Postpartum Period

after, delivery, 12

The Postpartum Period: Background

-The time _______ delivery when maternal physiologic changes related to pregnancy return to non-pregnant state

-The postpartum period begins upon __________ of the infant

-ACOG defines the end of the postpartum period as __ weeks after delivery

shivering, contraction, hemorrhage, fundus, two

Postpartum Physiologic Changes

-_________

• Starts 1-30 minutes after delivery and can last for 2-60 minutes

-Uterine involution

• The uterus begins to return to its non-pregnant size and condition

• ___________ of the interlacing myometrial muscle bundles constricts the intramyometrial vessels and impedes blood flow. This prevents ____________ at the placental site 

• The ______ recedes by approximately 1 cm/day after delivery and is not palpable abdominally by ___ weeks postpartum 

shedding, mucous, shed, discharge, pinkish, white, dilated, normal

Postpartum Physiologic Changes

-Lochia → normal _________ of the blood and decidua 

• Decidua → the thick layer of modified _______ membrane which lines the uterus during pregnancy and is ____ after delivery 

• Lochia rubra → red/red-brown _________ for the first few days following delivery 

• Lochia serosa → ________-brown discharge for 2-3 weeks 

• Lochia alba → ____ discharge up to 6-8 weeks after delivery 

-Cervix → remains 2-3 cm _________ for the first few days after delivery, and is less than 1cm dilated at one week postpartum

-Abdominal wall → initially very lax, but regains most ________ muscular tone over several weeks

• Diastasis rectus abdominis may persist

fall, menstruation, engorgement, loss

Postpartum Physiologic Changes

-hCG levels _____

-Hot flashes

-Return of ____________ 45-64 days postpartum

-Return of ovulation 45-94 days postpartum

-Breast _____________

-Striae fade from red to silvery but are permanent

-Hair ____ 1-5 months after delivery, which is usually self-limited and returns to normal by 6-15 months after

hemorrhage, fundal, perineal, VTE, positive, pain

Maternal Care

-Monitoring → vital signs and postpartum __________

• Perform ______ checks to assess uterine tone and _______ checks to assess for excessive vaginal bleeding

-Labs → hemoglobin

-Perineal care

-Prevention of ___ → prophylaxis for women at high risk

-Anti-D immune globulin for RhD-negative mothers of RhD-________ infants

-Pelvic muscle exercises

-_____ management

-Postpartum contraception

car seat, sleep, retention, varicose, dryness, pain, headache 

Postpartum Counseling and Complications

-Counseling

• ____ ______ instructions, safe _____ counseling, follow-up appointments for mom and baby, and education on signs and symptoms of potential complications 

-Complications 

• Postpartum urinary ________, hemorrhoids, incontinence, lower extremity _______ veins, mild vulvar edema, surgical site infection, endometritis, mastitis, UTI, septic pelvic thrombophlebitis, C. diff infection, neuropathy, vaginal ________, pelvic girdle and musculoskeletal ____, and postdural puncture ___________ after epidural 

headache, seizure, bleeding, pain

Postpartum women with __________, new hypertension, _______, excessive _________, dyspnea or chest pain, severe abdominal ____, or vulvar symptoms should be evaluated promptly

perineum, 6, low, 1, delivery, hypothyroidism

More Postpartum Issues

-Sexual Dysfunction

• Safe to resume sexual activity when the woman’s ________ is comfortable and bleeding is diminished, usually around _ weeks

• However, sexual health issues can last for months, especially ___ libido

-Postpartum thyroiditis

• Higher risk in women with type _ diabetes

• Hyperthyroidism usually within 1-4 months after delivery and lasts 2-8 weeks

• Followed by ____________ that lasts 2 weeks-6 months

bleeding, hypovolemia, mortality, 24, 12, atony, rupture

Postpartum Hemorrhage: Background

-Obstetric emergency characterized by _________ that is greater than expected and results in signs/symptoms of _________

• Cumulative blood loss > 1000 mL or blood loss with signs/symptoms of hypovolemia within 24 hours 

-One of the top five causes of maternal __________

-Primary PPH = within __ hours after delivery 

-Secondary/late/delayed PPH = 24 hours - __ weeks after delivery

-Most common cause is uterine _______, which is a lack of effective contraction of the uterus after delivery 

-Can also be caused by trauma due to lacerations, uterine ________, incisions, placental disorders, and coagulopathy 

retained, second, instrumental, large, demise, trauma, thrombin

Postpartum Hemorrhage: Risk Factors and Etiology

-Risk Factors

• __________ placenta/membranes, failure to progress during the _______ stage of labor, morbidly adherent placenta, lacerations, ____________ delivery, _____ for gestational age newborn, hypertensive disorders, induction of labor, prolonged first or second stage of labor, placental abruption, and intrauterine fetal _______

