Post-natal care Flashcards
how managed in days after delivery
Analgesia as required
Help establishing breast or bottle-feeding
Venous thromboembolism risk assessment
Monitoring for postpartum haemorrhage
Monitoring for sepsis
Monitoring blood pressure (after pre-eclampsia)
Monitoring recovery after a caesarean or perineal tear
Full blood count check (after bleeding, caesarean or antenatal anaemia)
Anti-D for rhesus D negative women (depending on the baby’s blood group)
Routine baby check
primary care involvement post natally
6 week check offered by GP
to 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)
is bleeding after birth normal
yes, as endometrium initially breaks down and then returns to normal over time = called lochia.. mix of blood, endometrial tissue and mucus. increased during breatfeeds as oxytocin causes uterus to contract
tampons post birth?
avoided as risk of infection for around 6 weeks
define lactational amenorrhoea
The absence of periods related to breastfeeding
can last 6 mths of longer
bottle feeding women menstruation
from 3 weeks onwards
very irregular and delayed
when does fertility return after pregnancy
21 days after giving birth…no contraception until then
contraception post natally - when start and how
After 21 days women are considered fertile, and will need contraception (including condoms for seven days when starting the combined pill or two days for progestogen-only contraception).
is lactational amenorrhoea effective contraceptive
over 98% effective if fully breastfeeding and amenorrhoeic
contraception used during breastfeeding
POP and implant used
copper coil or IUS within 48 hours of birth or more than 4 weeks after birth, otherwise c/i
COCP c/i! - before 6 weeks after childbirth in women that are breastfeeding
endometritis definition
inflammation of the endometrium, usually caused by infection. It can occur in the postpartum period, as infection is introduced during or after labour and delivery.
endometritis risk fx
post caesarean section
endometritis prophylaxis
abx given during caesarean
endometritis organism
gram-negative, gram-positive and anaerobic bacteria. It can also be caused by sexually transmitted infections such as chlamydia and gonorrhoea.
clinical fx 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
ix when suspect postpartum endometritis
Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)
Urine culture and sensitivities
USS - rule out retained products of contraception
sepsis - blood cultures
mx of postpartum endometritis
if septic - A combination of clindamycin and gentamicin is often recommended
if mild - in community with oral abx - eg: co amoxiclav
name a significant risk fx for retained products of contraception
placenta accreta
clinical fx of retained products of contraception
Vaginal bleeding that gets heavier or does not improve with time
Abnormal vaginal discharge
Lower abdominal or pelvic pain
Fever (if infection occurs)
diagnosis of retained products of conception
USS
mx of retained products of conception
evacuation of retained products of conception. GA required
uses vacuum aspiration and curretage
2 key complications of ERPC
endometritis
asherman’s syndrome
mx of postpartum anaemia
FBC day after delivery if had any of:
Postpartum haemorrhage over 500ml
Caesarean section
Antenatal anaemia
Symptoms of anaemia
postpartum anaemia definition
a haemoglobin of less than 100 g/l in the postpartum period
tx of postpartum anaemia
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
a woman is shown to be anaemic postpartum, bground of crohns disease, which tx is optimal
iron infusion
a woman is shown to be anaemic postpartum, bground of hospital acquired pneumonia currently being tx
active infection is a contraindication to an iron infusion. Many pathogens “feed” on iron, meaning that intravenous iron can lead to proliferation of the pathogen and worsening infection.
a woman is shown to be anaemic postpartum, bground of asthma
avoid iron infusion - risk of allergy and anaphylaxis
when baby blues occur
first week or so after birth
esp likely if first time mother
baby blues sx
Mood swings
Low mood
Anxiety
Irritability
Tearfulness
causes of 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
classic triad of PND
Low mood
Anhedonia (lack of pleasure in activities)
Low energy
when does PND occur
3 mths after birth
how long does PND have to be present for in order to diagnose
2 weeks at least
tx of postnatal depression
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
how screen for PND
edinburgh postnatal depression scale
10 Q’S
total score of 30, if 10 or more +ve
when does puerpal psychosis occur
2-3 wks after delivery
puerperal psychosis clinical fx
Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder
tx of puerperal psychosis
Admission to the mother and baby unit
Cognitive behavioural therapy
Medications (antidepressants, antipsychotics or mood stabilisers)
Electroconvulsive therapy (ECT)
what is the mother and baby unit
specialist unit
allowed to admit for 12 months after birth
so can remain together
specialist tx
existing mental health concerns prep during pregnancy
referred to perinatal mental health services for advice and specialist input
psych meds
SSRI’s taken during pregnancy risk
neonatal abstinence syndrome (also known as neonatal adaptation syndrome)
how does neonatal abstinence syndrome present
in the first few days after birth with symptoms such as irritability and poor feeding.
neonatal abstinence syndrome tx
supportive
Mastitis definition
inflammation of breast tissue, and is a common complication of breastfeeding
Mastitis caused by
caused by obstruction in the ducts and accumulation of milk
Or infection…bacteria enter at nipple and into tract
Most common bacteria causing mastitis
Staph aureus
Clinical fx of mastitis
Breast pain and tenderness (unilateral)
Erythema in a focal area of breast tissue
Local warmth and inflammation
Nipple discharge
Fever
Mx of mastitis
If caused by blockage - continue breastfeeding, express milk and massage (even if infection)
Heat lacks and warm showers and analgesia
Infection or continued issues - FLUCLOXACILLIN 1st line or erythromycin if allergic (milk can be sent for culture and sensitivity)
Rare complication of mastitis
Breast abscess (require incision and drainage)
Complication following tx for mastitis
Candidal infection of nipple - after course of abx
Leading to recurrent mastitis - cracked skin on nipple
Associations of candida of nipple
Oral thrush
Candidal nappy rash in infant
Clinical fx of candida infection of nipple
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
Tx of candida of nipple
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)
Postpartum thyroiditis definition
changes in thyroid function within 12 months of delivery, affecting women without a history of thyroid disease. It can involve thyrotoxicosis (hyperthyroidism), hypothyroidism, or both.
Which type thyroid dysfunction is more likely to remain long term
Hypo
Pathophysiology of postpartum thyroiditis
leading theory is that pregnancy has an immunosuppressant effect on the mother’s body, to prevent her from rejecting the fetus. Once delivery has occurred, there can be an exaggerated rebound effect, with increased immune system activity and expression of antibodies. This may include antibodies that affect the thyroid gland, for example, thyroid peroxidase antibodies…inflammation of thyroid gland so over or under active
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)
Mx of postpartum thyroiditis
TFT ‘s performed 6-8 weeks after delivery
Referral to endocrinology
Thyrotoxicosis: symptomatic control, such as propranolol (a non-selective beta-blocker)
Hypothyroidism: levothyroxine
Sheehans syndrome caused by
PPH
Patho of Sheehan’s
PPH causes 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 posterior pituitary gland affected in Sheehan’s
No
Blood supply to anterior pituitary
hypothalamo-hypophyseal portal system
Which hormones affected by Sheehan’s
anterior pituitary releases:
Thyroid-stimulating hormone (TSH)
Adrenocorticotropic hormone (ACTH)
Follicle-stimulating hormone (FSH)
Luteinising hormone (LH)
Growth hormone (GH)
Prolactin
Sheehan’s clinical fx
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)
Mx of Sheehan’s
Oestrogen and progesterone as hormone replacement therapy for the female sex hormones (until menopause)
Hydrocortisone for adrenal insufficiency
Levothyroxine for hypothyroidism
Growth hormone
