Postnatal Obstetrics Flashcards
Define puerperium?
o 6 weeks after delivery
VTE management of the puerperium in 1st few days?
90% of DVT in pregnancy in L leg, 70% above knee
Any woman needing antenatal VTE prophylaxis – must be given 6 weeks post-partum
Any women undergoing Emergency LSCS need 7 days postpartum LMWH
Rhesus management of the puerperium in 1st few days?
o If Rh -ve women, give 500U Anti-D within 72h
Monitoring management of the puerperium in 1st few days?
o Check temp, BP, breasts, legs, lochia, fundal height if heavy PV losses
o Check Hb on postnatal day 1 or > day 7: postpartum haemodilution occurs from days 2-6
Hb 80-100 – oral iron
Hb <80 & symptomatic may require transfusion
General management of the puerperium in 1st few days?
o Teach pelvic floor exercises
o Vaccinate if not immune to Rubella
o Discuss contraception
Symptoms and management of endometritis?
Lower abdominal pain, offensive lochia and tender uterus
IV Co-amoxiclav
If penicillin allergic - clindamycin + metronidazole
Give the stages of lochia in puerperium?
Lochia rubra (red for 1st 3 days)
Lochia serosa (yellow)
Lochia alba (white over next 10 days)
Until 6 weeks
Breast changes in puerperium?
o Breasts produce milky discharge and colostrum during last trimester
Milk replaces colostrum 3 days after birth
o Breasts swollen, red, tender with engorgement at 3-4 days
What checks are performed at 6 week examination postnatally?
o See how mother and baby relate o BP & weight o FBC if anaemic postnatally o Arrange cervical smear if due o Check contraceptive plans
Recommendations for contraception in puerperium?
- Recommended abstinence or gentle intercourse for 6 weeks post-partum
- Sexual problems are common
When is contraception not needed after a baby?
• Not needed for first 3 weeks
Describe lactational amenorrhoea and when can it be considered effective?
o Delays return of ovulation (breastfeeding disrupts frequency and amplitude of gonadotrophin surges, so ovulation does not occur)
o If breast feeding day and night, <6 months postpartum and amenorrhoeic – 98% effectiveness
o Need additional contraception once efficacy decreased
When can the POP be started postnatally?
o Started at any time postpartum but if after 21 days, precautions for 2 days
o Does not affect breast milk production
When can the COCP be started postnatally?
o Start at 3 weeks if not breastfeeding
o Not recommended until 6 months in breast feeding women (can be used at 6 weeks if other methods unacceptable)
When can EC be used postnatally? When is it not needed?
o Use of progesterone method suitable for all
o Not needed 21 days postpartum
Recommendations for the Depot injection as postnatal contraception?
o Not recommended until 6 weeks in breastfeeding
o Medroxyprogesterone acetate 150mg deep IM 12-weekly can start 5 days postpartum if bottle feeding
o Norethisterone Enantate 200mg IM 8-weekly (licenced short-term but can give if medroxyprogesterone gives heavy bleeding)
When is implant contraception recommended postnatally?
o Insertion not recommended until 6 weeks in breastfeeding
o Implant at 21-28 days in those bottle feeding
When can IUCD be inserted postnatally?
o Inserted within first 48h postpartum or delayed until 4 weeks
o Minimise risk of perforation
o Levonorgestrel-releasing IUD (Mirena) also inserted at 4 weeks
When can diaphragms or cervical caps be used postnatally?
o Fitted at 6 weeks
o Alternative contraception needed from day 21
When can sterilisation be considered postnatally?
o Wait appropriate amount of time as immediate ligation has increased failure rate
What are the common analgesic problems identified at the 6 week postnatal check?
Pain
• Common in post partum period.
• ‘After pains’ due to uterine contractions cause lower central abdominal pain, mainly in first four days.
• Perineal pain could be severe, especially after instrumental delivery, episiotomy or vaginal tears.
