Week 5 part 1 Flashcards
Rupture of membranes (ROM):
The amniotic sac has ruptured.
Spontaneous rupture of membranes (SROM):
The amniotic sac has ruptured spontaneously
Prolonged rupture of membranes (also PROM):
The amniotic sac ruptures more than 18 hours before delivery.
Prematurity
Prematurity is defined as birth before 37 weeks gestation. The more premature the baby, the worse the outcomes
The World Health Organisation classify prematurity as:
- Under 28 weeks: extreme preterm
- 28 – 32 weeks: very preterm
- 32 – 37 weeks: moderate to late preterm
Prophylaxis of Preterm Labour options
Vaginal Progesterone
Cervical Cerclage
Vaginal Progesterone
Progesterone can be given vaginally via gel or pessary as prophylaxis for preterm labour. Progesterone has a role in maintaining pregnancy and preventing labour by decreasing activity of the myometrium and preventing the cervix remodelling in preparation for delivery. This is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation.
Cervical Cerclage
Cervical cerclage involves putting a stitch in the cervix to add support and keep it closed. This involves a spinal or general anaesthetic. The stitch is removed when the woman goes into labour or reaches term.
Cervical cerclage is offered to women with a cervical length less than 25mm on vaginal ultrasound between 16 and 24 weeks gestation, who have had a previous premature birth or cervical trauma (e.g. colposcopy and cone biopsy).
“Rescue” cervical cerclage may also be offered between 16 and 27 + 6 weeks when there is cervical dilatation without rupture of membranes, to prevent progression and premature delivery.
Diagnosis of Preterm Prelabour Rupture of Membranes
Speculum examination revealing pooling of amniotic fluid in the vagina. No tests are required.
Management of Preterm Prelabour Rupture of Membranes
Prophylactic antibiotics should be given to prevent the development of chorioamnionitis. The NICE guidelines (2019) recommend erythromycin 250mg four times daily for ten days, or until labour is established if within ten days.
Induction of labour may be offered from 34 weeks to initiate the onset of labour.
Preterm Labour with Intact Membranes
Preterm labour with intact membranes involves regular painful contraction and cervical dilatation, without rupture of the amniotic sac.
Diagnosis of Preterm Labour with Intact Membranes
Clinical assessment includes a speculum examination to assess for cervical dilatation. The NICE guidelines (2017) recommend:
• Less than 30 weeks gestation, clinical assessment alone is enough to offer management of preterm labour.
• More than 30 weeks gestation, a transvaginal ultrasound can be used to assess the cervical length. When the cervical length on ultrasound is less than 15mm, management of preterm labour can be offered. A cervical length of more than 15mm indicates preterm labour is unlikely.
Fetal fibronectin
An alternative test to vaginal ultrasound. Fetal fibronectin is the “glue” between the chorion and the uterus, and is found in the vagina during labour. A result of less than 50 ng/ml is considered negative, and indicates that preterm labour is unlikely.
Tocolysis
Tocolysis involves using medications to stop uterine contractions. Nifedipine, a calcium channel blocker, is the medication of choice for tocolysis. Atosiban is an oxytocin receptor antagonist that can be used as an alternative when nifedipine is contraindicated.
When can tocolysis be used?
Tocolysis can be used between 24 and 33 + 6 weeks gestation in preterm labour to delay delivery and buy time for further fetal development, administration of maternal steroids or transfer to a more specialist unit (e.g. with a neonatal ICU). It is only used as a short term measure (i.e. less than 48 hours).
Antenatal Steroids
Giving the mother corticosteroids helps to develop the fetal lungs and reduce respiratory distress syndrome after delivery. They are used in women with suspected preterm labour of babies less than 36 weeks gestation.
An example regime would be two doses of intramuscular betamethasone, 24 hours apart.
Magnesium Sulfate
Giving the mother IV magnesium sulfate helps protect the fetal brain during premature delivery. It reduces the risk and severity of cerebral palsy. Magnesium sulphate is given within 24 hours of delivery of preterm babies of less than 34 weeks gestation. It is given as a bolus, followed by an infusion for up to 24 hours or until birth.
