Post-Partum Problems (the Puerperium) Flashcards
Demonstrate detailed knowledge and understanding of the aetiology, recognition and management of primary and secondary postpartum haemorrhage.
Primary PPH: Blood loss of 500mL or more within 24 hours of labour
Secondary PPH: Excessive blood loss between 24 hours and 6 weeks after labour
Minor 500mL - 1000mL
Major 1000 - 2000 mL
Massive/Severe > 2000mL
Aetiology
Primary PPH:
- Tone (90%) - uterine atony, uterine inversion (overdistended uterus due to twins or polyhydramnios, prolonged labour, infection, retained tissue, no active management of the 3rd stage, placenta abruption causing bleeding into the uterine muscle which prevents uterine contraction)
- Tissue - Retained placenta, large placenta, abnormal placental site (placenta praevia/accreta/percreta)
- Thrombin - Coagulation disorders
- Traumatic delivery - Genital tract trauma
Secondary PPH:
- Infection
- Poor healing
- Retained tissue
Risk factors
Antenatal risk factors: Previous PPH, previously retained placenta, high BMI, para 4 or >, antepartum haemorrhage, overdistention of the uterus, uterine abnormalities, low-lying placenta, maternal age > 35 years
Intrapartum risk factors: Induction of labour, prolonged 1st/2nd/3rd stage, use of oxytocin, vaginal operative delivery, CS
Recognition
- PV bleeding
- Lochia rubra present for > 4 days
- Reduced uterine involution
- Maternal anaemia
Management
Lochia: Vaginal discharge in the post-partum period
The vaginal discharge from the placental site may persist for 3-6 weeks, on average 4/52. Has a ‘fishy odour’ and is alkaline
Lochia rubra: Red colour. Usually last 1-4 days
Lochia serosa: Paler in colour (pink/brown). Usually lasts from day 4-10
Lochia alba: Yellow/clear in colour. From day 10 until around day 28
Importance of monitoring lochia
- Prolonged redness of lochia may indicate prolonged involution of the uterus - may be due to retained tissue or infection
- Offensive odour may indicate infection
Demonstrate detailed knowledge and understanding of the aetiology, recognition (symptoms and investigations) and management of thromboembolism – detection and prevention.
Aetiology:
- Presence of risk factors* - prophylactic LMWH should be given antenatally for those with 4 or > current risk factors
- Pregnancy is a hypercoagulable state
- DVT is more common in the antenatal period whilst thromboembolism is more common in the puerperium
Recognition:
DVT symptoms: Swelling, redness, tenderness of the calf, pyrexia, elevated WBC, lower abdominal pain, focal signs in the chest (e.g. reduced air entry)
Investigations:
- Ultrasound (compression or duplex)
- Contrast venography
- MRI
PE symptoms: Tachycardia, sudden onset dyspnoea, chest pain (pleuritic), haemoptysis, collapse, raised JVP
Investigations:
- ECG: Sinus tachycardia, non-specific ST segment and T wave changes, SIQIIITIII (peaked, peaked, inverted)
- CXR: Used to assess for ddx such as pneumonia or pneumothorax. Enlarged pulmonary artery may be seen
- ABG
- V/Q scan
Management:
- Anticoagulant therapy: LMWH
Peak anti-Xa activity should be measured to ensure adequate anticoagulation at 3 hours post-injection
BD regime for treatment of VTE in pregnancy
Should be continued for at least 6 weeks after delivery
Warfarin may be used postnatally - safe for breast feedings
- Leg elevation and compression stockings - reduce oedema
- Ensure haemodynamic stability
Management of life-threatening massive PE
Thrombolytic therapy, percutaneous catheter thrombus fragmentation or surgical embolectomy may be required
*Risk factors for VTE assessed at booking visit: Previous VTE, thrombophilia, medical comorbidities, > 35 years old, obesity, parity > 3, smoking, gross varicose veins, paraplegia, multiple pregnancy. Other risk factors arising in pregnancy/labour - current pre-eclampsia, CS, prolonged labour, stillbirth, preterm birth, PPH > 1L
Demonstrate detailed knowledge and understanding of the aetiology, recognition and management of the physiology of neonatal adaptation to extrauterine life
