Group sessions - Obstetrical case discussions Flashcards
Puerperium
Definition
Begins after delivery of the placenta and lasts until reproductive organs return to their pre-pregnant state
About 6 weeks
Outline some general physiological changes during puerperium
Uterus: rapid involution, return to pelvis by 2 weeks
Cervix: Cervical os gradually closes after delivery, barely more than 1cm dilated by 2 weeks
Lochia: 3-6 weeks flow, sloughed off necrotic decidual layer mixed with blood, initially red, then paler, then yellowish white discharge
Breast: Engorged between 2nd and 4th days
Other changes:
CVS: CO, ECF volume return to normal in ~1 week with fluid loss
- apparent ↑Hct, Hb, serum Na, HCO3 and plasma osmolality
clotting: note ↑clotting factors, fibrinogen, platelet count + fx in postpartum state
endocrine:
- rapid ↓estrogen, progesterone → pre-pregnant on day 7
- ↓hCG → pre-pregnant on day 10
- ↑PRL if breastfeed
List major causes of morbidity during puerperium
Secondary postpartum hemorrhage: any excess bleeding occurring between 24 hours and 6 weeks post-natally
Causes
- RPOG
- Endometritis (especially by iatrogenic causes)
- Genital tract tears
- Gestational trophoblastic disease
- AV malformation
Venous thromboembolism
- Increased incidence during puerperium
- Caused by venous stasis in lower limbs, pro-coagulative state during pregnancy
- Presents with low-grade fever, symptoms of PE and DVT
Puerpural pyrexia (Genital cause vs non-genital cause)
- Presence of fever in a mother >= 38 in the first 14 days after birth
- Most common cause of maternal mortality before induction of antibiotics
Pain:
- After-pains due to uterine contraction
- Perineal pain
- Urinary retention: after instrumental delivery, extensive tears, pain and edema, treat with catheterisation
- Constipation: increase water and fibre intake, stool softeners
- Pubic symphysis pain: worse on weight-bearing, resolve by 6-8 weeks
Mental health problem:
- Postpartum blues, postpartum depression, postpartum psychosis
Predisposing factors of puerperal pyrexia
Antepartum
- Anaemia
- Duration of membrane rupture
Intrapartum:
- Duration of labour
- Bacterial contamination during vaginal exam
- Instrumentation
- Trauma e.g. episiotomy, tears, C/S
- Haematoma
Predisposing factors of Uterine infection/ endometritis
Presenting symptoms
Predisposing factors:
- C-section
- Intrapartum chorioamnionitis
- Prolonged labour
- Multiple pelvic examinations
- Internal fetal monitoring
Symptoms:
- Fever
- Foul, profuse, bloody discharge
- Subinvolution of uterus
- Tender bulky uterus on abdominal exam
List genital and non-genital causes of puerperium pyrexia
Genital causes:
- Uterine infection
- Perineal wound infection (e.g. after episiotomy)
Non-genital causes:
- Breast: Mastitis, breast abscess
- Urinary tract infection (commonly E. coli, Proteus, Klebsiella): due to hypotonic bladder resulting in stasis and reflux of urine; catheterisation; birth trauma
- Respiratory: Atelectasis, Aspiration, Bacterial pnuemonia; highly associated with C-section
- Skin wound infection (esp. obese, DM, poor haemostasis after surgery)
- Venous thromboembolism
First line investigations of puerperal pyrexia
Basline bloods
Microbiological workup:
- For genital cause: Swab from cervix and vagina
- For non-genital cause: Blood culture, MSU, Wound swabs, CXR
General management of puerperal pyrexia
Supportive:
- Analgesics and anti-pyretics
- Wound care for wound infection
- Ice packs for pain from perineum or mastitis
Antibiotics
Surgical drainage of abscess
Puerperal psychiatric diseases
Symptoms
Screening
General treatment
Symptoms:
- Symptoms of depression: Sleep disturbance, anxiety, increased irritability, apathy…etc
- Post partum blues: brief period of emotional instability from 3 days after delivery to spontaneous resolve in 10 days
General treatment
- Psychotherapy/ Counselling by psychologist
- Anti-depressant
- Social worker help
Uterine involution
Mechansim
Timeline of involution
Mechanism:
- uterine smooth muscle cells diminish in size by enzymatic digestion of cytoplasm (i.e. autolysis)
- excess protein produced is absorbed into bloodstream and excreted in urine
Timeline of involution: 1FB/d, accelerated by breastfeeding (↑oxytocin)
- day 1: at umbilical level, ~1kg
- day 10-14: not palpable above symphysis, i.e. inside pelvis
- 6 weeks: non-pregnant size, ~100g
Causes of delay in involution of uterus
