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Gwen - Reproductive Medicine (Obs, Gyn, Breast) > Post-partum care and complications > Flashcards

Post-partum care and complications Flashcards

1
Q

Whats meant by the term puerparium?

A

Period of 6 weeks after childbirth where the mothers reproductive organs return to pre-pregnant state

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2
Q

What are the main aspects of immediate post-partum care?

A
  • 15-60 minute observations
  • Ensure that:
    • Uterus remains contracted
    • Prophylactic antibiotics if needed
    • Appropriate thrombopropphylaxis
    • Monitoring of spinal/epidural anaesthesia
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3
Q

What care takes place on the post natal ward?

A
  • 4 hourly observation
  • Ensure no abnormal bleeding
  • Observe
  • for infection
  • Thrombiprophylaxis
  • Ensure fit for discharge (usually 2 day stay)
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4
Q

What care takes place in the community?

A
  • Initially day visits by community midwife
  • After day 10 health visitor
  • Ensure no abnormal bleeding, observe for infection
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5
Q

What common problems occur in the postnatal period?

A
  • Medical problems
    • PPH
    • Venous thrombosis
    • Sepsis
    • Perineal trauma
  • Postnatal psychiatric disorders
    • Suicide (baby blues)
    • Post natal depression
    • Peurperal psychosis
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6
Q

At what point do all women receive a post-natal check by the GP?

A

6 weeks after birth

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7
Q

What hormonal changes take place in the mother puerparium?

A
  • B-HCG levels fall rapidly
  • Human placental lactogen levels fall rapidly
  • Pre-pregnant levels of oestrogen and progesterone reached 7 days post birth
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8
Q

What changes occur in the uterus post-partum?

A

Rapid involution - returns to pelvis and is no longer felt in the abdomen

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9
Q

What changes occur in the vagina post-partum?

A
  • Initially swollen, but rapidly regains tone
  • Vascularity and oedema decrease
  • Rugae reappear - less prominent than nulliparous
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10
Q

What changes occur in the cervix poat-partum?

A

Os closes gradually after delivery - almost completely closed at day 10-14 post labour

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11
Q

What CVS changes occur in the post-partum/peurperium period?

A
  • 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
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12
Q

What changes occur in the breast in the peurperium period?

A

Days 2-4

  • Breasts become encorged
  • Vascularity increases
  • Areolar pigmentation increases
  • Lobules enlarge
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13
Q

What is lochia?

A

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

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14
Q

What is a primary post-partum haemorrhage?

A

Blood loss of >/= 500 ml from the genital tract occuring within the 24 hrs of delivery

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15
Q

What is regarded as secondary post-partum haemorrhage?

A

Excessive loss (>/= 500 ml) of blood between 24 h and 6 weeks of delivery

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16
Q

What are causes of primary PPH?

A

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
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17
Q

What is the most common cause of primary PPH?

A

Uterine atony (90%)

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18
Q

What is uterine atony?

A

Failure of uterus to contract effectively after delivery, which can lead to an acute hemorrhage, as the uterine blood vessels are not sufficiently compressed

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19
Q

What can cause uterine atony?

A
  • Overdistended uterus
  • Prolonged labour
  • Infection
  • Retained tissue
  • Failure to actively manage 3rd stage labour
  • Placental abruption
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20
Q

What gential tract trauma can lead to primary PPH?

A
  • Tears
  • Episiotomy
  • Lacerations of the cervix
  • Rupture of the uterus
21
Q

What problems with placental site can increase the risk of primary PPH?

A
  • Placenta praevia
  • Placenta accreta
  • Placenta percreta
22
Q

What are antenatal risk factors for PPH?

A
  • Previous PPH
  • Previously retained placenta
  • Increasedd BMI
  • Para 4 or more
  • Antepartum haemorrhage
  • Overdistention of uterus
  • Uterine abnormalities
  • Maternal age >35 yrs
23
Q

What are intrapartum risk factors for PPH?

