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Reproductive Health Block > Post-Partum Period & Complications > Flashcards

Post-Partum Period & Complications Flashcards

1
Q

What is the Edinburgh tool used for?

A

Detecting/screening for postnatal depression

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2
Q

What percentage of women are affected by “baby-blues”?

A

60-70%

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3
Q

Who is the baby-blues most commonly seen in?

A

Primips

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4
Q

What are the baby-blues?

A

Mood disorder experienced after childbirth, typically characterised by anxiety, tearfulness, and irritability.

Experienced 3-7 days following birth.

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5
Q

How should baby-blues be managed?

A

With reassurance and support, often the health visitor plays a key role.

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6
Q

What is the next step up in severity from baby-blues?

A

Post-natal depression

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7
Q

How common is post-natal depression?

A

Around 10% of women are affected

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8
Q

When does postnatal depression strike?

A

Within a month after birth, and usually peaks at 3 months.

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9
Q

How does post-natal depression present?

A

Like normal depression, but in the post-natal period

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10
Q

What are the elements of management for postnatal depression?

A
  • Reassurance and support throughout
  • CBT
  • SSRIs if severe
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11
Q

Which SSRIs can be used in severe post-natal depression?

A

Sertraline and paroxetine

Paroxetine is recommended by SIGN as it has a low milk/plasma ratio

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12
Q

What is the next step up from post-natal depression?

A

Puerperal psychosis

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13
Q

How common is puerperal psychosis?

A

Approx. 0.2% of women are affected

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14
Q

When does puerperal psychosis start to affect a woman?

A

Onset within first 2-3 week after birth

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15
Q

How is puerperal psychosis different to postnatal depression?

A

It is more severe - more severe mood swings similar to bipolar, disordered perception, including auditory hallucinations.

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16
Q

How should puerperal psychosis be managed?

A

Usually hospital admission is needed.

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17
Q

If a woman suffers from puerperal psychosis, how likely is it she will suffer from it again?

A

20% risk of recurrence

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18
Q

What is a post-partum haemorrhage?

A

Excessive bleeding following delivery.

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19
Q

What are primary and secondary postpartum haemorrhage?

A

Primary is loss of blood over 500ml from genital tract within 24 hours of delivery.
Secondary is from 24 hours after delivery until six weeks postpartum.

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20
Q

What is classified as minor and major PPH?

A

Minor is up to 1000mls

Major is over 1000mls

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21
Q

What memory aid can we use to rememeber the causes of PPH?

A 
Four Ts:
Tone
Trauma
Tissue
Thrombin
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22
Q

What tone issues can cause PPH?

A

Uterine atony

Distended bladder

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23
Q

What trauma issues can cause PPH?

A

Lacerations of the uterus, cervix, or vagina

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24
Q

What tissue issues can cause PPH?

A

Retained placenta or clots

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25
Q

What thrombin issues can cause PPH?

A

Pre-existing or acquired coagulopathy

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26
Q

What are the 2 most common causes of PPH, and which is the most most common?

A
  1. Uterine atony

2. Retained placenta

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27
Q

How common is PPH?

A

Incidence is roughly 5-10%.

Major PPH incidence is roughly 1%.

28
Q

What antenatal factors increase the risk of PPH?

A
  • Antepartum haemorrhage
  • Placenta praevia or abruption
  • Multiple pregnancy
  • Pre-eclampsia/HTN
  • Grand parity
  • Prev. PPH
  • Maternal obesity
  • Maternal age
  • Maternal anaemia
  • Asian ethnic origin
29
Q

What delivery factors increase the risk of PPH?

A
  • Emergency or elective c-section
  • Retained placenta
  • Induction of labour
  • Operative vaginal delivery
  • Labour over 12 hours
  • Big baby
30
Q

What pre-existing maternal factors increase the risk of PPH?

A

Von Willebrand’s disease

Factor 8 or 9 deficiency (Haemophilia A or B carrier)

31
Q

What signs accompany the blood loss in PPH?

A

Signs of shock e.g. tachycardia, hypotension, tachypnoea

32
Q

Which syndrome is associated with PPH?

A

HELLP syndrome

33
Q

How should PPH be managed?

A

ABCDE!!!

IV access with 2 x 14 gauge cannulae.

Blood transfusion asap, with warmed IV fluids (up to 2L) until it is available.

Take measures to stop the bleeding.

34
Q

How many units of blood should be crossmatched for a major PPH?

A

At least 4

35
Q

What measures can be taken to stop bleeding in PPH?

A

Establish the cause, treat the cause:
-Uterine atony - bimanual compression, empty bladder, Oxytocin 5 units by IV infusion. Repeat as necessary. Ergometrine can be given unless hx of HTN. Carboprost and Misoprostol can also be used. Surgically, balloon tamponade, ligatoin of ateries, or selective arterial embolisation can be used. Hysterectomy is last line option.

36
Q

What are the complications of PPH?

A
  • Hypovolaemic shock
  • DIC
  • AKI
  • Liver failure
  • ARDS
  • Death
37
Q

What is the prognosis like for PPH?

