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Pregnancy care planner NHS Choices
Pregnancy Calculator BNF extra
Obstetrics Rural Health West au Mar 2009
Preconceptual/antenatal counselling
NICE CG62 Antenatal care Mar 2008
NICE CG63 Diabetes in pregnancy Mar 2008
Obstetric history
Obstetric history drcog-mrcog.info
Obstetric history en.wikiversity.org
| Gravida Para Abortus | ||
|---|---|---|
| Gravida | number of pregnancies | the total number of times a woman has been pregnant, regardless of whether these pregnancies were carried to term. Any current pregnancy is included |
| Para | number of viable births | Para indicates the number of viable (>20 wks) births Pregnancies consisting of multiples, such as twins or triplets, count as ONE birth for the purpose of this notation. |
| Abortus | abortions/miscarriages | the number of pregnancies that were lost for any reason, including induced abortions or miscarriages. The abortus term is sometimes dropped when no pregnancies have been lost. |
| Examples nulligravida no pregnancies G0 nullipara no births P0 primigravida 1 pregnancy G1 secundigravida 2 pregnancies both of which resulted in live births G2 G4, P3, A1 A woman who had 4 pregnancies, one of which was miscarried |
||
Gravida – total number of times a woman has been pregnant (including the current), regardless of whether these pregnancies were carried to term.
Para – number of viable (>20 wks) births(and stillbirths) (Multiple pregnancies count as ONE)
Abortus – number of pregnancies lost including induced abortions or miscarriages.
miscarriage – pregnancy loss before 24 weeks resulting in expulsion of foetus showing no signs of life
stillbirth – as above with delivery after 24 weeks
early neonatal death – death within 1 week of delivery of live newborn regardless of gestation
late neonatal death – as above between 1-4 weeks
perinatally related infant death – death from a perinatallly related cause between 4 weeks and 1 year.
GTPAL = Gravida / Term / Preterm / Abortions / Living
Antenatal timeline
| Physiological changes in pregnancy | |
|---|---|
| CVS | |
| Cervix | |
| Endocrine | |
| GIT | |
| Haematology | |
| Pulmonary | |
| Renal | |
| Uterus | |
| Vagina | |
Physiological Changes In Pregnancy PUK
| Pregnancy booking visit ANC |
|---|
| 1. History (i) Menstrual, LMP EDD (ii) Previous obstetric and gynaecological history (iii) Marital and social history (iv) Family history (twins, diabetes, etc.) |
| 2. Physical parameters (i) Height and shoe size (ii) Weight (iii) Physical examination if appropriate |
| 3. Antenatal parameters as per cooperation card (urine, weight, BP etc.) |
| 4. Advice about antenatal care, breast feeding, smoking, alcohol, taking of iron supplements and self medication |
| 5. Tests (i) Blood group and rhesus antibodies (ii) VDRL or other test for syphilis (iii) Test for immunity to rubella (iv) AFP at 16-18 weeks (v) Scan if unsure dates, large for dates, etc. (vi) MSU often included (vii) Check on cervical cytology status |
| LMP EDD Gestational Age |
|---|
| 9 months+7 days from the 1st day of last menstrual period Nageles Rule: EDD = first day LMP – 3m + 7 days |
| www.obstetriccalculator.com |
Low risk pregnancies
1. Nulliparae over 5 ft in height, aged between 20 and 30 years
2. Second or third pregnancies, providing patient under 35 years
3. No previous abnormality in the medical (e.g. diabetes), obstetric (e.g. previous post partum haemorrhage, previous manual removal of placenta, caesarean section, etc.) or gynaecological history
4. No rhesus antibodies
5. No previous psychiatric problems
ROUTINE ANTENATAL CARE
Every 4 weeks to 28 weeks
Every 2 weeks from 28 to 36 weeks
Weekly from 36 weeks
Size
Palpable abdominally at 12 weeks
Usually below umbilicus at 20 weeks but above it at 24 weeks
Palpation not as accurate as measuring height of fundus from the symphysis pubis in centimetres
Urine
1. Proteinuria: if not due to preeclampsia may be due to asymptomatic UTI take an MSU
2. Glycosuria: may be low renal threshold but if on two occasions or once in early pregnancy « 16 weeks) it is advisable to do a GTT (glucose tolerance test), usually at 32 weeks, to detect a gestational diabetes
Weight
Most women gain between 10kg and 12.5 kg during pregnancy.
