Puerperium Flashcards
1
Q
why is puerperium care important?
A
- Applicable to all women who deliver
- Physiological changes of labour, delivery and iatrogenic interventions revert to non pregnant state
- Complications could be life threatening and life changing for the mother
2
Q
define puerperium
A
- Period from delivery of placenta through first few weeks after delivery
- Approximately 6 weeks in duration
- Physiological changes of pregnancy, labour and delivery revert to non pregnant state
3
Q
cardiovascular changes during pregnancy
A
- Increased circulatory/vascular volume in pregnancy (blood volume increases by 30% / plasma volume increases by 45%)
- Cardiac output increases by 30-50%
- Stroke volume increases by 25%
- Heart rate increases by 15-25%
- Peripheral vascular resistance decreases by 15-20%
4
Q
cardiovascular changes after birth
A
- Dramatic change
- Stabilisation of increased cardiac output
- Diuresis days 2-5 postpartum dissipates extra volume
- Normalisation from 2 weeks postpartum
5
Q
coagulation system changes in pregnancy and puerperium
A
- Hypercoagulable states in pregnancy
- Profound physiological changes in blood and coagulation after birth
- Remains high for 10-14 days before normalising
- Resulting haemostasis protects against haemorrhage
- Increased risk of VTE
- Virchows triad – vessel wall injury, stasis, hypercoagulability
6
Q
describe changes to uterus in the puerperium period
A
- Involution occurs
- Fundus palpable at maternal umbilicus immediately postpartum, approx. 20 weeks size pregnancy
- Returns to true pelvis within 2 weeks
- Recedes to only slightly larger than pre-pregnancy at end of puerperium
- Restoration of endometrium by 16th day except at placental attachment site
- Changes at placental bed site results in production of lochia (rubra, serosa, alba)
7
Q
describe changes to cervix in puerperium period?
A
- Reverts to non pregnant state
* External os closes such that a finger cannot be easily introduced
8
Q
describe changes to vulva, vagina and perineum in puerperium period?
A
- Resolution of increased vascularity and oedema by 3 weeks
- Restoration of vagina rugae variable depending on breast feeding status (6-10 weeks)
- Swelling and engorgement of already stretched and traumatised vulva/perineum
- Tears and episiotomies heals in couple of weeks
- Pelvic muscle tone regained by 6 weeks depending on extent of damage
9
Q
describe changes to abdominal wall in puerperium?
A
- Laxity in tone of abdominal wall muscles
- Diastasis recti – split/gap in rectus abdomini muscles
- Usually resolves with exercises
10
Q
describe changes to ovaries in puerperium
A
- Resumption of normal ovarian activity and resulting menstruation variable
- Greatly influenced by mode of baby/newborn feeding
- High levels of prolactin inhibit ovulation
- Lactational amenorrhoea up to 6 months (upto ¾ women)
- Formula feeding could result in ovulation as early as 28 days post partum
- Mean time to first menses is 7-9 weeks
11
Q
describe changes to breasts in peurperium?
A
- Changes to breasts in preparation for lactation occur throughout pregnancy
- Development of the ablity to secrete milk occurs as early as 16 weeks gestation
- High levels of circulating progesterone activates mature alveolar cells in the breast
- Rapid decline in progesterone after delivery triggers the onset of milk production
- Swelling, or engorgement, of breasts in postpartum period
- Colostrum high in protein and antibody (first 4 days after delivery)
- Removal of milk from breast stimulats more milk production (autocrine process)
- Breast milk matures over the first 7 days
12
Q
describe the process of lactation
A
- Process of continued secretion of copious milk
- Requires regular breast emptying
- Prolactin release from anterior pituitary gland
- Suckling causes nipple stimulation
- Oxytocin release from posterior pituitary gland
- Contraception of myoepithelial cell of breasts
- Milk flow -> alveolar lumens -> ducts and the nipple
13
Q
describe how the breast responds to formula feeding as opposed to breast feeding/expressing?
