19 - Postpartum Care Flashcards
What are the contraindications to breastfeeding?
- Mother with TB infection
- Mothers with uncontrolled/unmonitored HIV
- Infants of mothers who are taking medications which may be harmful e.g. amiodarone, anticancer drugs, lithium, oral retinoids, iodine
What are the benefits of breastfeeding for mothers and infants?
Mother
- Stimulates uterus to contract and return to normal size
- Promotes faster weight loss after birth
- Less risk of postpartum depression
- Less postpartum bleeding
- Fewer urinary tract infections
- Less chance of anemia
Baby
- Immunity via IgA antibodies for baby’s nose, ears, throat
- Reduces risk of SIDs
- Reduces obesity and CVD risk in adulthood
What is the APGAR score?
Assessment of infant’s clinical status immediately after birth done at one and five minutes after rubbing baby with warm towel
5 domains with score of 2 in each
Score of 7-10 is normal so if below need urgent senior review
If 3-5 after 5 minutes high risk of cerebral palsy
What are the limitations of the APGAR score?
- May be affected by anaesthesia
- Black skin
What women may need additional postnatal care?
- women who misuse substances
- recent migrants or women who do not speak English very well
- young women aged under 20
- women who experience domestic abuse
Some women may go to a post-natal ward after delivery to be monitored. What are some things that are monitored during this period?
- Analgesia PRN
- Help establishing breast or bottle-feeding
- VTE risk assessment
- Monitoring for PPH
- Monitoring for sepsis
- Monitoring blood pressure (after pre-eclampsia)
- Monitoring recovery after a caesarean or perineal tear
- FBC check (after bleeding, caesarean or antenatal anaemia)
- Anti-D for rhesus D negative women (depending on the baby’s blood group)
- Routine baby check
Before a woman’s care is transferred to the community/midwife leaves a home birth, what things need to be done?
- Assess mother and baby health
- Check mum’s bladder by measuring volume of first void
- If baby has not passed meconium tell them to seek help from GP if not passed within 24 hours
- Make sure plan for feeding baby with at least 1 observed successful feed
- Importance of pelvic floor exercises
- Educate about the postnatal period and what to expect
- Educate about what support is available (statutory and voluntary services) and who to contact if any concerns arise at different stages.
When should a midwife and health visitor visit a mother when her care has been transferred to the community?
Midwife: Within 36 hours
Health Visitor: 7 to 14 days after transfer of care from midwifery team
What topics should be discussed at post-natal midwife check ups?
- Postnatal period and what to expect
- Postpartum mental health signs and symptoms
- Post party physical health signs and symptoms e.g VTE, mastitis
- Importance of pelvic floor exercise
- Nutrition
- Contraception
- Sexual intercourse
- Safeguarding concerns inc DV
- Perineal or Wound healing
GPs often perform a 6 week post natal check up on both mother and baby. What things are looked at for the mother in this check up?
- General wellbeing
- Mood and depression
- Bleeding and menstruation
- Scar healing after episiotomy or caesarean
- Perineal health
- Contraception
- Breastfeeding
- Cervical screening
- Fasting blood glucose (after gestational diabetes)
- Blood pressure (after hypertension or pre-eclampsia)
- Urine dipstick for protein (after pre-eclampsia)
Baby health checks are performed 72 hours after birth and then after 6-8 weeks. What things should be looked at during this check?
- appearance: colour, breathing, behaviour, activity and posture
- head (including fontanelles), face, nose, mouth (including palate), ears, neck and general symmetry of head and facial features
- eyes: opacities, red reflex and colour of sclera
- neck and clavicles
- limbs, hands, feet and digits: assess proportions and symmetry
- heart: position, heart rate, rhythm and sounds, murmurs and femoral pulse volume
- lungs: respiratory effort, rate and lung sounds
- abdomen: assess shape and palpate to identify any organomegaly; check condition of umbilical cord
- genitalia and anus: completeness and patency and undescended testes in boys
- spine: inspect and palpate bony structures and check integrity of the skin
- skin: colour and texture as well as any birthmarks or rashes
- central nervous system: tone, behaviour, movements and posture; check newborn reflexes only if concerned
- hips: symmetry of the limbs, Barlow and Ortolani’s manoeuvres
- cry: assess sound
What supplement is recommended for breast feeding mothers?
