Postpartum Care

Question 1

What is endometritis?

Answer 1

an inflammation of the endometrium, which is the inner lining of the uterus
-most common cause of infection after childbirth

Question 2

What is endometritis caused by?

Answer 2

by an infection of the endometrium from bacteria that normally live in the female lower genital tract, but it could also be caused by bacteria from outside the body

Question 3

When can endometritis happen?

Answer 3

during childbirth, gynecologic procedures , and due to the presence of an intrauterine contraceptive device
-other cases of endometritis are due to sexually transmitted infections, typically due to Chlamydia trachomatis and Neisseria gonorrhoeae

Question 4

What are the characteristics of endometritis?

Answer 4

can be acute or chronic
-people with acute endometritis are more likely to have symptoms, whereas many of those with choleric endometritis are asymptomatic

Question 5

What are the symptoms of endometritis?

Answer 5

include fever, lower abdominal pain, and abnormal vaginal bleeding or discharge

Question 6

What are the risks of endometritis?

Answer 6

C-section, PROM, vaginal delivery, D&C, pelvic exams

Question 7

What are the complications of endometritis?

Answer 7

including the spread of the bacterial infection from the endometrium to the underlying myometrium, where it’s called endometritis, or to the peritoneum causing peritonitis

• the infection can also spread to the fallopian tubes, causing salpingitis, or to the ovaries causing oophoritis
• one potential complication of chronic endometritis, especially when it’s caused by tuberculosis, is Asherman syndrome, also known as intrauterine adhesions

Question 8

How is endometritis dx?

Answer 8

the diagnosis of endometritis is usually based on clinical findings

• however, an endometrial biopsy can help make the diagnosis, although its not routinely done
• on histology, acute endometritis has neutrophils in the endometrium, while in chronic endometritis, the presence of plasma cells in the endometrium is diagnostic

Question 9

What are the clinical findings of endometritis?

Answer 9

• fever, tachycardia
• possible vaginal bleed (foul-smell)
• abdominal pain and uterine tenderness
• 2-3 days post C-section, postabortal

Question 10

What is the tx of endometritis?

Answer 10

treatment of endometritis involves the use of antibiotics

• for endometritis that occur after childbirth, a combination of clindamycin and gentamicin is used
• if endometritis is caused by remaining placental or fetal tissues, dilation and curettage is done
• for endometritis cause by Chlamydia trachomatis or Neisseria gonorrhoeae, a combination of doxycycline and ceftriaxone is used to treat the infection
• finally, if endometritis is caused by tuberculosis, the treatment will include the use of anti-tuberculosis drugs such as isoniazid, rifampin, pyrazinamide, and ethambutol

Question 11

How long does the puerperium or postpartum period last?

Answer 11

generally lasts 6 weeks and is the period of adjustment after delivery when the anatomic and physiologic changes of pregnancy are reversed, and the body returns to normal, non pregnancy state

Question 12

What is immediate puerperium?

Answer 12

first 24 hours after parturition when acute post anesthetic or post-delivery complications may occur

Question 13

What is early puerperium?

Answer 13

extends until the first week postpartum

Question 14

What is remote puerperium?

Answer 14

includes the period of time required for involution of the genital organs and return of menses, usually approximately 6 weeks

Question 15

What is normal during puerperium?

Answer 15

anatomic and physiologic changes

Question 16

What are the characteristics of uterine involution?

Answer 16

at the end of the first postpartum week, it normally will have decreased to the size of a 12-week gestation and is palpable at the symphysis pubis
-in case of abnormal uterine involution, infection and retained products of conception should be ruled out

Question 17

What are the characteristics of changes in the placental implantation site?

Answer 17

• after delivery of the placenta, there is an immediate contraction of the placental site to a size less than half the diameter of the original placenta
• this contraction, as well as arterial smooth muscle contractions, leads to hemostasis
• normal postpartum discharge begins as loch rubra, containing blood, shreds of tissue, and decidua
• the amount of discharge rapidly tapers and changes to a reddish-brown color over the next 3-4 days
• typically during the fifth or sixth week postpartum, the lochial secretions cease as healing nears completion

Question 18

What are the changes in the cervix, vagina, and muscular walls of the pelvic organs?

