Post-Partum Problems Flashcards
what is the puerperium?
6 weeks following birth
period of repair and recovery
how does vaginal discharge change over first 3 weeks of puerperium?
3-4 days = fresh red blood (“rubra”)
4-14 days = brownish-red, watery (“serosa”)
10-20 days = yellow (“alba”)
what is uterine involution?
group of changes which occur during puerperium
what changes occur in uterine involution?
endometrial lining regenerates by day 7
fundus returns to physiological location within pelvis by 2 weeks
uterine weight decreases to 5% of immediate post birth weight
does lower repro tract return to normal after pregnancy?
no
regress but never return to pre-pregnancy state
by which month of pregnancy will breasts have fully adapted to produce milk?
5th or 6th month
what is colostrum?
first milk a breastfed baby will receive
thick yellowish substance
contains more protein and vitamins than later milk
essential for early immunological protection in newborn
how is lactation initiated?
expulsion of the placenta in stage 3 of labour
also the decrease in oestrogen and progesterone levels
what inhibits milk production during pregnancy?
high levels of oestrogen and progesterone block release of prolactin from anterior pituitary
is prolactin produced in pregnancy?
yes
but its prevented from carrying out its function of milk production
how does prolactin cause milk production?
after birth, hormone levels drop abruptly (while prolactin is still being produced at high levels)
prolactin is therefore released triggering milk production by lactocytes in mammary alveoli
how is prolactin release maintained?
via a positive feedback mechanism whereby the suckling infant promotes prolactin production by stimulating nipple mechanoreceptors
what is the let-down reflex?
mechanism of milk release from the breast during feeding
suckling stimulates production of oxytocin from posterior pituitary > oxytocin stimulates myoepithelial cells which surround breast alveoli > myoepithelial cells contract in response to oxytocin and squeeze milk out of the nipple
what else can trigger let down reflex?
pain
alcohol
sight and cry of an infant
path of milk from production to leaving nipple?
milk produced in lactocytes in mammary alveoli
myoepithelial cells squeeze milk from alveoli so it drains into lactiferous ducts
milk pools in lactiferous sinus before being discharged through nipple pores
is breastfeeding recommended by WHO?
exclusive breastfeeding for first 6 months is recommended
its recommended that breastfeeding should continue past 6 months but alongside introduction of appropriate solid foods for up to 2 years or as long as mother chooses
what is mastitis?
inflammation of the breast
can be due to infectious and non-infectious causes
most common cause of mastitis?
infectious
staph aureus = most common infecting organism
coag +ve staph = 2nd most common cause
what can cause a non-infective mastitis?
duct ectasia (blocked lactiferous duct) foreign body such as breast implant or nipple piercing
how can lactation mastitis occur in breastfeeding?
most commonly linked to improper breastfeeding technique
trauma to breast and subsequent milk stasis and ineffective milk release make the breast more likely to harbour bacteria and therefore more prone to infection
risks of maltreatment of lactation mastitis?
can lead to an abscess (usually in peripheral breast in breastfeeding women)
what should a focused history of mastitis evaluate for?
MAIDS
- milk stasis?
- abscess present?
- Inflammation?
- discharge from nipple?
- systemic symptoms of infection?
how is mastitis diagnosed?
clinical diagnosis
empirical treatment of lactation mastitis?
full course of staph aureus sensitive antibiotics as soon as signs of the condition appear
- flucloxacillin 500mg orally every 6 hrs for 7 days
- augmentin 625mg every 8 hrs for 7 days
should examine patient every few days to check therapeutic response
important that breastfeeding continues (can even use a breast pump for infected breast if needed)
what is done if patient is showing signs of an abscess?
breast US
aspiration with an 18-guage needle for culture should be performed to confirm the diagnosis
PPH definition?
blood loss of 500ml or more after the birth of the baby
primary vs secondary PPH?
primary = bleeding occurs within 24 hrs of delivery secondary = bleeding occurs between 24 hrs and 6 weeks post delivery
minor vs major PPH?
