Puerperium

Question 1

Define Puerperium

Answer 1

Puerperium is the 6-week period following delivery when the body returns to its pre-pregnant state

Question 2

How long does the uterus take to reduce in its size? When will the uterus not be palpable?
What might be experienced during this period?

Answer 2

Uterus takes over 6 weeks to reduce in its size and will become non-palpable within 10 days.
Contractions or ‘after pains’ might be experienced for 4 days.

Question 3

How many days does it take for the internal os of the cervix to close?

Answer 3

3 days

Question 4

What is the name of the discharge from the uterus during puerperium?
Describe the colour of the discharge

Answer 4

Lochia.
May be blood stained for 4 weeks, but thereafter becomes yellow or white.
Rubra –> Serosa –> Alba

Question 5

Why are women predisposed to thrombosis in puerperium?

Answer 5

Women are predisposed to thrombosis due to the rise in Platelet and clotting factors during puerperium.

Question 6

What are the 3 main common reasons that cause PPH?

Answer 6

Retained placental fragments, atonic uterus and perineal trauma

Question 7

What is the management of atonic uterus?

Answer 7

Bimanual compression, followed by IV oxytocin or Ergometrine.
If uterine atony persist, prostaglandin F2 is injected into the myometrium

Question 8

What is the routine drug given to women during the 3rd stage of labor?

Answer 8

Oxytocin

Question 9

After how long will there be intervention to remove the retained placenta?

Answer 9

A retained placenta will be removed manually if it is not expelled by normal methods within 60 mins of delivery

Question 10

What is postpartum pyrexia?

Answer 10

Maternal fever of >38 degree celsius in the first 14 days

Question 11

What is a major cause of postpartum pyrexia? What is the major cause of maternal mortality?

Answer 11

Infection, with genital tract sepsis being the major cause of maternal mortality.

Question 12

What are the symptoms and signs of genital tract sepsis?

Answer 12

The lochia may be offensive and the uterus is enlarged and tender.

Question 13

What are the causes and sites of postpartum pyrexia?

Answer 13

IV site, Chest infection, Mastitis, Urinary tract infection, wound infection after Caesarean section, endometritis, deep vein thrombosis

Question 14

What are the urinary tract issues that can arise postpartum?

Answer 14

Retention of urine
Urinary tract infection
Incontinence

Question 15

What are the hormonal changes in puerperium - sex steroids, thyroid hormones, prolactin, cortisol, aldosterone, renin.

Answer 15

In puerperium, there will be falling levels of sex steroids, thyroid hormones, renin, cortisol and aldosterone.
Prolactin falls unless mother is breast-feeding.

Question 16

What are the changes in Hb levels, Haematocrit and plasma volume?

Answer 16

There is a fall in plasma volume, a rise in Hb and haematocrit from day 4.

Question 17

Define secondary PPH

Answer 17

Secondary PPH is bleeding after 24 hours postpartum, until 6 weeks postnatal.

Question 18

What could be the causes of secondary PPH? Describe the symptoms

Answer 18

RPOC - retained products of conception: Persistent heavy lochia
Endometritis - Sudden heavy bleeding and malaise

Question 19

What is the management of RPOC?

Answer 19

ERPC - evacuation of retained products of conception, with USS guidance
Antibiotics

Question 20

What are the main direct causes of maternal collapse and death?

Answer 20

Thrombosis, Genital tract sepsis, Haemorrhage and Amniotic fluid embolism

Question 21

What are the main indirect causes of maternal collapse and death?

Answer 21

Cardiac disease, sepsis from pneumonia or flu

Question 22

What are the risks of getting amniotic fluid embolism?

Answer 22

Hyperstimulated uterus (too much oxytocin)
ARM - artificial rupture of membrane
Polyhydramnios
Pre-eclampsia
advanced maternal age >35 years old
Placental problems like placental abruption

Question 23

When is the most likely period to get amniotic fluid embolism?

Answer 23

During labour or immediately after delivery

Question 24

What is the presentation of the mother with amniotic fluid embolism?

Answer 24

Sudden SOB, acute hypoxia, respiratory distress, sudden hypotension

Question 25

Define Maternal Collapse

Answer 25

Maternal collapse is an acute event involving the cardiorespiratory systems and brain, resulting in a reduced or absent conscious level (and potential death) at any stage in pregnancy up to 6 weeks after delivery.

Question 26

What are the causes of maternal collapse?

Answer 26

4H - Hypovolaemia (bleeding, sepsis, neurogenic shock), Hypoxia, Hypothermia, Hypo/Hyperkalaemia
4T - Tamponade, Toxicity, Tension Pneumothorax, Thromboembolism
Eclampsia and Intracranial haemorrhage