174 Normal Postpartum Care and Breastfeeding for the PANCE & How to Win

Hello and welcome to episode 174 of the Physician Assistant Exam Review Podcast. This week, we’re going to be covering normal postpartum care and we’re going to do something a little different. We’re going to do the priming questions right at the top of the show here. A red wedge-shaped area on a nursing mother’s breast suggests what diagnosis? Stop and think for just a second. A red wedge-shaped area on a nursing mother’s breast suggests what diagnosis? How about this one? Uterine cramping that worsens during breastfeeding is driven by what hormone? What’s the hormone that causes uterine cramping during breastfeeding? A breastfed infant needs what daily supplement? What daily supplement are we talking about? What infant metabolic disorder rules out both breast milk and standard formula? What metabolic issue makes it so the child can’t get breast milk or standard formula? A white count of 20,000 on postpartum day one with no fever needs what management? What are you going to do?

My name is Brian Wallace, I’m the host and creator here at Physician Assistant Exam Review where we’ve been working with students for over 15 years and the priming questions are one way to get your brain working as we move into the material. This show teaches the medicine, but what we really want to do is make sure that you’re locking it in, so that you’re ready for your EOR, your PACKRAT, your EOC, or the PANCE or whatever you have coming next. The idea is that we’re going to make sure that you have this information, not just that you cram it for the next exam coming up, but that you have it forever. The last episode, we finished the intrapartum emergencies and today we’re doing normal postpartum care. Next episode, we’re going to do the postpartum visits and we’re going to do postpartum contraception. We’ll go through all of that. Perfect. So today only has two topics. It’s going to take us about 20 minutes to get through normal puerperium, which is uterine involution, lochia, and vital signs and labs that are normal after delivery. So we went from monitoring the patient during the process to now monitoring mom after the process right after delivery. We’re also going to cover breastfeeding and lactation, how milk is made and how things like engorgement versus mastitis and we’ll get to all that shortly.

So normal, normal puerperium. This is the six week period after delivery during the time where the reproductive tract and maternal physiology return to the non-pregnant state. So the number one thing we’re thinking here is uterine involution. So immediately after delivery, the uterus becomes firm. We talked about that before, right? That’s it clamping down and stopping the… I was going to say blood flow, but that’s not, it’s stopping any bleeding is really the idea here. So that muscle is contracting. So immediately after delivery, the uterus should be firm and it should be just below the umbilicus. On a daily basis, the fundal height should decrease about one centimeter or one fingerbreadth. In about two weeks, it should return into the pelvis and no longer be palpable. If you’re, if you’re palpating the mom’s abdomen at two weeks, you should no longer be able to feel the uterus. And at six weeks we’re near a pre-pregnancy size, which is about the size of your fist.

Afterpains, you can get uterine cramping, right? From myometrial contraction during involution. So as the uterus is clamping down over this time period, you can absolutely get cramping. This is intensified with breastfeeding. And the reason is oxytocin is released in both situations. During breastfeeding oxytocin is released, but I can remember what oxytocin does is it increases contractions, right? So we run up against that. So we get that cramping that can occur. And this is more severe in multiparous women.

Lochia is the postpartum uterine discharge, and this can last for up to six weeks. So this should progress from red to pink, to brown, to yellow, white. And here’s the real key. I’m not sure if they’re going to ask you about colors. I feel like that might be a little overboard. It’s sort of like when people ask about bruising in colors, I always feel like it’s, yeah, you can kind of use it. And maybe it would be one test question, but it’s kind of, I don’t know. The real key here though, is if you have a foul odor from that fluid and the patient has a fever, what’s the concern then? So stop and think for a second. If you listened to last week, what’s the concern if there’s a foul odor and a fever? Well, we’re worried about endometritis, right? We’re worried about the endometrium being infected. The other thing we’re worried about is if we get bright red bleeding, then what are we worried about? If we get bright red bleeding. Well, we’re worried that we have retained placenta, some retained placenta in there, right? Now, normally that’ll happen earlier after delivery, but it’s something you want to be aware of.

