Post Partum Care Flashcards
What is the difference between primary PPH and secondary PPH?
PRIMARY = blood loss of 500ml or more from the genital tract, occurring within 24h of delivery
SECONDARY = excessive loss occurring between 24h and 6 weeks after delivery
MAJOR = loss of >1000ml
What are the main causes of PPH? (4 Ts)
TONE (most common)
-Uterine atony means the uterus is unable to contract after delivery
TISSUE
-Large placenta or abnormal placenta site (praevia, accreta)
TRAUMA
-Genital tract trauma (tears, episiotomy, lacerations to cervix, uterine rupture
THROMBIN
-Coagulation disorders (eg placental abruption, sepsis, autoimmune disease, clotting disorders)
What can cause uterine atony?
-Over-distended uterus eg polyhydramnios, twins
-Prolonged labour
-Induction
-Infection
-Retained tissue
-Failed active management of 3rd stage
What are some antepartum and intrapartum risk factors contributing to PPH?
ANTEPARTUM
-Previous PPH
-Previous retained placenta
-High BMI
-Para 4+
-Antepartum haemorrhage
-Over-distended uterus
-Uterine abnormalities
-Low-lying placenta
-Maternal age >35
INTRAPARTUM
-Induction
-Prolonged labour
-Use of oxytocin
-Instrumental delivery
-C-section
How is PPH managed?
-If placenta is retained – manual removal under GA / spinal
-Bimanual compression if bleeding is uncontrolled
-If uterine atony is the cause:
–1st line = syntocinon IV
–2nd line = ergometrine IV
–3rd line = carboprost IM
–4th line = misoprostol PR
-Fluid resus
-Surgery
What are the main postpartum complications?
-PPH
-VTE
-Eclampsia
-Septic shock
-Amniotic fluid embolus
-Uterine rupture
How is eclampsia managed in the post partum period?
-A-E, recovery position
-O2
-Bloods - FBC, U+Es, LFTs, coagulation screen
-Haemolysis –> elevated liver enzymes, low platelets
What is the most common causative organism of PP septic shock?
-Strep A
How is PP septic shock managed?
-IV broad spec abx eg cefotaxime, metronidazole, gentamicin
-Uterine evacuation if retained products noted
What are the signs and symptoms of amniotic embolus and how is it normally diagnosed?
-Collapse
-DIC
-Unaccountable bleeding
-Usually diagnosed by exclusion or at post-mortem
How is an amniotic embolus managed?
-Supportive treatment, transfer to ICU
-Correct clotting
What are the signs and symptoms of uterine rupture?
NB almost always occurs during labour, rare in primigravid patients
-Fresh vaginal bleeding
-Haematuria
-Foetal distress
-Constant severe abdo pain
-Shock
How is uterine rupture managed?
-A-E, resuscitation
-Immediate laparotomy to salvage baby –> either repair or hysterectomy
What are the two forms of lactation product?
Colostrum
-Thick yellow fluid produced from 20 weeks gestation
-High levels of secretory IgA and protein-rich
-Promotes gut maturity and immunity in the infant
-Small quantities produced following birth
Human milk
-Produced rapidly, increasing to 500ml at 5 days
-More energy efficient than formula milk
What factors influence early initiation of breastfeeding?
-Skin-to-skin contact (increases success of breastfeeding initially and also 2-3 months later)
-Feeding within the first 2 hours
How frequently should infants breastfeed and for how long?
-Varies widely
-Demand feeding should be encouraged - promotes weight maintenance and prevents hyperbilirubinaemia and breast engorgement
-Median = 8 times a day
-Exclusive breast feeding is recommended for 4-6 months
Which viruses can the mother pass on her immunity and which can she directly pass on during breastfeeding?
DIRECT TRANSMISSION
-HIV
-Rubella
ANTIBODIES
-VZV
-Rubella
NO EFFECT
-HBV
-HSV
-CMV
What benefits does breastfeeding have for both the infant and mother?
INFANT - reduces:
-GI illness
-UTIs
-Chest infections
-Likelihood of atopy
-Childhood leukaemia
MOTHER
-Helps uterine involution
-Reduces risk of breast cancer, ovarian cancer and osteoporosis
-Amenorrhoea
What drugs are contraindicated or should be avoided in breastfeeding?
