Postpartum care

This presentation done by Family resident R1
Any mistake "if there" is from the sources

1. Postpartum care & breast feeding counseling Dr.Lamyaa ALGhafli R1

2. Normal postpartum findings and changes 1- Shivering Shivering usually starts 1 to 30 minutes postdelivery and lasts for 2 to 60 min. The cause is not known, it may be a response to a fall in body temperature following labor, fetal-maternal bleeding, micro-amniotic emboli, placental separation, anesthesia or bacteremia . Treatment is supportive with warm blankets and/or warm air.

3. Cont.. 2- Uterine involution Immediately 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. Large vessels at the placental site thrombose, which is a secondary hemostatic mechanism for preventing blood loss.

4. Cont.. Inadequate myometrial contraction will result in atony ( ie , a soft, boggy uterus), which is the most common cause of early postpartum hemorrhage. The fundus will not palpable abdominally by two weeks postpartum and attains its normal nonpregnant size by six to eight weeks postpartum. Although assessment of uterine size is routinely performed in the early postnatal period, there is no evidence that uterine size is predictive of complications.

5. Cont.. 3- Lochia The basal portion of the decidua remains after the placenta separates. This decidua divides into two layers: 1- The superficial layer is shed 2- The deep layer regenerates new endometrium, which covers the entire endometrial cavity by the 16 th postpartum day.

6. Cont.. Microscopically, lochia consists of serous exudate, erythrocytes, leukocytes, decidua, epithelial cells, and bacteria. Malodorous lochia: The most common cause is a retained gauze sponge inadvertently left in situ after repair of an episiotomy or laceration. Removal of the foreign body will lead to resolution of the purulent malodorous discharge.

7. Cont.. 4- Cervix After delivery, the cervix is soft and floppy. The cervix remains 2 to 3 cm dilated for the first few postpartum days and is less than 1 cm dilated at one week. The external os never resumes its pregravid shape: the small, smooth, regular circular opening of the nulligravida becomes a large, transverse, stellate slit after childbirth Histologically, the cervix does not return to baseline for up to three to four months after delivery.

8. Cont.. 5- Vagina and vulva The vagina is capacious and smooth immediately after delivery. It slowly contracts, but not to its nulligravid size.

9. Cont.. 6- Abdominal wall The abdominal wall is lax postpartum but regains most, if not all, of its normal muscular tone over several weeks Separation (diastasis) of the rectus abdominis muscles may persist.

10. Cont.. 7- Reproductive hormones hCG values return to normal nonpregnant levels two to four weeks after term delivery but can take longer. Some women report hot flashes in the postpartum period, with resolution over time. The cause is unknown but may be due to thermoregulatory dysfunction, initiated at the level of the hypothalamus by estrogen withdrawal after delivery of the placenta.

11. Cont.. 8- Effect of breastfeeding on ovulatory hormones  The 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. When nutrition is adequate and basal body mass and composition are normal, intensive lactation is less likely to result in prolonged suppression of GnRH. When nutrition is inadequate to meet the energy demands of both daily living and lactation, GnRH suppression is more likely to persist for an extended time period, resulting in prolonged oligo- or anovulation.

12. Cont.. 9- Breast engorgement Breast engorgement results in breast fullness and firmness, which is accompanied by pain and tenderness, and may give rise to a mild temperature elevation. The condition spontaneously resolves over a few days, but supportive care (warm compresses or a warm shower before feeding, cool compresses after or between feedings, mild analgesics such as paracetamol or ibuprofen). The affected area varies from primarily areolar involvement in some mothers, more peripheral involvement in others, and, in some mothers, both peripheral and areolar involvement.

13. Cont.. Primary engorgement is due to interstitial edema and onset of copious milk production. It occurs between 24 and 72 hours postpartum, with a normal range of one to seven days. Peak symptomatology averages three to five days postpartum.

14. Cont.. 10- Skin and hair Striae , if present, fade from red to silvery but are permanent. Abdominal skin may remain lax if extensive rupture of elastic fibers occurred during pregnancy. Chloasma resolves, although the exact timing is not known. Telogen effluvium is the hair loss commonly noted one to five months after delivery. It is usually self-limited with restoration of normal hair patterns by 6 to 15 months after delivery.

