Post+Partum+Rounding

Postpartum Orientation Handout toc

Try to have fun—holding and admiring babies is an important part of the job.

Rounding

 * First**, obtain the sign-out list of postpartum moms from the perinatal resident on-call the night before. Sometimes this is posted on the counter in postpartum.The residents should see some patients, including sicker or more complicated women that they know or someone they delivered, before they leave post-call or to clinic. The residents may need prescriptions co-signed by the attending.On weekends, the dayfloat resident is usually available to help starting at 9 AM, depending on if there are admissions to do.


 * Second**, note mothers who are sick or potential discharges. Sick mothers should be seen first, then patients undergoing PPTL, confirmed discharges, followed by potential timely discharges (24-hour), and then, lastly, uncomplicated moms who are not going home.

Women who are not being discharged should have as much done as possible, e.g. discuss contraception, so that they are ready the next day.Women who might go home later in the day need to have everything set so that if they do go home ideally the resident can just give a verbal OK.


 * Steps to Rounding**
 * 1) Review chart (H and P, delivery notes), admission medication reconciliation form, hemoglobin result and vital signs.
 * 2) Ask the patient standard questions about bleeding, eating, ability to urinate, pain, breastfeeding.Address any concerns about the delivery or the baby (can refer to peds).Ask where they were seen for prenatal care and about contraception plans.Ask if they still have prenatal vitamins at home.Admire the baby or ask about condition of baby if not with mom.
 * 3) Focused exam (see postpartum progress note cues)
 * 4) Remove C-section bandage by POD#2.
 * 5) Replace staples from Cesarean with steri-strips if pfannenstiel incision and healing well on POD #3 (supplies may be in a pink basket by nursing station). If morbidly obese or not closing schedule staple removal in clinic.
 * 6) Fill out progress note.

When postpartums are completed let the resident covering L and D know that all is complete and sign out any concerns.Please ask if anything is unclear.

Postpartum Tubal Ligations
PPTLs are performed on weekdays as add-on surgeries. On the weekends, they can be done if there is another OR case or if there are two or more tubals to do. Please identify these women early.
 * 1) Verify that they want the procedure
 * 2) Obtain a history and discuss any concerns with the OB attending (morbid obesity, hx of prior abdominal surgery, prior salipingectomy, etc)
 * 3) Confirm that their 30-day consent has been obtained and is correct.
 * 4) Sign a CCRMC surgery consent form.
 * 5) Make sure they are NPO.
 * 6) Inform the OR attending about the case so they can get them on the OR schedule.
 * 7) Sign these patients out to the attending/resident before leaving so that they remember to resume their diet, if the surgery cannot be done.

Timing of Discharge
Women with uncomplicated vaginal deliveries generally stay a minimum of 24 hours and up to 2 days postpartum. They can request to stay the maximum time but a discharge at 24 hours, if OK’d by pediatrics, is preferred by many, especially experienced moms, and can help minimize overcrowding on the unit.Women with little home support, or mental health or social issues, requiring more evaluation and education usually need to stay the maximum time.The mother cannot stay beyond 48 hours post delivery without a medical indication.

Women with uncomplicated cesarean deliveries usually stay until the 3rd postpartum day but can be discharged 2-4 days postpartum if eating and surgically stable.

If the baby is staying longer, particularly if the mother is breastfeeding, it is usually better to encourage her to stay the maximum time before discharging her, hopefully to a boarder room.Women going to the boarder room can get discharge meds from the inpatient pharmacy but they do not receive nursing or physician care.

Discharge Medications

 * Routine Medications for all patients:**


 * Motrin** 600mg. one q 6 hours prn cramping or pain #30
 * DSS** 250 mg. one bid prn constipation #20; give #60 for 3rd and 4th degree laceration.

Give FeSO4 325mg. 1 daily #50 if Hb 8-10 Give FeSO4 325mg. 1 bid #100 for Hb <8
 * Iron** is given if significantly anemic:


 * Prenatal Vitamins**: If they have run out, prescribe 1 daily, #100.


 * Vicodin**: Post ceserean and PPTL.


 * Milk of Magnesia**: give for all women with 3rd and 4th degree laceration.


