Puerperium Flashcards
Puerperium definition
Time from delivery until the anatomic and physiologic changes of pregnancy have resolved
Approximately 6 weeks
Post-natal check
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
topics in routine midwife follow up
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)
6 week post-natal 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)
how long for periods to come back in breastfeeding
6 months
how long for periods to come back in bottle feeding
3 weeks
lochia
endometrium breaks down then returns to normal over time
avoid tampons
bleeding settles within 6 weeks
physiological changes after pregnancy
lochia
uterine involution
lactation
menstruation
examination after pregnancy
Temperature, BP, pulse, RR, Sats
Uterine size and involution
Vaginal bleeding
Lochia/ discharge
Abdominal wound (if CS)
Perineum and para-vaginal tissue
Breast
Lower limbs for DVT
Enquire about bladder function
Enquire about bowel function
when does fertility return after childbirth?
21 days
contraception after childbirth
lactational amenorrhea
POP and implant
COCP
copper coil or IUS
when can IUD IUS be inserted?
within 48 hours
>4 weeks after birth
breast feeding advantages to newborn
easily digested nutrients antibodies in colostrum aboid milk allergies good source of nutrition cannot overfeed low risk of hypocalcaemia
breast feeding advantages to mother
promoted bonding
improved uterine involution
reduced risk of breast cancer, contraception
safe and cheap
difficultues with breast feeding
nipple inversion
maternal fatigue
emotional stress
management of mastitis
flucloxacillin
candida of the nipple management
topical miconazole after breastfeed
miconazole gel or nystatin in baby
puerpal pyrexia
temperature >38 in 6 weeks after delivery
causes of puerpal pyrexia
UTI endometritis breast chest DVT
investigations for puerpal pyrexia
sepsis pathway MSU HVC blood culture sputum if indicated USS, VQ
secondary PPH definition
bleeding after 1st 24 hours
secondary PPH causes
retained products or blood clots
infection
management of secondary PPH
conservative
antibiotics
evacuation under GA
risk factors for thromboembolic disease
Operative delivery
Past history of VTE
FH of VTE
Thrombophilia
Obesity
Maternal age >35
Immobilisation
Prolonged labour
post-natal depression
low mood in postnatal period
post-natal mental health illnesses
baby blues
postnatal depression
puerpal psychosis
baby blues time line
starts day 3/4-14 days
symptoms of baby blues
Mood swings
Low mood
Anxiety
Irritability
Tearfulness
post-natal depression triad
Low mood
Anhedonia (lack of pleasure in activities)
Low energy
post-natal depression timeline
2 weeks- 3 months
management of post-natal depression
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
edinburgh postnatal depression scale
The Edinburgh postnatal depression scale can be used to assess how the mother has felt over the past week, as a screening tool for postnatal depression.
There are ten questions, with a total score out of 30 points. A score of 10 or more suggests postnatal depression.
patient factors causing poor detection
Stigma
Putting on a brave face
Being considered a bad mother
Baby might be taken away
Not knowing what is normal
Not knowing if treatment will help
health professional factors causing poor detection
Not asking
Time constraints
Not recognising risk factors or red flags
Normalising or dismissing symptoms
Lack of training or confidence
Lack of access to specialist services
Brief questions to screen for depression
During the past months have you been bothered by feeling down, depressed or hopeless?
During the past month have you often been bothered by having little interest or pleasure in doing things?
Is there something you feel you need help with?
risk factors of post natal depression
Poor diagnosis of mental health illness
FH of severe perinatal health illness
History of childhood abuse and neglect
Domestic violence
Language barrier
Interpersonal conflict
Inadequate social support
Substance misuse
Migration status, language and cultural barriers
Unplanned or unwanted pregnancy
Pregnancy complications or traumatic birth
Fetal or neonatal loss
red flags for postnatal depression
bipolar disorder severe depression disclosure recent change in mental health chronic mental illness
puerpal psychosis symptoms
Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder
treatment of puerpal psychosis
Admission to the mother and baby unit
Cognitive behavioural therapy
Medications (antidepressants, antipsychotics or mood stabilisers)
Electroconvulsive therapy (ECT)
mother and baby unit in puerpal psychosis
The mother and baby unit is a specialist unit for pregnant women and women that have given birth in the past 12 months. They are designed so that the mother and baby can remain together and continue to bond. Mothers are supported to continue caring for their baby while they get specialist treatment.
ECT
Anti-psychotics, mood stabilisers, anti-depressants
CBT in recovery phase
Risk of recurrence is 50% higher if next pregnancy within 2 years of recovery
sodium valproate side effects
Increase risk of neural tube defect by 1-2%
Neurodevelopmental issues
Teratogenic
carbamazepine side effects
cleft lip
lithium side effects
Fetal hypotnia
Poor reflexes
Arrhythmias
Ebstein’s anomaly
Neonatal goitre
Use with caution
lamotrigine side effects
SJS
olanzapine side effects
fetal macrosomia
GDM
SSRI side effects
pulmonary HTN
paroxetine: cardiac defects
antimanic drugs side effects
Monitor infants for sedation
Poor feeding, behavioural defects and developmental milestones
neonatal withdrawal syndrome
Poor adaptation
Jitteriness
Irritability
Poor gaze control
Poor feeding
Rarely seizures
neonatal abstinence syndrome
neonatal withdrawal syndrome
paroxetine is the worst for withdrawal symptoms
withdrawal symptoms are self-limiting and generally occur within 24-48 hours (fluoxetine)
