Postpartum Problems Flashcards
What is puerperium?
The puerperium is a period of repair and recovery after birth where tissues return to their nonpregnant state
How long does puerperium normally last?
6 weeks post-partum on average
What colour is the discharge 3-4 days post partum?
Fresh red
What colour and consistency is the discharge 4-14 days post partum?
Brownish-red and watery
What colour is the discharge 10-20 days post partum?
Yellow
What uterine changes occur during the puerperium?
- The endometrial lining of the uterus rapidly regenerates by day 7
post-partum - The fundus of the uterus returns to its physiological location within the pelvis by around 2 weeks.
-uterine weight decreases
What is colostrum?
This is the first
milk a breastfed baby receives and is more protein and vitamin rich than later milk produced by
the mother. Colostrum is essential for early immunological protection to the newborn.
What causes the initiation of lactation?
y expulsion of the placenta in stage 3 of labour as well as a decrease in
oestrogen and progesterone levels
What is the let-down reflex and how does it work?
The let-down reflex refers to the mechanism of milk release from the breast during feeding.
In response to suckling (or alcohol, pain, the cry of a baby), oxytocin is stimulated and released from the posterior pituitary which in turn stimulates the myoepithelial cells which surround the breast alveoli to contract which squeezes breast milk out of the breast alveoli and nipple
What hormone is primarily responsible for the production of breast milk?
Prolactin
What hormone is primarily responsible for the release of breast milk?
Oxytocin
How long , according to the WHO, should exclusive breastfeeding occur?
The World Health Organisation (WHO) recommends exclusive breastfeeding for the first six
months of an infant’s life
What is the most common reason women stop breastfeeding? What is this usually due to?
Insufficient milk. The main reasons as to why milk won’t eject as effectively are ineffective attachment and infrequent feeding
What is the most common cause of lactational mastitis?
Infective from Staphylococcus aureus
what are the most common causes of non-infective mastitis?
Duct ectasia (blocked lactiferous duct) or foreign body such as a piercing.
How can improper breastfeeding technique lead to lactational mastitis?
Trauma to the breast and subsequent milk stasis and ineffective milk release make the breast
more likely to harbour bacteria and therefore be more prone to infection.
Where is the most common site for a breast absess in someone who is breastfeeding? And in a non-breastfeeding person?
Breastfeeding = peripheral breast
Non-breastfeeding = sub-areolar
What topics should be included in a focused breast history in someone with suspected mastitis?
- Milk stasis (decreased milk output)
- Possible abscess (tender lump)
- Symptoms related to possible breast inflammation (e.g., warmth, pain, swelling,
firmness, erythema) - Nipple discharge, which may be present with mastitis and occurs more often with duct
ectasia (dilated ducts with inflammation); however, purulent discharge is usually
indicative of breast infection - Systemic symptoms of infection (fever, malaise, myalgia)”
What is the treatment for lactational mastitis?
Flucloxicillin 7 days and continue to breastfeed
What is the definition of post partum haemorrhage?
blood loss equal to or exceeding 500ml after the
birth of the baby
What is the difference between primary and secondary PPH?
If the bleeding occurs within 24 hours of delivery this is referred to as Primary
PPH, whereas if the bleeding occurs from 24 hours to 6 weeks post-delivery, this is therefore
Secondary PPH.
What volume of blood loss is associated with a minor PPH? And a major PPH?
Minor = 500-1000ml blood loss Major = >1000ml OR Signs of cardiovascular collapse OR ongoing bleeding
What are the causes of PPH?
4Ts:
- Tone (70%): Uterine atony
- Trauma (20%): Vaginal tear, cervical laceration, rupture
- Tissue (10%): Retained Products of Conception
- Thrombin (<1%): Coagulopathy
What are the antenatal risk factors for PPH?
- placental probelms (praevia, abruption)
- past obstetric history of retained placenta, C-section, PPH
- multiple pregnancy
- obesity
- polyhydramnios
- foetal macrosomia
What are the intrapartum risk factors for PPH?
