PUERPERIUM Flashcards
What is the puerperium?
The period from the delivery of the placenta through the first 6 weeks after delivery. This is when the various changes that occurred during pregnancy, labour and delivery revert to the non-pregnant state
Cardiovascular changes during pregnancy?
Increased circulatory volume - plasma volume increases by 45% and blood volume by 30%
CO increases by up to 50%
SV increases by 25%
HR increases by up to 25%
Peripheral vascular resistance decreases by 20%
Cardiovascular changes after birth?
Cardiovascular system reverts to normal during the first 2 postpartum
These changes are dramatic and there will likely be diuresis on days 2-5 postpartum to dissipate the extra volume of fluid
Changes in coagulation system postpartum?
The hypercoagulable state from pregnancy will remain high for up to 2 weeks postpartum before starting to normalise
This is to protect against haemorrhage
But it increases the risk of VTE
Uterus changes in the postpartum period?
After delivery of the placenta, the uterus is the size of a 20 week pregnancy i.e. fundus palpable at maternal umbilicus
It will reduce in size by 1 finger breadth each day and will likely not be able to be palpated by 12th day
By the end of the puerperium it will only be slightly larger than pre-pregnancy
Lochia changes post partum?
First 3-4 days - lochia rubra - bright/dark red and may be small clots
Day 4-10- lochia serosa - watery pinkish brown
Day 10-28 - Lochia alba - yellowish white
Lochia can persist up to 5 weeks postpartum!
What is lochia?
Postpartum bleeding
Changes to the cervix in the puerperal stage?
It will revert to the non pregnant state and external os will close such that a finger cannot be easily introduced
Os will be more “slit-like” compared to the round os it was before
Changes to the vulva, vagina and perineum in the puerperal phase?
Resolution of the increased vascularity and oedema by 3 weeks
Restoration of vagina rugae will be variable dependant on breast feeding status (6-10 weeks)
Tears and episiotomies will heal within a couple of weeks
Pelvic muscle tone will be regained by 6 weeks
How does breastfeeding affect the vagina?
Breast feeding keeps oestrogen levels low
= vaginal rugae take longer to return to pre-pregnant state and vaginal atrophy may occur
What is diastasis recti?
An increased distance between rectus abdominal muscles at the midline caused by weakness in the anterior abdominal wall
Usually back to normal by 8 weeks postpartum
Regular pelvic floor and deep stomach muscle exercise can help
Earliest time of ovulation possible after giving birth?
28 days post partum if formula feeding!
Mean time to first menses post-pregnancy?
7-9 weeks
What is lactation all amenorrhoea?
The absence of periods related to breastfeeding
Breastfeeding disrupts release of GnRH
Changes to the breasts in preparation for lactation to occur throughout pregnancy?
Lactogenesis occurs as early as 16 weeks gestation
High levels of circulating progesterone actives mature alveolar cells in the breast but it does not allow secretion - stage 1 lactogenesis
The rapid drop in progesterone after deliver triggers onset of milk production within 24-48 hours - stage 2 lactogenesis
Regulation of milk production?
Suckling = neuro-endocrine reflex = hypothalamus reduces secretion of dopamine and increases prolactin secretion = more milk is produced
Milk let-down reflex?
Suckling = oxytocin released from pituitary gland = myoepithelial cells are stimulated and squeeze milk out of the breast
Despite suckling being the major stimulus for milk let down, the reflex can be conditioned. The cry or sight of an infant and preparation of the breast for nursing may cause let-down, whereas pain, embarrassment or alcohol may inhibit it.
Maintaining milk production?
Sufficient suckling to maintain pro,actin secretion and remove accumulated milk
If this stops then alveolar distension restricts blood flow to the alveoli and feedback inhibitor of lactation is released = interferes with milk production
Mammary involution would occur within 2-3 weeks
Maternal mortality rates and effects of ethnic minority backgrounds and deprivation?
Maternal death during pregnancy and up to 6 weeks after is 4x higher in black women, 3 times higher in mixed-ethnicity women and 2 x higher in Asian women
Women living in the most deprived areas are 2.5x more likely to die compared to women living in the least deprived areas
When should the first midwife visit occur?
Within 36 hours after transfer of charge from place of birth/ after a home birth
Should be face-to-face
When should the first health visitor visit occur?
7-14 days after transfer of care from midwifery care
What will be done at each postnatal contact?