15. Cont.. 11- Physiologic weight loss The mean weight loss from delivery of the fetus, placenta, and amniotic fluid is 13 pounds (6 kg). Contraction of the uterus and loss of lochial fluid and excess intra- and extracellular fluid leads to an additional loss of 5 to 15 pounds (2 to 7 kg). Approximately one-half of gestational weight gain is lost in the first six weeks after delivery, with a slower rate of loss through the first six months postpartum.

16. Cont.. 12- Hematologic system Pregnancy-related hematologic changes return to baseline by 6 to 12 weeks after delivery. The prothrombotic state takes weeks to resolve, so postpartum women remain at increased risk for thromboembolic disease.

17. Postpartum care The postpartum period begins one hour after delivery of the placenta and generally lasts six weeks.

18. 1-Medical Complications 1- Headache most postpartum headaches are not associated with serious underlying pathology. The postpartum period is characterized by hormonal and other physiological changes, sleep deprivation, irregular food intake, psychological stress, and fatigue . 2- Symptomatic hemorrhoids Symptomatic hemorrhoids are common postpartum. The treatment approach depends on the specific symptoms (pruritus, bleeding, pain, or prolapse).

19. Cont … 3- Symptomatic lower extremity varicose veins Pregnancy is a risk factor for varicose veins, which may appear and become symptomatic anytime during the antepartum or postpartum period. Leg elevation, exercise, and compression therapy improve oxygen transport to the skin and subcutaneous tissues, decrease edema, reduce inflammation, and compress dilated veins. Varicose veins are a risk factor for superficial phlebitis and thrombosis.

20. Cont …. 4- Mild vulvar edema It can be managed with ice packs and other comfort measures to provide relief of symptoms. It has been associated with use of tocolytics for preterm labor, prolonged second stage of labor, and preeclampsia. 5- Fever/infection/wound complications Postpartum febrile morbidity as an oral temperature ≥38.0°C (≥100.4°F) on any two of the first 10 days postpartum, exclusive of the first 24 hours. The first 24 hours are excluded because low-grade fever during this period is common and often resolves spontaneously, especially after vaginal birth.

21. Differential diagnosis of postpartum fever 1- Surgical site infection: ( eg , episiotomy, laceration, abdominal incision) are usually localized to the skin and subcutaneous tissue. On examination, the area appears swollen and erythematous with a purulent exudate.

22. Cont … Treatment consists of opening the wound, drainage, irrigation, and debridement of foreign material and necrotic tissue. Antibiotics are not necessary unless there is accompanying cellulitis. The area will heal by granulation.

23. Cont …. 2- Postpartum endometritis 1 to 3 percent after vaginal deliveries, 7 percent risk of endometritis after elective cesarean section. In nonelective cesarean deliveries, the average was 19 percent in women who received intraoperative antibiotics and 30 percent in women who did not. Clinical findings: postpartum fever, tachycardia, hyperthermia, midline lower abdominal pain, and uterine tenderness . Clindamycin and gentamicin are the drugs of choice to manage endometritis.

24. Cont … 3- Mastitis or breast abscess Lactation mastitis presents as a firm, red, and tender area of one breast with a maternal temperature that exceeds 38.5°C. A tender, fluctuant area is more indicative of an abscess. Systemic complaints may be present and include myalgia, chills, malaise, and flu-like symptoms .

25. Cont …. 4- Urinary tract infection, both cystitis and pyelonephritis Cystitis symptoms include dysuria, frequency, urgency, suprapubic pain and/or hematuria but not fever if infection is isolated to the bladder. Pyelonephritis may be associated with cystitis but is characterized by fever (>38°C), chills, flank pain, costovertebral angle tenderness, and nausea/vomiting.

26. Cont …. 5- Septic pelvic thrombophlebitis Patients present with one of two distinctive syndromes: 1- Patients with ovarian vein thrombophlebitis are usually acutely ill, with fever and abdominal pain within one week after delivery, thrombosis of the ovarian vein (usually on the right side ( . 2- Patients with deep septic pelvic thrombophlebitis present more with isolated fever in the early postpartum and do not have abdominal or pelvic tenderness.