Answer 18

• the cervix gradually closes during the puerperium; at the end of the first week, it is little more than 1 cm dilated
• cervical lacerations heal in most uncomplicated cases, but the continuity of the cervix may not be restored, so the site of the tear may remain as a scarred notch
• after a vaginal delivery, the over distended and smooth-walled vagina gradually returns to its antepartum condition by about the third week
• ovulation occurs as early as 27 days after delivery, with a mean time of 70-75 days in in non-lactating women and 6 months in lactating women
• in lactating women, the duration of an ovulation ultimately depends on the frequency of breastfeeding, duration of each feed, and proportion of supplemental feeds
• ovulation suppression is due to high prolactin levels, which remain elevated until approximately 3 weeks after delivery in non lactating women and 6 weeks in lactating women
• normal changes in the pelvis after uncomplicated term vaginal delivery include the widening of the symphysis and sacroiliac joints
• the voluntary muscles of the pelvic floor and the pelvic support gradually regain their tone during the puerperium
• tearing or overstitching of the musculature or fascia at the time of delivery predisposes to genital prolapse and genital hernias (cystocele, rectocele, and enterocoele)
• overdistention of the abdominal wall during pregnancy may result in rupture of the elastic fibers of the cutis, persistent striae, and diastasis of the rectus muscles
• involution of the abdominal musculature may require 6-7 weeks, and vigorous exercise is not recommended until after that time

Question 19

What are the characteristics of the urinary system?

Answer 19

in the immediate postpartum period, the bladder mucosa is edematous as a result of labor and delivery, and the bladder capacity is increased

• overdistention and incomplete emptying of the bladder with the presence of residual urine are common problems
• resolution of collecting system dilatation by 6 weeks postpartum in most women
• urinary stasis may persist in more than 50% of women at 12 weeks postpartum
• the incidence of urinary tract infection is generally higher in women with persistent dilatation
• significant renal enlargement may persist for many weeks postpartum
• nearly 50% of patients have mild proteinuria for 1-2 days after delivery
• pregnancy is accompanied by an estimated increase of approximately 50% in the glomerular filtration rate
• these values return to normal or less than normal during the eighth week of the puerperium
• creatinine clearance returns to normal by 8 weeks

Question 20

What is the management of the puerperium?

Answer 20

• most patients will benefit from 2-4 days of hospitalization after delivery
• only 3% of women with vaginal delivery and 9% of women having a cesarean section have a childbirth-related complication requiring prolonged postpartum hospitalization or readmission
• although a significant amount of symptomatic morbidity may exist postpartum (painful perineum, breastfeeding difficulties, urinary infections, urinary and fecal incontinence, and headaches), most women can return home safely 2 days after normal vaginal delivery if proper education and instructions are given, if confidence exists with infant care and feeding, and if adequate support exists at home
• optimal care includes home nursing visits the fourth postpartum day

Question 21

What are the recommendations for activity during the puerperium?

Answer 21

if the delivery has been uncomplicated, the patient may be out of bed as soon as tolerated

• in uncomplicated deliveries, more vigorous activity, climbing stairs, lifting of heavy objects, riding in or driving a car, and performing muscle toning exercises may be resumed without delay
• exercise postpartum does not compromise lactation or neonatal weight gain
• it may be beneficial in decreasing anxiety levels and decreasing the incidence of postpartum depression

Question 22

What are the recommendations for diet during the puerperium?

Answer 22

A regular diet is permissible as soon as the patient wishes in the absence of complication

• protein-rich foods, fruits, vegetables, milk products, and high fluid intake are recommended, especially for nursing mothers
• women will need approximately 500 kcal per day more than the recommended level for non pregnant and non lactating women

Question 23

What are the recommendations for sex during the puerperium?

Answer 23

It is safe to resume sexual activity when the women’s perineum is comfortable and bleeding is diminished

• the mediant time for the resumption of intercourse after delivery is 6 weeks and the normal sexual response returns at 12 weeks, sexual desire and activity very tremendously among women
• bathing = as soon as the patient is ambulatory, she may take a shower

Question 24

What is the care of the perineum?

Answer 24

• postpartum perineal care, even in the patient with an uncomplicated and satisfactorily repaired episiotomy or laceration, usually requires no more than routine cleaning with a bath or shower and analgesia
• immediately after delivery, cold compresses (usually ice) applied to the perineum decrease traumatic edema and discomfort
• the perineal area should be gently cleaned with plain sop at least once or twice per day after voiding or defection
• if the perineum is kept clean, healing should occur rapidly

Question 25

What is a perineal laceration?