Another thing that mom needs to be aware of is you can get postpartum diuresis for days two to five. And what this is, is just a removal of the extracellular fluid that’s been accumulating throughout pregnancy. So it’s not, it’s normal is what I’m trying to say.

Another big thing in this period is you can get hypercoag, you are hypercoagulable. Mom is hypercoagulable here. So you have an increased risk of venous thrombosis that peaks at about three weeks after delivery, but it remains elevated for about six weeks. So to me, that falls into a really good question. What I’m thinking is, how do I write questions? How is this going to come to me in the PANCE? How is this going to come to me on my EOR? That’s something that kind of jumps out to me. Are they going to ask you about postpartum diuresis on days two to five? Maybe, maybe it’s possible. But to me, that heightened coagulability peaking at three weeks and staying elevated through six weeks is something I would pay much closer attention to.

Ovulation is going to begin to reoccur at some point, right? If the mom is not breastfeeding, this can be as early as day 25. But if she is breastfeeding, this is usually delayed, but it can be variable.

Something that can absolutely be a question is that an increased temperature, so let’s say 38 degrees Celsius in the first 24 hours, is to be treated as normal, right? We’re not going to get too excited about that right out of the gate. So that can be elevated due to dehydration, due to the exertion of labor for all those things. But when we get higher than that, when we get higher than 100.5, then we start to be concerned. And again, what are we concerned about? Well, mostly it’s endometritis. That’s the big scary thing that we want to watch out for, right? You can also get a urinary tract infection. You can get surgical or perineal wounds can be a problem. You can get an elevated temperature from a DVT. So you want to pay attention to all of these things if you have that elevated temperature, but just have that in the back of your mind.

Another thing that can throw people off is a white blood cell count of 20,000 to 25,000 can be normal for the first couple of days. That alone isn’t a cause to ring the alarm bells for an infection, but you have that with the overall picture, right? You have a fever, you have high white blood cells. Now you’re starting to get concerned. But on its own, it’s not necessarily an indicator right after delivery.

How do we work through this period? That period right after delivery, analgesia. So pain control, NSAIDs, ibuprofen, and acetaminophen are first line. So we’re going to do Tylenol and ibuprofen right out of the gate. Can we give opioids? Yes, but it’s going to be a short course and really like to avoid them, but we are going to use them especially after a C-section. Perineal care is going to be important, especially depending on how the delivery went. Ice packs, for example, at least for the first 24 hours, then the sitz bath is a good idea. Stool softeners are a really nice idea here as well. A lot of pregnant women have hemorrhoids, so a stool softener will certainly help with that.

Another mainstay after anything like this is early ambulation. So I think about it, and again, I tend to group things, so this may sound funny, but I think about it like a surgery, right? So after surgery, I want people up and moving. After a delivery of a child, I’m thinking about they need to be up and moving. And why? Because we want to reduce the chance of a DVT. We also want to get them breathing. This wasn’t in my notes here, but it’s something I know we think very carefully about with surgery, which is that you’re not taking deep breaths laying in bed, right? Your lungs don’t fill, so you can get some, I’m not going to go into a deep here, but you can get some junk buildup in the bottom and you can get some pneumonia-type symptoms, and you can get, some people can get very sick from not taking those deep breaths. That’s why we use the incentive spirometer following surgery, just forces you and or trains you to take deep breaths, but getting up and walking will do the same thing.

All right, exam keys here. The fundus at the umbilicus after delivery, right? That’s where it should be. It should descend about one centimeter per day, and it should be not, no longer palpable at about two weeks after delivery. The lochia turns from red to pink-brown to yellow to white. That’s over like about six weeks, but our real concern here is foul odor plus fever equals endometritis. A temp up to 38 degrees Celsius in the first 24 hours and a white blood cell count up to 25,000, we’re going to consider that normal if there’s nothing else going on. But a fever after 24 hours, we’re going to be concerned about.