Ask women about general health and assess general wellbeing e.g. signs of postnatal mental health problems, physical problems, importance of pelvic floor exercises, fatigue, nutrition/diet/physical activity/smoking/alcohol/drug use, contraception, sexual intercourse, safegaurding concerns
Assess woman’s psychoglcial and emotional wellbeing
Assess for signs of infection, pain, vaginal loss, bladder and bowel function, nipple/breast discomfort, signs of VTE/anaemia/pre-eclampsia
For women who had a vaginal birth check perineal healing
For women who had a c-section check wound healing and signs of infection
Inform women of red flags!
What to do if a pregnant woman is experiencing perineal pain following pregnancy?
Analgesia
Examine to rule out infection or haematoma
Perineal swabs and antibiotics if infection suspected
Urticaria evacuation if haematoma infection
What causes urinary retention following pregnancy?
How common is it?
Possible secondary to pudendal nerve damage after vaginal delivery. This is usually stress incontinence.
About 50% of women will develop some urinary incontinence
Managing urinary retention following pregnancy?
May require catheterisation
Pelvic floor exercises should be encouraged
Why is constipation a common puerperal problem?
Regular use of opioids, lack of food and water during labour etc
What is mastitis?
Inflammation of the breast tissue that may indicate infection
Advice about resuming sexual activity after birth?
No rules but most woman its about 6 weeks
Many women need lubricant to make it more comfortable
Remind them its possible to get pregnant as little as 3 weeks after birth
How common is puerperal backache?
Affects 1/3rd of women after birth!
Anaemia in puerperal period?
Common - possible cause is blood loss during or after childbirth
Check FBC and iron studies - likely IDA
What are baby blues?
A period of low mood, anxiety, tearful and irritability that starts 3-4 days after birth, lasts about 7 days and doesnt require treatment
More common in primiparous women
How common is baby blues?
Up to 70% of women
What can cause baby blues?
Sudden drop in oestrogen and progesterone after birth
Management of baby-blues?
Reassurance and support - the health visitor has a key role in this!
What screening tool can we use to screen for postnatal depression?
The Edinburgh scale
It’s a 10 item questionnaire with a max score of 30 that indicates how the mother has felt over the previous week
Score >14 indicated depressive illness of varying severity
How common is postnatal depression?
When does it typically start?
Features?
Affects 10% of women
Most cases start within 1 months and peak at 3 months
Features are similar to depression
Management of postpartum depression?
Reassurance and support
CBT
SSRIs
Which SSRIs are best for postpartum depression?
Sertraline and paroxetine
How common is puerperal psychosis?
When does it typically occur?
Features?
Prognosis?
0.2% of women
Onset within first 2-3 weeks following birth
Severe mood swings and disordered perception e.g. auditory hallucinations. Usually starts with confusion. May appear withdrawn or manic - very variable. Sleep disturbance is very common!
Prognosis is generally good. More women take 6-12 months to recover fully
Management of puerperal psychosis?
Admit to a hospital - ideally a mother&baby unit
May require antipsychotics
Risk of recurrence of puerperal psychosis in future pregnancy?
25-50% chance
Risk factors for peurperal psychosis?
Bipolar disorder
Schizoaffective disorder
Previous postpartum psychosis
FHx of postpartum psychosis
Leading 3 causes of death in puerpal period?
VTE
Mental-health related deaths e.g. suicide
Sepsis
How do you confirm a DVT in the post-partum period and why?
Compression duplex USS
Because D-diner cannot be used - will be raised physiologically from pregnancy
How common is a thromboembolism in the puerperium?
1 in 10000 pregnancies
4-5 times more like in pregnancy
20 times more likely in puerperium - time of highest risk!
Management of DVT?
LMWH - start immediately from suspicion. Continue for at least 3 months
If USS comes back negative but DVT is still suspected then stop LMWH but repeat USS on day 3 and day 7
Diagnosing and treating a PE in the puerperium?
Perform ECG and CXR
If a DVT is present and PE suspected then start treatment
If DVT is not suspected then get a V/Q scan or CTPA
Treat with LMWH and continue for at least 3 months
How can women reduce the risk of venous thromboembolism during pregnancy and in the puerperium?
Risk assessments during pregnancy
Stay as active as possible
Wear TED stockings or LMWH treatment
Keep hydrated
Stop smoking and losing weight
What increases the risk of VTE during and after pregnancy?
> 35
Having 3 babies already
Previous VTE
FHx of VTE
Thrombophilia
Medical condition e.g. lung disease
Severe varicose veins that are painful or above the knee with redness/swelling
Wheelchair user
BMI>30
Smoker
IV drug user
Admitted to hospital during pregnancy
Multiple pregnancy
Become dehydrated or less mobile during pregnancy e.g. vomiting
Have pre-eclampsia
Immobile for long periods of time e.g. after c-section
Labour lasting >24 hours
Large PPH
Leading cause of maternal mortality worldwide?