In latter half of pregnancy excess weight gain (1 kg or more a week) may be a sign of developing preeclampsia
Static weight or weight loss may mean intrauterine growth retardation
Hb
1. Haemoglobin aim to keep above 10 g/dl
2. If rhesus negative a blood test(s) will be needed for antibodies later in pregnancy
4. AFP is taken at 1618 weeks as a screen for neural tube defects. Refer if raised, after taking a repeat sample. May of course have been taken at wrong gestation (confirm dates) or be a twin pregnancy
High risk pregnancy early booking
rcog.org.uk high risk pregnancy management
Dietary advice NHS Choices
| Pregnancy dietary advice | |
|---|---|
| General Advice | As always, a sensible balanced diet, rich in fruit and vegetables, is recommended. However, the following specific dietary advice should be given: Dairy products are a good source of calcium (ideally the low-fat varieties), as are oily fish with edible bones (eg sardines), bread, green vegetables and nuts. Some seafish contain high levels of mercury, which may affect the fetus.Pregnant women on Income Support or income-based Jobseeker’s Allowance can get seven pints of cow’s milk free per week. Unpasteurised milk and milk products are not recommended (eg some goat’s milk and sheep’s milk). |
| Folic Acid | Women should take 400 mcg folic acid during the first 12 weeks of pregnancy (or 5 mg per day if on antiepileptic medication, previous NTC, DM coeliac disease or other malabsorption syndromes). |
| Other Vitamins | Other vitamin supplements are rarely needed, although a small percentage of women with inadequate diets or lack of exposure to sunlight may need additional vitamin D; this can be obtained free of charge if they receive Income Support or income- based Jobseeker’s Allowance. |
| Fe | Anaemia in pregnancy is defined as a haemoglobin level of <11 g/dl initially or <10.5 g/dl at 28 weeks. These women may need iron supplements. |
| Alcohol | Alcohol should be limited to no more than 7 units per week, spread out over the week. |
| Toxoplasma | All fruit and vegetables should be washed, eat and poultry handled properly and cooked fully. Ready-made meals should be heated through thoroughly |
| Salmonella | Cook eggs fully and avoid softboiled. |
| Listeria | All pates and mouldripened soft cheeses should be avoided, as should blue-veined cheeses such as stilton; Soft cheeses and sptrads made from pasteurised milk are fine. |
| Liver | should be avoided because of its high vitamin A content. |
| Atopy | Women who have a personal history of atopy (eg eczema, asthma or hayfever), or who have an affected partner should avoid peanuts and foods containing peanuts |
Community midwife
birth choice uk.com Maternity Care
Mat B1
Abdo pain in pregnancy
Abdo pain in pregnancy medscape
Abdo pain in pregnancy Cork Emergency Medicine
Abdo pain in pregnancy bestpractice.bmj.com
Early pregnancy bleeding
Vaginal bleeding in pregnancy Medline plus
Management of bleeding in early pregnancy in accident and emergency departments BMJ 1994
what to expect.com subchorionic bleeding
