Puerperium Flashcards
What is the definition of puerperium?
begins after delivery of placenta and lasts until reproductive organs have returned to pre-pregnant state - usually about 6 weeks
What are 6 things which change in the puerperial period?
- Hormones
- Genital tract
- Perineum
- Lochia
- Breasts
- Cardiovascular system
What are 4 types of hormones whose levels change in the pueperium and how?
- Human placental lactogen
- beta hCG
both fall rapidly; by 10 days neither should be dectable
- Oestrogen
- Progesterone
non-pregnant levels achieved by 7 days post partum
What changes happen to the uterus in the puerperium?
undergoes rapid involution
weight of uterus falls from 1kg to 500g at the end of a week
by 2 weeks, returns to pelvis and is no longer palpable abdominally
What are 3 aspects of the genital tract that change in the puerperium?
- Uterus
- Cervix
- Vagina
By what point is the uterus no longer palpable postnatally?
after 2 weeks have passed
What happens to the vagina in the puerperial period?
initially vaginal wall is swollen, but rapidly regains tone although remaining fragile for 1-2 weeks
gradually vascularity and oedema decrease, by 4 weeks rugae reappear, but are less prominent than in a nullipara
What lasting changes are there to the vagina following delivery compared witha nulliparous woman?
rugae reappear but are less prominent
What happens to the cervix in the puerperium?
- cervical os gradually closes after delivery
- admits 2-3 fingers for first 4-6 days
- by end of 10-14 days is dilate to barely more than 1cm
What happens to the perineum in the puerperium?
perineal oedema persists for some days
may take longer if there was a prolonged second stage, especially with long period of pushing, operative vaginal delivery, or perineal tears that needed repair
What are 3 things that can cause perineal oedema to take longer to settle?
- prolonged second stage, especially with long period of pushing
- operative vaginal delivery
- perineal tears that needed repair
What is meant by lochia?
sloughed off necrotic decidual layer mixed with blood
initially red (lochia rubra), becomes paler as bleeding reduces (lochia serosa) and finally becomes a yellowish white (lochia alba)
What are the 3 stages of lochia in the post-partum period?
- initially red (lochia rubra)
- becomes paler as bleeding reduces (lochia serosa)
- finally becomes a yellowish white (lochia alba)
How long might the flow of lochia last for?
3-6 weeks
What happens to the breasts during puerperium?
between 2nd and 4th days, breasts become engorged, vascularity increases, areolar pigmentation increases
Enlargement of lobules results from an increase in number and size of the alveoli
When do the key changes to the breast in the postpartum period occur?
between 2 and 4 days post delivery
What causes enlargement in breast lobules following delivery?
increase in number and size of alveoli (tiny, hollow sacts)
What are 3 changes that happen in the cardiovascular system in the puerperium?
- Cardiac output initially increases due to return of blood from contracted uterus
- Plasma volume (expanded 40% during pregnancy), rapidly decreases due to diuresis and returns to normal by 2-3 weeks post-partum
- Heart rate decreases and returns to pre-pregnancy rate, and is partly responsible for reduced cardiac output
What are 3 things that cause changes in blood volume in the puerperium?
- Blood loss at delivery
- Excretion of extracellular fluid
- Reduction of plasma volume due to changes in hormonal status
By what point does plasma volume decrease back to pre-pregnancy levels following birth?
2-3 weeks post-partum
What are 3 major causes of morbidity in the post-natal period?
- Secondary PPH
- VTE
- Puerperal pyrexia
What is the definition of secondary PPH?
any abnormal bleeding occurring 24h to 6 weeks postnatally
What proportion of postnatal women are admitted to hospital with secondary PPH in developed countries? What proportion undergo surgical evacuation?
2%
50% of these undergo surgical evacuation
What are 3 key things which can cause secondary PPH?
- Retained products
- Endometritis
- Tear
What is important to remember about the presentation of VTE in the postpartum period?
may be asymptomatic until it presents with PE
What are 6 signs and symptoms of deep vein thrombosis?
- Leg pain or discomfort (especially in left leg)
- Swelling
- Tenderness
- Erythema, increased skin temperature and oedema
- Lower abdominal pain (high DVT)
- Elevated white cell count
What are 8 signs and symptoms of pulmonary thromboembolism?