- operative vaginal delivery
- Induced labour
- retained placenta
- C-Section
- Labour more than 12 hours
- Perineal tear/Episiotomy during delivery
How would you assess PPH?
- ABCDE Process
- Give oxygen via a non-rebreather mask at 15l/min
- IV access with a grey/orange bore cannula
- Retrieve blood for G&S, FBC, coagulation screen, fibrinogen, U&Es, LFTs, lactate
- Cross-match 6 units red packed cells
- Check vital signs every 15 minutes
- Determine cause of bleeding using the 4 T’s
- Consider utilising the Tayside Massive Haemorrhage Protocol
- Early blood transfusion
- Administer Tranexamic acid 0.5-1g IV to stop bleeding, regardless of the cause
What are first line non-surgical ways to stop the bleeding in PPH?
TONE/TISSUE- Uterine massage using bimanual compression
- THROMBIN- Expel clots manually
- TONE/TISSUE- Administer 5 units IV Syntocinon
- TONE- Insert a urinary catheter to minimise bladder pressure on the uterus
What are second line non-surgical ways to stop bleeding in PPH? (if bleeding does not resolve after first line)
TONE/TISSUE- Administer 500mcg IV Ergometrine if no response to Syntocinon
- TRAUMA- Exclude/repair trauma
- TONE/TISSUE- Give Carboprost 250 mcg IM every 15 minutes
- TONE/TISSUE- Give Misoprostol 800mcg PR
What are surgical ways to stop bleeding in PPH?
Examine under anaesthetic (EUA) in theatre to look for trauma, RPOC, rupture etc
- Balloon insertion to put pressure on bleeding blood vessels
- Arterial Embolisation via Interventional Radiology
- “B-Lynch” sutures
- Uterine artery ligation
- Internal Iliac ligation
- Hysterectomy as a last resort!
What are ways to prevent secondary PPH?
- Give thromboprophylaxis
- Debrief couple
- Manage anaemia with iron supplementation
What is a first degree perineal tear?
- 1st degree: involving the skin only
What is a second degree perineal tear?
- 2nd degree: involving the skin and levator ani; usually requires stitches
What are third and fourth degree perineal tears?
- 3rd degree and 4th degree: extend to the external anal sphincter muscle; these may need
operated on as mothers can experience faecal incontinence due to overstretching of the
pudental nerve branches
What surgical technique is used to repair perineal tears?
episiotomy
What are the psychiatry perinatal red flags?
- Recent significant change in mental state or emergence of new symptoms
- New thoughts or acts of violent self-harm
- New and persistent expressions of incompetency as a mother or estrangement from
their baby
When should you consider admission to a mother and baby unit?
- A rapidly changing mental state
- Suicidal ideation (particularly if violent)
- Pervasive guilt or hopelessness
- Beliefs of inadequacy as a mother
- Evidence of psychosis
What are baby blues?
a brief period of emotional instability where mothers can become tearful, irritable, anxious and confused. It usually occurs 3 days postnatally and last up to a week.
How do you manage baby blues?
The condition is self limiting and so reassurance and support is mainstay management.
What is puerperal psychosis?
Puerperal psychosis is a rare but severe mental health condition which typically occurs 2 weeks postnatally and can lead to symptoms such as sleep
disturbance, confusion and irrational ideas, mania, delusions and hallucinations
What are the key risk factors for developing puerperal psychosis?
- bipolar disorder
- 1st degree relative with a history of puerperal psychosis
- previous experience of puerperal psychosis
What is the management for puerperal psychosis?
emergency admission to a mother-and-baby unit.
What is postnatal depression?
Depression which begins 2-6 weeks postnatally and presents with tearfulness, irritability, anxiety, lack of enjoyment, poor sleep and weight
loss. The depressive episode can last weeks- several months.
What is the management of postnatal depression?
