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OB48 Obstetrics
Postpartum Care
Toronto Notes 2019
The acronym “BUBBLES” for what to ask about when rounding on postpartum care. Modify this for C/S or vaginal delivery
Baby care and breastfeeding–- Latch? Amount?
Uterus – firm or boggy?
Bladder function – Voiding well? Dysuria? Bowel function – Passing gas or stool? Constipated?
Lochia or discharge – Any blood? Episiotomy/laceration/incision – Pain controlled?
Symptoms of VTE – Dyspnea? Calf pain?
Postpartum Care
Postpartum Office Visit at 6 Weeks
Care of Mother (The 10 Bs)
• Becareful:donotusedouchesortamponsfor4-6wkpost-delivery
• Befit:encouragegradualincreasesinwalking,Kegelexercises
• Birthcontrol:assessforuseofcontraceptives;breastfeedingisNOTaneffectivemethodofbirthcontrol
(see Gynecology, GY15, for more detail about different contraceptive options postpartum)
• Bladder: assess for urinary incontinence, maintain high fluid intake
• Blood pressure: especially if gestational HTN
• Blood tests: CBC (for anemia if had PPH)
• Blues:(seePostpartumMoodAlterations,OB47)
• Bowel:fluidsandhigh-fibrefoods,bulklaxatives;forhemorrhoids/perinealtenderness:painmeds,
doughnut cushion, Sitz baths, ice compresses
• Breast and pelvic exam: watch for Staphylococcal or Streptococcal mastitis/abscess, ± Pap smear at 6 wk
Physiological Changes Postpartum
• uterusweightrapidlydiminishesthroughcatabolism,cervixlosesitselasticityandregainsfirmness
■ should involute ~1 cm below umbilicus per day in first 4-5 d, reaches non-pregnant state in 4-6 wk
postpartum
• ovulationresumesin~45dfornon-lactatingwomenandwithin3-6moforlactatingwomenand
sometimes later
• lochia:normalvaginaldischargepostpartum,uterinedecidualtissuesloughing
■ decreases and changes in colour from red (lochia rubra; presence of erythrocytes, 3-4 d) → pale (lochia serosa) → white/yellow (lochia alba; residual leukorrhea) over 3-6 wk
• foul-smellinglochiasuggestsendometritis
Breastfeeding Problems
• inadequatemilk:considerdomperidone
• breastengorgement:coolcompress,manualexpression/pumping
• nipplepain:cleanmilkoffnippleafterfeeds,moisturecream,topicalsteroidifneeded
• mastitis:treatpromptly(seePostpartumPyrexia,OB46)
• invertednipples:makesfeedingdifficult
• maternalmedications:mayrequirepediatricconsultation(seeBreastfeedingandDrugs,OB48)
Bladder Dysfunction
• pelvicfloorprolapsecanoccuraftervaginaldelivery
• stressorurgeurinaryincontinencecommon
• increasedriskwithinstrumentaldeliveryorprolongedsecondstage
• conservativemanagement:pelvicfloorretrainingwithKegelexercises/pelvicphysiotherapy,vaginal
cone, or pessaries, lifestyle modifications (e.g. limit fluid, caffeine intake)
• surgicalmanagement:minimallyinvasiveprocedures(tension-freevaginaltape,transobturatortape,
midurethral sling)
Puerperal Pain
• “afterpains”commoninfirst3dduetouterinecontractions;encouragesimpleanalgesia • icepackscanbeusedonperineumifpainful
• encourageregularanalgesiaandstoolsoftener
Breastfeeding and Drugs
Table 24. Drug Safety During Breastfeeding
Safe During Breastfeeding
Analgesics (e.g. acetaminophen, NSAIDs) Anticoagulants (e.g. heparin)
Antidepressants (e.g. sertraline, fluoxetine, tricyclic antidepressants)
Antiepileptics (e.g. phenytoin, carbamazepine, valproic acid) Antihistamines
Antimicrobials (e.g. penicillins, aminoglycosides, cephalosporins) β-adrenergics (e.g. propanolol, labetalol)
Insulin
Steroids
OCP (low dose) – although may decrease breast milk production
Contraindicated When Breastfeeding
Chloramphenicol (bone marrow suppression) Cyclophosphamide (immune system suppression) Sulphonamides (in G6PD deficiency, can lead to hemolysis) Nitrofurantoin (in G6PD deficiency, can lead to hemolysis) Tetracycline
Lithium
Phenindione
Bromocriptine
Anti-neoplastics and immunosuppresants Psychotropic drugs (relative contraindication)