27. Cont …. 6- C. difficile infection Manifestations of the disease include watery diarrhea up to 10 or 15 times daily with lower abdominal pain cramping, low grade fever, and leukocytosis . These symptoms generally occur in the setting of recent antibiotic administration. Initial treatment generally involves cessation of the causative antibiotic and initiation of oral therapy with metronidazole.

28. 6- Urinary incontinence Risk factors for urinary incontinence three months postpartum:

29. 7- Thyroid disorders prevalence of 4 to 7 percent in the first year postpartum. Symptoms can include hypothyroidism or hyperthyroidism and may overlap with other common postpartum problems (e.g., fatigue, emotional lability, depression). Although thyroid screening is not recommended for asymptomatic postpartum patients, physicians should consider screening high-risk women ( type 1 diabetes, a history of postpartum thyroiditis, or postpartum depression). Twenty-five percent of women with postpartum hypothyroidism develop long-term hypothyroidism.

30. 8- Persistent vaginal bleeding Vaginal bleeding that persists for more than approximately eight weeks after delivery is unusual and may be due to infection, retained products of conception, a bleeding diathesis , or, rarely, choriocarcinoma or a uterine vascular anomaly .

31. 2- Mental health issues Postpartum blues : transient condition characterized by several mild depressive symptoms such as sadness, crying, irritability, anxiety, insomnia, exhaustion, and decreased concentration , as well as mood lability that may include elation. Symptoms develop within two to three days of delivery, peak over the next few days, and resolve within two weeks. The blues is considered a physiologic phenomenon triggered by hormonal changes and augmented by sleep deprivation, nutritional deficiencies, and the stress of new motherhood.

32. Cont … Postpartum psychosis usually presents in the first two weeks postpartum as manic, restless behavior. Postpartum psychosis is usually a manifestation of bipolar affective disorder, and women with this disorder are at increased risk of recurrence following future pregnancies and stressful life events. Possible risk factors for post-traumatic stress disorder (PTSD) include pre-pregnancy stress ( eg , sexual trauma, high anxiety), pregnancy-related issues ( eg , fear of childbirth, low support, perceived lack of control, maternal morbidity), and delivery issues (emergency cesarean, instrumental vaginal)

33. Cont.. Postpartum depression is one of the most common complications after childbirth (13 percent of postpartum women in the United States per year). (DSM-IV), postpartum depression has its onset within four weeks postpartum, although studies often define onset up to three months postpartum. The depression usually lasts about seven months if untreated.

34. 3- Sexuality and Contraception Libido may decrease after delivery, possibly because of decreased estrogen levels. Breastfeeding can delay the return to intercourse, possibly because estrogen levels remain low in these women. The length of time for women to wait to have intercourse following delivery is variable; the average is six to eight weeks, but it may be shorter or much longer. No consistent correlation exists between delivery complications (e.g., vaginal lacerations) and a delay in resuming intercourse. Other significant factors affecting postpartum sexual function include body image changes, fatigue, and fear of pregnancy.

35. Key Elements of Postpartum Care Six to 12 hours postpartum Three to six days postpartum Six weeks postpartum Six months postpartum Baby Breathing Warmth Feeding Umbilical cord care Immunization Feeding Infections Routine tests Weight and feeding Immunization Development Weaning Mother Blood loss Pain Blood pressure Advice Warning signs Breast care Fever Infection Lochia Mood Recovery Anemia Contraception Libido General health Contraception Continuing morbidity

36. Routine postpartum care The routine postpartum visit should occur four to six weeks after delivery. An early postpartum visit at one to two weeks postpartum should be considered for women with cesarean delivery, medical issues that require close follow-up and women at risk for postpartum depression ( eg , past episodes of depression, family history of mood disorder, concurrent stressful life events).

