Monday, 2 December 2013

Post partum

POST PARTUM PERIOD AN UPDATE
post partum period is defined as time from delivery of baby and placenta upto 6-8 weeks
SHIVERING seen in 50% women. Starts 30 min post delivery and may last for 60min
 Reason- 
1)fetomaternal hge
2) maternal thermogenesis reaction
3) micro amniotic emboli

UTERINE INVOLUTION Within 24hrs of delivery-
uterine fundus is near umbilicus at 1 week postpartum. - midway between umbilicus and Symphysis
At 2weeks --pelvic organ
Returns to nonpregnant size by. 4 weeks
Entire ENDOMETRIUM regenerated by 16thday postpartum
LOCHIA
Lochia Rubra Reddish brown Lasts for 3-4 days
Lochia serosa Pinkish brown. Lasts for 2-3 weeks
Lochia alba. Yellowish white. Lasts for 1week
Total volume of Lochia in 1 month (usual duration) 200-500ml
Maximum duration of Lochia can be for 8 weeks
Lochia made up of serous exudate , WBC, RBC,decidua, epithelial cells, bacteria
ULTRASOUND features OF POST PARTUM UTERUS
Day1-3 postpartum - empty uterus
Day 14postpartum - fluid and debris in uterus
Day28 postpartum - empty cavity with white line
Endometrial gas can be seen normally after CS ,
manual removal of placenta and sometimes after NVD.
CERVIX IN post partum
External os remains dilated , becomes a transverse slit
Cervix for first few days is 2-3 cm dilate
At 1 week it is <1cm dilated
HISTOLOGICALLY cervix returns to baseline 3-4 months after delivery
VAGINA and VULVA
Smooth immediately after delivery
Rugae are restored in 3rd week when edema subsides
HCG returns to normal after 2-4 weeks after full term delivery
Mean return of menstruation 45-64days
Mean return time to ovulation 45-94 days( but can occur as early as 25 days)
Gonadotropins and sex steroids are at low level for first 2-3 week
VENOUS THROMBOEMBOLISM
is more common after CS than after vaginal delivery
Maximum risk is in first 2 weeks
No increased risk after 6 weeks
CONTRACEPTION should be started no later than 3 weeks in non breast fed
In breast feeding should be started by 3 months
Post partum tubal ligation ideally done within
48hrs but can be done upto 7 days postpartum.
Postpartum IUD insertion should be done within
10 mins of placental seperation
BREAST ENGORGEMENT
No medical management to be given for suppression of lactation, bromocriptine is not recommended now as it can cause seizures, MI, stroke
Only treatment is tight underclothing and avoidance of lactation
POST PARTUM URINARY RETENTION
When patient is unable to void within 6 hrs of delivery and residual volume is > 150 ml
Most common reason for urinary retention is injury to pudendal nerve
Initial management is non invasive - warm bath, analgesics
If not helpful then do catheterisation
Urinary retention usually resolves within 1 week postpartum
Postpartum HGE primary within 24 hrs and secondary beyond 24 hrs
Post partum ECLAMPSIA most cases occur within 48 hrs of delivery
Postpartum FEVER
Oral temp greater than 38degrees Celsius on any two of first 10 days excluding the first 24 hrs
Causes
UTI
WOUND INFECTION
MASTITIS
ENDOMETRITIS
SEPTIC PELVIC THROMBOPHLEBITIS
VULVAR EDEMA
Associated with tocolytic use
Prolonged second stage
Preeclampsia
Management ice packs
WOUND INFECTION
related to LSCS
USUALLY OCCURS 4-7 days after LSCS
ENDOMETRITIS
more common after CS
occurs within 5 days of delivery
Characterised by uterine tenderness, foul Lochia , leukocytosia and fever
PERIPARTUM CARDIOMYOPATHY
decreased LVEF in last month of pregnancy or within 5 months of delivery in the absence of
heart disease
Optimal inter delivery interval 18-59 months
Ideal time for discharge 48 hrs after NVD
96 hrs after CS

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