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
Continuous vs. interrupted
for perineal tear
Cochrane review
Continuous for all layers:
- Reduction in short term pain
- Reduction in suture removal
Continuous suture for skin:
- Reduction in analgesia
No difference in long term pain or need for resuturing
Episiotomy should be considered where…
there is a high likelihood of severe laceration
Soft tissue dystocia
Requirement to accelerate birth of a compromised fetus
Need to facilitate operative vaginal birth
History of FGM
Incidence of OASIS
UK incidence: 2.9% (range 0-8%)
Primiparae 6.1%
Multiparae 1.7%
Risk factors for OASIS
However RF do not allow accurate prediction of OASIS
Nulliparity Asian ethnicity Birthweight >4kg OP position Shoulder dystocia Prolonged second stage Instrumental delivery - Ventouse without episiotomy OR 1.89 - Ventouse with episiotomy OR 0.57 - Forceps without episiotomy OR 6.53 - Forceps with episiotomy OR 1.34
Midline episiotomy
OASIS repair technique
Cochrane
- at 1y f/u, overlap had reduced incontinence and urgency
- at 36/12 - no difference
Anorectal mucosa repair - 3/0 vicryl (cont or interrupted)
IAS - 3/0 PDS interrupted or mattress without any attempt to overlap the IAS
EAS 3-0 PDS:
- 3C - either overlapping or end-to-end technique
- 3A or 3B - end-to-end technique
Post-op management of OASIS
Document
Broad-spectrum antibiotics
- reduce the risk of post-op infections and wound dehiscence
Bladder catheterisation
Analgesia
Diet
Laxatives
- associated with earlier and less painful BM and early postnatal discharge
- To reduce the risk of wound dehiscence
Physiotherapy
GOPD follow up 6-12 weeks post-natal
- Manometry
- Endosonography
6 week review for OASIS
Review symptoms
- 60-80% will be asymptomatic
Consider investigations
- Anal manometry - balloon in rectum which is inflated to check the muscle function of the IAS/EAS
- Endoanal USS - looks for defect in the muscle
Referral to General Surgeons if symptomatic or abnormal investigations
- If family complete would recommend secondary sphincter repair
Non-surgical management
- dietary advice - egulate bowels - Constipating agents e.g. loperamide - Pelvic floor exercises and biofeedback
5-7% risk of sustaining another OASIS tear
- 17% of women will develop worsening faecal symptoms
If symptomatic –> c-section
If chooses vaginal birth then hands on delivery with experienced practitioner
Role of episiotomy in next pregnancy unclear - should have episiotomy if clinically indicated
Risk factors for recurrent OASIS in subsequent pregnancy
Asian ethnicity
Forceps delivery
Birthweight >4kg
Anatomy of the breast
Contain mammary glands which produce milk
Breasts composed of glandular tissue and fatty tissue
Cooper’s ligaments - anchor’s breast tissue to chest wall
15-25 lobes arranged radially with interposed fat
Composed of lobules and alveoli - alveoli synthesise milk
Each alveoli has a draining duct
Contractile unit made up of myoepithelial cells which eject breastmilk into ducts
Each alveoli is drained by a duct which joins to form a single large duct for each lobe
Lacteriferous duct open separately on the nipple
Areola / Montgomery glands secrete lipoid fluid which moisturisers the nipple and also has a scent to attract baby
Blood and nerve supply of the breast
Blood supply from the internal mammary and lateral thoracic arteries
Innervated by the intercostal nerves of the 4th and 5th intercostal spaces
Lactogenesis
Lactogenesis I:
- Human placental lactogen –> breast growth
- Begins at 15-20/40 - breast develops capacity to secrete milk components
- Prolactin stimulates mammary cells to produce milk, nipple growth
- High levels of progesterone inhibit lactation
- Mammary fat pads decrease in size and are replaced by developing ducts and alveoli
Lactogenesis II:
- Onset of copious milk production
- Begins 30-40h after birth, complete by day 8 PP
- Delivery of placenta –> rapid drop in progesterone and estrogen –> increased levels of prolactin –> breast milk biosynthesis
