Puerperium Flashcards
What is the puerperium period
Time from delivery of the placenta through the first 6 weeks post-delivery
By this time, most of the changes of pregnancy, labour, and delivery have resolved and the body has reverted to the nonpregnant state
What are some of the physiological changes of the puerperium
Genital: uterine contraction (felt for 4 days), uterine size reduces (not palpable past 10 days), lochia passed
CV: cardiac output and plasma volume decrease, BP returns to normal
Urinary: dilation reduces, GFR decreases
Bloods: returns to normal
What is lochia
blood-stained discharge from the uterus
Normal lochia process: Rubra (red) → serosa (yellow) → alba (white)
Usually quite heavy at first so may need highly absorbent sanitary pads (avoid tampons until 6 weeks postnatal check because of infection risk), this may carry on for a few weeks, but it will eventually become brown and stop → USS if persistent past 6 weeks
Infection = any offensive smell, or greenish colour
What does the initial postnatal consultation involve
How they are, confirm when they had the delivery
Any pain
Any bleeding
Eating and drinking
Urinary symptoms/catheter (can come out day Fred but have to pass two)
Bowel symptoms, passing gas
Feel uterus - will be painful
- Palpation of the uterus is to ensure that it has contracted down, fundus should be below the umbilicus
Check for bowel sounds
Advice is to not have a baby before 18 months to allow the wounds to heal. Have they had a conversation about contraception (POP or implant)
No difference in care/scans if pregnancy occurs soon after - worried about risk of uterine rupture or ectopic pregnancy
What does postnatal care involve
Counselling
Debrief
Keep mother and baby together
Counselling and help with breastfeeding
Contraception advice
Safety net about signs of infection (e.g. swelling, discharge, redness, fever)
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Intervention
Early mobilisation
Analgesics for perineal pain
Pelvic floor exercises
Monitoring
Monitoring of uterine involution, lochia, BP, temperature, pulse and perineal wounds
Fluid balance checks, especially if epidural was given
Check FBC and consider iron supplementation
Psychiatric screening
What is the post-vaginal delivery care postpartum
Stitches (episiotomy, perineal)
- Local cooling
- topical anaesthetics
- Clean daily using tap water
- pat dry
- Change sanitary pads regularly
- Simple analgesia e.g. paracetamol (AVOID codeine)
80% pain in the first 3 days, 25% pain after 10 days
What is the expected healing for episiotomies
Takes 4 weeks to heal (superficial skin by 2 weeks)
Dissolvable sutures are used so does not need to have them taken out
Pain in the first 2 weeks is common, and 20% have pain at 8 weeks
What is the post-caesarean care
Average stay is about 3-4 days (regular painkillers, encourage baby contact, encourage mobilisation)
Wound: gently clean with tap water and dry every day, wear loose cotton clothing, take painkillers, watch out for signs of infection, sterile dressing placed in theatre will be removed after 24 hrs, non-dissolvable stitches are taken out by midwife after 5-7 days
Post-op Hb measurement (ideally day 2-3)
- Asymptomatic women with mild-moderate anaemia (Hb > 7 g/dL) can be treated with iron tablets
- SEVERE anaemia, are likely to need a blood transfusion
Scar fades with time
Stay mobile and return to normal activities
1-6 weeks of LMWH will be given to those with multiple risk factors
Caution should be taken with certain activities including driving, exercising, heavy lifting, sex (delayed until 6 weeks post)
What should be done before discharging postpartum
Assess health
Assess bladder function with first void volume
Assess baby’s health
If the baby has not passed meconium, advise parents to seek advice from a professional if they do not do so
Observe 1 effective feed and make sure there is a plan
Advise on pelvic floor exercises
Notify GP/involved professionals of any complications
What is the advice regarding birth intervals postpartum
Fertility can return quickly, you can ovulate after day 21 so with UPSI should have a preg test if not on any contraceptives
The risk of child mortality is highest for very short birth-to-pregnancy intervals (i.e. less than 12 months).
