Postnatal Flashcards
What is PPH?
Blood loss after delivery of baby + placenta.
Primary - within 24 hours of birth
Secondary - 24 hours - 12 weeks after
500ml after vaginal or 1000ml after CS. Minor <1L, Major >1L, mod 1-2L, severe >2L.
Causes of PPH?
4 T’s:
Tone: uterine atomy, soft boggy uterus + ineffective contractions (normally compress BVs). Uterine overdistension (multiple gest, polyhydramnios). Uterine fatigue (prolonged labour), full bladder, preterm labour, fibroids/Ca, anaesthetics esp halothane, Mg sulfate, nifedipine.
Trauma: perineal tear, trauma, surgical incision (section, episiotomy).
Tissue: retained placenta fragments, placenta accrete, XS traction on UC
Thrombin: impaired clotting, VWD, DIC, related to obstetric complication eg eclampsia, placenta previa.
RFs for PPH?
prev PPH, obesity, PE, placenta accrete/previa, GA, XS oxytocin, ↑age, emergency CS ritodrine (β adrenergic receptor agonist for tocolysis).
Features of PPH?
XS bleeding
↑HR, ↓BP, pulse pressure, O2 sat, haematocrit, delayed CRT.
Shock signs usually appear when haem advanced due to normally ↑pregnancy blood volume
Soft boggy uterus
Prevention of PPH?
treat anaemia via blood transfusion
empty bladder before labour
active Tx of 3rd stage.
Tranexamic acid during CS in 3rd stage for high risk
Group + cross match 4 units.
Investigation of secondary PPH?
Retained products of conception or infection i.e. endometriosis
Investigations: USS – see products, endocervical + high vaginal swabs for infection
Management: surgical evacuation of RPOC, Abx of infection
Management of PPH?
2 large bore cannulas
Warmed IV fluids + bloods
Syntometrine: when head + ant shoulder delivered, otherwise can cause shoulder dystocia
Mechanical: rub uterus through abdo > stim contractions. Catheter ↓bladder distension
Syntocinon: oxytocin 10U, slow injection, followed by continuous infusion (40 units in 500mls)
Ergometrine: IV/IM, stim smooth muscle contractions. CI in HTN. 500micrograms
Carboprost: IM prostaglandin analogue, stim uterine contraction. Caution in asthma.
Misoprostol: sublingual prostaglandin analogue. Stimulate uterine contraction.
Tranexamic acid: antifibrotic, ↓bleeds
IU balloon tamponade: press against bleeding
B-lynch suture: suture around uterus + compress
Hysterectomy: last resort, save woman’s life
Interventional radiology: uterine artery embolism
What is shoulder dystocia?
Ant shoulder of baby stuck behind pubis symphysis after head delivered
RFs for shoulder dystocia?
fetal macrosomia (maternal DM)
↑maternal BMI
prolonged labour
IOL
Features of shoulder dystocia?
Difficulties delivering face + head
Failure of restitution: head remains faced down, doesn’t turn sideways
Turtleneck: head delivered but retracts back into vagina.
Fetal hypoxia: CP
Brachial plexus injury + Erb’s palsy
Perineal tears
PPH
Management of shoulder dystocia?
Stop pushing
McRobert’s: work in 90% bring knees to abdo, lift pubic symphysis out of way, pressure on ant shoulder on suprapubic
Episiotomy: allows other manoeuvres
Robins: reach into vagina, pressure on post aspect of baby’s ant shoulder.
Wood screw: rotate baby, top shoulder pushed forward + bottom backwards to move baby 180°
Zavaneli’s: usually LT consequences for baby. Pushing baby’s head back into vagina so baby can be delivered CS.
Cleidotomy: fracture fetal clavicle
Symphysiotomy: cutting pubic symphysis
What is Sheehan’s syndrome?
postpartum pituitary necrosis secondary to a postpartum haemorrhage
Pit ↑ size in gestation
↑no of lactotrophs
↑blood demand w/o ↑blood supply.
PPH
pit infarct
necrosis. Pit gland scars + shrinks.
Only ant pit: TSH, FSH ACTH, LH, GH PRL
Symptoms of Sheehan’s syndrome?
↓lactation: PRL
Amenorrhea: ↓LH + FSH. Infertility, loss of libido.
Adrenal insuff + crisis: ↓ cortisol + ACTH. Tiredness, postural hypotension.
Hypothyroidism
Investigations for Sheehan’s syndrome?
MRI: pit ring sign (halo around empty sella)
Pit hormone levels
Obstetric history
Management of Sheehan’s syndrome
Replacement of missing hormones
GC replacement (emergent) if adrenal insufficiency
Causes of puerperal pyrexia and sepsis?
Fever>38, within 6wks PP.
Endometritis: most common.