Management of early pregnancy bleeding and miscarriage by general practitioners in Victoria
Antepartum haemorrhage (bleeding after 28 weeks) – refer all cases and never do a vaginal examination (VE) prior to referral
Ectopic pregnancy
Miscarriage
Rhesus in pregnancy (maternity)
250textbooks/rhesus-in-pregnancy-2
NICE TA 156 Aug 08 Rhesus prophylaxis QRG
Medical conditions in pregnancy |
|
|---|---|
| UTI /frequency | Send sample in pregnant females to confirm UTI plus post-treatment sample required to confirm cure.1st line First trimester, nitrofurantoin (Macrobid m/r capsules) 100mg twice daily or 50mg four times daily for seven days. Second or third trimester, trimethoprim 200mg twice daily for seven days. 2nd line Cefalexin 500mg every 8 hours for a minimum of seven days. Obtain post-treatment sample.Infection UTI and asymptomatic bacteriuria must be treated (risk of pyelonephritis). Penicillins are safe and nitrofurantoin a second choice for UTI. Avoid tetracyclines (and cotrimoxazole and metronidazole in first trimester) |
| Vaginal discharge | Candidiasis Canesten pessaries are safe |
| Heartburn | Heartburn antacids safe in 2nd and 3rd trimester, e.g. Mucaine or Gaviscon |
| Constipation | Constipation best treatment is to increase fibre intake |
| Piles | highfibre diet and Anusol ointment |
| Varicose veins | support tights and avoid excess standing |
| Ankle swelling | |
| Hyperemesis | Hyperemesis NHS ChoicesNausea and vomiting usually resolves about 14-16 weeks. |
| Skin changes | americanpregnancy.org skin changesSkin Changes in Pregnancy aafp |
| Fibroids | Women who have a personal history of atopy (eg eczema, asthma or hayfever), or who have an affected partner should avoid peanuts and foods containing peanuts |
| Anaemia | Anaemia In Pregnancy PUKAnaemia in pregnancy BTS UKMidwifery.org.uk anaemia in pregnancy |
DVT in Pregnancy
RCOG reducing risk of thrombosis
Hypertension in pregnancy
Chronic hypertension in pregnancy NeLM Aug 11
Pre eclampsia
Syndrome of hypertension + proeinuria + oedma occuring in second half of pregnancy of mainly in primips.
Hypertension = 140/90 or an increase of 30/15 mHg over baseline.
NICE CG107 Hypertension in pregnancy Aug 2010
Eclampsia
Proteinuria in pregnancy
Proteinuria in Pregnancy
HELLP
Renal disease in pregnancy
Renal disease in pregnancy PUK
Renal disease in pregnancy Medscape
Chronic kidney disease in pregnancy BMJ 2008
Renal disease in pregnancy RCOG
Cardiovascular disease in pregnancy
Cardiac disease in pregnancy PUK
Cardiovascular disease in pregnancy European Society of Cardiology
Management of Cardiac Disease in Pregnancy Medscape
Pregnancy and Heart Disease Cleveland Clinic
Thyroid problems in pregnancy
Thyroid problems in pregnancy PUK
Hypothyroidism
TFTs should be checked at least once every trimester.
Thyroxine dose usually needs to be increased; if the mother is hypothyroid, there is a risk that the fetus will be affected.
Postpartum thyroid disease affects 5-7% of previously euthyroid women after delivery, especially women who have a positive family history or who have other autoimmune disease. May resolve spontaneously.
source GPCSG?
