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Postpartum complications

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Postpartum complications Case 2 Which one of the following statements regarding the lactational amenorrhoea method (LAM) of contraception post-partum is correct? – PowerPoint PPT presentation

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Title: Postpartum complications


1
Postpartum complications
2
  • Following NVD the average hospital stay is 1.4
    days (1.7 for first-time mothers 1.2 for
    previous mothers)
  • 2 days for an assisted vaginal delivery 3.4
    days following a caesarean.

3
  • Haemorrhage
  • Infection
  • PE
  • 6/52 postnatal check

4
  •  A 25 year old female presents to her GP with
    thick, smelly and bloody discharge two weeks
    after the delivery of her first child. She was
    otherwise well and was recovering at home from
    the uncomplicated birth of her child. On
    examination, the lady was pyrexial and was tender
    over the suprapubic region. 
  •  
  • 1)What sort of PPH is this?
  • 2)What is the likely pathology?
  • 3)What was the GP's course of management?

5
PPH
  • Minor PPH (500 mls- 1L) / Major gt 1L
  • Primary PPH gt500mls within 24 hours
  • Secondary PPH abnormal bleeding 24hours 6
    weeks.

6
Primary PPH
  • Common cause 70 uterine atony

7
Secondary PPH
  • Infection Endometritis
  • RPOC

8
PPH 4 Ts
  • Tone (uterine tone) 70
  • Tissue (retained tissue - placenta) 20
  • Trauma ( Lacerations and uterine rupture) 10
  • Thrombin ( coagulation disorders) 1

9
Management
  • Primary PPH
  • If haemodynamically unstable ? ABC, O2 and IV
    access. Bimanual compression and uterine massage.

10
Management of 2nd PPH in primary care
  • Investigations
  • FBC
  • Midstream Urine
  • High vaginal swab
  • Ultrasound
  • Start broad spectrum abx Co-amoxiclav
    metronidazole

11
Infection -Endometritis
  • Infection of endometrium
  • Ascending infection from lower genital tract
  • most important factor the mode of delivery
  • 1-3 after NVD, 15-40 after C-section

12
  • Hx
  • Fever, abd pain, offensive d/c, dispareunia
  • O/E
  • Pyrexia, tachycardia, lower abd tenderness,
    offensive d/c, uterine and adnexal tenderness

13
  • Ivx
  • Blds FBC,CRP
  • Microbiology HVS, endpocervical/chlamydia swab
  • Management
  • Broad spectrum antibiotic, surgery for RPOC
  • 90 resolve after 48-72 hours IV abx

14
  • 35 years old lady, 17 day postnatal. Breast
    feeding, sore and warm right breast for the past
    48 hours.
  • 1)Diagnosis
  • 2)Management
  • 3)Advice

15
Mastitis
  • Inflammation or infection of the breast
  • 1 in 3 mothers will have mastitis
  • Symptoms
  • Mastalgia, swelling and erythema (start usually
    in section near nipple), temperature, flue like
    symptoms.
  • Common organism S.aureus

16
Management

  • Mild mastitis ?no treatment. Encourage breast
    feeding
  • Infective mastitis start antibiotics
  • - Flucloxacillin 500mg qdsfor 14 days
  • If penicillin allergic
  • - Erythromycin 500 mg qds for 10-14days

17
Advice
  • - Continue to feed from the affected breast
  • - After each feed express any remaining milk
    from affected breast
  • - Analgesia (paracetamol Ibuprofen)
  • - Avoid wearing a bra
  • Complications
  • Breast abscess 1 in 100

18
Infections (other)
  • C-section wound infection
  • Episiotomy site
  • - Ensure early detection and management

19
Pulmonary Embolism
  • More likely to occur 6/52 post delivery.
  • The risk is 1/500
  • Increase risk of thrombosis if
  • - Prolonged labour gt24 hours
  • - C section
  • - Received a blood transfusion

20
  • Symptoms
  • Dyspnoea/ pleuritic chest pain
    /cough-haemoptysis/ R HF in severe cases
  • Signs
  • Tachypnoea/ tachycardia/Hypoxia
  • IF PE suspected, start treatment dose LMWH and
    admit to hospital

21
Postnatal prophylaxis
22
6 weeks postnatal check
23
Postnatal check
  • Should cover
  • - Physical
  • - Psychological
  • - Social

24
Physical
  • Mode of delivery
  • Concerns about own health
  • Perineum/ C- section scar healing well?
  • Discharge/ periods
  • Bowel and bladder
  • If breast feeding, soreness or engorgement