37. Cont … 1- Patient education: Patients should be instructed about signs of possible complications that should prompt them to seek further medical advice, these include, but are not limited to the following: Excessive postpartum bleeding Fever New or worsening perineal or uterine pain Dysuria Breast problems Dyspnea, chest pain, leg pain or swelling Significant mood disturbance ( eg , affecting relationships or normal activity)

38. Cont … Activity  There are no data to base recommendations regarding postpartum physical activity. Contraception 2- Maternal monitoring: 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 over distended bladder. The perineum is examined for signs of edema, purulent discharge, or dehiscence. 3- Laboratory testing Hgb , WBC 4 - Support for breast feeding

39. Cont … 5- Perineal care Stool softeners and laxatives, as needed, are probably useful until perineal healing is nearly complete, especially in women with a disrupted anal sphincter. 6 - Prevention of venous thrombosis Thromboembolic events are the leading cause of direct maternal mortality. Venous thromboembolism (VTE) is more common in postpartum women than in antepartum and nonpregnant women, and more common after cesarean than vaginal birth. The risk is highest in the first few weeks postpartum and then gradually declines to baseline by 12 weeks postpartum.

40. Cont … 7 - Routine immunization Indications and procedures for vaccination of postpartum women are similar to those described for the general population. 8- Pelvic muscle exercise No decrease in urinary incontinence in postpartum women who performed supervised pelvic floor muscle exercises for 16 weeks. Supervised pelvic floor muscle exercises in the immediate postpartum period may be contraindicated in women who sustain injury to the levator ani muscle complex at childbirth because exercise may be harmful in the early phase of injury recovery.

41. Safety of common analgesics in breastfeeding women  Most analgesics are safe for breastfeeding women. Paracetamol enters breast milk but is considered compatible. NSAIDs (Ibuprofen and diclofenac suppositories) which have a short half-life (<6 hours), are considered compatible with breastfeeding. Naproxen should be avoided because it has a long half-life (>6 hours), thus a greater potential to accumulate in the infant's plasma. All NSAIDs should be avoided if the breast-fed infant has a ductal-dependent cardiac lesion.

42. Cont … Opioid analgesia postpartum may affect infant alertness and suckling vigor. Opiates are generally safe, although infants should be observed for sedation. Use of all opioid agents should be limited to the lowest effective dose for the shortest time required to control acute pain. Patients requiring any opioid should be switched to a nonopioid alternative as soon as the level of pain permits.

43. Breast feeding Counseling

44. Key Recommendations Breastfeeding is a public health issue, not merely a lifestyle choice. WHO recommends that a child breastfeed for at least two years. The American Academy of Pediatrics, like the AAFP, recommends that all babies, be exclusively breastfed for six months and continue breastfeeding with appropriate complementary foods for at least one year. Family physicians should not undermine breastfeeding by providing formula samples or coupons to breastfeeding mothers if formula supplementation not medically indicated .

45. Health Effects for the baby

46. Health Effects for the mother The data on postpartum weight loss suggest that the role of breastfeeding is minor compared with diet and exercise, although studies suggest that at least six months of exclusive breastfeeding may increase maternal weight loss. Another study suggested that longer duration of breastfeeding led to greater sustained weight loss. Not breastfeeding is associated with an increased risk of postpartum depression, type 2 diabetes, breast cancer, ovarian cancer, hypertension, and cardiovascular disease.

47. Breastfeeding education

48. Breastfeeding Considerations Infant Illness

49. Maternal Illness

50. Infections Most infections do not preclude breastfeeding

51. Tobacco Use Infants should not be exposed to cigarette smoke. Babies who are breastfed immediately after their mother smokes demonstrate changes in their sleep and wake patterns . Breastfeeding infants who bed share with parents who smoke have a higher risk of sudden infant death syndrome (SIDS) . Breastfeeding women who smoke are at risk of insufficient milk supply because of the negative effect of nicotine on prolactin levels.

52. Pumping, Expressing, and Storage Guidelines For occasional brief absences, hand expression and/or the use of a hand pump is usually sufficient. The longer and more frequent the separations, the more important it is for the mother to use a hospital grade double-pumping electric pump. To avoid a significantly reduced milk supply during the work week, try frequent breastfeeding when they are with their infants, pumping at a frequency as close to the feeding frequency as possible.

