19 - Postpartum Care

Question 1

What are the contraindications to breastfeeding?

Answer 1

• Mother with TB infection
• Mothers with uncontrolled/unmonitored HIV
• Infants of mothers who are taking medications which may be harmful e.g. amiodarone, anticancer drugs, lithium, oral retinoids, iodine

Question 2

What are the benefits of breastfeeding for mothers and infants?

Answer 2

Mother

• Stimulates uterus to contract and return to normal size
• Promotes faster weight loss after birth
• Less risk of postpartum depression
• Less postpartum bleeding
• Fewer urinary tract infections
• Less chance of anemia

Baby

• Immunity via IgA antibodies for baby’s nose, ears, throat
• Reduces risk of SIDs
• Reduces obesity and CVD risk in adulthood

Question 3

What is the APGAR score?

Answer 3

Assessment of infant’s clinical status immediately after birth done at one and five minutes after rubbing baby with warm towel

5 domains with score of 2 in each

Score of 7-10 is normal so if below need urgent senior review

If 3-5 after 5 minutes high risk of cerebral palsy

Question 4

What are the limitations of the APGAR score?

Answer 4

• May be affected by anaesthesia
• Black skin

Question 5

What women may need additional postnatal care?

Answer 5

• women who misuse substances
• recent migrants or women who do not speak English very well
• young women aged under 20
• women who experience domestic abuse

Question 6

Some women may go to a post-natal ward after delivery to be monitored. What are some things that are monitored during this period?

Answer 6

• Analgesia PRN
• Help establishing breast or bottle-feeding
• VTE risk assessment
• Monitoring for PPH
• Monitoring for sepsis
• Monitoring blood pressure (after pre-eclampsia)
• Monitoring recovery after a caesarean or perineal tear
• FBC check (after bleeding, caesarean or antenatal anaemia)
• Anti-D for rhesus D negative women (depending on the baby’s blood group)
• Routine baby check

Question 7

Before a woman’s care is transferred to the community/midwife leaves a home birth, what things need to be done?

Answer 7

• Assess mother and baby health
• Check mum’s bladder by measuring volume of first void
• If baby has not passed meconium tell them to seek help from GP if not passed within 24 hours
• Make sure plan for feeding baby with at least 1 observed successful feed
• Importance of pelvic floor exercises
• Educate about the postnatal period and what to expect
• Educate about what support is available (statutory and voluntary services) and who to contact if any concerns arise at different stages.

Question 8

When should a midwife and health visitor visit a mother when her care has been transferred to the community?

Answer 8

Midwife: Within 36 hours

Health Visitor: 7 to 14 days after transfer of care from midwifery team

Question 9

What topics should be discussed at post-natal midwife check ups?

Answer 9

• Postnatal period and what to expect
• Postpartum mental health signs and symptoms
• Post party physical health signs and symptoms e.g VTE, mastitis
• Importance of pelvic floor exercise
• Nutrition
• Contraception
• Sexual intercourse
• Safeguarding concerns inc DV
• Perineal or Wound healing

Question 10

GPs often perform a 6 week post natal check up on both mother and baby. What things are looked at for the mother in this check up?

Answer 10

• General wellbeing
• Mood and depression
• Bleeding and menstruation
• Scar healing after episiotomy or caesarean
  
  • Perineal health
• Contraception
• Breastfeeding
• Cervical screening
• Fasting blood glucose (after gestational diabetes)
• Blood pressure (after hypertension or pre-eclampsia)
• Urine dipstick for protein (after pre-eclampsia)

Question 11

Baby health checks are performed 72 hours after birth and then after 6-8 weeks. What things should be looked at during this check?

Answer 11

• appearance: colour, breathing, behaviour, activity and posture
• head (including fontanelles), face, nose, mouth (including palate), ears, neck and general symmetry of head and facial features
• eyes: opacities, red reflex and colour of sclera
• neck and clavicles
• limbs, hands, feet and digits: assess proportions and symmetry
• heart: position, heart rate, rhythm and sounds, murmurs and femoral pulse volume
• lungs: respiratory effort, rate and lung sounds
• abdomen: assess shape and palpate to identify any organomegaly; check condition of umbilical cord
• genitalia and anus: completeness and patency and undescended testes in boys
• spine: inspect and palpate bony structures and check integrity of the skin
• skin: colour and texture as well as any birthmarks or rashes
• central nervous system: tone, behaviour, movements and posture; check newborn reflexes only if concerned
• hips: symmetry of the limbs, Barlow and Ortolani’s manoeuvres
• cry: assess sound

Question 12

What supplement is recommended for breast feeding mothers?

Answer 12

Vitamin D as breast milk lacks this

Question 13

What advice should you give a woman on the return of menstruation following giving birth?