Diabetes and IGT in pregnancy
Lifestyle and drugs in pregnancy
Molar pregnancy
Molar pregnancy / trophoblastic disease / choriocarcinoma
American pregnancy.org molar pregnancy
| Antenatal Infections | |
|---|---|
| Toxoplasmosis | Toxoplasmosis is caused by the Toxoplasma gondii parasite, which can be acquired by eating undercooked meat and by coming into contact with cat faeces. Pregnant women should be advised not to change cat-litter trays or to handle soil that might have been contaminated. All fruit and vegetables should be washed thoroughly and rubber gloves should be used when gardening.Women who have ‘flulike’ symptoms in pregnancy or who believe themselves to be at significant risk from toxoplasmosis can be offered serological testing. A negative result implies that the patient has never had toxoplasmosis and is not immune. One in three women has a positive result, usually because of previous exposure; in this case, the blood sample is sent to a reference laboratory to exclude current infection. It is thought that it takes between 4 and 6 weeks for toxoplasmosis to pass from mother to baby and the risk of congenital infection depends on when the woman was affected. If infection occurred shortly before conception (ie 23 months before1, there is a very low risk of transmission «1 %1. Most affected fetuses will miscarry at this stage. If infection occurs in the first trimester, the transmission rate is about 15%. This rate increases as the pregnancy progresses and is as high as 65% by the third trimester. Most affected babies will be symptomatic. The severest disabilities are found in children whose mothers were infected early on in pregnancy, and include hydrocephalus and retinochoroiditis. Children whose mothers were infected in the third trimester often appear healthy at birth, but most will develop symptoms later on (months or even years afterwards), usually visual problems. Amniocentesis testing can be offered to affected women. Treatment with spiramycin reduces the risk of transmission from mother to baby, but cannot prevent damage to a fetus who is already infected. |
| Parvovirus | for parvovirus IgG and IgM should have a repeat test 1 month after the time of contact. Those with proved parvovirus B19 infection in the first 20 weeks of pregnancy should be followed up by serial ultrasound and referred to a regional specialist centre for consideration of fetal blood sampling and intrauterine transfusion if hydrops fetalis is detected. (Communicable Disease and Public Health Vol 5, No 1, March 2002) |
| Group B Streptococcus | Group B Streptococcus (GBS) is the most common cause of severe infection in neonates within the first 7 days of life. In some counties women with are screened at 35-37 weeks of gestation is recommended and affected women are given intrapartum iv penicillin or ampicillin. Approximately 25% of women of childbearing age in the UK are GBS carriers UAntimicrobial Chemother; 1986; 18: 5965), so In general practice, women are sometimes incidentally found to be GBS carriers. In these cases, oral antibiotics at the time of diagnosis are not recommended; giving them does not reduce the likelihood of the woman becoming recolonised at the time of delivery (Am JObstet Gynaeco/1979; 135: 10625). The decision of whether or not to give intrapartum antibiotics is more difficult. If the swab was taken at 3537 weeks, there is a 0.2% chance of the baby being affected, although this risk may be greater if the swab was taken from the upper vagina or if there is GBS present in the urine. In any case, the final decision will be made by an obstetrician, and the main responsibility of the GP is to record the swab result in the woman’s antenatal records and to explain the situation to her.AAP Recommendations for the Prevention of Perinatal Group B Streptococcal (GBS) DiseaseGroup B streptococcal disease in infants aged younger than 3 months NELM/Lancet Jan 2012 youtu.be/iScO_bJaev4youtu.be/RdeXGB8fulcyoutu.be/T8jCOxTERwg |
| Genital herpes | Neonatal herpes infection is rare in the UK (incidence 1.65/100 000 live births per year UAntimicrobial Chemother 2000; 45 Suppt 3: 713) but potentially very serious. The risk is highest if the mother acquires the infection for the first time during the later stages of her pregnancy. Oral aciclovir is often used for women who develop a first episode of genitalnherpes during pregnancy (RCOG Clinical Guideline No 30, March 2002). Caesarean section is recommended for all women presenting with their first episode of genital herpes at the time of delivery (or within 6 weeks of the expected date of delivery), but not for women presenting in the first or second trimester. For women presenting with recurrent genital herpes at the time of delivery, the risk to the baby is small and elective Caesarean section is not mandatory. Operative delivery is not recommended if there is a recurrent episode of genital herpes occurring at any other time during pregnancy. |
