Postnatal care Flashcards
What is part of rountine postnatal care on the ward?
analgesia breast or bottle fed advice VTE risk assessment monitoring PPH monitoring sepsis monitoring blood pressure monitoring recovery after c section or perineal tear FBC after bleeding anti D routine baby check
What are the aspects of follow up with the midwife?
general wellbeing mood and depression bleeding and menstruation urinary incontinence and pelvic floor exercises scar healing after episiotomy or c section contraception bleeding vaccines
Describe menstruation after delivery
endometrium initially breaks down
blood, endometrial tissue and mucus= lochia
should settle within 6 weeks
tampons should be avoided due to the risk of infection
breastfeeding leads to the release of oxytocin, causing uterus to contract and slightly heavier bleeding (normal)
What is the absence of periods called due to breastfeeding?
lactational amenorrhoea
when do women not breastfeeding restart periods?
3 weeks onwards
unpredictable
What contraception is used after delivery?
fertility doesn’t return until 21 days
lactational amenorrhoea-98% effective for up to 6 months after birth (must be fully breastfeeding and amenorrhoeic)
progesterone only pill and implant safe in breastfeeding and started at any time
COCP-avoided in breastfeeding, UKMEC 4 6 weeks postpartum UKMEC 2 >6 weeks
copper coil and IUS inserted before 48 hours or more than four weeks after birth
When can the COCP be started?
non breastfeeding: anytime with 7 days barrier protection
breastfeeding: not started before 6 weeks afterbirth
What is endometritis?
inflammation of the endometrium, usually caused by infection
more common after c section
prophylactic antibiotics may be given
gram negative, positive, anaerobic bacteria
STIs
need to rule out retained products of conception
What is the presentation of endometritis?
foul smelling discharge bleeding that gets heavier lower abdominal pain sepsis fever
Treatment for endometritis
broad spectrum co-amoxiclav
When does retained products of conception occur?
after delivery
miscarriage
termination of pregnancy
placenta acrcreta (significant risk factor)
What are the complications of retained products of conception?
Endometritis
Ashermans syndrome
Presentation of retained products of conception
vaginal bleeding that doesn’t improve
abnormal vaginal discharge
lower abdominal pain
fever
what is ashermans syndrome?
adhesions form in the uterus
endometrial curettage can damage the basal layer of endometrium
heals abnormally creating scar tissue connecting areas of the uterus not normally connected
endocervix can seal shut
what does ashermans syndrome lead to?
Amenorrhoea and infertility
what is the definition of postpartum amenorrhoea?
<100g/l
common after acute blood loss
what is the treatment for postpartum anaemia?
<100g/l start oral iron 3 times a day for 3 months
<90g/l iron infusion plus oral iron
<70g/l blood transfusion in addition to oral iron
when is iron infusion considered?
poor adherence to oral treatment
cannot tolerate oral iron
failure to respond to oral iron
cannot absorb oral iron (IBD)
when is oral iron contraindicated?
active infection
pathogens feed off the iron leading to proliferation
when does the baby blues happen and what are the symptoms?
occur in the first week
affect more than 50%, particularly first time mothers
mood swings, low mood, anxiety, irritability, tearfulness
no treatment required and recovers in 2 weeks
when does postnatal depression occur and what are the symptoms?
occur around 3 months
1 in 10 women
low mood, anhedonia, low energy
how is moderate cases of depression treated?
SSRI and CBT
what screening tool is used for depression?
Edinburgh postnatal depression scale
>10 suggests postnatal depression
assess how mother has felt over the last week
when does puerperal psychosis occur?
onset 2-3 weeks after delivery
why are the symptoms of puerperal psychosis?
delusions, hallucinations, depression, mania, confusion, thought disorder
treatment for puerperal psychosis?
admission to mother baby unit
CBT
antidepressants, antipsychotics, mood stabilisers
ECT
what is the risk of SSRIs in pregnancy?
can lead to neonatal abstinence syndrome
presents with irritability and poor feeding
neonates require monitoring and supportive management
what is lactational mastitis?
inflammation of breast tissue
common complication of breastfeeding
occur with or without associated infection
bacteria can enter through cracked nipples causing inflammation and infection (staph aureus)
why is mastitis caused?
can be caused by obstruction in ducts and accumulation of milk
what is the management of mastitis?
continue breastfeeding (even when suspected infection, it encourages flow) express milk breast massage heat packs, warm showers analgesia
presentation of mastitis?
breast pain, tenderness erythema of local area local warmth and inflammation nipple discharge fever
What antibiotics are used when conservative management doesn’t work and suspected infection?
flucloxacillin
erythromycin (penicillin allergic)
complication of mastitis?
breast abscess
incision and drainage
describe candida of the breast?
occurs after a course of antibiotics
may lead to recurrent mastitis, as it causes cracked nipples and entrance for infection
associated with oral thrush and candidal nappy rash in infant
treatment of candida of the breast?
topical miconazole (after each breastfeed) treatment for baby-oral miconazle gel or nystatin (anti fungal)
Why does postpartum thyroiditis occur?
cause is unknown
pregnancy is an immunosuppressant to prevent rejection of the foetus
after delivery there is a rebound affect and increased immune system activity and expression antibodies
affect the thyroid e.g. thyroid perioxdase antibodies
causes inflammation of the thyroid gland leading to over or under activity
what is the typical pattern?
- thyrotoxicosis (first 3 months)
- hypothyroidism (3-6 months)
- thyroid function returns to normal
management of thyroiditis?
thyrotoxicosis-symptom control propanolol
hypothyroidism-levothyroxine
women will need annual monitoring of TFTs even after condition has resolved due to risk of developing long term hypothyroidism
What is sheenan’s syndrome
rare complication of postpartum haemorrhage
drop in circulating blood volume leads to avascular necrosis of the pituitary gland
reduced perfusion leads to ischaemia of the cells of the pituitary leading to cell death
What part of the pituitary is affected in sheenans syndrome?
anterior pituitary
what hormones are affected in sheenan’s syndrome?
TSH ACTH FSH LH GH prolactin
presentation of sheenans
reduced lactation
amenorrhoea
adrenal insufficiency
hypothyroidism
management of sheenans
replacement of missing hormones oestrogen and progesterone hydrocortisone levothyroxine growth hormone
what hormones are produced by the posterior pituitary?
ADH
oxytocin
