Obs: Postnatal care Flashcards
what things will be discuss in routine midwife follow up following birth?
- General wellbeing
- Mood and depression
- Bleeding and menstruation
- Urinary incontinence and pelvic floor exercises
- Scar healing after episiotomy or caesarean
- Contraception
- Breastfeeding
- Vaccines (e.g. MMR)
what is the six week postnatal check?
offered by GP practices to check how the mother is doing - done at the same time as the 6 week baby check
discuss:
- General wellbeing
- Mood and depression
- Bleeding and menstruation
- Scar healing after episiotomy or caesarean
- Contraception
- Breastfeeding
- Fasting blood glucose (after gestational diabetes)
- Blood pressure (after hypertension or pre-eclampsia)
- Urine dipstick for protein (after pre-eclampsia)
what is lochia?
bleeding in the post natal period - mix of blood, endometrial tissue and mucus. initially red and over time will turn dark red/brown in colour
usually settles in 6 weeks
avoid tampons - risk of infection
why might bleeding be heavier during breastfeeding?
breastfeeding releases oxytocin which can cause uterus to contract - reassure women this is completely normal
when will womens periods return after delivery?
breastfeeding - may not return for 6 months of longer (lactational amenorrhoea)
bottle-feeding women - menstrual periods from 3 weeks onwards (unpredictable and often irregular at first)
when is fertility considered to return after giving birth?
considered to return at 21 days
contraception is not required up to this point
how effective is lactational amenorrhea as a method of contraception?
98% effective for up to 6 months. women must be fully breastfeeding and amenorrhoeic (no periods)
when can the POP or the implant be used following delivery?
can be started at any time after birth
considered to be the safest in breastfeeding
when can the COCP be given after delivery?
avoided in breastfeeding
UKMEC 4 before 6 weeks
UKMEC 2 after 6 weeks
what are the rules regarding the copper coil or the IUS post delivery?
either within 48 hours of delivery or more than 4 weeks after birth
what is postpartum endometritis?
inflammation of the endometrium usually caused by infection introduced during or after labour and delivery
is endometritis more common post c section or vaginal delivery, and what is given to prevent it?
more common after caesarean and prophylactic antibiotics given to reduce risk of infection
what are some common microorganisms which cause endometritis?
gram-negative, gram-positive and anaerobic bacteria
sexually transmitted infections - chlamydia and gonorrhoea
how does endometritis present?
foul-smelling discharge or lochia
bleeding that is getting heavier
lower abdo pain/pelvic pain
fever
sepsis
how is endometritis diagnosed?
vaginal swabs
urine culture and sensitivities
ultrasound to rule out retained products of conception
how is endometritis managed?
septic patients - hospital admission and sepsis 6
milder symptoms and no signs of sepsis may be treated in community with oral abx - typically co-amoxiclav
what is retained products of conception?
when pregnancy related tissues (placental tissue or fetal membranes) remain in uterus after delivery
can also occur after miscarriage or termination of pregnancy
how does retained products of conception present?
- Vaginal bleeding that gets heavier or does not improve with time
- Abnormal vaginal discharge
- Lower abdominal or pelvic pain
- Fever (if infection occurs)
how is retained products of conception diagnosed?
ultrasound scan
how is retained products of conception managed?
evacuation of retained products of conception - surgical procedure involving GA
cervix is gradually widened using dilators and retained products manually removed through the cervix using a vacuum aspiration and curettage
what are 2 complications of dilatation and curettage?
Endometritis
Asherman’s syndrome
What is Asherman’s syndrome?
where adhesions form within the uterus
endometrial curettage can damage basal layer of the endometrium
damage may heal abnormally creating scar tissue connecting areas of the uterus.
can lead to infertility
what is postpartum anaemia?
defined as haemoglobin of less than 100 g/l in the postpartum period
what are the indications for an FBC to be conducted the day after delivery?
PPH over 500ml
CS
antenatal anaemia
symptoms of anaemia
what is postpartum anaemia managed?