Answer 13

• Lochia will start dark red and get lighter. Bleeding will be worse after breastfeeding due to release of oxytocin. DO NOT USE TAMPONS AS RISK OF INFECTION. Should settle after 6 weeks.
• Menstruation may start 3 weeks after birth if bottle feeding
• Menstruation may cease for 6 months (lactational amenorrhea) if exclusively breastfeeding

Question 14

What advice should you give a woman who has just given birth about contraception?

Answer 14

• Fertility does not return until 21 days after birth
• Contraception needed after 21 days if not breastfeeding exclusively
• Lactational amenorrhea is 98% effective only if exclusively breastfeeding and no periods and only up to 6 months

Question 15

What contraception can be started in the post part period?

Answer 15

USE CONDOMS FOR 7 DAYS WHEN STARTING COCP AND 2 DAYS FOR POP

• POP: start anytime
• Implant: anytime
• COCP: cannot use for 6 weeks postpartum or if breastfeeding
• Coils: <48 hours post delivery or >4 weeks post part

Question 16

Post-partum endometritis is more common following C-section so prophylactic antibiotics are given. What are the signs of postpartum endometritis?

Answer 16

lochia is vaginal discharge that occurs after giving birth and is a normal part of the postpartum healing process. It’s made up of blood, mucus, and uterine tissue, and usually lasts for four to eight weeks
* Foul smelling discharge or lochia
* Bleeding that gets heavier or does not improve with time
* Lower abdominal or pelvic pain
* Fever
* Sepsis

Question 17

What investigations are done if you suspect post part endometritis?

Answer 17

• Vaginal swabs inc chlamydia and gonorrhoea
• Urine culture and sensitivities
• US to rule out retained POC

Question 18

How is postpartum endometritis managed?

Answer 18

If septic admit to hospital and do sepsis six

Sepsis Abx: IV Clindamycin + Gentamicin

Endometritis Abx: PO Co-amoxiclav in community. Same for post procedure endometritis

Question 19

What antibiotics are given for the following obstetric infections/scenarios:

• Chorioamnionitis
• Intrapartum Group B Strep
• Infected Perineal wound
• Mastitis

Answer 19

• Chorioamnionitis: IV Cefuroxime + Metronidazole
• Group B Strep: IV Benzylpenicillin
• Perineal Wound: PO Flucloxacillin + Metronidazole
• Mastitis: PO Flucloxacillin

Question 20

What antibiotics are given for the following obstetric infections/scenarios:

• PROM
• Sepsis in Labour
• TOP
• 3rd and 4th degree tears
• UTI in pregnancy

Answer 20

• PROM: PO Erythromycin for 10 days or until baby born
• Sepsis in Labour: IV Cef/Met, if unwell IV meropenem
• TOP: Only if surgical TOP. Give Metronidazole PR if C.Trachomatis negative, Give PO Azithromycin and PR Metronidazole if positive
• 3rd and 4th degree tears: Co-Amoxiclav PO as prophylaxis
• UTI in pregnancy: Nitrofurantoin but avoid at term, give Trimethoprim if term

Question 21

What is the biggest risk factor for retained products of conception?

Answer 21

Placenta Accreata

Question 22

Retained products of conception can occur after a miscarriage or after birth. What is the presentation of this?

Answer 22

• PV bleeding that gets heavier or does not improve with time
• Abnormal discharge
• Lower abdominal pain
• Fever

Question 23

How is retained products of conception diagnosed and managed?

Answer 23

Ix

• US

Mx

• Evacuation of RPC (ERPC): Uses GA, cervix is dilated and products manually removed via curettage and vacuum aspiration

Question 24

What are the complications with dilatation and curettage for ERPC?

Answer 24

• Asherman’s syndrome
• Endometritis

Question 25

When are women screened for postpartum anaemia?

Answer 25

FBC checked day after delivery if: * PPH\>500ml * C-Section * Antenatal Anaemia * Symptoms of anaemia

Question 26

How is postpartum anaemia treated?

Answer 26

* **Hb\<100:** Start PO Iron TDS for 3/12 (Ferrous Sulphate) * **Hb\<90**: Consider Iron infusion as well as PO iron * **Hb\<70:** Blood transfusion as well as PO iron

Question 27

Why do you have to take care with iron infusions for treatment of post partum anaemia?

Answer 27

* **Risk of allergies and anaphylactic reaction** so be careful in patients with **history of asthma or allergies** * **Contraindicated in active infection** as iron can lead to proliferation of bacteria and worsening infection

Question 28

What is baby blues and how is it managed?

Answer 28

* 50% of women get this in first week after birth * **Symptoms:** mood swings, low mood, anxiety, irritability, tearful * Symptoms usually only last a few days and **resolve within 2 weeks** of delivery * No treatment needed

Question 29

Why is baby blues so common?

