Problems in the Puerperium

Question 1

What period does the puerperium cover? What is the percentage of maternal deaths that occur here?

Answer 1

• 6 weeks post-partum
• 60%

Question 2

What is puerperial sepsis? What are the risk factors for this condition?

Answer 2

• Any febrile condition >38 that remains or recurs in the first 14 days after birth excluding day 1
• Prolonged ROM, frequent cathetisation, prolonged labour, interventions during birth (instruments, episiotomy), PPH, CS

Question 3

What are the most common aetiologies for puerperial sepsis/pyrexia?

Answer 3

• Uterine (more common post emergency CS)
  
  • Pain and tenderness in lower abdo, foul lochia
• Breast infection (mastitis +/- abscess)
• UTI
• VTE
  
  • 1:3000 pregnancies. More common post-CS

Question 4

What defines a secondary PPH? What are the most common causes?

Answer 4

• PPH between 24 hours and 6 weeks post-partum
• Retained POC, infection

Question 5

What are the management principles of a secondary PPH?

Answer 5

• Ix - FBE/coags, group, swabs + culture
• Fluid/blood and treat underlying cause:
  
  • Antibiotics
  • Uterotonics
  • DCR/embolisation/hysterectomy

Question 6

What period does post-partum depression occur over? Compared to the “post-partum blues”, how common is it?

Answer 6

• Day 3/4 post-delivery up to 1 year
• 10-15% as opposed to 80%

Question 7

Describe some symptoms that might be observable in someone with post-partum depression

Answer 7

• Rapid mood swings
• Irritability
• Anxiety
• Decreased concentration
• Insomnia
• Tearfulness
• Crying spells

Question 8

What are some risk factors for postpartum depression? What are the maternal and child risks if a woman has it untreated?

Answer 8

• Complicated pregnancy, PHx depression/anxiety, poor social support
• Increased suicide risk, adverse infant development (SIDS predisposition, anxiety/depression/alcohol dependence)

Question 9

How common is post-partum psychosis? How is it managed?

Answer 9

• 1-2:1000 births
• Prevent sleep deprivation in women with PHx (benzos), admission to mother/baby unit, medications (lithium, valproate, antidepressants)

Question 10

Describe how perineal tears are graded

Answer 10

• 1st degree - laceration involving perineal skin or vaginal mucosa only
• 2nd degree - extending into submucosa
• 3rd degree - involving anal sphincter
• 4th degree - laceration involving rectal mucosa

Question 11

Describe the structures cut during an episiotomy

Answer 11

• Perineal skin and subcutaneous tissue
• Posterior vaginal wall
• Bulbocavernosus muscle
• Superficial transverse perineal muscle
• Pubococcygeus muscle
  *

Question 12

What are the most common causes of a uterine rupture?

Answer 12

• Scar rupture (i.e. previous CS)
• Obstructed labour

Question 13

Describe some broad possible complications of Caesarean section

Answer 13

• Anaesthesia - aspiration, hypotension, spinal headache
• Haemorrhage - uterine atony, placenta praevia/accreta, lacerations
• UT and GI injuries
• Infection - endometritis, wound infection