-Etiology

• 4 Ts of tone, _______, tissue, and thrombin

• Tone → Atonic uterus

• Trauma → lacerations, hematomas, inversion, rupture

• Tissue → retained tissue, invasive placenta

• Thrombin → coagulopathies

lightheadedness, tachycardia, pallor, lethargy

Postpartum Hemorrhage: Signs and Symptoms

-EBV 500-1000 mL → palpitations, _____________, no or mild increase in heart rate

-EBV 1000-1500 mL → weakness, sweating, ___________, tachypnea

-EBV 1500-2000 mL → restlessness, confusion, _______, oliguria, tachycardia, cool and clammy skin

-EBV 2000-3000 mL → ______, air hunger, anuria, collapse, tachycardia

massage, evacuation, oxytocin

Postpartum Hemorrhage Management: Uterine Atony (Tone)

-Fundal/uterine ________

-Bimanual compression/__________ of clots 

-Uterotonic medications → __________, misoprostol, methergine, hemabate, cytotec, tranexamic acid 

-Tamponade of uterus via bakri balloon or packing with gauze 

-Uterine artery ligation

-Hysterectomy 

lacerations, repair, conservatively, inspect, retained, D&C, coagulation, DIC, transfusion

Postpartum Hemorrhage: Management of Trauma, Tissue, and Thrombin

-Trauma

• Assess for __________, expanding hematomas, or uterine rupture

• _______ any actively bleeding laceration as soon as possible

• Most hematomas managed ___________, but if rapidly expanding and abnormal vital signs, consider I&D

-Tissue

• Visually _______ placenta for completeness

• Manual examination for __________ placenta or bedside US evaluation of uterine cavity

• If suspected, try to remove retained portion manually or consider ___

-Thrombin

• Evaluate a patient’s ___________ status

• Consider possible etiologies leading to ___ like placental abruption and amniotic fluid embolism

• Correct with replacement of clotting factors, fibrinogen, or other replacement sources (massive __________ protocol)

oxytocin, massage, umbilical

Postpartum Prevention

-Active management of 3rd stage of labor → __________ administration

• Substantially reduces the incidence of PPH due to atony

-Uterine ________

-_________ cord traction

pituitary, infarction, failure, amenorrhea, hypotensive, adrenal

Sheehan Syndrome

-A rare but potentially life-threatening complication of postpartum hemorrhage

-The ________ gland is normally enlarged in pregnancy and therefore prone to __________ from hypovolemic shock

-Hypovolemic shock from PPH → resulting pituitary damage

-Hypopituitarism can range from mild to severe → can reduce secretion of one, several, or all of its hormones

-Common presentation → ________ to lactate postpartum and ___________/oligomenorrhea

• However, any manifestations of hypopituitarism can occur at any time from the immediate postpartum period to years after birth

-Patients who remain ____________ after control of PPH and volume replacement should be evaluated and treated for _______ insufficiency in the immediate postpartum period

• Evaluation of other hormonal deficiencies can be deferred until 4-6 weeks postpartum

6, cesarean, history, immobility, early, compression, LMWH

Postpartum Thromboembolism

-Highest risk period → first _ weeks postpartum

-Risk factors → ________ delivery, obesity, advanced maternal age, smoking, personal or family ________ of VTE, thrombophilia, and prolonged _________ or hospitalization

-Prevention and Management → ______ ambulation encouraged after delivery, ___________ devices for cesarean patients or high-risk individuals, pharmacologic prophylaxis (____) in high-risk patients, and risk assessment should be performed for every postpartum patient 

endometrium, fever, cesarean, migrate, sterile

Postpartum Endometritis: Background

-Infection of the pregnancy _____________ (decidua)

-Common cause of postpartum _____ and uterine tenderness

-Significantly more common after ________ delivery than vaginal delivery

-Pathogenesis → During labor and delivery, endogenous cervicovaginal flora ________ into the uterine cavity and contaminate its normally _______ contents

cesarean, antibiotic, amniotic, DM

Postpartum Endometritis: Risk Factors

-_________ delivery → need ________ prophylaxis

-Other risk factors → chorioamnionitis, prolonged labor, prolonged rupture of membranes, multiple cervical examinations, internal fetal or uterine monitoring, large amount of meconium in ________ fluid, manual removal of the placenta, low socioeconomic status, maternal __ or severe anemia, preterm or postterm birth, operative vaginal delivery, obesity, HIV infection, colonization with group B streptococcus, nasal carriage of staph aureus, and heavy vaginal colonization by E. coli

fever, pain, soft, bleeding, malodorous, WBC, tenderness, purulent

Endometritis Clinical Findings and Diagnosis

-Signs and Symptoms → _____, uterine tenderness, tachycardia, and midline lower abdominal ____

-Physical exam → slightly ____ and subinvoluted uterus, which may cause excessive uterine ___________. ____________ purulent lochia can be seen too. 

