Obstetrisian amp Gynecologist dennisvaidakisgmailcom wwwdrvaidakiscom Postnatal Care By the end you should be able to Interview a postnatal patient about their experiences of pregnancy and labour ID: 1032198
Download Presentation The PPT/PDF document "Postnatal Care Dennis Vaidakis MD,Ph.D.,..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1. Postnatal CareDennis Vaidakis MD,Ph.D.,M.PHObstetrisian & Gynecologistdennisvaidakis@gmail.comwww.drvaidakis.com
2.
3. Postnatal CareBy the end, you should be able to:Interview a postnatal patient about their experiences of pregnancy and labour Understand the importance of psychological and social factors in the postnatal period. Be aware of potential complications in the postnatal period Recognise risk factors and symptoms of postnatal depression Offer appropriate health promotion and contraception advice
4. Part IDefinitions and millstones
5. DefinitionsPostpartum period & postnatal period“postpartum” refers to issues pertaining to the mother “postnatal” refers to those concerning the baby. postnatal period begins immediately after the birth of the baby and extends up to six weeks (42 days) after birth immediate: first 24 hours Early: Days 2 through 7 Late: Days 8 through 42
6. The importance of postpartum and postnatal care substantial health risks for both mother and newborn infant. > 500 000 women die each year due to complications of pregnancy and childbirth most deaths occur during or immediately after childbirthEvery year three million infants die in the first week of life, and another 900 000 die in the next three weeks
7. Part IIInterview a woman in postnatal period
8. Postnatal InterviewLabour and Delivery Gestation weeksOnset of LabourType of DeliveryNaturalCaesarean Length of Time in Labour 1st stage - from onset of labour to full dilatation of the cervix 2nd stage - from full dilatation to birth of the baby3rd stage - from birth of the baby to delivery of the placenta Type of pain relief usedAny Maternal Complications Baby’s SexBirth weight of babyFeeding
9. General Symptoms (mother)Remember to ask about pain Breast soreness or lumpiness Sore nipples usually due to a ‘latching on problem’ Sleep disturbance (may be ‘normal’ but that does not make it easier to cope with), and fatigue Mood swings and tearfulness Worries about the baby Bowel problems Incontinence/sexual discomfort
10. General Symptoms (neonate)Regarding baby Feeding Hearing Is mum happy with growth, bowels, etc? Has baby established a feeding pattern yet?MovementsSleeping Neonatal jaundiceVaccination
11. Physical Examination Routine Health Screening BP Uterine retraction Breast examinationAnaemiaVaginal bleedingEpisiotomy or CS scarRoutine Screening for Depression
12. Routine postnatal care (mother) check for bleeding, check temperatureSupport breastfeeding, checking the breasts to prevent mastitisanaemia promote nutrition vitamin A supplementation Complete tetanus toxoid immunisation, if requiredProvide counselling and a range of options for family planningRefer for complications such as bleeding, infections, or postnatal depressionCounsel on danger signs and home care
13.
14. Health Education MotherPersonal HygienePhysical activity NutritionEarly detection of life threatening condition Lifestyle choices BabyHygieneNutritionEarly detection of life threatening condition
15. Routine postnatal care (newborns)Ensure warmth by delaying the baby’s first bath to after the first 24 hours, practising skin-to-skin careputting a hat on the baby Encourage and facilitate birth registration Refer for routine immunisations Counsel on danger signs and home care
16. Extra careThe majority of newborn deaths occur in LBW babies, many of whom are pretermIdentify the small babyAssess for danger signs and manage or refer as appropriate Provide extra support for breastfeeding, including expressing milk and cup feeding, if needed Pay extra attention to warmth promotion, such as skin-to-skin care or Kangaroo Mother Care Ensure early identification and rapid referral of babies who are unable to breastfeed or accept expressed breastmilk
17.
