Lactation and maternal problems following birth

Question 1

List the most common problems encountered in the puerperium

Answer 1

• post partum blues (d 3-4 after birth)
• post partum depression (and psychosis), sleep deprivation
• libido/physical changes, incontinence
• secondary post partum haemorrhage
• purpural sepsis, endometritis, mastitis, CS wound infection, UTI (VTE, URTI, Surgical, IV site, epidural site)
• lactation issues (nipple problems, engorgement, perceived or truly inadequate supply, sore breasts, thrush, vasospasm, blocked ducts/mastitis/abscess, transmission of infection (HIV= contraindication in Australia)/drugs)

Question 2

Define puerperal sepsis and list the most common types of infections, most common organisms and discuss diagnosis and management strategies

Answer 2

• Maternal temperature >38 within 2 weeks birth 
• Sources 
	• Obstetric
          – Endometritis 
          – Mastitis 
	  – CS Wound 
	• UTI
• Less common 
– VTE – URTI – Surgical – Iv site – Epidural site

Endometritis
-Polymicrobial (usually)
aerobes (strep GAS, GBS, enterococcus, E.coli, S. aureus, Klebsiella, Gardnerella)
anaerobes (peptostreptococcus, bacteroides, clostridium) mycoplasma (ureaplasma, mycoplasma)
-Treatment
– Risk factors, prevention
may need blood +/- fluid resuscitation
-outpatient Mx: oral Augmentin
-inpatient Mx: Amp/ Gent/ Flagyl IV
+/- careful curettage after delay for antibiotics

Question 3

Define secondary postpartum haemorrhage and the most common causes and outline the medical and surgical approaches to its management

Answer 3

• excess vaginal bleeding more than 24 hours after delivery
• Risk factors (caesar, esp in labour. Prolonged labour etc)
• Causes: retained products of conception (RPOC)/infection
• Ex: fever, tachycardia, tender bulky uterus, offensive vaginal loss
• Ix: HVS (high vaginal swab), ultrasound, blood cultures

Question 4

List specific complications after caesarean section and vaginal delivery

Answer 4

Not in lec (just went off the top of my head)
CS
-increased risk with following vaginal births/uterine rupture
-wound infection/break down
-regional or general anaesthesia risks
-scar ectopic in future pregnancies
Vaginal
-pelvic floor damage, urinary/faecal incontinence
-perineal tears
-dystochia

Question 5

Understand how lactation is established and maintained; have an understanding of the benefits of breast feeding and how to support women to breast feed

Answer 5

• Pregnancy – estrogen, progesterone, prolactin, HPL
• Delivery – fall progesterone, allows prolactin
• Maintenance of lactation – regular emptying of the breast and stimulation of the nipple (local breast effect)
– Prolactin and oxytocin
– increased by feeding
– Supply and demand

-benefits of breastfeeding:
Mother
-assists return to prepregnant weight
-oxytocin encourages involution of uterus/less blood loss
-reduction in cancer (breast, ovarian, CVD?)
-contraceptive
Child
-reduced atopy/asthma/metabolic disease/hypertension
-SIDS (?)
-more intelligent
-less infections/hospitalisation/mortality (esp d+ and respiratory)
-GIT: less necrotising enterocolitis,
-better mother-child bond
-better for the environment/cheap/convenient

How to support:
WHO recommends for 2yrs, exclusively for 6mo.
-antenatal education, including breast exam at 1st antenatal visit.
-early breast feeding/skin to skin after delivery (all babies w/in one hour)
-encourage demand feeding
-avoid supplemental feeding and dummies
-encourage rooming in
-troubleshoot issues (Lactation consultant, midwife, education. Eg. perceived/true lack of supply, sore nipples etc)
-restrictions on advertising/free samples on formula

Question 6

Be aware of options for post partum contraception

Answer 6

• Choices while breastfeeding:
– Lactational amenorrhoea (97% effective contraceptive if
– baby < 6 months old
– no formula or solids supplementary feeds
– Amenorrhoea
Adding minipill brings contraceptive efficacy up to 99%)

– Progestagen methods 
     – safe in breast feeding 
     – Minipill (30 microgram levenorgestrel) 
	     • commence D21 (earlier starting results in increased spotting in puerperium) 
     – Depo Provera (150 mg medroxyprogesterone acetate) 
         – Implanon (68mg etonorgestrel)
– Barrier methods (condoms, IUCD- if inserting PP do within 48/24 or after 4/52, diaphrams)
– Irreversible (tubal ligation)

If not breast feeding:
• Combined Oral Contraceptive Pill “The pill” (OESTROGEN/PROGESTERONE)
– contra-indicated in breast feeding (reduces quantity and quality of milk; contraceptive steroids cross in breast milk)
– if not breast feeding, ovulation may return within 25 days (mean 45 days); therefore advise commencement of COCP at 21 days

Question 7

Lactation qus quantity

Answer 7

Do your breasts feel empty after a feed?