Postnatal care Flashcards
What do women receive in the 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
What will new mothers discuss in their routine follow up with the midwife?
- 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 topics are covered at the 6 week postnatal check at the GP? (usually done at same time as 6-week newborn baby 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 type of vaginal bleeding occurs in the period shortly after birth?
Vaginal bleeding as the endometrium initially breaks down (mix of blood, endometrial tissue and mucus called lochia)
Initially a dark red colour and over time turns brown and becomes lighter in glow and colour
Tampons should be avoided as they carry a risk of infection
Bleeding should settle within 6 weeks
Why does slightly more vaginal bleeding occur during episodes of breastfeeding?
Breastfeeding releases oxytocin which can cause the uterus to contract leading to slightly more bleeding
What is the absence of periods related to breastfeeding called?
Lactational amenorrhoea
When will bottle feeding women begin having menstrual periods after giving birth?
From 3 weeks onwards (unpredictable)
Periods can be delayed or irregular at first
When is fertility considered to return after birth?
21 days
How effective is lactational amenorrhoea at contraception?
Over 98% effective - women must be fully breastfeeding and amenorrhoeic (no periods)
What forms of contraception are safe in breastfeeding?
Progesterone only pill and implant started at any time after birth
What contraceptive should be avoided in breastfeeding?
COCP (UKMEC 4 before six weeks and UKMEC 2 after six weeks)
Due to possible effects on milk production and infant growth and increased risk of thromboembolism in mother
When can the copper coil or IUS (mirena) be inserted after a lady gives birth?
Within 48 hrs of birth or after 4 weeks
Not between 48 hrs and 4 weeks
What is endometritis?
Inflammation of the endometrium usually caused by an infection
What type of delivery is more commonly associated with endometritis?
Caearean section (prophylactic abx are given)
What usually causes endometritis unrelated to pregnancy?
PID
How does postpartum endometritis present?
Foul-smelling discharge or lochia
Bleeding that gets heavier or does not improve with time
Lower abdominal or pelvic pain
Fever
Sepsis
How is postpartum endometritis diagnosed?
Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)
Urine culture and sensitivities
Ultrasound (to rule out retained products of conception (although not used to diagnose endometritis)
How are patients with postpartum endometritis managed?
Septic patients require hospital admission and sepsis 6 incl blood cultures and broad spectrum abx
Combination of clindamycin and gentamicin is often recommended.
Blood tests will show signs of infection (e.g. raised WBC and CRP)
Milder symptoms can be treated with oral abx e.g. co-amoxiclav
What is a significant risk factor for retained products of conception?
Placenta accreta
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 are retained products of conception diagnosed?
Ultrasound
How is postpartum retained products of conception managed?
Surgically
Evacuation of retained products of conception (ERPC) is a sugical procedure involving a general anaesthetic
Cervix is gradually widened using dilators and retained products are manually removed through the cervix usign vacuum aspiration and curettage (scraping).
Procedure is referred to as “dilatation and curettage”
What are two key complications of dilatation and curettage?
Endometritis
Asherman’s syndrome- adhesions (synechiae) form within the uterus, endometrial currettage can damage the basal layer of the endometrium, the damaged layer heals abnormally and creates scar tissue (adhesions) connecting areas of uterus that are not usually connected- can lead to amenorrhoea or infertility
What is postpartum anaemia?
Haemoglobin of less than 100g/l in the postpartum period
What is the management of postpartum anaemia?
If there has been PPH > 500ml, CS, antenatal anaemia, symptoms of anaemia- check FBC day after delivery
If Hb <100 : oral iron
If Hb <90 : consider iron infusion (contraindication: active infection, risk of allergy/ anaphylaxis, caution in asthma/ allergy hx)
If Hb <70 : blood transfusion + oral iron
What is postnatal depression characterised by?
Low mood in the postnatal period
What are the different severities of postnatal depression?
Baby blues is seen in the majority of women in the first week or so after birth
Postnatal depression is seen in about one in ten women, with a peak around three months after birth
Puerperal psychosis is seen in about one in a thousand women, starting a few weeks after birth
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
When do baby blues typically resolve?
Within about two weeks of delivery
How does postnatal depression present?
Classic triad of:
- Low mood
- Anhedonia (lack of pleasure in activities)
- Low energy
When are women typically affected with postnatal depression?