Magnesium toxicity symptoms
Mothers need close monitoring for magnesium toxicity at least four hourly. This involves close monitoring of observations, as well as tendon reflexes (usually patella reflex). Key signs of toxicity are:
• Reduced respiratory rate
• Reduced blood pressure
• Absent reflexes
The Bishop score
The Bishop score is a scoring system used to determine whether to induce labour.
Five things are assessed and given a score based on different criteria (minimum score is 0 and maximum is 13):
• Fetal station (scored 0 – 3)
• Cervical position (scored 0 – 2)
• Cervical dilatation (scored 0 – 3)
• Cervical effacement (scored 0 – 3)
• Cervical consistency (scored 0 – 2)
What bishop score predicts a successful induction of labor?
A score of 8 or more predicts a successful induction of labour. A score below this suggests cervical ripening may be required to prepare the cervix.
There are two means for monitoring during the induction of labour; what are they?
- Cardiotocography (CTG) to assess the fetal heart rate and uterine contractions before and during induction of labour
- Bishop score before and during induction of labour to monitor the progress
Uterine hyperstimulation
Uterine hyperstimulation is the main complication of induction of labour with vaginal prostaglandins. This is where the contraction of the uterus is prolonged and frequent, causing fetal distress and compromise.
The criteria for uterine hyperstimulation varies slightly between guidelines (always check local policies and involve experienced seniors). The two criteria often given are:
- Individual uterine contractions lasting more than 2 minutes in duration
- More than five uterine contractions every 10 minutes
Uterine hyperstimulation can lead to:
- Fetal compromise, with hypoxia and acidosis
- Emergency caesarean section
- Uterine rupture
Management of Uterine hyperstimulation
- Removing the vaginal prostaglandins, or stopping the oxytocin infusion
- Tocolysis with terbutaline
Cardiotocography (CTG)
Used to measure the fetal heart rate and the contractions of the uterus. It is also known as electronic fetal monitoring. It is a useful way of monitoring the condition of the fetus and the activity of labour.
CTG can help guide decision making and delivery. However, it should not be used in isolation for decision making, and it is essential to take into account the overall clinical picture.
The indications for continuous CTG monitoring in labour include:
- Sepsis
- Maternal tachycardia (> 120)
- Significant meconium
- Pre-eclampsia (particularly blood pressure > 160 / 110)
- Fresh antepartum haemorrhage
- Delay in labour
- Use of oxytocin
- Disproportionate maternal pain
Accelerations in CTG monitoring
Accelerations are generally a good sign that the fetus is healthy, particularly when occurring alongside contractions of the uterus.
Decelerations in CTG monitoring
Decelerations are a more concerning finding. The fetal heart rate drops in response to hypoxia. The fetal heart rate is slowing to conserve oxygen for the vital organs. There are four types of decelerations to be aware of: • Early decelerations • Late decelerations • Variable decelerations • Prolonged decelerations
Early decelerations
Early decelerations are gradual dips and recoveries in heart rate that correspond with uterine contractions. Early decelerations are normal and not considered pathological. They are caused by the uterus compressing the head the fetus, stimulating the vagus nerve of the fetus, slowing the heart rate.
Late decelerations
Are gradual falls in heart rate that starts after the uterine contraction has already begun. There is a delay between the uterine contraction and the deceleration. The lowest point of the declaration occurs after the peak of the contraction. Late decelerations are caused by hypoxia in the fetus, and are a more concerning finding. They may be caused by excessive uterine contractions, maternal hypotension or maternal hypoxia.
Variable decelerations
Variable decelerations are abrupt decelerations that may be unrelated to uterine contractions.
Variable decelerations often indicate intermittent compression of the umbilical cord, causing fetal hypoxia. Brief accelerations before and after the deceleration are known as shoulders, and are a reassuring sign that the fetus is coping.
Prolonged decelerations
Prolonged decelerations last between 2 and 10 minutes with a drop of more than 15 bpm from baseline. This often indicates compression of the umbilical cord, causing fetal hypoxia. These are abnormal and concerning
The four categories for CTG are:
- Normal
- Suspicious: a single non-reassuring feature
- Pathological: two non-reassuring features or a single abnormal feature
- Need for urgent intervention: acute bradycardia or prolonged deceleration of more than 3 minutes
Fetal Bradycardia
There is a “rule of 3’s” for fetal bradycardia when they are prolonged:
• 3 minutes – call for help
• 6 minutes – move to theatre
• 9 minutes – prepare for delivery
• 12 minutes – deliver the baby (by 15 minutes)
A sinusoidal CTG
A sinusoidal CTG is a rare pattern to be aware of, as it can indicate severe fetal compromise. It gives a pattern similar to a sine wave, with smooth regular waves up and down that have an amplitude of 5 – 15 bpm. It is usually associated with severe fetal anaemia, for example, caused by vasa praevia with fetal haemorrhage.