 * Contraception:**
 * Most women leave with some form of contraception even though they are advised not to have sex for 4-6 weeks.
 * Brookside San Pablo will arrange contraception for their clients so only send them out with condoms.
 * Brookside Richmond prefers for us to prescribe birth control before discharge.
 * Only order OCPs that are covered by MediCal for MediCal patients (Orthotricyclen and Micronor are generally safe).
 * Nuvaring is not covered by MediCal
 * Depoprovera can be given at discharge as an order or deferred to the first postpartum visit.
 * Plan B can be ordered, and there are information sheets to give out.

Follow-up Planning

 * 1) Women seen in our system receive a postpartum visit at four weeks linked to the 1 mo well baby visit.
 * 2) Cesareans receive wound check follow-up visit in one week (ideally with baby's visit). Staples are usually removed from pfannenstiel incisions before discharge but vertical incisions may need an appointment for staple removal (usually by 10 days).
 * 3) Uncomplicated Tubal Ligations can usually get by with education about self monitoring the wound and a prn visit if there is a problem.
 * 4) Sooner visits may be scheduled for other indications such as diabetes, elevated blood pressure, depression, etc.
 * 5) Brookside Community Clinic would like all their patients to return at 2 weeks. Schedule one week follow-up for C-section wound checks. Brookside also follows the babies.
 * 6) La Clinica would like to see patient at 4-6 weeks post partum and they also follow babies. C-section wound checks are seen at one week.
 * 7) Planned Parenthood patients are seen for the 4-6 week postpartum visit at Planned Parenthood but should be scheduled for wound checks and any medical problems in our system.The clerk is good about getting these set up correctly.

Discharge Paperwork
To **discharge** a patient the following steps should be completed: Nurses and Residents can help you get through this paperwork and help you find supplies such as staple removers, contraception handouts, etc.
 * 1) Complete purple-bordered discharge summary (usually started by delivering resident).Dictate brief summary for all patients.
 * 2) Write a Discharge order in the chart (i.e. d/c IV d/c home).
 * 3) Fill out postpartum discharge medication prescription.**Initial** chosen items and **cross out** other items.
 * 4) Any additional medications need a prescription (Vicodin, Keflex, etc.) (usually done on RXM), and they also need to be written at the bottom of the admission medication reconciliation form.
 * 5) Sign the bottom of the admit/discharge med reconciliation form whether or not you add meds.Do not write on the nursing form (the one with the stop signs).

Breastfeeding
 Most medications are OK with breastfeeding—consult [|LactMed] and discuss with an Attending before telling a woman she cannot breastfeed.  Hepatitis B and C are not contraindications to breastfeeding in most cases. Breastfeeding is contraindicated in HIV infection, Methamphetamine, Cocaine and Heroid Abuse.

Postpartum Contraception
Vaginal intercourse should not be resumed until 4-6 weeks postpartum, particularly with laceration repairs. However, many women will resume intercourse prior to the routine postpartum visit at 6 weeks post delivery. Thus, all women are offered contraception at discharge. The following options are available:


 * Depoprovera 150 mg. IM day of discharge**: This injection will last for 12 weeks and is very effective. There are no contraindications but use caution in patients with a history of depression. The most common side effects are irregular bleeding or amenorrhea, increase in acne and and a possible increase in weight (2-5lbs). Depoprovera is thought to be safe with breastfeeding. A depoprovera order sheet is available to schedule repeat doses in clinic. Patients with restricted MediCal will only get ongoing depoprovera covered through Family Pact funding at Planned Parenthood or in Public Health or Women’s Health clinics.


 * Combined OCPs:** Effective if taken correctly. Orthotricyclen and Orthocyclen are reliably covered by Medi-Cal but any covered pill may be prescribed. Give 3 months with 3 refills in most cases. She should start 2-4 weeks from delivery to avoid the thromboembolic risks in the immediate postpartum period. Estrogen containing contraception (combined pills, Nuvaring, patches) should not start sooner than 3 weeks postpartum and are generally delayed to 4-6 weeks, if breastfeeding. Breastmilk volume can decrease so she should be advised to breastfeed more frequently when starting the pill, and to delay starting and use alternative contraception if she is having trouble breastfeeding. Contraindications: hypertension, history of DVT or thromboembolic event, migraines with neurologic symptoms, significant liver disease (steatohepatitis).


