Postpartum: Routine Care Flashcards
A routine care appointment is offered when after birth? [1]
What is check during this appointment? [4]
Six weeks post natal check by GP to check how mother is doing - at same time as 6 week newborn baby check
* 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)
Describe what is meant by a lochia [1]
How long does it last? [1]
What should be avoided during this time? [1]
a mix of blood, endometrial tissue and mucus post birth
- initially dark red colour that turns brown
- settles within 6 weeks
- avoid tampons as they have risk of infection
How does breastfeeding interact with menstruation after delivery? [2]
Breastfeeding releases oxytocin, which can cause the uterus contract, leading to slightly more bleeding during episodes of breastfeeding. This is normal.
Women who are breastfeeding may not have a return to regular menstrual periods for six months or longer (unless they stop breastfeeding). The absence of periods related to breastfeeding is called lactational amenorrhoea.
When does fertility return after giving birth? [1]
Fertility is not considered to return until 21 days after giving birth, and contraception is not required up to this point
After 21 days women are considered fertile, and will need contraception (including condoms for seven days when starting the combined pill or two days for progestogen-only contraception).
How effective is lactational amenorrhea as contraception? [1]
Lactational amenorrhea is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods).
Which methods of contraception are safe for breastfeeding? [3]
When can you put in the copper or IUS coils after birth? [2]
The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.
The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before six weeks postpartum, UKMEC 2 after six weeks).
A copper coil or intrauterine system (e.g. Mirena) 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).
TOM TIP: Remember that the combined pill should not be started before six weeks after childbirth in women that are breastfeeding. The progesterone-only pill or implant can be started any time after birth.
A patient wants to start contraception after birth - what advise what you give them?
‘postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.’
- after day 21 additional contraception should be used for the first 2 days
Combined oral contraceptive pill (COCP)
* absolutely contraindicated - UKMEC 4 - if breastfeeding < 6 weeks post-partum
* UKMEC 2 - if breastfeeding 6 weeks - 6 months postpartum
* the COCP may reduce breast milk production in lactating mothers
* after day 21 additional contraception should be used for the first 7 days
The intrauterine device or intrauterine system
- can be inserted within 48 hours of childbirth or after 4 weeks.
Why is COCP after < 6 weeks post-partum an UKMEC4? [1]
Increased risk of VTE
Describe what is meant by post-partum endometritis [1]
When is it most commonly caused and how do you reduce the risk of this happening? [1]
Infection of the endometrium caused during / after labour as the process of delivery opens the uterus to allow bacteria from the vagina upwards
Endometritis occurs more commonly after caesarean section compared with vaginal delivery. Prophylactic antibiotics are given during a caesarean to reduce the risk of infection.
Describe the presentation of post-partum endometritis [4]
- Foul-smelling discharge or lochia
- Bleeding that gets heavier or does not improve with time
- Lower abdominal or pelvic pain
- Fever
- Sepsis
How do you dx post-partum endometritis? [2]
- Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)
- Urine culture and sensitivities
- Ultrasound may be considered to rule out retained products of conception (although it is not used to diagnose endometritis).
name a significant risk factor for retained products of conception [1]
Describe the presentation of RPOC [4]
Placenta accreta is a significant risk factor for retained products of conception.
Presentation
- Retained products of conception may be present in patients without any suggestive symptoms. It may present with:
* Vaginal bleeding that gets heavier or does not improve with time
* Abnormal vaginal discharge
* Lower abdominal or pelvic pain
* Fever (if infection occurs)