Real quick before we get into breastfeeding and lactation, when I’m releasing this, it’s PA Week, which means I’m jumping on board with everybody else and doing a huge giveaway. In fact, there’s over $1,200 in prizes for the giveaway. If you go to physicianassistantexamreview.com/giveaway, which is a little hard to spell, but you’ll figure it out. You’ll get all the details in there, but you’re going to get access to The Final Step 3.0 before anyone can buy it. You’re going to get a ticket into 33 Days to Pass the PANCE, and you’re going to get a one-to-one session with me, which I don’t do that many of to help break you out of where you’re stuck, what’s going on with you, and see if we can’t get you moving forward and get your problems solved. All of that’s going to be included there. There’s actually going to be three winners, but head on over there and check out the details. It closes out on Friday as PA Week comes to an end, and then I’m going to announce the winner on Monday.

All right, let’s hop back in and get to breastfeeding and lactation. The American Academy of Pediatrics and the WHO recommend exclusive breastfeeding for about six months, then continued breastfeeding, but with complementary foods. Prolactin is the hormone that stimulates milk production, and this you should absolutely, I would know the six month thing as well, but this you should absolutely know. Prolactin is the hormone that stimulates milk production.

Delivery of the placenta leads to a fall in progesterone, which leads to the milk coming in in about two to five days. Retained placental fragments delay lactation. That’s another sort of sign if you get bleeding and delayed lactation, which I could kind of see written up in a test question.

Something else to note here, which is going to absolutely be a test question, is Sheehan syndrome. This seems kind of strange, and I had trouble grasping it when I first learned about it in PA school, but this is a postpartum pituitary infarction after a severe hemorrhage. So what happens is the pituitary does not get enough blood because mom’s losing so much blood, and then we do not get lactation because prolactin’s not made. Does that make sense? So Sheehan syndrome is a postpartum pituitary infarction after severe hemorrhage, and it causes, the first place you’re going to see this show up is a failure to lactate because you’re not getting prolactin.

Now oxytocin is the other part here where we have prolactin and oxytocin. Oxytocin stimulates milk ejection, so it allows the milk to come down. It also contracts the uterus. So remember, this is what’s going to cause increase in pain, in abdominal pain and cramping, is going to go along with breastfeeding because of the oxytocin.

Another term you should know is colostrum. This is the very first milk. It’s thick and kind of yellowy, and it’s very high in IgA and proteins. There is a recommendation that breastfed infants get vitamin D because breast milk is very low in vitamin D.

So what are the benefits of breastfeeding? Well, you have two sides of benefits for breastfeeding. One is for the infant and one is for the mother. Let’s talk about the infant here. I know we’re not doing a pediatric section, but we’ll hit it since we’re here anyway. In the infant, breastfeeding lowers the rates of otitis media, respiratory infections, and GI infections. So to me, I’m just going to hold onto the idea that it lowers the risks of infections right after delivery. You can know each one, and I understand why you’d want to, and you probably should, but for me, I don’t have that strong of memory. I’m going to just realize that I’m going to hold onto the fact that it helps with infections early on. It decreases the risk of sudden infant death syndrome. It lowers the risk of necrotizing enterocolitis, which obviously you want to stay away from. It lowers the risk of childhood obesity and type two diabetes later in life, interestingly enough.

In mom, you get a faster involution and less postpartum blood loss. Why? Again, we’re talking about that oxytocin again. So the uterus shrinks down quicker, and you get less postpartum blood loss with breastfeeding. It actually lowers breast and ovarian cancer risk, and it lowers type two diabetes and hypertension risk. Interestingly enough.

What are the contraindications? When are we not going to do breastfeeding? There are a handful, right? And there are things that you should absolutely know. Galactosemia in the infant is one. This is kind of rare, but it’s the inability to metabolize galactose. So this is detected on the newborn screen, but in this case, breast milk and formula aren’t going to work. You’re going to need soy-based formula. If they can’t break down galactose, you’re going to need soy-based formula.

