postnatal care and lactation Flashcards
when should we not be able to palpate the uterus in the postpartum period?
2 weeks postpartum
what is lochia?
normal vaginal blood loss consisting of decidua and leukocytes after the baby is born
what are the characteristics of normal lochia?
up to 500mls of lochia is normal
mother may bleed up to 1 month post birth
–> need to ask how much she is bleeding, the colour of the blood and whether she is having afterbirth contractions
what are some physiological changes during the postpartum period?
CV- look for a diuresis; resolution of oedema and return to normal blood volume
Genitourinary tract- risk of UTI and pyelonephritis
Hypercoagulable state- thromboembolic prophylaxis
what are the benefits of breastfeeding in babies?
Fetal benefits: Reduction in atopy, infections etc (immunological benefits) Nutritional benefits Increased IQ Reduced obesity in the long term
Maternal benefits:
reduction in rates of breast cancer, ovarian ca, CVD
?contraceptive effects
?aids maternal weight loss
what are some contraindications to breastfeeding?
if the mother has HIV and lives a resource adequate society then they shouldn’t breastfeed
if the mother is on: antineoplastic agents, ergotamine, methotrexate, cyclosporine and radiopharmaceuticals
what is ‘demand feeding’?
feeding when the baby is hungry rather than to a schedule
How is lactation maintained?
dependent on supply and demand
regular emptying of the breast and stimulation of the nipple –> maintains lactation
–> autocrine control
describe colostrum fluid?
small volume thick, yellow, Ig and lipid rich milk
–> early breastfeeding
how might we manage sore nipples due to breastfeeding?
correct positioning of infant on breast
A mother comes in worried that she has poor ‘milk supply’ and cannot breastfeed her baby adequately. What are some things you will look for in the baby that might support the mother’s concern?
-baby not growing or putting on weight
-producing infrequent small amounts of concentrated urine
(Less than 3 wet nappies per 24 hours after 72 hours age
Less than 5-6 heavy wet nappies per 24 hours after day 5)
-producing small amounts of hard green faeces
-lethargic, floppy baby; poor tone; dry mucous membranes
essentially signs of dehydration
how do we increase breastmilk supply?
more frequent feeds (increase demand to increase supply) or domperidone
what is a complication of mastitis and when does it occur?
a breast abscess, needs to be managed surgically (i.e. drained)
usually occurs 1-2 weeks post mastitis
what is the normal postnatal hospital admission duration for uncomplicated vaginal and caesarean deliveries?
2 nights for vaginal delivery
4 nights for caesarean
define puerperal sepsis?
Maternal temperature > 38 within 2 weeks of birth
common sources for puerperal sepsis in postpartum woman?
Endometritis/mastitis
Caesarean wound
UTI
non-obstetric- flu, URTI, infections from IV/epidural sites etc
what is the most common cause of secondary PPH?
retained products of conception/infection
what is secondary PPH?
excess vaginal bleeding more than 24 hrs post delivery up to 6 weeks
when does postpartum blues normally occur?
day 3 or day 4 post delivery
how effective is breastfeeding alone as contraception?
97%
how might we augment the breastfeeding contraceptive effect?
mini pill
how do we manage mastitis?
oral flucloxacillin if conservative measures do not work within 24-48 hours
- encourage continued breastfeeding
- analgesia, fluids
- no bra; use cold pack after breastfeeding
if abscess occurs- requires surgical drainage
what antibiotics do we give outpatients who have endometritis?
oral amoxycillin
what are your ddx for cause for postpartum fever?
- UTI
- endometritis (not chorioamniotis bc this term implies the baby is still in the uterus)
- Mastitis
- infection from episiotomy/cannula/catheter etc
retained products in the uterus can cause infection
how do we follow up women and their baby in the postpartum period after they have been discharged from hospital?
maternal and child health nurse visits- weekly to monthly
6 week formal health assessment of baby at the GP
when is the ideal time post delivery to commence breastfeeding?
generally 1 hour post delivery in ideal situations!
what are some factors which might contribute to ACTUAL low supply of breastmilk?
