives as needed

Question 30

bonding theory states that...

Answer 30

to achieve optimal development outcomes, a "sensitive period" of bonding between mother and infant should be allowed in the immediate postpartum period; this sensitive period means close contact is necessary and avoidance of separation is goal early skin to skin contact at birth or some after promotes this^^

Question 31

postpartum blues vs postpartum depression -time frame -incidence -s/sx

Answer 31

1. pp blues -80% affected -begins 3-5 days pp -vary labile emotions (giddiness, sadness, crying) -generally time-limited over 1-2 weeks -supportive, sensitive care is usually all thats required 2. pp depression -6-12% affected -DSM 5 defines as major depressive disorder: with peripartum onset if onset of mood symptoms occurs during pregnancy or within 4 weeks following delivery -clinical practice: occurring anytime within 4 weeks after childbirth or 3, 6, 12 months after childbirth

Question 32

risk factors for pp depression include...

Answer 32

-hx of mood or anxiety problems, particularly untreated depression and anxiety during pregnancy -likely rapid decline and shift of hormones in postpartum period -genetic -social factors: IPV, prior abuse, lack of social support, negative life events

Question 33

symptoms -onset

Answer 33

-onset around 4-6 weeks pp; generally worsen over time SX: -sleep disturbance -feeling overwhelmed -anxiety -irritability -unable to perform activities of daily living -obsession with infants health -suicidal thoughts

Question 34

screening for postpartum depression

Answer 34

-ALL PREGNANT WOMEN -Edinburgh Postnatal Depression Scale (EPDS) -r/o other causes: pp thyroiditis, anemia, infection, sleep deprivation

Question 35

diagnostic criteria of pp depression according to the DSM-5

Answer 35

1. at least on of the following: -depressed mood -loss of interest in or pleasure 2. in addition, 4 or more of the following: -depressed mood most of the day, nearly every day -marked diminished interest or pleasure in all or almost all activities -significant unintentional weight loss or decrease or increase in appetite -insomnia or hypersomnia -psychomotor agitation or retardation -fatigue or loss of energy -feelings of worthlessness or excessive or inappropriate guilt -diminished ability to think or concentrate -suicidal ideation, with or without plan for committing suicide

Question 36

pharm interventions for depression

Answer 36

1. SSRIs ^most pass into breastmilk but usually compatible with breastfeeding babies 2. severe depression: benzodiazepine agents

Question 37

postpartum psychosis symptoms -management includes

Answer 37

a. disorganized thinking, bizarre behavior and speech b. hallucinations with auditory or visual perceptual disturbances c. delusions PSYCH EMERGENCY- usually requires hospitalization

Question 38

b. return to SA

Answer 38

-complete pelvic rest is recommended until 4-6 weeks pp -but 50% usually have resumed sexual activity by 6 week postpartum visit

Question 39

c. hyper coagulable state

Answer 39

-pp patients continue to be in a state of hypercoagulability for 3-4 weeks after birth as part of a physiologic adaptive mechanism to prevent pp hemorrhage -estrogen containing contraceptive methods should be AVOIDED

Question 40

d. lactation status

Answer 40

COCs should be avoided at least the first 21 days

Question 41

what is the only contraception available to women immediately after delivery of the placenta?

Answer 41

copper IUD!! LNG-IUD can be inserted too BUT risk of perforation is higher both totally fine to insert after 4 weeks pp (typically we insert around 6 weeks pp)

Question 42

Postpartum breastfeeding patient contraception a. < 21 days postpartum

Answer 42

a. don't recommend anything

Question 43

how many weeks pp should we initiate contraception in the pp BREASTFEEDING patient? what kind of contraception is best?

Answer 43

between 30-42 days (about 6 weeks; initiate around 6 week pp visit) -Nexplanon, DMPA, POP all great options! just want to avoid CHC because estrogen will limit the milk supply

Question 44

postpartum contraception in the non breastfeeding client -initiate at -options

Answer 44

-should wait at least three week, 42 days (6 weeks) is best -Nexplanon, DMPA, IUD, POP, CHC

Question 45

T/F you must wait until involution to use cervical cap/diaphragm for barrier emethod

Answer 45

true!