A
  • Induction of labour
  • Prolonged 1st, 2nd, 3rd stage
  • Use of oxytocin
  • Precipitate labour
  • Vaginal operative delivery
  • C-section
24
Q

How would you manage someone with uterine atony?

A
  1. Phyical methods to contract - bimanual compression, massage
  2. Medical management
    • 500 mg ergometrine IV
    • 40U oxytocin infusion
    • Consider 800 mg misoprostol PR - if bleeding continues
    • Consider 250 mg Carboprost
  3. Surgical management
25
Q

What is the general principles to PPH management?

A
  • Empty uterus - deliver foetus, remove placenta
  • Treat atony - Massage, bimanual compression, medications
  • Repair genital tract damage
26
Q

What are causes of secondary PPH?

A
  • Retained products
  • Endometritis
  • Tear/trauma
27
Q

What are the main problems that can arise in the post-partum period?

A
  • PPH
  • VTE
  • Sepsis and puerpural pyrexia
  • Post-partum depression/psychosis
28
Q

What are causes of endometritis?

A
  • C-section
  • Prelabour rupture of membranes
  • Intrapartum chorioamnionitis
  • Prolonged labour
  • Multiple pelvic examinations
  • Intenral foetal monitoring
29
Q

What are symptoms of endometritis?

A
  • Fever
  • Foul smelling, profuse, bloody discharge
  • Features of sepsis
30
Q

What are causes of puerperal pyrexia/sepsis?

A
  • Endometritis
  • Perineal wound infection
  • Mastitis/Breast abscess
  • UTI
  • Thrombophlebitis
  • Abdominal wound infection
31
Q

What investigations would you do if you suspected puerperal infection/pyrexia/sepsis?

A
  • 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
32
Q

How would you generally manage someone with puerperal sepsis?

A
  • Supportive - antipyretics, fluids
  • Antibiotics - broad spectrum if no obvious cause
33
Q

How long after delivery is contraception needed?

A

>3 weeks - breast feeding can be used as contraception (lactational amenorrhoea)

34
Q

What is the pharmacological options in the management of PPH?

A
  • 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
35
Q

How would you manage endometritis?

A
  • Urgent IV Abx
  • Uterine curettage
36
Q

How does breastfeeding cause amenorrhoea?

A

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

37
Q

When is the average 1st menstruation in a fully breastfeeding mother post-partum?

A

28 weeks - this method of contraception is 98% effective

38
Q

How would you manage the risk of VTE after vaginal delivery?

A
  • LMWH - ASAP after delivery in adsence of PPH
    • Continue for 7 days
  • Consider ted stockings
39
Q

What are common post-natal problems that can occur?

A
  • Anaemia
  • Bowel problems
  • Incontinence
  • Perineal breakdown
  • PPH
  • VTE
  • Infection
  • Psychiatric problems - depression, psychosis
40
Q

When is the peak of onset of post-natal depression?

A

Weeks 3-4 post-delivery

41
Q

What are sepcific features of post-natal depression?

A
  • Irritability
  • Tiredness
  • Decreased libido
  • Guilt at not loving/caring enough
  • Anxiety
42
Q

What are the baby blues?

A

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

43
Q

What is post natal depression?

A

Can continue from baby blues. Most cases start wihtin a month and peak at 3 months.

44
Q

What antidpressant is best used in a lady who is breast feeding?

A

Paroxetine

45
Q

What scale is used to screen for post natal depression?

A

Edinburght post natal depression scale

46
Q

What are features of puerperal psychosis?

A

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

47
Q

Risk factors for perineal trauma

A
  • Primigravida
  • Large babies
  • Precipitant labour
  • Shoulder dystocia
  • Forceps
48
Q

Describe the grades of perineal trauma

A
  • 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

Gwen - Reproductive Medicine (Obs, Gyn, Breast) (49 decks)

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