What are the common urinary problems identified at the 6 week postnatal check? And how are they managed?
• Urinary retention
o Following instrumental delivery or extensive tears (especially periurethral), pain and oedema can cause voiding difficulties and retention.
o Reassurance along with analgesics is helpful is most situations.
o Occasionally catheterisation is required to prevent overdistension.
o Urinary retention can also occur with an epidural as bladder sensation and the desire to void is masked.
• UTI
o Low threshold for suspicion of UTI as catheterisation during labour may predispose.
o Confirm with MSU and treat with appropriate Abx and oral fluids
Antibiotics used in pregnancy - UTI?
o Avoid trimethoprim – DO NOT USE in 1st trimester
o Avoid nitrofurantoin – DO NOT USE in 3rd trimester
o Cephalosporins and penicillins safe
Antibiotics used in pregnancy - RTI?
o Penicillins and macrolides safe
Antibiotics used in pregnancy - PPROM?
o Erythromycin
Antibiotics used in pregnancy - Chorioamnionitis?
o Cefuroxime + Metronidazole
Antibiotics used in pregnancy - endometritis?
Co-amoxiclav
If penicillin allergic - clindamycin + metronidazole
Define endometritis?
o Uterine infection, common after delivery, ToP, miscarriage, IUCD insertion
When is endometritis more common?
o Day 2-10
o More common following CS
Presentation of endometritis?
Lower abdominal pain
Fever, malaise, rigors
Uterine tenderness, offensive vaginal discharge
Secondary PPH
Test in endometritis?
High vaginal swabs and blood cultures
FBC, CRP
Management of endometritis?
Remove IUCD
Co-amoxiclav
If penicillin allergic - clindamycin + metronidazole
Describe the different milk products in lactation?
Colostrum
• Thick yellow fluid produced from around 20 weeks gestation.
• Has a high concentration of secretory IgA.
• Rich in proteins which play an important part in gut maturation and immunity for the infant.
• Produced in small quantities following the birth of the baby.
Human milk
• The amount of milk produced rapidly to ~500mL at 5 days post partum.
• Is more energy efficient than formula milk
Initiation of lactation occurs when?
Skin to skin contact should start as soon as possible after delivery
• Increases breastfeeding chances after delivery and 2-3 months
What frequency of breast feeding should be advise?
Demand feeding should be encouraged
Frequent feeding associated with less neonatal jaundice
Exclusively breast-fed term infants feed a median of 8x a day.
• 6x during the day.
• 2x at night.
Describe the frequency of feeding patterns in neonate? When should it stop?
Feeds tend to be infrequent in the first 24-48 hours and could be as few as 3 feeds in the first 24 hours (this should not cause concern in an otherwise well baby).
The frequency gradually and reaches a peak around 5th day of life.
WHO recommends exclusive breast-feeding for 4-6 months, with production of appropriate complementary foods after this period
Physiology of lactation?
Dependent on prolactin and oxytocin
Prolactin from anterior pituitary stimulates milk secretion
Rapid decline in oestrogen and progesterone levels after birth cause milk secretion
Oxytocin from the posterior pituitary stimulates ejection in response to nipple suckling, which also stimulates prolactin release and therefore more milk secretion
How much milk can be produces per day? What can inhibit milk production?
As much as 1000+mL of milk per day can be produced, dependent on demand
Since oxytocin release is controlled via the hypothalamus, lactation can be inhibited by emotional or physical stress
Advice to give for ideal breast-feeding environment?
Women should be gently encourages to breastfeed when the baby is ready.
Early feeding should be on demand.
Correct positioning of the baby is vital - the baby’s lower lip should be planted below the nipple at the time that the mouth opens in preparation for receiving milk, so that the entire nipple is drawn into the mouth.
This could largely prevent the main problems of insufficient milk, engorgement, mastitis and nipple trauma.
A restful, comfortable environment is important, not least because oxytocin secretion and therefore milk ejection, can be reduced by stress.
