Gastrointestinal Tract Changes
Constipation. Decreased GI tract motility, because of perineal pain and fluid mobilization, canlead to constipation. Management is oral hydration and stool softeners.
Hemorrhoids. Prolonged second-stage pushing efforts can exaggerate preexisting hemor-rhoids. Management is oral hydration and stool softeners.
Psychosocial Problems
Bonding. Impaired maternal–infant bonding is seen in the first few days postdelivery. Lack ofinterest or emotions for the newborn are noted. Risk is increased if contact with the baby is limited because of neonatal intensive care, as well as poor social support. Management is psy-chosocial evaluation and support.
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OB Triad
Impaired Maternal–Infant
Bonding
• Postpartum Day 1
• SVD: 1,900-g 31-week male in NICU
• Mom shows no interest in baby
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USMLE Step 2 l Obstetrics
OB Triad
Postpartum Blues
• Postpartum Day 2
• S/P SVD of term normal baby
• Mom cares for baby: tears
OB Triad
Postpartum Depression
• Postpartum Day 21
• S/P SVD of term normal baby
• Mom does not get out of bed, does not care for self or baby
OB Triad
Postpartum Psychosis
• Postpartum Day 21
• S/P SVD of term normal baby
• Mom exhibits bizarre behavior, hallucinations
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Blues. Postpartum blues are very common within the first few weeks of delivery. Mood swingsand tearfulness occur. Normal physical activity continues and care of self and baby is seen. Management is conservative with social support.
Depression. Postpartum depression is common but is frequently delayed up to a month afterdelivery. Feelings of despair and hopelessness occur. The patient often does not get out of bed with care of self and baby neglected. Management includes psychotherapy and antidepressants.
Psychosis. Postpartum psychosis is rare, developing within the first few weeks after delivery.Loss of reality and hallucinations occur. Behavior may be bizarre. Management requires hospi-talization, antipsychotic medication, and psychotherapy.
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POSTPARTUM CONTRACEPTION AND IMMUNIZATIONS
Contraception Planning
Breast feeding. Lactation is associated with temporary anovulation, so contraceptive use maybe deferred for 3 months. A definitive method should be used after that time.
Diaphragm. Fitting for a vaginal diaphragm should be performed after involution of pregnancychanges, usually at the 6-week postpartum visit.
Intrauterine Device (IUD). Higher IUD retention rates, and decreased expulsions, are seen ifIUD placement takes place at 6 weeks postpartum.
Combination Modalities. Combined estrogen-progestin formulations (e.g., pills, patch, vaginalring) should not be used in breast-feeding women because of the estrogen effect of diminish-ing milk production. In nonlactating women, they should be started after 3 weeks postpartum to allow reversal of the hypercoagulable state of pregnancy and thus decrease the risk of deep venous thrombosis.
Progestin-only Contraception. Progestin steroids (e.g., mini-pill, Depo-Provera, Nexplanon)do not diminish milk production so can safely be used during lactation. They can be begun immediately after delivery.
Postpartum Immunizations
RhoGAM. If the mother is Rh(D) negative, and her baby is Rh(D) positive, she should beadministered 300 mg of RhoGAM IM within 72 hours of delivery.
Rubella. If the mother is rubella IgG antibody negative, she should be administered active immu-nization with the live-attenuated rubella virus. She should avoid pregnancy for 1 month to avoid potential fetal infection.
POSTPARTUM HEMORRHAGE
Definition: vaginal delivery blood loss≥500 mL or cesarean section blood loss≥1,000 mL
Uterine Atony (80%)
This is the most common cause of excessive postpartum bleeding.
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Chapter 18 l Postpartum Issues
Risk Factors. Rapid or protracted labor (most common), chorioamnionitis, medications (e.g.,
MgSO4, b-adrenergic agonists, halothane), and overdistended uterus.
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Clinical Findings. A soft uterus (feels like dough) palpable above the umbilicus.
Management. Uterine massage and uterotonic agents (e.g., oxytocin, methylergonovine, orcarboprost).
Lacerations (15%)
Risk Factors. Uncontrolled vaginal delivery (most common), difficult delivery, and operativevaginal delivery.
Clinical Findings. Identifiable lacerations (cervix, vagina, perineum) in the presence of a con-tracted uterus.
Management. Surgical repair.
Retained Placenta (5%)
Risk Factors. Accessory placental lobe (most common) and abnormal trophoblastic uterineinvasion (e.g., cervix, vagina, perineum).
Clinical Findings. Missing placental cotyledons in the presence of a contracted uterus.
Management. Manual removal or uterine curettage under ultrasound guidance.
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