Postnatal Care Flashcards
What aspects of care are important in the post-natal period?
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
What is covered at the 6 week postnatal check?
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?
Vaginal bleeding as the endometrium breaks down, mix of blood, endometrial tissue and mucus.
Initially dark red colour then becomes brown.
Tampons avoided as can introduce infection
Should settle within 6 weeks
What is lactational amenorrhoea?
Women who are breastfeeding may not have a return to regular menstrual periods for 6 months or longer unless they stop breastfeeding
When can periods return after birth?
Can begin from 3 weeks onwards, can be unpredictable
When does fertility return after birth?
21 days, contraception required after this point
Including condoms for seven days when starting the COCP, and two days with POP
What is the lactational amenorrhoea contraceptive method?
98% effective for up to 6 months after birth, must be fully breastfeeding and amenorrhoeic
What other contraceptive options are there following birth?
POP and implant safe in breastfeeding
Can be started any time after birth
COCP avoided in breastfeeding
UKMEC before 6 weeks postpartum
UKMEC2 after 6 weeks
Copper coil or IUS e.g. mirena, can be inserted within 48 hours of birth, or more than 4 weeks after birth but not in between
What is endometritis?
Inflammation of the endometrium caused by infection
Can occur postpartum as delivery allows bacteria from vaginal to travel upwards
Occurs more commonly after caesarean
Prophylactic antibiotics given to reduce risk
What is the presentation of endometritis?
Can present shortly after birth or several weeks postpartum
Foul smelling discharge or lochia Bleeding gets heavier or does not improve Lower abdominal or pelvic pain Fever Sepsis
How can endometritis be diagnosed?
Vaginal swabs including chlamydia and gonorrhoea if there are risk factors
Urine culture and sensitivities
USS considered to rule out retained products of conception
What is the management of endometritis?
Look out for sepsis
Clindamycin and gentamicin
If milder symptoms and no signs of sepsis, could be treated in the community with oral antibiotics e.g. co-amoxiclav
What is the management of retained products of conception postpartum?
Remove surgically
Evacuation erpc use of general anaesthetic, cervix gradually widened using dilators and retained products manually removed through cervix using vacuum aspiration and curettage (scraping)
Key complications - endometritis and asherman’s
What is the presentation of retained products of conception?
Vaginal bleeding gets heavier or does not improve over time
Abnormal vaginal discharge
Lower abdominal or pelvic pain
Fever if infection
USS investigation of choice to confirm
What is postpartum anaemia?
Haemoglobin less than 100g/L in postpartum period, most common after delivery due to acute blood loss
What is a contraindication to an iron infusion?
Active infection
Many pathogens ‘feed’ on iron, meaning it can lead to proliferation and worsening infection
What is the management of postpartum anaemia?
Full blood count checked the day after delivery if there has been PPH c-section antenatal anaemia symptoms of anaemia
Hb under 100 - start oral iron, ferrous sulphate 200mg three times daily for three months
Under 90 - consider iron infusion in addition to oral iron
Under 70 blood transfusion and oral iron
When can an iron infusion also be considered in postpartum anaemia?
May have poor adherence to oral treatment
Cannot tolerate oral iron
Fail to respond to oral iron
Cannot absorb oral iron e.g. inflammatory bowel disease
Use with caution in those with hx of allergy or asthma
What are the symptoms of baby blues?
Mood swings Low mood Anxiety Irritability Tearfulness
What may baby blues be the result of?
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
What is the triad of symptoms in postnatal depression?
Low mood
Anhedonia (lack of pleasure in activities)
Low energy
What is the treatment for 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
What are the symptoms of puerperal psychosis?
onset between two to three weeks after delivery
Delusions Hallucinations Depression Mania Confusion Thought disorder
What is the treatment for puerperal psychosis?
Admission to the mother and baby unit
Cognitive behavioural therapy
Medications (antidepressants, antipsychotics or mood stabilisers)
Electroconvulsive therapy (ECT)
How can mental health issues be treated during pregnancy?
Perinatal mental health services for advice and specialist input
SSRI antidepressants taken during pregnancy can lead to neonatal abstinence syndrome (also known as neonatal adaptation syndrome). It 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 all that is required.
What is mastitis?
Inflammation of breast tissue
Common complication of breastfeeding.
Can occur with or without associated infection.
What can be the causes of mastitis?
Obstruction in the ducts and accumulation of milk.
Infection - bacteria can enter nipple and back-track into ducts, staph aureus.
What is the presentation of mastitis?
Breast pain and tenderness (unilateral) Erythema in a focal area of breast tissue Local warmth and inflammation Nipple discharge Fever
What is the management of mastitis?
If due to blockage of ducts; conservative, continue breastfeeding, expressing milk, breast massage.
Heat packs, warm showers and simple analgesia.
If not effective, or infection suspected - flucloxacillin first line or erythromycin if allergic to penicillin.
Sample of milk can be sent for culture and sensitivites.
What is a rare complication of mastitis is not treated?
Breast abscess
May need surgical incision and drainage
What is candida of the nipple?
Can occur after a course of antibiotics
Can lead to recurrent mastitis, as causes cracked skin on nipple creating an entrance for infection
Associated with oral thrush, and candidal nappy rash in the infant.
What is the presentation of candida of the 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
What is the management of candida of the nipple?
Topical miconazole 2% after each breastfeed
Treatment for the baby (e.g. miconazole gel or nystatin)
What is postpartum thyroiditis?
Changes in thyroid function within 12 months of delivery, affecting women without a history of thyroid disease.
Can involve thyrotoxicosis or hypothyroidism.
Over time function returns to normal.
What is thought to be the pathophysiology of postpartum thyroiditis?
Pregnancy has an immunosuppressant effect on the body to stop from harming baby
Then exaggerated rebound effect after birth increased antibodies and increased thyroid peroxidase antibodies
What are the 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 the signs and symptoms of thyrotoxicosis?
Anxiety and irritability Sweating and heat intolerance Tachycardia Weight loss Fatigue Frequent loose stools
What are the 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 postpartum thyroiditis?
In thyrotoxicosis, you expect raised T3 and T4 and suppressed TSH.
In hypothyroidism, you expect low T3 and T4 and raised TSH.
What is the management of postpartum thyroiditis?
Low threshold for thyroid function testing, performed 6-8 weeks after delivery.
Abnormal TFTs referral to endocrinology.
Thyrotoxicosis - symptomatic control
Hypothyroidism - levothyroxine
Annual monitoring even after condition resolved, in case go onto develop long term hypothyroidism
What is Sheehan’s?
Rare complication of PPH
Drop in circulating blood volume leads to avascular necrosis of the pituitary gland
Low BP and reduced perfusion of the pituitary gland leads to ischaemia and cell death
Only affects anterior pituitary, so posterior pituitary hormones spared
What hormones are impacted by Sheehan’s?
Thyroid-stimulating hormone (TSH) Adrenocorticotropic hormone (ACTH) Follicle-stimulating hormone (FSH) Luteinising hormone (LH) Growth hormone (GH) Prolactin
What is the presentation of Sheehan’s?
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)
What is the management 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