- Hb under 100 g/l – start oral iron (e.g. ferrous sulphate 200mg three times daily for three months)
- Hb under 90 g/l – consider an iron infusion in addition to oral iron (e.g. Monofer, CosmoFer or Ferinject)
- Hb under 70 g/l – blood transfusion in addition to oral iron
when is an iron infusion considered in women?
- May have poor adherence or oral treatment
- Cannot tolerate oral iron
- Fail to respond to oral iron
- Cannot absorb oral iron (e.g. inflammatory bowel disease)
what are the risks of iron infusions?
allergic and anaphylactic reactions
used with caution in pt with a hx of allergy or asthma
what is a contraindication to an iron infusion?
active infection as many pathogens feed on iron
wait for infection to be treated before giving iron
what is baby blues?
affects more than 50% of women in the first week or so after birth,
present with Mood swings
- Low mood
- Anxiety
- Irritability
- Tearfulness
what are some of the reasons for baby blues?
- Significant hormonal changes
- Recovery from birth
- Fatigue and sleep deprivation
- The responsibility of caring for the neonate
- Establishing feeding
- All the other changes and events around this time
how is baby blues managed?
symptoms are usually mild
only last a few days and resolve within 2 weeks of delivery
no treatment required
what is postnatal depression?
triad of low mood, anhedonia and low energy - symptoms lasting 2 weeks before diagnosis
typically affects women 3 months after birth
how is postnatal depression managed?
- Mild cases may be managed with additional support, self-help and follow up with their GP
- Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy
- Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit
what is the edinburgh postnatal depression scale?
used to assess how the mother has felt over the past week as a screening tool for postnatal depression
10 questions, with a total score out of 30 points
what is puerperal psychosis
rare but severe illness that typically has an onset between 2-3 weeks after delivery
woman experience full psychotic symptoms:
- Delusions
- Hallucinations
- Depression
- Mania
- Confusion
- Thought disorder
how is puerperal psychosis managed?
- Admission to the mother and baby unit
- Cognitive behavioural therapy
- Medications (antidepressants, antipsychotics or mood stabilisers)
- Electroconvulsive therapy (ECT)
what is a mother and baby unit?
specialist unit for pregnant women and women that have given birth in the past 12 months
designed so mother and baby can stay together and continue to bond
mothers supported to continue caring for baby while they get specialist treatment
how are women with existing mental health problems supported throughout pregnancy?
referred to perinatal mental health services for advice and specialist input
what is neonatal abstinence syndrome?
SSRI antidepressants taken during pregnancy can lead to neonatal abstinence syndrome
presents in the first few days after birth with symptoms such as irritability and poor feeding. neonates are monitored for this after delivery
supportive management is usually sufficient
what is mastitis?
inflammation of the breast tissue
common complication of breastfeeding
+/- infection
what causes mastitis?
caused by obstruction in the ducts and accumulation of milk - regularly expressing breast milk can help prevent this occurring
can also be caused by infection - can enter nipple and back-track into the ducts causing infection and inflammation
what is the most common bacteria associated with mastitis?
staph aureus
how does mastitis present?
- Breast pain and tenderness (unilateral)
- Erythema in a focal area of breast tissue
- Local warmth and inflammation
- Nipple discharge
- Fever
how is mastitis managed?
conservative - expressing milk, breast massage, heat packs, warm showers, simple analgesia
infection - flucloxacillin or erythromycin. sample of milk can be sent to lab for culture and sensitivities
fluconazole for candidal infections
what is a rare complication of mastitis and how is this managed?
breast abscess - surgical incision and drainage
when does candidial infection of the nipple often occur?
following a course of antibiotics
can lead to recurrent mastitis as it causes cracked skin on the nipple that create an entrance for infection
how may candida infection of the nipple present?
- Sore nipples bilaterally, particularly after feeding
- Nipple tenderness and itching
- Cracked, flaky or shiny areola
- Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash
how is candida of the nipple treated?
Both the mother and baby need treatment, or it will reoccur. Treatment is with:
- Topical miconazole 2% after each breastfeed
- Treatment for the baby (e.g. miconazole gel or nystatin)
how is candida of the nipple treated?