CONTRAINDICATED
-Aspirin
-Amiodarone
-Chloramphenicol
-Ergometrine (reduces lactation)
-Iodines
-Methotrexate (and other antineoplastics)
-Lithium
-Tetracycline
-Pseudophedrine
AVOID
-Acebutalol, ACEis
-Alcohol, caffeine, cocaine, marijuana
-Fluoxetine, iodine, sulphonamides
What pattern do women’s periods follow in the post-natal period and when is contraception needed?
PERIODS
-Return within 5-6 weeks if not breastfeeding
-Lactational amenorrhoea means BF delays periods
-Can become pregnant before periods start
CONTRACEPTION
-Not needed within first 3 weeks - earliest ovulation occurs 28 days post-birth
-If exclusively breastfeeding, can be used as contraception
What considerations can affect the choice of contraception in the post-natal period?
-COCP, patch and ring should not be used until 6 weeks post partum or breastfeeding (bear in mind risks of breastfeeding)
-IUD and IUS can start within 48h of birth
-Emergency pill can be used from 21 days
-Emergency IUD can be used from 28 days
How common are ‘baby blues’ and how long do they last?
-50% of women experience a mild period of emotional instability
-Usually starts around 3 days after delivery and resolves spontaneously within 10 days
-Tearfulness, irritability, anxiety, poor sleep
What features does postnatal depression have?
-Key features of depression eg low mood, anhedonia, reduced energy
-Specific parents worries eg bad mother, preoccupations about baby’s health
-Reduced affection, poor bonding
-Failure to respond to appropriate reassurance
When should postnatal depression be screened for?
-Antenatally
-At 4-6 weeks post delivery
-3-4 months post delivery
RISK ASSESSMENT IS VITAL
How does postnatal depression affect the mother’s future mental health?
-High lifetime risk of further depression
-25% risk of depression in subsequent deliveries
How does puerperal psychosis tend to present?
-Rapid onset, usually within 2 weeks
-Early signs tend to be non-specific - insomnia, agitation, odd behaviour, fluctuating presentation, rapidly changing mood
-Florid psychosis may be rapidly progressive (develops within hours)
–Labile mood, mania, confusion, delusions, rambling
-A psychiatric emergency - significant risk to mother and child
How common is puerperal psychosis?
-1 in 500 deliveries
-5% associated suicide risk and 4% infanticide risk
What risk factors are associated with puerperal psychosis?
-Personal history of BAD
-Previous episode of puerperal psychosis
-1st degree relative with a history of the above
What physiological changes occur in the postpartum period?
-Involution of uterus - fungus recess from below umbilicus into pelvis, no longer palpable after 2 weeks
-Lochia (=blood + necrotic decidua)
–Beware of anaemia
-Lactation (regulated by prolactin and oxytocin)
What thresholds of Hb require treatment?
-Hb 80-100g/l –> oral iron
-Hb <80g/l + symptomatic –> blood transfusion
-Hb 80-100g/l + symptomatic –> iv iron
What is endometritis and how does it present?
-Infection with the uterus
-Starts around day 2-10
SYMPTOMS
-Offensive vaginal loss
-Fever, malaise, rigors, headache
-Abdo pain
-Lochia stops and then gets heavier
-Secondary PPH
-Suprapubic tenderness / uterine enlargement
What is Sheehan’s syndrome?
-Aka postpartum hypopituitarism
-Reduction in function of the pituitary gland following ischaemic necrosis due to blood loss and hypovolaemic shock following birth
What is checked in the day 1 post-delivery check?
-Maternal obs
-Pain relief
-Observe lochia, involution, wounds
-Ensure passing urine, flatus and stool normally
-Eating and drinking
-VTE risk assess
-Encourage mobility
-Assess for anaemia
-Anti-D if Rh-
-Mental health risk assessment
When is the post-natal check?
-6 weeks after delivery
When should mastitis be treated?
-If systemically unwell, nipple fissure present, symptoms not improving
-Flucloxacillin 10-14 days
-Affects 1 in 10
-Can be caused by engorgement and blocked ducts
