Post-partum care Flashcards
Physiology of post-partum
Uterine involution
- 10-14 days after delivery fundus should not be palpated abdominally
Internal os of cervix closed by 48h postpartum
Duration of lochia is variable
Fall in oestrogen causes atrophy of lower genital tract
Decreased secretions from glandular tissue
Ligament laxity resolves as progesterone and relaxin levels reduce
Divarication of the rectus abdominus muscle is common
Pulse rate and CO return to pre-pregnancy level by 6 weeks PP
Diuresis (3rd day PP) –> reduction in plasma volume –> increase in Hb levels
Cochrane - early skin-to-skin associated with:
Increased likelihood of breastfeeding in the first 1-4 months and increased breastfeeding duration
Less infant crying
Increased infant interaction with their mother
No harmful or negative outcomes
WHO recommends skin to skin immediately after birth for at least 1-2h
As little as 15-20 mins can be beneficial
Improves thermal regulation in the neonate and facilitates mother infant attachment
Incidence of PPH
Define
- major
- primary
- secondary
incidence 5-15%
Major / severe PPH
>1000ml, complicates 1-5% of deliveries
Primary PPH - Within 24h of delivery
Secondary PPH - Between 24h and 6 weeks postpartum
Incidence 0.47% to 1.44%
Total blood volume at term
~100ml/kg
- Maternal blood volume may be approx 7L for a 70kg woman
Blood flow to the placental bed is approximately 750ml/min at term
Blood loss may be life-threatening with unreplaced volume loss of as little as 30%
Risk factors for atony
Uterine overdistension Increasing parity Functional or anatomical distortion of the uterus - Prolonged labour - Precipitous labour - Fibroids - Uterine anomalies - Placenta praevia Intra-amniotic infection (chorioamnionitis) Oxytocin withdrawal Instrumental birth Uterine relaxants Previous PPH - 3-fold increase IOL Iron deficiency anaemia Bladder distension
Prevention of PPH
Active management of third stage with prophylactic oxytocics and CCT
- Reduce risk of PPH by at least 50%
- Cochrane review - reduction of 68%
- Majority of PPH cases occur in the absence of known risk factors
- Physiological third stage cannot be recommended
- CCT should only be applied once uterus is well contracted and the placenta is separated
Uterine massage is of no benefit in the prophylaxis of PPH
Treat anaemia / iron deficiency antenatally
Determine placental site at anatomy scan
Fetal pillow for second stage CS - reduces the risk of uterine extension
With prophylactic uterotonic
Women without risk factors delivering vaginally - Oxytocin 10 iu IM
Women delivering by CS- Oxytocin 5 iu slow IV injection
Women with increased risk of PPH - Ergometrine-oxytocin
Women with increased risk of PPH, delivering by CS - Consider IV TXA
Meta-analysis compared oxytocin 5IU, 10 IU and syntometrine
- Similar efficacy in preventing PPH >1000ml
- Syntometrine associated with small reduction in risk of PPH of >500ml
Oxytocin
- dose
- mechanism of action
- pros and cons
Direct relaxant effect on vascular smooth muscle
Structurally similar to vasopressin –> antidurectic effects
Caution if possibility of undiagnosed second twin (no USS in pregnancy) when using for active management
Adverse effects:
- Rapid IV bolus can cause profound hypotension, esp if hypovolaemia
- Antidiuretic effects can lead to water intoxication and hyponatraemia
Ergometrine
- dose
- mechanism of action
- pros and cons
Syntometrine 1ml IM = oxytocin 5 units/ml + ergometrine 500mcg/ml
Alpha-adrenoceptor and dopamine receptor agonist –> strong sustained uterine contractions
Causes vasoconstriction
Contrainidcation:
- Hypertension
- Severe cardiac disease
ADR:
5-fold risk of adverse effects over oxytocin
Nausea and vomiting
HTN
Misoprostol
- dose
- mechanism of action
- pros and cons
Less effective than oxytocin
Cheap, stable, can be used in under-resourced countries
ADR: GI disturbance Dizziness Headache Fever
Carboprost
- dose
- mechanism of action
- pros and cons
0.25mg IM
Synthetic prostaglandin