A
- Absence of milk removal
- Elevated intramammary pressure due to accumulation of milk within alveolar lumen
- Alveolar distention restricts blood flow to alveoli
- Interference with milk production
- Increase in pressure triggers inhibitor of lactation
- Mammary involution within 2-3 weeks
14
Q
describe perineal pain in peurperium
A
- Usually immediate/early presentation
- Could be due to swelling, bruising, repair from tears or episiotomies
- Requires regular analgesia
- Important to examine to R/O infection, haematoma
- Perineal swabs and antibodies if suspected infection
- Haematoma will need evacuation
15
Q
describe micturition in peurperium
A
- Urinary retention (maybe secondary to pudendal nerve damage) may need catheterisation
- 50% will develop urinary incontinence
- Usually stress incontinence
- May persist after pregnancy
- Pelvic floor exercises should be taught and encouraged
16
Q
describe bowel problems in peurperium?
A
- Constipation may due to regular use of opioids for perineal trauma or pain
- Stool softeners may be useful
- Haemorrhoids may be more painful after birth than before
- Can occasioanlly appear for first time
17
Q
mastitis
A
- May result from failure to express milk from one part of the breast
- It can be treated by ensuring all milk is expressed, feeding on affected side first so this side is emptied effectively
- May be complicated by infection with staphylococcus aureus and require treatment with flucloxacilin
18
Q
backache in peurperium
A
- May persist after birth and affects approxiately 1/3
- Could last several months
- If early presentation with associated headachein woman who had regional anaesthesia needs to rule out complications such as dural tap
19
Q
anaemia in peurperium
A
- This is common and may easily be overlooked
- FBC to confirm diagnosis
- Require iron tables and rarely haemotransfusion
20
Q
psychological problems in peurperium?
A
- Baby blues – days 3-5 postpartum
- Significant proportion of women become temporarily sad, anxious, iritable and emotional
- Precise cause unknown and may involve hormonal changes, reaction to reality of motherhood and doubts by the mother about her ability to care for the child
- Management consists of an explanation and reassurance; feelings should go within a few days
21
Q
VTE in peurperium
A
- Leading cause of maternal mortality in UK (MBRRACE 2013-15)
- Puerperium is the time of highest risk (20 fold increased risk)
- Increased risk in overweight, age >35 years of caesarean section
- Treat with LMWH
- Start treatment immediately on suspicion of thromboembolism
Reducing risk
• Proactivity
• Risk assessment
• Prevention (thromboprophylaxis)
22
Q
diagnosing DVT in peurperium
A
- Leg pain, swelling (unilateral), tender and painful calf muscles on firm palpation
- Lower abdominal pain or thigh pain and tenderness, low grade fever
- Clinical signs are unreliable (and D-dimer cannot be used in pregnancy and puerperium), so confirmation is needed with compression duplex ultrasound
- Treatment is with LMWH start immediately
- If ultrasound is negative but DVT is still suspected, LMWH can be stopped but ultrasound repeated on days 3-7
23
Q
diagnosting and managing PE in peurperium
A
- Dyspnoea, haemoptysis, pleural pain, cyanosis may develop later. Massive PE may present with collapse
- Friction rub may be heard in chest
- ECG performed. Abnormal in 41% but may suggest an alternative diagnosis, such as CHD
- CXR – abnormal in under 50% but may suggest alternative diagnosis, such as pneumothorax
- If DVT suspected, PE may be diagnosed and treatment started if DVT confirmed on compression duplex ultrasound
- If DVT is not suspected, a ventilation/perfusion scan or computerised tomography pulmonary angiogram should be performed
- Treat with LMWH (IV unfractionated heparin bolus followed by infusion with or without thrombolysis for massive PE)
- Self administered LMWH or oral warfarin is continued for at least 3 months
- LMWH is associated with significantly lower risk of post thrombotic syndrome compared with warfarin
24
Q
post partum haemorrhage
- definition
- types
A
- Blood loss of more than 500mL from female genital tract after delivery of fetus (or >1000mL after caesarean)
Second leading direct cause of maternal deaths in UK MBRACE 2013-15
Leading cause of maternal mortality in world - Primary post partum haermorrhage- loss of more than 500mls of blood from genital tract within 24 hours of delivery / atonic uterus 76-80%