Delay of involution: no clinical significance if asymptomatic, otherwise consider
full bladder
loaded rectum
uterine infection
retained products of conception
fibroids
broad ligament hematoma
Management of subinvolution of uterus
Outline endometrial changes and lochia changes during puerperium
Lochia: contain RBCs, WBCs, epithelial cells and bacteria
- superficial layer of decidua become necrotic → sloughed off as lochia
- basal layer adjacent to myometrium is involved in regeneration of new endometrium → complete by 3rd week
Normal clinical evolution of lochia: 200-500mL in total over 1m
- day 1-5 (lochia rubra): red lochia, shedding of blood and decidua
- day 5-10 (lochia serosa): pinkish brown, watery lochia; less RBCs, more WBCs, wound discharge, cervical mucus as endometrium is formed
- day 10-28 (lochia alba): light brown to yellow lochia; decidual cells, WBCs, epithelial cells
- cessation: usu stop 2-4w normally, but can sometimes persist till return of menstruation
Physiology of return of ovulation and menstruation during puerperium
Return of ovulation:
- normal ovulation suppression: suppressed by high prolactin immediately postpartum
first ovulation: occur when PRL return to pre-pregnant level
- seldom occur <3w unless prolactin is suppressed, e.g. by drugs
- median 6w in non-lactating women
lactational amenorrhea: PRL remain high in lactating women
- suckling → ↑sensitivity to estrogen feedback → ↓pulsatile GnRH release → ↓FSH/LH
- generally much longer (up to 6m) but more variable
- note that 10% have ovulatory cycles while on BF, e.g. non-consistent feeding (milk formula supplementation), insufficient prolactin secretion
Return of menstruation: occur 2w after first ovulation, therefore
- earliest = 5w as earliest first ovulation = 3w
- median = 8w as median first ovulation = 6w
- variable and later (>6m) in lactating women
- Return of fertility: earliest first cycle but many first cycles will be subfertile
Approach to bleeding <5 weeks, post-partum amenorrhea and contraception use
Clinical implications:
- 2° PPH: ↑vaginal bleeding ≤5w is unlikely due to return of menses → should workup for causes
- postpartum amenorrhea: need not be investigated until 6m postpartum (if no BF) or 6m post-weaning (戒奶/斷奶) (whichever is later)
- contraception: even the first cycle can be fertile → needed before return of menses!
Investigations for uterine contractions and blood loss postpartum
- Timing
- Alarming features
Timing:
- after delivery of placenta (+ BP/P, temperature)
- after repair of episiotomy or tear
- 1 hour after delivery (+ BP/P, temperature)
- ± further measurements & observation Q30-60min if instrumental delivery, PPH or noted
- significant CVS condition
Alarming features
- excessive bleeding
- uterine atony
- pulse > 100
- SBP < 100
List all metrics measured in puerperal chart
Daily record in the subsequent days
first void after delivery: time, volume
pulse and temperature: BD
- Q4h if fever, inform doctor if HR>100, T>38°C
breast exam: daily
- breast: soft, medium, hard, lumpy ± pain
- nipple: good condition, sore, lacerated, cracked
fundal height: daily
- ensure bladder is emptied before measurement
- expressed in relation to umbilicus (i.e. NOT SFH)
lochia condition: daily (by inspection of pads)
- amount: profuse, moderate, scanty, absent
- color: red, pink, whitish
perineum condition: daily if laceration/episiotomy
Recommended interpregnancy interval
Options for contraceptives and suitability
Interpregnancy interval: counsel ≥24m by WHO, ≥6-18m by ACOG to ↓fetal/maternal morbidity
Timing: can be initiated immediately after delivery
Options:
- barrier method: good first choice
- COCP: deferred ≥21d post-partum due to risk of VTE, and can suppress lactation in BF
- progestin-only modalities: can be initiated any time postpartum
- IUD: safe even if immediately postpartum but generally a/w ↑expulsion rates in 40h-4d postpartum (relatively C/I)
Breast feeding and nipple care advice during puerperium
breastfeeding
- pumping may be used for premature infants on special care unit
- feed babies in respond to feeding cues
- offer both breasts on d1-2 for adequate breast stimulation
- stay on one breast each time after “milk comes in” in order to get hind milk
care for nipple soreness
- check baby’s position and attachment
- apply breastmilk to nipples and air-dry between feeds
- express engorged breast before feeds to soften areola for better feeding
