Disorders post-partum

Question 1

What is the puerperium?

Answer 1

from the delivery of the placenta to six weeks post birth

Question 2

What changes happen to the woman in the puerperium?

Answer 2

Involution of the uterus (uterus contracts down fully and is felt at the level of the umbilicus) and GU tract
Muscle- ischaemia, autolysis and phagocytosis to return to normal thickness
Endocrine Changes- Profound decrease in serum levels of placental hormones (human placental lactogen, hcg, oestrogen and progesterone), Increase of prolactin
The decidua is shed as lochia: rubra, serosa and alba

Question 3

Describe the lochia rubra, serosa and alba

Answer 3

rubra (day 0-4) contains blood, decidua, fetal membrane, meconium (fetal stool) and vernix waxy stuff that covers baby post birth)

serosa (day 4-10) contains mucus, exudate, WBC and micro-organisms

alba (day 10-28) contains cholestrol, fat, micro-organisms, leukocytes and epithelial cells.

Question 4

Describe the physiology of breast feeding

Answer 4

At birth the woman produces colostrum from her breast which contains antibodies and growth factors but has less carb, lipids and K+ than mature milk.
Lactogenesis II starts once pregnancy hormones decrease
Lactoferrin is present in breast milk and has antibacterial properties.

Question 5

What hormones are in control of breastfeeding?

Answer 5

prolactin -milk production

oxytocin- milk ejection

Question 6

What is the difference between sepsis, spetic shock and severe sepsis?

Answer 6

Sepsis= infection plus systemic manifestations of infection
Severe sepsis= sepsis plus organ dysfunction/ low tissue perfusion
Septic shock= hypoperfusion continues despite fluid replacement

Question 7

What are risk factors for sepsis?

Answer 7

obesity, DM, aneamia, amniocentesis, prolonged SROM, trauma

Question 8

What are causes for sepsis?

Answer 8

Infections such as endometritis, UTI, mastitis, pneumonia, gastroenteritis, epidural related

Question 9

What are two mneumonics for sepsis?

Answer 9

BUFALO (plus 2 in obstetrics) and 3 Teas with White Sugar

Question 10

Explain 3 Teas with White Sugar

Answer 10

3Ts = temperature(<36 or >38), tachycardia (HR >90), tachypnoea (RR >20)

White= raised WCC

Sugar= hyperglycaemia

Question 11

Explain BUFALO

Answer 11

• Bloods cultures ( also so FBC, U+Es, LFTs, clotting, glucose, crp, ABG)
• Urine output
• Fluid Resuscitation (bolus of Hartmann’s or saline)
• Antibiotics (broad spectrum)
• Lactate (>2 is serious)
• Oxygen

Plus 2 = delivery and VTE prophylaxis

Question 12

What is primary post-partum haemorrhage?

Answer 12

> 500ml loss post birth

Question 13

What is the difference between minor and major post-partum haemorrhage?

Answer 13

Minor- <1500mls

Major-1500mls +

Question 14

What is secondary post-partum haemorrhage?

Answer 14

Secondary= excess bleeding between 24hrs and 12 weeks postpartum

Question 15

What are the causes of PPH?

Answer 15

Endometritis, retained products of conception, subinvolution of the placental implantation site (delayed closure and sloughing of the spiral arteries at the placental site), atonia, blood disorders, trauma eg baby big or c-section, Av malformations

Question 16

What are the investigations for PPH?

Answer 16

Bacteriology screen or U/S for retaine dproducts can be done but main focus is on management

Question 17

What are the risk factors for VTE?

Answer 17

Risk increases with age of gestation- reaches height post-birth

Other risks: age, weight, parity of 3+, smoking, c-section, Fhx, varicose veins, pre-eclampsia, infection, immobile, stillbirth, PPH, 24 hour+ labour, premature, thrombophilia, antithrombin deficiency, surgery in the puerperium.

Question 18

What is the leading cause of maternal death?

Answer 18

VTE

Question 19

How many risk factors do you need for VTE prophylaxis?

Answer 19

two

Question 20

What is used for prophylaxis of VTE?

Answer 20

LMWH

Question 21

What can happen post epidural?

Answer 21

Post-Dural puncture headache due to CSF leak leading to decrease in pressure

Question 22

What type of headache is a post epidural one and what are the other associated symptoms?

Answer 22

headache which increases with sitting and standing, neck stiffness, photophobia

Question 23

What is the management of a post-dural headache?

Answer 23

Management: lie flat – which also relieves pain, analgesia, epidural blood patch (aim is that blood seals the hole in the dura and stops leakage of fluid), fluids, caffeine

Question 24

How soon after birth should a woman be able to micturate?

Answer 24

6 hours

Question 25

What are the risk factors for urinary retention post-birth?

Answer 25

epidural, prolonged labour, extensive laceration, forcep/ventouse use

Question 26

What mental health problems may affect the woman in the post-partum period?

Answer 26

post-partum depression, PTSD, post-partum psychosis

Question 27

What are the complications of post-partum mental health problems?

Answer 27

Women may delay or avoid future pregnancies
Request caesarean sections to avoid vaginal delivery
Avoidance of intimate physical relationships
Impact on breastfeeding
Poor bonding with baby

Question 28

What is homans sign?

Answer 28

discomfort behind the knee upon forced dorsiflexion of the foot - if positive sign of DVT

Question 29

What is the mx for a DVT if the wells score says one is likely vs if it doesnt?

Answer 29

likely: U/S — if cannot be carried out within 4 hours of being requested, D-dimer testing, interim therapeutic anticoagulation, US after 24 hrs offered instead
unlikely: D-dimer