Risk of preterm birth, low birthweight, SGA babies
Interbirth intervals of at least 2 years are recommended by WHO for the health of both mother and infant
What is the contraceptive advice postpartum
Options: IUD, progesterone implant, progesterone pill, progesterone depot, COCP
ask them to use condoms to reduce risk of STIs
IUD: immediately after placental delivery OR at 6 weeks
Implant: immediately and any time after
Pill:
COCP: delay until 6 weeks postpartum (breastfeeding: UKMEC 4, UKMEC 2 6 weeks-6 months)
All women should undergo a risk assessment for VTE postnatally
What is required for lactational amenorrhoea to be effective
The patient has to be amenorrhoeic
less than 6 months postpartum
fully breastfeeding day and night (no other liquids given or only water, juice, or vitamins given infrequently in addition to breastfeeds).
No long intervals between feeds day or night (e.g. more than 4 hours during day and more than 6 hours at night).
What sterilisation techniques can be used after birth
Partial salpingectomy and tubal occlusion (Filshie clips) - quicker
Modified Pomeroy technique
Women should be advised that some LARC methods are as, or more, effective than female sterilisation and may confer non-contraceptive benefits e.g. reduced uterine bleeding
Describe the lactation process
Lactation is dependent on prolactin and oxytocin
Prolactin levels are high at birth, but it is the rapid decline in oestrogen and progesterone (inhibits prolactin)
1. Sucking stimulus
2. Sucking stimulation → prolactin from anterior pituitary → Cuboidal cells in the breast alveoli secrete milk
3. Sucking stimulation → posterior pituitary secretes oxytocin → myoepithelial cells around the alveoli contract → milk ejection/let-down
4. Feedback inhibitor of lactation (FIL) is a polypeptide present in breastmilk that regulates the local control of milk production within the breast
- Accumulation of FIL within the milk → inhibition of milk secretion → prevents the breast from becoming too full
- Regular feeding or expressing is necessary to remove FIL and promote milk production
What is colostrum
Yellow fluid containing fat-laden cells, proteins (IgA) and minerals passed in the first 3 days
What are the advantages of breastmilk
Protection against infection in the neonate
Bonding
Cannot give too much
Cost saving, cheaper than formula feed
Readily available at the right temperature and ideal nutritional value
Has a contraceptive effect associated with amenorrhoea
Reduced:
- Necrotising enterocolitis risk in preterm babies
- Childhood infective illness (especially gastroenteritis)
- Atopic illness(e.g. eczema, asthma)
- Juvenile diabetes
- Childhood cancer (especially lymphoma)
- Premenopausal breast cancer
What advice should be given about breastfeeding
Gently encourage women to breastfeed when the baby is ready
Early feeding should be on demand
Positioning: Baby’s lower lip should be planted below the nipple at the time the mouth opens in preparation for receiving milk, so the entire nipple is drawn into the mouth
Restful, comfortable environment is important
What is postpartum pyrexia and what are the causes
Maternal fever >38 in the first 14 days
Cause:
- Infection → genital tract sepsis
- - Group A streptococcus
- - Staphylococcus
- - E. Coli
- UTI
- Chest infection
- Mastitis
- Perineal infection
- Wound infection after caesarean
What is the postpartum advice regarding urination
Around 1L of urine may be produced → can lead to hypocontractile bladder → overflow incontinence
A small amount of leaking urine is normal → Try pelvic floor exercises
* Drink plenty of water (dilutes the urine) and eat a healthy balanced diet (not pooing for a few days is normal)
Voiding difficulty + overdistention can be common esp if reg anaesthetic has been used (can take up to 8hrs to regain norm sensation of bladder)
Formal assessment 6 hours postnatally
If little to no urine has been passed → small intermittent catheter insertion (at least 48h)
What are the features and management of urinary retention postpartum
Common
S/S: pain, increased frequency, stress incontinence, severe abdominal pain
Monitor fluid charts and examine the abdomen regularly
Consider post-micturition US to assess residual volume non-invasively
Management: catheterisation for 24h at least
Complications: infection, overflow incontinence, permanent voiding difficulties
What are the features of incontinence in postpartum women
20% of women
Overflow and infection should be excluded (postmicturition ultrasound or catheterisation and MSU)
May be an obstetric fistulae
What are the common bowel issues postpartum
Constipation and haemorrhoids (20%)
Incontinence
What is the management for constipation postpartum
Adequate fluid intake, incr fibre in diet
Laxatives can be given
With 3rd/4th degree perineal tears, avoid constipation by giving lactulose and fibrogel
What are the causes and risk factors for faecal incontinence
consider pudendal nerve and anal sphincter damage
RF: forceps delivery, large babies, shoulder dystocia, persistent occipito-posterior positions
Evaluate using anal manometry and US