53. Cont … The milk can be stored at room temperature for six to eight hours, in an insulated cooler bag with ice packs for 24 hours, and in the refrigerator for up to five days. Milk can be stored in a freezer for up to six months. Small amounts of milk can be added to previously expressed milk, but the fresh milk should be chilled before adding to already frozen milk. Room should be left in the container for expansion during freezing. The best storage containers are hard plastic or glass containers.

54. Cont … Warming and thawing of milk should not be done in the microwave. Thawing can be accomplished by placing the frozen milk in the refrigerator overnight, or with the use of a bowl of warm water or running warm water. Once thawed, the milk should not be refrozen but can be stored in the refrigerator for 24 hours. Because any thawed milk that has been partially consumed must be discarded, it is advisable to use small containers to avoid unnecessary waste.

55. Supplementation Routine supplementation of healthy, term breastfeeding infants is not recommended unless medically indicated. It is recommended that all babies receive 400 IU of vitamin D supplementation daily beginning soon after birth.

56. Breastfeeding and the Preterm Infant and Late Preterm Infant Some relatively mature preterm infants may be able to breastfeed right away. Newborns born at 35 to 37 weeks of gestation have special nutritional needs and require extra lactation support compared with newborns who are full term. They tend to be sleepy and at high risk of not feeding enough at the breast. This increases their risk of hypoglycemia and dehydration. Because of their relative immaturity, they are also at risk of delayed hepatic bilirubin excretion leading to jaundice. These babies require monitoring of adequate breast milk.

57. Breastfeeding Multiples Mothers of multiples will need additional support for breastfeeding. Most mothers can fully breastfeed twins . They must be prepared to counsel prior to delivery and support breastfeeding with reassurance of adequate supply, along with the usual recommendations of proper rest, nutritious diet, and the need for intensive support and help.

58. Donor Milk, Adoptive Breastfeeding There are 17 nonprofit human milk banks in the United States and Canada. Many adoptive mothers are physiologically capable of producing milk, to a greater or lesser extent. A multiparous woman will likely produce more milk than a nulliparous mother. Although the adoptive mother may not develop a full milk supply, with induced lactation techniques and the use of galactagogues , it is possible to provide a significant amount of mother’s milk.

59. Weaning weaning is the gradual process of transitioning infants from mother’s milk to complementary foods. Complete weaning should be a gradual process accomplished over a long period to lessen the risk of engorgement, plugged ducts, galactoceles , mastitis, and breast abscess, emotional trauma for herself and the child and the risk of infectious illnesses, dehydration, and malnutrition in the child . Like other developmental milestones, weaning takes place when a child is ready, physically and psychologically. Most children who self-wean do so between two and four years of age.

60. Cont…. Some women who need to wean develop feelings of guilt. During the weaning process, the child may need more attention and cuddle time to take the place of nursing time. When the woman is ready to initiate weaning, the options are: 1- Gradually eliminate one breastfeeding session every two to five days 2- Shortening nursing sessions slowly or lengthening the time between them 3- Wean the child during the day and continue breastfeeding at night, it is a good option for women who are unable to pump breast milk while working

61. Cont… Pre-bedtime or nighttime feedings are usually the last to go. Falling asleep while bottle feeding can lead to "baby bottle tooth decay" and is not recommended. Once breastfeeding has stopped, the breasts will stop producing milk. Even after breastfeeding has stopped, there may be milk in the breasts for several months to years.

62. Father’s Role in Breastfeeding Support Approval and support of breastfeeding by the father is associated strongly with the decision to breastfeed. They need to understand that what they may perceive as problems, such as soreness, physiologic infant weight loss, jaundice, baby fussiness, and frequency of feedings, especially at night.

