Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

obstetrics > 9. Normal puerperium. Immediate care for the mother. > Flashcards

9. Normal puerperium. Immediate care for the mother. Flashcards

1
Q

what is puerperium ?

A

the period of about six weeks after childbirth during which the mother’s reproductive organs return to their original non-pregnant condition.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

what are the stages of puerperium ?

A

there are three stages :

acute/ immediate - first 24 hours

subacute/ early - unto a week

and remote - unto 6 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

in puerperium what are the major organs and their morphology we look out for ?

A

uterus
vagina
cervix

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

clinical involution of the uterus

A

following delivery, the uterus becomes firm and retract with alternate hardening and softening

=====

after delivery the uterus measures 20cm vertically and 10 cm , anteroposteriorly
7.5cm3 thickness
and weight about 1000g

======
normal involution takes 6 weeks
One hour after delivery the fundus of the uterus lies At the umbilicus
or 13.5 cm above symphysis pubis for the first 24 hours following delivery then steady decrease in 1.25cm in the next 24 hours.

day 14 should not become palpable

endometrium starts regeneration on day 7 - It occurs from the epithelium of the uterine gland mouths and interglandular stromal cells. Regeneration of the epithelium is completed by 10th day and the entire endometrium is restored by the day 16, except at the placental site where it takes about 6 weeks.

the uterine by the end of 6 weeks should be 60 g

and uterine involution is usually complete by 6-8 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

what is the involution of vagina ?

A

Broad ligaments and round ligaments require considerable time.

6–10 weeks to involute
mucosa remains delicate for the first few weeks and submucous venous congestion persists even longer.

Rugae partially reappear at 3rd week but never to the same degree as in prepregnant state.

assessment of vaginal discharge

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

characteristic changes of the vaginal discharge after delivery ?

A

vaginal discharge of first night - offensive fishy smell

========

lochia - vaginal discharge after giving birth

lochi rubra = 1-4 days ,

discharge of blood , fetal membranes , decidual remnants , meconium , vernix caseoa , lanugo

=====

lochi serosa = 5-9 days
yellowish or pink or pale brownish

more leukocytes than rbc,
mucus from cervix , wound exudates ,
micro-organisms
decidua

=====

lochi alba = 10-15 days

lots of decidual
cells ,
leukocytes , mucus ,
cholestrin crystals , fatty epithelial cells , microorganisms

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

because of the vaginal discharge women are advised to wear what ?

A

pampers

normal duration of lochis may extend up to 3 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

women who deliver vaginally should also do what type of excersies

A

kegel exercises

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

if there is a malodour in the vaginal discharge what does this suggest ?

A

infection such as ecoli

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

what is the clinical significance if the discharge is scant or absent?

A

infection

lochiostasis where the lochia is retained in the uterus and result in lochiometra - distension of the uterus pushing it out of shape

following premature labor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

what is the clinical significance if there is excessive lochia?

A

indicate infection

or hydramnios

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

what is the clinical significance if red colour in lochia persist

A

sub involution at placenta sight - inadequate closure and sloughing of spiral arteries

or
retained products of conception

these two lead to
secondary PPH (other causes uterine infection
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

divisions for the immediate care for mother after delivery

A

Secondary PPH/bleeding

RESPIRATORY FUNCTION

Cardiovascular function

haematological study

BOWEL function - constipation

Lactation

Psychiatric disorders

temperature

urinary tract

weight loss

menstruation

ovulation

rest and early ambulation

diet - lactating - high calorie and protein and fat

immunisation anti-d- gamma globulin

maternal infant bonding

postnatal exercises

to prevent infection - hygiene of bladder , vulva , care of epistomy wound

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

what are the changes to the urinary tract and how is it clinically important ?

A

pronounced diuresis 2,3rd day,

over distension of bladder
incomplete emptying leading to
urinary stasis in the ureters and bladder (observed even up to 12 weeks postpartum.)
Glomerular filtration
Dilated ureters and renal pelvis return to normal size within 8 weeks

== all leading to high risk of urinary infections

to asses there is no urinary tract infection clean catch of mis stream urine need to be collected and cultured without the presence of lochia

======
causes are —
 (1) unaccustomed position 
(2) pain from the perineal injuries.
An increase in progesterone level, which inhibits the bladder muscle and leads to urinary retention.

If the patient still fails to pass urine,
physically moving around
analgesia
catheterization also indicated in case of incomplete emptying of the bladder evidenced by the presence of residual urine of more than 60 mL.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what are the cardiovascular changes ? and clinical significance ?

A

immediate reduction in blood volume after birth

consequently rise in CO according through out 1st week
blood pressure rises in first 48 hours

all return to normal in two weeks

clinical significance
post partum eclampsia
give nifedipine
review after 2 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

when does menstruation resume ?

A

if not breast fed resumes in 12 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

when does ovulation resume ?

A

non lactating mother - as early as 4 weeks

lactating - 10 weeks

exclusive breastfeeding - 98 percent contraception up to 6 months

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

how does lactation provide contraceptive and amenorrhea ?

