Labour & Delivery Flashcards
Labour is dependant on what 3 mechanical factors?
Power expelling the fetus (POWER)
Pelvis dimensions + resistance of soft tissues (PASSAGE)
Fetal head diameter (PASSENGER)
What structures allow for uterine contractions to push DOWNWARDS
How does the cervix become effaced/dilated?
What 2 factors can cause reduced uterine activity?
Cardinal + uterosacral ligaments = lower uterus attached to pelvis
Intermittent uterus contractions / fetal head pushing
Nulliparous + Induction
What are the 3 main planes of the pelvis and their rough diameters?
Inlet - 13cm transverse (x 11 AP)
Mid-Cavity - 11x11cm
Outlet - 12.5cm AP (x 11 transverse)
Describe the physiology behind cervical ‘ripening’
Prostaglandins → inhibit collagen synthesis / stimulate collagenase activity
Which 3 factors of the fetal head determines its ease through the pelvis?
Attitude (presentation)
Rotation
Size
What are the 2 fontanelles called?
Bregma (frontal/brow)
Occiput
How is diagnosis of labour confirmed?
Painful uterine contractions AND cervical effacement/dilation
OR
Painful uterine contractions AND show / rupture of membranes
Describe the mechanism of labour in 6 steps
- Oblong head enters inlets in OT (occipital-transverse) position
- The neck flexes / head descends / cervix dilates (measured by ischial spine station)
- Internal rotation in the mid-cavity to OA (occipito-anterior) position (in 5% rotates to OP) + shoulders enter inlet
- Head descends / delivered by extension of neck
- External rotation (transverse - L/R) so shoulders enter AP diameter
- Anterior then posterior shoulder delivered by lateral flexion
What 4 things are managed in the mother during the 1st/2nd stage of labour?
Fluid
Position
Analgesics
Observations
How is the fetus managed during the 1st/2nd stage of labour?
Intermittent auscultation / CTG
FBS if HR abnormal (only possible in 1st stage)
LSCS if fetal distress
How is progression of the 1st stage assessed and what 2 interventions can be done to augment it?
1st stage progression assessed by VE (cervical dilation)
If nulliparous / slow progression - augment with ARM ± Oxytocin
How is progression augmented in the 2nd stage?
At what stage would instrumental delivery be done?
Oxytocin if nulliparous ± station high
If not delivered after 1hr of pushing
What does the 1st stage consist of?
+ time periods/cervical dilation of Latent + Active phase
1st stage = labour Dx → full 10cm dilation
Latent = 3cm, several hrs
Active 1-2cm/hr, shouldn’t be >12hrs
What does the 2nd stage consist of?
What happens/time periods of Passive + Active Phase
2nd stage = full dilation → delivery
Passive = head to pelvic floor + maternal desire to push; few mins
Active = mother pushing, 20-40m (dep on parity)
What is the 3rd stage? / time period
What happens?
How is it managed (what does the midwife do)?
Delivery of placenta, approx. 15mins
Uterine contractions compress / shear away vessels
Blood loss approx. 500ml
Suprapubic pressure + gentle continuous traction on cord
What time frame classes the 3rd state as ‘retained placenta’?
What is the incidence of retained placenta
3rd stage >30mins
2.5% deliveries
What is the main complication of a retained placenta?
How is a retained placenta managed?
Partial separation → intrauterine blood loss
Oxytocin infusion via umbilical cord vv
If still retained + absence of bleeding for 1hr → manually remove (under GA/Spinal)
Define 1st - 4th degree tears
1st: skin only
2nd: perineal muscles
- a: <50% anal sphincter
- b: >50%
- c: internal anal sphincter involved
4th: anal sphincter + mucosa involved
How are 1st - 4th degree tears repairs
1st + 2nd → local anaesthetic + sutured
3rd/4rd repaired under spinal/epidural in theatre
What is the incidence of 3rd/4th degree tears?
What are the RFs? (3)
1-3% deliveries
RFs: large baby, nulliparous, forceps
What instances are episiotomies reserved for? (not routine practice)
Large tear likely
Fetal distress
Failure of head to pass perineum despite effort
What 5 factors determine the Bishops score
At what scores are interventions done?
Cervical dilation Cervical length Cervical consistency Cervical position (post/anterior) Station of head (relative to ischial spines)
Score ≥6 → Prostaglandins
Score <6 → ARM + Prostaglandins
What are the 3 methods of induction of labour?
