Postpartum Care Flashcards
(42 cards)
What is endometritis?
an inflammation of the endometrium, which is the inner lining of the uterus
-most common cause of infection after childbirth
What is endometritis caused by?
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
When can endometritis happen?
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
What are the characteristics of endometritis?
can be acute or chronic
-people with acute endometritis are more likely to have symptoms, whereas many of those with choleric endometritis are asymptomatic
What are the symptoms of endometritis?
include fever, lower abdominal pain, and abnormal vaginal bleeding or discharge
What are the risks of endometritis?
C-section, PROM, vaginal delivery, D&C, pelvic exams
What are the complications of endometritis?
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
How is endometritis dx?
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
What are the clinical findings of endometritis?
- fever, tachycardia
- possible vaginal bleed (foul-smell)
- abdominal pain and uterine tenderness
- 2-3 days post C-section, postabortal
What is the tx of endometritis?
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
How long does the puerperium or postpartum period last?
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
What is immediate puerperium?
first 24 hours after parturition when acute post anesthetic or post-delivery complications may occur
What is early puerperium?
extends until the first week postpartum
What is remote puerperium?
includes the period of time required for involution of the genital organs and return of menses, usually approximately 6 weeks
What is normal during puerperium?
anatomic and physiologic changes
What are the characteristics of uterine involution?
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
What are the characteristics of changes in the placental implantation site?
- 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
What are the changes in the cervix, vagina, and muscular walls of the pelvic organs?
- 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
What are the characteristics of the urinary system?
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
What is the management of the puerperium?
- 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
What are the recommendations for activity during the puerperium?
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
What are the recommendations for diet during the puerperium?
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
What are the recommendations for sex during the puerperium?
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
What is the care of the perineum?
- 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