Maternal HIV positive is going to be another contraindication. We’re probably going to use formula here. Now, there is some guidance that allows breastfeeding with mom on antiretroviral therapy, depending on the viral load. We’re not going to go into that here. That’s probably enough for where we’re at.

Something else that came up in my notes is untreated active TB. It’s not really an issue with the breastfeeding. It’s more an issue of being in the same room, right? So expressed milk can be given, but not by mom. So if you’re going to pump, you can do that and then have someone else in the room to give it to the child. I thought that was an interesting caveat that came up. A herpes simplex lesion on the breast, right? We’re not going to feed through an active herpes infection. If mom is an illicit drug user, we’re probably not going to do breastfeeding at that point. If she’s on cocaine or opioids or things of that nature, not a great idea. Obviously if mom’s on certain medications as well, chemotherapies and other agents, I don’t think that’ll come up, but keep it in mind.

This is a list that’s kind of interesting and may be valuable to you. What are not contraindications for breastfeeding that you might think are? So hepatitis B is not a contraindication. Hepatitis C, from what I could read, is not a contraindication unless the nipples are cracked or bleeding. Mastitis is not a contraindication and hopefully you know that, but we’ll go over it. And most maternal infections and most antibiotics, not reasons to stop breastfeeding.

All right, along with breastfeeding, we can get engorgement, which is bilateral. That’s a key here. It’s days two to five as the milk comes in. The breast feels firm, full and tender. There’s no focal erythema. That’s one of the ways you can tell the difference here between a mastitis and engorgement is the redness. The tenderness is going to be there regardless. A mastitis is going to present as unilateral and wedge-shaped. In most cases, again, it’s not always going to present like the books say, but engorgement is bilateral. Mastitis is unilateral wedge-shaped area of erythema. It’s going to feel warm and yes, there’s going to be tenderness. So these are going to be what you’re trying to decide between.

With a mastitis, you’re going to expect to see a fever above like a 38.3 or 101. You can get chills and myalgias. And the most common bug: Staph aureus.

The other thing you want to keep an eye out for when we’re talking about engorgement mastitis is breast abscesses. This is a fluctuant, tender mass. Often following mastitis, that’s not getting better. So you wouldn’t usually start with an abscess. You’d usually have an infection that would then become an abscess.

So here are questions that would be something like, a woman three weeks after delivery with a fever and a red wedge-shaped area on one breast then ask you whether she should stop breastfeeding. And the answer is no. With mastitis, we don’t stop breastfeeding. It’s not a problem.

How are we going to treat this? Well, engorgement is going to be we feed the baby. We can do cold compresses. We can do ibuprofen. We’re not going to do antibiotics here. There’s nothing to treat. With mastitis, now we’re going to do antibiotics. That’s going to be our first line, right? Dicloxacillin or cephalexin for 10 to 14 days should clear this up. Again, we’re going to continue breastfeeding. You’re not going to want to do excessive pumping but you’re just going to want to continue breastfeeding.

If there’s no improvement following antibiotic, what do we do next? Again, I don’t want to just feed you these things. I want you to stop and think. This is what’s important here. If there’s no improvement after three days of an antibiotic in a suspected mastitis, what are we doing next? We’re going to think it might be an ultra, I mean, it might be an abscess. So what do we do to figure out if it’s an abscess or not? Well, we can do an ultrasound and we can look for that abscess. And then we can do a needle aspiration and pull out some of the fluid and see what’s going on if we find it. So it’s sort of a continuum. This is what we’re trying to discover what we’re trying to figure out as we go.

All right, if we do not want to breastfeed, we can use a supportive bra, ice packs, and avoid nipple stimulation to help to suppress lactation.