63. 1- In the prenatal workup for a 24-year-old patient, you discover she is not immune to rubella. When is the best time to vaccinate her against rubella? a. Immediately b. In the second trimester of pregnancy c. In the third trimester of pregnancy d. In the early postpartum period e. At least 4 weeks postpartum

64. The answer is d Rubella is normally a mild selflimited illness, but infection during pregnancy can result in fetal death or congenital defects known as congenital rubella syndrome (CRS). CRS is devastating, and rubella immunity is important for women considering pregnancy. If a woman is found to be rubella nonimmune, vaccination should not occur if she is pregnant or planning pregnancy in the next 4 weeks. Although the vaccine is contraindicated in pregnancy, inadvertent vaccination is not an indication for therapeutic abortion. If the patient is currently pregnant and nonimmune, she should be vaccinated as early in the postpartum period as possible.

65. 2- Early breast-feeding is associated with A) Improved growth in the first 2 months B) Lower risk of aspiration C) Less temperature instability D) Fewer apneic spells E) Higher rates of postpartum depression

66. The answer is C. Mothers of newborn infants should initiate breast-feeding as soon as possible after giving birth. When mothers initiate breast-feeding within one-half hour of birth, the baby’s suckling reflex is strongest, and the baby is more alert, which facilitates feeding. Early breast-feeding has been shown to be associated with fewer nighttime feeding problems and better mother–infant bonding. Additionally, infants who are breast-fed earlier have been shown to have higher core temperatures and less temperature instability.

67. 3- The most common cause of postpartum bleeding is A) Retained placenta B) Vaginal laceration C) Uterine atony D) Coagulopathy E) HELLP syndrome

68. The answer is C. Hemorrhage after placental delivery should prompt vigorous fundal massage while the patient is rapidly given oxytocin in their intravenous fluid. If the fundus does not become firm, uterine atony is the presumed (and most common) diagnosis. While fundal massage continues, the patient may be given methylergonovine (Methergine) intramuscularly, with the dose repeated at 2- to 4-hour intervals if necessary. Methylergonovine may cause cramping, headache, and dizziness. The use of this drug is contraindicated in patients with hypertension. Carboprost (Hemabate), 15-methyl prostaglandin F2a, may be administered intramuscularly or intramyometrially every 15 to 90 minutes, up to a maximum dosage. As many as 68% of patients respond to a single carboprost injection, with 86% responding by the second dose. Another prostaglandin that is increasingly used in the treatment of postpartum hemorrhage is misoprostol which is most commonly administered rectally in a 800-to-1,000-mcg dose, though it can also be administered buccally or vaginally.

69. 4- Which of the following is recommended for postpartum breast engorgement? A) Firm binding of breast with a comfortable wrap B) Cabbage leaves C) Bromocriptine D) Initiation of oral contraceptives E) Topical vitamin E

70. The answer is A. The best way to prevent postpartum breast engorgement is to bind the breasts firmly with a comfortable wrap. Other suggestions include cold packs, analgesics, and the avoidance of direct warm water during showering. The use of bromocriptine (a dopamine agonist) to stop lactation is associated with rebound lactation after discontinuation of the medication, hypotension, hypertension, seizures, and stroke; it is no longer approved by the U.S. Food and Drug Administration for this use. Other medications, such as estrogen and testosterone combinations, are not recommended because of their increased risk for thromboembolism and hair growth, respectively. In most cases, breast engorgement resolves within 72 hours.

71. 5- Puerperal psychosis typically develops A) During the first month after delivery B) 3 to 4 months after delivery C) 6 to 12 months after delivery D) After the child has reached the age of 1 year

