POSTPARTUM CARE

Puerperium
This is the period which begins with the termination of third stage of labour and lasts till genital organs have resumed their normal condition again. The normal duration of the puerperium is for 6 weeks following delivery.

Normal Postpartum Care

In order to
To assess the health status of mother To detect & treat the early gynecological problem arising because of parturition To note the progress of baby including immunization To impart family planning guidance

Following delivery patient should be visited daily for a week.

 Maternal temperature,pulse,lochia,involution of uterus,state of bowel and bladder should be observed. Blood pressure every 4 hr, hourly pulse,temp and resp rate must be noted for 48hrs. Temperature > 100 deg F with chills and rigor think of sepsis. Give diet with plenty of protein, meat , fish,fresh fruit,green vegetables Additional 400 to 700 Kcal to cover the energy requirement of lactation. Iron and calcium supplementations till 3mnths after delivery.

 Early ambulation, reduces the frequency of puerperal venous thrombosis and pulmonary embolism. Mild Analgesics relieve the pain. Perineum must be clean after each urination and defecation. Ice bags and warm sitz bath may be required to reduce edema and discomfort. Genitalia should be cleaned and protected after every evacuation of bowel.

 Effort be made to induce the patient to pass urine within 6 to 8 hours of delivery if unable to empty

Catheterize

Short course of Anti microbial therapy after the catheter removed

 Keep the breast clean and have the nipple drawn out. Cleaning the areola with water and mild soap is helpful after each nursing.use nipple shield for irritated nipples. Educate the mother for exclusive demand feeding,prevent sore nipples and breast congestion. Educate the mother about the advantage of breast feeding.

 Immunization of baby according to WHO immunization schedule and mother with Rubella & Anti D gamma globulin.
Childwelfare clinics and family planning clinics should run together. Proper exercise to strengthen the pelvic floor muscles in order to correct slight degree of cystocele, rectocele.

Postpartum eclampsia
Because of mobilization of interstitial edema fluid and redistribution into intravenous compartment. Risk enhanced by normal postpartum diuresis Magnesium sulphate conc reduced in serum Convulsions recurs It is called as Persistant Postpartum Hypertension.

 It is associated with thrombocytopenia, renal dysfunction caused by thrombotic microangiopathy. Thrombotic microangiopathy is differentiated from Thrombotic thrombocytopeniac purpura by ADAMTS 13 enzyme activity. Another entity called Postpartum angiopathy is associated with seizures , persistant CNS findings is also called as Reversible Cerebral Vasoconstriction syndrome.

Risk of PIH in Future Pregnancy:

Increased frequency of pre eclampsia after donor insemination and oocyte donation. Risk of Pre eclampsia in second pregnancy increased with maternal age and interval between pregnancies. Obesity is a definitive risk factor for developing PIH eclampsia because of increased cytokine mediated oxidative stress.

 Increased uterine artery vascular impedance in pregnancies complicated by pre eclampsia increases the chances of recurrence of pre eclampsia and growth restriction during the next pregnancy. Low plasma volume in a postnatal period,will predispose to increased sympathetic activity and decreases baroreflex activity. Thus women who are thrombophilic,with contracted plasma volume or those having an cardiovascular abnormalities can possibly be identified as high risk for developing pre eclampsia in future pregnancy.

 Pre eclampsia before 30 wks of gestation have 40% recurrence in future pregnancy. Recurrence rate higher among multiparous women with pre eclampsia. In recurrence ,the pre eclampsia is sudden in onset ,rapidly progressive in subsequent pregnancy . Early onset severe pre eclampsia have metabolic abnormalities and risk factors like
Factor V mutations

Antiphospholipid antibodies Hyperhomocysteinemia Protein S deficiency

Postpartum care in eclampsia:

Postpartum care extended incase of eclampsia than normal. Hypertension and other sign & symptoms of organ dysfunction associated with pre eclampsia should remit by 6 wks postpartum. Women should be counseled that they are at a higher risk of Hypertension complication in subsequent pregnancies.

 Antihypertensive treatment and magnesium sulphate regimen continued for 24 to 48 hrs following delivery. Post delivery assessment of blood count ,liver function ,coagulation profile should be done every 6 to 8 hourly for 48 hrs. In case of severe thrombocytopenia(<50,000) platelet transfusion can be given. Coagulopathy can be corrected with whole blood/ FFP/ cryo precipitate.

Prevention
Regular frequent antenatal visit to tertiary care centre. Educate the patient about Signs and symptoms of pre eclampsia and eclampsia and regular Antihypertensive therapy in Gestational Hypertension

Prophylactic
Low dose aspirin 50 to 150 mg

Oral calcium Fish oil Multivitamin once a week Anti oxidants Regular exercise :
Increases Placental growth & Vascularity Decreases Oxidative stress Reversal of maternal endothelial dysfunction