Lactogenesis III:
- Maintenance of milk production
- “Supply and demand”
WHO’s baby friendly initiative and 10 steps to successful breastfeeding
- Having a written breastfeeding policy that is routinely communicated to all health care staff
- Training all health care staff in skills necessary to implement this policy
- Informing all pregnant women about the benefits and management of breastfeeding
- Helping mothers initiate breastfeeding within a half hour of birth
- Showing mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants
- Giving newborn infants no food or drink other than breastmilk, unless medically indicated
- Practicing rooming in - allowing mothers and infants to remain together 24h a day
- Encouraging breastfeeding on demand
- Discouraging the use of artificial teats or pacifiers in breastfeeding infants
- Fostering the establishment of breastfeeding support groups and referring mothers to them on discharge from the hospital
The value of breastfeeding - for infants
Decreased infant mortality
Enhanced immunity and decreased risk and severity of infections
Decreased risk of asthma, eczema and allergies
Decreased risk of SIDS
Decreased risk of obesity, diabetes, hypercholesterolaemia
Enhanced cognitive development
Decreased risk of childhood cancers
Decreased risk of certain chronic diseases
The value of breastfeeding - for mothers
Enhanced psychological bonding
Decreased PP bleeding and rapid uterine involution due to the action of oxytocin
Decreased risk of breast, ovarian and endometrial cancer
Earlier return to pre-pregnancy weight
Causes of decreased milk supply
RPOC PPH Maternal diabetes Hormonal issues - Hypopituitarism - Sheehan's syndrome - Thyroid disease Stress Inadequate or infrequent nipple / breast stimulation Separation from infant Medications Anatomic issues, e.g. previous breast surgery Systemic infection Mother-infant separation CS
Management of low supply
Assess attachment Increase feeds including waking infant Express Increase skin to skin time Domperidone - Acts by increasing prolactin
Breast engorgement
May occur within first few days of established breastfeeding
Result of interstitial oedema, increased blood flow and accumulation of milk in the breast
Usually bilateral pain, redness, hardness of breasts
As for low supply
- check position and attachment
- If above current, then express for comfort
Treat by unlimited, frequent feeding
Lactational Mastitis
Flu-like symptoms, rigors, red and tender breasts
May be localised area of tenderness = blocked milk duct
If symptoms persist more than a few hours after management for blocked duct, evaluate ? infective mastitis (Symptoms do not improve, or are worsening, after 12-24h despite effective milk removal)
Only 4% of mastitis is infective
Blocked duct
Causes build up and inflammation Tender and palpable lump Management: - Encourage mother to feed on affected side first - Position infants chin towards blockage - Massage when feeding / expressing - May progress to mastitis
Risk factors for mastitis
Poor breastfeeding technique Failure to alternate between breasts - Can cause nipple fissures, cracks (inconclusive evidence), sores Not wearing a well-fitting maternity support bra Abrupt discontinuation of breastfeeding Past history of mastitis Primip Maternal fatigue
Infrequent or interrupted feeding Mixed bottle and breastfeeding Delayed initiation of feeding Time limited feeds Incomplete emptying Late shift from colostrum to milk production
Incidence of mastitis
and common pathogens
Acute mastitis in 2-3% of postpartum women
Lactation mastitis in 10-33%
Breast abscess in untreated mastitis is ~3%
Common pathogens:
- Staphylococcus aureus
- Staphylococcus epidermidis
If recurrent - mixed flora including anaerobes
Beta haemolytic strep A B F
Haemophilus influenzae
E. Coli
Physiological changes in pregnancy affecting CPR
Difficult to intubate - breast enlargement, laryngeal oedema, weight gain