 * Ortho Evra Patches** : Same start times and contraindications as the combined pill. Covered by both MediCal and Health Plan.


 * Nuvaring** : Same start times and contraindications as the combined pill. Covered by Health Plan, not MediCal.


 * Progesterone only pill** : Norethindrone 0.35 mg each day. Not as effective as the combined preparations but works well enough in the exclusively breastfeeding woman. NO PILL FREE WEEK. Common side effects are spotting, irregular bleeding Start 2 weeks postpartum. No contraindications.


 * IUD (Paraguard or Mirena** ): Can be placed at 6-8 weeks postpartum. Consider interval contraception. Mirena can be placed 10 minutes after delivery but will have a higher expulsion rate and we don’t have experience doing this.


 * IMPLANON:** Available in the pharmacy. Can be placed immediately postpartum if not breastfeeding. FDA approved after 4 weeks when breastfeeding. We will place Implanons if there is someone available who has completed the training and the mom is not breastfeeding (FDA approved after 4 weeks if breastfeeding).


 * Condoms and contraceptive foam** . Prescribe 12 condoms and one package contraceptive foam. Consider Plan B as well.


 * Vasectomy:** If he does not have coverage refer to Public Health or Planned Parenthood. She will need interval contraception.


 * Laparascopic/Essure tubal Ligation** : Can be done at 6 weeks postpartum if 30 day consent done. Consider GYN clinic appt. in 2-3 weeks to facilitate scheduling. Consider another method to cover the gap.


 * Plan B** : Emergency contraception progesterone only. Easiest to use if already in the patient’s possession. Give at discharge to anyone with uncertain contraception plans. Take both pills as soon as possible after intercourse within 5 days.


 * Diaphragm** : Not popular in our population. Can be fitted at 6 weeks postpartum.

**Quantiferon Postive**
CXR is done for positive QuantiFeron, or positive TST (PPD)—if positive TST and negative QuantiFeron then CXR is not necessary. If low risk, no screening is necessary. If history of 6 months INH, CXR is not needed.
 * Low risk: not out of the country for more than one month in the last 5 years, no jail, homelessness, or street drugs in the last two years.
 * Ideally CXRs are looked at on Web 1000 before discharge.

INH for positive Quantiferon, negative CXR should not be prescribed unless follow-up is established—usually it is prescribed in the clinic at a follow-up visit. (See TB Wiki Page)

**Gestational Diabetes**
A 75 gram glucose tolerance test is recommended by ACOG at 6 weeks postpartum for all patients with GDM in order to diagnose type II diabetes.However, the important message to the patient is that lifelong dietary changes/weight control can prevent diabetes, and periodic screening is needed. If she has a glucometer recommend doing periodic fasting levels with follow-up for FBS>110.

Endomyometritis
Mothers with endomyometritis should be with IV antibiotics until 24-48 hours afebrile. Oral antibiotics are not necessary.

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Post Partum Depression
Patients with a history of significant depression or postpartum depression may be started prophylactically on a SSRI, given a sooner follow-up or educated on coming in or calling for persistent symptoms of depression.Zoloft is the SSRI with the best safety profile for breastfeeding (covered on CCHP)

Prevena
C-sections patients who are high risk for post op infections are being fitted with a Prevena woundvac. It is placed in the OR immediately post-op and kept on 2 - 7 days. Routine removal in clinic is indicated by POD #7 Prevena does not treat wounds, it is preventative therapy, so the patient has a wound closed with staples or subcuticular sutures underneath the dressing. Remove the Prevena prior to 7 days if you suspect a wound infection, redness, purulence, fever, etc. You may find a small wound dehisence or seroma under the pravena when removed and this should be treated like any wound breakdown, do not replace the Prevena onto an open wound.

For instructions on use see the Patient Guide
 * To turn off hold button for 5 seconds
 * To turn on hold button for 2 seconds

**Miscellaneous Issues**

Rhogam is given by protocol if mom is Rh negative and baby is Rh positive. Please make sure the nurses do not miss this. MMR is given at discharge if mom is non-immune to Rubella The nurses will fill out WIC forms, and medical records helps with birth certificates.

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