Symptoms start around 1 month after birth and peak 3 months after birth
How long do symptoms have to last before a diagnosis of depression can be made?
2 weeks
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)- sertraline, paroxetine (avoid fluoxetine due to long half life) and cognitive behavioural therapy
Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit
What screening tool is ther for postnatal depression?
Edinburgh postnatal depression scale
To assess how the mother has felt over the past week
10 questions, score greater than 10/30 indicates postnatal depression
What is puerperal psychosis?
Rare illness which onsets between 2 to 3 weeks after delivery with psychotic symptoms- delusions, hallucinations, mania, confusion, thought disorder, depression
What is the treatment 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?
Unit for pregnant women + women who have given birth in the last 12 months
Mothers are supported with childcare whilst they get specialist treatment
What preparation is there for pregnant women with existing mental health concerns?
Referral to perinatal mental health services, for:
- Decisions on medications e.g. SSRIs, antipsychotic, lithium
- Plan for after delivery with follow up
What is the problem with using SSRIs during pregnancy?
Neonatal abstinence syndrome (neonatal adapation syndrome)- irritability, poor feeding
Supportive mx
What is mastitis?
Inflammation of the breast tissue, a common complication of breastfeeding, can occur with or without associated infection
What is mastitis caused by?
Obstruction - regularly expressing milk can help prevent
Infection - bacteria entering at the nippep (usually 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
What is the management of mastitis?
Depends on cause:
- Blockage = conservative, continued breastfeeding, heat packs, warm showers, simple analgesia
- Infection = abx started flucloxacillin or erythromycin sample of milk can be sent for culture and sensitivites (fluconazole for suspected candidal infections) - women should be encouraged to continue breastfeeding, even when infection is suspected
What is a complication of mastitis?
Breast abscess - may need incision and drainage
When can candida of the nipple occur?
After a course of antibiotics leading to recurrent mastitis as it causes cracked skin on the nipple
Associated with oral thrush and candidal nappy rash in the infant
How may candidal 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
What is the treatment for candidal infection 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 (hyperthyroidism) or hypothyroidism or both
What is the cause of postpartum thyroiditis?
Unclear, leading theory is that pregnancy has an immunosuppressant effect on the mother’s body to prevent her from rejecting the fetus
Once delivery has occured there may be an exaggerated rebound effect with increased immune system activity and expression of antibodies (e.g. thyroid peroxidase antibodies)
What are the three stages to postpartum thyroiditis?
Thyrotoxicosis (usually in the first 3 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 test should be done on a woman presenting with postnatal depression ?
Thyroid function tests performed 6-8 weeks after delivery
Whats the management for patients with postpartum thyroiditis?
Referral to an endocrinologist:
- Thyrotoxicosis: symptomatic control, such as propranolol (a non-selective beta-blocker)
- Hypothyroidism: levothyroxine
Annual monitoring of TFTs even after the condition resolves, to identify those who go on to develop hypothyroidism
What is Sheehan’s syndrome?
Rare complication of post-partum haemorrhage, where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland leading to ischaemia in the cells of the pituitary and cell death
Which gland does Sheehan’s syndrome affect?
Anterior pituitary gland - hormones produced by the posterior pituitary are spared
Where does the anterior pituitary get its blood supply from?
Low-pressure system called the hypothalamo-hypophyseal portal system - susceptible to rapid drops in blood pressure
Where does the posterior pituitary get its blood supply from?
Various arteries and so not susceptible to ischaemia
Which hormones does the anterior pituitary release?
Thyroid-stimulating hormone (TSH)
Adrenocorticotropic hormone (ACTH)
Follicle-stimulating hormone (FSH)
Luteinising hormone (LH)
Growth hormone (GH)
Prolactin
Which hormones does the posterior pituitary release?
Oxytocin
Antidiuretic hormone (ADH)
How does Sheehan’s syndrome present?
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?
Replacement of the 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
What are the absolute contraindications to breastfeeding?
- Infants of mothers with TB infection
- Infants of mothers with uncontrolled/unmonitored HIV
- Infants of mothers who are taking medications which may be harmful e.g. amiodarone
What medication can be used to suppress lactation?
Cabergoline- dopamine receptor agonist- inhibits prolactin