Question 46

T/F male and female condoms may be used immediately

Answer 46

true

Question 47

lactation amenorrhea method

Answer 47

a. full or nearly full breastfeeding: -feeding an avg of 4 hours during the day -feeding an avg of every 6 hours at night -has not substituted solid foods for breastfeeding for any meals b. infant less than 6 months old c. no menses d. choose alternative method if woman and infant do not fit all three criteria

Question 48

what postpartum patient MUST be followed up on in 1-2 weeks after being discharged from hospital following delivery??

Answer 48

any high risk patient (hypertensive patients, GDM)

Question 49

follow up for GDM patients in the postpartum period

Answer 49

fasting 2-hour, 75 gram OGTT

Question 50

follow up for hypertension (pregestational or gestational)

Answer 50

-follow up with primary care! -for severe hypertensive status, referral to cardiology

Question 51

separated symphysis pubis referral

Answer 51

1. physical therapy 2. occupational therapy

Question 52

anticipatory guidance -vaginal bleeding -lochia -menses return

Answer 52

1. lochia: at 4-6 weeks, may continue to have scant amount of lochia (alba) but typically resolved by this time 2. resumption for menses -non breastfeeding women: 4-6 weeks pp -breastfeeding women: depends when baby weans

Question 53

T/F vaginal dryness during lactation may contribute to dyspareunia

Answer 53

TRUE

Question 54

Postpartum Complications 1. urinary retention -diagnosis (s/sx) -risk factors -complications -management

Answer 54

a. inability to void spontaneously within 6-8 hours after birth or removal of urinary catheter (post-residual void > 150 ml), palpable bladder, fundus displaced b. risk factors: epidural, operative vaginal delivery, episiotomy, LGA baby c. complications: UTI, bladder dysfunction d. MNGMNT -intermittent cath

Question 55

Postpartum Complications 2. postpartum fever and infection -definition -differential diagnoses -s/sx

Answer 55

-> 100.4 x 2 during pp days 2-10 differentials: endometritis, wound infection, UTI s/sx: flu-like, tachycardia, abdominal pain, malodorous lochia

Question 56

risk factors for endometritis Gold standard tx??

Answer 56

1. prolonged rupture of membrane 2. prolonged labor 3. multiple cervical exam 4. cesarean section 5. chorioamnionitis TX: clindamycin and gentamicin Vancomycin only added if Staph aureus suspected

Question 57

risk factors for abdominal infection

Answer 57

-obesity (think about skin folds) -diabetes (think about sugar) -corticosteroid therapy -immunosuppression -anemia

Question 58

T/F postpartum hemorrhage is the leading cause of maternal mortality worldwide

Answer 58

TRUE

Question 59

ACOG definition of pp hemorrhage vs traditional definition

Answer 59

estimated blood loss of 1000 ml regardless of route of delivery blood loss accompanied by s/sx of hypovolemia within 24 hours after birth TRADITIONAL a. EBL of 500 ml after vaginal delivery b. EBL of 1000 ml after c/s

Question 60

risk factors of pp hemorrhage

Answer 60

1. prolonged labor/prolonged use of oxytocin 2. chorioamnionitis 3. high parity 4. twins, multiple gestation 5. polyhydramnios 6. macrosomia 7. operative vaginal delivery

Question 61

Etiology of pp hemorrage a. primary/#1 cause -other causes?

Answer 61

1. UTERINE ATONY -soft, boggy uterus (accounts for 70-80%) -MNGMNT: empty bladder, bimanual exam, MASSAGE THE FUNDUS, uterotonics 2. obstetric trauma -identify source of bleeding and manage it 3. lacerations 4. retained placenta*** -visually inspect the placenta!! 5. placenta accreta 6. coagulation defects 7. inversion of the uterus

Question 62

Lactation 1. cooper's ligaments 2. milk ducts 3. basic glandular unit 4. nipples and areola 5. montgomery tubercles

Answer 62

1. cooper's ligaments: support shape of breasts 2. milk ducts: each contains 4-18 primary milk ducts that converge at the nipple 3. basic glandular unit: contains 4-18 lobules, each containing alveoli for milk ejection 4. nipples and areola: become darker during pregnancy 5. montgomery tubercles: located IN areola; sebaceous glands that provide protective secretion and lubrication to the nipple

Question 63

physiology of lactation 1. mammary changes during pregnancy 2. lactogenesis I 3. lactogenesis II 4. lactogenesis IV