Circulatory adaptation
- Neontal circulation: Umbilical vein → liver → ductus venosus shunts blood to the IVC → delivered to the right atrium → passes to the left atrium via the foramen ovale → to left ventricle → directed to foetal head and upper extremities → deoxygenated blood is directed back to the right atrium by the SVC → blends with oxygenated blood from the placenta → enters the right ventricle and pulmonary artery → shunted across the ductus arteriosusu into the descending aorta → provides oxygen to the lower half of the body → returns to the placenta via the 2 umbilical veins
- Clamping of the placenta triggers an increase in systemic vascular resistance, blood pressure and left sided heart pressure
- Pulmonary vascular resistance decreases
- Elimination of the ductus venosus - hepatic shunt
- Foetus gains a ‘normal’ circulation
Respiratory adaptation
- Umbilical cord clamping decreases oxygen concentration, increases CO2 and decreases pH. This stimulates aortic and carotid chemoreceptors, activating the respiratory centre in the medulla to initiate respiration
- Mechanical compression during birth forces 1/3 of fluid out of the foetal lungs
- Passive inspiration of air replaces fluid
- Crying creates a positive intrathoracic pressure which keeps the alveoli open
- Function requires adequate pulmonary blood flow, adequate surfactant and adequate respiratory musculature
Cardiovascular adaptation
- Ductus arteriosus closes in response to elevated oxygen levels and reduction in prostaglandin levels
- Foramen ovale closes
Demonstrate knowledge of the diagnosis and management of maternal collapse including massive obstetric haemorrhage, cardiac problems, pulmonary and amniotic embolism.
State the possible causes of maternal collapse
Demonstrate knowledge of the management of medical disorders (postnatal management of those identified antenatally)
Baby-blues:
- First week post-partum
- Generally, reassurance is all that’s required
- Complete risk assessment, safety net and ensure there is adequate support at home
Post-natal depression
- Generally seen at around 3/12
- Assess risk
- Have a low threshold for provision of SSRIs - fluoxetine is the most suitable
Puerperal psychosis
- Most commonly seen a few weeks following delivery
- Hallucinations, disordered thoughts and delusions
- Assess risk to self and baby
- Most require admission to psychiatric unit
Demonstrate knowledge of the diagnosis and management of puerperal pyrexia.
Aetiology:
Genital causes: Uterine infection/endometritis, perineal wound infection
Risk factors: CS, prelabour rupture of membranes, intrapartum chorioamnionitis, prolonged labour, multiple pelvic examinations
Prophylactic Abx should be given following CS to reduce the risk of puerperal pyrexia
Non-genital causes: Breast causes (mastitis, breast abscess), UTI, thrombophlebitis, abdominal wound infection, respiratory complications, DVT (may cause low grade pyrexia)
Diagnosis:
Maternal pyrexia (> 38ºC) in the first 14 days following labour.
Signs and symptoms of genital causes of maternal pyrexia
- Fever (> 37.5ºC)
- Foul smelling, profuse and blood discharge
- Subinvolution of uterus
- Tender bulky uterus on abdominal examination
Physical examination as indicated - abdomen, breast, IV accesss sites, chest and legs
Investigations - to identify the source of infection and causative organism
- FBC
- Blood cultures
- MSU (midstream urine sample)
- Swabs from the cervix and lochia for chlamydia and bacterial culture
- Wound swabs
- Throat swabs
- Sputum culture and CXR
Management:
Sepsis 6:
Take bloods/venous lactate, cultures and regular observations
Give Abx, fluids and xygen
Supportive: Analgesia and NSAIDs; wound care in infective causes; ice packs for pain from the perineum or mastitis
Antibiotics
! Tetracyclines should be avoided in breast-feeding mothers
- Flucloxacillin is indicated in mastitis persisting beyond 24 hours or with systemic upset.
