Post Pregnancy Flashcards
1
Q
What is Puerperium?
A
- Time from delivery until the anatomic and physiologic changes have resolved. Period of major physical, social and emotional changes involving adaptation
- Can take up to 6 weeks
2
Q
What are the physiological changes that occur in Puerperium?
A
- Lochia and uterine involution
- Lactation
- Menstruation and resumption of ovulation
3
Q
What is Lochia?
A
- Defined as the vaginal discharge containing blood mucous and uterine tissue which may continue for up to 6 weeks after childbirth.
4
Q
What occurs in Uterine Involution?
A
- Uterus is at the umbilicus after delivery of placenta.
- It becomes a pelvic organ by 10 days.
- The cervical Os closes by 3 weeks
5
Q
How does growth of breast tissue occur?
A
- OESTROGEN stimulates duct growth.
- PROGESTERONE stimulates alveolar growth.
- PLACENTAL LACTOGEN affects growth of epithelium in the alveoli.
6
Q
What leads to lactation?
A
- Initiation of lactation is dependent on fall in oestrogen which stimulate release of prolactin from hypothalamus.
- Milk ejection needs oxytocin from posterior pituitary.
- Colostrum produced in first 3 days (has a clearer and turbid colour). This is then followed by milk secretion and continued lactation is dependent on suckling.
7
Q
What is the interaction between menstruation and resumption of Ovulation?
A
-
Non-lactating woman
- Resumption of menstruation in approximately 8 weeks and 1st ovulation is approx. 10 weeks. 40% of 1st cycles are ovulatory.
-
Lactating women
- If for <1 month: menstruation resumes in approx. 10 weeks
- If breast feeding after first month, can take 16 weeks
- Breast-feeding on its own does not provide secure contraception beyond the 9th week postpartum
8
Q
How are mothers managed in the postnatal period?
A
At Discharge
- Inform GP and arrange for midwife and health
- Anti-D if indicated
- Discuss contraception
- Discuss breast feeding
- Perianal care and post-natal exercise
- Vaginal loss/Hb check
Postnatal visit in 6 weeks: Discuss problems and assessment faecal or urinary incontinence
9
Q
What is examined in the post-natal period?
A
- Temperature, BP, Pulse, RR, SATS
- Uterine size and involution
- Vaginal bleeding
- Lochia/discharge
- Abdominal wound (c-section)
- Perineum and paravaginal tissues
- Breast
- Lower limbs for DVT
- Enquire about bladder function and bowel function
10
Q
What are advantages of breast feeding for the newborn?
A
- Easily digested nutrients
- Antibodies in colostrum: Leads to lower incidences of gastroenteritis, respiratory infection, otitis media and narcotising enterocolitis (lysozyme, lactoferrin IgA)
- Avoids milk allergies (1% for cow’s milk)
- Good source of nutrition except Vit C, D and Iron
- Cannot overfeed
- Lower risk of hypocalcaemia
11
Q
What are benefits of breast feeding for the mother?
A
- Promotes bonding
- Improves uterine involution with oxytocin release
- Reduces risk of breast cancer and acts as contraception
- Safe and cheap
12
Q
What are some counselling points regarding breastfeeding?
A
- Babies sleeping in the same room as mothers breastfeeding but not in the same
- If still hungry, weigh before and after feeding: can be fed more often or supplement added
- Check if mother is on medication.
- Contraindicated if active TB or HIV
- Sore nipples are corrected by correcting baby position at breast
- Express milk for babies in special care units
13
Q
How does breastfeeding impact upon medication administration?
A
- Virtually all medications are excreted in milk.
- Amount depends on molecular weight, lipid solubility (high) and protein binding (low).
- Try to take medications after breastfeeding to avoid peak concentration.
- Some drugs such as chemotherapeutics, iodides and lithium are absolutely contraindicated
14
Q
What are some complications encountered in Puerperium?
A
- Puerperal pyrexia
- Secondary post-partum haemorrhage
- Thromboembolic disease: need high index of suspicion in postpartum period
- Mood change (e.g. post-natal depression)
- Urinary or faecal incontinence
15
Q
How does Urinary or faecal incontinence present in Puerperium?
A
- Transient urinary retention common postpartum due to physiological effects of pregnancy and pain. May need catherization and prophylactic antibiotics but usually resolves by itself. Women may get urinary incontinence which may respond to pelvic floor exercises
- Faecal incontinence following childbirth occurs due to damage to perineum particularly with forceps delivery.
16
Q
What are causes of Obstetric haemorrhage?
A
Antepartum: Previous PPH, Placenta abruption/praevia/accrete, Grand multipartity, Anaemia, medical OC, PET, HELLP, Over distended uterus
Intrapartum: Prolonged 1st, 2nd stage, Oxytocin use, Precipitate labour, Operative vaginal delivery (episiotomy), Second stage caesarean section
Post-partum: Uterine Atony, Retained products, Trauma, Thrombin
17
Q
What is Post-Partum Haemorrhage?
A
Defined as blood loss of > 500mls and may be primary or secondary
- Major >1000
- Moderate Major: 1000-2000 mls
- Massive Major: >2000 or 150mls/min
18
Q
What is Primary and Secondary PPH?