25
Examination
  • Abdominal examination
    ??endometritis/RPOC
  • Consider checking BP and Hb
  • Contraception
  • Pelvic floor exercises

26
Psychological
  • Any issues around the birth that need discussing
  • Mood. Can use a postnatal depression screening
    tool
  • Any concerns about the baby (should be covered in
    baby 6 weeks check)

27
Social
  • Support at home
  • Sleep
  • Smoking

28
Summary
  • PPH? 4 Ts
  • Endometritis
  • Mastitis?S.aureus?Flucloxacillin or erythromicin
    for 2/52
  • PE ensure high risk women are on LMWH post
    delivery.
  • Holistic approach to postnatal check

29
References
  • Postpartum Haemorrhage, Prevention and Management
    (Green-top 52)
  • West Midlands Key Health Data 2006/07
  • GP notebook Mastitis
  • http//www.fastbleep.com/medical-notes/o-g-and-pae
    ds/16/36/503 (cases)
  • http//www.patient.co.uk/doctor/Mother's-6-Week-Po
    stnatal-Check.htm
  • http//www.planapregnancy.co.uk/PP2010/static/GT37
    ReducingRiskThrombo.pdf
  • Oxford handbook of obstetrics and gynaecology.
    2nd edition

30
?
31
Cases
32
  • A 24-year-old woman presents 8 days after giving
    birth. She complains of a persistent pink vaginal
    discharge which is 'smelly'. On examination her
    pulse is 90 / min, temperature 38.2ºC and she has
    diffuse suprapubic tenderness. On vaginal
    examination the uterus feels generally tender.
    Examination of her breasts is unremarkable. Urine
    dipstick shows blood . What is the most
    appropriate management?
  • A. Arrange urgent ultrasound to exclude retained
    products send MSSU take high vaginal swab
  • B. Send MSSU take high vaginal swab start
    oral co-amoxiclav metronidazole
  • C. Arrange urgent ultrasound to exclude retained
    products send MSSU start oral co-amoxiclav
  • D. Admit to hospital
  • E. Send MSSU take high vaginal swab start
    oral co-amoxiclav

33
  • This woman by definition has puerperal pyrexia,
    likely secondary to endometritis. She needs to be
    admitted for intravenous antibiotics.

34
Case 2
  • Which one of the following statements regarding
    the lactational amenorrhoea method (LAM) of
    contraception post-partum is correct?
  • A. 1-2 top up feeds per day are allowed as long
    as this is in addition to breastfeeding
  • B. Is recommended for mothers with HIV
  • C. Should only be used if women decline
    long-acting reversible contraceptives
  • D. Is 100 effective if the woman is amenorrhoeic
  • E. The effectiveness decreases after 6 months

35
  • Lactational amenorrhoea method (LAM)
  • is 98 effective providing the woman is fully
    breast-feeding (no supplementary feeds),
    amenorrhoeic and lt 6 months post-partum

36
Case 3
  • A 29-year-old woman who is 2 weeks postpartum
    consults you regarding contraception. She is
    interested in having an intrauterine device (IUD)
    inserted and asks when it could be fitted. She
    had a emergency caesarean section for failure to
    progress. What is the most appropriate advice to
    give?
  • A. An IUD can be inserted 4 weeks postpartum
  • B. An IUD can be inserted 12 months postpartum
  • C. An IUD can be inserted today
  • D. An IUD can be inserted 12 weeks postpartum
  • E. An IUD is contraindicated in the long-term

37
  • Answer A
  • between 48 hours and 4 weeks postpartum
    (increased risk of perforation)

38
Case 4
  • woman rings for advice 18 days post-partum. She
    is keen to start her progestogen-only pill again.
    There have been no problems since giving birth
    and breast feeding is going well. What is the
    most appropriate advice?
  • A. Contraindicated if breast-feeding
  • B. Start immediately, effective immediately
  • C. Start on day 28, effective after 7 days
  • D. Start on day 28, effective after 2 days
  • E. Can be started after 3 months, effective after
    2 days

39
  • Answer B
  • Progestogen only pill (POP)
  • the FSRH advise 'postpartum women (breastfeeding
    and non-breastfeeding) can start the POP at any
    time postpartum.'
  • after day 21 additional contraception should be
    used for the first 2 days
  • a small amount of progestogen enters breast milk
    but this is not harmful to the infant
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