Postpartum Problems

Question 1

What is classed as postpartum?

Answer 1

End of 3rd stage of labour until 6 weeks after

Question 2

Describe the physiological postpartum changes of the uterus

Answer 2

Contracts immediately after delivery. The top of the uterus sits at the umbilicus but by 10 days post natal it reduces to below the pubic symphysis and is no longer palpable

Question 3

By what day is the cervical os shut?

Answer 3

10 days

Question 4

When will menstruation return?

Answer 4

6 weeks if not breast feeding but can occur as early as 28 days

Question 5

How long does the cardiovascular system take to return to normal?

Answer 5

CO and PV reduce to normal by the end of the first week

Oedema and BP will be normal within 6 weeks

Question 6

Name four types of tear that can occur in childbirth

Answer 6

Vaginal wall
Labial
Perineal

Question 7

Describe the difference between the degrees of tears

Answer 7

1st - superficial tissues
2nd - superficial tissue and deep perineal muscles
3a - involves <50% external anal sphincter
3b - >50% external anal sphincter
3c - involves internal anal sphincter
4 - anal or rectal mucosa

Question 8

How are first and second degree tears managed?

Answer 8

Sutured by midwife or if very small may heal naturally

Question 9

What is the purpose of an episiotomy?

Answer 9

Speed up delivery or prevent anal sphincter tear - right medio-lateral direction (2nd degree)

Question 10

How are 3rd and 4th degree tears managed?

Answer 10

Repair in theatre with regional anaesthesia, antibiotics, laxative, physio and follow up

Question 11

How long are antibiotics given for a tear repair?

Answer 11

IV then 7 days oral

Question 12

What is the purpose of prescribing laxatives in tear repair?

Answer 12

Prevent disruption of repair

Question 13

How are the different risks for venous thromboembolism managed?

Answer 13

Low - hydration and mobilisation
Moderate - 10 days prophylactic LMWH
High - 6 weeks prophylactic LMWH

Question 14

What are the risk factors for postpartum infection?

Answer 14

Prolonged labour, prolonged ROM, multiple vaginal examinations, retained placenta and c-section

Question 15

Which organisms commonly cause postpartum infection?

Answer 15

GBS, staph aureus, staph epidermidis, E.coli, anaerobes

Question 16

Describe the progression of infection

Answer 16

Chorionamnitis - endometritis - salpingitis - pelvic infection - abscess - peritonitis

Question 17

What investigations are done in a postpartum woman?

Answer 17

Blood tests - FBC, CRP, UandE, coagulation, culture and high vaginal swabs
Ultrasound - retained placenta
CT - pelvic abscess

Question 18

How is postpartum infection treated?

Answer 18

IV antibiotics - co-amoxyclav, metronidazole, gentamicin

IV Fluids

Question 19

What other infections can postpartum women still experience?

Answer 19

Chest infection, mastitis, UTI, endometritis, wound infection, DVT, IV site, perineal infection (tear)

Question 20

What are the two common causes of secondary post partum haemorrhage?

Answer 20

Endometritis - hyperaemia

Retained placenta

Question 21

How is secondary postpartum haemorrhage treated?

Answer 21

Bloods, clotting screen, HVS, ultrasound for retained placenta tissue and broad spec antibiotics

Question 22

What can cause urinary retention?

Answer 22

Pain 
Vaginal trama 
Vulval haematoma 
Epidural 
Catheter removal

Question 23

How is urinary retention managed?

Answer 23

Catheterise for 48 hours - TWOC afterwards

Avoid bladder overdistention (>1litre)

Question 24

Describe the main cause of urinary incontinence in the developing world

Answer 24

Vesicle-vaginal fistula - abnormal hole between bladder and vagina - prolonged obstructed labour tissue is compressed between the baby’s head and the pelvic bones
Avascular necrosis - fistula formation

Question 25

In the developed world how can urinary incontinence occur

Answer 25

Overflow incontinence with retention after removal of catheter usually short lived

Question 26

Name four changes woman can experience due to lactation

Answer 26

• cracked/sore nipples
• breast engorgement
• mastitis
• breast abscess

Question 27

What organism commonly causes mastitis?

Answer 27

Staph aureus

Question 28

How does mastitis present?

Answer 28

Fever and breast tenderness

Question 29

How is mastitis managed?

Answer 29

Continue breast feeding

Oral/IV flucloxacillin

Question 30

If a sore progresses to an abscess how is it managed?

Answer 30

Surgical drainage

Question 31

Which forms of contraception cannot be started immediately post partum?

Answer 31

COCP - delay 6 weeks

LARC - 6 weeks or at time of C section

Question 32

How long after c-section should women wait to have another baby?

Answer 32

1 year

Question 33

Which form of contraception can be started straight away?

Answer 33

POP