Postnatal Care, Lactation and Maternal Problems Flashcards
What is lochia?
Blood and decidua. Normal discharge from uterus after childbirth
What are the genital tract changes after birth?
- Uterus returns to pelvis ~2 wks
- Afterbirth pains
- Lochia (200-500mL; ~1month)
What are the haem/CV changes after birth?
- Diuresis
- Resoution of oedema
- Return to normal blood volume
- Hypercoaguable state (need VTE prophylaxis)
What is the composition of human milk?
- 4%fat (TGs, phospholipids)
- Carbs: lactos, oligosaccharides
- Proteins: casein, lactoferrin, IgA
- Minerals: Na, K, Cl, Mg, Ca
- Enzymes, GFs, trace elements
- Leukocytes, epithelial cells
What are the benefits to the baby of breastfeeding?
- Nutritional - digestion
- Obesity, HT
- SIDS
- Dec atopy incidence
- Dec infection, hospitalisations, mortality from infections (diarrhoea and respiratory)
- IQ
What are the benefits of breastfeeding to the mother?
- Faster return to pre weight
- oxytocin encourages involution of the uterus, less blood loss
- some protection against breast, ovarian Ca; CVD
- contraceptive effect
Breastfeeding CIx?
-Viruses: HIV
-Drugs (some): 1% will cross to infant.
>antineoplastics
>ergotamine
>methotrexate
>cyclosporine
>radiopharmaceuticals
What are the keys to successful breastfeeding?
- Antenatal education
- Early feeding / skin contact
- Encourage demand feeding
- Avoid supplemental feeds and dummies
- Encourage rooming in
What triggers initiation of lactation?
- Preg: oestrogen, progesterone, prolactin, HPL
- Delivery: fall progesterone, allows prolactin
What is colostrum?
During early breastfeeding. Thick, small volume (0.5-1mL) yellow; lipid and immunoglobulin rich
How to minimise sore / cracked nipples?
- Correct positioning: nipple forms distal third of teat with baby’s jaw and lower tongue against areola and breast tissue
- Lanolin
Mx engorgement?
- “supply and demand”
- Express to soften breast to ensure correct attachment
- Firm bra, cold packs
- analgesia
Mx candida infection?
Treat mother and baby after feed.
- M: miconazole / fluconazole
- B: nystatin, miconazole
What are the general indicators of low milk supply?
- breasts feel softer
- baby feeds more often
- baby takes less time to feed
- baby unsettled
- baby settles better on formula
- growth slows after 3 months
what are the physical changes in baby indicating low milk supply?
-weight gain
How to increase milk supply?
- positioning and attachment
- increase number of feeds
- increase duration of feeds
- offer both breasts at each feed
- express after feeds
- supplemental feeding line
- metoclpramide / domperidone
What is mastitis?
Breast infection due to blocked duct. Indurated, painful red area with systemic symptoms. May require admission.
Mx mastitis?
- Keep feeding
- Flucloxacillin
- Analgesia, fluids
- Consider breast abscess if fails to respond and drain surgically
LOS post birth?
2 night vaginal; 4 c section
Daily review early post natal?
- General appearance, wellbeing
- T, P, BP
- Uterus involution (palpation, lochia)
- Wound appearances (perineum, abdominal)
- Urinary and bowel function
- Breast, nipple symptoms
- Allied health as appropriate
What is puerperal pyrexia / maternal sepsis?
Maternal temp >38 within 2 weeks birth (not first 24h)
What are the sources of maternal sepsis?
A. Ob specific: uterine / adnexal, wound infection B. Breast infection C. UTI D. Thrombophlebitis E. Haematoma F. Anaesthetic infection
What are the causes and features of secondary post partum haemorrhage / endometritis?
- RPOC
- Infection
- Idiopathic subinvolution
- Coagulopathy
- Trauma
CFx:
- fever, tachy
- tender bulky uterus
- offensive vaginal loss
What is the causes of endometritis (micro aetiology)?
Polymicrobial
-aerobes (strep GAS, GBS, enterococcus, E.coli, S. aureus, Klebsiella, Gardnerella)
-anaerobes (peptostreptococcus, bacteroides, clostridium)
mycoplasma (ureaplasma, mycoplasma)
Mx endometritis?
may need blood +/- fluid resuscitation
- Outpatient Mx: oral Augmentin
- Inpatient Mx: Amp/ Gent/ Flagyl IV
- +/- careful curettage after delay for antibiotics
Mood disorders postpartum?
- Post partum blues 80%
- PP depression
- PP psychosis
Efficacy of lactational contraception?
97% effective contraceptive if
– baby
What are the options for hormonal contraception?
Progesterone-only contraception. Safe in breast feeding.
– Minipill (30 microgram levenorgestrel)
• commence D21 (earlier –> inc spotting in puerperium)
– Depo Provera (150 mg medroxyprogesterone acetate)
– Implanon (68mg etonorgestrel )
IUD insertion post partum time frame?
Either within 48/24 OR after 4/52
RFx puerperual pyrexia / sepsis?
- Prolonged rupture of membranes
- Frequent use of urinary catheters
- Prolonged labour
- Assisted birth
- Vaginal lacerations
- Post partum haemorrhage
- C section
What are the major pathogens causing puerperal pyrexia
– Group A streptococcus (Str. Pyogenes)
– Group B streptococcus
– Aerobic gram-neg bacilli (E Coli, Klebsiella pneumoniae, Proteus)
– Anaerobic gram-neg bacilli (Bacteriodes, Prevotella)
– Staphylococcus Aureus
– Methicillin-resistant S. Aureus (MRSA), clostridium
septicum, morganella morganii
Ix in secondary post partum haemorrhage?
- FBE
- Coags
- Blood group
- Vaginal swabs / cultures
mx secondary post partum haemorrhage?
- IVF and blood if required
- Correct coagulation defects
- Instigate medical mx: ABx, uterotonics
- Surgical Mx if required: suction curettage (24h ABx prior)
- Embolisation
- Hysterectomy
Preventative strategies to minimise secondary post partum haemorrhage?
- Active Mx of third stage
- Careful inspection of placenta
- AB during labour or immediate post partum if woman at risk of endometritis
Screening tool for mental health problems post natally
Edinburgh postnatal depression scale
Degrees of perineal laceration?
- First: laceration of vaginal mucosa
- Second: laceration of vaginal epithelium, perineal skin and muscle of perineal body but does not include anal sphincter
- Third: tear through whole of perineal body and involves external sphincter
- Fourth: extends into anal canal or rectal mucosa
What is included in episiotomy?
- Perineal skin and s/c tissue
- Post vaginal wall
- bulbocavernosus muscle
- superficial transverse perineal muscle
- pubococcygeus muscle
What is a vulval haematoma?
- A/w nulliparity, episiotomy, operative delivery
- excruciating pain, appearance of tense, fluctuating swelling covered by discoloured skin
- bleed can be considerable and lead to hypovolemia, shock and severe anaemia
