Chapter 21 Nursing Care of the Family During the Postpartum Period Quizlet
Postpartum Care: An Approach to the Fourth Trimester
Am Fam Physician. 2019 October 15;100(8):485-491.
Patient information: A handout on this topic is available at https://familydoctor.org/recovering-from-delivery.
Related letter of the alphabet: Postpartum Relapse Prevention: The Family Physician'southward Function
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Article Sections
- Abstract
- Timing and Frequency of Postpartum Visits
- Postpartum Health Bug and Patient Concerns
- References
The postpartum menstruation, defined as the 12 weeks subsequently delivery, is an important fourth dimension for a new female parent and her family and tin be considered a fourth trimester. Outpatient postpartum care should exist initiated within 3 weeks after delivery in person or past phone, and may require multiple contacts with the patient to fully address needs and concerns. A full cess is recommended within 12 weeks. Care should initially focus on acute needs and risks for morbidity and bloodshed and then transition to care for chronic atmospheric condition and health maintenance. Complications of pregnancy, such every bit hypertensive disorders and gestational diabetes mellitus, impact a woman'southward long-term wellness and crave specific attention. Women diagnosed with gestational diabetes should receive a 75-g two-hour fasting oral glucose tolerance test between four and 12 weeks postpartum. Patients with hypertensive disorders of pregnancy should have a claret pressure cheque performed within seven days of delivery. All women should take a biopsychosocial cess (e.1000., low, intimate partner violence) screening in the postpartum flow, and preventive counseling should be offered to women at high adventure. Additional patient concerns may include urinary incontinence, constipation, breastfeeding, sexuality, and contraception. Treating these bug during the postpartum menses is important to the new mother'due south immediate and long-term wellness.
The 12 weeks later on delivery, known every bit the postpartum period or the 4th trimester, are a disquisitional time in the life of a mother and her infant. Maternal mortality, which is defined as deaths that occur during pregnancy and the first year postpartum, is highest in the first 42 days postpartum and represents 45% of total maternal bloodshed.1,2 Early on postpartum visits should evaluate complications from pregnancy besides as common postpartum medical complications.iii–5 Subsequent care should include a full biopsychosocial assessment and be tailored to private patient needs going forrad.iii Family physicians should be aware of the importance of social determinants of health and disparities in maternal outcomes according to race, ethnicity, and public wellness insurance status.
Timing and Frequency of Postpartum Visits
- Abstract
- Timing and Frequency of Postpartum Visits
- Postpartum Health Issues and Patient Concerns
- References
Historically, physicians have performed a single postpartum visit betwixt 4 and six weeks subsequently delivery to close the prenatal intendance relationship.ane In that location is a growing consensus to initiate care within the first three weeks postpartum, and to extend the postpartum period to transition to care of chronic weather.vi–8 The American Higher of Obstetricians and Gynecologists (ACOG) recommends a postpartum evaluation within the first three weeks later on delivery in person or past phone, with a consummate biopsychosocial assessment to be completed within 12 weeks postpartum.three The World Wellness Organization recommends visits at three days, seven to 14 days, and six weeks postpartum, inclusive of newborn care.iii,nine A routine pelvic examination is not indicated unless there are patient concerns.
Postpartum Health Problems and Patient Concerns
- Abstract
- Timing and Frequency of Postpartum Visits
- Postpartum Wellness Problems and Patient Concerns
- References
Wellness issues in the postpartum menses include medical complications, patient concerns, and conditions that may crusade hereafter wellness risks (Tabular array i).4,10–52 Family physicians may demand to go on to provide medical care for these conditions beyond 12 weeks after commitment. Complications that occur during the prenatal period may reveal areas for intervention and surveillance.20,21
Tabular array one.