Ergometrine
It stimulates smooth muscle contraction, both in the uterus and blood vessels. This makes it useful for delivery of the placenta and to reduce postpartum bleeding. It may be used during the third stage of labour (delivery of the placenta) and postpartum to prevent and treat postpartum haemorrhage. It is only used after delivery of the baby, not in the first or second stage.
Syntometrine
Syntometrine is a combination drug containing oxytocin (Syntocinon) and ergometrine. It can be used for prevention or treatment of postpartum haemorrhage.
Nifedipine
Nifedipine is a calcium channel blocker that acts to reduce smooth muscle contraction in blood vessels and the uterus. It has two main uses in pregnancy:
• Reduce blood pressure in hypertension and pre-eclampsia
• Tocolysis in premature labour, where it suppresses uterine activity and delays the onset of labour
Terbutaline
Terbutaline is a beta-2 agonist, similar to salbutamol. It stimulates beta-2 adrenergic receptors. It acts on the smooth muscle of the uterus to suppress uterine contractions. It is used for tocolysis in uterine hyperstimulation, notably when the uterine contractions become excessive during induction of labour.
Carboprost
Carboprost is a synthetic prostaglandin analogue, meaning it binds to prostaglandin receptors. It stimulates uterine contraction. It is given as a deep intramuscular injection in postpartum haemorrhage, where ergometrine and oxytocin have been inadequate. Notably, it needs to be avoided or used with particular caution in patients with asthma, as it can cause a potentially life-threatening exacerbation of the asthma.
What are the three phases of the 1st stage of labour?
- Latent phase – from 0 to 3cm dilation of the cervix. This progresses at around 0.5cm per hour. There are irregular contractions.
- Active phase – from 3cm to 7cm dilation of the cervix. This progresses at around 1cm per hour, and there are regular contractions.
- Transition phase – from 7cm to 10cm dilation of the cervix. This progresses at around 1cm per hour, and there are strong and regular contractions.
Partogram
Women are monitored for their progress in the first stage of labour using a partogram. It is worth becoming familiar with partograms and how they are recorded.
Uterine contractions
Uterine contractions are measure in contractions per 10 minutes. When the midwife says “she is contracting 2 in 10”, it means she is having 2 uterine contractions in a 10 minute period.
The main options for managing failure to progress are:
- Amniotomy, also known as artificial rupture of membranes (ARM) for women with intact membranes
- Oxytocin infusion
- Instrumental delivery
- Caesarean section
Pethidine and diamorphine
Pethidine and diamorphine are opioid medications, usually given by intramuscular injection. They may help with anxiety and distress. They may cause drowsiness or nausea in the mother, and can cause respiratory depression in the neonate if given too close to birth. The effect on the baby may make the first feed more difficult.
Patients-controlled intravenous remifentanil
Patients may be offered the option of patient-controlled intravenous remifentanil. This involves the patient pressing a button at the start of a contraction to administer a bolus of this short-acting opiate medication.
Adverse effects of epidural analgesia in pregnancy and labour
• Headache after insertion
• Hypotension
• Motor weakness in the legs
• Nerve damage
• Prolonged second stage
• Increased probability of instrumental delivery
Women need urgent anaesthetic review if they develop significant motor weakness (unable to straight leg raise). The catheter may be incorrectly sited in the subarachnoid space (within the spinal cord), rather than the epidural space.
Cord prolapse
Cord prolapse is when the umbilical cord descends below the presenting part of the fetus and through the cervix into the vagina, after rupture of the fetal membranes. There is a significant danger of the presenting part compressing the cord, resulting in fetal hypoxia.
Umbilical cord prolapse diagnosis
Umbilical cord prolapse should be suspected where there are signs of fetal distress on the CTG. A prolapsed umbilical cord can be diagnosed by vaginal examination. Speculum examination can be used to confirm the diagnosis.