Maternal factors: inadequate breast tissue, smoking, PPH, anaemia
Infant factors: tongue tie (can’t drain breast), medical problems like heart defects or infection
Other: delayed breastfeeding and retained placenta (delivery of the placenta is crucial for lactogenesis)
a mother presents with concerns regarding breastfeeding her infant. what are some EXAMINATION things you will be looking for?
Mother- general assessment, examination of breasts (intramammary distance, asymmetry, shape)
Baby- FLUID ASSESSMENT; growth chart, oral anatomy (tongue tie, cleft)
observe a feed if you can
what medications can you use to increase breastmilk supply?
dopamine antagonists like metoclopramide or domperidone as dopamine inhibits PRL secretion
what are some clinical features of mastitis?
Hot, red, swollen breast; breast feels hard, fever present, generalised muscle aching
what medication options do we have for managing thrush infection in a breastfeeding mother who had antibiotics for mastitis
Mother= analgesia, muciprocin ointment in mild cases applied to the nipple post breastfeeding, oral nystatin or fluconazole for more severe cases
Baby- oral miconazole gel or nystatin drops
a breastfeeding mother comes in concerned that she has mastitis bc she noticed a red itchy rash on her breasts. what is the most likely diagnosis?
nipple eczema
mastitis generally does not cause an overt rash
most common cause of secondary postpartum haemorrhage?
endometritis
retained products of conception
what are some management options for secondary PPH?
broad spectrum antibiotics
oxytocin
dilation and evacuation if presence of retained products of conception
what are the 3 maternal complications that we need to monitor for in the postpartum period?
- infection- puerperal sepsis
- postpartum haemorrhage
- VTE
what are the clinical characteristics of endometritis?
• Endometritis is a clinical diagnosis with fever, uterine tenderness, a foul purulent vaginal discharge, and/or increased vaginal bleeding.
It occurs most commonly 5–10 days after delivery.
what is your management of a woman who has had a major PPH?
regular monitoring of BP, fundal tone, vaginal loss every 15 mins
weigh the perineal pads to estimate blood loss
monitor for signs of DIC or shock
monitor O2 sats. if low, administer O2
fluid balance assessment
uterine packs or consider bakri balloon
TED stockings for thromboembolic prophylaxis
when should a baby regain birthweight?
by two weeks i.e. 14 days
what are some postpartum management considerations for a lady who is about to be discharged from hospital?
• Discuss complications such as VTE (thromboembolic prophylaxis), infection, abnormal vaginal bleeding, constipation
• Recommend to allow 6 weeks before sexual intercourse
• Advise that exclusive breastfeeding is a relatively good contraception however not 100% effective.
• The mini-pill can be used for contraception whilst breastfeeding; need to consider contraception 4 weeks postpartum
• Avoid oestrogen containing contraceptives because it decreases milk supply
• Address abnormal mood for postpartum blues or PND
Arrange 6 week check at GP
when does the internal cervical OS close after the delivery of the baby?
by 2 weeks postpartum
when should contraception be commenced in the postpartum period?
4 weeks postpartum
what is some management advice you can give to a woman who had perineal trauma during delivery?
Avoid constipation
Keep area clean and dry
good personal care
Monitor for infection
what is sheehan’s condition and how does it affect breastfeeding?
A rare cause of lactation failure in the modern era is ‘pituitary apoplexy of Sheehan’ where postpartum haemorrhage and hypotension causes pituitary infarction and failure, hence prolactin insufficiency.
what pathogens usually cause endometritis?
ascending colorectal bowel flora
how might you manage retained products of conception causing secondary PPH?
- IV antibiotics
- management of blood loss e.g. transfusion if required
- dilation and curretage/evacuation of the products of conception
what does lactogenesis II refer to?
the conversion from colostrum to mature milk
when does the ‘mature milk come in’ post birth?
day 4 post delivery
Describe how a baby should properly attach to the breast for breastfeeding
The baby’s mouth should be open. It may be necessary to stroke the corner of the mouth with the nipple to elicit the ‘rooting’ reflex in which the baby opens the mouth.
The baby is brought to the breast rather than feeding the nipple and breast into the baby’s mouth.
It is important that the baby attaches adequately by taking a good amount of the breast, including the nipple and much of the areola into the mouth
Nipple should extend to the junction of the hard and soft palate of the baby