minor = 500 - 1000ml major = >1000ml or signs of cardiovascular collapse or ongoing bleeding
how can severity of PPH be related to size of patient?
estimate blood volume as equivalent to 100mls per kg and multiple this by patients weight in kg
eg a 65kg patients blood volume would be estimated at 6500ml (6.5L)
causes of PPH (4Ts)?
tone (uterine atony) = main cause
trauma = 2nd most common
tissue (retained products of conception) = 3rd most common
thrombin = least common cause
antenatal risk factors for PPH?
placental problems (praevia, accreta, percreta)
previous history of retained placenta, C-section or PPH
multiple pregnancy
polyhydramnios
obesity
fetal macrosomnia
intrapartum risk factors for PPH?
operative vaginal delivery syntocinon/syntometrine use (induced labour) retained placenta c-section labour >12 hrs perineal tear/episiotomy during delivery
initial assessment and stabilisation of PPH?
ABCDE oxygen (15l/min via non-rebreather mask) get IV access bloods cross-match 6 units red packed cells check vital signs every 15 mins determine cause of bleeding consider initiating massive haemorrhage protocol early blood transfusion give tranexamic acid 0.5-1g IV to stop the bleeding (regardless of cause)
how can you stop the bleeding non-surgically in PPH?
uterine massage expel clots manually give 5 units syntocinon insert catheter to minimise bladder pressure on uterus give 500mcg IV ergometrine if no response to syntocinon exclude repair/trauma give carboprost 250mcg IM every 15 mins give misoprostol 800mcg PR
surgical methods of stopping the bleeding in PPH?
balloon insertion to put pressure on bleeding blood vessels
arterial embolisation via interventional radiology
“B-lynch” sutures
uterine artery ligation
internal iliac ligation
hysterectomy is a last resort
how is fluid replacement done in PPH?
2 large bore IV access
rapid fluid resuscitation (crystalloid, 0.9% saline)
blood transfusion early (consider O- if life threatening)
if DIC/coagulopathy occurs then give FFP, cryoprecipitate, platelets
use a blood warmer
how can secondary PPH be prevented?
give thromboprophylaxis
debrief the couple
manage anaemia with iron supplementation
how common is perineal tear?
9 in 10 first time mothers
what are the 4 degrees of tear?
1 = involves skin only
2 = involving skin and perineal muscles such as levator ani, usually needs stitches
3 + 4 = extend to external anal sphincter muscle, may need surgery as mother may experience faecal incontinence due to overstretching of pudendal nerve branches
how as an episiotomy different from perineal tear?
episiotomy is a surgical cut made with patients consent
how is anaesthesia used in episiotomy?
local anaesthetic injected along the site of the tear/episiotomy to anaesthetise branches of pudendal nerve (12)
blood supply to foetus while in the womb?
via placenta
umbilical vein (belonging to foetus) carries oxygenated blood from placenta to two areas (little bit to foetal liver and rest to foetal IVC via ductus venosus)
this causes blood to mix as the IVC carries oxygenated blood
the mixed blood drains into the right atrium of the heart as the deoxygenated blood from SVC
function of foramen ovale in the foetus?
small hole in the septum where blood from the right atrium can pass into the left atrium
exists to relieve pressure on the right side of the heart caused by increased pulmonary resistance
possible paths of blood flow once it enters right atrium?
can drain into the right ventricle to then be pumped via the pulmonary arteries to the lungs
or
can pass into the left atrium via the foramen ovale
why is there increased pulmonary resistance in the foetus?
alveoli contain fluid rather than air which means they lack oxygen
as a result, nearby arterioles vasoconstrict in response to the alveoli’s hypoxic state and increase the pulmonary resistance
what other structure helps relieve the pressure on the right side of the foetal heart due to increased pulmonary resistance?
ductus arteriosus
what does the ductus arteriosus do?
vessel which connects the pulmonary arteries to the aort