Management of Umbilical cord prolapse
Emergency caesarean section
McRoberts manoeuvre
Involves hyperflexion of the mother at the hip (bringing her knees to her abdomen). This provides a posterior pelvic tilt, lifting the pubic symphysis up and out of the way.
Rubins manoeuvre
Rubins manoeuvre involves reaching into the vagina to put pressure on the posterior aspect of the baby’s anterior shoulder to help it move under the pubic symphysis.
Shoulder dystocia complications are:
- Fetal hypoxia (and subsequent cerebral palsy)
- Brachial plexus injury and Erb’s palsy
- Perineal tears
- Postpartum haemorrhage
Instrumental delivery
Refers to a vagina delivery assisted by either a ventouse suction cup or forceps. Tools are used to help deliver the baby’s head. About 10% of births in the UK are assisted by an instrumental delivery.
What drug is given after instrumental delivery to reduce the risk of maternal infection?
A single dose of co-amoxiclav is recommended after instrumental delivery to reduce the risk of maternal infection.
Risks of having instrumental delivery
- Cephalohaematoma with ventouse
* Facial nerve palsy with forceps
Cephalohaematoma
This involves a collection of blood between the skull and the periosteum.
Rarely an instrumental delivery may result in nerve injury for the mother. This usually resolves over 6 – 8 weeks:
The affected nerves may be:
may be:
• Femoral nerve
• Obturator nerve
Obturator nerve injury
May be compressed by forceps during instrumental delivery or by the fetal head during normal delivery. Injury causes weakness of hip adduction and rotation, and numbness of the medial thigh.
Femoral nerve injury
May be compressed against the inguinal canal during a forceps delivery. Injury to this nerve causes weakness of knee extension, loss of the patella reflex and numbness of the anterior thigh and medial lower leg.
Perineal tear
Occurs where the external vaginal opening is too narrow to accommodate the baby. This leads to the skin and tissues in that area tearing as the baby’s head passes.
Perineal tears can range from a graze, to a large tear involving the anal sphincter (third-degree) and rectal mucosa (fourth-degree).
The degrees of perineal tears
- First-degree – injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin
- Second-degree – including the perineal muscles, but not affecting the anal sphincter
- Third-degree – including the anal sphincter, but not affecting the rectal mucosa
- Fourth-degree – including the rectal mucosa
Episiotomy
Where the obstetrician or midwife cuts the perineum before the baby is delivered. This is done in anticipation of needing additional room for delivery of the baby (e.g. before forceps delivery).
A cut is made at around 45 degrees diagonally, from the opening of the vagina downwards and laterally, to avoid damaging the anal sphincter.
Classifications of post-partum hemorrhage
To be classified as postpartum haemorrhage, there needs to be a loss of:
• 500ml after a vaginal delivery
• 1000ml after a caesarean section
It can be classified as:
• Minor PPH – under 1000ml blood loss
• Major PPH – over 1000ml blood loss
Major PPH can be further sub-classified as:
- Moderate PPH – 1000 – 2000ml blood loss
* Severe PPH – over 2000ml blood loss
Primary and secondary PPH
- Primary PPH: bleeding within 24 hours of birth
* Secondary PPH: from 24 hours to 12 weeks after birth
Risk Factors for post-partum hemorrhage (PPH)
- Previous PPH
- Multiple pregnancy
- Obesity
- Large baby
- Failure to progress in the second stage of labour
- Prolonged third stage
- Pre-eclampsia
- Placenta accreta
- Retained placenta
- Instrumental delivery
- General anaesthesia
- Episiotomy or perineal tear
Management of PPH.
- Resuscitation with an ABCDE approach
- Lie the woman flat, keep her warm and communicate with her and the partner
- Insert two large-bore cannulas
- Bloods for FBC, U&E and clotting screen
- Group and cross match 4 units
- Warmed IV fluid and blood resuscitation as required
- Oxygen (regardless of saturations)
Oxytocin administration in PPH
The intravenous infusion of oxytocin is given as 40 units in 500 mls. You may hear midwives or obstetricians referring only to “40 units” without specifying the drug. They are referring to an oxytocin infusion for PPH.