| Maternal chickenpox | Chickenpox Contact and Pregnancy PUKNeonatal infections rch.org.auNHS Choices Maternal Chickenpoxyoutu.be/63lcTKz4L3 |
| Rubella and Viral Rashes | TORCH’S non-bacterial infections affecting the foetus Toxoplasmosis Other STDs eg syphilis Rubella Cytomegalovirus Herpes eg chickenpox Slapped cheek (parvovirus B19)HPA Viral Rashes In Pregnancy Downloadbettertesting.org.uk/?id=-1193youtu.be/krgIMlxwaksyoutu.be/CkK9fTykGLE |
leedsteachinghospitals antenatal infection screening
Twins and multiple pregnancy
The management of twin and triplet pregnancies in the antenatal period NICE CG 129
http://www.nice.org.uk/newsroom/pressreleases/MultiplePregnancyGuideline.jsp
Polyhydramnios oligohydramnios
Excess liqour which may be idiopathic or due to
Anencephaly
Open spina bifida
Gastroschisis
Exophalos
Oesophageal atresia
Duodenal atresia
Monozygotic twin pregnancy
DM
http://emedicine.medscape.com/article/975821-overview
http://emedicine.medscape.com/article/404856-overview
http://www.patient.co.uk/doctor/Oligohydramnios.htm
http://www.umm.edu/ency/article/003267.htm
Small for dates
Wrong dates
Twins/ Multliple pregnancy
Big baby (macrosomia >4.5kg)) eg in diabetes
Gravid fibroid uterus
Polyhydramnios
Large for dates
CP disproportion
Breech
Flexed breech – breech presentation with flexion at knees and hips
Frank breech – flexion at hip and extension at knees
Footling breech – one or both feet or knees presenting
Abnormal lie
Lie
presentation
effacement
Antepartum haemorrhage
Any bleeding from 24 weeks to delivery.
APH
Abrupion – normally sited placenta separates prematurely from uterine wall
Placenta praevia (vas praevia) – placenta overlies lower uterine segment
Hardly known/idiopathic (40%) (may include marginal haemhorrage cervical polyp/ca and spurious causes suchh as haematuria and rectal bleedibg)
Premature/Preterm Rupture of membranes
Rupture of membranes without onset of labour before 37 weeks
Antenatal kick charts
http://www.ncbi.nlm.nih.gov/pubmed/21585644?dopt=Abstract
Fetal movements are usually felt between 16 and 18 weeks in multips, 18 and 20 weeks in primigravidae
Caesarian Section LSCS
Proposed NICE Caesarian Section guidelines Oct 2011 @ NHS Choices
http://www.bmj.com/content/343/bmj.d7632
http://guidance.nice.org.uk/CG132
Placental functions
| Placental functions |
|---|
| endocrine |
| excretion |
| nutrition |
| respiration |
Postnatal exam
1. Uterus never returns to size of nullip. By 10 days has usually returned to pelvis. Also check episiotomy site
2. Breasts-encourage breast feeding
3. Check on rubella and cervical cytology status. Organize as appropriate
4. Discuss any problems of the pregnancy, e.g. check BP of those who were hypertensive, consider referral for IVP if pyelonephritis of pregnancy, etc.
5. Contraception. An IUCD may be fitted postnatally, the mini-pill prescribed for those breast feeding or the combined pill for those not
6. The baby. A good time to mention immunization, check on registration of baby and ask about any worries
7. Ensure claim forms for maternity work and contraception are submitted to the FPC
(old revise)
GPs are paid a fee for up to five postnatal visits (although these can be carried out by the midwife) and the postnatal examination between 6 and 12 weeks
Postnatal problems include:
1. Pyrexia > 38C consider genital tract infection, UTI, breast and chest infections. Also remember DVT
2. Secondary postpartum haemorrhage (PPH)blood loss more than 24 h after confinement. Many settle. Exclude infection. If more than slight or uterus enlarged and non involuting (?retained products)refer
3. Psychiatric problems~baby blues’ common on third and fourth day but can get a true psychosis. Do not underestimate a psychosis or a true postnatal depression there is a real risk to mother and baby. Refer for a psychiatric opinion
4. DVT Remember’ Older patients, obese patients and after caesarean, especially at risk. Pulmonary embolism commonest cause of death in puerperium
Postnatal Depression
Depression and other psychological morbidity
INITIAL ASSESSMENT
Ask how the woman is feeling
Be especially aware if:
there is a history of psychiatric illness;
her relationship with her partner is difficult or she is unsupported;
what appeared to be the blues does not resolve
EMERGENCY ACTION IS REQUIRED IF:
Woman showing symptoms of puerperal psychosis
Woman who the healthcare professional considers to be at risk of suicide or child abuse
WOMAN SHOWING SYMPTOMS OF DEPRESSION
If concerned that a woman may be depressed, discuss this and refer (urgent action).