Answer 63

1. mammary changes during pregnancy 2. lactogenesis I -early pregnancy to third day postpartum -dependent on HORMONAL changes -secretion of small amounts of colostrum: high concentrations of immunoglobulins, oligosaccharides -approx. 100 ml of breastmilk produced on pp day 1 3. lactogenesis II -days 2-4 postpartum -second stage initiated by: delivery of placenta, decrease in progestin, increase in prolactin -VOLUME: increases; no approx. 500 mL on day 4 pp, COPIOUS milk production, "milk coming in" 4. lactogenesis IV -begins between 7-14 days pp -mature milk established -maintenance of milk supply depends on supply-demand relationship (frequent milk transfer --> suckling stimulated nipple --> sends message to hypothalamus to secrete prolactin and oxytocin --> prolactin stimulates milk production) --> oxytocin is the hormone responsible for stimulating contraction of myoepithelial cells; the contraction of cells causes milk ejection aka "the let-down reflex"

Question 64

what is responsible for milk ejection/the let down reflex

Answer 64

OXYTOCIN

Question 65

what is responsible for stimulating milk production

Answer 65

PRO lactin!

Question 66

contraindications to breastfeeding -infections, drugs, specific medications

Answer 66

a. maternal infections: 1. HIV 2. Herpes. active lesions on nipple and breasts 3. flu 4. untreated TB 5. varicella infection developed 5 days prior to birth to 2 days after birth b. illicit drug use c. specific medications 1. antiretrovirals (again, HIV) 2. anticonvulsants (valproate) 3. chemotherapy agents 4. radiation therapy 5. retinoids 6. statins

Question 67

breast engorgement prevention

Answer 67

a. proper position and attachment b. emptying one breast at each feeding c. alternating which breast is offered first d. frequent milk transfer

Question 68

treatment of breast engorgement

Answer 68

-acupuncture, warm compress PRIOR to feeding, cold packs after, breast massage, hand expression, cabbage leaves

Question 69

T/F there is no scientific evidence for effectiveness and safety herbal products, foods and beverages used as galactagogues

Answer 69

TRUE includes: Fenugreek, Goat's rue, milk thistle, dandelion, seaweed

Question 70

pharm galactagogues a. Domperidone 2. Metoclopramide -warnings??

Answer 70

a. domperidone: increases QT interval and implicated in ventricular arrhythmias and sudden cardiac death b. Metoclopramide: CNS effects like sedation, depression, extrapyramidal symptoms

Question 71

mastitis -incidence -s/sx

Answer 71

-1 in 5 -erythematous, edematous, wedge-shaped area in the breast, typically UNILATERAL -fever > 101.3 -flu like symptoms

Question 72

risk factors for mastitis

Answer 72

-damaged nipples -infrequent feedings -ineffective milk transfer and removal -poor latch -oversupply of milk -bra that is too tight -previous mastitis

Question 73

treatment of mastitis a. analgesia b. antibiotics

Answer 73

a. analgesia i. NSAIDS like ibuprofen to help reduce inflammation b. antibiotics: i. Docloxacillin or flucloxacillin 500 mg PO QID x 10-14 days ii. Cephalexin (Keflex) 500 mg QID x 10-14 days iii. if penicillin allergic, clindamycin: 300 mg QID or 500 mg QID x 10-14 days symptoms typically resolves within 48 hours of antibiotic initiation

Question 74

breast abscess -the most likely infecting organism?

Answer 74

S. aureus

Question 75

management of breast abscess

Answer 75

surgical drainage, needle aspiration, antibiotics

Question 76

Raynaud's phenomenon is where...

Answer 76

there's a vasospasm of the nipple after breastfeeding or when the nipples are exposed to cool air nipple color changes to purple or blanches severe pain; sharp, burning sensation

Question 77

Fungal infection -s/sx in infant -clinical manifestations

Answer 77

-s/sx in infant: may have signs of thrush or diaper rash -manifestations: shiny, red nipple, flaky skin around the nipple, burning, itching, stabbing pain like "shards of glass" in the breasts

Question 78

treatment of fungal infection on breasts include

Answer 78

i. topical nystatin, miconazole, clotrimazole ii. Gentian violent 1% in 10% alcohol applied to nipple x 4 days iii. APNO (Dr. Newman's formula)