Valerie Hill - Postpartum

How long is the PP period

• Lasts 6-12 weeks

Involution

• Return of the uterus to a non-pregnant state. Begins instantly after expulsion of placenta. The fundus descends 1-2cm every 24 hours.

• Uterus should not be palpable after 2 weeks.

• Excess cells laid down during pregnancy actually remain postpartum, and explain why the uterus is bigger after each pregnancy.

• Subinvolution is when the uterus does not return, and is mostly caused by placental fragments or infection.

Placental Site/Endometrium

After the placenta is expelled, the vasculature contracts, and clots which reduces the placental site. The endometrium then grows, which causes the necrotic tissue to slough off, leaving no typical wound healing scar. Endometrial regen is complete by the 16th PP day, however the placental site only regens 6 weeks PP.

Lochia (Rubra, Serosa, Alba)

• For the first 2 hours after birth, Lochia is like a normal heavy menstrual period, and slowly reduces after.

• Lochia Rubra

  • Blood and debris. Red. Lasts 3-4 days

• Lochia Serosa

  • Pinkish brown. Old blood, serum, leukocytes, tissue debris

  • Lasts 2-4 weeks

  • If it is still there after 4 weeks it might be endometritis.

• Lochia alba

  • Whitish yellow

  • Mostly cells

  • 4-6 weeks PP. But not everyone has it

• Increases with ambulation or standing after lying down.

• Sudden but brief increase in bleeding 1-2wks PP due to placental site sloughing.

Cervix PP

• Dilates down to 2-3cm by day 2-3 and to 1cm 1 week after birth.

• Ectocervix appears bruised and has some small lacerations.

• The external os never regains its pre-pregnancy appearance, and is instead a jagged slit.

Vagina PP

• PP estrogen deprivation (from PP and BF) thins vaginal mucosa and affects the appearance of rugae (diminished). The rugae and vagina will never be the same as they were before pregnancy.

• The introitus should be barely distinguishable from nulliparity by 2 weeks PP.

Abdomen PP

Returns to pre-pregnancy state in 6 weeks.

Metabolism/Endocrine PP

• Low BG due to decrease in lactogen, estrogen, cortisol, etc

• Diabetic patients usually require less insulin during the first few PP days

• Thyroid volume decreases to normal by 3 months, and levels decrease to normal in 4 weeks.

Hormones PP

• Prolactin rises throughout pregnancy, and after, esp in people who BF. It is the highest 1 month PP. In non lactating patients, it decreases to pre pregnancy by 3 weeks PP.

• Periods return in 12 weeks to non-lactating patients, and 6 months to lactating. Ovulation occurs as early as 27 days PP in NL.

BUBBLLEE Acronym

• B: Breasts (firmness) and nipples 

• U: Uterine fundus (Location and consistency)

• B: Bladder function (amount and frequency)

• B: Bowel function (gas + BM)

• L: Lochia (amount and color)

• L: Legs (edema)

• E: Episiotomy/Laceration/C Section

• E: Emotional Status

Bladder Distension

Bladder distention can cause uterine atony which can cause heavy bleeding, because a distended bladder pushes the uterus in such a way that it limits contractions.

PP Hemorrhage

• Leading cause of maternal mortality worldwide

• Defined as the loss of 500ml or more of blood after vaginal birth, or 1000ml or more after cesarean. Can also be defined as a 10% decline in Hgb conc. Any blood loss that has the potential to produce hemodynamic instability should be defined as PPH.

Primary PPH

• Occurs within 24h of birth.

Secondary PPH

• Occurs after 24h but before 12 weeks Caused by retained products and/or infection, or subinvolution (which can be the result of the previous two).

• After the placenta has been expelled, excessive blood loss is usually the result of uterine atony, or prolapse.

Four T’s of PPH - Causes

Tone

Tissue

Trauma

Thrombin

Tone - 4T’s

Uterine atony/hypotonia.Leading cause of PPH. Cause by conditions that overstretch the uterus. Can also be caused by traumatic birth, use of halogens, magnesium sulfate, prolonged labor, or oxytocin.

Tissue - 4T’s

Retained placenta fragments. The placenta is considered retained if not delivered 30-60mins after birth.

Trauma - 4T’s

 Lacerations of the genital tract, cesarean birth, uterine rupture, and uterine inversion. PPH related to lacerations should be suspected when bleeding continues despite a firm contracted uterus.

Hematomas PP

Can be vulvar, vaginal or retroperitoneal. Vulvar is the most common and causes perineal, vaginal or rectal pain. Vaginal hematomas can be a result of the use of forceps. Retroperitoneal hematomas are life threatening, and may not be very painful, and the first symptoms may actually be signs of shock.

Uterine Inversion

Life threatening. Can be incomplete, complete or prolapsed. Incomplete is not visible, but can be palpated from the dilated cervix. Complete is a small mass visible outside the os. Prolapsed is a very obvious red rounded mass that protrudes 20-30cm outside the vaginal introitus. Sudden severe bleeding, shock and pain, and inability to palpate the uterus abdominally.

Immune Thrombocytopenic Purpura

An immune disorder that leads to decreased lifespan of platelets, causing low platelet counts, resulting in increased bleeding and capillary fragility.  Treated with corticosteroids, IV immunoglobulin, or platelet replacement.

Von Willebrand Disease

•  Defect in a clotting protein called von willebrand factor. Patients are at risk for bleeding up to 4 weeks PP. Treated with desmopressin. 

DIC

• Imbalance between the body's clotting and fibrinolytic systems. Consumes large amounts of clotting factors, leading to widespread unstoppable bleeding. Vessels may also get occluded from small clots. Can lead to shock.

Management of PPH

• Firm fundal massage, elimination of clots and bladder distension, and continuous IV infusion of 10-40U of oxytocin in 1000mL lactated ringers or normal saline. If no help, then administer misoprostol or methylergonovine or prostaglandins. 

Patho of Hypovolemic Shock

Initial hemorrhage/hypovolemia → Adrenal glands release catecholamines, causing vasoconstriction that aims to redirect blood to the most important organs → Reduction in cellular oxygen due to shunting blood away from structures → Lactic acidosis from anaerobic metabolism → Ateriolar vasodilation → More pooling, less oxygenation, more acidosis.

Superficial Venous Thrombosis

• Thrombosis close to the skin

Deep Venous Thrombosis

• Most common in the legs. A thrombosis in deeper vasculature

Pulmonary Embolism

• Complication of DVT where the deeper clot is carried to the pulmonary artery, blocking blood flow to the lungs.

DVT treatment

• DVT is treated with 3-5 days of IV heparin, followed by ab 3 months of oral warfarin. 

• Green leafy veg avoided while on anticoagulants.

PE Treatment

PE is treated with IV heparin until symptoms resolve, followed by 6 months of subcut or oral heparin.

Green leafy veg avoided while on anticoagulants.

Postpartum Infection

• Any infection that occurs 42 days after expulsion of a fetus.

• Endometritis: Usually begins as a localized infection at the placental site, but can spread to the entire endometrium. Most common PP infection. Most common in patients who had C section, prolonged labor and ROM.

Postpartum Blues

• Begins 3-5 days after birth and resolves in 2 weeks. Period of heightened emotion and sleep issues. 

• Suicide is the leading cause of death in the perinatal year.

PPD Screening Scales

Edinburgh Postnatal Depression scale and Postpartum Depression Screening Scale are the most commonly used assessments for PPD. The max score on the EPDS is 30, but a score of 12+ is indicative of depression.