Secondary postpartum haemorrhage – abnormal bleeding after 24 hours up until 6 weeks postpartum
25
Q
PRIMARY POSTPARTUM HAEMORRHAGE poor uterine tone 1. clinical findings 2. investigation 3. management
A
- abdominal palpation - uterus relaxed, boggy and soft. uterine fundus - felt above umbilicus if uterine cavity filled with blood and clots
- FBC, coag, U+E. if not responsive to fluid and blood - abdominal USS to exclude uterine rupture or intraperitoneal bleeding
- uterotonic agents - oxytocics, prostaglandins, ergot alkaloids. uterine balloon tamponade. haemostasis
26
Q
PRIMARY POSTPARTUM HAEMORRHAGE tears or trauma 1. clinical findings 2. investigation 3. management
A
- bleeding, uterine rupture, extension of uterine angles, tears during caesarean, extragenital causes (subscapular live rupture or rupture of ovarian or spenic vessels)
- inspect during C.section, ultrasound to identify free fluid
- management - repair of trauma, pelvic arterial embolisation (in cases of broad ligament or supralevator haematoma)
27
Q
PRIMARY POSTPARTUM HAEMORRHAGE retained tissue 1. clinical findings 2. investigation 3. management
A
- retained placenta and membranes - identified during bimanual examination
- examine under anaesthesia
- manual removal - of placenta or retained products of conception under regional or general anaesthetic
28
Q
PRIMARY POSTPARTUM HAEMORRHAGE coagulopathy 1. clinical findings 2. investigation 3. management
A
- continuing bleeding, contracted uterus
- U+E, FBC, coag
- medical - immediate replacement of blood and coag factors and platelets. surgical - only with trauma or atonic haemorrhage unresponsive to medical treatment
29
Q
SECONDARY POSTPARTUM HAEMORRHAGE endometritis 1. clinical findings 2. investigation 3. management
A
- uterine tenderness, guarding and rebound tenderness
- ultrasound to exclude retained products of conception, pelvic abscess. high vaginal swabs
- oral antibiotics, admit for IV antibiotics if unwell or haemodynamically unstable
30
Q
SECONDARY POSTPARTUM HAEMORRHAGE pseudo-aneurysm, uterine artery 1. clinical findings 2. investigation 3. management
A
- profuse bleeding, shock (24hr after birth)
- doppler uss, MRI, pelvic angiography
- medical - antibiotics, correction of blood volume. surgical - uterine artery embolisation
31
Q
SECONDARY POSTPARTUM HAEMORRHAGE retained tissue 1. clinical findings 2. investigation 3. management
A
- foul smelling or offensive vaginal discharge, fever, uterine tenderness
- USS- confirm retained products of conception and exclude pelvic abscesss
- medical - oral antibiotics or admit for IV antibiotics if haemodynamically unstable
surgical- evacuation of retained products of conception.
32
Q
describe the significance of mental health problems in postnatal period?
A
- Highest risk of severe mental illness when pregnant and soon after than at other time in life
- Between 2009-2013 there were 101 maternal deaths due to suicide in UK
- Screening questions for depression and anxiety should be considered in early postnatal period
- 10-15% of women experience postnatal depression which may present at any time during the first year after delivery
33
Q
signs and symptoms of postnatal depression
A
- Feeling very low or despondant, that life is long, hopeless
- Feeling tired and very lethargic
- Not wanting to do anything or take an interest in outside world
- Feeling sense of inadequacy or unable to cope
- Feeling guilty about not coping, or about not loving their baby enough
- Being unually irritablle, which makes guilt worse
- Wanting to cry/cry a lot or constantly
- Having obsessive and irrational thoughts which can be scary
- Loss of appetite which may go with feeling hungry all the time but being unable to eat
- Difficulty sleeping – not getting to sleep, waking early or having vivd nightmares
- Being hostile or indifferent to their partner and/or baby
- Having difficulty in concentrating or making decisions
- Experiencing physical symptoms such as headaches
- Having obsessive fears about babys health or wellbeing or about themselves and other members of family
- Having disturbing thoughts about harming themselves or their baby
- Having thoughts about death/suicide
34
Q
postpartum psychosis
incidence
presentation
A
- Affects 1-2/1,000 women following delivery and usually appears as mania or depression
- Can present with apparent schizophrenia.