72. The answer is A. When trying to determine if the presence of a symptom is a sign of depression or a normal postpartum reaction, the physician should consider the circumstances. Loss of energy and diminished concentration are frequently the result of sleep deprivation. However, for a postpartum woman to have no energy or to have such difficulty in concentrating that she frequently loses her train of thought or has considerable difficulty in making decisions is cause for concern. Determining how much time has elapsed since delivery helps the physician to distinguish Psychotic Major Depression (PMD) from subclinical mood fluctuations, which occur with such frequency during the first 2 weeks after delivery that they are considered part of the normal postpartum experience. Postpartum blues refer to a transient condition characterized by mild, and often rapid, mood swings from elation to sadness, irritability, anxiety, decreased concentration, insomnia, tearfulness, and crying spells. Forty percent to 80% of postpartum women develop these mood changes, generally within 2 to 3 days of delivery, with symptom peak on the fifth postpartum day and resolution of symptoms within 2 weeks. Women who experience them have an increased risk for PMD later in the postpartum period, especially if the blues symptoms were severe. Subclinical mood swings in either direction (high vs. low) after delivery are an indication for more intensive follow-up later in the postpartum period, and clinician are encouraged to screen for PMD and related symptoms at the first postpartum follow-up visit or at least by 6 weeks postpartum. Finally, PMD must be distinguished from puerperal psychosis. Most puerperal psychoses have their onset within the first month of delivery and are related to mania. An inability to sleep for several nights, agitation, expansive or irritable mood, and avoidance of the infant are early warning signs that herald the onset of puerperal psychosis. Because the woman is at risk of harming herself or her baby (or both), postpartum psychosis is a medical emergency. Most patients with puerperal psychosis are treated in a hospital with neuroleptic agents and mood stabilizers. Before a definitive diagnosis of PMD is made, depression caused by a medical condition such as thyroid dysfunction or anemia must be ruled out.

73. 6- A 27-year-old gravida 2, para 2 woman is now 6 months postpartum and complains of excessive hair loss. The most likely diagnosis is A) Alopecia areata B) Telogen effluvium C) Trichotillomania D) Tinea capitis E) Hypothyroidism

74. The answer is B.

75. 7- Which of the following statements about breast-feeding is true? A) The infant should feed on each side for 8 to 15 minutes every 2 to 3 hours after birth. B) Colostrum is excreted 7 to 10 days after delivery and contains important antibodies, high calories, and other nutrients. C) The mother should weigh infants before and after feeding to quantify the amount consumed. D) Breast-feeding usually provides adequate nutrition for 2 to 4 months; supplementation should begin at that point. E) Breast-feeding should be based on timed intervals rather than on demand.

76. The answer is A. Breast-feeding is encouraged for all mothers. Currently, as many as 50% of mothers (especially those in higher socioeconomic groups) breast-feed. In most cases, the infant should feed at each breast for 8 to 15 minutes every 2 to 3 hours after birth and can be started immediately after delivery. Colostrum, a yellowish fluid excreted from the breast immediately after delivery, contains important antibodies, high calories, and high proteins, as well as other nutrients and helps stimulate the passage of meconium. Some studies have shown that delaying breastfeeding, trying to quantify amounts of feeding with prefeed and postfeed weights, and providing infant formula decrease the percentage of women who breast-feed by discouraging the practice. Breast-feeding is usually adequate nutrition for 6 to 9 months. If mothers develop sore nipples, they should be counseled with regard to proper positioning of the baby’s mouth on the breast. The production of a lubricant from Montgomery’s glands occurs and helps protect the breast from excessive drying. Typically, breast-fed infants require more frequent feedings than bottle-fed infants. Breast-feeding should occur based on demand rather than by the clock. Breast engorgement can be avoided with more frequent feedings or manual expression of excessive milk production with breast pumps. New mothers should initiate breast-feeding as soon as possible after giving birth. When mothers initiate breast-feeding within one-half hour of birth, the baby’s suckling reflex is strongest, and the baby is more alert. Early breast-feeding is associated with fewer nighttime feeding problems and better mother infant communication. Babies who are put to breast earlier have been shown to have higher core temperatures and less temperature instability.

77. 8- Which of the following drugs is concentrated in breast milk and should be avoided by women who are breast-feeding? A) Heparin B) Alcohol C) Digoxin D) Penicillin E) Amitriptyline