Encourage support of partner (and/or close relative or friend) in caring for baby.
Ensure that the woman knows how to contact the healthcare professional at any time.
Avoid conflicting advice.
Offer self-help and support group literature.
If at any time the healthcare professional suspects the existence of any other psychological morbidity, such as severe anxiety disorders or stress reactions, the woman should be referred (urgent action)
The summary below sets out the main features of the blues, depression and psychosis, and action to be taken by the healthcare professional.
Postpartum blues Postnatal depression Puerperal psychosis
Frequency 50°1080% 713% 1 in 500
Symptoms Tearfulness; Lethargy; tearfulness; Thought disorders; irritability; oversensitivity; delusion; confusion; lability of hopelessness; anxiety; ag itation; fear;
mood; guilt; irrational fears; insomnia; severe sometimes disturbed sleep depression. Rarely headache patterns suicide! infanticide
Onset Few days after Mainly within first Most commonly in first
delivery month or two of four weeks after
delivery delivery
Duration A few days or Most resolve within Variable
less about 3 months or less, especially with treatment, but can persist
Action Transient If suspected refer Immediate referral
condition. (urgent action) (emergency action).
No action except Do not leave woman
reassurance alone.
needed unless Explain to family
does not
resolve
| Postnatal problems | |
|---|---|
| PPH | Primary PPH – vaginal bleeding > 500mls within 24hrs delivery Secondary PPH excessive vaginal bleeding 24 hrs-6weeks post delivery.Causes Caesatrian section Retained placental tissue Cervical trauma Atonic uterusNICE CG55 Intrapartum care Sep 2007 |
| Endometritis and abnormal blood loss | Obtain ‘baseline’ recording of involution for all women Assess blood loss Note problems with delivery or third stage from delivery detailsEMERGENCY ACTION IS REQUIRED IF: Secondary PPH Tender and/or bulky uterus Pyrexia above 38 Offensive lochiaENDOMETRITIS AND ABNORMAL BLOOD LOSSGENERAL ADVICE Change maternity pads regularly, each time toilet visited if pads are stained, and at least four times a day for the first few days Blood loss may be heavy for the first few days, but it will gradually become less. It should have a nonoffensive smell The healthcare professional should be contacted if the loss becomes: heavier bright red after the first week of delivery offensive |
| Breast-feeding problems | SSESSMENT ALL BREASTFEEDING WOMEN Evaluate breastfeeding: on course to feed effectively problem already present Ask about the behaviour of the baby Assess knowledge and give general advice as appropriateURGENT ACTION IS REQUIRED IF: Maternal or infant thrush Infective mastitis Breast abscess Concern about baby’s well-being Concern about onset and/or severity of jaundicePAINFUL NIPPLES Assess positioning and attachment of baby on the breast Advise mother of appropriate nursing position No evidence to justify use of creams, ointments or sprays Further visit(s) to reviewENGORGEMENT If areola engorged, mother may need to express milk before a feed Pain relief (paracetamol) may be required Unrestricted feeding will help relieve problem If engorgement is not relieved the mother may develop mastitis Further visit(s) to reviewINSUFFICIENT MILK Reassure that this can almost always be dealt with Discuss importance of positioning and attachment of baby on breast Emphasise importance of baby taking foreand hind milk There should be no limit on the duration of feeds If above do not solve problem and there is concern about baby’s growth, refer (urgent action)Emphasise the importance of correct positioning and attachment of the baby on the breast Advise about different nursing positions; as long as correct positioning and attachment on the breast are achieved, no one position is better than another If suckling causes pain take the baby off the breast, re-position