PPH
Whats the definition of puerperal pyrexia?
Temperature >38 in the first 14 days following delivery
Common causes of puerperal pyrexia?
Endometritis
UTI
Wound infections - perineal tears + c-sections
Mastitis
VTE
Genital tract infection
Why should tampons not be used to manage lochia?
As they carry a risk of infection
Why may lochia be more during episodes of breastfeeding?
As the oxytocin released by breastfeeding can cause the uterus to contract leading to slightly more bleeding
Normal
Which spp cause UTis in 95% of cases in the puerperal period?
E.coli
Proteus spp
Klebsiella spp
What most commonly causes genital tract infections in the puerperal period?
E.coli
Group A strep
Staph
Clostridium Welchii - rare but serious
What is the biggest risk factor for puerperal pyrexia?
How can we reduce the risk?
Lower segment C-section
Appropriate antibiotic prophylaxis before skin incision - said to reduce risk of endometritis by up to 75%
Signs of peurperal sepsis?
Pyrexia
Sustained tachycardia
Breathlessness
Abdominal or chest pain
Diarrhoea and vomiting due to endotoxins
Uterine or renal angle pain and tenderness
Woman generally unwell or seemed unduly anxious/distressed
Clinical assessment and investigation for puerperal sepsis?
Full history and exam - chest, breast, genital tract and legs
Wound swabs
High vaginal swabs
Blood cultures
Urine microscopy and cultures
Throat swabs and sputum cultures
Radiology - CXR and pelvic USS
When giving analgesia for puerperal sepsis and pyrexia, what should you NOT give?
Why?
NSAIDs - they can impede the ability of polymorphs to fight group A strep infections ?? Unsure if this is still correct
What are the 3 stages of postpartum thyroiditis?
Thyrotoxicosis first 3 months
Hypothyroidism 3-6 months
Normal thyroid function usually within 1 year
This is the typical pattern but not all women will follow this!1
What is postpartum thyroiditis?
Women have changes in thyroid function within 12 months of delivery, affecting women without a history of thyroid disease
Over time the thyroid function will return to normal
A small portion of women will remain hypothyroidi and need long term thyroid hormone replacement therapy
Pathophysiology of postpartum thyroiditis?
The cause of postpartum thyroiditis is not clear.
The leading theory is that pregnancy has an immunosuppressant effect on the mother’s body, to prevent her from rejecting the fetus.
Once delivery has occurred, there can be an exaggerated rebound effect, with increased immune system activity and expression of antibodies. This may include antibodies that affect the thyroid gland, for example, thyroid peroxidase antibodies. These antibodies cause inflammation of the thyroid gland, leading to over or under activity.
In what % of cases are thyroid peroxidase antibodies found in postpartum thyroiditis?
90%
Diagnosing postpartum thyroiditis?
There should be a low threshold for testing thyroid function in women with suggestive symptoms, particuarly post natal depression!!
Thyroid function tests are performed 6-8 weeks after delivery!
If abnormal results them refer to an endocrinologist for specialist management
Management of postpartum thyroiditis?
thyrotoxic phase:
propranolol for symptom control
not usually treated with anti-thyroid drugs as the thyroid is not overactive.
hypothyroid phase:
usually treated with levothyroxine
Monitoring of women with postpartum thyroiditis?
Annual monitoring of thyroid function tests even after condition has resolved
Some go on to develop chronic hypothyroidism
Managing anaemia on postpartum period?
Hb under 100 g/l – start oral iron (e.g. ferrous sulphate 200mg three times daily for three months)
Hb under 90 g/l – consider an iron infusion in addition to oral iron (e.g. Monofer, CosmoFer or Ferinject)
Hb under 70 g/l – blood transfusion in addition to oral iron
Why is active infection a contraindication of an iron infusion?
Many pathogens “feed” on iron, meaning that intravenous iron can lead to proliferation of the pathogen and worsening infection. It is important to wait until the infection is treated before giving an iron infusion.
Presentation of postpartum endometritis?
Foul-smelling discharge or lochia
Bleeding that gets heavier and does not improve with time
Lower abdominal or pelvic pain
Fever
Sepsis
Diagnosis of postpartum endometritis?
High vaginal swabs - including chlamydia and gonorrhoea if risk factors
Urine culture and sensitivities
USS may be done to rule out retained products of conception
Presentation of retained products of conception?
