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4th Year GOSH > Postpartum Care > Flashcards

Postpartum Care Flashcards

1
Q

Excruciating pain in perineum a few hours after delivery?

A

Paravaginal haematoma - Drained under anaesthetic.

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2
Q

Definition of primary PPH?

A

Loss of >500mL of blood within <24 of delivery.

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3
Q

Risk factors for PPH?

A
  • Previous history
  • Previous caesarean delivery
  • Coagulation defect/anticoagulation
  • Instrumental or caesarean delivery
  • Retained placenta
  • Antepartum haemorrhage
  • Polyhydramnios and multiple pregnancy
  • Grand multiparity
  • Uterine malformations or fibroids
  • Prolonged and induced labour
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4
Q

4 Ts of PPH?

A
  • Tissues
  • Thrombin
  • Trauma
  • Tone
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5
Q

Most common cause of PPH? what is it associated with?

A

Uterine atony - is more common with prolonged labour, grand multiparity and with overdistension of uterus (polyhydramnios and multiple pregnancy) and fibroids.

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6
Q

Vaginal trauma in PPH?

A

20% - bleeding from perineal tear or episiotomy is obvious but high vaginal tear must be considered, particularly after an instrumental delivery

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7
Q

Prevention of PPH?

A

Routine use of oxytocin in third stage of labour reduces incidence of PPH by 60%.

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8
Q

Clinical features of PPH?

A

Enlarged uterus suggests uterine cause. Vaginal walls and cervix should be inspected for tears.

Blood loss may abdominal – collapse without overt bleeding.

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9
Q

Initial management of PPH? (resus)

A

Lie patient flat, obtain IV access, X-match, restore blood volume.

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10
Q

Management of PPH if caused by retained placenta?

A

Remove manually if there is bleeding or if it is not expelled by normal methods within 60 minutes of delivery.

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11
Q

Management of PPH caused by uterine atony?

A

o Give IV syntocinon (oxytocin) to contract uterus if trauma not obvious – bolus then infusion.
o Syntomerine (Combination of Oxytocin 5 units and Ergometrine 500mcg) – IM bolus. Ergometrine is an ergot alkaloid derivative
o Misoprostol – Prostaglandin E1 800mcg PR
o Haemabate (carboprost) – PG F2α 250mcg IM

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12
Q

Options in persistent PPH?

A

• Requires surgery – Rusch balloon, brace suture, uterine artery embolization.

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13
Q

What is secondary PPH? Causes?

A

Excessive blood loss between 24h-6 weeks after delivery.

Due to endometritis with or without retained placental tissue, or incidental gynaecological pathology or gestational trophoblastic disease.

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14
Q

Management of secondary PPH?

A
  • Vaginal swabs/FBC/X-match
  • USS
  • Abx given
  • Evacuation of retained products of conception (ERPC) if heavy
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15
Q

What % of pre-eclampsia occurs postnatally?

A

40%

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16
Q

% of VTE deaths are postnatal?

Prevention of VTE?

A

Half

Early mobility and hydration important.

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17
Q

What is endometritis? When does it occur? When is it more common?

A

o Infection within the uterus
o Day 2-10
o More common following section

18
Q

Symptoms and signs of endometritis?

A 
o	Symptoms:
	Fever, malaise, rigors, headache
	Abdo pain
	Offensive lochia
	Secondary PPH

o Signs:
 Fever, tachycardia
 Suprapubic tenderness / uterine enlargement
 Offensive lochia

19
Q

Investigations for endometritis?

A

FBC, CRP
High vaginal swab
Blood cultures

20
Q

Organism that most commonly causes endometritis?

A

Group A strep

Other Gram + organisms eg Staph and Enterococcus
Gram –ve organisms eg E coli
Anaerobes eg Peptococcus, peptostreptococcus

21
Q

Management of endometritis?

A

Co-amoxiclav or cefuroxime + metronidazole

22
Q

What is lactation dependent on?

A

Prolactin

Oxytocin

23
Q

How does prolactin work

A
  • Prolactin from the anterior pituitary stimulates milk production

o Prolactin levels high after birth
o Rapid decline in oestrogen and progesterone following birth causes milk to be secreted (as prolactin antagonized by oestrogen and progesterone)

24
Q

How does oxytocin work?

A
  • Ocytocin from posterior pituitary

o Stimulates milk ejection in response to nipple sucking
o This stimulates prolactin release and further milk secretion
o Can be inhibited by emotional or physical stress

25
Q

Benefits of breastfeeding?

A
  • Protection against neonatal infection
  • Bonding
  • Protection against maternal cancer
  • Cannot give too much
  • Cost saving
26
Q

When should you encourage breasfeeding?

A

Gently encourage to breastfeed when baby demands (within 1 hr of birth)

27
Q

Correct position for breastfeeding?

A

Lower lip below nipple so whole nipple is drawn into mouth when suckling.
Prevents main issues of insufficient milk, engorgement, mastitis and nipple trauma

28
Q

Contraception after delivery?

A

Lactation ok but not adequate alone - hormonal contraception 4-6 weeks after delivery (one period before beginning method)

29
Q

COCP after delivery?

A

Suppresses lactation –> contraindicated in breastfeeding

30
Q

Progesterone only contraceptives?

A

Safe with breastfeeding

31
Q

What is ‘third day blues’?

A

temporary emotional lability which affects 50% of women. Support and reassurance required.

32
Q

Incidence of PND? Scale that detects it?

A

10%

Edinburgh PND scale

33
Q

Symptoms of PND?

A

Tiredness, guilt, feelings of worthlessness

34
Q

Treatment for PND?

A

Social support/psychotherapy

Antidepressants

35
Q

Recurrence of PND?

A

Frequently reoccurs in subsequent pregnancies – 70% risk of depression later in life.

36
Q

Incidence of puperal psychosis? When is onset? In whom is it common?

A

0.2%
Abrupt onset, around 4th day
Common in primigravid women with FH

37
Q

Treatment of puperal psychosis

A

 Psychiatric admission to specialist mother and baby unit - allows the mother to remain close to her baby, ensure the needs of the baby are being met and encourages ongoing close contact between them
 Major tranquilisers (after exclusion of organic illness)

38
Q

Puperal psychosis prognosis?

A

o Usually a full recovery, but some develop mental illness later in life and 10% relapse after a subsequent pregnancy.

39
Q

What to include in post-natal check?

A
  • Maternal Observations
  • Pain relief – perineal trauma, LSCS wound, “after pains”
  • Observe Lochia and involution
  • Observe wounds- perineal or LSCS
  • Ensure urine is passed normally
  • Eating and drinking/flatus + stool
  • Venous Thromboembolism (VTE) risk assessment
  • Encourage mobility-prevent VTE
  • Observe for signs of VTE
  • HB check if signs of anaemia
  • Rubella vaccination- MMR
  • Anti D for rhesus negative women
40
Q

Risk factors for postnatal VTE?

A

Previous VTE, thrombophilia, FH of VTE, increased age/parity, maternal illness, obesity

C-section, prolonged labour, severe haemorrhage, hyperemesis, immobility

4th Year GOSH (23 decks)

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