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