Vaginal bleeding that gets heavier or does not improve with time
Abnormal vaginal discharge
Lower abdominal or pelvic pain
Fever (if infection occurs)
Diagnosis of retained products of conception?
USS
Management of retained products of conception?
Evacuation of retained products of conception under GA - cervic gradually widened using dilators and then retained products are manually removed through vacuum aspiration and curettage
What are the 2 key complication sof an evacuation of ERPC (aka dilatation and curettage)?
Endometritis
Ashermanns syndrome
Most common bacteria that can cause mastitis?
Staph aureus
Mastitis presentation?
Breast pain and tenderness (unilateral)
Erythema in a focal area of breast tissue
Local warmth and inflammation
Nipple discharge
Fever
Management of mastitis?
Continue breast feeding or expressing milk
Breast massage
Heat packs and warm showers
Analgesia
If this is ineffective or infection is suspected…
Antibiotics - flucloxacillin
But still encourage continuing breastfeeding
Send a sample of milk to lab for culture & sensitivities!
Complication of mastitis?
Breast abscess- rare
When is candida of the nipple most likely to occur? What can it lead to?
After a course of antibiotics
Can lead to recurrent mastitis as it causes cracked skin on the nipple which is an entrance for infection
How would candidia of the nipple present?
Sore nipples bilaterally, particularly after feeding
Nipple tenderness and itching
Cracked, flaky or shiny areola
Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash (as associated with oral thrush and candidal nappy rash in infant)
Management of candidia of the nipple?
Both the mother and baby need treatment, or it will reoccur. Treatment is with:
Topical miconazole 2% after each breastfeed
Treatment for the baby (e.g. miconazole gel or nystatin)
Which part of the pituitary gland does Sheehan syndrome affect? Why only this part?
Anterior pituitary gland
As it receives its blood from the hypothalamo-hypophyseal portal system which is a low-pressure system susceptible to rapid drops in blood pressure. The posterior pituitary gets a good blood supply from various arteries and is therefore not susceptible to ischaemia when hypotension occurs
What hormones does the anterior pituitary release?
ACTH
Prolactin
LH
GH
TSH
FSH
“APLGTF”
Anterior Pituitary Lets Go of These Factors”
What hormones does the posterior pituitary release?
Oxytocin
ADH
Presentation of sheehans syndrome?
Reduced lactation (lack of prolactin)
Amenorrhoea (lack of LH and FSH)
Adrenal insufficiency (lack of ACTH)
Hypothyroidism (lack of TSH)
Management of sheehans syndrome?
Oestrogen and progesterone until menopause (due to lack of LH and FSH)
Hydrocortisone - due to lack of ACTH
Levothyroxine - due to lack of TSH
GH
After pregnancy, from when will women need contraception?
After 21 days!
How effective is lactation all amenorrhoea?
What are the 3 conditions
Over 98% effective for up to 6 months after birth
Provided that:
Woman is fully breastfeeding
Woman is amenorrhoeic
<6months post-partum
When can postpartum women start the progesterone-only pill?
Do they need any additional contraception?
At any time postpartum!
If they start it after day 21 they require additional contraception for the first 2 days
When is COCP contraindicated in the postpartum period? why?
Within 6 weeks postpartum if breastfeeding - because they can reduce breast milk production
If breast feeding then it can be used after 6 weeks to 6 months with some risks. After 6 months there are no restrictions
Should definitely not be used in the first 21 days due to increased VTE risk!!
If not breastfeeding:
You can use it after 3 weeks provided no risk factors for VTE!
Do you need additional contraception if you start COCP after day 21 postpartum?
Yes for the first 7 days
When can the IUD or IUS be inserted in the postpartum period? Why?
Within 48 hours of childbirth
Or delay until 4 weeks postpartum due to increased risk of IUD expulsion
When can sterilisation be done postpartum?
Can be performed at the time of c-section
Otherwise delay until at least 6 weeks post deliver
How quick can Group A strep infections progress to severe sepsis in the postpartum period?
48-96 hours it can progress to septic shock and multi organ failure
Breast feeding: Signs of successful attachment and positioning
Chin touches breast
Mouth is wide open
Cheeks are round and full
Sucks become slower and longer
You can see some of you breast above the baby’s top lip
You feel a strong drawing sensation
Breast feeding: Signs of successful feeding in babies
Audible and visible swallowing
Sustained rhythmic suck
Relaxed arms and hands
Moist mouth
Regular soaked nappies
Breast feeding: Signs of successful feeding in women?
Nipples and breasts do not hurt
Breasts feel softer after feeding
Nipple shape is the same as before, or lightly longer. I.e. not flattened!
She feels relaxed and sleepy
