1. Post Natal Care of the Mother Cate Price Medical Advisor Obstetrics Shared Care

2. Contents 1.Puerperium 2.Who does what? 3.Schedule of visits 4.Physical considerations 5.Emotional aspects 6.Contraception 7.Pap smears 8.Immunisations

3. Puerperium Defined as the time from the delivery of the placenta through the first few weeks after delivery. Usually considered to be 6 weeks in duration.

4. Post Natal Visits Public hospitals provide a variety of post natal visits. 1-2 visits, more for primips. Child and Family Health Services. A referral is made at the time of discharge (with parental consent), visit occurs at 1-2 weeks.

5. Schedule Of Visits GP OSC SA recommends post natal visits at two and six weeks post partum for both mother and baby. – Advise of the two week visit at the last antenatal visit.

8. Physiology of Puerperium Uterus returns to pelvis by 2 weeks. PV blood loss ceases on average by 5 weeks.

9. Physiology of Puerperium cont. Epithelium of cervix has regenerated sufficiently to allow a Pap smear to be performed by 6 weeks. Vaginal wall has returned to normal by 6-10 weeks (later in breast feeding mothers due to persistently decreased oestrogen levels).

10. Physiology of Puerperium cont. The resumption of normal ovarian function is greatly influenced by breastfeeding the baby. Non breastfeeding mothers may ovulate as early as 27 days most women have a period by 12 weeks Breastfeeding mothers the resumption of menses is highly variable. 50-75% resume menses within 36 weeks.

11. Contraception Condoms Lactational amenorrhoea method Combined oral contraceptive pill Progesterone only methods – “mini pill” – Implanon – Depo provera – Mirena

12. Lactational Amenorrhoea Method 98% effective Less than 6 months postpartum Amenorrhoea post partum The baby is fully breast fed (or breastfed with very infrequent supplements)

13. Combined OC Pill Breastfeeding – Detrimental effect on the volume of breast milk under 6 weeks post partum. There is little evidence for an effect on the quality or quantity of breast milk over 6 weeks post partum to six months post partum. Not breastfeeding – Can be started 21 days after childbirth.

14. Progesterone Only Methods POP, Implants, Depo All methods can be started at any time after delivery, either breastfeeding or not Intrauterine devices Generally accepted practice would be 8 weeks post NVD, 12 weeks post LSCS

15. Edinburgh Post Natal Depression Scale EPDS is the most widely accepted screening instrument used in the perinatal period. Excludes some symptoms that are common in the perinatal period (tiredness, sleep disturbance, irritability) that other depression instruments include Should be used to assess a women’s mood over the past 7 days Routine administration at 6-8 weeks is recommended.

16. Other Considerations Follow up immunisations- Rubella, Pertussis (can now be given during the 3 rd trimester) Follow up pregnancy complications – BP, low Hb, Gestational Diabetes, low Vitamin D Pap smear Intercourse Bowels/Bladder

17. Scenario 1 Melissa comes to see you 6 weeks after the birth of her first child. She had her antenatal care with the local hospital and they told her to visit her GP at 6 weeks. She feels well and is enjoying her new baby. Breastfeeding has been difficult and at the advice of her mother she has added in 1-2 bottles of formula at night, so she can get more sleep. She thinks her pap smear is due and is not sure what she wants to do for contraception.

18. Scenario 1 Can you do a pap smear? What advice would you give Melissa regarding contraception?

19. Scenario 2 Mandy comes to see you at two weeks after the delivery of her first child. She is very happy, but exhausted. She knew this wouldn’t be easy at 40, but is overwhelmed and not getting much sleep.

20. Scenario 2 What tool would help you with Mandy? How do you administer it? What would you do next?

21. Scenario 3 Jane has just had her second baby in 12 months and asks about contraception. She is fully breastfeeding, as she was when she fell pregnant with her second child She doesn’t want another baby!!

22. Scenario 3 What contraceptive advice would you offer Jane? Mirena – When can it be inserted? Who inserts it? Implanon – When can it be inserted? Contraceptive pill – Mini pill, how efficient?

23. Scenario 4 Emma visits you at 2 weeks post delivery. You note that she was not immune to Rubella at her booking bloods and the hospital discharge letter has asked you to sort this out.

24. Scenario 4 How do you give her a Rubella vaccine? What precautions do you tell her about? Can you give it if she is breast feeding? Should you re test her immunity? If so when? Any other post partum immunisations?

25. Scenario 5 Mary has just had her second child, you did shared care with her and then “lost” her to the hospital when she developed Gestational Diabetes. Her discharge letter states that she has been entered onto the GDM Recall Register.

26. Scenario 5 What does this involve for Mary? GTT 6-8 weeks post partum Annual fasting glucose/HbA1c Early screening in pregnancy – 12-14 weeks Reminder are sent to the woman every year by SA Health

27. Scenario 6 Fatima had a low Vitamin D at booking bloods ( Vit D < 60) She has been taking Vitamin D supplements 1000 IU during her pregnancy A repeat level at 28 weeks was > 60

28. Scenario 6 What advise do you give Fatima post natally? Do you re check her Vitamin D levels? When? What advice do you give for her baby?