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Obstetrics and Gynaecology > Postnatal care - done > Flashcards

Postnatal care - done Flashcards

1
Q

What do women receive in the days after delivery?

A

Analgesia as required

Help establishing breast or bottle-feeding

Venous thromboembolism risk assessment

Monitoring for postpartum haemorrhage

Monitoring for sepsis

Monitoring blood pressure (after pre-eclampsia)

Monitoring recovery after a caesarean or perineal tear

Full blood count check (after bleeding, caesarean or antenatal anaemia)

Anti-D for rhesus D negative women (depending on the baby’s blood group)

Routine baby check

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2
Q

What will new mothers discuss in their routine follow up with the midwife?

A

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)

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3
Q

What topics are covered at the 6 week postnatal check at the GP? (usually done at same time as 6-week newborn baby check)

A

General wellbeing

Mood and depression

Bleeding and menstruation

Scar healing after episiotomy or caesarean

Contraception

Breastfeeding

Fasting blood glucose (after gestational diabetes)

Blood pressure (after hypertension or pre-eclampsia)

Urine dipstick for protein (after pre-eclampsia)

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4
Q

What type of vaginal bleeding occurs in the period shortly after birth?

A

Vaginal bleeding as the endometrium initially breaks down (mix of blood, endometrial tissue and mucus called lochia)

Initially a dark red colour and over time turns brown and becomes lighter in glow and colour

Tampons should be avoided as they carry a risk of infection

Bleeding should settle within 6 weeks

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5
Q

Why does slightly more vaginal bleeding occur suring episodes of breastfeeding?

A

Breastfeeding releases oxytocin which can cause the uterus to contract leading to slightly more bleeding

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6
Q

What is the absence of periods related to breastfeeding called?

A

Lactational amenorrhoea

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7
Q

When will bottle feeding women begin having menstrual periods after giving birth?

A

From 3 weeks onwards (unpredictable)

Periods can be delayed or irregular at first

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8
Q

When is fertility considered to return after birth?

A

21 days

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9
Q

How effective is lactational amenorrhoea at contraception?

A

Over 98% effective - women must be fully breastfeeding and amenorrhoeic (no periods)

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10
Q

What forms of contraception are safe in breastfeeding?

A

Progesterone only pill and implant started at any time after birth

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11
Q

What contraceptive should be avoided in breastfeeding?

A

COCP (UKMEC 4 before six weeks and UKMEC 2 after six weeks)

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12
Q

What contraceptive can be inserted within 48 hours of birth or more than 4 weeks after birth?

A

Copper coil

Intrauterine system

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13
Q

What is endometritis?

A

Inflammation of the endometrium usually caused by an infection

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14
Q

What type of delivery is more commonly associated with endometritis?

A

Caearean section (prophylactic abx are given)

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15
Q

What usually causes endometritis unrelated to pregnancy?

A

PID

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16
Q

How does postpartum endometritis present?

A

Foul-smelling discharge or lochia

Bleeding that gets heavier or does not improve with time

Lower abdominal or pelvic pain

Fever

Sepsis

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17
Q

How is postpartum endometritis diagnosed?

A

Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)

Urine culture and sensitivities

Ultrasound (to rule out retained products of conception (although not used to diagnose endometritis)

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18
Q

How are patients with postpartum endometritis managed?

A

Septic patients require hospital admission and sepsis 6 incl blood cultures and broad spectrum abx

Combination of clindamycin and gentamicin is often recommended.

Blood tests will show signs of infection (e.g. raised WBC and CRP)

Milder symptoms can be treated with oral abx e.g. co-amoxiclav

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19
Q

What is a significant risk factor for retained products of conception?

A

Placenta accreta

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20
Q

How does retained products of conception present?

A

Vaginal bleeding that gets heavier or does not improve with time

Abnormal vaginal discharge

Lower abdominal or pelvic pain

Fever (if infection occurs)

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21
Q

How are retained products of conception diagnosed?

A

Ultrasound

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22
Q

How is postpartum retained products of conception managed?

A

Surgically

Evacuation of retained products of conception (ERPC) is a sugical procedure involving a general anaesthetic

Cervix is gradually widened using dilators and retained products are manually removed through the cervix usign vacuum aspiration and curettage (scraping).

Procedure is referred to as “dilatation and curettage”

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23
Q

What are two key complications of dilatation and curettage?

A

Endometritis

Asherman’s syndrome

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24
Q

What is Asherman’s syndrome?