- Dyspnoea
- Collapse
- Chest pain
- Haemoptysis
- Faintness
- Raised jugular venous presure (JVP)
- Focal signs in chest
- Symptoms and signs associated with DVT
What is the management of women presenting with signs and symptoms of DVT/PE in the postpartum period
high level of suspicion if present with symptoms
urgent investigation warranted starting with pulse oximetry, ECG, CXR
What is the definition of puerperal pyrexia?
presence of fever in a mother ≥38°C in the first 14 days after giving birth
What is the definition of sepsis and the 6 criteria?
infection with symptoms and signs of systemic inflammatory response (SIRS), a combination of 2 or more of:
- new onset of confusion or altered mental state
- hypo (<36oC) or hyperthermia (>38.3oC)
- tachycardia (>90/min)
- tachypnoea (>20/min)
- raised WBCs (>12 or <4 x 109/L)
- blood sugar >7.7mmol/L in a non-diabetic
What is severe sepsis?
organ dysfunction of hypoperfusion of tissues; hypotension, lactic acidosis, or organ failure e.g. renal
What is septic shock?
persisting hypotension despite adequate fluid resuscitation in the presence of sepsis (morality could be up to 60%)
What prophylaxis is very important for saving lives from puerperal sepsis?
influenza vaccine
Why is it so important to regularly monitor maternal pulse, BP, RR and temperature on a MEWS chart (modified early warning score)?
young, healthy mothers maintain vital parameters slightly altered then suddenly decompensate; MEWS can help identify worsening condition early
What is the management of postpartum sepsis?
- Sepsis 6 care bundle - start within 1 hour of diagnosis
- take ABG
- take blood cultures
- take blood for Hb and lactate
- measure urine output hourly
- give high flow oxygen
- commence IV broad-spectrum antibiotics
- give fluid resuscitation
- review by senior doctors and midwives
When level of lactate in postpartum sepsis defines 1. severe sepsis 2. septic shock?
- >2
- >4
Which colleagues should you seek help from in pregnant or post-partum women with acute severe illness e.g. sepsis with circulatory failure?
senior medical staff, including anaesthetic and critical care colleagues
telephoning senior colleague to discuss case valuable in acute emergencies
What is recommended for recently delivered women with unexplained pain who require opiate analgesia?
require urgent senior review
What are 6 maternal signs that mean you must act immediately to treat?
- Systolic BP <90 or has dropped >40mmHg
- Heart rate >130/min
- Oxygen sats <91
- RR >25
- Unresponsive or responds to voice or painful stimulus
- Blood lactate >2
What are 3 pieces of advise to give to a woman in the postpartum period to reduce the risk of postpartum sepsis?
- Hand washing after toilet use
- Cleaning the perineum
- Change of pad
When is it particularly important to emphasise the importance of hygiene to a mother in the postpartum period to avoid infection?
if anyone living at home has an URTI
What are 2 categories that puerperal pyrexia can be grouped into?
genital and non-genital causes
What are 2 genital causes of puerperal pyrexia?
- Uterine infection (endometritis)
- Perineal wound infection
What are 7 predisposing factors to uterine infection (endometritis) in the puerperal period?
- Caesarean section - more with failure to use prophylactic antibiotics
- Prelabour rupture of membranes - incidence increases with the latency to onset of labour
- Intrapartum chorioamnionitis
- Prolonged labour
- Multiple pelvic examinations
- Internal fetal monitoring - use of scalp electrodes/ intrauterine pressure catheters
- Other risk factors e.g. anaemia, low-socioeceonmic status
What are 4 signs and symptoms of uterine infection (endometritis) as a cause of puerperal pyrexia?
What can cause perineal wound infection?
Infection of episiotomy wounds and repaired lacerations
What happens in perineal wond infection?
perineum becomes painful and erythematous
may cause breakdown of wound
What are 6 possible complications of pelvic infection (such as perineal wound infection and uterine infection)?
- Wound dehiscence
- Adnexal infections
- Pelvic abscess
- Septic thrombophlebitis
- Sepsis
- Subsequent subfertility
What are 2 antepartum factors predisposing to puerperal pyrexia?
- Anaemia
- Duration of membrane rupture
What are 5 intrapartum factors predisposing to puerperal pyrexia?
- Duration of labour
- Bacterial contamination during vaginal examination
- Instrumentation
- Trauma e.g. episiotomy, vaginal tears, CS
- Haematoma
What are 5 non-genital causes of puerperal pyrexia?
- Breast causes - mastitis, abscess
- Urinary tract infection
- Thrombophlebitis
- Respiratory complications
- Abdominal wound infection
What proportion of women develop fever from breast engorgement?
15%
What features may be associated with a breast cause of puerperal pyrexia?
fever - may be as high as 39oC, associated with painful and hard breast
What is the recommended management of breast-related causes of puerperal pyrexia (mastitis, abscess)?
antibiotics may be needed; breast feeding should bec ontinued
abscess may ned surgical drainage
What proportion of women develop UTI post-partum?
2-4%
What factors are thought to contribute to urinary tract infection postpartum?
hypotonic bladder may result in stasis and reflux of urine
catheterisation, birth trauma, pelvic examinations during labour
What are 3 presenting symptoms of UTI following pregnancy and what are 3 further symptoms that may be present in pyelonephritis?
- Micturition
- Dysuria
- Urgency
Pyelonephritis:
- High fever
- Rigors
- Loin pain
What are 3 of the most common organisms involved in postpartum UTI?
- E. coli
- Proteus
- Klebsiella
What is meant by thrombophlebitis when considering non-genital causes of puerperal pyrexia?
superficial or deep venous thrombosis of legs may cause pyrexia; caused by venous stasis
How is the diagnosis of thrombophlebitis in the puerperal period made?
observation of painful, swollen leg, usually accompanied by calf tenderness
Within what time frame are respiratory complications following delivery usually seen?
first 24h
Following which type of birth are respiratory complications of delivery more likely?
almost invariably after delivery by caesarean section
What are 3 types of respiratory complications that can occur following delivery?
- Atelectasis
- Aspiration
- Bacterial pneumonia
What is the incidence of abdominal wound infection following CS and what could the rate of infection be with prophylactic antibiotics?
- 6%
- <2%
What do recent guidelines recommend about prophylactic antibiotics to prevent wound infection following CS?
Cefuroxime 1.5g IV prior to wound incision
if sensitive then clindamycin 900mg IV
(co-amoxiclav avoided for fear or necrotising enterocolitis in the neonate)
What are 4 risk factors for abdominal wound infection following CS?
- Obesity
- Diabetes
- Corticosteroid therapy
- Poor haemostasis at surgery with subsequent haematoma
What are 7 investigations that may be needed in the cases of puerperal pyrexia?
- FBC
- Blood cultures
- MSU
- Swabs from cervix and lochia for chlamydia and bacterial culture
- Wound swabs
- Throat swabs
- Sputum culture and chest radiograph
What are 3 possible aspects of the management of puerperal pyrexia?
- Supportive
- Antibiotics
- Surgical
What are 3 possible supportive types of management of puerperal pyrexia?
- Analgesics and anti-inflammatory drugs (NSAIDs)
- Wound care in cases of wound infection
- Ice packs for pain from perineum or mastitis
What is advised for the antibiotic regimen for puerperal pyrexia?
regimen with activity against Bacteroides fragilis group and other penicillin-resistant anaerobic bacteria is better than one without
What is 1 side effect profile of antibiotics to treat puerperal pyrexia to bear in mind?
cephalosporins associated with less diarrhoea; no evidence any one regimen associated with fewer side effects though
What antibiotics are considered appropriate for the treatment of endometritis in the puerperal period?
combination of clindamycin and an aminoglycoside (such as gentamicin)
What type of antibiotics should be avoided in breast-feeding women?
tetracyclines
In women with puerperal pyrexia who fail to respond to antibiotics, what is the recomended next step?
involvement of microbiologists
What are 3 types of surgical interventions that might be needed in cases of puerperal pyrexia?
- Incision and drainage of breast abscess
- Secondary repair of wound dehiscence
- Drainage of pelvic haematomas and abscesses
What are 6 ways of preventing puerperal pyrexia?
- Antenatal suspected UTI should be investigated and any infection treated vigorously
- Advice should be offered with regard to breast-feeding and care of breasts during antenatal period
- Prevention and treatment of pre-existing anaemia
- Rigid antiseptic measures taken during labour and delivery
- Prophylactic antibiotic administration at CS
- Treatment with broad-spectrum antibiotics while waiting for culture results
What are 4 examples of the rigid antiseptic measures that should be taken during labour and delivery to help eliminate the risk of infection and puerperal sepsis?
- Hand washing and use of alcohol hand gel by midwives and doctor before examining patient
- Examining in sterile environment and using sterile instruments
- Use of antiseptic creams and lotions
- Catheterising only when it is indicated and using all sterile precautions while introucing the catheter
In addition to puerperal pyrexia, what are 6 further of postnatal problems?
- Pain
- Bladder problems
- Bowel problems
- Symphysis pubis discomfort
- Maternal obstetric paralysis
- Mental health problems
What is postpartum pain often termed and what causes it?
- After-pains
- Uterine contractions cause lower central abdominal pain
When do ‘after-pains’ following delivery typically occur?
during the first 3-4 days
What are 3 things which can cause particularly severe perineal pain after delivery?
- Instrumental delivery
- Episiotomy
- Vaginal tears
What could increasing perineal pain following delivery be a sign of?
infection - antibiotics should be prescribed depending on the local policy
What type of analgesics may be useful for postpartum perineal pain?
paracetamol and NSAIDs believed to be as effective as oral narcotic medications
application of local anaesthetic e.g. 1% lidocaine gel may be helfpul
What are 2 types of bladder problems which may occur in the puerperal period?
- Urinary retention
- UTI
What commonly causes urinary retention after delivery? 2 key things
- commonly occurs with an epidural as bladder sensation and desire to void is masked
- instrumental delivery or extension tears (especially peri-urethral), perineal pain and oedema can cause voiding difficulties and retention
What is the management of urinary retention following delivery?
- Reassurance and analgesics helpful in most situations
- Occasionally catheterisation required to protect from over-distension, may be best to leave indwelling for 24-48h
What are 4 factors that can contribute to postpartum constipation?
- Lack of fluid and food
- Dehydration during labour
- Pain and fear of wound disruption following perineal tears could further exacerbate the problem
- Opiate analgesia can exacerbate
What are 3 ways to manage postpartum constipation?
- Advice to increase intake of fibre and fluids
- Osmotic laxatives such as lactulose
- Women with 3rd or 4th degree tears should be prescribed stool softeners and laxatives
What are the symptoms of puerperal symphysis pubis discomfort?
severe pubic and groin pain exacerbated by weight bearing
After what amount of time do most cases of symphysis pubis discomfort resolve?
by 6-8 weeks
What is the management of symphysis pubis discomfort?
- conservative approach: rest, belt that warps around femoral trochanters to discourage separation, weight-bearing assistance, analgesics
- Rarely - surgical assistance may be needed
How does maternal obstetric paralysis manifest?
intrapartum foot drop
What are 2 things that can cause maternal obstetric paralysis?
- lumbosacral trunk compression by fetal head at pelvic brim
- placing legs on lithotomy without protection at the region of the head of the fibula can compress peroneal nerve and cause palsy
What is the pathology underlying maternal obstetric paralysis?
primary pathology is demyelination
How long does recovery from maternal obstetric paralysis usually take?
usually complete in up to 5 months
What management is recommended for maternal obstetric paralysis?
referral for neurological assessment and input
What should you consider to incorporate into postnatal care?
ethnic/ cultural consideration
When is contraception needed in the post-partum period?
not needed in first 3 weeks
What type of contraception can be used in breast-feeding women?
POP/ progesterone containing options
Which type of contraception should not be used in lactating women and why?
COCP - can affect milk composition and increase incidence of breast-feeding failure
At what point can bottle-feeding women start the COCP?
21 days post-partum
What risk is increased with early commencement of COCP following delivery?
risk of VTE
Although women are not routinely screened for rubella during pregnancy, if they are found to be seronegative for rubella what is the management?
rubella vaccination after delivery. before discharge from maternity unit
Is breast-feeding a contraindication for rubella immunisation?
no, but women should be warned to avoid conceiving in following 3 months (although risk is only theoretical)
What is the recommended management of non-sensitised RhD negative women?
should be administered anti-D 500 IU to every non-sensitised RhD negative woman within 2 hours after delivery of rhesus positive infant
What are the recommendations regarding women identified as hepatitis B negative during antenatal screening?
no specific recommendations for post-artum vaccination against HBV, but could be offered to individuals who are at increased risk because of lifestyle or occupation
Are pregnancy or lactation a contraindication for hepatitis B vaccination of susceptible women?
neither are a contraindication
When is neonatal hepatitis B vaccination recommended?
recommended for babies of women at risk or who already have the virus