Used when ergometrine is contraindicated or ineffective
Can repeat dose at 15 min intervals until total 2mg
Contraindications:
- Asthma
- Cardiac disease
- Pulmonary disease
ADR: Bronchospasm Vasodilation HTN Increased risk of infection
Retained placenta
- incidence
- risk factors
3% of vaginal deliveries
Retained placenta diagnosed after:
- 1 hr of physiological management - 30 mins of active management
Causes and risk factors:
- Full bladder - Atony - Previous uterine scar - Fibroid uterus - Other uterine abnormality - Cervical constriction ring - Placenta accreta spectrum - Umbilical cord snapping - Premature birth - Stillbirth
Associated with recurrence
Secondary PPH
Causes:
- Endometritis
- RPOC
- Subinvolution of the placental implantation site
- Rarely: Pseudoaneurysm, AVM
10% present with massive haemorrhage and require immediate attention
ERPOC associated with 1.5% risk of perforation
41% occur - 8-14 days
Balloon tamponade
for PPH
No clear evidence for duration to remain in
Tamponade controls atony in upper segment and placental bed bleeding in lower segment
Bakri balloon - usually requires 300ml saline, but has capacity for 500mls
In most cases 4-6 hours should be adequate to achieve haemostasis
- Most units 12-24h
Remove during daytime hours
Cover with antibiotics
Haemostatic brace suture for PPH
75% success in avoiding hysterectomy
B-lynch requires hysterotomy
Absorbable suture with large needle
Hayman suture (2 separate sutures)
Risk factors and common presentation of Sheehan syndrome
Risk factors:
- PPH - T1DM - Sickle cell disease
Common presentation:
- Failure to lactate post-delivery - Amenorrhoea or oligomenorrhoea
Can present with any of the manifestations of hypopituitarism, e.g. hypotension, hyponatraemia, hypothyroidism
If patient remains hypotensive after control of haemorrhage and volume replacement, evaluate and treat for adrenal insufficiency immediately
Evaluate for other hormone deficiencies at 4-6 weeks post-partum
Risk factors for uterine inversion
- Accreta
- Fundal placental insertion
- Any condition that predisposes to atony and prolapse
- CCT without countertraction in an uncontracted uterus
Management of uterine inversion
Goals:
- Replace the fundus to correct position
- Management PPH and shock
- Prevent recurrent inversion
Discontinue uterotonic drugs
Do not remove the placenta
- Do after uterus is replaced as likely will increase blood loss
Immediately attempt to manually replace the inverted uterus - Johnson manoeuvre
- Once reverted, keep hand in uterus, and restart oxytocin
Transfer to OT for manual removal
If unstable after initial attempt, reasonable to proceed to laparotomy
If haemodynamically stable
- GTN
- Terbutaline
Can try hydrostatic pressure
Prevent recurrent inversion:
- Uterotonic meds
- Hold uterus in place
- Prophylactic antibiotics
Documentation
Debrief
Perineal tear classification
1st degree = Injury to perineal skin and/or vaginal mucosa only
2nd degree = Injury to perineum involving perineal muscles but not anal sphincter
3rd degree = Injury to perineum involving anal sphincter complex
3A <50% of EAS torn
3B >50% of EAS torn
3C Both EAS and IAS torn
4th degree = Injury to perineum involving anal sphincter complex and anorectal mucosa
Preventing perineal trauma
Cochrane 2017 - Hands off vs. hands on - no difference - Reduction in OASIS: ○ Warm compresses during second stage ○ Perineal massage during antenatal period (last month of pregnancy) - May also be beneficial in second stage - Further research needed
Evidence for the protective effect of episiotomy is conflicting
There is evidence that a mediolateral episiotomy should be performed with instrumental deliveries as it appears to have a protective effect on OASIS
Benefits of rapid absorbable suture for tear repair over standard synthetic absorbable
Reduced analgesia up to 10 days postpartum
Less suture material removal required
Increased superficial partial skin gaping
No difference in longer term outcomes
