Post-partum care and complications Flashcards
Whats meant by the term puerparium?
Period of 6 weeks after childbirth where the mothers reproductive organs return to pre-pregnant state
What are the main aspects of immediate post-partum care?
- 15-60 minute observations
-
Ensure that:
- Uterus remains contracted
- Prophylactic antibiotics if needed
- Appropriate thrombopropphylaxis
- Monitoring of spinal/epidural anaesthesia
What care takes place on the post natal ward?
- 4 hourly observation
- Ensure no abnormal bleeding
- Observe
- for infection
- Thrombiprophylaxis
- Ensure fit for discharge (usually 2 day stay)
What care takes place in the community?
- Initially day visits by community midwife
- After day 10 health visitor
- Ensure no abnormal bleeding, observe for infection
What common problems occur in the postnatal period?
- Medical problems
- PPH
- Venous thrombosis
- Sepsis
- Perineal trauma
- Postnatal psychiatric disorders
- Suicide (baby blues)
- Post natal depression
- Peurperal psychosis
At what point do all women receive a post-natal check by the GP?
6 weeks after birth
What hormonal changes take place in the mother puerparium?
- B-HCG levels fall rapidly
- Human placental lactogen levels fall rapidly
- Pre-pregnant levels of oestrogen and progesterone reached 7 days post birth
What changes occur in the uterus post-partum?
Rapid involution - returns to pelvis and is no longer felt in the abdomen
What changes occur in the vagina post-partum?
- Initially swollen, but rapidly regains tone
- Vascularity and oedema decrease
- Rugae reappear - less prominent than nulliparous
What changes occur in the cervix poat-partum?
Os closes gradually after delivery - almost completely closed at day 10-14 post labour
What CVS changes occur in the post-partum/peurperium period?
- Cardiac output initially increases - return of blood from contracted uterus
- Plasma volume decreases - due to diuresis
- HR decreases - decreases CO in combination with decreased plasma voluem
What changes occur in the breast in the peurperium period?
Days 2-4
- Breasts become encorged
- Vascularity increases
- Areolar pigmentation increases
- Lobules enlarge
What is lochia?
Sloughed-off necrotic decidual layer mixed with blood - initially red and becomes paler as bleeding is reduced. It may last for up to 3-6 weeks
What is a primary post-partum haemorrhage?
Blood loss of >/= 500 ml from the genital tract occuring within the 24 hrs of delivery
What is regarded as secondary post-partum haemorrhage?
Excessive loss (>/= 500 ml) of blood between 24 h and 6 weeks of delivery
What are causes of primary PPH?
4 T’s - Tone, tissue, trauma, thrombin
- Uterine atony
- Genital tract trauma
- Coagulation disorders
- Large placenta
- Abnormal placental site
- Retained placenta
- Uterine inversion
- Uterine rupture
What is the most common cause of primary PPH?
Uterine atony (90%)
What is uterine atony?
Failure of uterus to contract effectively after delivery, which can lead to an acute hemorrhage, as the uterine blood vessels are not sufficiently compressed
What can cause uterine atony?
- Overdistended uterus
- Prolonged labour
- Infection
- Retained tissue
- Failure to actively manage 3rd stage labour
- Placental abruption
What gential tract trauma can lead to primary PPH?
- Tears
- Episiotomy
- Lacerations of the cervix
- Rupture of the uterus
What problems with placental site can increase the risk of primary PPH?
- Placenta praevia
- Placenta accreta
- Placenta percreta
What are antenatal risk factors for PPH?
- Previous PPH
- Previously retained placenta
- Increasedd BMI
- Para 4 or more
- Antepartum haemorrhage
- Overdistention of uterus
- Uterine abnormalities
- Maternal age >35 yrs
What are intrapartum risk factors for PPH?
- Induction of labour
- Prolonged 1st, 2nd, 3rd stage
- Use of oxytocin
- Precipitate labour
- Vaginal operative delivery
- C-section
How would you manage someone with uterine atony?
- Phyical methods to contract - bimanual compression, massage
-
Medical management
- 500 mg ergometrine IV
- 40U oxytocin infusion
- Consider 800 mg misoprostol PR - if bleeding continues
- Consider 250 mg Carboprost
- Surgical management
What is the general principles to PPH management?