Postpartum Health Bug and Patient Concerns
| Condition/concern | Diagnostic considerations | Treatment considerations | Notes |
|---|---|---|---|
| Secondary postpartum hemorrhage10–12 | Ultrasonography to look for retained placental fragments | Uterotonics are outset-line handling May need uterine curettage Antibiotics for endometritis if infection is suspected | Occurs in upwards to ii% of women in the postpartum flow Hemorrhage can occur up to 12 weeks postpartum Risk factors include firsthand postpartum hemorrhage, vaginal (vs. cesarean) commitment, and maternal age of 35 years or older |
| Endometritis13,xiv | Fever with no other source, may be accompanied by uterine tenderness and vaginal discharge | Unremarkably requires intravenous antibiotics, about testify for clindamycin and gentamicin | Higher likelihood of anaerobic infection or chlamydia in late infections |
| Thromboembolic disease15–17 | Adventure is five times college during postpartum flow than pregnancy Elevated risk persists upwardly to 12 weeks postpartum | Avoid directly thrombin inhibitors and direct oral anticoagulants in women who are breastfeeding | — |
| Hypertensive disorders4,18,19 | Highest hazard is < 48 hours after delivery Recommend part visit to check blood pressure inside seven days of commitment | Treat if blood pressure level ≥ 150/100 mm Hg, can use oral nifedipine or labetalol Hospitalize if signs of end organ harm or blood pressure level ≥ 160/110 mm Hg Recommend lifestyle changes and annual follow-upward for claret force per unit area and trunk weight monitoring | Occurs in upwardly to 10% of women in postpartum catamenia Risk factor for future cardiovascular disease, cerebrovascular disease, and venous thromboembolism |
| Gestational diabetes mellitus20–22 | 75-g, 2-hour fasting oral glucose tolerance exam four to 12 weeks postpartum to detect type 2 diabetes mellitus, and so screening every i to iii years | Recommend lifestyle changes and annual follow-up | five% to 10% of women with gestational diabetes proceed to have type 2 diabetes after delivery Lifetime chance of developing type two diabetes is multiplied at to the lowest degree eightfold after a diagnosis of gestational diabetes Take a chance increases with a college torso mass alphabetize, more abnormal glucose tolerance examination results, nonwhite race, and older historic period |
| Thyroid disorders23,24 | Can have symptoms of hyperthyroidism or hypothyroidism Test thyroid-stimulating hormone and free thyroxine Positive thyroid-stimulating hormone receptor antibodies distinguish Graves disease from postpartum thyroiditis | Hyperthyroidism is transient and usually non treated Beta blockers can be used as needed for symptoms Hypothyroidism is treated with thyroid hormone therapy | Up to ten% of women develop postpartum thyroiditis Up to one-half of patients will exist hypothyroid at one year postpartum, sometimes later initial recovery of thyroid office The American Thyroid Association recommends annual screening for hypothyroidism in women with a history of postpartum thyroiditis |
| Postpartum depression25–29 | Edinburgh Postnatal Depression Calibration and Patient Health Questionnaire-2/9 are valid diagnostic tools for postpartum depression | Consider counseling and medication | Occurs in upward to 10% of women in postpartum period Recommend counseling to preclude low in high-risk women |
| Intimate partner violence30,31 | Use HARK (humiliation, afraid, rape, kick) or HITS (injure, insult, threaten, scream) tools to evaluate for intimate partner violence | Consider counseling, domicile visits, and parenting support | Prioritize patient safe, consider referral to intimate partner violence prevention organizations |
| Urinary incontinence32–34 | Evaluation includes history, exam including coughing stress test with a full bladder and assessment of urethral mobility, urinalysis, and measurement of postvoid residual urinary volume | Bladder grooming, weight loss, pelvic floor muscle exercises effective as outset-line handling | More than one-fourth ofwomen experience moderate or severe urinary incontinence in the outset year postpartum |
| Hemorrhoids and constipation35 | Consider furnishings of medications and supplements such as atomic number 26 | Increased dietary fiber and water intake Osmotic laxatives (polyethylene glycol [Miralax] or lactulose) recommended for constipation Stool softeners recommended for hemorrhoids May need excision or ligation for refractory hemorrhoids or grade III or higher | Constipation may affect upwardly to 17% of women in the kickoff twelvemonth postpartum |
