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Components of Postpartum Care Visit

1. Early detection and management of complications


2. Promoting health and preventing disease
3. Woman centered education and counseling
Key Elements to Postpartum Care
6-12 hours postpartum
Pain
Blood loss
BP
Advice warning signs
3-6 days postpartum (prevention of infection)
Breast care
Fever
Infection
Lochia
Mood
6 weeks postpartum (recovery)
Recovery
Anemia
Contraception
libido
6 months postpartum
General health
Contraception
Continuing morbidity
*AVOID SEXUAL INTERCOURSE UNTIL PERINEAL WOUNDS
HEAL/DECREASE LOCHIA
Management of the 3
rd
stage of labor
Expectant Management
1. Physiological management
2. Placenta delivered by gravity and maternal effort
3. Cord clamped after delivery of the placenta or after
pulsation stops
*OXYTOXICS ARE NOT USED
Active management
1. Early cord clamping
2. Injection of oxytocics after the delivery of the baby
3. Controlled cord traction with counter traction branth
Andrews maneuver
4. Massage uterus
Advantages
Expectant Active
Does not interfere with normal
labor process
Decrease length of 3
rd
stage
Does not require special
drugs/skills and supplies
Decreases risk of postpartum
hemorrhage

Disadvantages
Expectant Active
Increase length of 3
rd
stage Requires oxytocin and supplies
Increase risk of postpartum
hemorrhage
Requires birth attendant with
training in giving injection and
controlled cord traction
COMPARISON BETWEEN OXYTOCIN AND ERGOMETRINE
OXY ERGO
storage 15-30*c 2-8 protect from light, dont freeze
MOA Rhythmic
uterine
contraction
Sustained uterine contraction
Side effect Water
retention- lead
to cerebral
edema
Hypotension
*can be given
to induced the
labor.
*can still be
given after
delivery of the
placenta
Headache,vomiting,nausea,dizziness
Hypertension
*contraindicated in HPN, Heart dse
*can still be given after delivery of
the placenta

Models of Prenatal Care
TRADITIONAL
- Emphasis on no. & freq of visits
- Uncomplicated pregnancy: > 12 visits
- Ritualistic
- More cost and workload
GOAL ORIENTED
- Quality rather than no. of visits
- Uncomplicated pregnancy: 4 visits
- Essential goal: directed elements
- Cost effective: lessen workload
- Quality of care emphasized
New paradigm: every pregnant woman faces risk
- Access to quality maternity care and EmONC
- Screen to detect. NOT screen to predict complications
- Identification & treatment (referral) of pre-existing health
conditions
- Early detections of complications
- Health promotion & dse prevention
- Birth preparedness & complication readiness planning
Postpartum hemorrhage
NSD: more than 500 ml
CS: more than 1000 ml
Differential definitions:
- Pad getting soaked in less than 5 mins
- Constant trickling of blood
- 10% drop in hemoglobin
- s/s of hypovolemia
any bleeding that has potential to result hemodynamic instability if left
untreated, should be considered postpartum hemorrhage
MATERNAL DEATH(2007)
1. complication r/t pregnancy 45.1%
2. HPN 26.6%
3. PPH 17.7%
4. Abortion 10.5%
In the Philippines
- 319 maternal deaths/1000 livebirths (17.7%)
Early PPH W/IN 24 HRS 99%
Late PPH after 24 HRS- 1.%
Suspect or anticipate shock if ANY of the ff:
Vaginal bleeding
Trauma; infection
Management
1. Massage the uterus
2. Inject oxy 10 u IM
3. Insert IV (NSS/LR)
4. Still relaxed? + 20 U to IV (60gtts/min)
5. Refer
If the woman is in SHOCK, insert a second IV line and run at a fast
rate appropriate for the womans condition.
Life saving measures Massive Bleeding
1. Bimanual compression of the uterus
- Wash hands & wear sterile gloves
- Insert right hand into vagina and form a fist
- Apply pressure on the anterior of the uterus
- Place left hand on the abdomen behind uterus
- Firmly press uterus between two hands
2. Compression of the aorta
- Apply direct downward pressure w/ a closed fist
- On the abdomen just above the umbilicus & slightly to the
left
- Maintain compression until bleeding is controlled
3. Uterine packing
- Guide the tip of 24 F foley catheter into the uterine cavity
- Fill balloon w/ 60-80 ml
Anemia
Hemoglobin <11g/dl (1
st
) & 3
rd
trimester <10.5g/dl during 2
nd

