The Puerperium Flashcards
Routine post-natal care
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
What happens at the 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)
What is lochia?
Vaginal bleeding as endometrium initially breaks down, then returns to normal over time
Mix of blood, endometrial tissue and mucus
Initially dark red, then brown, then lighter in flow and colour
Tampons should be avoided during this period, as they carry a risk of infection
Bleeding should settle within six weeks
What is lactational amenorrhoea?
Women who are breastfeeding may not have a return to regular menstrual periods for six months or longer (unless they stop breastfeeding)
How soon after birth do periods return for bottle-feeding mothers?
3 weeks onwards
When does fertility return after birth?
21 days onwards
How long is lactational amenorrhoea effective for as contraception?
Up to 6 months
99% effective
Must be fully breastfeeding and amenorrhoeic
Contraception after birth
POP and implant safe during breastfeeding and can be started any time after birth
COCP should be avoided during breastfeeding and should not be started earlier than 6 weeks after childbirth
IUD/IUS can be inserted EITHER within 48hrs or after 4 weeks
What is postpartum endometritis?
Inflammation of endometrium (usually caused by infection)
More common after C-section
Presentation of postpartum endometritis
Foul-smelling discharge or lochia
Bleeding that gets heavier or does not improve with time
Lower abdominal or pelvic pain
Fever
Sepsis
Diagnosis of postpartum endometritis
Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)
Urine culture and sensitivities
Presentation of retained products of conception
Vaginal bleeding that gets heavier or does not improve with time
Abnormal vaginal discharge
Lower abdominal or pelvic pain
Fever (if infection occurs)
Key complications of ERPC
Endometritis
Sherman’s syndrome
What is postpartum anaemia?
Hb <100 in the postpartum period
Common due to acute blood loss
In which patients is FBC checked the day after delivery?
Postpartum haemorrhage over 500ml
Caesarean section
Antenatal anaemia
Symptoms of anaemia
Management of postpartum anaemia
Hb <100 g/l – start oral iron (e.g. ferrous sulphate 200mg three times daily for three months)
Hb <90 g/l – consider an iron infusion in addition to oral iron (e.g. Monofer, CosmoFer or Ferinject)
Hb <70 g/l – blood transfusion in addition to oral iron
Contraindication to iron infusion
Infection
What are “baby blues”?
First week of birth
Affects >50% of women
Mild symptoms resolving within two weeks of delivery
Symptoms of baby blues
Mood swings
Low mood
Anxiety
Irritability
Tearfulness
What is post-natal depression?
Typically around 3 months after birth
Low mood
Anhedonia
Low energy
Management of post-natal depression
Mild: additional support, self-help and follow up with their GP
Moderate: antidepressants (e.g. SSRIs) and CBT
Severe: may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit
Symptoms of puerperal psychosis
Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder
Management of puerperal psychosis
Urgent assessment and input from specialist mental health services
Admission to the mother and baby unit
Cognitive behavioural therapy
Medications (antidepressants, antipsychotics or mood stabilisers)
Electroconvulsive therapy (ECT)
Mastitis presentation
Breast pain and tenderness (unilateral)
Erythema in a focal area of breast tissue
Local warmth and inflammation
Nipple discharge
Fever
Mastitis causes
Obstruction - occurs in ducts and milk accumulates
Infection - bacteria enter nipple and back-tuck into ducts (Staph. aureus)
Management of mastitis
Conservative: continue BF, express milk, breast massage, simple analgesia, heat packs
Medical: flucloxacillin or erythromycin
Candida of the nipple presentation
Sore nipples bilaterally, particularly after feeding
Nipple tenderness and itching
Cracked, flaky or shiny areola
Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash
Management of candida of the nipple
Both mother and baby need treatment
Topical miconazole 2% after each breastfeed
Treatment for the baby (e.g. miconazole gel or nystatin)
What is postpartum thyroiditis?
Changes in thyroid function within 12 months of delivery, affecting women without a history of thyroid disease
Can involve thyrotoxicosis (hyperthyroidism), hypothyroidism, or both
Stages of postpartum thyroiditis
- Thyrotoxicosis (usually in the first three months)
- Hypothyroid (usually from 3-6 months)
- Thyroid function gradually returns to normal (usually within one year)
Levels of TSH and T3/T4 in hyperthyroidism
TSH - Low
T3/T4 - High
Levels of TSH and T3/T4 in hypothyroidism
TSH - High
T3/T4 - Low
Management of thyrotoxicosis
Symptomatic control e.g. beta-blocker
Management of hypothyroidism
Levothyroxine
Follow up in postpartum thyroiditis
Annual monitoring of TFTs
Identifies those that go on to develop long-term hypothyroidism
What is Sheehan’s syndrome?
Rare complication of PPH where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland
Hormones affected in Sheehan’s syndrome
Anterior pituitary hormones
Thyroid-stimulating hormone (TSH) Adrenocorticotropic hormone (ACTH) Follicle-stimulating hormone (FSH) Luteinising hormone (LH) Growth hormone (GH) Prolactin
Presentation of Sheehan’s syndrome
Reduced lactation (lack of prolactin)
Amenorrhea (lack of LH and FSH)
Adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH)
Hypothyroidism with low thyroid hormones (lack of TSH)
Management of Sheehan’s syndrome
Oestrogen and progesterone as hormone replacement therapy for the female sex hormones (until menopause)
Hydrocortisone for adrenal insufficiency
Levothyroxine for hypothyroidism
Growth hormone
