PN- mum

Question 1

an

Why important to ensure woman can PU?

Answer 1

Avoid overdistension of bladder- can lead to permanent injury
full bladder can inhibit involution (thus = heavier bleeding) + increase afterpains

Question 2

What are normal timeframes for maternal PU?

Answer 2

<6 hrs post partum
normally:
- without analgsia, within 2hrs
- with regional anaestheisa- 4hrs
- elective C section/ spinal- can be >6hrs

Question 3

What is normal bladder activity postpartum

Answer 3

Increased PU (first 2-5 days)
stinging (due to grazes)
oedema- may be more difficult to control PU

Question 4

what is normal Bowel function postpartum?
what are symptoms of constipation

Answer 4

can be delayed up to 3days post partum (due to emptying of bowel in labour)

Question 5

describe haemorrhoids + mgmt

Answer 5

• swollen veins around anus becoming prolapsed and painful
• common to become worse in pregnancy (due to pressure on tissue)- esp with forceps/big baby/ prolonged second stage
• generally improve as progesterone effects decrease. but may continue up to a year
• requires referral if severe / swollen /rectal bleeding

MW mgmt
- ask women at each appointment
- discuss strategies avoid constipation (worsens pain) / can gently push haemarrhoids back in warm bath / with KY jelly
- medication- proctosedyl/ anusol
- if symptoms are severe, offer visual inspection. GP referral.

Question 6

describe constipation + mgmt

Answer 6

BNO >3 days post partum
Constipation can occur post partum (pain, discomfort, straining, hard stools)
hydration , fibre, exercise
consider kiwicrush but be mindful of the type of perineal tear

Question 7

When do you start contraception?

Answer 7

• Women can start ovulating 3wks postpartum (breastfeeding provides some contraception, but not 100%)

Question 8

What are contraception options when BF?

Answer 8

2) 1) oral contraceptive (progestogen only) “Noriday”
* * no impact on BF. Take at same time daily.

2) Condoms
$5 / 144 pack. Safe BF
check latex allergy.

3) Jadelle- implant upper arm
4-5 years. Safe BF.

4) Mirena- Intrauterine device
5yrs. releases progesterone. BF safe

6) Contraceptive Injection (Depo Provera)
** IM injection lasts 3 mths.

Question 9

What are contraceptive options if not BF?

Answer 9

Combine oral contraceptive **
**Levelen Ed **progesterone + oestrogen.
slightly improved contraction, can take anytime of day.
likely reduce supply breastmilk

Question 10

what are considerations for using BF as contraction method?

Answer 10

• no return of period
• <6mths old
  -exclusively BF with no long intervals between feeds

Question 11

post partum anaemia- considerations + signs

Answer 11

considerations-excessive bleeding, low Hb in pregnancy
signs- pallor, tiredness, dizzy, loss of appetite, oedema

Question 12

Rh-Neg women- Post partum assessment

Answer 12

Check bloods
-Direct Coombs test -from Placenta cord bloods, checking for maternal antibodies
Kleihauer test- from maternal bleed, checking # fetal cells

If indicated- administer anti-D within 72hrs to reduce risk of RhD alloimmunisation

Question 13

Cervical screening

Answer 13

testing for human papillomavirus which can cause cancer.
cancer develops slowly without you knowing.
recommend testing every 5 years
refer to GP to organise vaginal swab (Self swab) - may be free (maori/pasifika/ never had a screen/ community service card)

Question 14

Post partum care- GDM

Answer 14

DM medication / infusions should be discontinued post partum.
monitor BGL’s after meals for 24hrs to rule out T1/T2 DM

IF GDM-
document in GP referral
explain important to screen for T2 DM (from 3mths uing HbA1c)

Question 15

Post partum care- pregnancy induced hypertension

Answer 15

Discontinue IV infusions at birth
discointinue insulin + metformin

Question 16

Discharge discussion re. documentation

Answer 16

recommend you save a copy of your records
by law, we keep your Records safe for 10 years (on expect)
you always have right to access them

Question 17

What analgesia is appropriate post partum- NVB

Answer 17

Paracetamol PRN- 500mg tab, (1g QID)
NSAID-
- Iburoprofen PRN- 200MG (2 TAB TDS
- OR Diclofenac (Voltaren - 50mg (1 tab every 8hrs)
- Contraindicated- codeine (inhibits BF)

Question 18

What analgesia is given post caesarean?

Answer 18

• oxycodone first 48hrs
• Paracetamol + NSAID (iburoprofen / diclofenac)- 5-7 days, then PRN
• • oral morphine + TRAMADOL prn
    – Contraindicated- codeine (inhibits BF)

Question 19

what are 3 stages of lactogenesis

Answer 19

**lactogenesis I-
**occurs in pregnancy
development of breast tissue + production of colostrum (may be secreted)
*
**lactogenesis II
**- 60hrs post partum
indicated by full breasts, changed milk composition, increased vol
regulated by endocrine control (prolactin/ oxytocin)- so skin to skin / freq stimulation important
Frequent sucking stimulates production of proaclctin receptor sites (influencing long term vol)*

lactogenesis III
Production / maintenance mature breast milk- from ~2 -6 wks
regulated by autocrine control (amount of milk produced is in response to amount removed),

Question 20

how may interventions influence BF?

Answer 20

analgesia
- epidural- reduce baby alertness (up to 3days) + - delay lactogenesis II
- morphine- sedation +respiratory depression 10hrs
- pethidine- 13 days!!

IV fluids AND / OR syntocin
oedema (fluid from blood vessels seeps into breast tissue)
makes it difficult to latch, risking nipple damage + poor milk transfer

C section
baby- sleepy / uncoordinated suck/ fewer +shorter feeds = LESS PROLACTIN RECEPTORS

Traumatic / instrumental birth
delay lactogenesis
baby - tired/ sleepy / may have damaged facial nerves so painful to feed

Question 21

Mastitis- First line management

Answer 21

Any breast inflammation- redness, discomfort, blocked areas
NOT necessarily bacterial infection

Management

1) Check infection ( temp / HR/ feeling unwell)
2) If no infection present
- continue BF (or otherwise hand express to regularly drain milk)
- Rest
- Cold compress on breast
- NSAID (iburoprofen) to reduce inflammation)
- Paracetamol (analgesia)

Question 22

Bacterial mastitis

Answer 22

Breast inflammation that has become infected.

1) Treat with AB’s
First line treatment- flucloxacillin / Dicloxacillin 10-14 days
Second line- clindamycin

2) Monitor for bresat abscess
area of breast that remains hard, red, painful (even though Woman may be feeling better after ABs/ no pyrexia)
Mgmt
- Breast ultrascan to idetify abscess
- needle aspiration