Post-partum care Flashcards

Question

Risk factors for OASIS

Answer 1

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

Answer 2

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

Answer 3

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

Answer 4

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

Answer 5

Asian ethnicity Forceps delivery Birthweight >4kg

Answer 6

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

Answer 7

Blood supply from the internal mammary and lateral thoracic arteries Innervated by the intercostal nerves of the 4th and 5th intercostal spaces

Answer 8

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"

Answer 9

1. Having a written breastfeeding policy that is routinely communicated to all health care staff 2. Training all health care staff in skills necessary to implement this policy 3. Informing all pregnant women about the benefits and management of breastfeeding 4. Helping mothers initiate breastfeeding within a half hour of birth 5. Showing mothers how to breastfeed, and how to maintain lactation even if they should be separated from their infants 6. Giving newborn infants no food or drink other than breastmilk, unless medically indicated 7. Practicing rooming in - allowing mothers and infants to remain together 24h a day 8. Encouraging breastfeeding on demand 9. Discouraging the use of artificial teats or pacifiers in breastfeeding infants 10. Fostering the establishment of breastfeeding support groups and referring mothers to them on discharge from the hospital

Answer 10

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

Answer 11

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

Answer 12

``` 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 ```

Answer 13

``` Assess attachment Increase feeds including waking infant Express Increase skin to skin time Domperidone - Acts by increasing prolactin ```

Answer 14

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

Answer 15

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

Answer 16

``` 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 ```

Answer 17

``` 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 ```

Answer 18

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

Answer 19

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

Answer 20

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

Answer 21

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

Answer 22

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

Answer 23

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%

Answer 24

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

Answer 25

``` 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 ```

Answer 26

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%

Answer 27

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

Answer 28

calcium gluconate (10mls of 10%)

Answer 29

4 Hs and 4 Ts - Haemorrhage - Hypoxia - Hypo/hyperkalaemia - Hypothermia - Thromboembolism - Toxicity including sepsis - Tamponade - Tension pneumothorax Also intracranial haemorrhage and eclampsia

Answer 30

1. Recognition 2. Communication and teamwork 3. Resuscitation 4. Monitoring and investigation 5. Management of PPH