Postpartum Problems 1

Question 1

What is the normal post partum period?

Answer 1

6 weeks following delivery when the body returns to the prepregnant state

Question 2

What changes occur in the postpartum period in the genital tract?

Answer 2

placenta separates
uterus contracts and size decreases
after pains for 4 days
fibres of myometrium occlude blood vessels that supplied placenta
discharge (locia) may be blood stained for 4 weeks then yellow/white
menstruations delayed by lactation but 6 weeks later if not

Question 3

What changes occur to the CV system in the postpartum period?

Answer 3

CO and plasma volume decreases within a week

loss of oedema up to 6 weeks

Question 4

What changes occur to the urinary tract in the post partum period?

Answer 4

dilation reduced over 3 months

GFR decreases

Question 5

How is anaemia managed in the postpartum period?

Answer 5

FBC including haemoglobin, serum ferritin, serum soluble transferrin receptor

treat with iron tablets or IV

Question 6

What is the structure and reason for a postnatal review?

Answer 6

mum and baby should not be separated
encourage early mobilisation
help with breastfeeding
uterine involution, loch, BP, temp, pulse and perineal wounds checked daily
fluid balance checked for those that had an epidural
analgesia and pelvic floor exercises for perineal pain
FBC checked before discharge
alert GP of complications

Question 7

Is contraception needed in the post partum period?

Answer 7

Lactation not adequate alone

Contraception usually started 4-6 weeks after delivery

Combined contraceptive contraindicated if breastfeeding (suppresses lactation)

Progesterone-only (pill/depot) safe in breastfeeding

IUD safe (screen for infection, then insert at end of third stage or at 6 weeks)

Question 8

What is a primary PPH?

Answer 8

loss of >500mls blood <24hours after delivery or >1000ml after C-section

10% of women

Question 9

What are the causes of primary PPH?

Answer 9

retained placental fragments 
atonic uterus 
perineal trauma
uterine rupture 
cervical tear 
high vaginal tear 
coagulopathy

Question 10

When is atonic uterus more common?

Answer 10

with prolonged labour, grand multiparty, polyhydramnios, multiple pregnancy, fibroids

Question 11

How are primary PPHs recognised?

Answer 11

enlarged uterus suggests uterine cause
inspect vaginal walls and cervix for tears
collapse without pain/over bleeding suggests abdominal blood loss

Question 12

How are primary PPHs managed?

long

Answer 12

Resus - IV access, blood cross match and restore blood volume
Retained placenta - remove manually if bleeding or if not expelled by uterus in 60mins of delivery
Identify cause of bleeding - vaginal exam and bimanually palpate uterus
May need to examine under anaesthetic
Prostaglandin F2a injected into myometrium for persistent uterine atony
Persistent haemorrhage despite medical treatment needs surgery

Question 13

What surgery is used in primary PPH?

Answer 13

Rusch ballon
Brace suture
Uterine artery embolisation
Hysterectomy

Question 14

What is used in primary PPH is there is persistent uterine atony?

Answer 14

prostaglandin F2a is injected into myometrium

Question 15

What is a secondary PPH?

Answer 15

persistent excessive blood loss between 24hours and 6 weeks after delivery

Question 16

What are the causes of secondary PPH?

Answer 16

Endometritis +/- retained placental tissue (most common)

Incidental gynaecological pathology

Gestational trophoblastic disease

Question 17

How is secondary PPH managed?

Answer 17

Vaginal swabs + FBC taken (cross match in severe cases)

US often used but retained placenta may be mistaken for blood clot/vice versa

Antibiotics

Evacaution of retained products of conception if bleeding heavy

Question 18

What are the causes of thromboembolism?

Answer 18

DVT/PE leading cause of maternal mortality but<0.5% affected
Half the deaths postnatally usually after discharge from hospital

Question 19

How can thromboembolism be prevented?

Answer 19

mobilisation
hydration
compression stockings
LMWH (antenatally if high risk and frequently used postpartum)

Question 20

What hormones is lactation dependent on?

Answer 20

prolactin and oxytocin

prolactin (ant pituitary gland) antagonised by oestrogen and progesterone

Question 21

How much milk is produced by each day?

Answer 21

1000+ml of milk per day

depends on demand

Question 22

What are the advantages of breast feeding?

Answer 22

Protection against infection in neonate
Bonding
Protection against cancers (mother) 
Cannot give too much 
Cost saving

Question 23

What are the third day blues?

Answer 23

temporary emotional lability affects 50% of women, require support and reassurance

Question 24

How is post natal depression managed?

Answer 24

social support
psychotherapy
antidepressants

Question 25

How common is post natal depression?

Answer 25

affects 10% of women

more common if socially/emotionally isolated, have history or after pregnancy complication

Question 26

How common is puerperal psychosis?

Answer 26

affects 0.2% of women, characterised by abrupt onset of psychotic symptoms around 4th day

more common is primigravid women with family history

Question 27

What is the treatment for puerperal psychosis?

Answer 27

psychiatric admission
major tranquillisers
after exclusion of organic illness

Question 28

How is perineal trauma managed?

Answer 28

perineal trauma repaired after delivery of placenta
pain persists >8 weeks in 10%
superficial dyspareunia common even years later
diclofenac effective

Question 29

What is a more severe complication of perineal trauma?

Answer 29

paravaginal haematoma - excruciating pain in perineum a few hours after delivery, sometimes haematoma only visible on VE, drained under anaesthetic