Postpartum problems

Question 1

What is the postnatal period also known as and what is the timeframe?

Answer 1

From the end of 3rd stage of labour (delivery of placenta until 6 weeks after delivery

Also known as the puerperium

Question 2

What occurs in puerperium?

Answer 2

Slow return back to pre-pregnancy physiology
- Involution (shrinking) of uterus
- Cessation of lochia/postpartum bleeding (approx 4 weeks)
- Prothrombotic phase slowly resolves after 6 weeks

Question 3

What injuries can occur as a result of childbirth?

Answer 3

Perineal tears
Vaginal tears/grazes
Labial tears/grazes
Urethral/clitoral tears

Question 4

How many grades of perineal tears are there?

Answer 4

4 grades (grade 1-4) with increasing severity

Question 5

Grade 1 perineal tear?

Answer 5

Tear of frenulum of labia minor with no perineal muscle involvement.

Question 6

Grade 2 perineal tear?

Answer 6

Tear of both labia minor frenulum and perineal muscles.

Question 7

How many subgroups are there for grade 3 perineal tears?

Answer 7

3 subgroups

Grade 3a-3c

Question 8

Grade 3a-c perineal tears?

Answer 8

3a - involves <50% of external anal sphincter

3b - involves >50% of external anal sphincter

3c - involves both external and internal anal sphincter

Question 9

Grade 4 perineal tear?

Answer 9

Involves all areas including rectal mucosa

Question 10

Grades 3 +4 need repair in theatre by experienced obstetrician and good anaesthetic. True/false?

Answer 10

True

Question 11

What is OASI?

Answer 11

Obstetric anal sphincter injury

Question 12

What increases risk of OASI (perineal tears)?

Answer 12

Primiparity

Foetal macrosomia >4kg

Malposition (OP position - occipital posterior)

Asian ethnicity

Shoulder dystocia

Prolonged second stage

Operative vaginal birth (reduced by episiotomy)

Question 13

What is the management of OASI?

Answer 13

Repair in theatre
- Typically under regional anaesthesia
- Interrupted non absorbable sutures of anal/rectal mucosa and sphincters

Antibiotic prophylaxis (PO co-amoxiclav)

Consider Fragmin prophylaxis depending on VTE risk score

Laxatives

Analgesia (beware constipation)

Physiotherapy follow up

Offer PN debrief appointment

Question 14

What is a major cause of maternal death?

Answer 14

Venous thrombo-embolism since pregnancy is a hypercoagulable state

Question 15

What risk is assessed during pregnancy and labour?

Answer 15

VTE risk

Question 16

Based on the VTE risk assessment, was treatment is given?

Answer 16

Low risk – hydration + mobilisation

Mod. risk – 10 days prophylactic LMWH

High risk – 6 weeks prophylactic LMWH

Question 17

What is puerperal sepsis?

Answer 17

An infection of the genital tract occurring at any time between rupture of membrane or labour and 42 days postpartum.

Question 18

What features are mainly present in puerperal sepsis?

Answer 18

Pelvic pain

Fever (temperature ≥38.5oC on any occasion)

Abnormal vaginal discharge

Delay in the rate of uterine involution

Question 19

Causative organisms of puerperal sepsis?

Answer 19

E Coli

Group A and Group B strep

Anaerobes

Staphylococci

Question 20

What are the risk factors that could lead to puerperal sepsis?

Answer 20

Prolonged labour

Prolonged rupture of membranes

Operative birth

Repeated vaginal examinations

Retained products of conception

Question 21

Investigations/management for puerperal sepsis?

Answer 21

SEPSIS 6 BUNDLE and ABCDE approach

Blood tests
FBC, CRP, U+Es, Coag, blood cultures

IV Antibiotics
- Co-amoxiclav
- Clindamycin
- +/- Gentamycin
- Tazocin

IV fluids

Ultrasound

CT scan

Question 22

What is primary PPH?

Answer 22

Vaginal bleeding occurring within 24 hours of birth

Question 23

What is secondary PPH?

Answer 23

> 24 hours after birth and up to 6 weeks post delivery

(some definitions can vary where it mentions up to 12 weeks post delivery)

Question 24

Main causes of secondary PPH?

Answer 24

4T’s

Tone
Trauma
Thrombin
Tissue - RPOC

More commonly caused by infection or retained products of conception (RPOC)

Question 25

Investigations and management of secondary PPH?

Answer 25

High vaginal swab
Bloods (FBC, CRP, Lactate, Coag)
Ultrasound
Antibiotics
Consider oxytocics – syntocinon / ergometrine
Evacuation of retained placental tissue (consider MVA)

Question 26

Common postpartum urinary problems?

Answer 26

Urinary Tract Infection

Urinary Retention

Urinary Incontinence

Question 27

Main causes of urinary retention in postpartum?

Answer 27

Pain

Vaginal trauma

Question 28

Management of urinary retention in postpartum?

Answer 28

Catheterise

Treat any underlying cause

Avoid bladder overdistention

Question 29

Main causes of urinary incontinence in postpartum?

Answer 29

In UK:
- Overflow incontinence with retention
- Can occur initially after removal of catheter

but in the developing world….
- Vesico-vaginal (obstetric) fistula

Question 30

What is a fistula?

Answer 30

An abnormal hole between bladder and vagina (sometimes the rectum).

Question 31

How is a fistula caused?

Answer 31

Prolonged obstructed labour

Death of tissue compressed between baby’s head and pelvic bone