Postnatal Care Flashcards
Pt with erythematous, firm, swollen area in a wedge-shaped distribution on left breast. Small fissure on nipple. Examination is painful Temperature is 37.7 degrees. Appropriate 1st line management:
Advise her to continue breastfeeding & start empirical antibiotics (usually flucloxacillin), if flucloxacillin allergic–> macrolides eg erythromycin or clarithromycin
(Macrolides inhibit bacterial protein synthesis. The mechanism of action of macrolides revolves around their ability to bind the bacterial 50S ribosomal subunit causing the cessation of bacterial protein synthesis.)
A milk culture should be performed to determine sensitivities but ABx shouldn’t be delayed to wait for this.
This is lactational mastitis
when should Abx be started in lactational mastitis?
- if symptoms haven’t improved with continuous lactation after 12-24 hours
- nipple fissure that appears infected
- breast milk culture is positive
most common organism for lactational mastitis:
staphylococcus aureus (gram positive grape-like clusters)
Breast abscess presentation
Localized breast erythema, warmth, induration, edema, and tenderness.
Most frequently areolar or periareolar (may also be peripheral)
Fluctuance, although swelling may limit ability to palpate a mass.
May have associated fever or axillary lymphadenopathy.
when should women with breast infection be admitted?
- If oral Abx fail to improve situation
- sepsis
- IV abx & drainage if evidence of breast abscess
midwife-led care in postnatal 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
routine followup with midwife postpartum:
- General wellbeing
- Mood and depression (eg edinburgh postnatal depression questionnaire)
- Bleeding and menstruation
- Urinary incontinence and pelvic floor exercises
- Scar healing after episiotomy or caesarean
- Contraception
- Breastfeeding
- Vaccines (e.g. MMR)
6 week postnatal check at GP:
- 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)
menstruation after delivery:
In the period shortly after birth, there will be vaginal bleeding as the endometrium initially breaks down, then returns to normal over time. This is a mix of blood, endometrial tissue and mucus, and is called lochia.
-Initially, it will be a dark red colour and over time will turn brown, and become lighter in flow and colour.
-Tampons should be avoided during this period, as they carry a risk of infection. Bleeding should settle within six weeks.
Breastfeeding releases oxytocin, which can cause the uterus contract, leading to slightly more bleeding during episodes of breastfeeding. This is normal.
Women who are breastfeeding may not have a return to regular menstrual periods for six months or longer (unless they stop breastfeeding). The absence of periods related to breastfeeding is called lactational amenorrhoea.
Bottle-feeding women will begin having menstrual periods from 3 weeks onwards. This is unpredictable, and periods can be delayed or irregular at first.
contraception after childbirth:
Fertility is not considered to return until 21 days after giving birth, and contraception is not required up to this point. The risk of pregnancy is very low before 21 days.
- 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).
Lactational amenorrhea is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods).
The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.
The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before six weeks postpartum, UKMEC 2 after six weeks).
A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than four weeks after birth (UKMEC 1), but not inserted between 48 hours and four weeks of delivery (UKMEC 3).
TOM TIP: Remember that the combined pill should not be started before six weeks after childbirth in women that are breastfeeding. The progesterone-only pill or implant can be started any time after birth.
high flow oxygen (vs sepsis screen)