18. Early identification of emergenciesDanger signs for the mother Excessive bleedingsmelly vaginal dischargeFever with or without chillsSevere abdominal painExcessive tiredness or breathlessnessSwollen hands, face and legs with severe headaches or blurred visionPainful, engorged breasts or sore, cracked, bleeding nipples
19. Genital tract sepsisIn the absence of any signs and symptoms of infection, routine assessment of temperature is unnecessary.Temperature should be taken and documented if infection is suspected. If the temperature is above 38oC, repeat measurement in 4-6 hours.If the temperature remains above 38oC on the second reading or there are other observable symptoms and measurable signs of sepsis, evaluate further (emergency action).Postpartum haemorrhageIn the absence of abnormal vaginal loss, assessment of the uterus by abdominal palpation or measurement as a routine observation is unnecessary.Assessment of vaginal loss and uterine involution and position should be undertaken in women with excessive or offensive vaginal loss, abdominal tenderness or fever. Any abnormalities in the size, tone and position of the uterus should be evaluated. If no uterine abnormality is found, consider other causes of symptoms (urgent action).Sudden or profuse blood loss, or blood loss accompanied by any of the signs and symptoms of shock, including tachycardia, hypotension, hypoperfusion and change in consciousness, should be evaluated (emergency action).Pre-eclampsia and eclampsiaA minimum of one blood pressure measurement should be carried out and documented within 6 hours of the birth.Routine assessment of proteinuria is not recommended.Women with severe or persistent headache should be evaluated and pre-eclampsia considered (emergency action).If diastolic blood pressure is greater than 90 mmHg, and there are no other signs and symptoms of pre-eclampsia, measurement of blood pressure should be repeated within 4 hours.If diastolic blood pressure is greater than 90 mmHg and accompanied by another sign or symptom of pre-eclampsia, evaluate further (emergency action).If diastolic blood pressure is greater than 90 mmHg and does not fall below 90mmHg within 4 hours, evaluate for pre-eclampsia (emergency action).ThromboembolismWomen should be encouraged to mobilise as soon as appropriate following the birth.Women with unilateral calf pain, redness or swelling should be evaluated for deep venous thrombosis (emergency action).Women experiencing shortness of breath or chest pain should be evaluated for pulmonary thromboembolism (emergency action).Routine use of Homan's sign as a tool for evaluation of thromboembolism is not recommended.Obese women are at higher risk of thromboembolism and should receive individualised care.
20. Early identification of emergenciesDanger signs for the baby ConvulsionsMovement only when stimulated or no movement, even when stimulatedNot feeding wellFast breathing (more than 60 breaths per minute), grunting or severe chest in-drawing Fever (above 38°C)Low body temperature (below 35.5°C),Very small baby (less than 1500 grams or born more than two months early)Bleeding
21. Part IIIPostnatal care
22. POSTPARTUM FINDINGS AND CHANGESShiveringPostpartum shivering or chills are observed in 25 to 50 percent of women The cause is not known a response to a fall in body temperature following labor, fetal-maternal bleeding, micro-amniotic emboli, placental separation, anesthesia, bacteremia, or administration of certain drugsUterine involutionImmediately after delivery of the placenta, the uterus begins to return to its nonpregnant size and condition, Contraction of the interlacing myometrial muscle bundles constricts the intramyometrial vessels and impedes blood flow, which is the major mechanism preventing hemorrhage at the placental site. Myometrial retraction (brachystasis) is a unique characteristic of the uterine muscle that enables it to maintain its shortened length following successive contractions
23. POSTPARTUM FINDINGS AND CHANGESLochiaThe basal portion of the decidua remains after the placenta separates. The total volume of postpartum lochial secretion is 200 to 500 mL, which is discharged over a mean duration of one monthThe duration of lochia does not appear to be related to lactation or to the use of either estrogen-containing or progesterone-only contraceptives,Cervix After delivery, the cervix is soft and floppy. Small lacerations can be found at the margins of the external os. The cervix remains 2 to 3 cm dilated for the first few postpartum days and is less than 1 cm dilated at one weekThe external os never resumes its pregravid shape
24. POSTPARTUM FINDINGS AND CHANGESVagina and vulvaThe vagina is capacious and smooth immediately after delivery. It slowly contracts, but not to its nulligravid size; rugae are restored in the third week as edema and vascularity subside. The hymen is replaced by multiple tags of tissue called the carunculae hymenales (myrtiformes). Fascial stretching and trauma during childbirth result in pelvic muscle relaxation, which may not return to the pregravid state. Abdominal wallThe abdominal wall is lax postpartum but regains most of its normal muscular tone over several weekshowever, separation (diastasis) of the rectus abdominis muscles may persist. Long-term sequelae may include abdominal discomfort and cosmetic issues.