Supplementation is unnecessary, although Vitamin K should be given to decrease the chances of haemorrhagic disease of the newborn
Benefits of breast feeding neonate?
Human breast milk contains numerous protective factors against infectious disease and may influence immune system development *(IgA)
These include the effect of colostrum on immunity, fewer diarrhoea diseases, the benefits of omega-3 fatty acids on visual developments in small infants
Infant benefits of breast feeding?
• Less – GI illnesses, UTIs, respiratory infection, atopic illness
Parent benefits of breast feeding?
• Uterine involution
o Breast feeding helps in uterine involution and reduces the risk of post-partum haemorrhage.
• Amenorrhoea and contraception
o Lactational amenorrhoea and full or nearly full breast-feeding for up to 6 months is nearly 99% effective as contraception.
o At 12 months the effectiveness during amenorrhoea drops to 97%.
o Amenorrhoea can be helpful for anaemia in developing countries.
• Other benefits
o Breastfeeding protects the mother against pre-menopausal breast cancer, ovarian cancer and osteoporosis.
Problems in breast feeding?
Inadequate milk supply
• Treatment – adequate fluids, nutrition, secure environment, dopamine antagonists, thyrotopin-releasing hormones
Breast engorgement, mastitis, breast abscess
Sore or cracked nipples
Drugs that reduce milk production:
• Progestins, oestrogens, ethanol, cabergoline
Mastitis
Describe mastitis and management?
- Is characterised by swollen, red and painful area on breast, tachycardia, pyrexia and an aching, flu-like feeing, often accompanied by shivering and rigors.
- Infective usually S.aureus
- Usually give flucloxacillin
- Continue breast feeding
Medications generally safe in pregnancy?
- Heparin
- Insulin
- Aminoglycoside antibiotics
- Third generation cephalosporins
- Omeprazole and lansoprazole
- Inhaled steroids and beta agonists
Medications which are contraindicated in pregnancy?
- Amiodarone
- Antineoplastic
- Chloramphenicol
- Ergotamine
- Cabergoline
- Ergot alkaloids
- Iodides
- Methotrexate
- Lithium
- Tetracycline
- Pseudoephedrine
Medications to avoid in breast feeding?
- Acebutalol
- ACE inhibitors (except captopril).
- Alcohol
- Caffeine
- Cocaine
- Marijuana
- Fluoxetine
- Iodine
- Sulphonamides
What to avoid prescribing in lactation?
Avoid oestrogen containing contraception as suppresses lactation
Avoid aspirin (Reye’s syndrome)
Advice about breastfeeding in HIV?
• Avoid breastfeeding in HIV positive mother
Advice about breastfeeding in Hep B?
• May breast feed, immunise at birth
Advice about breastfeeding in HSV?
• If no breast lesions then breastfeeding encouraged
Advice about breastfeeding in Chicken pox?
• Continue to breastfeed, passive immunity
Define primary PPH?
o Bleeding of >500mls in 1st 24 hours after delivery
o Occurs after 6%
o Major is >1L
Risk factors for PPH?
Previous PPH BMI >35 Maternal Hb <85 Antepartum haemorrhage Multiparity >4 Maternal age >35 Uterine malformations Large/Low placental site Abruption Prolonged labour Induction/Operative birth
Causes of PPH?
Tone - e.g uterine atonia / hypotonia of uterus
Tissue - e.g retained placental tissue, placenta accrete
Trauma - e.g laceration of cervix, uterus
Thrombosis - e.g coagulopathy, DIC
Define secondary PPH?
o Excessive bleeding from the genital tract between 24 hours and 6 weeks post-partum
o Usually occurs 5-12 days and usually due to retained placental tissue or clot, often with infection (endometritis)
Immediate management of PPH?