Secondary postpartum haemorrhage
Secondary postpartum haemorrhage is where bleeding occurs from 24 hours to 12 weeks postpartum. This is more likely to be due to retained products of conception (RPOC) or infection (i.e. endometritis).
Secondary postpartum haemorrhage diagnosis
- Ultrasound for retained products of conception
* Endocervical and high vaginal swabs for infection
Severe sepsis in pregnancy
Severe sepsis is when sepsis results in organ dysfunction, such as hypoxia, oliguria or raised lactate. Septic shock is defined when arterial blood pressure drops and results in organ hypo-perfusion.
Two key causes of sepsis in pregnancy are:
- Chorioamnionitis
* Urinary tract infections
Chorioamnionitis
Chorioamnionitis is an infection of the chorioamniotic membranes and amniotic fluid. Chorioamnionitis is a leading cause of maternal sepsis and a notable cause of maternal death (along with urinary tract infections). It usually occurs in later pregnancy and during labour.
MEOWS chart
All patients admitted to maternity inpatient units, such as at the antenatal ward and labour ward, will have monitoring on a MEOWS chart. MEOWS stands for maternity early obstetric warning system. This includes monitoring their physical observations to identify signs of sepsis.
Maternal sepsis management
Early recognition and management is essential. This will involve the septic six (see below).
Amniotic fluid embolisation
Amniotic fluid embolisation is a rare but severe condition where the amniotic fluid passes into the mother’s blood. This usually occurs around labour and delivery. The amniotic fluid contains fetal tissue, causing an immune reaction from the mother. This immune reaction to cells from the foetus leads to a systemic illness. It has more similarities to anaphylaxis than venous thromboembolism. The mortality rate is around 20% or above.
Presentation of Amniotic fluid embolisation
- Shortness of breath
- Hypoxia
- Hypotension
- Coagulopathy
- Haemorrhage
- Tachycardia
- Confusion
- Seizures
- Cardiac arrest
Management of Amniotic fluid embolisation
Supportive. No specific treatments.
Medical emergency – get help immediately. It requires the input of experienced obstetricians, medics, anaesthetics, intensive care teams and haematologists. They are likely to need transfer to the intensive care unit.
Uterine rupture
Uterine rupture is a complication of labour, where the muscle layer of the uterus (myometrium) ruptures. With an incomplete rupture, or uterine dehiscence, the uterine serosa (perimetrium) surrounding the uterus remains intact. With a complete rupture, the serosa ruptures along with the myometrium, and the contents of the uterus are released into the peritoneal cavity.
Uterine rupture leads to significant bleeding. The baby may be released from the uterus into the peritoneal cavity. It has a high morbidity and mortality for both the baby and mother.
The main risk factor for uterine rupture
A previous caesarean section. The scar on the uterus becomes a point of weakness, and may rupture with excessive pressure (e.g. excessive stimulation by oxytocin). It is extremely rare for uterine rupture to occur in a patient that is giving birth for the first time.
Presentation of uterine rupture
- Abdominal pain
- Vaginal bleeding
- Ceasing of uterine contractions
- Hypotension
- Tachycardia
- Collapse
Uterine inversion
Uterine inversion is a rare complication of birth, where the fundus of the uterus drops down through the uterine cavity and cervix, turning the uterus inside out. It is a very rare occurrence, and you are unlikely to see one in your career unless you become a midwife or obstetrician. It is a life-threatening obstetric emergency.
Incomplete uterine inversion (partial inversion)
Incomplete uterine inversion (partial inversion) is where the fundus descends inside the uterus or vagina, but not as far as the introitus (opening of the vagina). Complete uterine inversion involves the uterus descending through the vagina to the introitus.
Uterine inversion presentation
Uterine inversion typically presents with a large postpartum haemorrhage. There may be maternal shock or collapse.
An incomplete uterine inversion may be felt with manual vaginal examination. With a complete uterine inversion, the uterus may be seen at the introitus of the vagina.
Management of Uterine inversion
- Johnson manoeuvre
- Hydrostatic methods
- Surgery
Six-Week Postnatal Check
A routine six-week postnatal appointment is commonly offered by GP practices to check how the mother is doing. It is usually done at the same time as the six-week newborn baby check.
