Post-Partum Care Flashcards
What is the management of 1st and 2nd degree tears and uncomplicated episiotomies?
Sutured under local anaesthetic
Failure to suture reduces healing and may cause more pain
What is the management of 3rd and 4th degree tears?
Repaired in theatre under regional / GA
Post op broad-spectrum abx
Post op laxatives
Physiotherapy and pelvic floor exercises for 6-12wks post partum
Follow up with obstetrician 6-12wks later
- If incontinence or pain at follow up, refer to a specialist gynaecologist or colorectal surgeon for possible secondary sphincter repair
What is the prognosis of 3rd / 4th degree tears?
What is the risk of developing another 3rd or 4th degree tear in a subsequent delivery?
30% have complications
- Incontinence (faeces or flatus) or urgency
60-80% symptom free after 12 months
5-7% recurrence risk
What should be the labour management of women who have experienced a 3rd or 4th degree tear in a previous pregnancy?
If symptomatic / show anal sphincter defects on endoanal USS = counsel them about risks and offer option of elective CS
All other women = advise to have a vaginal delivery
What two hormones are involved in lactation?
Prolactin and oxytocin
Where is prolactin produced and what is its role?
Released from anterior pituitary gland
Stimulates milk secretion
Where is oxcytocin produced and what is its role?
Posterior pituitary gland
Stimulates milk ejection in response to nipple sucking
What is the physiology of lactation?
Oestrogen and progesterone antagonise prolactin
Their massive decrease in birth allows milk to be produced
How much breast milk can be produced / day?
Up to 1000ml depending on demand
What are some advantages of breast feeding? (4)
1) Protection against infection in neonate (IgA)
2) Bonding
3) Protection against cancer (maternal)
4) Cost saving
When should breast feeding be encouraged?
Asap (within 4 hours of birth)
But must not be abandoned if not successful initially, often it is not established until mother and baby are at home
What problems may be encountered in first week of breast feeding?
1) Engorged breasts
2) Cracked nipples
3) Excessive air swallowing by baby due to too rapid flow of milk
What medication can be given to women who do not wish to / cannot breastfeed but still produce milk?
Cabergoline = suppresses lactation
What virus may be vertically transmitted to newborn via breastfeeding?
HIV
What is lactation amenorrhoea?
aka postpartum infertility
Temporary period in which a postpartum woman is not menstruating
If meets these 3 criteria there is a 98% chance a woman will not get pregnant:
1) Baby <6mnths
2) Amenorrheic
3) Woman fully or nearly fully breastfeeding (ie if stopping night feeding doesn’t count)
What are options for postnatal contraception?
Usually start 4-6wks after delivery
COCP decreases lactation so is CI in breastfeeding
POP / depot / implant / IUD / IUS safe in breastfeeding
- Intrauterine contraception may be inserted after 3rd stage of labour or 6 weeks after
- Some women of high parity may undergo sterilisation during CS
What can an interval of <12mnths between births increase risks of?
1) Preterm birth
2) SGA
3) Low birth weights
What is lochia?
Contains blood, mucus and uterine tissue - is normal
When should lochia be investigated?
If persists >6wks post partum
What are ‘the baby blues’?
Approx 50% women feel tearful and depressed 3-5 days after delivery
Usually short lived
What is the management of ‘the baby blues’?
Support and reassurance and assessment of mental state in case of more serious depression
What factors may prolong ‘the baby blues’? (6)
1) Postparum pyrexia
2) Anaemia
3) Inadequate sleep
4) Delayed healing of episiotomy / CS wound
5) Delay in established breastfeeding
6) Lack of support
What is postnatal depression?
Depression occurring within 1 year of giving birth
How common is postnatal depression?
10% women
What are some signs of postnatal depression? (6)
1) Tiredness
2) Sleeplessness even when the baby is sleeping
3) Weeping for no reason
4) Feelings of guilt and worthlessness
5) Failure to respond to the baby and its needs
6) Anxiety and withdrawal
What are some risk factors for postnatal depression? (4)
1) Social or emotional isolation
2) Prev hx of postnatal depression / other mental health problems
3) FH
4) Complications in pregnancy
What is the recurrence risk of postnatal depression?
Frequently recurs in later pregnancies
Associated with a 70% risk of depression later in life
What is the management of postnatal depression?
Involve psychiatrist
- ‘Watchful waiting’
- Psychological eg CBT
- Antidepressants
- Combination
What antidepressants can be used during breastfeeding?
None are specifically licensed for breastfeeding
Consider newborn
- Sick / low birthweight / premature infants should not be exposed via breastmilk
TCAs can be given safely
- Usually imipramine and nortiptyline
Preferred SRIs = sertraline and paroxetine
MAOIs (venlafaxine, duloxetine, St John’sWort) NOT recommended 1st line
What antidepressants are preferred during pregnancy?
SSRIs eg fluoxetine
How may puerperal psychosis present?
1) Abrupt onset of psychotic symptoms usually around the 4th day
2) Rejection of the baby
3) Delusions
4) Confusion and afitation
How common is puerperal psychosis?
Rare
0.2% women
In which women is puerperal psychosis more common?
Primigravida
Positive FH
What is the treatment of puerperal psychosis?
Psych admission with 24hr supervision
Appropriate medication eg tranquillisers
Exclusion of organic illness
What is the recurrence risk of puerperal psychosis?
10-20%
risk decreased by pregnancy gap >2yrs
When is a postnatal visit usually carried out?
6 weeks postpartum
Who usually carries out a postnatal visit?
GP or midwife
What is included in a postnatal visit?
Review mood - any symptoms of depression?
Check health of woman and baby
Examination - weight, BP, urine dip, examine CS scar or perineal repair, incontinence
Arrange cervical smear - usually for 3 months after delivery if overdue
Check contraception arrangements / menstruation