- Empty uterus - deliver foetus, remove placenta
- Treat atony - Massage, bimanual compression, medications
- Repair genital tract damage
What are causes of secondary PPH?
- Retained products
- Endometritis
- Tear/trauma
What are the main problems that can arise in the post-partum period?
- PPH
- VTE
- Sepsis and puerpural pyrexia
- Post-partum depression/psychosis
What are causes of endometritis?
- C-section
- Prelabour rupture of membranes
- Intrapartum chorioamnionitis
- Prolonged labour
- Multiple pelvic examinations
- Intenral foetal monitoring
What are symptoms of endometritis?
- Fever
- Foul smelling, profuse, bloody discharge
- Features of sepsis
What are causes of puerperal pyrexia/sepsis?
- Endometritis
- Perineal wound infection
- Mastitis/Breast abscess
- UTI
- Thrombophlebitis
- Abdominal wound infection
What investigations would you do if you suspected puerperal infection/pyrexia/sepsis?
- Bedside - Urine dipstick, cervical/lochia swab, wound swabs, throat swabs, sputum culture
- Bloods - FBC, U+E’s, blood cultures consider ABG for lactate
- Imaging - CXR
How would you generally manage someone with puerperal sepsis?
- Supportive - antipyretics, fluids
- Antibiotics - broad spectrum if no obvious cause
How long after delivery is contraception needed?
>3 weeks - breast feeding can be used as contraception (lactational amenorrhoea)
What is the pharmacological options in the management of PPH?
- Oxytocin - slow injection or IV infusion (30 IU in 500ml saline at 125ml/hr)
- Synometrine/ergometrine IM
- Carboprost IM 250mcg every 15 minutes - max 2 mg
- Misoprostol
- Tranexamic acid
How would you manage endometritis?
- Urgent IV Abx
- Uterine curettage
How does breastfeeding cause amenorrhoea?
Suckling disrupts frequency and amplitude of gonadotrophin surges so that although there is gonadotrophin rise in response to falling placental sex steroids after delivery, ovulation does not occur
When is the average 1st menstruation in a fully breastfeeding mother post-partum?
28 weeks - this method of contraception is 98% effective
How would you manage the risk of VTE after vaginal delivery?
-
LMWH - ASAP after delivery in adsence of PPH
- Continue for 7 days
- Consider ted stockings
What are common post-natal problems that can occur?
- Anaemia
- Bowel problems
- Incontinence
- Perineal breakdown
- PPH
- VTE
- Infection
- Psychiatric problems - depression, psychosis
When is the peak of onset of post-natal depression?
Weeks 3-4 post-delivery
What are sepcific features of post-natal depression?
- Irritability
- Tiredness
- Decreased libido
- Guilt at not loving/caring enough
- Anxiety
What are the baby blues?
Usually occurs 1-3 days post natally for a few days only.
Fatigue, tearfullness, anxiety, irritability.
Generally resolves 10-14 days post delivery, peaking at day 5.
Very common following first delviery (50%)
Reassurance, support, heath visitor
What is post natal depression?
Can continue from baby blues. Most cases start wihtin a month and peak at 3 months.
What antidpressant is best used in a lady who is breast feeding?
Paroxetine
What scale is used to screen for post natal depression?
Edinburght post natal depression scale
What are features of puerperal psychosis?
Presentation is by day 7 post-partum in 50%, by 3 months in 90%
- High suicidal drive
- Severe depression
- Mania
-
Schizophrenic symptoms - rare
- Delusions of malformed child
SEVERE mental illness
Need inpatient care
Risk factors for perineal trauma
- Primigravida
- Large babies
- Precipitant labour
- Shoulder dystocia
- Forceps
Describe the grades of perineal trauma
- 1st degree = tear within vaginal mucosa only (superfical, no muscle involvement)
- 2nd degree = tear into subcur tissue (injury to muscle not sphincter)
- 3rd degree = laceration extends into external anal sphincter
- 4th degree = lacteration extends through external anal sphincter into rectal mucosa
