Puerperium Flashcards
What important issues can occur in the puerperium?
- Eclampsia/Cx of pre-eclampsia - if during pregnancy, risks continue for 3-4 days post-partum
- Fever/sepsis - endometritis, mastitis, C-section wound, perineal/episiotomy, thrombophlebitis, UTI, respiratory (esp. influenza)
- Bowel, bladder issues, haemorrhoids
- Secondary PPH
- Pain - back, perineum, breast
- MH issues - adjustment disorder, PND, baby blues
- Breastfeeding issues/concerns
- Social - relationship issues, change of roles, loss of income, sexual issues
- DVT/PE - less common but persists for short time after delivery
- Tiredness
What are the normal bodily changes/things to expect in the puerperium?
- Uterus will gradually contract down over a couple of weeks - should not be palpable in the abdomen >2w
- Milk will initially be colostrum and milk won’t come in until ~Day 3-4 - usually note increased breast size and lumpiness
- Lochia - blood & decidua will occur - on average bleed for ~1/12. Should not be profuse or offensive
- Expect some nipple pain in first week if breastfeeding but usually subsides after this
- Expect fatigue/altered sleep pattern
What are some potential psychosocial issues for women after birth?
Change in role, loss of role/work/income Sleep deprivation Altered libido Confidence in parenting Returning to work
At the 6-week post-natal check, what are the key things to be elicited on history?
- Generally how mother and baby are coping and what their current supports are (partner, family etc)
- How long post-partum, how many other children
- Gestation child born, birthweight
- NVD or C-section (emergency vs. elective)
- Pregnancy issues, delivery issues, neonatal health issues (specifically trauma, instruments, bleeding, HTN, GDM, premature ROM, prolonged ROM, GBS status, fever during labour)
- Pain - back, perineum, wounds, breasts, calves, chest, (SOB)
- Lochia/discharge/bleeding - ? still bleeding, increase in volume, offensive
- Feeding - BF (when milk came in, any pain, swelling, redness, lumps, concerns about supply?), encourage BF
- Bowels - opened bowels, constipation
- Urinary symptoms
- Pelvic floor exercises - doing them? encourage
- Self-care - eating, sleeping, showering?
- MH - baby blues? coping? mood? anxiety?
- Sex - resumed? libido? contraception?
What are DDx for post-partum fever?
Endometritis/pelvic infection UTI Mastitis Line/c-section wound Thrombophlebitis Respiratory/flu Less commonly DVT/PE
What are symptoms & Rx of endometritis?
Increased and offensive lochia, may be purulent
Abdominal/pelvic pain - often midline, lower abdo
Tachycardia
Fever, malaise, chills, rigors
Tender uterus on palpation
Simple/outpatient - oral co-amoxyclav
More severe/hospital - IV ampicillin, metronidazole, gentamycin
Ix - FBE, CRP, swabs (vaginal less helpful as usually commensals), Urine MCS, blood cultures, other septic work-up as relevant
May require resuscitation, gentle curettage
Causes - usually polymicrobial, 60% anaerobic, 40% aerobic
What are risk factors for post-partum sepsis?
Maternal fever during delivery/labour PROM Preterm birth - more for foetus Prolonged ROM Perineal trauma GBS positive - more for feotus Emergency C-section Excessive VEs Haemorrphage
What are symptoms, causes and Rx for mastitis?
Systemic features - fever, malaise
Wedge of breast tissue that is red, hot, swollen and painful
Blocked duct leading to statsis of milk leading to secondary infection - Most commonly caused by S.aureus
Continue breastfeeding - reduce risk of abscess
Flucloxacillin (oral or IV depending on severity)
Rest, fluids, simple analgesia
What is the difference between blocked duct vs. breast engorgement vs. mastitis?