Vitamin D as breast milk lacks this
What advice should you give a woman on the return of menstruation following giving birth?
- Lochia will start dark red and get lighter. Bleeding will be worse after breastfeeding due to release of oxytocin. DO NOT USE TAMPONS AS RISK OF INFECTION. Should settle after 6 weeks.
- Menstruation may start 3 weeks after birth if bottle feeding
- Menstruation may cease for 6 months (lactational amenorrhea) if exclusively breastfeeding
What advice should you give a woman who has just given birth about contraception?
- Fertility does not return until 21 days after birth
- Contraception needed after 21 days if not breastfeeding exclusively
- Lactational amenorrhea is 98% effective only if exclusively breastfeeding and no periods and only up to 6 months
What contraception can be started in the post part period?
USE CONDOMS FOR 7 DAYS WHEN STARTING COCP AND 2 DAYS FOR POP
- POP: start anytime
- Implant: anytime
- COCP: cannot use for 6 weeks postpartum or if breastfeeding
- Coils: <48 hours post delivery or >4 weeks post part
Post-partum endometritis is more common following C-section so prophylactic antibiotics are given. What are the signs of postpartum endometritis?
- Foul smelling discharge or lochia
- Bleeding that gets heavier or does not improve with time
- Lower abdominal or pelvic pain
- Fever
- Sepsis
What investigations are done if you suspect post part endometritis?
- Vaginal swabs inc chlamydia and gonorrhoea
- Urine culture and sensitivities
- US to rule out retained POC
How is postpartum endometritis managed?
If septic admit to hospital and do sepsis six
Sepsis Abx: IV Clindamycin + Gentamicin
Endometritis Abx: PO Co-amoxiclav in community. Same for post procedure endometritis
What antibiotics are given for the following obstetric infections/scenarios:
- Chorioamnionitis
- Intrapartum Group B Strep
- Infected Perineal wound
- Mastitis
- Chorioamnionitis: IV Cefuroxime + Metronidazole
- Group B Strep: IV Benzylpenicillin
- Perineal Wound: PO Flucloxacillin + Metronidazole
- Mastitis: PO Flucloxacillin
How is postpartum anaemia treated?
- Hb<100: Start PO Iron TDS for 3/12 (Ferrous Sulphate)
- Hb<90: Consider Iron infusion as well as PO iron
- Hb<70: Blood transfusion as well as PO iron
What is baby blues and how is it managed?
- 50% of women get this in first week after birth
- Symptoms: mood swings, low mood, anxiety, irritability, tearful
- Symptoms usually only last a few days and resolve within 2 weeks of delivery
- No treatment needed
What is postnatal depression?
Triad of:
- Low mood
- Low energy
- Anhedonia
Usually presents around 3 months after birth and symptoms have to be for at least two weeks for diagnosis
Can occur up to 1 year post partum
What screening tool is used for post-natal depression?
Edinburgh Postnatal Depression scale
Score out of 30, if 10 or more suggests PND
What is puerperal psychosis and how does it present?
Onset within two to three weeks after delivery
- Delusions
- Hallucinations
- Depression
- Mania
- Confusion
- Thought disorder
- Paranoia
What mothers are at a higher risk of puerperal psychosis?
- Previous history of severe mental illness, such as schizophrenia or bipolar
- Family history of postpartum psychosis
- Personal history of postpartum psychosis
How may mastitis present?
- Unilateral breast pain and tenderness
- Erythema in focal area
- Local warmth and irritation
- Nipple discharge
- Fever
How may candida of the nipple present and why is it an issue?
Can occur after a course of antibiotics and can lead to recurrent mastitis due to cracked skin on surface of nipple
- Sore nipples bilaterally
- Nipple tenderness and itching
- Cracked, flaky or shiny areola
- White patches in mouth of baby
What is the typical pattern of postpartum thyroiditis?
- Thyrotoxicosis in first 3/12
- Hypothyroid from 3-6 months
- Thyroid function gradually returns to normal within a year
What is Sheehan’s syndrome?
Complication of PPH where drop in circulating volume and blood pressure leads to avascular necrosis of pituitary gland
Only affects anterior hormones
How may Sheehan’s syndrome present?
- Reduced lactation due to lack of PRL
- Amenorrhea due to lack of FSH, LH
- Adrenal Insufficiency due to low cortisol from low ACTH
- Hypothyroidism due to lack of TSH