| Breastfeeding problems36–38 | Evaluate latch, swallow, nipple type and condition, and hold of the infant | Interventions include professional back up, peer support, and formal education | — |
| Postpartum weight retention/metabolic risk39,40 | Women with higher gestational weight gain, black race, and lower socioeconomic status are at college chance | Dietary changes, or diet and exercise in combination are effective | Increased risk of hereafter obesity and blazon 2 diabetes |
| Sexuality 41,42 | Symptoms of low postpartum libido and reduced sexual role probable caused by low estrogen levels and multiple psychosocial factors | Reassurance normally appropriate Resolves over fourth dimension | Address earlier render of sexual activity with contraception to avoid unintended closely spaced pregnancies |
| Contraception41–52 | — | For women who are breastfeeding: progestin-but methods can be used immediately postpartum (e.m., etonogestrel implant [Nexplanon], levonorgestrel-releasing intrauterine system [Mirena], medroxyprogesterone [Depo-Provera]) | Firsthand use is not harmful to the infant Can improve pregnancy spacing |
| Adolescents: begin motivational interviewing, discussion of long-acting reversible contraception during pregnancy | Intervention during pregnancy is superior to postpartum period | ||
| Timing: offer progestin-simply methods immediately (no estrogen until three weeks postpartum) to all women regardless of lactation | Before introduction of contraception |
SECONDARY POSTPARTUM HEMORRHAGE
Secondary postpartum hemorrhage is defined as significant vaginal haemorrhage that occurs across 24 hours postpartum. Rates may be as high as 2%,ten and retained placental tissue and infection are the virtually common causes. Women with secondary postpartum hemorrhage may need to be examined in the emergency section or infirmary for prompt evaluation, including ultrasonography to investigate for retained placental tissue.11 Treatment may include uterotonic medications, uterine curettage, or antibody handling for endometritis.12
ENDOMETRITIS
Women with a fever and tachycardia during the postpartum period should exist evaluated for endometritis. Patients may likewise have uterine tenderness or vaginal discharge. Late postpartum endometritis occurs more than than seven days afterwards delivery. Chance factors include chorioamnionitis and prolonged rupture of membranes.thirteen Endometritis usually requires handling with intravenous antibiotics, with virtually evidence supporting the use of gentamicin and clindamycin.14
THROMBOEMBOLIC DISORDERS
The risk of venous thromboembolic disease, including deep venous thrombosis and pulmonary embolism, is 5 times higher during the half dozen weeks postpartum than during pregnancy.17 A lesser degree of increased risk persists upward to 12 weeks postpartum.5 Boosted risk factors are increasing age, cesarean delivery, postpartum hemorrhage or infection, and a history of preeclampsia.xv
Patients with a history of thromboembolism should be treated with anticoagulation for at least the first 6 weeks postpartum, and potentially longer if in that location are other risk factors. Warfarin (Coumadin) is teratogenic during pregnancy; even so, information technology is minimally excreted in chest milk and is considered safe for women who are breastfeeding. At that place is a lack of data on the use of direct oral anticoagulants in breastfeeding, and they are not recommended for these patients.xvi
HYPERTENSIVE DISORDERS
Up to 10% of women have elevated blood pressure during pregnancy, including chronic hypertension, gestational hypertension, and preeclampsia. Women with hypertensive disorders of pregnancy should take a follow-up blood pressure check within seven days of delivery and exist evaluated for signs or symptoms of end organ damage such as hepatic injury or pulmonary edema.4,18 Patients with new-onset blood pressure of 150/100 mm Hg or college or with signs of stop organ harm should be treated with antihypertensive medications. Patients with signs of cease organ damage or a blood force per unit area of 160/110 mm Hg or college should exist hospitalized and treated with parenteral magnesium sulfate to prevent eclampsia.18 Nonsteroidal anti-inflammatory drugs are preferred over opioid analgesia and take been shown to be safe for women with a history of hypertension in pregnancy.xix,53,54
Women with hypertensive disorders have an increased risk of cardiovascular events afterward in life.18,55,56 They as well have an elevated adventure of cardiovascular illness, cerebrovascular disease, and venous thromboembolic disorders, and are at risk of these complications at an earlier age than the full general population. All patients with a history of hypertensive disorders of pregnancy should be counseled on behavior modification and have blood pressure and body weight monitored at to the lowest degree once a twelvemonth.18,55