A

Very good - UK risk for death due to PPH is 1 in 100,000 deliveries.

38
Q

How can we prevent PPH?

A

Active thrid stage management - prophylactic oxytocics (IM for vaginal, IV for c-section). Misoprostol is good alternative for low resource area.

39
Q

What are the 2 most common causes of secondary post partum haemorrhage?

A
  1. Infection (endometritis)

2. Retained products of conception

40
Q

How do secondary PPH present?

A

Symptoms include:

  • Fever
  • Abdo pain
  • Offensive smelling lochia
  • Abnormal PV bleed or discharge
  • Dyspareunia
  • Dysuria
  • General malaise
41
Q

What hx would indicate higher risk of PPH?

A

Extended labour
Difficult thrid stage
Ragged placenta
PPH

42
Q

What does the fundus feel like in RPOC?

A

It is elevated and feels boggy

43
Q

How should ?2ndary PPH be investigated?

A 
FBC
Blood culture
MSU
High vaginal swab and chlamydia/gonorrhoea swab
USS (for RPOC)
44
Q

How should secondary PPH be managed?

A

ABCDE!! Look for red flag sepsis also.

IV/oral abx for endometritis (depending on how unwell pt is).

Elective curettage with abx cover.

45
Q

Which abx are suggested by the RCOG guidelines for sepsis following pregnancy?

A

Piperacillin or tazobactim

46
Q

What is the biggest risk of removing RPOC with curettage?

A

High risk of uterine perforation.

47
Q

How common are 3rd/4th degree perineal tears in:

a) primiparous women?
b) multiparous women?

A

a) 4-7%
b) 1.4-2.5%

Lower for spontaneous vaginal than instrumental delivery.

48
Q

What are the indications for an episiotomy?

A
  • Delayed delivery due to rigid perineum
  • Tear imminent and episiotomy preferable
  • In some instrumentals to facilitate delivery
  • In some premature deliveries
49
Q

Should episiotomies be done routinely or restrictively? Why?

A

Restrictively - lower risk of clinically relevant morbidities.

50
Q

What is defined as a first degree perineal tear?

A

Damage to the fourchette and vaginal mucosa, but underlying muscles are not torn (but are exposed).

51
Q

What is defined as a second degree perineal tear?

A

Posterior vaginal wall and perineal muscles, but anal sphincter is intact.

52
Q

What is defined as a third degree perineal tear?

A

Tear extends to anal sphincter but the rectal mucosa is intact

53
Q

What is defined as a fourth degree perineal tear?

A

Anal canal is opened and tear spreads into the rectum

54
Q

When should an episiotomy be performed?

A

During the second stage of labour when the perineum is being stretched.

Informed consent is needed, and this can’t be given when the baby is crowning.

55
Q

What kind of episiotomy is usually recommended?

A

A mediolateral episiotomy

56
Q

Why are midline episiotomies not recommended?

A

They may extend backwards into the rectum to produce a third or fourth degree tear

57
Q

How should perineal tears be managed?

A

Ensure adequate analgesia.

Stitches and sutures usually used for 2nd-4th degree tears.
First degree often left to heal by secondary intention.

58
Q

What can be done to minimise the risk of perineal tear?

A
  • Antenatal perineal massage
  • Warm compress during second stage of labour
  • Water births
59
Q

What are the complications associated with perineal trauma?

A
  • Pain
  • Infection
  • Bleeding
  • Extension of original cut/tear
  • Problems with micturition and defecation
60
Q

What does WHO recommend about breastfeeding?

A

Exclusive breastfeeding for first 6 months of life

61
Q

Which demographics of mothers are more likely to breast feed?

A
  • Minority ethnic groups
  • Managerial/professional occupations
  • Over 30
  • First time mothers
  • Left full time occupation after age 18
62
Q

What are the social benefits and detractions of breastfeeding?

A

Benefit - free, no need to buy equipment or formula.

Detractions - socially taboo.

63
Q

What are the medical benefits of breastfeeding for the child?

A
  • Immunity/infection protection
  • Protection against eczema and asthma
  • Reduced rate of SIDS
  • Reduced risk of future type 2 diabetes.
64
Q

What are the medical benefits of breastfeeding for the mother?

A

Reduced risk of breast and ovarian cancer, diabetes and metabolic syndrome, as well as working as a form of contraception.

65
Q

What are the medical disadvantages of breastfeeding for the mother?

A

Vertical transmission of HIV.

Certain medications can be fed to the baby via breast milk

66
Q

What are the problems associated with breast feeding?

A
  • Cracked/sore nipples
  • Blocked ducts
  • Mastitis/abscess
  • Thrush/ductal candidiasis
  • Insufficient milk/frequent feeding - very normal to have to feed frequently, but mothers often lose confidence in their ability to feed the baby.
67
Q

When should breastfeeding be estabilshed?

A

Within an hour of birth, and then on demand, as often as the baby needs.

Reproductive Health Block (10 decks)

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