-Lab → elevated ___ count and bacteremia 

-The diagnosis is made in patients with at least two of the following signs or symptoms → fever (>100.4 F), uterine or abdominal pain/____________ with no other recognized cause, and _________ drainage from the uterus 

Clindamycin, gentamicin, 60

Endometritis Treatment and Prevention

-Broad spectrum antibiotics → ____________ + ____________

-Prophylactic antibiotics within __ minutes prior to making the skin incision for all cesarean deliveries 

transient, week, hormonal, neurotransmitter, anxiety, decreased, 2-3

Postpartum Blues: Background

-Differentiating factor between other mental health issues → _________

-Develops in approximately 40% of women within a _____ of delivery

-Pathogenesis → unknown, but may be due to postnatal _________ changes that lead to abnormal _____________ levels or activity

-Symptoms → sadness, crying, irritability, _______, insomnia, exhaustion, __________ concentration, mood lability

-Symptoms typically develop within ____ days of delivery, peak over the next few days, and resolve within two weeks

spontaneously, reassurance, sleep, night, CBT, suicidal

Postpartum Blues: Management

-Generally resolves ____________ and does not require treatment

-Watchful waiting as well as ____________ and support for the woman and her family

-Adequate time for the patient to _____ and rest is essential

-Recruiting someone else to care for the baby at _____ is often sufficient to manage insomnia

-If insomnia persists, ___, pharmacotherapy, or both may be indicated

-If symptoms worsen or persist beyond two weeks, or if there is ________ ideation, patients should be evaluated for postpartum depression and referred for indicated treatment

stress, fear, hemorrhage, PTSD

Postpartum PTSD

-Prevalence of 4% in the general obstetric population

-Risk factors

• Pre-pregnancy ______ → sexual/physical trauma, history of PTSD

• Negative pregnancy experience → _____ of childbirth, low support, perceived lack of control, maternal morbidity, pregnancy complications

• Delivery issues and complications → lack of social support, emergency C-section, instrumental vaginal birth, postpartum ___________, and poor neonatal outcomes

-Typical ____ symptoms and treatment 

genetic, stressful, depressive, 12

Postpartum Depression: Background

-Prevalence is approximately 9% in the US

-Pathogenesis → unknown, but may involve _______ susceptibility, hormonal changes, psychological and social problems, and ________ life events

-Symptoms of major _________ episodes during the postpartum period, generally considered as the first __ months after birth

health, bonding, development, suicide, death, history, single, violence, fear, stress

Postpartum Depression: Consequences and Risk Factors

-Consequences

• Impaired maternal functioning, poor nutrition and ______ in the offspring, impaired _________, abnormal infant and child _____________, cognitive impairment and psychopathy in the child, strained marital relationships, _______ (increases in the first year after childbirth and is the leading cause of maternal _____ in the general population), infanticide

-Risk Factors

• _______ of depression prior to pregnancy, stressful life events during pregnancy or after delivery, poor social and financial support, young age, ______ marital status, multiparity, family history, intimate partner _________, unintended pregnancy, negative attitudes towards pregnancy, ____ of childbirth, poor perinatal physical health, body image dissatisfaction, history of PMS/PMDD, perinatal anxiety, perinatal sleep disturbance, season of delivery, adverse pregnancy/neonatal outcomes, postpartum blues, breastfeeding difficulties, and childcare ______ such as colic or infant sleep disturbance

Edinburgh, 6, 1, CBT, SSRI

Postpartum Depression: Screening and Treatment

-Screening should be performed by PCPs, OBGYNs, and pediatricians

-____________ Postnatal Depression Scale 

• Recommended at _ week postpartum visit 

• Also done at pediatrician offices at _, 2, 4, and 6-month well-infant visits 

-Treatment 

• ___, couples/family therapy, group therapy, ____ (sertraline or paroxetine), brexanolone, zuranolone, ECT

mania, decreases, mood, younger, hospitalization, suicidal, substance, lithium

Postpartum Bipolar Disorder

-Episodes of major depression, ______, and hypomania during the postpartum period