A

high release of prolactin inhibit the release of gonadotropin - FSH -hypoestrogenic state and therefore no menstruation

prolactin suppress LH = an ovulation

exclusively breast feed - contraception for 6 months post partum

Nonlactating mother should use contraceptive measures in 3rd postpartum week and the lactating mother in 3rd postpartum month

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

what are the temp changes?

A

should not be above 37.2°C (99°F) within the first 24 hours

3rd day, there may be slight rise of temperature due to breast engorgement which should not last for more than 24 hours

20
Q

what is a complication in acute phase after delivery

A

POSTPARTAL BLEEDING

21
Q

what are the subacute diseases in puerperium ?

A

increased risk of DVT- particularly women with c cessation

Anticogaulants may be prescribed or physical activity

======

postpartum infections = puerperal pyrexia

=====

urinary tract infections

urinary incontinence

=====

postpartum depression

or postraumatic stress disorder
due to all hormonal changes

====

puerperal mastitis

22
Q

why breast feeding should be recommenced as care for the mother ?

A

gives passive immunity - igA

breast feeding accelerates the involution of the uterus - because suckling and contact with the mother and child releases oxytocin - thereby causing increased uterine contractions

breast feeding has also shown to reduce breast cancer in women

weight reduction

essential amino acids delivered from the mothers milk
source of omega 3 fatty acid - which is important for brain development

====

first few days is colostrum - high in protein immunological - igaA, G.M , lactoferrin , complements
lower carbohydrate, fat and potassium than the breast milk

======

after 3-4 days replaced by mature breast milk - high in fat then carbs and low in protein

23
Q

what are the two mechanisms important in lactation ?

A

milk secretion actually starts on
3rd or 4th postpartum day even though prolactin is high during pregnancy

it is only when there is drop in placental hormones esp oestrogen and progesterone prolactin from anterior pituitary gland (lh , fsh) becomes effective in lactogeneisis

Prolactin, glucocorticoids are the important hormones. Including growth hormone, thyroxine and insulin.

second suckling - release oxytocin from posterior pituitary gland - oxytocin causes contraction of the myoepithelial cells cells in the alveoli of milk ducts milk is forced down into the ampulla of the lactiferous ducts, where from it can be expressed by the mother or sucked out by the baby.
Presence of the infant or infant’s cry can induce this without suckling.

====

Galactopoiesis:
maintenance

Prolactin single most important galactopoietic hormone.
ALSO equally important For maintenance is effective and continuous (>8/24 hours) is essential.

Distension of the alveoli by retained milk is due to failure of suckling. This causes decrease in milk secretion by the alveolar epithelium.

24
Q

how does post partum affect repsiratory changes ?

A

there is immediate reduction in intrabdominal pressure

and the chest wall compliance returns to normal with the with the relief of diaphragmatic pressure

they all return to normal after 1-3 weeks postpartum - mother can feel dyspnea

25
Q

there can be perineal complication because?

A

discomfort infected episiotomy

26
Q

what are the bowl complications?

A

constipatin - can be due to progesterone decreasing the bowel movements

fecal incontinece due to 3rd -4th degree tear

27
Q

haematological changes and their clinical significance

A

RBC volume and hematocrit values returns to normal by 8 weeks postpartum

leukocytosis

increase in plates and adhesiveness between them -4-10 days postpartum- esp c section
fibrinogen high till 2 weeks postpartum

= hypercoaguble state = 48 hrs postpartum

and
fibirnolytic activity enhanced first 4 days postpartum = protective

high risk for thromboembolism
in first week

28
Q

what are the psychiatric disorders ?

A

depression due to hormonal changes

29
Q

puerperium of cervix regained in ?

A

the external os admits two fingers for a few days but by the end of 1st week, narrows down to admit the tip of a finger only

6 weeks = for contour to be regained

External os never reverts back to nulliparas

30
Q

describe closure of epstiotomy wound ?

A

begin by epithelial suture at the 5mm abve the apex ( the highest point of the epstiotmy) to take in any cotracted arteries
and continuous non locking sutures is put n first

then the dead space between the perineal muscles closed by intereputed suture - so there is no hematoma

if this is done propery then the perineal skin and is lying close to each ther and this is then zeaed again by continues subcuticular catgut suture

31
Q

describe the care for epstiotomy wound and vulva ??

A

Shortly after delivery, the vulva and buttocks are washed with soap water down over the anus and a sterile pad is applied

perineal wound should be dressed with spirit and antiseptic powder after each act of micturition and defecation or at least twice a day.

sitz baths,
ice pack

pain relief medications - ibuprofen

32
Q

if loch alba is beyond 3 weeks ?

A

lochia alba beyond 3 weeks suggests local genital lesion

33
Q

management of sub involution ?

A

Mere size of the uterus is not important , provided there is absence of features, such as excessive lochia or irregular bleeding or sepsis, the size of the uterus can be safely ignored.

Appropriate therapy is to be instituted only when subinvolution is found to be a mere sign of some local pathology:

(1) Antibiotics in endometritis,
(2) dilation and currtegae for retained products,
(3) Pessary in prolapse or retroversion.