A

Adhesions (sometimes called synechiae) form within the uterus.

Endometrial curettage (scraping) can damage the basal layer of the endometrium - then heals abnormally - adhesions could form within the endocervix, sealing it shut = infertility

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25
Q

What is postpartum anaemia?

A

Haemoglobin of less than 100g/l in the postpartum period

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26
Q

What is the management of postpartum anaemia?

A

FBC checked the day after delivery, if there has been:

Postpartum haemorrhage over 500ml

Caesarean section

Antenatal anaemia

Symptoms of anaemia

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27
Q

What is the treatment of postpartum anaemia (roughly)?

A

Hb under 100 g/l – start oral iron (e.g. ferrous sulphate 200mg three times daily for three months)

Hb under 90 g/l – consider an iron infusion in addition to oral iron (e.g. Monofer, CosmoFer or Ferinject)

Hb under 70 g/l – blood transfusion in addition to oral iron

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28
Q

When is an iron infusion considered in women with PPH?

A

May have poor adherence or oral treatment

Cannot tolerate oral iron

Fail to respond to oral iron

Cannot absorb oral iron (e.g. inflammatory bowel disease)

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29
Q

What is the risk with iron infusions?

A

Allergic and anaphylactic reation - used in caution in those with history of allergy or asthma

30
Q

What is a contraindication to an iron infusion?

A

Active infection as pathogens “feed” on iron

31
Q

What is postnatal depression characterised by?

A

Low mood in the postnatal period

32
Q

What are the different severities of postnatal depression?

A

Baby blues is seen in the majority of women in the first week or so after birth

Postnatal depression is seen in about one in ten women, with a peak around three months after birth

Puerperal psychosis is seen in about one in a thousand women, starting a few weeks after birth

33
Q

What proportion of women experience baby blues?

A

50% in the first week or so

34
Q

What are the symptoms of baby blues?

A

Mood swings

Low mood

Anxiety

Irritability

Tearfulness

35
Q

What may baby blues be the result of?

A

Significant hormonal changes

Recovery from birth

Fatigue and sleep deprivation

The responsibility of caring for the neonate

Establishing feeding

36
Q

When do baby blues typically resolve?

A

Within about two weeks of delivery

37
Q

How does postnatal depression present?

A

Classic triad of:

Low mood

Anhedonia (lack of pleasure in activities)

Low energy

38
Q

When are women typically affected with postnatal depression?

A

Three months after birth

39
Q

How long do symptoms have to last before a diagnosis of depression can be made?

A

2 weeks

40
Q

How is postnatal depression managed?

A

Mild cases may be managed with additional support, self-help and follow up with their GP

Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy

Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit

41
Q

What screening tool is ther for postnatal depression?

A

Edinburgh postnatal depression scale

To assess how the mother has felt over the past week

10 questions, score greater than 10/30 indicates postnatal depression

42
Q

What is puerperal psychosis?

A

Rare illness which onsets between 2 to 3 weeks after delivery with psychotic symptoms

43
Q

What are the symptoms of puerperal psychosis?

A

Delusions

Hallucinations

Depression

Mania

Confusion

Thought disorder

44
Q

What is the treatment of puerperal psychosis?

A

Admission to the mother and baby unit

Cognitive behavioural therapy

Medications (antidepressants, antipsychotics or mood stabilisers)

Electroconvulsive therapy (ECT)

45
Q

What is the mother and baby unit?

A

Unit for pregnant women + women who have given birth in the last 12 months

Mothers are supported with childcare whilst they get specialist treatment

46
Q

What preparation is there for pregnant women with existing mental health concerns?

A

Referral to perinatal mental health services, for:

  • Decisions on medications e.g. SSRIs, antipsychotic, lithium
  • Plan for after delivery with follow up
47
Q

What is the problem with using SSRIs during pregnancy?

A
48
Q

What is mastitis?

A

Inflammation of the breast tissue, a common complication of breastfeeding, can occur with or without associated infection

49
Q

What is mastitis caused by?

A

Obstruction - regularly expressing milk can help prevent

Infection - bacteria entering at the nippep (usually staph aureus)

50
Q

How does mastitis present?

A

Breast pain and tenderness (unilateral)

Erythema in a focal area of breast tissue

Local warmth and inflammation

Nipple discharge

Fever

51
Q

What is the management of mastitis?

