Postnatal Care & Contraception Flashcards
What care will mothers receive in the initial days after delivery?
1) analgesia as required
2) help establishing breast or bottle feeding
3) VTE risk assessment
4) monitoring for PPH
5) monitoring for sepsis
6) monitoring BP (after pre-eclampsia)
7) monitoring recovery after a caesarean or antenatal anaemia
8) FBC check: after bleeding, caesarean or antenatal anaemia
9) anti-D for rhesus D negative women (depending on baby’s blood group)
10) routine baby check
After the initial postnatal period, new mothers will have routine follow up with a midwife to discuss topics such as:
1) General wellbeing
Mood and depression
Bleeding and menstruation
Urinary incontinence and pelvic floor exercises
Scar healing after episiotomy or caesarean
Contraception
Breastfeeding
Vaccines (e.g. MMR)
When is a postnatal appointment commonly offered by GP practices to check how the mother is doing?
6 weeks postnatal check, this is usually done at the same time as the six-week newborn baby check.
What topics are covered at the 6 week postnatal check?
1) general wellbeing
2) mood & depression
3) bleeding & menstruation
4) scar healing after episiotomy or caesarean
5) contraception
6) breastfeeding
7) fasting blood glucose (after gestational diabetes)
8) blood pressure (after hypertension or pre-eclampsia)
9) urine dipstick for protein (after pre-eclampsia)
What is lochia?
Vaginal bleeding in the period after childbirth: a mix of blood, endometrial tissue and mucus.
Describe vaginal bleeding in period after birth?
Initially, it will be a dark red colour and over time will turn brown, and become lighter in flow and colour.
Bleeding should settle within six weeks.
Why should tampons be avoided during the period after delivery?
Due to increased risk of infection.
Why is there slightly more vaginal bleeding during episodes of breastfeeding?
Breastfeeding releases oxytocin, which can cause the uterus contract.
This is normal.
How may breastfeeding affect periods?
Lactational amenorrhoea: women who are breastfeeding may not have a return to regular menstrual periods for six months or longer (unless they stop breastfeeding).
When will bottle-feeding women begin having menstrual periods after delivery?
From 3 weeks onwards (unpredictable, and periods can be delayed or irregular at first).
When is fertility considered to return after childbirth?
21 days after giving birth (contraception is not required up to this point).
How long are condoms required for when starting the COCP?
7 days
How long are condoms required for when starting the POP?
2 days
Is lactational amenorrhoea an effective method of contraception?
Yes - over 98% effective
What 2 criteria must be met for lactational amenorrhoea to be an effective method of contraception?
1) women must be fully breastfeeding
2) women must be fully amenorrhoeic (no periods)
Discuss the different contraceptive options in breastfeeding/after delivery:
a) POP
2) implant
3) COCP
4) copper coil or IUS (e.g. Mirena)
1) safe in breastfeeding and can be started at any time after birth
2) safe in breastfeeding and can be started at any time after birth
3) should be avoided in breastfeeding (UKMEC 4 before six weeks postpartum, UKMEC 2 after six weeks)
4) 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).
What is UKMEC for COCP <6 weeks postpartum?
UKMEC 4
What is UKMEC for COCP >6 weeks postpartum?
UKMEC 2
What is UKMEC for inserting copper coil or IUS within 48 hours of birth?
UKMEC 1
What is UKMEC for inserting copper coil or IUS from 48 hours of birth until 4 weeks postpartum?
UKMEC 3
What are the risks of a birth-to-conception time of less than 12 months?
Increased risk of:
1) premature delivery
2) low birth weight
3) small for gestational age babies
4) fetal mortality
How long is lactational amenorrhoea effective for?
Up to 6 months from delivery
When is the insertion of IUD & IUS contraindicated after birth?
If pelvic infection
When is IUD & IUS safe to start after delivery?
1) Post-placental: within 10 minutes of delivery of the placenta
2) Postpartum: within 48h of delivery
3) Delayed: over 4 weeks after delivery
When is the POP safe to start after delivery?