25. POSTPARTUM FINDINGS AND CHANGESReproductive hormonesThe fall and disappearance (hCG) Gonadotropins and sex steroids low levels for the first two to three weeks postpartum. the mean return of menstruation following delivery ranged from 45 to 64 days postpartum and the mean time to ovulation ranged from 45 to 94 days, but occurred as early as 25 days postpartum Some women report hot flashes in the postpartum period, The plasma prolactin concentration increases rapidly during suckling and is mediated through stimulation of nerve endings in the nipple-areolar complex.
26. POSTPARTUM FINDINGS AND CHANGESEffect of breastfeeding on ovulatory hormonesThe degree to which breastfeeding suppresses gonadotropin-releasing hormone (GnRH) secretion is modulated by the intensity of the breastfeeding and maternal nutritional status and body mass During exclusive breastfeeding, approximately 40 percent of women will remain amenorrheic at six months postpartum Amenorrhea during breastfeeding may be related, in part, to higher prolactin levels compared with women who become ovulatory while breastfeeding, since prolactin inhibits pulsatile GnRH release from the hypothalamus
27. Breast engorgement Breast engorgement results in breast fullness and firmness, which is accompanied by pain and tenderness. between 24 and 72 hours postpartum, with a normal range of one to seven daysBreast engorgement is uncomfortable Drug therapy is not recommended for suppression of lactation. Skin and hairStriaeAbdominal skin may remain lax if extensive rupture of elastic fibers occurred during pregnancy.Chloasma resolves, although the exact timing is not known.The increase in the ratio of "growing" or anagen hair relative to the "resting" or telogen hair during pregnancy reverses in the puerperium.
28. Physiologic weight lossThe mean weight loss from delivery of the fetus, placenta, and amniotic fluid is 6 kg. Contraction of the uterus and loss of lochial fluid and excess intra- and extracellular fluid leads to an additional loss of 2 to 7 kg during the puerperiumCardiovascular system Hematologic system
29. ROUTINE POSTPARTUM CARERooming in Rooming in 24 hours a day is one component The term "Baby-Friendly" Maternal monitoringIn addition to routine vital signs:Vaginal bleeding is frequently assessed to identify excessive bleeding, which is a subjective assessment in the absence of hemodynamic instability. The suprapubic area is palpated to identify an overdistended bladder; a distended bladder is palpable abdominally. The perineum is examined for signs of edema, purulent discharge, or dehiscence.
30. ROUTINE POSTPARTUM CARELaboratory testing Evaluation of postdelivery hemoglobin should be individualized based on specific patient characteristics. Routine postdelivery hemoglobin testing is generally prudent, and is warranted in situations such as predelivery anemia or postpartum hemorrhage, estimated blood loss <500 mL at deliveryPerineal careThere is a paucity of evidence-based information regarding care of the perineum after childbirth. Stool softeners and laxatives, as needed, are probably useful until perineal healing is nearly complete, especially in women with a disrupted anal sphincter.Support for breastfeedingHuman milk is recognized as the optimal food for all infants because of its proven health benefits to both infants and their mothers. Multiple issues related to breastfeeding are discussed in detail separately.
31. ROUTINE POSTPARTUM CAREPrevention of venous thrombosisThromboembolic events are the leading cause of direct maternal mortality in many developed countries. Venous thromboembolism (VTE) is more common in postpartum women than in antepartum and nonpregnant women, more common after cesarean than vaginal birth Prophylaxis is recommended for women at high risk of having a thromboembolic event, although specific criteria to identify these women vary among institutions and guidelines.