Mild-moderate cases can be treated with
self-help and counselling. Moderate to severe cases are treated with a combination of
psychotherapy and antidepressants.
When is the heel prick test carried out?
5 days post birth
What is the heel prick test?
A blood test done to check for 9 serious medical conditions including cystic fibrosis, congenital hypothyroidism, sickle cell disease and phenylketonuria
What scoring modality is most typically used to assess the health of a newborn?
APGAR score
What is tested within the APGAR score?
- appearance (pallor)
- pulse
- grimace (relfex irritability)
- activity (muscle tone)
- respiration
When carrying out a neonatal examination, what areas should you cover in the general inspection?
- Assess pallor
- Tone: Gently move limbs and observe them when picked up
- Level of arousal: Assess cry and note sound
When carrying out a neonatal examination, what areas should you cover in the examination of the head?
- Shape: Check fontanelles to see if normal/sunken/bulging
- Head circumference: Take 3 measurements for accuracy
- Face: Check for asymmetry, palsy, abnormality
When carrying out a neonatal examination, what areas should you cover in the examination of the eyes?
- Appearance: Normal or abnormal
- Red reflex: Check for presence (IMPORTANT to detect early to prevent chronicity)
- Eye abnormalities: Any cataract/coloboma or infection?
When carrying out a neonatal examination, what areas should you cover in the examination of the ears?
- Appearance: Note shape and size (are they normal or low-set?)
- Patency of external auditory meatus
When carrying out a neonatal examination, what areas should you cover in the examination of the mouth?
- Inside: colour of mucous membranes, observe palate form/fusion
- Suckling reflex: Insert finger gently into baby’s mouth
- Inspect for chonal atresia (back of nasal passage blocked by bone/soft tissue)
When carrying out a neonatal examination, what areas should you cover in the examination of the arms/hands?
- Hands: Are they moving? Shape? Number of fingers? Palmar creases present?
- Traction birth injury: Check for any palsies by inspecting from neck to hand
When carrying out a neonatal examination, what areas should you cover in the examination of the heart?
- Palpate for thrills and heaves
- Auscultate the aortic region: Second right intercostal space
- Auscultate the pulmonary region: Second left intercostal space at the left sternal border
- Auscultate the tricuspid region: Left intercostal space at the lower sternal border
- Auscultate the mitral region: Left 5th intercostal space, midclavicular line
- Auscultate the midscapular region: In between scapulae to check for coarctation of the
aorta
When carrying out a neonatal examination, what areas should you cover in the examination of the lungs?
- Assess respiratory rate, pattern and depth
- Inspect: Intercostal recession? Nasal flaring? Grunting?
- Auscultate: Added sounds eg crackles/stridor?
When carrying out a neonatal examination, what areas should you cover in the examination of the abdomen?
- Inspect: Abdominal girth/shape, umbilicus for infection/hernias
- Palpate: Feel for organs, masses, herniae (NB palpable liver/spleen is a normal sign)
When carrying out a neonatal examination, what areas should you cover in the examination of the genetalia?
- Inspect: Abnormalities in size/shape/position (NB some spotting is normal in girls)
- Palpate testes in boys
- Inspect anus and establish whether meconium has been passed
When carrying out a neonatal examination, what areas should you cover in the examination of the back/hips?
- Inspect: Skin over back (flesh creases, dimples, hair?), spinal curvature, symmetry
- Palpate: Spine from neck to coccyx
- DDH: Perform Barlow (adduction, posterior force on thigh) and Ortolani (abduction,
anterior force on thigh) manoeuvres - Observe groin creases for symmetry and leg length
When carrying out a neonatal examination, what areas should you cover in the examination of the legs?
- Observe movements at each joint
- Check for evidence of talipes equinovarus (clubfoot)
- Count toes and check for shape and abnormal gaps
When carrying out a neonatal examination, what areas should you cover in the examination of the CNS?
- Observe tone, behaviour, movements and posture
- Test for newborn reflexes if appropriate e.g Moro, grasp reflexes