and re-attach Reassure that colostrum will fully meet the needs of the baby and supplementary feeds are not necessary Emphasise the importance of unrestricted feeding on demand Include partner and any close relatives involved in care of the baby, in discussion of breastfeeding advantages If problem develops, midwife can be contacted Provide addresses/telephone numbers of local breastfeeding support groupsADVICE ON HAND EXPRESSING BREAST MILK Advise the woman to practise hand expressing before stored supplies are required, for example, before she recommences employment. As the mother becomes more confident, she may find other ways of expressing milk which she feels are better for her To hand express, the mother should place her thumb flat on the upper edge of the areola and cup the rest of her hand under her breast. Her forefinger should rest on the lower edge of the areola. She should then gently squeeze her thumb and forefinger together, and at the same time, gently press her whole hand back and in, towards the chest wall. Doing these movements together enables milk from the deep breast tissue to be expressed as well as the ducts beneath the areola and nippleBLOCKED MILK DUCT Show mother how to ‘milk’ the duct Discuss different feeding positionsNON-INFECTIVE MASTITIS Advise analgesia (paracetamol) prior to feed Feed from affected side first Frequent feeds Encourage bed rest, until flu-like symptoms have resolved If symptoms not eased in 6-8 hours (telephone to find out), refer (urgent action) If symptoms have eased, increase visit frequency until resolved INVERTED OR NON-PROTRACTILE NIPPLES |
| Suppression of lactation | http://www.fpnotebook.com/ob/Lactation/LctnSprsn.htmhttp://apps.who.int/rhl/pregnancy_childbirth/care_after_childbirth/cd005937_Tchoffopa_com/en/index.htmlhttp://www.medscape.com/viewarticle/464568 |
| Postnatal wound problems | Caesarean section wound care and pain relief INITIAL ASSESSMENT ALL WOMEN DELIVERED BY CAESAREAN SECTION Ask about wellbeing; any signs of fever Determine current medication and reason for prescription Discuss pain relief requirements and need for vigilance repossible infection Assess condition of the wound for: Separation (dehiscence) of wound edges; tenderness; discharge (type, e.g. pus/serous); redness spreading from incision line; localised heat or swelling; odourCAESAREAN SECTION WOUND CARE AND PAIN RELIEF Inspect wound at each postnatal visit Retain high index of suspicion for infection If sutures/clips in situ, remove as policy If wound appears suspect at any assessment, follow relevant sections of guidelineDEHISCENCE If dehiscence severe, immediate referral (emergency action). Apply sterile, nonocclusive dressing if available wet sterile pack or pad if bowel visible Explain to woman and partner that hospital admission may be required If dehiscence superficial, treat as other symptoms of infectionSUMMARY GUIDELINE: 3 CAESAREAN SECTION WOUND CARE AND PAIN RELIEF EVIDENCE OF INFECTION DETECTED (PYREXIA, LOCALISED PAIN, ERYTHEMA, LOCAL OEDEMA, EXCESS EXUDATE, OFFENSIVE ODOUR) Inspect wound and record findings Record pulse 8: temperature If there is exudate, take swab, apply simple occlusive dressing and refer (urgent action) If sutures or clips in situ, remove alternate ones if appropriate If pyrexial, advise paracetamolbased analgesia unless contraindicated. Refer if temperature over 38°C or fails to settle after 24 hours (emergency action) Look for other possible sources of infection Reassure, and advise woman to contact healthcare professional if the symptoms worsen Review as appropriateGENERAL ADVICE Take prescribed pain relief as necessary If prescribed antibiotics complete the full course Take care of the wound: bath or shower daily; do not apply a dressing unless supplied by the doctor or midwife Wear loose clothing, use cotton underwear Take care to find a comfortable position to feed the baby Do not lift heavy