Answer 25

a tear of the soft skin and other soft tissue structures which, in women, separate the vagina from the anus

Question 26

What are the characteristics of perineal lacerations?

Answer 26

• it is the most common form of obstetric injury
• 85% of women having a vaginal birth sustain some form of perineal trauma
• a perineal tear is distinct from an episiotomy, in which the perineum is intentionally incised to facilitate delivery
• episiotomy was historically used to routinely in order to reduce perineal tears
• however, its routine use has declined as there is some evidence it increases the severity of tears when it is not indicated

Question 27

What is a 1st degree perineal laceration?

Answer 27

perineal skin and vaginal mucosa

Question 28

What is a 2nd degree perineal laceration?

Answer 28

injury to the perineal body

Question 29

What is a 3rd degree perineal laceration?

Answer 29

through the external anal sphincter

Question 30

What is 4th degree perineal laceration?

Answer 30

injury through the rectal mucosa

Question 31

What is the tx of a perineal laceration?

Answer 31

treatment is either to let the tear heal naturally or to surgically repair it

• 3rd and 4th degree tears generally require surgical repair
• among women who experience a third or fourth-degree tear, 60-8-0% are asymptomatic after 12 months
• fetal incontinence, fecal urgency, chronic perineal pain, pain with sex, and fistula formation occur in a minority people, but may be permanent

Question 32

What is an episiotomy?

Answer 32

also known as perineotomy, is a surgical incision of the perineum and the posterior vaginal wall

Question 33

What are the characteristics of an episiotomy?

Answer 33

usually performed during the second stage of labor to quickly enlarge the opening for the baby to pass through
-increases diameter of soft tissue pelvic outlet to allow delivery

Question 34

What is the rationale of an episiotomy?

Answer 34

reduce 3rd and 4th-degree lacerations

Question 35

What is the indication of an episiotomy?

Answer 35

fetal distress

Question 36

What are complications of an episiotomy?

Answer 36

vaginal bleeding, increase postpartum pain, unsatisfactory anatomic results, sexual dysfunction, infections

Question 37

What are the types of an episiotomy?

Answer 37

midline, mediolateral (MC), lateral, j-shaped

Question 38

What is the controversy of an episiotomy?

Answer 38

since about the 1960s, routine episiotomies have been rapidly losing popularity among obstetricians and midwives in almost all countries in Europe, Australia, Canada and the United States

• some compare routine episiotomy to female genital mutilation
• one study found that women who underwent episiotomy reported more painful intercourse and insufficient lubrication 12-18 months after birth but did not find any problems with orgasms or arousal

Question 39

What is postpartum hemorrhage?

Answer 39

a significant loss of blood after giving birth, and it’s the number one reason for maternal morbidity and maternal death around the world

Question 40

How is postpartum hemorrhage defined?

Answer 40

as losing >500 ml of blood within the first 24 hours after vaginal delivery or 1,000 ml after a cesarean delivery
-additional criteria include a decrease of 10% or more in hematocrit from baseline and changes in the mother’s heart rate, blood pressure, and oxygen saturation - all of which suggest a significant blood loss

Question 41

What are the most common causes of postpartum hemorrhage?

Answer 41

can easily be remembered as the “4 Ts”: Tone, Trauma, Tissue, and Thrombin

• uterine atony (most common) - defined as a boggy and enlarged uterus - 90% of postpartum hemorrhages
• genital tract trauma - precipitous labor, operative vaginal delivery (forceps, vacuum extraction)
• retained placental tissue - occurs when the separation of the placenta from uterine wall or explosion of placenta is incomplete
• coagulation disorders (thrombin) - a condition that prevents blood clots from forming normally, for example, a genetic disorder like von Willebrand disease or an obstetric condition like eclampsia and placental abruption which may result in a clotting disorder, and these can lead to DIC
• DIC is associated with severe preeclampsia, amniotic fluid embolism, placental abruption

Question 42

What is the tx of postpartum hemorrhage?

Answer 42

• the most common cause - uterine atony - can usually be managed with fundal massage and medications to help the uterus contract (Oxytocin IV, misoprostol) last resort hysterectomy
• genital track trauma - lacerations greater than 2 cm are repaired surgically
• retained placental tissue - placenta accrete (the placenta grows too deeply into the uterine wall) and the uterine rupture may require a hysterectomy
• a hematologist should be called for cases of bleeding dyscrasias