Prostaglandins (insert suppository in posterior fornix)
→ 2 doses max (if 1st fails), min 6hrs b/wn
ARM (amniotomy(hook) ± oxytocin)
→ if no labour induced within 2hrs, IV oxytocin
Natural induction (cervical sweeping)
What are the fetal indications for induction? (5)
What are the materno-fetal indications? (2)
Prolonged pregnancy Suspected IUGR APH Poor ObHx Prelabour term rupture of membranes
Pre-Eclampsia
Maternal Diabetes
What are the absolute contraindications of IoL? (5)
What are the relative contraindications? (2)
Placenta praevia Acute fetal compromise Abnormal lie Pelvic obstruction (disproportion/mass) > 1 previous C-Section
Prematurity
1 previous C-Section
When is CTG required in IoL?
1hr CTG required 1h after induction method
Also required if oxytocin used
What are some complications of Induction of Labour (5)
Failed/slowed uterine activity → Instrumental/LSCS
Uterine hyperstimulation
Amniotomy can → umbilical cord prolapse
Increased risk of PPH
Increased risk of intrapartum/postpartum infection
What is the incidence of prolonged pregnancies?
6-10% pregnancies ≥42wks
How is maternal hypotension with an epidural managed?
IV fluids + ephedrine
What is pyrexia (>37.5) in labour usually due to?
When are Abx given?
Usually due to chorioamnionitis
Abx if >38 or if other risk factors for sepsis
What is uterine hyperactivity assoc w.?
How is it managed?
Too much oxytocin
SE of Prostaglandins
Placental Abruption
LSCS / IV salbutamol
What is recorded on the partogram? (5)
Progress of cervical dilation Progress of head descent Maternal Observations Fetal HR Liquor colour
What is the incidence of meconium staining of liquor in normal pregnancies? (+ in prolonged pregnancies)
Why can it sometimes suggest fetal compromise
How is it graded
15%
40% in ≥42wks
Related to parasymp relaxation of anal sphincter - poss due to hypoxia
Grade 1-3 depending on liquor content and meconium consistency (thicker = worse)
What may affect maternal supply to the placenta? (2)
Hyperstimulation
Spinal/epidural may → hypo perfusion of placenta
What may fetal hypoxia lead to intrapartum?
Peripheral vasoconstriction (blood → heart/brain) ACIDOSIS (from anaerobic)
What are some neonatal complications of prolonged vasoconstriction in fetal hypoxia?
Necrotising Enterocolitis
Acute Renal Failure
Resp Distress
What investigations can identify fetal hypoxia?
CTG/Fetal HR (increased baseline HR - high false +ve rate)
Fetal scalp sample
What are the indications for fetal scalp sampling? (4)
What cervical dilation to make scalp sampling possible?
Variable/Late/Prolonged decelerations on CTG
Signif meconium staining of liquor (Grade 2/3) PLUS CTG abnormal
Persistent fetal tachycardia
Prolonged loss of baseline variability
Cervix must be at least 2-3cm dilated
What are the contraindications for fetal scalp sampling? (5)
Risk of maternal infection transmission to baby
Fetal bleeding tendency
Placenta praevia
<34wks (don’t want to induce labour/want to delay)
Fetal membranes intact
How does pH reflect fetal status?
At what pH are interventions carried out? (and what done if borderline?)
pH = momentary
pH <7.20 → LSCS / instrumental
pH 7.20-7.25 → repeat at 30-60m
How does Base Excess reflect fetal status?
What is normal value for base excess + what value reflects metabolic acidosis
Reflects longer-term change
Normal = BE > -6
Metab acidosis = BE < -8
What interventions done if abnormal fetal blood sample?
if in 1st stage → LSCS
if in 2nd stage → Instrumental
What measures/investigations done to predict a long-term prognosis of fetal hypoxic injury? (4)
CTG (can represent time in hypoxia)
Apgar scores (immediate status - prolonged low suggestive)
Neonatal behaviour (maintenance of respiration / abnormal tone + reflexes / altered consciousness or seizures)
Neonatal brain imaging
What % of fetal hypoxic injuries are antenatally caused and what % caused in labour?
