Postnatal care and lactation

Question 1

Physiological changes after birth?

Answer 1

• uterus:
  
  • usually returns to pelvis within 2 weeks - no longer palpable after this time.
  • afterbirth pains - further contractions particularly with breastfeeding (analgesia)
  • Lochia = blood and decidua - up to 6 weeks
    
    • 200-500ml over 1 month
  • abnormal - infection or retained placenta
• cervix
  
  • vaginal delivary = linear hole
  • small circle hole
• CVD
  
  • diuresis - resolution of oedema + return to normal blood volume
  • hypercoagulable - TE prophylaxis, RFs:
    
    • operative
    • advancing age
    • pre-eclampsia
    • high BMI
• GU
  
  • kidney and ureters dilatation back to normal

Question 2

What is in breastmilk that isn’t in formula? What are the beneftis? What stops that?

Answer 2

• active cells capable of phagocytosis - leukocytes and epithelial cells

Benefits:

• less likely to get necrotising enterocolitis (NEC)
• less likelt to die of SIDS
• decreased infections and hospitalisations (gastro)
• less obesity
• makes you smarter (confunder)

Benefits to mother:

• involution of uterus
• reduces CVD, breast cancer, ovarian cancer
• contraceptive effect
• faster to return to pre-pregnancy weight
• socioeconomic status limits formula
  
  • low resource settings formulas dangerous (following instructions).
  • breastfeeding is cheaper.

Question 3

What are the barriers to breastfeeding? Explain the epidemiology.

Answer 3

WHO suggests 2 years of breastfeeding (developing world suggestion, contraception and immunity)

• discharge = 85.8%, 6 months = 45.6%

Contraindications:

• HIV except in low resource settings
• a small number of drugs
  
  • antineoplastic agents
  • methotrexate, cyclosporine, ergotamine, radiopharmaceuticals
  • NIH resource called LactMed

Question 4

Successful Breastfeeding Measures?

Answer 4

• antenatal education
• skin to skin after delivery within 1 hour
• encourage demand feeding
• avoid supplementation + dummies
• encourage ‘rooming in’
• reduce advertising of breast milk substitutes

Question 5

Physiology of breastfeeding?

Answer 5

• initiation
  
  • pregnancy = oestrogen, progesterone, prolactin to HPL
  • delivery = fall in progesterone + allows prolactin
• maintenance = regular emptying of breasts and stimulation of the nipple - supply and demand. (twins)
• early breast-feeding = colostrum - thick small volume yellow lipid and immunoglobulin rich.
• milk coming in at day 3-4. blue/white high in volume. Increased size in breasts. Uncomfortable, full hard limpy.

Question 6

Problems with breastfeeding?

Answer 6

• nipple problems:
  
  • cracked, grazing, bleeding
    
    • 50% first babies
    • avoid with correct positioning (distal 1/3 forms teet - jaw/lower tongue against areolar). Attachment.
    • learnt skill - lanolin to moisturise
  • candida/other infections
• engorgement
  
  • commonest in first week - breast doesn’t know ‘supply and demand’ too much milk. Can’t attach.
  • expresses a little bit to get baby on, analgesia and settle down over a few days
  • cold cabbage
• Presumed low supply
  
  • comparing, growth slows down, breast feels softer
  • common reason women stop breastfeeding
  • baby unsettled
• Actual low supply - treatment - convince breasts more demand (attach well, both breasts, express after feed, drugs but unclear)
  
  • weight gain <500g/month
  • baby less than birth weight at 2 weeks.
  • passing small amounts of strong urine <6/day
  • infrequent amounts of stool
  • lethargic, sleepy, weak, dry skin (dehydrated)
• Structural
  
  • surgery - breast augmentation (incisions around nipple)
  • inverted nipples, flat nipples
• blocked ducts/mastitis/abscess
  
  • mastitis - blocked duct with infection.
  • unpleasant - vomiting, febrile.
  • may require admission due to dehydration
  • important to keep feeding (staph doesn’t bother baby)
  • flucloxacillin, analgesia, fluids.
  • no response get abscess. Surgical drainage.

Question 7

Talk through postnatal care, what are some things you should consider in these women?

Answer 7

• length of hospital stay
  
  • 4 nights c-section
  • 2 nights primiparous vaginal delivery - tired
  • longer stay if requires
• Well:
  
  • general appearance
  • involuted uterus
  • perineum healing
  • urinary/bowels
  • breastfeeding
• Psychosocial:
  
  • libido, culture, sleep, confidence, returning to work
  • family income reduction
  • supports: MCHC (maternal child health nurse), ABA, and specific groups.
• Ongoing care:
  
  • MCHN - 1 home visit - regularly clinic visits
  • 6week GP check
• Puerperal Sepsis
• Secondary PPH
• Mood disorders
• Contraception

Question 8

What are some of the causes of Puerperal Sepsis?

Answer 8

• maternal temp >38 within 2 weeks of birth
• sources:
  
  • endometritis
  • mastitis
  • CS wound
  • UTI
• less common:
  
  • VTE
  • URTI
  • Sx
  • IV site
  • Epidural sites

Question 9

Secondary PPH causes and management?

Answer 9

• endometritis often a common cause - retained products of birth. Products of conception and infection.
• often polymicrobial

Exam:

• fever, tachycardia, tender uterus, offensive vaginal losses

Ix:

• HVS
• US
• blood cultures

Tx:

• blood replacement, fluids
• oral augmentin outpatient
• inpatient Amp/Gent/Flagyl IV

Question 10

Contraception options post-partum?

Answer 10

• libido/vaginal dryness
• ovulation = at 8 weeks in absence of breastfeeding - can be 1 mth after
• choices while breastfeeding:
  
  • lactational amenorrhea
    
    • 97% effective if <6mths, no formula or solids, + mini-pill =99%
  • progestagen methods
  • IUCD
    
    • <48 hrs or >4mths otherwise will fall out
  • barrier methods
  • irreversible - tubal ligation at the same time as c-section
  • no oestrogen if breastfeeding (in some women oestrogen reduces milk supply, theoretical concern around baby getting oestrogen through milk).

Question 11

What is an acronym for the things you should assess when discharging a new mother?

Answer 11

BUBBLE HE

• Breast size/tenderness
• uterine firm
• bladder
• bowel
• lochia
  
  • 4-6weeks after delivery
  • go to doc if: >1 pad/hr, change in colour/odour, clots
• episiotomy recovery
• homan’s sign (DVT)
• emotional well being

Question 12

What are some causes of decreased milk supply in a women, what would you find? How can you treat this?

Answer 12

Findings:

• dehyrdration
• change in urine
• <150g/week growth
• hard green stools

Causes:

• insufficient breast development (surg, androgens high, endocrine)
• delayed progression (obesity, HTN, PCOS, increased androgens)
• medications (SSRIs/oxytocin/COCP)

Treatment:

• rule out neonate anatomy
• technique
• dopamine receptor antagonists (meto/domperidone)