GESTATIONAL DIABETES MELLITUS
Gestational diabetes mellitus is a significant risk gene for the development of type ii diabetes mellitus, hypertension, and subsequent heart disease. A woman with a history of gestational diabetes has an eight- to xx-fold gamble of developing type 2 diabetes during her lifetime.20,21 Women with gestational diabetes should exist screened for impaired glucose tolerance with a 75-k 2-hr fasting oral glucose tolerance test at iv to 12 weeks postpartum, and should be evaluated for development of hypertension with blood pressure monitoring.20,53 They should continue to be screened for diabetes every i to three years because the risk of type ii diabetes is elevated.21
THYROID DISORDERS
Postpartum thyroiditis tin can impact up to ten% of women during the first twelvemonth postpartum, with similar rates of hyperthyroidism and hypothyroidism.23 Postpartum hyperthyroidism is normally transient and does non need to be treated. Hypothyroidism is treated with thyroid hormone therapy. The risk of Graves disease is also increased postpartum, and women with a history of this illness are more probable to relapse. Positive thyroid-stimulating hormone receptor antibodies can distinguish Graves disease from postpartum thyroiditis. Infants of women who are breastfeeding and being treated for thyroid disorders should be monitored for growth and development; however, laboratory monitoring of infants' thyroid office is not necessary.23,24 The American Thyroid Association recommends annual thyroid function screening in women with a history of postpartum thyroiditis.23
POSTPARTUM DEPRESSION
Up to 10% of women will experience low in the starting time year postpartum. The U.Due south. Preventive Services Chore Forcefulness (USPSTF), ACOG, and American Academy of Pediatrics recommend 1 or more screening examinations for postpartum low in settings where systems are in place to ensure diagnosis, treatment, and follow-up.25–27 The American Academy of Pediatrics has specific recommendations for timing of screening at the one-, two-, four-, and six-month well-child visits. The Patient Wellness Questionnaire-2, Patient Health Questionnaire-9, and Edinburgh Postpartum Low Scale are appropriate screening tools.
The USPSTF as well recommends preventive counseling for women at loftier risk of perinatal low.28 Risk factors include a personal or family history of low, a history of intimate partner violence, stressful life events including unplanned or undesired pregnancy, poor social or fiscal support, and medical complications. A previous American Family Physician (AFP) commodity reviewed identification and direction of peripartum depression.29
INTIMATE PARTNER VIOLENCE
The USPSTF recommends screening women of reproductive age for intimate partner violence with a validated screening tool such equally HARK (humiliation, afraid, rape, boot; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2034562/table/T1/) or HITS (injure, insult, threaten, scream; https://www.aafp.org/afp/2016/1015/p646.html#afp20161015p646-t2), followed by referral to support services if indicated.30 Interventions such equally counseling and home visits tin reduce intimate partner violence for women postpartum.
URINARY INCONTINENCE
In one big cohort study, 28.v% of women reported moderate or severe urinary incontinence in the offset twelvemonth postpartum.32 Bladder grooming, fluid management, body weight loss, and pelvic floor muscle exercises ameliorate symptoms for all types of urinary incontinence, merely studies accept included women who are perimenopausal and not postpartum.34 It is uncertain whether pelvic floor muscle preparation during the postpartum period has an upshot on urinary incontinence; however, it does reduce postpartum urinary incontinence by about one-third when initiated prenatally.33
HEMORRHOIDS AND CONSTIPATION
Hemorrhoids may be acquired by constipation or by pushing during the second stage of labor. Initial therapy involves treatment for constipation.35 Up to 17% of women report constipation in the offset six weeks postpartum. Iron supplements taken orally during pregnancy can be a contributing cistron. Offset-line treatments include increased intake of water and fiber, and osmotic laxatives such as polyethylene glycol (Miralax) or lactulose. Patients with hemorrhoids should besides be treated with stool softeners.