List some antenatal causes of fetal hypoxic injury (6)
90% antenatal, 10% in labour
Intrauterine infection IUGR Csomal / congenital abn Coagulation disorder APH Prematurity
List some RFs for Fetal Compromise (13)
Placental insufficiency (IUGR/Pre-Eclampsia/Abruption)
Cord Prolapse
Uterine rupture
Pre/post-maturity
Multiple Pregnancy
Oligohydramnios
Induction
Prolonged labour
Uterine hyperstimulation
Maternal Diabetes
Maternal hypotension (e.g. epidural)
Maternal pyrexia
Chorioamnionitis
What general measures are done if suspect fetal compromise? (3)
L lateral position
O2
CTG (if abnormal → VE to exclude malpresentation/prolapse and to assess progress)
What is the management of fetal compromise due to maternal hypotension?
+ due to maternal dehydration / ketosis
+ due to uterine hyperstimulation
Hypotension → fluid bolus
Dehydration/ketosis → IV fluids
Uterine hyperstim → stop syntocin infusion + start tocolytics (salbutamol, ritodrine)
What are some non-medical methods of pain relief in labour? (best for early labour) (5)
Antenatal class prep Back rubbing TENS machine Maintenance of mobility Water at body temp
What can overuse of Entonox (gas and air) lead to?
Light-headedness
Nausea
Hyperventilation
Which systemic opiates can be used in pregnancy? (+ how administered?) (2)
3 disadvantages of opiate use
Pethidine + Diamorphine IM
Require anti-emetics
More sedative than analgesic
Can cause resp depression in newborn (requiring naloxone reversal)
Which space is an epidural inserted into?
L3/4
Advantages of an epidural (2)
Disadvantages of an epidural (6)
Pain-free
Can help lower BP in hypertensives
Reduced bladder sensation (can → urinary retention)
Requires midwifery supervision (check obs)
Increased incidence of instrumental deliveries
Immobility (→ pressure sores)
Hypotension
Maternal fever
What are 2 serious possible complications of an epidural?
Spinal tap (puncture dura mater) → CSF leakage → severe headache (worse sitting up)
Local anaesthetic into spine → total spinal analgesia + respiratory paralysis
Where is the local anaesthetic inserted in a spinal?
When is a spinal done? (2)
Through dura mater into CSF b/wn L3/4
C-Sections + Mid-Cavity instrumentals
What anatomical location is a pudendal nerve block inserted into?
When is it used?
Bilaterally around pudendal nerve, near ischial spines
Low-Cavity instrumentals
Which type of instrumentals allow for delivery with correction of presentation (OP→OA)
Ventouse + Keillands (rotational) forceps
What are some maternal complications of forceps delivery? (3)
And fetal complications of forceps delivery? (3)
Vaginal laceration
3rd degree tear
Blood loss
Facial nerve damage
Scalp laceration
Skull/neck fractures
List 4 indications for instrumental delivery
Prolonged 2nd stage
Fetal distress
Prophylactic (avoid pushing in e.g. severe cardiac / hypertension)
Breech (forceps to after-coming head to control delivery)
What is the Caesarean section rate in developed countries?
20-30%
What cases would a rare Classical Caesarean section be carried out?
Multi-fibroids
Extreme prematurity
Transverse lie
Describe the anatomical incision of LSCS
Suprapubic transverse incision
Indications for emergency C-Section (2)
Prolonged 1st stage
Fetal distress
Elective C-sections carried out at what gestation?
What must be administered if earlier than this gestation?
39wks (maximise lung development)
<39wks → Steroids
List some absolute indications for C-Section (5)
List some relative indications for C-Section (6)
Placenta Praevia Severe antenatal fetal comprimise Uncorrectable abnormal lie Previous vertical (Classical) C-Section Gross pelvic deformity
Previous C-Section Breech Severe IUGR Twins Diabetes / other medical disease Older nulliparous women
What are the operative risks of a C-Section (5)
What is the risk for subsequent pregnancies after a C-section (2)
Haemorrhage (/need for transfusion) Wound / uterus infection Bladder / bowel damage Post-op pain/ immobility VTE
Increased incidence of placenta praevia
Risk uterine rupture
What is placenta accreta and placenta percreta?
How are they diagnosed
Accreta = Placenta implanted within myometrium Percreta = placenta implanted in surrounding structures (e.g. bladder)
What is the incidence of shoulder dystocia
What structure can shoulder dystocia lead to the damage of?