All right, let’s run through our exam keys here. Prolactin is the milk-producing hormone. Oxytocin is the milk-ejecting hormone, but it also causes uterine contractions, which we know from previous studies, right? Breastfed infants should get vitamin D. Our contraindications to breastfeeding are galactosemia, maternal HIV, herpes lesion on the breast, all the medications and things we went through. Knowing the difference between engorgement, mastitis, and abscess, really important. I can absolutely see that coming up. The thing that always stood out to me was also the idea that you’re going to continue to breastfeed through mastitis.

All right, so the postpartum timeline. Let’s just run through this real quick before we wrap up for today. 24 hours after delivery. A slight fever is going to be normal. After 24 hours, we’re concerned, right? Especially about endometritis. Day two to five, the milk comes in. You can get engorgement and postpartum diuresis. At two weeks, the uterus should no longer be palpable in the abdomen. I would know that timeline. I think that’s valuable.

Perfect. All right, that covers our two topics for today. Excellent, excellent work. Before we get to the answers to our priming questions, I want to just talk about our study tip for today. And it’s something that’s been coming up a lot recently when I’m working with students. And that’s the idea of winning the day. Win the day you’re working on.

People try to map out how many questions should I do every day? Should it be 60? Should it be 20? Should it be 100? Well, all kinds of different things. Should I be setting six hours a day? Every day is different, right? I have some students who are doing 12-hour shifts in the ER or in surgery. Well, they’re not going to be able to accomplish everything they want to get done and do a 12-hour shift just isn’t going to happen. But you also don’t want to wait for everything to the weekend or when you have a day off. Because that’s trying to stack a lot of things into one day.

So my recommendation is win the day. When we’re talking about studying, when we’re talking about getting ready, when we’re talking about moving through PA school, win the day that’s in front of you. Make a plan. What’s the minimum standard I’m going to achieve today? And then do that. It doesn’t have to be the same thing every single day. If studying for 30 minutes and doing five questions is what you get to today, great to get that done. Make sure that you get that done and mark that off as a win and be proud of it. Too many times we would do something like that and then worry that we’re not getting enough done.

Every day is not going to be the same. Some days your car breaks down. You can still win on those days. Everything doesn’t have to get thrown out the window because something goes wrong or because you have a longer day than usual. Set the minimum and get that done before the day starts. And get as much of a win as you possibly can on each and every day. And if you can stack those days, you’ll find even if you have a tough week, by the time you get to the weekend and you think you’re going to make up studying, you have done a lot already.

Not to mention that almost like going to the gym, it’s not quite the same, but it’s similar in the sense that if you don’t go to the gym all week and then you go for five hours on the weekend and then don’t go all week and then go for five hours on the weekend and then don’t go all week and go for five hours on the weekend, not the same as doing 45 minutes a day. Half an hour a day, not the same. And it’s the same thing when you come to study. Crushing it every weekend for eight hours, not the same as doing 45 minutes a day or half an hour a day.

Great, okay. Next week, we’re going to cover birth control after delivery, which methods on which days and why estrogen waits till day 21 and get through all of that stuff that’s going to show up on your PANCE.

Let’s jump into the priming questions. Let’s see if we can get these answered for you today. A red wedge-shaped area on a nursing mom’s breast suggests what diagnosis? This should be super easy now, super easy. Mastitis. Uterine cramping that worsens during breastfeeding is driven by what hormone? I think I said this about 50 times. Oxytocin. A breastfed infant needs what daily supplement? Vitamin D. What infant metabolic disorder rules out both breast milk and standard formula? What infant metabolic disorder rules out both breast milk and standard formula? Galactosemia. A white count of 20,000 on postpartum day one with no fever needs what management? What do we do if we see a white count of 20,000 on postpartum day one and no fever? We don’t do anything, reassurance, that’s it.

All right, great work today. Get over to physicianassistantexamreview.com/giveaway and get logged in there before Friday. I’d love to have you get a chance to win that. And that’s it for today. Think different, work different, score different. I’ll see you next week.