Methergine, often prescribed to enhance the involution process, is of little value in prophylaxis.

34
Q

urinarY traCt infeCtion: It is one of the common causes of puerperal pyrexia, what is the cause ?

A

effect of frequent catheterization, either during labor or in early puerperium to relieve retention of urine,

(b) stasis of urine

35
Q

organism reposnisble for urinary tract infection

A

E. coli, Klebsiella, Proteus and S. aureus

36
Q

what is puerperal pyrexia ?

A

A rise of temperature reaching 38°C

on two separate occasions 24 hours apart within first 10 days following delivery

37
Q

what are the leading cause of puerperal pyrexia?

A

puerperal sepsis - infection of the genital tract occurring as a complication of delivery

urinary tract infections - cysts pyelonephritis

mastitis or breast abcess

38
Q

what causes puerperal sepsis?

A

due to

endometritis , endomyometritis and endoparametritis = pelvic cellulitis if all affected

due to

intrapartum -
repeated vaginal examination ,

dehydration and ketoacidosis during labour

traumatic vaginal delivery ,

hemorrhage ,

retained placenta , tissue or membrane

prolonged labour

======

antepartum - PROM ,

39
Q

what are the sites where the bacteria colonise to get an infection ?

A

damaged cervicovaginal mucous membrane

open wound where the decidua cleaves when the placenta detaches

blood clot at placental site - excellent site for bacteria growth

40
Q

what are the microorganism which causes puerperal sepsis ?

A

aerobic :
* group a , beta hemolytic strep

  • staphylococcus aureus
  • ecoli

klebsiella

pseudomonas

proteus

chlamydia

anaerobic :
*ANEROBIC STREPTOCCCUS (MOST PREDOMINANT) bacteroides (fragilis)
clostridia ,
mobiluncus , peptococcus

mixture of aerobic and aerobic usually causes the puerperal sepsis

41
Q

what are the clinical features of puerperal infection ?

A

if local
rise of temp
malaise
iflammatory signs of local wound - pain

uterine

mild
rise in temp 
rise in pulse 
offensive smelling , copious discharge 
sub involuted uterus and tender

severe - acute onset with rise of temp and chills
rapid pulse
dysuria , dyspareunia
scanty and odourless loch (group a beta haemolytic strep)
sub involuted uterus , tender

42
Q

what are the complications of puerperal sepsis ?

A

pelvic cellulitis - lymphatic or hematogenous route

peritonits - usually c section - dehiscence and incision wound
or spread of infection from the tubules
lymphatic
RARELY generalised peritonitis

salpingitis -
interstitial most common - lymphatic spread
or perisalpingitis

pelvic abcess following pelvic peritonitis

SEPTIC PELVIC THROMBOPHLEBITIS - ovarian vein , uterine vein , pelvic vein
= commonly anaerobic

septic shock
streptococci - streptococcal tocix shock syndrome
or
aerobic strep

necrotising fasciitis - rare but fatal - muscle and fascia involved
diabetets , hypertension are risk factors
cause group a beta hemolytic strep

43
Q

what are the outcomes of septic pelvic thrombophlebitis ?

A

complete resolution or suppuration

44
Q

what are the clinical features of the complication of puerperal sepsis ?

A

parametritis or pelvic cellulitis - tissue inflammation adjacent to uterus esp broad lig

usually 7-10th day of puerperium

constant pelvic pain

vaginal examination
UNILATERAL ,hard tender mass pushing the uterus to one site

rectal examination confirm the indurationesp extending along uterosacral lig

rise in temp

========

pelvic peritonitis - high temp
high pulse
abdominal pain and tenderness ,
muscle guarding may be absent unlesss generalised

vaginal examination - tender fornix with movement of cervix

if pus reach the pouch of douglas - swinging temp , diarrhea ,, bulging fluctuant mass through posterioir fornix

45
Q

what is the diagnosis and treatment of puerperal pyrexia ?

A

high vaginal and endocervical swabs for culture

clean catch midstream of urine and culture

blood - cup and leukocytosis

blood culture is fever associated with CHILLS AND RIGOR - septicaemia

pelvic ultrasound

CT or MRI

====

prophylaxis

prophylactic antibiotic at time of c section
aseptic working conditions atleast 1 week after delivery
reduce any vaginal examination

treatmnet
isolate the patient
empiric - gentamicin and clindamycin , metronidazole iv empiric

if severe sepsis - piperacillin tazobactum,
or
carbapenem pls clindamycin

MRSA 0 vancomycin and teicoplanin

septic pelvic thrombophlebitis - iv heparin

pelvic abcess - drainage under ultrasound guidance

perineal wound - drainage of pus
SITZ BATH cleavage of wound
dressing with antiseptic ointment or powder

wound dehiscence through eptisotomy or c section = scrubbing wound nice daily
debridement
closing wound with secondary suture

laparotomy last case when unresponsive peritonitis ,

necrotising fasciitis - rehydration , wound scrubbing , debridement his dose broad spectrum antibiotics

septic shock - 
rehydration 
high dose antibiotics 
cardiopulmonary support 
hemodilaysis

obstetrics (44 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions