Postnatal care

Question 1

what is the post natal period

Answer 1

Also called the “puerperium”
= the first 6 weeks after baby is born

Question 2

what occurs in the first 9-10 days postnatally

Answer 2

see midwife at home for first 9-10 days, thereafter referred to health visitor

Continue to observe for signs of abnormal bleeding
Observe for evidence of infection
Wound (perineal or CS) / Endometritis / Breast
Debrief events around birth (especially if emergency CS)
Mental health

Question 3

what occurs 6 weeks post natally

Answer 3

6 weeks post natal check at GP

contraception
mental health / general well being

Question 4

what are common problems post natally

Answer 4

infant feeding problems
problems bonding
social issues

Question 5

what should be advised in relation to breast feeding to women

Answer 5

Women should be advised re: benefits of breast feeding but supported whatever their feeding choices
Prescribing in breast feeding

Question 6

what are some complications of breastfeeding

Answer 6

Mastitis
Blocked milk ducts
Difficulty feeding / baby latching
Skin irritation “cracked nipples”

Question 7

what are some key post-natal conditions

Answer 7

Post partum haemorrhage

Venous thromboembolism

Sepsis

Psychiatric disorders of the puerperium

Don’t forget pre-eclampsia

Question 8

what is primary post partum haemorrage

Answer 8

= blood loss of >500ml within 24 hrs of delivery

Tone, Trauma, Tissue, Thrombin (4 T’s)

Question 9

what is secondary post partum haemorrage

Answer 9

= blood loss > 500ml from 24 hrs post partum to 6 weeks
Retained tissue, Endometritis (infection), Tears / trauma

Question 10

what is lochia

Answer 10

Lochia normal for 3-4 weeks postnatal “should be like a period or less”

Question 11

what are the four T’s of post partum haemorrage

Answer 11

Tone: Uterine atony
Trauma: Lacerations, hematomas, inversion, or rupture
Tissue: Retained tissue or invasive placenta
Thrombin: Coagulopathy

Question 12

what are signs of thromboembolic disease in women

Answer 12

Suspicious = women with unilateral leg swelling and/or pain and women complaining of SOB or chest pain

Sometimes the only sign of a PE will be an unexplained tachycardia

May present atypically in pregnancy / postnatally

Always have a high index of suspicion for VTE in pregnant or postnatal women

Question 13

is pregnancy a hyper-coagulative state?

Answer 13

Pregnancy and the immediate post partum period is a hypercoagulable state

Pregnant women 6-10 times more likely to develop thromboembolism (DVT or PE)

High quality risk assessment and appropriate thromboprophylaxis is required to reduce this risk

Question 14

what increases the risk of thromboembolic disease

Answer 14

Immobilisation following spinal anaesthetic / caesarean section will further increase risk
D-dimer unreliable in pregnancy

Question 15

what investigations should be done for women with suspected thromboembolic disease

Answer 15

ECG
Leg Dopplers
CXR +/- VQ scan or CTPA (NB: radiation exposure during pregnancy /breast feeding)
Treat with low molecular weight heparin
WARFARIN IS TERATOGENIC, but can be used when Breast feeding

Question 16

what is the typical presentation puerperal sepsis

Answer 16

usually atypical

Question 17

what is the treatment plan for women with puerperal sepsis

Answer 17

In any woman you suspect sepsis – prompt IV antibiotic administration “golden hour”

erform full septic screen – blood cultures, LVS, MSSU, wound swabs

Antipyretic measures, IV fluids and referral to hospital if you are concerned a pregnant or postnatal woman is septic

Question 18

how impactful is mental health in the post-natal period

Answer 18

MMBRACE report 2015 - Almost a quarter of women who died between six weeks and one year after pregnancy died from mental-health related causes
1 in 7 of those women died from suicide
Suicide is the second largest cause of direct maternal deaths during or within the 42 days after birth (2019 MBBRACE report)

peri-natal mental health team

Baby blues
Affects most women due to hormonal changes around the time of birth – usually 1-3 days PN
Does not affect functioning and requires no specific treatment

Question 19

what are signs of post natal depression

Answer 19

Can continue on from baby blues or start sometime later
Has classical ‘depressive’ symptoms

Affects functioning, bonding and often requires treatment

Question 20

when is there an increased risk of post-natal depression

Answer 20

increased risk in women with personal or family history of affective disorder

Question 21

what is puerperal psychosis

Answer 21

Rare but serious psychotic illness of the postnatal period
Women can be a danger to themselves and their babies
Requires inpatient psychiatric care
Much more common in women with personal or family history of affective disorder,

Question 22

when do most eclamptic seizures occur

Answer 22

Most eclamptic seizures occur in the postnatal period

Pre-eclampsia can develop postnatally or may worsen several days following delivery

Women may be discharged on antihypertensives – need follow up in the community