-Etiology is unknown → may be due to __________ in estrogen and progesterone, decreased or erratic sleep, increased stress associated with caring for the newborn, social issues, genetics

-Risk Factors → prenatal ____ symptoms and episodes, ________ age at delivery, unplanned pregnancy, primiparity, history of previous postpartum mood episodes, and family history of mood disorder

-Treatment → inpatient ____________ may be required for severely ill patients

• _______ or homicidal ideation or behavior, aggressive behavior, psychotic features, __________ dependence, impaired functioning, and poor judgement that places the patient or others at risk of being harmed

• _______ or lamotrigine

emergency, reality, sleep, two, insomnia, history, first

Postpartum Psychosis: Background

-Medical ___________

-A disturbance in an individual’s perception of _______

-Pathogenesis → unknown, but research points to genetic, immunologic, and hormonal factors, as well as ______ deprivation

-Most commonly presents within ____ weeks of childbirth

-Persistent severe __________ is often the first indication of an incipient postpartum psychosis

-Risk Factors → _______ of postpartum psychosis, family history, history of BPD/schizophrenia/schizoaffective disorder, family history of bipolar disorder, _____ pregnancy, and discontinuation of psychiatric medications

hallucinations, mood, less, harming, thought, insomnia, agitation

Postpartum Psychosis: Symptoms

-___________ → command auditory hallucinations may be present, instructing the mother to harm the baby or herself

-Delusions → tend to be related to the patient’s _____ state. Typically involve their baby and are ____ bizarre than typically seen in schizophrenia

• 9% of women hospitalized for postpartum psychosis had thoughts of _________ their infants 

-_______ disorganization, bizarre behavior, manic or depressed mood, severe ________, rapid mood changes, anxiety, irritability, psychomotor ________ may be present, and disorientation to person/place/time 

hospitalization, alone, lithium, psychotherapy, benzodiazepine

Postpartum Psychosis: Treatment

-___________ → do not leave the mother _____ with their children

-Preferred pharmacologic treatment → an antipsychotic and ______

-Adjunctive ____________ focusing on education and encouraging adherence to medication

-if there is prominent insomnia, add a ______________

-ECT is also an option

Postpartum hemorrhage

What is the most likely diagnosis in this patient?

A 26 y/o woman is 1 hour postpartum after a prolonged labor with oxytocin augmentation. She suddenly develops heavy vaginal bleeding and soaking of pads within minutes. Her uterus feels boggy on exam. BP is 90/58, HR 128.

Postpartum thromboembolism

What is the most likely diagnosis in this patient?

A 32 y/o woman, 5 days after an uncomplicated vaginal delivery, presents with unilateral leg swelling, warmth, and tenderness. She notes the pain worsens when she walks. She has a history of obesity and was mostly immobile at home due to fatigue. 

Postpartum endometritis

What is the most likely diagnosis in this patient?

A 29 y/o woman is 3 days postpartum after a cesarean delivery for prolonged rupture of membranes. She develops fever, lower abdominal pain, and foul-smelling lochia. Her uterus is tender to palpation.

Postpartum blues

What is the most likely diagnosis in this patient?

A 25 y/o first-time mother, 4 days postpartum, reports sudden episodes of tearfulness, feeling overwhelmed, and mild anxiety. She is sleeping poorly but denies suicidal thoughts. Her symptoms are intermittent and she feels bonded to the baby.

Postpartum PTSD

What is the most likely diagnosis in this patient? 

A 30 y/o woman, 6 weeks after a traumatic emergency C-section for fetal distress, reports nightmares, flashbacks to the delivery, and avoidance of anything related to the hospital. She becomes panicked when hearing beeping sounds similar to monitors. 

Postpartum depression

What is the most likely diagnosis in this patient?

A 33 y/o woman, 4 weeks after delivery, reports persistent sadness, loss of interest in activities, severe fatigue, and feelings of worthlessness. She struggles to bond with her baby and has trouble concentrating. She denies psychosis or mania but says, “I don’t feel like myself at all”

Postpartum bipolar disorder

What is the most likely diagnosis in this patient?

A 27 y/o woman with no prior psychiatric history presents 3 weeks postpartum with periods of elevated mood, increased energy, decreased need for sleep, rapid speech, and impulsive spending, followed by episodes of deep depression. Her symptoms fluctuate dramatically within days.

Postpartum psychosis

What is the most likely diagnosis in this patient?

A 24 y/o woman, 2 weeks postpartum, is brought in by family for bizarre behavior. She reports hearing a voice telling her the baby is “possessed”, has paranoia, disorganized thoughts, and visual hallucinations. She has not slept for 3 days.