o Call for help – senior staff plus pairs of hands
o Massive obstetric haemorrhage is loss of >1500mls and should prompt 2222 call
o ABC
o High flow facial oxygen & tilt bed head down
o Site 2 large bore cannulae & give 500 mls NaCl
o send bloods for FBC, clotting screen, crossmatch 4 units blood
o urinary catheter
o check fetal condition
o if necessary give O negative or group specific blood
o assess cause of bleeding
Management of primary PPH?
o Retained placenta - arrange manual removal under G.A or spinal depending on condition
o Atonic uterus – series of drugs to make uterus contract
o Give ergometrine as IV bolus
o Commence Syntocinon infusion
o Carboprost 0.25mg IM repeated up to 8 times
o may need examination under anaesthesia + / - laparotomy
o genital tract trauma – repair
Management of secondary PPH?
o Check for retained products and endometritis
o Require 24 hours antibiotics
o US to look for retained products
o Evacuation
Describe baby blues? When does it occur and what presents with?
o Transient, self-limiting condition seen in up to 75% of new mothers
o Most often 3-5 days after delivery, lasting for 1-2 days (can be for up to 2 weeks)
o Tearful, anxious and irritable
Management of baby blues?
Reassurance with increased social/family support
May need psychiatric review
How common is postnatal depression?
o Affects 10%, use Q-aires to diagnose
Risk factors for postnatal depression?
o Hx of postpartum depression o Unipolar/Bipolar depression o Unplanned pregnancy o Lack of support, marital problems, social circumstances, sleep deprivation o Not breastfeeding
Symptoms of postnatal depression?
o Usually resolves in <6 months o Tearfulness o Irritability o Anxiety o Poor sleep
Diagnosis of postnatal depression?
o Enquire about symptoms, screen for suicidal ideation
o Assess using Edinburgh Postnatal Depression Scale (EPDS)/PHQ-9
o Diagnosed according to ICD-10 criteria for depression
DDx for postnatal depression?
o Baby blues o Postpartum psychosis o Bipolar Disorder o Anxiety o Postpartum thyroiditis
Treatment of postnatal depression?
o Screened at 6 weeks postnatally
o Input from health visitor – promote parents to work as a team, take some burden off mother in puerperium
o GP/Psychiatric appointment
CBT
• If mild to moderate – self-help psychotherapy
• Severe may need intensive CBT
Antidepressants
• SSRIs (paroxetine/sertraline) and TCAs considered safe in breastfeeding
• NOT FLUOXETINE
• Monitor baby for SE
If severe postnatal depression - management?
o If severe, refer to mental health team/admission to Mother and Baby unit//ECT
Self-harm/harm to others, self-neglect, bipolar, Hx of severe mental illness
Antidepressants
Psychotherapies
Antipsychotics
ECT
When does postpartum psychosis occur?
o Peak onset 2 weeks postpartum
o 1 in 1000 deliveries
Risk factors for postpartum psychosis?
o Hx of postpartum psychosis (30% recurrence risk) o PHx of bipolar disorder o Single parent o Reduced social support o Previous mental illness
Symptoms of postpartum psychosis?
o Prominent depressive symptoms (withdrawal, confusion, catatonia, insomnia, fluctuating)
o Mania (elation, lability, agitation)
o Delusions (paranoia, jealousy, persecution, grandiosity)
o Hallucinations (auditory, visual, olfactory, tactile)
o Odd belief about baby
Diagnosis of postpartum psychosis?
o Clinical diagnosis – enquire about past and family history, refer early
Management of postpartum psychosis?
o Needs emergency referral to specialist mother and baby unit
o Medications
Antipsychotic
Mood stabiliser/Antidepressant
• Lithium treatment – mother should not breastfeed
ECT
o Reassurance and emotional support (with and for family)
o Follow-Up
Referral to local MHT and health visitors needed
Prognosis of postpartum psychosis?
o Risk of recurrence in subsequent pregnancies
o Low threshold for referral
Management of anaemia in postpartum period?
Loss of >500ml - need FBC
Hb 80-100 - oral iron
Hb<80 & symptomatic - blood transfusion
Can give IV iron