–> Secure airway early
High risk of aspiration - reduced oesophageal tone, raised intra-abdominal pressure from gravid uterus, decreased gastric motility
–> Secure airway early, PPI in labour
Rapid development of hypoxia - dilutional anaemia, reduced FRV from increased minute ventilation and diaphragm splinting, increased O2 consumption from uteroplacental unit
–> Give early, high-flow O2
Chest compressions more difficult - breast hypertrophy and a raised diaphragm –> decreased chest wall compliance
Reduced venous return and CO by 30-40% –> Do uterine displacement for CPR
Predisposition to haemorrhage and hypovolaemia
–> Aggressive fluid resuscitation
Dilutional anaemia - Plasma volume increased by up to 50% in pregnancy
–> Treat anaemia antenatally
Stages of DIC
Stage 1 = Hypercoagulable state
- Activation of clotting factors and development of microthrombi
Labs: decreased clotting, increased platelet adherence
Stage 2 = Consumptive hypercoagulable state
- Increased consumption of platelets and clotting factors –> bleeding
Labs: Increased clotting, decreased platelets and fibrinogen
Stage 3 = Secondary fibrinolytic state
- Substantial formation of fibrin degradation products and plasmin –> Marked bleeding
Labs: Increased thrombin time, decreased clot lysis time, increased fibrin degradation products
Perimortem C-section
Should be carried out within 4 mins or as soon as possible after loss of spontaneous circulation in gestations >20/40
12-15% of circulating blood volume at term supplies the uterus
Trigger the massive obstetric haemorrhage protocol in an undelivered woman at the time the decision to proceed with peri-mortem CS is made
Delivery should be achieved within 5 mins of cardiac arrest
- Maximises maternal survival and reduces risk of long-term neurological impairment
AFE diagnosis
Clinical diagnosis of acute hypotension or cardiac arrest, acute hypoxia and coagulopathy in the absence of any other potential explanation
Or diagnosed on post-mortem with presence of fetal debris in the pulmonary circulation
AFE Incidence
5.4 cases per 100,000 women giving birth (Au/NZ)
Case fatality rate of 15%
If the AFE occurs in utero, neonatal mortality up to 40%
Pathophysiology
of AFE
Poorly understood
Amniotic fluid enters maternal circulation via breach of barrier between maternal circulation and intact fetal membranes
Immune-mediated mechanisms suggested
Anaphylactic type reaction
Obstruction to pulmonary vessels
Complement activation - clotting problems
Risk factors
of AFE
Given low incidence, no change to clinical practice warranted AMA Placenta praevia Placental abruption Operative delivery Caesarean section Polyhydramnios IOL Trauma Multiple gestation Multi parity
Anaphylaxis presentation / pathophys
Rapidly developing
Airway, breathing, circulation problem
- Significant intravascular volume redistribution –> decreased CO
- Acute ventricular failure and myocardial ischaemia can occur
- Upper airway obstruction from angioedema, bronchospasm, mucous plugging of smaller airways
Skin signs present in up to 90%
Management of anaphylaxis
Remove trigger
Call for help
Lay patient flat with legs raised to combat vasodilation effects on circulation, unless prominent upper airway swelling
0.5ml (0.5mg) adrenaline 1:1000 IM at 5 minute intervals
STAT fluids
High-flow oxygen
Support with antihistamine and hydrocortisone
Blood tests for tryptase level
- Start of event, at 1 hour, and at 24h
Some patients can have a biphasic reaction so monitor for at least 6 hours
Management of toxicity of MgSO4
calcium gluconate (10mls of 10%)
Causes of cardiac arrest
4 Hs and 4 Ts
- Haemorrhage
- Hypoxia
- Hypo/hyperkalaemia
- Hypothermia
- Thromboembolism
- Toxicity including sepsis
- Tamponade
- Tension pneumothorax
Also intracranial haemorrhage and eclampsia
RANZCOG management considerations
for PPH
- Recognition
- Communication and teamwork
- Resuscitation
- Monitoring and investigation
- Management of PPH