- ALONGSIDE breast massage, expression of breast milk and warm/cold compress as required
- Candida of the nipple may occur following abx use. Requires topical miconazole for the nipple and topical treatment of the infants oral cavity
Surgical
- Incision and drainage of breast abscess
- Secondary repair of wound
- Drainage of pelvic haematomas and abscesses
Demonstrate and awareness of the structure and reasons for postnatal review.
NIPE within 72 hours of birth
Discharge between 6 - 24 hours after birth of the baby
Newborn hearing screening test and blood spot test at 5-8 days
Visits from your midwife up to 10 days after birth
Postnatal check at 6 weeks post-partum (mental health, contraception, wound care)
- Discussion surrounding mental health and well-being
- Asked if vaginal discharge is still present
- BP check if problems were present during pregnancy
- Examination of episiotomy or CS scar
- Ask if any problems with sexual intercourse. Advise use of lubricants - as breast feeding can casuse vaginal dryness
- Check BO - any pain/difficulty
- Discussion about contraception: It is possible to become pregnant within 21 days of labour, even if fully breastfeeding
- OGTT may be performed if gestational diabetes was diagnosed during the pregnancy
Baby’s 6 - 8 week check
Demonstrate an awareness of the issues relating to care of the perineum.
! Maternal morbidity and mortality associated with pregnancy is highest during this period.
Many women continue to have problems after discharge but the lack of contact with HCPs mean that problems often go untreated or unrecognised.
Possible problems:
- Post-partum bleeding
- Infection - endometritis, UTI, RPOC
- Psychiatric problems
- Wound healing/associated problems: Poor healing, infection, dyspareunia, dyschezia
Demonstrate an awareness of the issues relating to Lactation.
- Correct positioning of the baby is vital
- The lower lip should be planted below the nipple at the time that the mouth opens
- Insufficient milk, engorgement, mastitis and nipple trauma can be problems that arise due to breast feeding due to poor positioning
- Oxytocin levels can be reduced by stress
- IM vitamin K is required to reduce the likelihood of haemorrhagic disease of the newborn
- Tongue tie can make breast feeding difficult
- Combined contraception suppresses lactation and hence is contraindicated in breast feeding. Contraception is usually started 6 weeks after delivery.
- Progesterone only (pill or depot) is safe. An IUD may be inserted at the end of the third stage of labour or after 4 weeks (screen for infection first!)
Physiology of lactation:
Prolactin from the anterior pituitary gland stimulates milk secretion- rapid decline in progesterone and oestrogen remove antagonism of prolactin.
Oxytocin from the posterior pituitary gland stimulates ejection in response to nipple sucking.
Demonstrate an awareness of the issues relating to psychiatric disorders of the puerperium.
‘Baby blues’: Normally occur around day 3/4. Reassurance and support are required
Postnatal depression:
- Edinburgh Postnatal Depression Scale (EPDS) can be helpful in screening for postnatal depression
- Peak presentation at 3/4 weeks and 3 months post-partum
- Investigations to exclude organic causes should also be performed
- There is commonly a history of psychiatric problems
- Symptoms include tiredness, guilt and feelings of worthlessness
- Biopsychosocial approach
- SSRIs are preferred: Sertraline
Puerperal psychosis:
- Abrupt onset of psychotic symptoms
- Peak presentation is at 2 weeks
- Common in primigravid women with a FHx
Demonstrate a detailed knowledge and understanding of contraception.
- Can conceive from 21/7 post-partum
- If suffering from dyspareunia suggest use of a lubricant (breast feeding can particularly increase vaginal dryness)
- LAM may be used up to 6/12 post-partum, if fully breastfeeding
- MUST Assess VTE risk, especially if considering use of the COCP
- MUST do vaginal swabs and check for PID/fibroids before inserting an IUD
- Absolute contraindications:
- COCP before 6/12 post-partum
- IUD can only be inserted upto 48 hrs post-partum and after 4/52 post-partum