Both the mother and baby need treatment, or it will reoccur. Treatment is with:
- Topical miconazole 2% after each breastfeed
- Treatment for the baby (e.g. miconazole gel or nystatin)
how is candida of the nipple treated?
Both the mother and baby need treatment, or it will reoccur. Treatment is with:
- Topical miconazole 2% after each breastfeed
- Treatment for the baby (e.g. miconazole gel or nystatin)
how is candida of the nipple treated?
Both the mother and baby need treatment, or it will reoccur. Treatment is with:
- Topical miconazole 2% after each breastfeed
- Treatment for the baby (e.g. miconazole gel or nystatin)
how is candida of the nipple treated?
Both the mother and baby need treatment, or it will reoccur. Treatment is with:
- Topical miconazole 2% after each breastfeed
- Treatment for the baby (e.g. miconazole gel or nystatin)
what is postpartum thyroiditis?
condition where there are changes in the thyroid function within 12 months of delivery, affecting women without a history of thyroid disease
can involve thyrotoxicosis, hypothyroidism or both
what is the long term prognosis for postpartum thyroiditis?
thyroid function returns to normal over time and pt will become asymptomatic again
small. portion of women will remain hypothyroid and need long-term thyroid hormone replacement
what is the pathophysiology of postpartum thyroiditis?
not clear
pregnancy has an immunosuppressant effect on the mothers body to prevent her from rejecting the fetus, once delivered there can be exaggerated rebound effect with increased immune system activity and expression of antibodies - including antibodies that affect the thyroid gland - inflammation - over/under activity
what are the typical 3 stages of postpartum thyroiditis?
- Thyrotoxicosis (usually in the first three months)
- Hypothyroid (usually from 3 – 6 months)
- Thyroid function gradually returns to normal (usually within one year)
what are some signs and symptoms of thyrotoxicosis?
- Anxiety and irritability
- Sweating and heat intolerance
- Tachycardia
- Weight loss
- Fatigue
- Frequent loose stools
what are some signs and symptoms of hypothyroidism?
- Weight gain
- Fatigue
- Dry skin
- Coarse hair and hair loss
- Low mood
- Fluid retention (oedema, pleural effusions, ascites)
- Heavy or irregular periods
- Constipation
what TFTs do you expect in thyrotoxicosis?
raised T3 and T4 with suppressed TSH
what TFTs do you expect in hypothyroidism?
low T3 and T4 and raised TSH
what are TFTs performed after delivery?
6-8 weeks
how is postpartum postpartum thyroiditis managed?
- Thyrotoxicosis: symptomatic control, such as propranolol (a non-selective beta-blocker)
- Hypothyroidism: levothyroxine
women require annual monitoring of TFTs even after condition has resolved
what is Sheehan’s Syndrome?
rare complication of PPH where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland
low blood pressure and reduced perfusion of the pituitary gland leads to ischaemia in the cells of the pituitary and cell death
is the anterior or poterior pituitary gland affected in Sheehans syndrome?
anterior
how does the anterior pituitary get its blood supply?
low-pressure system called the hypothalamo-hypophyseal portal system
susceptible to rapid drops in blood pressure
what hormones does the anterior pituitary release?
- Thyroid-stimulating hormone (TSH)
- Adrenocorticotropic hormone (ACTH)
- Follicle-stimulating hormone (FSH)
- Luteinising hormone (LH)
- Growth hormone (GH)
- Prolactin
what hormones are released by the posterior pituitary gland?
oxytocin
ADH
how does Sheehan’s syndrome present?
lack of hormones produced by the anterior pituitary leading to signs and symptoms of Reduced lactation (lack of prolactin)
- Amenorrhea (lack of LH and FSH)
- Adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH)
- Hypothyroidism with low thyroid hormones (lack of TSH)
how is Sheehan’s managed?
managed under guidance of specialist endocrinologist - replacement of missing hormones
- Oestrogen and progesterone as hormone replacement therapy for the female sex hormones (until menopause)
- Hydrocortisone for adrenal insufficiency
- Levothyroxine for hypothyroidism
- Growth hormone
