Disorders of the Puerperium Flashcards
definition of puerperium
From the delivery of the placenta to six weeks following the birth
What hormonal changes occur in the pueperium?
hCG, oestrogen and progesterone, human placental lactogen decrease
prolactin increases
What happens to the uterus in the pueperium?
involution of the uterus by ischaemia, autolysis and phagocytosis
What happens to the decidua in the pueperium?
shed as lochia rubra, lochia serosa and lochia alba
endometrium regenerates
What is the lochia rubra made of?
blood
discharge
decidua
fetal membrane
What is the lochia serosa made of?
cervical mucus
WBCs
fetal membrane
What is the lochia alba made of?
cholesterol
fat
mucus
WBCs
What two hormones are involved in lactogenesis and what do they do?
Prolactin – milk production
Oxytocin – Milk ejection reflex
What does the colostrum contain?
protein
vitamin A
growth factors - stimulate development of the gut
antimicrobial factors - passive immunity
lactoferrin - helps in iron absorption, reduces infection
Where is prolactin produced?
anterior pituitary gland
Where is oxytocin produced?
posterior pituitary gland
What are the health benefits of breastfeeding?
Mother
- reduced risk of breast cancer
Infant
- reduced GI disease
- reduced resp disease
- reduced otitis media
- necrotising enterocolitis
List some relatively minor postnatal problems
infection PPH mastitis baby blues stress incontinence
list some major postnatal problems
sepsis severe PPH pre-eclapsia/eclampsia thrombosis uterine prolapse post dural puncture headache breast abscess depression/psychosis
who is normally involved in post natal care?
midwives
breast feeding support workers
nursery nurses
doulas - provide emotional support and information to pts during antenatal and post natal periods
What is used to record observations in the post-partum period?
MEOWS
Modified early obstetric warning score
what are the risk factors for obs sepsis?
obesity diabetes prolonged SROM vaginal trauma or C-section ethnic minorities
What are the causes of obs sepsis?
Endometritis Skin and soft tissue infection Mastitis UTI Pneumonia Infection related to epidural/spinal
What are the signs of sepsis?
teperature tachycardia tachypnoea raised WCC hyperglycaemia
3 Ts white with sugar
What are the symptoms of obs sepsis?
PROM/offensive liquor Offensive lochia dysuria Headache + neck stiffness Cellulitis/wound infection D and V Breast redness or pain Cough, sputum, chest pain Abdominal pain
How many red flag markers of sepsis do you need to start the sepsis 6?
one
what is the sepsis 6?
BUFALO plus 2 blood cultures urine output give fluids antibiotics IV within 1 hour lactate oxygen
consider delivery (evacuation of retained products of conception) and VTE prophylaxis
what amount of blood loss is considered post partum haemorrhage?
> 500 ml
Minor PPH - < 1500mls and no clinical signs of shock
Major PPH - ≥ 1500mls and continuing to bleed OR clinical shock
what is secondary PPH?
abnormal/XS bleeding from birth canal 24hrs-6 weeks post natally
What are the causes of secondary PPH?
endometritis
retained products of conception
subinvolution of the placental implantation site = delayed closure of the spiral arteries
What investigations would you do for secondary PPH?
Assess blood loss
Assess haemodynamic status eg BP
Bacteriological testing (HVS and endocervical swab)
Pelvic ultrasound
is VTE risk higher antepartum or post-partum
much higher post-partum up to 6 weeks after delivery
who is high risk for post natal DVT and what is done about this post-natally
high risk if:
- previous VTE
- antental LMWH
- thrombophilia
- low risk and FH
give 6 weeks LMWH post-partum
what would you do if someone was high, intermediate or low risk to avoid VTE post-partum?
HIGH
- give 6 weeks LMWH post-partum
INTERMEDIATE
- 10 days LMWH
LOW
- early mobilisation and avoid dehydration
what is a post dural puncture headache?
puncture of the dura when entering the epidural space
leakage of CSF and reduced pressure around the brain
What are the symptoms of a post dural puncture headache
Headache worse on sitting or standing
Starts 1-7 days after spinal/epidural sited
Neck stiffness
Dislike of bright lights
How do you treat a post dural puncture headache?
Lying flat!
Simple analgesia
Fluids and caffeine - incrases CSF pressure to relive the headache from the leak
Epidural blood patch
what are the symptoms of urianry retention after delivery?
having not urinated for 6 hours after delivery
aching or achless inability to empty bladder completely
What are the risk factors for urinary retention after delivery?
epidural analgesia
prolonged second stage of labour
forceps of ventouse
perineal tears
What proportion of mothers will get post-natal depression?
10%
what are the risk factors for post-natal psychosis?
- family history of mental health problems, particularly postpartum psychosis.
- a diagnosis of bipolar disorder.
- traumatic birth or pregnancy.
define maternal death
The death of a woman while pregnant or within 42days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.
what are the causes of maternal death
PPH Sepsis suicide pre-eclampsia VTE death from pre-existing disease or disease that devloped in pregnancy eg heart disease
