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.