A

Depends on cause:

  • Blockage = conservative, continued breastfeeding, heat packs, warm showers, simple analgesia

- Infection = abx started flucloxacillin or erythromycin sample of milk can be sent for culture and sensitivites (fluconazole for suspected candidal infections) - women should be encouraged to continue breastfeeding, even when infection is suspected

52
Q

What is a complication of mastitis?

A

Breast abscess - may need incision and drainage

53
Q

When can candida of the nipple occur?

A

After a course of antibiotics leading to recurrent mastitis as it causes cracked skin on the nipple

Associated with oral thrush and candidal nappy rash in the infant

54
Q

How may candidal infection of the nipple present?

A

Sore nipples bilaterally, particularly after feeding

Nipple tenderness and itching

Cracked, flaky or shiny areola

Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash

55
Q

What is the treatment for candidal infection of the nipple?

A

Topical miconazole 2% after each breastfeed

Treatment for the baby (e.g. miconazole gel or nystatin)

56
Q

What is postpartum thyroiditis?

A

Changes in thyroid function within 12 months of delivery affecting women without a history of thyroid disease.

Can involve thyrotoxicosis (hyperthyroidism) or hypothyroidism or both

57
Q

How does postpartum thyroiditis change over time?

A

Small proportion of women will remain hypothyroid and need long-term hormone replacement

58
Q

What is the cause of postpartum thyroiditis?

A

Unclear, leading theory is that pregnanct has an immunosuppressant effect on the mother’s body to prevent her from rejecting the fetus

Once delivery has occured there may be an exaggerated rebound effect with increased immune system activity and expression of antibodies (e.g. thyroid peroxidase antibodies)

59
Q

What are the three stages to postpartum thyroiditis?

A

Thyrotoxicosis (usually in the first 3 months)

Hypothyroid (usually from 3-6 months)

Thyroid function gradually returns to normal (usually within one year)

60
Q

What are the signs and symptoms of thyrotoxicosis?

A

Anxiety and irritability

Sweating and heat intolerance

Tachycardia

Weight loss

Fatigue

Frequent loose stools

61
Q

What are the signs and symptoms of hypothyroidism?

A

Weight gain

Fatigue

Dry skin

Coarse hair and hair loss

Low mood

Fluid retention (oedema, pleural effusions, ascites)

Heavy or irregular periods

Constipation

62
Q

What test should be done on a woman presenting with postnatal depression ?

A

Thyroid function tests performed 6-8 weeks after delivery

63
Q

Whats the management for patients with postpartum thyroiditis?

A

Referral to an endocrinologist:

  • Thyrotoxicosis: symptomatic control, such as propranolol (a non-selective beta-blocker)
  • Hypothyroidism: levothyroxine
64
Q

After the year of postpartum thyroiditis, is there any further managment?

A

Annual monitoring of TFTs - to identify those who go on to develop long term hypothyroidism

65
Q

What is Sheehan’s syndrome?

A

Rare complication of post-partum haemorrhage, where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland leading to ischaemia in the cells of the pituitary and cell death

66
Q

Which gland does Sheehan’s syndrome affect?

A

Anterior pituitary gland - hormones produced by the posterior pituitary are spared

67
Q

Where does the anterior pituitary get its blood supply from?

A

Low-pressure system called the hypothalamo-hypophyseal portal system - susceptible to rapid drops in blood pressure

68
Q

Where does the posterior pituitary get its blood supply from?

A

Various arteries and so not susceptible to ischaemia

69
Q

Which hormones does the anterior pituitary release?

A

Thyroid-stimulating hormone (TSH)

Adrenocorticotropic hormone (ACTH)

Follicle-stimulating hormone (FSH)

Luteinising hormone (LH)

Growth hormone (GH)

Prolactin

70
Q

Which hormones does the posterior pituitary release?

A

Oxytocin

Antidiuretic hormone (ADH)

71
Q

How does Sheehan’s syndrome present?

A

Reduced lactation (lack of prolactin)

Amenorrhea (lack of LH and FSH)

Adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH)

Hypothyroidism with low thyroid hormones (lack of TSH)

72
Q

What is the management of Sheehan’s?

A

Replacement of the missing hormones:

Oestrogen and progesterone as hormone replacement therapy for the female sex hormones (until menopause)

Hydrocortisone for adrenal insufficiency

Levothyroxine for hypothyroidism

Growth hormone

Obstetrics and Gynaecology (10 decks)

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