Lochia
In the period shortly after birth, there will be vaginal bleeding as the endometrium initially breaks down, then returns to normal over time. This is a mix of blood, endometrial tissue and mucus, and is called lochia
Postpartum Endometritis
Endometritis refers to inflammation of the endometrium, usually caused by infection. It can occur in the postpartum period, as infection is introduced during or after labour and delivery. The process of delivery opens the uterus to allow bacteria from the vagina to travel upwards and infect the endometrium.
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 and investigations in postpartum endometritis
• 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
A significant risk factor for retained products of conception
Placenta accreta
Management of postpartum retained products of conception
The standard management of postpartum retained products of conception is to remove them surgically.
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)
Diagnosis of postpartum retained products of conception
Ultrasound is the investigation of choice for confirming the diagnosis.
Postpartum anaemia
Postpartum anaemia is defined as a haemoglobin of less than 100 g/l in the postpartum period. Anaemia is common after delivery due to acute blood loss.
Iron infusion contraindications
Active infection is a contraindication to an iron infusion. Many pathogens “feed” on iron, meaning that intravenous iron can lead to proliferation of the pathogen and worsening infection. It is important to wait until the infection is treated before giving an iron infusion.
Baby Blues
Baby blues affect more than 50% of women in the first week or so after birth, particularly first-time mothers. It presents with symptoms such as: • Mood swings • Low mood • Anxiety • Irritability • Tearfulness
Postnatal depression
• Low mood
• Anhedonia
• Low energy
Typically, women are affected around three months after birth. Symptoms should last at least two weeks before postnatal depression is diagnosed.
Treatment is similar to depression at other times.
The 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.
Puerperal psychosis
Puerperal psychosis is a rare but severe illness that typically has an onset between two to three weeks after delivery. Women experience full psychotic symptoms, such as: • Delusions • Hallucinations • Depression • Mania • Confusion • Thought disorder
Mastitis
Mastitis refers to inflammation of breast tissue, and is a common complication of breastfeeding. It can occur with or without associated infection.
Mastitis can be caused by obstruction in the ducts and accumulation of milk. Regularly expressing breast milk can help prevent this occurring.
Mastitis can also be caused by infection. Bacteria can enter at the nipple and back-track into the ducts, causing infection and inflammation. The most common bacteria is staph aureus.
Causes of mastitis
Mastitis can be caused by obstruction in the ducts and accumulation of milk. Regularly expressing breast milk can help prevent this occurring.
Mastitis can also be caused by infection. Bacteria can enter at the nipple and back-track into the ducts, causing infection and inflammation. The most common bacteria is staph aureus.
Most common bacteria to cause mastitis
The most common bacteria is staph aureus
Mastitis presentation
- Breast pain and tenderness (unilateral)
- Erythema in a focal area of breast tissue
- Local warmth and inflammation
- Nipple discharge
- Fever
Management of mastitis
Where mastitis is caused by blockage of the ducts, management is conservative, with continued breastfeeding, expressing milk and breast massage. Heat packs, warm showers and simple analgesia can help symptoms.
When conservative management is not effective, or infection is suspect (e.g. the woman is febrile), antibiotics should be started. Flucloxacillin is first line, or erythromycin if allergic to penicillin. A sample of milk can be sent to the lab for culture and sensitivities. Fluconazole may be used for suspected candidal infections.
Complication of mastitis
A rare complication if not adequately treated, is a breast abscess. This may need surgical incision and drainage
Candida of the nipple
Often after a course of antibiotics. This can lead to recurrent mastitis, as it causes cracked skin on the nipple that create an entrance for infection. It is associated with oral thrush and candidal nappy rash in the infant.
Presentation of candida of the nipple
- 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
- Topical miconazole 2% after each breastfeed
* Treatment for the baby (e.g. miconazole gel or nystatin)
Postpartum thyroiditis
Where there are changes in thyroid function within 12 months of delivery, affecting women without a history of thyroid disease. It can involve thyrotoxicosis (hyperthyroidism), hypothyroidism, or both.
Sheehan’s syndrome presentation
- 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)
Puerperal pyrexia
Defined as a temperature of > 38ºC in the first 14 days following delivery.
Causes of Puerperal pyrexia
- endometritis: most common cause
- urinary tract infection
- wound infections (perineal tears + caesarean section)
- mastitis
- venous thromboembolism
