Pregnancy

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

 

Gravidity and Parity PUK

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

NHS Choices Pregnancy Planner

 

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

NICE CG62 Mar 08 ANC

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

nct.org.uk madwives

birth choice uk.com Maternity Care

 

Mat B1

Mat B1 hmrc.gov.uk

 

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

Early Pregnancy loss Medscape

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

Ectopic pregnancy Medscape

ectopic.org.uk

Ectopic pregnancy BMJ

youtu.be/4_PwAddVh4w

youtu.be/HsYHtczWiWI

 

Miscarriage

Pregnancies are being terminated unnecessarily after an incorrect diagnosis of miscarriage BBC news Oct 2011

NHS Choices Reply

 

Rhesus in pregnancy (maternity)

250textbooks/rhesus-in-pregnancy-2

NICE TA 156 Aug 08 Rhesus prophylaxis QRG

RCOG Rhesus D Prophylaxis

youtu.be/VkEY7k0vJIk

youtu.be/7OWp8d8WKkg

 

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

Perinatology.com (up to 2002)

 

DVT in Pregnancy

RCOG reducing risk of thrombosis

SIGN 122

 

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

youtu.be/xLJ883ry0ZQ

youtu.be/6OHpp3ymrkA

youtu.be/ONj-x9kF41Q

youtu.be/LRWLB2T96MQ

 

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

youtu.be/pOZxwXAa2gc

 

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

youtu.be/A-8de9LuVJQ

youtu.be/SGoGdsG3aK0

youtu.be/9XctFwImLHk

youtu.be/uX0XOT6hVEo

 

Lifestyle and drugs in pregnancy

 

Molar pregnancy

Molar pregnancy / trophoblastic disease / choriocarcinoma

hacking-medschool/cocs-cancer

Hydatiform Mole Medscape

American pregnancy.org molar pregnancy

youtu.be/jLTkCQkbkKg

youtu.be/bprrUG6i3pM

 

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

Antenatal Infections PUK

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
Reassure mother that babies breastfeed and do not ‘nipple’ feed
If only one breast is affected, feed from the unaffected side If initial problems experienced with direct breastfeeding, initiate lactation with breast pump and feed baby with cup or spoon. Direct breastfeed when milk is ‘in’

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
http://www.babycenter.com/0_postpartum-fatigue-how-to-cope_1152217.bc
http://arrow.uws.edu.au:8080/vital/access/manager/Repository/uws:740

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
Check that dietary intake is adequate and stress need to eat regularly
Where appropriate discuss social circumstances and lifestyle (e.g.young single mother). Refer if additional social
support would be beneficial
Explain importance of exercise. Advise short daily walk when the woman feels she has most energy, which should then be followed by a
short period of rest
Encourage the woman to discuss any problems or worries she may have with the midwife and/or a close friend or family member
It may be helpful if the woman keeps a diary of daily tasks to assess if fatigue is related to any particular activity or time of day and help her
plan activity to include rest periods

youtu.be/DS3ZM8lQT8

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

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