puerperium Flashcards
define puerperium
Time from delivery until the anatomic and physiologic changes of pregnancy have resolved
Approximately 6 weeks
Period of major physical, social, & emotional change and adaptation
what are the three physiological changes seen in puerperium
Lochia and Uterine Involution
2- Lactation
3- Menstruation and resumption of ovulation
what is lochia
passage of blood, mucus and uterine tissue that occurs during the puerperium*
bleeding after delivery of baby and placenta
bloody for 1st few days
Sero-sanguinous for up to 7-10 days
becomes clearer for 6 weeks
should be expected to cease after 4-6 weeks.
what is uterine involution
At umbilicus after delivery
Becomes a pelvic organ by 10 days
Os closed by 3 weeks
what is lactation
- Oestrogen stimulates duct growth
- Progesterone stimulates alveolar growth
- Placental lactogen affects growth of epithelium in alveoli
- Initiation of lactation is dependent on fall in oestrogen after delivering baby which stimulates release of prolactin from hypothalamus
- Milk ejection needs oxytocin from posterior pituitary
- Colostrum produced for first 3 days
Followed by establishment of milk secretion
Continued lactation dependant on suckling
what is colostrum
first secretion of the breast
when does menstruation occur in non lactating women
- resumption of menstruation approximately 8 weeks
first ovulation approximately 10 weeks
About 40% of first cycles are ovulatory
when does menstruation occur in lactating women
if for < 1 month: menstruation resumes in approximately 10 weeks
if breast feed after the first month: the average interval to first ovulation is 16 weeks
breast feeding does not offer secure contraception beyond the ninth week postpartum
management of puerperium at discharge
At discharge
- Inform GP and arrange for midwife and health visitor
- Anti-D if indicated
- Discuss contraception
- Discuss breast feeding
- Perineal care and postnatal exercise
- Vaginal loss / Hb check
At postnatal visit in 6 weeks
Discuss problems and assessment of faecal or urinary incontinence
examination of puerperium
Temperature, BP, pulse, RR, SATS Uterine size and involution Vaginal bleeding Lochia/discharge Abdominal wound (if CS) Perineum and para-vaginal tissue Breast - mastitis signs Lower limbs for DVT Enquire about bladder function Enquire about bowel function
contraception use during puerperium
- Barrier
- IUCD
PERMANENT CONTRACEPTION
- Tubal ligation: mini-laparotomy, laparoscopy 3 months after delivery
Hormonal: Minipill/Depot Injections Combined oral contraception: Reduces breast milk Excreted in milk If not breast feeding: start COP 3 weeks postpartum – increased risk of thrombosis if started earlier
advantages of breast feeding to newborn
- Easily digested nutrients
- Antibodies in colostrum:
lower incidence of gastro-enteritis
respiratory infection
otitis media
PREVENTS narcotising enterocolitis(as lysozyme, lactoferrin and IgA are present).
Avoid milk allergies (1% for cow’s milk)
Good source of nutrition except Vit C, D and iron.
Cannot overfeed
Lower risk of hypocalcaemia
advantages of breast feeding to mother
To Mother Promotes bonding Improves uterine involution ? Reduced risk of breast cancer. Contraception Safe and cheap can lose 500 calories
difficulties of breastfeeding
- Nipple inversion: correct by Waller shields in late pregnancy
- Maternal fatigue
- Emotional stress
what breast feeding advice will one give
Babies sleeping in same room as mothers encourages breast feeding
If still hungry, weigh before and after feeding:
can be fed more often, or supplements added
Check if mother on medication
Contraindicated if active TB/ HIV
Sore nipples are corrected by correcting baby’s position at breast
Express milk for babies in Special Care Units
symptoms of mastitis
Fever, chills, malaise, pain, erythema, tenderness, induration, tender axillary lymphadenopathy, milk may be purulent
what is acute intramammary mastitis
secondary to engorgement: empty breast, cold compresses. Antibiotics prophylactically.
what is infective mastitis
(Staph aureus) periareolar induration, axillary lymphadenopathy. Penicillin G resistant in 90% of cases
Continue breast feeding
If breast abscess: Drain
how to suppress lactation
Methods:
Firm supporting bra, analgesia +/- ice packs
No milk expression or nipple stimulation
Bromocriptine: Not used routinely.
complications of the puerperium
Puerperal pyrexia Secondary postpartum haemorrhage Thromboembolic disease Mood changes, postnatal depression Urinary or faecal Incontinence
define puerperal pyrexia
Temp of 38 on any occasion in the 6 weeks after delivery.
causes of puerperal pyrexia
UTI Endometritis Breast Chest DVT
Ix for puerperal pyrexia
Sepsis pathway MSU HVS - high vaginal swab Blood culture Sputum if indicated DVT - Ultrasound, VQ etc
DEFINE secondary postpartum haemorrhage
Bleeding after 1st 24 hours
causes of postpartum haemorrhage
Retained products or blood clots
Infection
Mx of postpartum haemorrhage
Conservative
Antibiotics
Evacuation under GA
RFs for thromboemboilc disease
parity above 3 dehydration varicose veins family history of VTE thrombophilia, obesity maternal age > 35 yrs, immobilisation prolonged labour
prophylatic measures for thromboembolic disease
TED stocking, LMW heparin important when risk factors exist particularly after emergency Caesarean Section
urinary problems in postpartum period
Transient urinary retention relatively common postpartum
Due to physiological effects of pregnancy, pain (haematoma in perineal area) etc
May need catheterisation and prophylactic antibiotics
Usually resolves spontaneously
May get urinary incontinence
Often under reported
May respond to pelvic floor exercises
After what period of time would continued lochia warrant further investigation with ultrasound?
after 6 weeks
Continue vaginal discharge beyond this time is an indication for ultrasound to investigate the possibility of retained products of conception.
high risk antenatal factors for DVT/VTE and the mx
Any previous VTE except a single event related
to major surgery
requires antenatal prophylaxis w LMWH
intermediate risk factors for DVT/VTE and the Mx
Hospital admission
Single previous VTE related to major surgery
High-risk thrombophilia + no VTE
Medical comorbidities e.g. cancer, heart failure,
active SLE, IBD or inflammatory polyarthropathy, nephrotic syndrome, type I DM with
nephropathy, sickle cell disease, current IVDU
Any surgical procedure e.g. appendicectomy
OHSS (first trimester only)
consider Mx
Risk factors that increase VTE/DVT
how many do u need to consider prophylaxis in first trimester and from 28 weeks
Obesity (BMI > 30 kg/m2 ) Age > 35 Parity ≥ 3 Smoker Gross varicose veins Current pre-eclampsia Immobility, e.g. paraplegia, PGP Family history of unprovoked or estrogen-provoked VTE in first-degree relative Low-risk thrombophilia Multiple pregnancy IVF/ART
prophylaxis from first trimester if there are more than 3 RFs
prophylaxis from 28 weeks