32. ROUTINE POSTPARTUM CARERoutine immunizations similar to those described for the general population. Both inactivated and live vaccines measles/mumps/rubella, varicella, Tetanus toxoids diphtheria acellular pertussis [Tdap], and human papillomavirus).All household members in the newborn's home should also have up-to-date immunizations Anti-D immune globulin within 72 hours
33. ROUTINE POSTPARTUM CAREPain managementAfterpainsPerineal painCesarean delivery Safety of common analgesics in breastfeeding women paracetamol NSAIDsOpioids
34. DISCHARGE PLANNINGACOG: Length of stayThere is sparse, low-quality evidence on the optimal length of stay after delivery. one day after scheduled cesarean delivery has been reported to be safe for mothers and infants and satisfactory to mothers in some populations.prior to 48 hours after a vaginal delivery or 72 hours after a cesarean delivery certain criteria should be metPatient education World Health Organization24 to 48 hours after birth
35. DISCHARGE PLANNINGUse of supplements There is little scientific evidence on the value of routine postpartum use of dietary supplements, such as prenatal or multi-vitamins, iron, and micronutrients in women with a healthy diet and no specific nutritional deficiencies or anemia.Diet and supplements for breastfeeding women are reviewed separately. Activity A reasonable approach is to tell the mother to resume activities when she is comfortable performing these activities,she should limit or avoid activities that cause pain or excessive fatigue.She should not engage in activities that require mental alertness until she has stopped using narcotic analgesics.
36. DISCHARGE PLANNINGVaginal intercourse safe in most women as early as two weeks postpartum, as long as the perineum is healed, contraception is available, and the patient is ready. However, most women will not be ready to resume coitus this soon after delivery because of fatigue, low sexual desire, pain, vaginal dryness or discharge, religious/cultural practices, psychological factors, or possibly postpartum blues or depression.
37. ContraceptionMost women resume sexual relations by six weeks postpartum, In women not exclusively breastfeeding, ovulation can occur as early as 25 days after delivery, so contraception should be initiated no later than the third postpartum week. Timing of initiation of contraceptive in the early postpartum period depends on the contraceptive method as some hormonal methods may affect lactation. estrogen-progestin contraceptives should be avoided in breastfeeding women who are less than 30 days postpartum.
38. Follow-up visitsTiming Patient assessment Counselling ScreeningDepression Intimate partner violence Diabetes Cardiovascular risk Cervical cancer Breast cancer Breastfeeding issues
39. POST-DISCHARGE ISSUES AND COMPLICATIONS Emergency department visit and readmission —complications of puerperiumurinary tract infection, wound complication, gallbladder disease, genitourinary tract infection, delayed postpartum hemorrhage, abdominal pain, headache, and inflammatory breast disease.After cesarean delivery, deep venous thrombosis, cardiomyopathy, and pneumonia were relatively common. Sexual dysfunction particularly low libido
40. Mental health issues Mental health issues Postpartum blues (maternity blues or baby blues)Depressive symptoms such as dysphoria, insomnia, fatigue, and impaired concentration can appear in both postpartum blues and postpartum major depression. Posttraumatic stress disorder (PTSD) Postpartum psychoses are less common but are serious and potentially life-threatening disorders.
41. POST-DISCHARGE ISSUES AND COMPLICATIONS Thyroid disease — Postpartum thyroiditis and Graves' disease is increased postpartum, Persistent vaginal bleeding Cervical cancer Atypical squamous cells of undetermined significance (ASC-US) or low-grade squamous intraepithelial lesions (LSIL) cytology should be repeated at least six weeks postpartum Women with a high-grade squamous intraepithelial lesion (HSIL), atypical squamous cells in which a high-grade squamous intraepithelial lesion cannot be excluded (ASC-H), or atypical glandular cells (AGC), diagnosed during pregnancy, should undergo colposcopy at least six weeks postdelivery.
42. Maternal Health
43. Maternal Health
44. Mother Health
45.
46. Scenario Sarah Jones attends, with baby Jack, for her postnatal check. Sarah had a forceps delivery at 40 weeks following a prolonged labour, it was her first pregnancy. She found the labour traumatic and feels guilty that she was unable to deliver naturally, as she hoped in her birth plan. She is fit and well with no significant past medical history. Her antenatal period was uneventful and she was really looking forward to the birth. Sarah lives with her partner Tom, both are teachers. They live in rented accommodation; Tom’s mum lives locally and helps look after Jack. Sarah’s family live in Yorkshire and have only been able to visit once. Sarah has been worried about Jacks health and had been to see the physician a few times but reassured all is well. She had problems with producing enough milk and had to switch to bottle feeding after Jack lost weight.
47. What additional questions may you wish to ask Sarah? What options are there for ongoing management, referral and follow up?
48.