Answer 29

* Hormonal changes * Recovery from birth * Fatigue and Sleep deprivation * Responsibility of caring * Establishing feeding

Question 30

What is postnatal depression?

Answer 30

Triad of: * Low mood * Low energy * Anhedonia - cant feel pressure Usually presents around 3 months after birth and symptoms have to be for at least two weeks for diagnosis Can occur up to 1 year post partum

Question 31

What screening tool is used for post-natal depression?

Answer 31

**Edinburgh Postnatal Depression scale** Score out of 30, if 10 or more suggests PND

Question 32

How is postnatal depression managed?

Answer 32

**Mild**: additional support, self help, follow up with GP **Moderate**: SSRIs, CBT **Severe:** Inpatient at mother baby unit

Question 33

What is puerperal psychosis and how does it present?

Answer 33

Onset within two to three weeks after delivery * Delusions * Hallucinations * Depression * Mania * Confusion * Thought disorder * Paranoia

Question 34

What mothers are at a higher risk of puerperal psychosis?

Answer 34

* Previous history of severe mental illness, such as schizophrenia or bipolar * Family history of postpartum psychosis * Personal history of postpartum psychosis

Question 35

How is postpartum psychosis managed?

Answer 35

* Admission to mother and baby unit * CBT * Antidepressants, Antipsychotics and Mood stabilisers * Electroconvulsive Therapy (ECT)

Question 36

What is the issue with SSRIs during pregnancy?

Answer 36

Can lead to **neonatal abstinence syndrome** Baby can be irritable and feed poorly Give supportive care

Question 37

What information do you need to give women who are on lithium for bipolar disorder when they get pregnant?

Answer 37

Try to gradually decrease lithium over 4 weeks if mother well but if not inform her of: * There is a risk of fetal heart malformations when lithium is taken in the first trimester * Lithium levels may be high in breast milk with a risk of toxicity for the baby * Lithium levels are monitored more frequently throughout pregnancy and the postnatal period

Question 38

What are the causes of mastitis?

Answer 38

* Obstruction of breast milk in ducts * Infection usually due to S.Aureus entering at nipple

Question 39

How may mastitis present?

Answer 39

* Unilateral breast pain and tenderness * Erythema in focal area * Local warmth and irritation * Nipple discharge * Fever

Question 40

How is mastitis managed?

Answer 40

**_Conservative_** * Continued breast feeding and expressing milk * Breast massage * Heat pads * Simple analgesia **_Medical_** * Flucloxacillin if febrile * Continue breast feeding **_Surgical_** * I and D if breast abscess forms

Question 41

How may candida of the nipple present and why is it an issue?

Answer 41

Can occur after a course of antibiotics and can lead to **recurrent mastitis** due to cracked skin on surface of nipple * Sore nipples bilaterally * Nipple tenderness and itching * Cracked, flaky or shiny areola * White patches in mouth of baby

Question 42

How is candida of the nipple treated?

Answer 42

Both mother and baby need treatment * **Topical Miconazole** 2% after each breast feed * Nystatin for baby If causing recurrent mastitis give Fluconazole

Question 43

What is postpartum thyroiditis?

Answer 43

Changes in thyroid function within 12 months of delivery that usually resolve over time Thought to be due to immunosuppressant effect during pregnancy causes rebound effect once delivered and increased immune system

Question 44

What is the typical pattern of postpartum thyroiditis?

Answer 44

1. **Thyrotoxicosis** in first 3/12 2. **Hypothyroid** from 3-6 months 3. **Thyroid function gradually returns to normal** within a year

Question 45

How is post partum thyroiditis managed?

Answer 45

Test TFTs 6-8 weeks post delivery **Thyrotoxicosis:** Symptomatic control e.g propanolol **Hypothyroidism:** Levothyroxine Close monitoring and treatment alteration. Once resolved **test TFTs annually** as some can develop **long-term hypothyroidism**

Question 46

What is Sheehan's syndrome?

Answer 46

**Complication of PPH** where drop in circulating volume and blood pressure leads to **avascular necrosis of pituitary gland** **Only affects anterior** hormones

Question 47

How may Sheehan's syndrome present?

Answer 47

* **Reduced lactation** due to lack of PRL * **Amenorrhea** due to lack of FSH, LH * **Adrenal Insufficiency** due to low cortisol from low ACTH * **Hypothyroidism** due to lack of TSH

Question 48

How is Sheehan syndrome managed?

Answer 48

* **Oestrogen and Progesterone** HRT until menopause * **Hydrocortisone** for adrenal insufficiency * **Levothyroxine** * **GH**

Question 49

there are low levels of which vitamin in the mothers breast milk

Answer 49

vitamin K, therefore newborns are given vitamin K IM injections to prevent haemmorhagic disease of the newborn