>
RF prolonged labour, PROM, CS retained placental/fetal tissue, IUD. GBS, ureaplasma urealyticum, peptostrem, chlamydia, gonorrhoea
UTI: e coli, proteus, klebsiella
Genital tract: e coli, GAS, staph, clostridium welchii
Mastitis
DVT, ovarian vein thrombophlebitis
Features of puerperal pyrexia and sepsis?
Pyrexia
Sustained ↑HR + RR
Abdo/CP
D/V
Uterine or renal angle pain + tenderness
Woman unwell or seems unduly anxious or distressed
Dyspareunia. Dysuria
Purulent + foul smelling lochia.
Investigations for puerperal pyrexia and sepsis?
Wound + high vaginal swabs
Blood cultures
FBC
Urine microscopy + cultures
Throat swabs + sputum cultures
CXR, pelvic USS
Management of puerperal pyrexia and sepsis?
Not unwell: ice packs for pain, rest, fluid intake, oral Abx broad spectrum
Clinically unwell: admission, clindamycin + gentamicin until afebrile for >24hrs. Analgesics (not NSAIDs > impede ability of polymorphs to fight infection)
Removal of retained tissue
What are baby blues?
3-7 days following birth
60-70% of women
Particularly 1st time mothers
Due to: hormonal changes, sleep deprivation, fatigue, overwhelming responsibility
Features - Mood swings, low mood, anxiety, Irritability, Tearfulness
Management - Self-limiting, Resolve within 2 wks, Self-limiting
What is post-natal depression?
Start within a month, peak around 3mnths
Lasts >2wks
10% of women
Sx: Low mood, low energy Anhedonia Inadequacy, unable to cope, feeling guilty, irritable wanting to cry Obsessive + irrational thoughts Loss of appetite Difficulty sleeping/ concentrating.
Hostile/ indiff to partner/ baby.
Thoughts about harming self/ baby
Diagnosis and management of post-natal depression?
Edinburgh PND scale: 10 item questionnaire indicates how mother felt over prev wk. >13.
Mild: self-help, follow up GP.
Mod: SSRI (sertraline + paroxetine), CBT
Severe: specialist in pt mother + baby unit
What is puerperal psychosis?
Few wks after birth
0.2% of women
25-50% recurrence
Begins abruptly
Sx: Delusions Hallucinations Depression Mania Confusion Severe moods swings Thought disorder
Diagnosis and management of puerperal psychosis?
Urgent assessment
Admission to mother + baby unit CBT Antidepressants Antipsychotics Mood stabilisers ECT.
What is breast engorgement?
Breasts become overly full - feel hard, tight and painful
1st few days after born
Milk accumulation in breast tissue, vascular congestion
can be due to newborn not feeding as much as perhaps they need to
Sx of breast engorgement?
Firm, tender breast
↑vascular markings
Pain, typically worse just before feed.
Milk tends to not flow well from engorged breast, infant find it hard to attach + suckle
Can cause:
Blocked milk duct
Mastitis
Difficulties BF
Management of breast engorgement?
Freq feedings, good latch to ensure empty breast
Pumping
Warm shower/ compress before feeding (enhances let down)
Cool compress after feed
NSAID.
Summary of sore, cracked nipples?
Cause: improper latch/ position
Pain, blister/bleb on nipple if pores plugged
Prevent: good BF technique
Cool/warm compress
Apply expressed milk to nipple.
What is mastitis?
an inflammation of breast tissue that sometimes involves an infection
Infective 30% (s aureus), non infective 70% (poor positioning, inadequate milk removal, milk stasis, back pressure, leaks into interstitial tissue > inflam.
Sx of mastitis?
Usually unilat
Localised warmth, tenderness/pain
Oedema
Erythema
Firmness
Acute onset flu like Sx
Complications - Breast abscess that may require incision + drainage.
Management of mastitis?
Prevention: good hygiene.
Continue breastfeeding
NSAIDs
Flucox 10-14 days: systemically unwell, nipple fissure, Sx don’t improve after 12-24 hrs of effective milk removal, if cultures indicate infection.
Summary of yeast infection of breast?
Candida albicans, Hx of infant oral/diaper/ maternal vaginal candida infection,
Infant plaques in oral
Mother: pain, red/sore cracked nipples
Prevention: good hygiene, avoid XS moisture by keeping breasts dry between feeds
Mother: miconazole cream after feeding.
Infant: nystatin solution swabbed into oral mucosa after feed.
What is Raynaud’s disease of the nipple?
blood vessels in the nipples are affected, causing pain during, immediately after, or between breastfeeds.
Blanching of nipple may be followed by cyanosis +/or erythema
Nipple pain resolves when nipples return to normal colour
Tx:
Advise minimising exposure to cold, use heat packs following BF, avoid caffeine, stop smoking.
if persist, refer to specialist for trial of nifedipine.