1/200
Can damage brachial plexus (→ Erb’s palsy)
What are the RFs for shoulder dystocia (6)
Large baby (>50% cases >4kg)
Diabetes
High maternal BMI
Short women
Previous shoulder dystocia
Instrumental delivery
How is shoulder dystocia managed in 90%?
How else may it be managed?
in 90% McRobert’s manouvre + suprapubic pressure works
in others, poss internal manoeuvres + episiotomy
What are the RFs for cord prolapse? (6)
Preterm Breech Abnormal lie Polyhydramnios Twins ARM
How is cord prolapse diagnosed?
Palpable cord vaginally
Fetal HR abnormal
How is cord prolapse managed? (3)
Push up + position all fours
Tocolytics
Emergency LSCS / Instrumental if cervix fully dilated + head low
What is the incidence rate of amniotic embolism?
And the mortality rate
1/50,000
Mortality rate 80%
What happens to the mother in amniotic embolism?
Anaphylaxis Sudden dyspnoea - Hypoxia / Pulm Oedema Seizures Hypotension / Cardiac arrest DIC/ARDS
What are the RFs for amniotic embolism? (3)
Caesarean
Termination
Strong contractions with polyhydramnios
What investigations can be done for amniotic embolism? (3)
Why is Dx not usually made until post-mortem?
ECG - shows RV strain
Coag abnormal
ABG shows reduced O2
Can be confused with other causes of maternal collapse
What are the management steps in amniotic embolism? (RIO FFADSI)
Resuscitation
Intubation
O2 100%
Fluids - restore circ vol FFP (fresh frozen plasma) - if fibrinogen low Acidosis correction Dopamine + Steroids - poss ITU transfer
List some causes for massive antepartum haemorrhage (6)
3 main ones:
Placenta praevia
Placental abruption
Undetermined origin
Genital tract pathology
Vasa praevia
Uterine rupture
How is massive APH managed?
Replace blood losses (to normovolaemia)
Stop bleeding if poss
Correct any coagulopathy (e.g. DIC)
Delivery
What are the 8 principle causes of maternal deaths?
Infection VTE Hypertensive disorders Cardiac disorders (e.g. VSD) Ectopic pregnancy and abortion Haemorrhage Neurological disorders Psychiatric disorders / suicide
What are the 5 principle causes of perinatal mortality?
Unexplained antepartum stillbirth IUGR Prematurity Congenital abnormalities Intrapartum hypoxia Antepartum haemorrhage
What proportion of multiple pregnancies are Dizygotic
What proportion of monozygotics are mono/dichorionic
2/3rds DZ (dichor/diamnio)
70% DZ monichorionic diamniotic
30% DZ dichorionic diamniotic
What 3 antenatal problems are commoner in multiple pregnancy?
Anaemia
Gestational Diabetes
Pre-Eclampsia
What further increases the risk of mortality / long-term handicap in multiple pregnancies? (3)
Preterm
IUGR
Monochorionic
List some complications of MC (monochorionic) twins (3)
Twin-twin transfusion syndrome
IUGR
Congenital abnormalities
What is the main cause of death in monoamniotic twins
V rare but cords entangle
What type of twins does Twin-Twin Transfusion Syndrome occur in?
(MZ) Monochorionic Diamniotic
List the complications of a multiple pregnancy
Multiple Pregnancy Is A Lot More Terrible And Painful
Mortality (perinatal) Preterm / miscarriage IUGR Abnormalities (congenital) Malpresentation Twin-Twin Transfusion Syndrome APH/PPH Pre-Eclampsia, Anaemia, DM
What is there increased risk of to the 2nd twin in delivery? (5)
Cord Prolapse Breech Placental Abruption Tetanic uterine contraction Hypoxia
What extra USS scans are done antenatally in multiple pregnancy?
USS cervix (to identify preterm risk) Serial USS growth scans (28/32/36) checking for IUGR
How is delivery managed differently in multiple pregnancy?
if 1st not cephalic → C-section (even in uncomplicated)
36-37wks MC
37wks DC
if 1st cephalic → NVD (+try ECV for 2nd)
Syntocinon post-delivery (prevent PPH)
What is Twin-Twin Transfusion syndrome?
What % of MC twins does it occur in?
