Postpartum Care Flashcards
Excruciating pain in perineum a few hours after delivery?
Paravaginal haematoma - Drained under anaesthetic.
Definition of primary PPH?
Loss of >500mL of blood within <24 of delivery.
Risk factors for PPH?
- 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
4 Ts of PPH?
- Tissues
- Thrombin
- Trauma
- Tone
Most common cause of PPH? what is it associated with?
Uterine atony - is more common with prolonged labour, grand multiparity and with overdistension of uterus (polyhydramnios and multiple pregnancy) and fibroids.
Vaginal trauma in PPH?
20% - bleeding from perineal tear or episiotomy is obvious but high vaginal tear must be considered, particularly after an instrumental delivery
Prevention of PPH?
Routine use of oxytocin in third stage of labour reduces incidence of PPH by 60%.
Clinical features of PPH?
Enlarged uterus suggests uterine cause. Vaginal walls and cervix should be inspected for tears.
Blood loss may abdominal – collapse without overt bleeding.
Initial management of PPH? (resus)
Lie patient flat, obtain IV access, X-match, restore blood volume.
Management of PPH if caused by retained placenta?
Remove manually if there is bleeding or if it is not expelled by normal methods within 60 minutes of delivery.
Management of PPH caused by uterine atony?
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
Options in persistent PPH?
• Requires surgery – Rusch balloon, brace suture, uterine artery embolization.
What is secondary PPH? Causes?
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.
Management of secondary PPH?
- Vaginal swabs/FBC/X-match
- USS
- Abx given
- Evacuation of retained products of conception (ERPC) if heavy
What % of pre-eclampsia occurs postnatally?
40%
% of VTE deaths are postnatal?
Prevention of VTE?
Half
Early mobility and hydration important.
What is endometritis? When does it occur? When is it more common?
o Infection within the uterus
o Day 2-10
o More common following section
Symptoms and signs of endometritis?
o Symptoms: Fever, malaise, rigors, headache Abdo pain Offensive lochia Secondary PPH
o Signs:
Fever, tachycardia
Suprapubic tenderness / uterine enlargement
Offensive lochia
Investigations for endometritis?
FBC, CRP
High vaginal swab
Blood cultures
Organism that most commonly causes endometritis?
Group A strep
Other Gram + organisms eg Staph and Enterococcus
Gram –ve organisms eg E coli
Anaerobes eg Peptococcus, peptostreptococcus
Management of endometritis?
Co-amoxiclav or cefuroxime + metronidazole
What is lactation dependent on?
Prolactin
Oxytocin
How does prolactin work
- 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)
How does oxytocin work?
- 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
Benefits of breastfeeding?
- Protection against neonatal infection
- Bonding
- Protection against maternal cancer
- Cannot give too much
- Cost saving
When should you encourage breasfeeding?
Gently encourage to breastfeed when baby demands (within 1 hr of birth)
Correct position for breastfeeding?
Lower lip below nipple so whole nipple is drawn into mouth when suckling.
Prevents main issues of insufficient milk, engorgement, mastitis and nipple trauma
Contraception after delivery?
Lactation ok but not adequate alone - hormonal contraception 4-6 weeks after delivery (one period before beginning method)
COCP after delivery?
Suppresses lactation –> contraindicated in breastfeeding
Progesterone only contraceptives?
Safe with breastfeeding
What is ‘third day blues’?
temporary emotional lability which affects 50% of women. Support and reassurance required.
Incidence of PND? Scale that detects it?
10%
Edinburgh PND scale
Symptoms of PND?
Tiredness, guilt, feelings of worthlessness
Treatment for PND?
Social support/psychotherapy
Antidepressants
Recurrence of PND?
Frequently reoccurs in subsequent pregnancies – 70% risk of depression later in life.
Incidence of puperal psychosis? When is onset? In whom is it common?
0.2%
Abrupt onset, around 4th day
Common in primigravid women with FH
Treatment of puperal psychosis
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)
Puperal psychosis prognosis?
o Usually a full recovery, but some develop mental illness later in life and 10% relapse after a subsequent pregnancy.
What to include in post-natal check?
- 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
Risk factors for postnatal VTE?
Previous VTE, thrombophilia, FH of VTE, increased age/parity, maternal illness, obesity
C-section, prolonged labour, severe haemorrhage, hyperemesis, immobility
