Common postnatal problems

Question 1

What is the puerperium?

Answer 1

6 week period following delivery, as body returns to pre-pregnant state
Maternal morbidity and mortality highest in this period

Question 2

What physiological changes occur to the genital tract in the puerperium?

Answer 2

Uterine contraction as soon as placenta separates (myometrium criss-cross fibres occlude blood vessels formerly supplying placenta)
Uterus reduces in size over 6w (no longer abdominally palpable after 10d
Contractions/after pains may be felt up to 4d
Internal os closed by 3d
Lochia blood stained for 4w, then yellow/white
Menstruation delayed by lactation, but occurs around 6w if not feeding/expressing

Question 3

What physiological changes occur to the CVS system after delivery?

Answer 3

CO and plasma volume decrease to normal with 1w
Loss of oedema can take up to 6w
If transient elevation, BP normal within 6w

Question 4

What physiological changes occur to the urinary tract after delivery?

Answer 4

Physiological dilatation of pregnancy reduces over 3m and GFR decreases

Question 5

What physiological changes occur to the blood after delivery?

Answer 5

U&E returns no normal because of reduction in eGFR
Hb and hct rise with haemoconcentration (unless haemorrhage occurs)
WBC falls
Platelets/clotting factors rise (predisposing to thrombosis)

Question 6

What should be done for women in puerperium?

Answer 6

General postnatal care
Thromboprophylaxis
Monitor sats
Assess uterine involution
Check PV/discharge/lochia
If Rh negative, give anti-D
Teach pelvic floor exercises
Discuss contraception
Check Hb on d1 or d7 (d2-6 haemodilution occurs)

Question 7

What might suggest endometritis or retained products?

Answer 7

Persistent red lochia
Failure of uterus to involute
PPH

Question 8

Should a woman be checked if she is immune to rubella?

Answer 8

Yes, and if not, vaccinate (simultaneously but in different limb to anti-D; if not possible, wait 3m between vaccinations)

Question 9

How is superficial thrombophlebitis managed?

Answer 9

Presents as painful tender (usually varicose) vein
Give NSAID (e.g. ibuprofen 400mg/8hrs PO)
Use TED stockings
Recovery usually within 4d
Rule out DVT

Question 10

How many women are affected by DVT/PE after delivery?

Answer 10

1 in 200 (half of deaths postnatally, usually after discharge)

Question 11

How is a DVT/PE managed?

Answer 11

Early mobility and hydration

Prevention with anti-coagulation

Question 12

What hypertensive disorders may affect puerperal women?

Answer 12

Pre-eclampsia (most deaths occur postpartum)
Although delivery is cure, symptoms do not subside for up to 24hrs postpartum
BP may take 4-5 days to peak, may need treatment for weeks
In pre-eclamptic patients, pay attention to fluid balance, renal function, urine output, BP and possibility of hepatic/cardiac failure
Continue measuring BP for 5d postnatally

Question 13

What bowel problems are often seen after delivery?

Answer 13

Constipation and haemorrhoids (20%); laxatives helpful
Incontinence (faeces/flatus), 4%, transient from sphincter/pudendal nerve damage (RFs = forceps, large baby, shoulder dystocia, persistent OP positions)
-Evaluation by manometry and USS
-Managed according to symptoms (formal repair may be required and future deliveries may be via CS)
-Exclude rectovaginal fistula

Question 14

When is perineal trauma repaired?

Answer 14

After placental delivery

Question 15

How long will pain from perineal trauma persist?

Answer 15

Resolved by 8w in 90%
Superficial dyspareunia common
Pain reduced if subcuticular Vicryl sutures used
NSAIDs best for analgesia
No benefit for USS, salt baths and Megapulse

Question 16

What is paravaginal haematoma?

Answer 16

Extreme pain in perineum several hrs after delivery
Usually only identifiable on PV exam
Drained under anaesthetic