Unequal disturb of blood within placenta → unequal liquor/blood/growth
Occurs in 15% MC twins
What features occur in the recipient in Twin-Twin Transfusion Syndrome? (6)
Larger, Polyhydramnios, Fluid overload Cardiomegaly + heart failure Hydrops fetalis Polycythaemia
What features occur in the donor in Twin-Twin Transfusion Syndrome (4)
Smaller Oligohydramnios Volume depleted Anaemia IUGR
What are the complications of Twin-Twin Transfusion Syndrome? (4)
Late miscarriage
Severe preterm
Neurological damage
Death in utero
What new intervention can be done in Twin-Twin Transfusion Syndrome ( + its fetal survival rates)
Laser ablation therapy
85% one twin survives
60% both twins survive
What are the 3 types of Breech presentation?
Extended
Flexed
Footling
What are the 4 causes / aetiological circumstances in which breech may occur?
Preterm
Room to move (polyhydramnios, high parity/lax uterus)
Turning prevented (twins, fetal/uterine abnormality)
Engagement prevented (praevia, pelvic tumours)
List 3 complications of breech babies
Increased risk neuro handicap (regardless of delivery method)
Cord Prolapse
Trapped head
How/when is ECV carried out?
What is the success rate?
37wks
Use tocolytic
CTG
Anti-D to Rh-ve
50% success rate (where fails, approx 3% spontaneously turn before delivery)
When/who is ECV less effective? (6)
Nulliparous High uterine tone Caucasians Obese women Engaged breech Reduced liquor volume
What are the risks of ECV (5)
Fetal damage Placental Abruption Uterine Rupture SROM Cord entanglement
What are the contraindications to ECV? (5)
Fetal compromise NVD contraindicated anyway (e.g. praevia) Twins Ruptured membranes Recent APH
What are the contraindications to vaginal breech birth? (8)
PROM Slow / no progress in labour (in 30%) Lack of birth attendants Severe prematurity IUGR / placental insufficiency Footling Fetus >4kg Fetal compromise
What is the incidence of placental abruption?
What % are ‘concealed’?
Occurs in 1% pregnancies (many undetermined APHs have element of PA)
20% concealed (haemorrhage within uterus)
List the RFs for placental abruption (8)
Pre-Eclampsia / Pre-existing Hypertension Maternal Smoking / cocaine use IUGR Multiple pregnancy High parity Previous abruption (6% risk)
Trauma
Sudden reduction in uterine volume (e.g. polyhydramnios + SROM)
What investigations might be done (if clear clinical Dx can’t be made)
CTG
FBC / Clotting
Transvaginal USS
What are the Signs/Symptoms of Placental Abruption
Dark vaginal bleeding Abdo pain Hard (woody), tender uterus Tachycardia Pallor Signs of fetal distress / absent heart sounds
List some other possible features of major placental abruption (3)
Maternal collapse
Coagulopathy
Renal failure / reduced urine output
What are the principles of management in major placental abruption?
Fetal condition: CTG Maternal condition: fluid balance, renal func, FBC + clotting IV fluids Steroids if <34wks Early delivery Transfuse blood ± Anti-D
How is delivery managed in placental abruption (dependant on fetal distress + gestation)
Preterm + No fetal distress → steroids (<34wks) + serial USS
No fetal distress + >37wks → IoL + amniotomy
Fetal distress → LSCS
What is the incidence of placenta praevia at term?
What are the 2 classifications of placenta praevia?
0.4% pregnancies at term (many ‘low-lying’ at 20wks but lower uterus segment grows in 3rdT)
Marginal (lower seg, not covering os)
Major (completely/partially covering os)
List the RFs for placenta praevia (P SMAC SMAC)
Previous PP Structural anomaly Multiple preg Age C-Sec previously Smoking Multiparity Assisted Conception
List the maternal complications of placenta praevia (4)
Air embolism
Haemorrhage (lower seg less able to contract/constrict)
Sepsis
What complication may arise with placenta praevia in a pt with previous LSCS
Praevia + previous LSCS scar → Accreta in 10%
May → massive haemorrhage at delivery + require hysterectomy
What are the possible fetal complications of placenta praevia? (3)
Hypoxia
Malpresentation
Prematurity
What are the clinical features of placenta praevia (4)
How is it diagnosed?
Recurrent painless APHs (increase in freq)
Head high/not engaged
Post-coital / post-VE bleeding (exclude before VE)
Malpresentation
Dx USS (3D USS Dx accreta)
How is placenta praevia managed if presenting with bleeding?
And if asymptomatic?