- It usually begins abruptly , initially with confusion, anxiety, restlessness and sadness.
- rapid development of delusions or hallucinations
- Any woman with symptoms suggestive of postpartum psychosis should be referred to a secondary mental health service for assessment within four hours. Admission to specialist mother and baby unit.
35
Q
peruperal pyrexia and sepsis
definition and mortality
A
• Fever >38 (within 6 weeks postpartum)
in the UK, sepsis in puerperium remains an important cause of maternal death
• The mortality rate related to genital tract sepsis decreased in the UK from 0.63 per 100,000 maternities in 2009-2011 to 0.29 deaths per 100,000 maternities in 2011-2013
36
Q
PUERPERAL PYREXIA AND SEPSIS
aetiology
A
- Urinary tract infection -95% caused by Escherichia coli, Proteus spp. and Klebsiella spp.
- Genital tract infection -May be caused by E. coli, other anaerobes, Group A streptococcus (GAS) (also known as Streptococcus pyogenes), Staphylococcus spp. and Clostridium welchii (rare, but serious).
- Mastitis
- Other infections(Chest/viral )
- Deep venous thrombosis(Low grade pyrexia)- venous stasis and hypercoagulability./ Painful, swollen calf.
- Ovarian vein thrombophlebitis (rare cause of persistent puerperal pyrexia).
37
Q
PUERPERAL PYREXIA AND SEPSIS
caesarean section wound infection
A
- Lower segment caesarean section-most important risk factor for puerperal pyrexia
- Significantly increased risk of postpartum sepsis, wound problems, urinary tract infections and fever following LSCS.
- In UK (8%) risk of infection following LSCS - appropriate antibiotic prophylaxis before skin incision should be offered routinely
- Prophylaxis reduces endometritis by 66-75% and also reduces rate of wound infection or perineal Wound infection
38
Q
PUERPERAL PYREXIA AND SEPSIS
caesarean section wound infection
A
- Lower segment caesarean section-most important risk factor for puerperal pyrexia
- Significantly increased risk of postpartum sepsis, wound problems, urinary tract infections and fever following LSCS.
- In UK (8%) risk of infection following LSCS - appropriate antibiotic prophylaxis before skin incision should be offered routinely
- Prophylaxis reduces endometritis by 66-75% and also reduces rate of wound infection or perineal Wound infection
39
Q
PUERPERAL PYREXIA AND SEPSIS
signs and symptoms for urgent referral for hospital admission
A
- Pyrexia > 38 degree celsius
- Sustained tachycardia (≥90 beats/minute).
- Breathlessness (respiratory rate ≥20 breaths/minute).
- Abdominal or chest pain.
- Diarrhoea and/or vomiting - may be due to endotoxins.
- Uterine or renal angle pain and tenderness.
- The woman is generally unwell or seems unduly anxious or distressed.
40
Q
PUERPERAL PYREXIA AND SEPSIS
clinical assessment and investigations
A
- Full history and examination (chest, breasts, genital tract, legs)
- Wound swabs
- High vagina swabs(HVS)
- Blood cultures
- Full blood count
- Urine microscopy & cultures
- Throat swabs & sputum cultures
- Radiology(chest X-ray and pelvic ultrasound scan)
41
Q
PUERPERAL PYREXIA AND SEPSIS
measures for suspeted viral illness, mastitis, wound infection if woman not clinically unwell
A
- Ice packs may be helpful for pain from perineal wounds or mastitis.
- Rest and adequate fluid intake are required, particularly for mothers who are breast-feeding.