Immediately after delivery
Is the POP safe in breastfeeding?
Yes
When is the implant safe to start after delivery?
Immediately
Is the implant safe in breastfeeding?
Yes
When is the COCP safe to start after delivery?
1) If breastfeeding: 6 weeks after delivery
2) If non-breastfeeding: 3 weeks after delivery
When is barrier contraception safe to start after delivery?
Condoms immediately
Diaphragm – wait 6 weeks
Why is there a delay in starting diaphragm barrier contraception after delivery?
Delay in diaphragm due to changing uterine size
When is female sterilisation safe after delivery?
Delay advised due to increased risk of regret if done immediately.
If a woman has requested sterilisation during an elective C-section ensure consent is taken at least 2 weeks before.
If a woman has requested sterilisation during an elective C-section, when must consent be taken?
At least 2 weeks before.
If a woman is not on contraception and has unprotected sex over 3 weeks, what can she be given?
She can safely be given ulipristal acetate or levonorgestrel as emergency contraception.
In breastfeeding women who have taken emergency contraception (ulipristal acetate or levonorgestrel), how long should they avoid breastfeeding for?
Breastfeeding women should be advised to avoid feeding for one week if they take ulipristal acetate and should instead express and discard the milk.
How soon after early pregnancy loss does fertility return?
From 5 days
What contraceptive methods are safe following uncomplicated abortion or miscarriage?
All hormonal methods are safe immediately after.
Intrauterine devices should be avoided if there is a risk of infection.
How can a depot injection affect abortion?
There is a slightly higher risk of failed abortion if depot started when mifepristone is taken.
What should you be concerned about in the case of an absent period after an abortion?
Medical attention should be sought in the case of an absent period as it may indicate a failed abortion, don’t assume it is due to hormonal contraception.
After taking methotrexate (e.g. in an ectopic pregnancy), how long should women wait before conceiving again?
methotrexate
Why should COCP be avoided in women with recurrent miscarriage?
As antiphospholipid syndrome should be ruled out first.
Define puerperium
6 week period following birth during which time the various changes that occurred during pregnancy and childbirthrevert to the non-pregnant state.
What is lochia?
A combination of mucous, tissue and blood that your womb sheds as it replaces its lining after you’ve given birth.
What blood loss during labour indicates need for FBC?
> 500mls (also consider if antenatally anaemic)
Management of anaemia:
a) Hb 80-100g/l
b) Hb <80g/l & symptomatic
a) oral iron
b) may require blood transfusion
Note - IV iron is also an option in women who are symptomatic but their Hb is not low enough to trigger a transfusion.
What is endometritis
Infection within the uterus that typically occurs day 2-10.
More common following c-section.
Symptoms of endometritis?
- Fever, malaise, rigors, headache
- Abdo pain
- Offensive lochia
- Secondary PPH (≥24h after delivery)
Signs of endometritis?
- Fever, tachycardia
- Suprapubic tenderness / uterine enlargement
- Offensive lochia
Investigations in endometritis?
- Sepsis 6 if septic
- FBC, CRP
- High vaginal swab
- Blood cultures
What are the 2 key organisms causing endometritits post-caesarean section?
1) Group A Strep (Strep. pyogenes)
2) Staph. aureus
Investigations of VTE in pregnancy?
1) Obs
2) ECG
3) CXR
4) ?leg doppler
5) V/Q scan or CTPA
Which leg do 90% of DVTs in pregnancy occur?
L left (and 70% are above the knee, whereas majority below knee in non-pregnant state)
Causes of PPH (4 T’s)?
Tone
Trauma (i.e. tears)
Tissue/infection
Thrombin
What % of cases of eclampsia occur in the postnatal period?
40%
Some emergencies in the postnatal period:
- VTE
- PPH
- Endometritis
- Breast problems
- Eclampsia
- Amniotic fluid embolism
What are the 3 types of postnatal depression?
1) baby blues (up to 75% of women)
2) postnatal depression (10-15%)
3) puerperal psychosis (significant cause of maternal death)