Bleeding → admission (risk massive APH)
FBC / Clotting / Cross-match / G&S / IV access
CTG
Steroids if <34wks
If asymp → delayed admission until 37wks / labour (but will need quick hosp access)
Both → delivery by C-Section 39wks
What are some indications for earlier C-Section in placents praevia (3)
≥37wks
Maternal/fetal compromise
Massive bleed (>1.5L) ± continuing
How is a C-Section carried out in accreta/percreta?
Incision should avoid placenta,
if accreta - leave placenta in situ or consent for hysterectomy
List some other causes of APH (3)
Undetermined origin (often small placental abruptions)
Vasa praevia
Uterine rupture
Gynaecological (cervical/endometrial carcinoma)
Define a primary and secondary PPH
Primary = within 24hrs; >500ml vaginal + >1000ml LSCS
Secondary = 24hrs - 6wks (usually b/wn 7-14d)
What are the 4 categories of causes of primary PPH (TTTT)
Tone - atonic uterus
Trauma - tear (perineal, cervical, high vaginal), LSCS
Tissue - retained placenta fragments
Thrombotic disorders
List the RFs for primary PPH (PP PARTUM)
Prolonged labour
Previous LSCS / PPH
Polyhydramnios APH (+Age) Retained placenta Twins (/multiple) Uterine fibroids Multiparity (lax uterus)
What investigations are done for primary PPH
Bloods - FBC/Clotting/Cross-match)
Obs (BP, Pulse, sats)
Urine output
VE + fundal ht
How is primary PPH prevented (3)
Treat anaemia during pregnancy
Identify pts at risk
Oxytocin in 3rd stage
What are the general management measures in primary PPH (3)
If if due to atonic uterus
If due to DIC
Rh Grp
Catheterise + estimate blood loss
Establish cause + treat
Atonic (high uterus on palp): IV syntometrine + Prostaglandins
DIC: call haematologist + keep APTT/platelets/fibrinogen over good level
When is the puerperium?
From delivery of placenta → 6wks after
List some of the physiological changes that occur in the puerperium
Uterus contracts + occludes vessels Blood-stained 'lochia' discharge Menstruation delayed (6wks due to lactation) BP/CO/Plasma Vol return to normal (loss of oedema up to 6wks) Hb + Haematocrit return to normal (if w/o haemorrhage) U&Es return to normal (due to reduced GFR)
List some aspects of general care in the puerperium period
Mobility Breastfeeding guidance Check daily: lochia / BP / pulse / temp / perineal wound Monitor any signs postnatal depression Check FBC before discharge Pelvic floor exercises Analgesics for perineal wounds
List some aspects of postnatal perineal care (LADS PAIS)
Local cooling + topical Anaesthetic (local) Diclofenac suppositories Swabs for culture Pus drainage Abx (broad spec) Irrigate wound (twice/day) Surgical repair (if gaping wound + no infection/cellulitis/exudate)
List the advantages of breast feeding
Cost saving Bonding Cancer protection (in mother) Infection protection (neonate) Cannot give too much
What is a secondary PPH usually due to?
+ What are the symptoms / Ix / Tx
Endometritis
S/s: Enlarged + Tender uterus, open cervical os
Ix: USS but poor (can’t diff b/wn clot + placenta)
Tx: Abx / ERPC (if heavy bleeding)
List the causes of postpartum pyrexia (7)
UTI (10%) Wound infection (C-Sec) Endometritis DVT Chest infection IV site infection Mastitis
How long can postpartum pyrexia take to develop after birth?
When is it commonest
Symptoms
What pathogens often causative?
Up to 14d (temp ≥ 38)
Commonest after C-Sec (give props abx)
Large/tender uterus
Offensive lochia
Grp A Strep, staph, E.Coli
What urinary problems can occur postpartum?
UTI
Urinary retention
Fistula
Stress incontinence
What is the incidence of 3rd day blues + PND?
Who is more likely to get PND? (3)
What is a DDx
50% 3rd day blues
10% PND
PMH PND, after-birth problems, socially/emotionally isolated
DDx - postpartum thyroiditis
What bowel problems can occur after pregnancy? (4)
Constipation + haemorrhoids (in 20%)
Incontinence / flatulence (from pudendal nn / anal sphincter damage)
List some RFs for postpartum bowel problems
Shoulder dystocia
Persistent OP position
Forceps
Large babies