Because blood volume of blood increases during pregnancy
(hemodilution), a moderate decrease in the concentration or RBC &
Hemoglobin is normal.
Assessment
Paleness periods,
Tiredness, weakness/fatigue
Breathlessness
Medication
Iron tab. OD
Iron dextran IM(no absorption of iron)
Instructions:
Take iron 1 hour before eating or b/w meals for better absorption
Bowel movement: black & often causes constipation
Never take with milk & calcium supplements
If in liquid form use straw
If IM z track method
Increase fiber & fluid intake to prevent constipation
High in vit C
abortion bleeding dilation Passage of
conception
threaten Y N N

Inevitable Y Y N
Incomplete Y Y Y
complete Y Y/N Y
Missed Y/N N N
Expulsion of all products of conception: complete
Three or more consecutive spontaneous abortions: habitual
Expulsion of some products: inc
Undetected death of an embryo/fetus thats not expelled & that
causes no bleeding(also called blighted ovum,anembryonic
pregnancy, or intrauterine embryonic demise): missed
Vaginal bleeding occurring 20 wks gestation w/out cervical dilatation
& indicating that spontaneous abortion may occur: threaten
Vaginal bleeding or rupture of the membranes accompanied by
dilation of the cervix: inevitable
Complications of PROM
Premature labor, infection & cord prolapsed
Preterm Labor
Labor that begins after 20 wks gestation & before 37 wks gestation
Medications:
1. Calcium channel blocker- nifedipine
2. NSAID: indomethacin- block the release of prostaglandin
not use > 34 wks bc it can lead to premature closure of
ductus posteriosus
3. Tocolytics- pitocine HCL
Terbutaline SO4
4. Anticonvulsant- mg SO4
5. Corticosteroid- betamethasone
Cord Prolapsed- descent of the umbilical cord into the vagina ahead
of the fetal presenting part w/ resulting compression of the cord;
emergency situation; variable deceleration
Management:
Position (t-position)
O2 @ 10-12 L/min (facemask)
Wrap gauze soaked in NSS
Infection of the lining in the uterus associated with chorioamnionitis &
CS birth : endometritis
The fever manifests on the 3
rd
/4
th
postpartal day
An increase in oral temperature to more than 100.4*f (38.6*C) for 2
consecutive 24 hr periods, excluding the first 24 hr period after is
suggesting infection.
If the cause of the fever is found to be related to childbirth but
involves a closed infection, such as thromboplebitis, w/ no danger of
the babys contracting the dse, the mother may care for her child as
long as she maintains bed rest in the prescribed position while doing
so.
If the infection involves drainage(e.g. endometritis, perineal abscess),
newborn visiting may be contraindicated. If rooming-in is continued,
the mother should wash her hands thoroughly before holding the
infant. She should never place the baby @ the bottom bed sheet,
where there may be some infected drainage from her perineal pad
(furnish a clean sheet to spread over the covers)
Sitting in a Fowlers position/walking encourages lochia drainage by
gravity & helps prevent pooling of infected secretion.
Complication
An added danger of endometritis is that it can lead to tubal scarring &
interference w/ future fertility
Clinical breast exam: @ least every 3 yrs for women ages 20-40 yrs
& then annually.
A thorough breast exam, including instruction in BSE takes 10 mins.
Edema & pitting of the skin may result from a neoplasm blocking
lymphatic drainage & giving the skin an orange peel appearance
(peau d orange), a classic sign of advanced breast ca.
To elicit a dimpling or retraction that may otherwise go undetected,
the examiner instructs the patient to raise both arms overhead. This
maneuver normally elevates both breasts equally.

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