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