A
Primary PPH (5-7% of deliveries): Occurs within 24 hours. Most common cause is uterine atony but other causes include genital trauma and clotting factors
Secondary PPH: Occurs between 24 hours – 12 weeks due to retained placental tissue or endometritis
19
Q
What are risk factors for Primary PPH?
A
- Previous PPH
- Prolonged labour
- Pre-eclampsia
- Increased maternal age
- Polyhydramnios
- Emergency C-section
- Placenta praevia
- Placenta accreta
- Macrosomia
- Ritodrine (beta-2 adrenergic receptor agonist used for tocolyisis)
20
Q
How is a Primary PPH managed?
A
- Resuscitation and observation
- Empty bladder
- Bimanual compression of the uterus
- Identify cause and treat: Uterine atony, remove placenta, suturing, coagulation
- ABC including two peripheral cannulas – 14 gauge
- Medications: IV syntocinon 10 units or IV ergometrine 500 mcg. IM Carboprost used as well.
- Surgical options if medical options fail
21
Q
What are surgical options for Primary PPH?
A
- 1st Line: Intrauterine balloon tamponade where uterine atony is only or main cause of haemorrhage
- *
- Other options: B-lynch suture, Ligation of Uterine arteries or internal iliac arteries
- If severe, uncontrolled haemorrhage, then a hysterectomy is performed as life-saving procedure.
22
Q
What is done in the event of a massive haemorrhage?
A
- Activation of Massive Obstetric Haemorrhage protocol
- MDT
- Transfer to theatre
- Think of 4 Ts: tone, trauma, tissue, thrombin, correct coagulopathy
- Correct coagulopathy: haemocue, TEG
23
Q
How is a Secondary PPH managed?
A
- Conservative
- Antibiotics
- Evacuation under GA if patient gets worse
24
Q
What is Puerparal Pyrexia?
A
- Temperature of >38 o on any occasion up to 6 week after delivery
25
What are causes of Puerperal Pyrexia?
* Endometritis: most common causes
* Urinary tract infection
* Wound infection (perineal tears and caesarean section)
* Breast engorgement and infective mastitis
* Chest infections
* Venous Thromboembolism
26
What are investigative procedures for Puerperal Pyrexia?
* Sepsis 6 Pathway if **_sepsis_**
* MSU
* High Vaginal Swab
* Blood cultures
* Sputum if indicated
* Ultrasound, V/Q etc
27
What is the management for Puerperal Pyrexia?
* If endometritis suspected, patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
28
What are ways to suppress lactation?
* Stop lactation reflex i.e. stop suckling/expressing
* Supportive measures: firm well supported bra and analgesia with or without ice packs
* Bromocriptine is medication of choice if required (cabergoline can also be used)
29
What are symptoms of Mastitis?
* Fever and chills
* Malaise
* Pain and tenderness
* Erythema
* Induration
* Tender axillary lymphadenopathy
* Purulent milk
30
What are types of Mastitis?
* **Acute inflammatory mastitis:** secondary to engorgement. Managed by emptying breast, cold compress and antibiotics prophylactically
* **Infective mastitis:** Staph aureus is usually cause. Leads to peri areolar induration, axillary lymphadenopathy. Penicillin G resistant in 90% of cases. Continue breast feeding
31
What is the management of Mastitis?
* Treat if: systemically unwell, if nipple fissure is present, if symptoms do not improve after 12-24 hours of effective milk removal or if culture indicate infection
* **First line antibiotics:** Flucloxacillin for 10-14 days
* If left untreated may develop into a breast abscess. This generally requires incision and drainage
32
What is the effect of Breast Engorgement?
* A cause of pain in breastfeeding women.
* Usually occurs in first few days after the infant is born and almost always affect both breasts
* Typically pain or discomfort is typically worse just before feeding. May present also with fever which settles within 24 hours. Breasts may appear red.
33
How does Raynaud's disease of the nipple present?
* Presents often with intermittent pain during and immediately after feeding.
* Blanching of the nipple may be followed by cyanosis and/or erythema.
* Nipple pain resolve when nipples return to normal colour
34
How is Raynaud's Disese of the nipple treated?
* Advice on minimising cold exposure
* Use of heat packs following breastfeeding
* Avoid caffeine and stop smoking
* If symptoms persist, consider specialist referral for trial of oral nifedipine (not licensed)
35
What is the management when there are concerns about poor infant weight gain?
* Around 1 in 10 breastfed babies lose more than the 'cut-off' 10% threshold in the first week of life.
* Prompts consideration of possible breastfeeding problems.
* Infant should also be examined to look for any underlying problems. NICE recommends an 'expert' review of feeding if this occurs (e.g. midwife-led breastfeeding clinics) and monitoring of weight until weight gain is satisfactory
36
What is a Galactocele?
* Typically occurs in women who have recently stopped breastfeeding due to occlusion of lactiferous duct.
* Build-up of milk creates cystic lesions in the breast.
* *Lesion can be differentiated from an abscess by fact that galactocele is usually painless with no local or systemic signs of infection*
37
Which medications are contraidicated if Breastfeeding?
* Antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
* Psychiatric drugs: lithium, benzodiazepines
* Aspirin (due to Reye’s syndrome)
* Carbimazole
* Methotrexate
* Sulfonylureas
* Cytotoxic drugs
* Amiodarone
* Clozapine
38
Which disease prohibit breastfeeding?
* Galactosaemia
* Viral infections - HIV in the developing world.