BREASTFEEDING Problems
A previous AFP commodity addressed breastfeeding recommendations and common problems.36 The USPSTF found moderate evidence that primary intendance–based interventions to increase breastfeeding are benign.37 Individual-level interventions take stronger evidence of effectiveness. These include professional person support past physicians, midwives, or lactation counselors; peer support; or formal teaching sessions. A Cochrane review found that support by trained personnel (eastward.grand., medical professionals, volunteers), face-to-face interventions, and interventions that took place over multiple encounters were more effective.38
POSTPARTUM WEIGHT Retentivity AND METABOLIC RISK
Although data are limited on postpartum torso weight retention, a National University of Sciences report estimates that nigh women at vi months postpartum volition weigh about eleven.8 pounds (v.4 kg) more than their prepregnancy body weight. Risk factors for higher postpartum weight retention include more trunk weight gain during pregnancy, blackness race, and lower socioeconomic status. Postpartum weight retention is a risk factor for subsequently metabolic risk including development of obesity, higher weight in future pregnancies, and blazon ii diabetes in women who accept previously had gestational diabetes.39 Counseling most dietary modifications or dietary and exercise modifications together are effective in helping women lose weight postpartum.twoscore
SEXUALITY AND CONTRACEPTION
Libido and sexuality are mutual concerns during the postpartum menstruum.41 Some studies have shown that pre-pregnancy estrogen levels may not return for every bit long as one twelvemonth postpartum, specially in women who are breastfeeding, which may contribute to a low libido.41,42 The length of time for women to wait to have intercourse following commitment is variable; the average is six to 8 weeks in the United States.41,42 No consistent correlation exists between delivery complications (due east.g., vaginal lacerations) and a filibuster in resuming intercourse.41,42 Because well-nigh patients report some type of sexual problem postpartum,42 information technology is important to assess patients, validate concerns, address contributing factors, reassure when appropriate, and offering support including counseling.
The prenatal period is the all-time time to discuss postpartum contraception. A 2015 Cochrane review reported low-quality prove for the effectiveness of nascency control method educational activity in the postpartum period; even so, a more recent study demonstrated the effectiveness of motivational interviewing resulting in a decrease in rapid repeat pregnancy and a higher employ of long-acting reversible contraception in pregnant adolescents.43,44
Women who are breastfeeding may likewise use the lactational amenorrhea method, lonely or with other forms of contraception. The woman must exist breastfeeding exclusively on need, be amenorrheic (i.e., no vaginal haemorrhage after 8 weeks postpartum), and have an baby younger than vi months. This method is less reliable one time the infant starts eating solid food. The failure charge per unit is less than 2% if these criteria are fulfilled.45,46
Information Sources: PubMed searches were done using the terms postpartum care, secondary/late postpartum hemorrhage/hemorrhage, postpartum endometritis, postpartum thyroid, hypertensive disorders of pregnancy, postpartum thromboembolism, postpartum mood disorders, postpartum substance employ, postpartum urinary incontinence, postpartum constipation, postpartum hemorrhoids, breastfeeding, postpartum weight, postpartum sexuality, postpartum contraception, maternal babe dyad, and postpartum complications. Also searched were the Cochrane database, Essential Bear witness Plus, and recommendations from the American College of Obstetricians and Gynecologists, the Centers for Affliction Control and Prevention, the U.S. Preventive Services Job Force, and the World Health System. Search dates: July and September 2018, and June 2019.
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