Postpartum problems Flashcards
What is the postnatal period also known as and what is the timeframe?
From the end of 3rd stage of labour (delivery of placenta until 6 weeks after delivery
Also known as the puerperium
What occurs in puerperium?
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
What injuries can occur as a result of childbirth?
Perineal tears
Vaginal tears/grazes
Labial tears/grazes
Urethral/clitoral tears
How many grades of perineal tears are there?
4 grades (grade 1-4) with increasing severity
Grade 1 perineal tear?
Tear of frenulum of labia minor with no perineal muscle involvement.
Grade 2 perineal tear?
Tear of both labia minor frenulum and perineal muscles.
How many subgroups are there for grade 3 perineal tears?
3 subgroups
Grade 3a-3c
Grade 3a-c perineal tears?
3a - involves <50% of external anal sphincter
3b - involves >50% of external anal sphincter
3c - involves both external and internal anal sphincter
Grade 4 perineal tear?
Involves all areas including rectal mucosa
Grades 3 +4 need repair in theatre by experienced obstetrician and good anaesthetic. True/false?
True
What is OASI?
Obstetric anal sphincter injury
What increases risk of OASI (perineal tears)?
Primiparity
Foetal macrosomia >4kg
Malposition (OP position - occipital posterior)
Asian ethnicity
Shoulder dystocia
Prolonged second stage
Operative vaginal birth (reduced by episiotomy)
What is the management of OASI?
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
What is a major cause of maternal death?
Venous thrombo-embolism since pregnancy is a hypercoagulable state
What risk is assessed during pregnancy and labour?
VTE risk
Based on the VTE risk assessment, was treatment is given?
Low risk – hydration + mobilisation
Mod. risk – 10 days prophylactic LMWH
High risk – 6 weeks prophylactic LMWH
What is puerperal sepsis?
An infection of the genital tract occurring at any time between rupture of membrane or labour and 42 days postpartum.
What features are mainly present in puerperal sepsis?
Pelvic pain
Fever (temperature ≥38.5oC on any occasion)
Abnormal vaginal discharge
Delay in the rate of uterine involution
Causative organisms of puerperal sepsis?
E Coli
Group A and Group B strep
Anaerobes
Staphylococci
What are the risk factors that could lead to puerperal sepsis?
Prolonged labour
Prolonged rupture of membranes
Operative birth
Repeated vaginal examinations
Retained products of conception
Investigations/management for puerperal sepsis?
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
What is primary PPH?
Vaginal bleeding occurring within 24 hours of birth
What is secondary PPH?
> 24 hours after birth and up to 6 weeks post delivery
(some definitions can vary where it mentions up to 12 weeks post delivery)
Main causes of secondary PPH?
4T’s
Tone
Trauma
Thrombin
Tissue - RPOC
More commonly caused by infection or retained products of conception (RPOC)
Investigations and management of secondary PPH?
High vaginal swab
Bloods (FBC, CRP, Lactate, Coag)
Ultrasound
Antibiotics
Consider oxytocics – syntocinon / ergometrine
Evacuation of retained placental tissue (consider MVA)
Common postpartum urinary problems?
Urinary Tract Infection
Urinary Retention
Urinary Incontinence
Main causes of urinary retention in postpartum?
Pain
Vaginal trauma
Management of urinary retention in postpartum?
Catheterise
Treat any underlying cause
Avoid bladder overdistention
Main causes of urinary incontinence in postpartum?
In UK:
- Overflow incontinence with retention
- Can occur initially after removal of catheter
but in the developing world….
- Vesico-vaginal (obstetric) fistula
What is a fistula?
An abnormal hole between bladder and vagina (sometimes the rectum).
How is a fistula caused?
Prolonged obstructed labour
Death of tissue compressed between baby’s head and pelvic bone