Blocked duct will be single lump, may be mildly inflammed and tender, no systemic features/feel well
Engorgement most common in first week, bilateral inflammation of breasts but with no systemic features/feel well
Mastitis is unilateral, inflammation with systemic features, sudden onset
What are common causes of nipple and breast pain?
Normal to have some nipple pain in first week but should subside
Persistent nipple pain most commonly due to incorrect latching technique
- Leads to dry, cracked, grazed nipples - common in primips
- Can result in thrush - excruciatingly painful, burning/sharp pain, present between feeds
- If thrush treat mother and baby (nystatin drops), lanolin cream for cracked nipples
Breast pain - obstructed duct, engoregement, mastitis
What are current recommendations for breast feeding?
Exclusive feeding until 6 months, partial feeding until 12 months
WHO recommends partial until 2 years
What are maternal benefits of breast feeding?
Logistically easier Free Easily portable cf with formula More environmentally friendly Weight loss Contraception Reduced risk of breast cancer, ovarian cancer and CVD
What are infant benefits of breast feeding?
Increased IQ Passive immunity Reduced risk of intolerances, allergy and childhood obesity and some chronic diseases Maternal bonding Reduced risk of SIDS
What general advice can you give women who want to express milk?
Express small amounts more frequently can increase supply
It is difficult, slow to express
Must store in sterile plastic or glass bottle
Cool before refridgerate - can keep for 3-5 days
~3months if frozen
How would you briefly describe the correct latch technique to a women?
Hold baby transverse in line with breast -support head and body
Bring baby to breast (not the other way around)
Gently stroke nipple with babys mouth to encourage mouth opening then move baby to breast quickly, ensuring they take a large ‘bite’ of breast tissue and areola
Should hear audible sucking and see babys head and jaw moving
What is the usual breast milk consumption for a healthy infant? How would you reassure a women their baby is getting enough breast milk?
150ml/kg is average consumption and what should be aimed for if expressing
If baby is having many wet nappies (6-8/day), stools are soft and mustardy/yellow colour (may only be once a week in BF), growing and gaining weight appropriately, baby is alert with good tone they are getting enough
If want to increase milk supply they can increase the number and duration of feeds, offer both breasts with each feed and express after feeds
What are DDx for fatigue post-partum?
Mental health - depression
Psychosocial factors
Post-partum thyroiditis
Anaemia
What are risk factors for PND?
Depression prior to and in pregnancy Unrealistic expectations, perfectionistic personality traits FHx depression and PND Bad birth experience Social, drug, alcohol issues
What are clinical features of PND?
Same as normal depression but if not sleeping or caring for self when baby is sleeping this is red flag
Tearfulness
What is the Rx of PND?
General advice - gentle exercise, find time to rest, increased supports and help with baby, talk to someone, when feeling very overwhelmed then put baby down in a safe place and walk away for a short time
Psychotherapy - counselling, CBT
SSRIs (esp. sertraline) best if breastfeeding
What are the clinical features of baby blues?
Common (~80%)
Typically occurs after a few days and passes by day 10-14 post partum
Tearful, mildly depressed, irritable
How is adjustment disorder different from PND?
Adjustment disorder are mild symptoms of depression/anxiety, not severe enough to diagnose as mood disorder
Should occur within 3 months and resolve within ~6months
What are the warning signs/features for post-partum psychosis?
Partner concerned that mother not herself
Often persecutory delusions related to the baby
Concerns something wrong with the baby
Typically occurs soon after birth but up to 14 days after
Rapid onset, symptoms may fluctuate during day
Risk factors - Bipolar, past hx, obstetric complications and infection
What are the Rx principles for post-partum psychosis?
Always admit - preferably to mother baby uni
Mother never to be left alone with child
Antipsychotics and or mood stabilisers
ECT if severe
Recovery usually within 6-12W
What are the most common causes of secondary PPH?
Retained products of conception/infection
Will have tachycardia, tender/bulky uterus and offensive vaginal loss
Ix - U/S, blood cultures, urine