- Oral antibiotics with broad spectrum cover
42
Q
PUERPERAL PYREXIA AND SEPSIS
management if clinically unwell or signs of severe sepsis
A
- Admission to hospital
- Antibiotics should be commenced after taking specimens and should not be delayed until the results are available.
- Administration of intravenous broad-spectrum antibiotics within one hour of suspicion of severe sepsis, with or without septic shock, is recommended
- Analgesia may be required. NB: non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided for pain relief in cases of sepsis, as they impede the ability of polymorphs to fight GAS infection.
- Multidisciplinary team approach involving Senior Obstetrician, microbiologist/virologist/intensivist required for severe sepsis /shock.
- Surgical intervention may be required if an abscess has formed.
43
Q
PUERPERAL PYREXIA AND SEPSIS
postpartum thyroiditis
what is it, symptoms, treatment
A
• Transient destructive lymphocytic thyroidis
• Anytime in first year postpartum
2 phases
• Thyrotoxicosis 1-4 months post partum, low TSH
• Hypothyroidism - increased TSH
Symptoms
• Hyperthyroidism - Anxiety, irritability, rapid heartbeat or palpitations,unexplained weight loss,increased sensitivity to heat, fatigue, tremor, insomnia.
• Hypothyroidism - Lack of energy, increased sensitivity to cold, constipation, dry skin, dificulty concentrating, aches and pains.
Treatment
• Usually self limiting
• Hyperthyroidism (Beta blockers if severe)
• Hypothyroidism (Thyroxin if severe symptoms)
44
Q
when is contraception in puerperium needed
A
- Great variation in the return to fertility and sexual activity following childbirth
- Earliest known time of ovulation is 27 days after delivery.
- No contraception needed until 21 days postpartum.
- Contraceptive options influenced by breastfeeding
45
Q
CONTRACEPTION IN PUERPERIUM
non breast feeding women <21 days postpartum
A
- progestogen only pill
- progestogen only injectables and implants
- barrier methods
46
Q
CONTRACEPTION IN PUERPERIUM
non breast feeding women >21 days postpartum
A
- all combined hormonal contraceptive methods
- POP
- progestogen only injectables and implants
- barrier methods
- fertility awareness based methods in previous user
47
Q
CONTRACEPTION IN PUERPERIUM
breast feeding women <6 weeks postpartum
A
- lactational amenorrhoea method
- POP
- progestogen only implants
- barrier methods
48
Q
POSTPARTUM CARE
A
- Women should be offered information to enable them to promote their own and their baby’s health and well-being and to recognise and respond to problems.
- At the first postnatal contact, women should be advised of the signs and symptoms of haemorrhage, infection, thromboembolism and preeclampsia/eclampsia and the appropriate action to take.
- All maternity care providers should encourage breast-feeding.
- contraceptive methods and advice about when to start them should be discussed within the first postpartum week
- At each postnatal contact, women should be asked about their emotional well-being, what family and social support they have and their usual coping strategies for dealing with day-to-day matters.
- Women and their families/partners should be encouraged to tell their healthcare professional about any changes in mood, emotional state and behaviour that are outside of the woman’s normal pattern.
49
Q
DRUGS AND BREASTFEEDING
principles
A
- Almost all drugs pass in breastmilk
- Prescribe only when absolutely indicated
- Choose ones with shorter half lives, less toxicity, those commonly used in infants and those with reduced bioavailability
50
Q
DRUGS AND BREASTFEEDING
medications with poor bioavailability and low risk
A
- Heparin.
- Insulin.
- Aminoglycoside antibiotics.
- Third generation cephalosporins.
- Omeprazole and lansoprazole.
- Inhaled steroids and beta agonists.
51
Q
DRUGS AND BREASTFEEDING
drugs contraindicated in breast feeding women
A
- Amiodarone.
- Antineoplastic.
- Chloramphenicol.
- Ergotamine.
- Cabergoline.
- Ergot alkaloids.
- Iodides.
- Methotrexate.
- Lithium.
- Tetracycline.
- Pseudoephedrine.