78. The answer is B. Medications that are classified as weak bases are usually concentrated in breast milk. Contraindicated drugs include anticancer drugs, therapeutic doses of radiopharmaceuticals, ergot and its derivatives (e.g., methysergide ), lithium, chloramphenicol, atropine, thiouracil , iodides, and mercurials . These drugs should not be used in nursing mothers, or nursing should be stopped if any of these drugs is essential. Other drugs to be avoided in the absence of studies on their excretion in breast milk are those with long half-lives, those that are potent toxins to the bone marrow, and those given in high doses long term. However, drugs that are so poorly absorbed orally that they are given (to the mother) parenterally pose no threat to the infant, who would receive the drug orally but not absorb it. Nicotine and alcohol are concentrated in breast milk and should be avoided by mothers who are breast-feeding. Other drugs, including heparin, acetaminophen, insulin, diuretics, digoxin, β- blockers, penicillins , cephalosporins , most over-the-counter cold remedies, amitriptyline, codeine, and ibuprofen, do not show up in significant amounts in breast milk . Some oral contraceptives can depress lactation (particularly large-dose, estradiolcontaining birth control pills), but in most cases are considered safe.

79. 9- Which of the following statements is true regarding breast-feeding and nipple confusion? A) The World Health Organization recommends avoiding the use of pacifiers or bottle-feeding to establish successful breast-feeding. B) There is compelling evidence that pacifier use and bottle-feeding are detrimental to successful breast-feeding. C) Early pacifier use is associated with increased breast-feeding at 1 month. D) Supplementation with a cup or bottle increases the duration of breastfeeding. E) Cup feeding was associated with a shorter duration of breast-feeding in comparison with bottle-feeding in mothers who had cesarean sections.

80. The answer is A. The UNICEF/World Health Organization Baby Friendly Hospital Initiative recommends avoiding the use of pacifiers or bottlefeeding to ensure successful breast-feeding; however, the evidence supporting this recommendation is limited. Cup feeding has been advocated as a safe alternative to bottle-feeding in breast-fed infants who require supplemental feedings to prevent “nipple confusion” or future problems with breast-feeding. Researchers conclude that early pacifier introduction is associated with fewer mothers exclusively breast-feeding at 1 month and decreased overall breast-feeding duration when compared with later pacifier introduction. Supplementation by cup or bottle led to a decrease in overall breast-feeding duration compared with infants receiving no supplementation. In mothers who had cesarean delivery, cup feeding was significantly associated with higher rates of exclusive breast-feeding and overall duration of breast-feeding compared with bottle-feeding.

81. 10- A 1-week-old is diagnosed with breast milk jaundice. You should instruct the mother to A) Maintain breast pumping and switch the child to formula feeding and monitor bilirubin levels B) Stop breast-feeding and start phototherapy C) Continue breast-feeding and start phototherapy D) Schedule an exchange transfusion E) Avoid any future breast-feeding and switch to formula feeding

82. The answer is A. Breast milk jaundice usually peaks in the 6th to 14 th days of life. This late-onset jaundice may develop in up to one-third of healthy breast-fed infants. Total serum bilirubin levels vary from 12 to 20 mg/dL (340 μmol/L) and are not considered pathologic. The underlying cause of breast milk jaundice is not entirely known. Substances in maternal milk, such as β-glucuronidases, and nonesterified fatty acids may inhibit normal bilirubin metabolism. The bilirubin level usually decreases continually after the infant is 2 weeks old, but it may remain persistently elevated for 1 to 3 months. If the diagnosis of breast milk jaundice is in doubt or the total serum bilirubin level becomes markedly elevated, breastfeeding may be temporarily interrupted, although the mother should continue to express breast milk to maintain production. With formula substitution, the total serum bilirubin level should decline rapidly over 48 hours (at a rate of 3 mg/dL [51 μmol/L]/day), confirming the diagnosis. Breast-feeding may then be resumed.

83. 11- Substances that are contraindicated during breast-feeding include all of the following except A) Alcohol B) Tetracycline C) Penicillin D) Ciprofloxacin E) Bromocriptine

84. The answer is C. Certain medications are contraindicated during breastfeeding, including quinolone antibiotics, tetracycline, chloramphenicol, bromocriptine, cyclosporine, cyclophosphamide, doxo-rubicin , methotrexate, lithium, and ergotamine . Other drugs that have relative contraindications include metronidazole, sulfonamides, salicylates, phenobarbital, other psychotropic medication, and antihistamines . Caffeine in large amounts should also be avoided. In addition, recreational drugs (e.g., alcohol, cocaine, marijuana) should be avoided.

85. Sources

86. x