Puerperium Flashcards
What are the 3 physiological changes which occur after childbirth?
- Lochia and Uterine involution [Lochia = vaginal discharge after birth]
- Lactation
- Menstruation and resumption of ovulation
What is the physiology behind lactation?
Oestrogen stimulates duct growth + Progesterone stimulates alveolar growth
Placental lactogen affects growth of epithelium in alveoli
Initiation of lactation is dependent on fall in oestrogen which stimulates release of Prolactin from hypothalamus
Milk ejection needs Oxytocin from the posterior pituitary
What are the newborn advantages to being breastfed? (give 4)
Easily digested nutrients
Antibodies in colostrum (lower incidence of gastroenteritis, respiratory infections, otitis media, necrotising enterocolitis)
Avoid milk allergies (1% for cow’s milk)
Good source of nutrition (Except Vit C, D and Iron)
Cannot overfeed
Lower risk of hypocalcaemia
What are the maternal advantages to being breastfed? (give 2)
Promotes bonding
Improves uterine involution
?reduced risk of breast cancer
Contraception (Lactational amenorrhoea)
Safe and cheap
Give 2 possible difficulties to breastfeeding
Nipple inversion: correct by Waller shields in late pregnancy
Maternal fatigue
Emotional stress
When is breastfeeding contraindicated?
Active TB/HIV
Give 2 drugs which are contraindicated in nursing mothers
Chemotherapeutics
Iodides
Lithium
Give 5 complications in the Peurperium period?
Post-partum haemorrhage (secondary)
Peurperal pyrexia
Post-partum mental health
Thromboembolic disease
Urinary or faecal incontinence
What is Peurperal Pyrexia? [give 3 causes]
Temperature of 38 on any occasion in the 6 weeks after delivery
Causes = UTI, Endometritis, DVT, Breast (Mastitis?), Chest (LRTI? PE?)
Give 3 investigations for Peurperal Pyrexia
Sepsis pathway (Blood cultures)
MSU + High vaginal swab
Sputum if indicated. Ultrasound. VQ scan
Give 2 causes for Secondary post-partum haemorrhage
Retained products or blood clots.
Infection
What are the risk factors for Thromboembolic disease in the post-partum period
Operative delivery
PMHx of VTE
FHx of VTE
Thrombophilia
Obesity
Immobilisation
Prolonged labour
Maternal age >35
What are the Perinatal Mental Health support + management steps
Perinatal Mental Health – support & management:
* Specialist perinatal mental health clinic
* Specialist perinatal mental health Midwife
* Specialist community perinatal Mental health team
* Community mental health team
* Senior duty psychiatrist
* Local mental health services crisis line
* Emergency department
What are the presenting features of Puerperal Psychosis
Feeling “high”, “manic” or “on top of the world”
Low mood and Tearfulness
Anxiety or Irritability
Rapid changes in mood
Severe confusion
Being restless and agitated
Racing thoughts
Behaviour that is out of character
Being more talkative, active and sociable than usual
Being very withdrawn and not talking to people
Finding it hard to sleep, or not wanting to sleep
Losing your inhibitions, doing things you usually would not do
Feeling paranoid, suspicious or fearful
Feeling as if you’re in a dream world
Delusions: odd thoughts or beliefs that are unlikely to be true (you may think your baby is possessed by the devil, or that people are out to get you)
Hallucinations: you see, hear, feel or smell things that aren’t really there
Give 4 risk factors for Peri-natal mental health problems
PMHx mental health illness
FHx (first degree relative) of severe mental health illness
Unplanned or unwanted pregnancy
Pregnancy or complications of traumatic birth
Fetal or neonatal loss
Other risk factors:
History of childhood abuse and neglect
Domestic violence
Interpersonal conflict
Inadequate social support
Substance misuse
Migration status, language and cultural barriers
What are the Red flag features for Perinatal Mental Health?
Bipolar disorder (1 in 5 = puerperal psychosis; 1 in 2 = severe postnatal depression)
Severe depression (1 in 2 = risk of postnatal relapse)
Disclosure (women who think they have a mental health problem and come forward, often do- take seriously)
Recent change in mental health (eg New and persistent expressions of incompetence as a parent or estrangement from infant. New thoughts or acts of violent self-harm.)
What investigations are performed for ?DVT in pregnancy?
FIRST LINE = Doppler ultrasound
Gold standard = Venography with Fetal shield
What investigations are performed for ?PE in pregnancy?
- Clinical assessment (Hx, Ex, Obs)
- Bloods = FBC, U&E, LFTs
- CXR (with abdomen shield) + ECG
- Commence LMWH (unless CI; DON’T wait for Ix»_space; start treatment first)
- Duplex USS if suspicion of DVT
- CXR Normal = V/Q scan
- CXR Abnormal = CTPA
What is the management of PE in pregnancy?
Full anticoagulation with LMWH (eg Dalteparin / Enoxaparin)
TEDS
Leg care advice
Advice re need for future prophylaxis (for pregnancy, surgery, flying, contraception)
In high risk cases consider Vena cava filters (eg if likely recurrent PE’s)