objectsNICE CG37 Postnatal care Jul 2006 QRGrcog.org.uk management of third and fourth degree perineal tearsAll women who have had a thirdor fourth degree tear should be followed up for 12 months after delivery, as symptoms may not appear straight away. If the woman is suffering from faecal incontinence, she should be offered an endoanal ultrasound and anorectal manometry. Secondary sphincter repair can be considered. Subsequent deliveries may worsen symptoms of faecal incontinence, or cause them to develop, so elective Caesarean section may be an option. Broadspectrum antibiotics and laxatives (usually an osmotic laxative such as lactulose, in combination with a bulking agent such as Fybogel®) are often prescribed after a thirdor fourth degree tear has been repaired: this is to reduce the incidence of wound dehiscence and postoperative infection. Metronidazole is usually included as part of the treatment, in order to cover anaerobic infection from faecal matter. |
| Postnatal headache | exclude diagnoses other than tension headache/migraine Obtain baseline recording of BP (at least one BP measurement should be obtained within 6 hrs of the birth)Ask about onset, location and duration of headache. History of trauma? Did the woman have epidural/spinal analgesia, and is headache postural (possible PDPH)? Are there other conditions which produce, exacerbate or relieve the headache? Is there a history of hypertension? What degree of incapacity does the headache produce?EMERGENCY ACTION IS REQUIRED IF: Diastolic BP 2:90 mmHg, with signs or symptoms of preeclampsia Diastolic BP remains 2:90 mmHg when repeated 4 hours after baseline in absence of signs or symptoms of preeclampsia Severe headache and history of hypertension during pregnancy Severe and sudden onset of ‘thunderclap’ headache. Headache associated with trauma. Headache associated with pyrexia, signs of fever. Severe or persistent headaches.HEADACHE What to do POSTPARTUM ‘SIMPLE’ HEADACHE If known migraine sufferer, continue with usual medication. Advise on relaxation. Discuss childcare and sleep ways to have a rest during the day? Mild analgesia (paracetamol) can be advised. If analgesia insufficient refer (urgent action). Attempt to identify factors which trigger headache. Reassure that headache is common and is generally no cause for concern.SYMPTOMS OF PDPH Contact anaesthetic department at hospital where delivered. Bed rest will alleviate symptoms but not prevent a headache. Record BP, temperature and pulse. Paracetamol can be taken as necessary. Avoid bending/lifting until headache resolved. Dehydration should be avoided. Tell woman about possible diagnosis and that treatment is available. Support with infant care. Review as required.HEADACHES AND HYPERTENSIVE DISORDERS If diastolic BP is 2:90 mmHg, with signs and symptoms of preeclampsia, refer (emergency action) If diastolic BP is 2:90 mmHg but no signs and symptoms of preeclampsia, repeat measurement within 4 hours. If pressure has not fallen, refer (emergency action). Known hypertension management as described, observe for symptoms of preeclampsia. Review the next day in all cases.GENERAL ADVICE Provide information on signs and symptoms of preeclampsia. Avoid factors which precipitate or exacerbate headache. Take short rest periods when possible during the day. Do relaxation exercises. |
| Postnatal fatigue |
http://www.motherhood-cafe.com/postpartum-fatigue-2.html Exclude depression anaemia and hypothyroidism Help the woman plan her time each day to include short periods of rest. If possible ask a relative or friend to help |
| Post natal depression PND | NICE CG45 Antenatal and postnatal mental health Feb 2007 Edinburgh Post Natal Depression Scale Download pdf Post Natal Depression direct.gov http://youtu.be/Ey3M6hFo3Mw http://youtu.be/pecCbMtqjos |
Postnatal Exercises
http://youtu.be/n0NhGLXOYgk
http://youtu.be/MKQ94vq_S8g
http://youtu.be/DS3ZM8lQT8k