Postnatal and Puerperium

Question 1

Describe the classification of Perineal Trauma.

Answer 1

First Degree - Injury to skin only
Second Degree - Injury to perineal muscles
Third Degree - involving anal sphincter complex
Fourth Degree - involving anal epithelium

Question 2

How are first and second degree tears managed?

Answer 2

Sutured under Local Anaesthetic

Question 3

How are third and fourth degree tears managed?

Answer 3

Sutured under epidural or spinal anesthetic in an operating theatre for better visualisation
Antibitoitcs, laxatives and analgesia are given
Physiotherpay assessment - sometimes with anal manometry is used.
Long term up to 30% of women have sequale usually incontinence of flatus, or urgency, but occasionally frank incontinence.

Question 4

Define the Puerperium and its significance.

Answer 4

The 6 week period following delivery, when the body returns to its pre-pregnant state.
Maternal morbidity and mortality is highest during this period.

Question 5

When should contraception be started post-delivery and which ones are used?

Answer 5

4-6 weeks post delivery

COCP CI if breastfeeding, so use POP, Depot or IUD.

Question 6

When does menstruation usually return following pregnancy.

Answer 6

It is delayed by lactation

Usually return by 6 weeks in a woman who is not breastfeeding.

Question 7

What is Lochia?

Answer 7

A discharge from the uterus, may be blood stained for the first 4 weeks following delivery, but after that is usually yellow or white.

Question 8

Describe some of the benefits of breastfeeding.

Answer 8

Protection against infection in the neonate
Increased mother-baby bonding
Protects mother against cancers
Can't over feed baby
Cost Saving

Question 9

Why is fluid monitoring important in the first few days following delivery?

Answer 9

Women who have had epidurals are at risk of urine retention, therefore fluid balance charts should be filled in properly

Question 10

What is classed as a post-partum pyrexia?

Answer 10

Temp >38 in first 14 days

Question 11

What are the common pathogens causing genital tract sepsis?

Answer 11

Group A Strep
Staphylococcus
E.Coli

Question 12

What signs might indicate the infection is in the genital tract?

Answer 12

Lochia may be offensive

Uterus may be enlarged and tender

Question 13

How would you define a Secondary Post Partum Haemorrhage?

Answer 13

Excessive blood loss occurring between 24hrs and 6 weeks after delivery

Question 14

List some of the common causes of Secondary Post Partum Haemorrhage

Answer 14

Endometritis (with or without retained placental tissue)
Incidental Gynaecological Pathology
Gestational Trophoblastic Disease

Question 15

What would you find on examination of a woman with Secondary Post Partum Haemorrhage

Answer 15

Uterus is enlarged and tender

Open iternal cervical os

Question 16

How might endometritis due to retained tissue classically progress.

Answer 16

Chronic Bleeding
Slows with antibiotic use
Gets worse again after the course is finished
ERCP is needed.

Question 17

How do we decide if women need thromboprophylaxis with a LMWH postntally

Answer 17

Postnatal risk assessment score for VTE is used.

Splits women into high, intermediate and moderate risk based on a number of different factors.

Question 18

Briefly describe the psychiatric problems of puerperium.

Answer 18

Third Day Blues - temporary emotional lability, affects 50% of women
Postnatal Depression - Affects 10% of women, tiredness, guilt, feelings of worthlessness
Puerperal Psychosis - affects 0.2% of women, abrupt onset of pshychotic Sx usually around day 4

Question 19

If a woman suddenly experiences excruciating pain in the perineum a few hours after delivery, invariably what is the diagnosis

Answer 19

Para-Vaginal Haematoma

Question 20

List some of the causes of maternal collapse, antenatally and postnatally.

Answer 20

Haemorrhage is the most common cause (revealed or abdominal)
Eclampsia or severe pre-eclampsia
PE or amniotic fluid embolus
Maternal Cardiac Disease