Puerperium Flashcards
What is puerperium?
- 6 week interval after delivery when everything goes back to normal
- Milk production begins
When does the uterus start to retun to the non-pregnant state?
Starts to return to the non-pregnant stage immediately after the placenta is delivered - involves shortening of the muscle fibres and death of the excess myometrial cells (known as involution)
Discuss oxytocin release after delivery
Oxytocin release continues days after delivery to compress the myometrial cells of the uterus. Excess cells die, the decidua is shed and replaced with endometrium. The loss consisting of decidual and trophoblastic debris = lochia, the lochia gradually decreases in volume and becomes less blood stained
At what rate does the fundus usually descend?
1-2cm daily
Why might a uterus fail to involute?
Retained placenta or infection
When does menstruation resume?
8 weeks after birth - in breast feeding women prolactin inhibits FSH secretion and prevents ovulation and as such the onset of menstruation is delayed
When are breasts capable of secreting milk?
From 20 weeks - progesterone inhibits this during pregnancy, after expulsion of the placenta progesterone levels drop and milk secretion is possible
Why does cardiac output increase during the puerperium?
Increases, blood from the placenta returns to the central circulation, excess extracellular fluid moves into the vascular compartment and caval compression reduces.
*this time is a high risk for women with cardiac conditions as they are unable to cope with the increased venous return and heart failure can occur
Why does urine output increase after women have given birth?
Declining levels of aldosterone and oxytocin leads to a decrease in tubular reabsorption of fluid - output increases to 3000mL/ day
Why is the puerperium important?
- Applicable to all women who deliver
- Physiological changes of pregnancy, delivery and iatrogenic interventions revert to non pregnant state
- Complications could be life threatening and changing for the mother
Anatomical and physiological changes during pregnancy
- Increased circulatory/ vascular volume: 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%
Cardiovascular changes after birth
- Stabilisation of cardiac output
- Diuresis 2-5 days postpartum dissipates extra volume
- Normalisation from 2 weeks post partum
Changes to the coagulation system in/ after pregnancy
- Pregnancy = hypercoagulable state
- Remains high for 10-14 days before starting to normalise
- Resulting haemostasis protects against haemorrhage but there is an increased risk of VTE
Uterine changes after delivery
- Involution occurs during the puerperium
- Fundus palpable at maternal umbilicus immediately post partum
- Returns to true pelvis within 2 weeks
- Recedes to only slightly larger than pre-pregnancy at the end of the puerperium
- Restoration of endometrium by 16th day apart from at site where placenta was attached
- Changes at the placental bed site results in the production of lochia
Breast changes during/ after pregnancy
- Changes to the breast occur during pregnancy
- Lactogenesis start at 16 weeks
- High levels of circulating progesterone activates mature alveolar cells in the breast
- Rapid decline in progesterone after delivery triggers onset of milk production
- Swelling/ engorgement of breasts in postpartum period
- Colostrum first 4 days after delivery
- Removal of milk from breast stimulates more production
- Breast milk matures over first 7 days
What happens to breast milk if woman does not breast feed?
- Absence of milk removal
- Elevated intramammary pressure due to accumulation of milk within the alveolar lumen
- Alveolar distension restricts blood flow to the alveoli
- Interference with milk production
- Increase in pressure triggers an inhibition of lactation
- Mammary involutions within 2-3 weeks
What % of women develop urinary incontinence following delivery?
50%
What is mastitis?
- Due to failure to express milk from one part of the breast
- Can be treated by feeding from the affected side first to empty the breast
- Can be complicated by staph aureus infection - treat with flucloxacillin
Serious adverse effects of the peripeurium
VTE
Leading cause of direct maternal mortality in the UK
Highest time of risk is puerperium (20x)
Higher risk if overweight, 35+ or c section
LMWH treatment - start immediately if VTE suspected even before confirmed
DVT
Leg pain, swelling - usually unilateral
Clinical signs unreliable
D-dimer cannot be used as raised during pregnancy so confirmed using compression duplex USS
LMWH treatment - start immediately
If DVT suspected following negative USS stop LMWH but repeat USS on day 3 and 7
PE
V/Q scan or CTPA to diagnose
LMWH treatment + self administered LMWH for 3 months
LMWH > warfarin (significantly lower risk of post-thrombotic syndrome
How can risk of VTE be reduced during puerperium?
- Proactivity
- Risk assessment
- Thromboprophylaxis
What is postpartum haemorrhage?
- >500mL blood loss from the genital tract after delivery of the foetus or >100mL after c-section
- 2nd leading cause of maternal death in UK
- Primary: blood loss occurs in first 24hrs
- Secondary: blood loss occurs from 24hrs - 12 weeks
Primary vs secondary PPH
Primary: within 24hrs
Secondary: 24hrs - 12 weeks after delivery
Psychological complications following delivery
- Pregnancy and puerperium represents a period of severe mental illness
- Consider screening for depression and anxiety
- 10-15% experience postnatal depression - can present any time during 1st year after delivery
- Low mood, lethargic, inadequacy, guilty, not loving baby enough, tearful, loss of appetite, obsessive/ irrational thoughts, poor sleep, fears for baby’s health, thoughts of harming themselves or baby
Post partum psychosis
- 1-2/1000
- Usually appears as mania or depression
- Begins abruptly with confusion, anxiety, restlessness and sadness
- Rapid development of delusions or hallucinations
- If any symptoms present - refer to secondary mental health service for assessment within 4 hrs
- Admit to specialist unit
Pyrexia and sepsis following delivery
- Fever, >38 degrees within 6 weeks of delivery
- Causes: UTI (95% E.coli, proteus spp. and klebsiella spp.
- Genital tract infection: cause by E.coli, other anaerobes, group A strep, staph spp. And clostridium welchii (rare but serious)
- Mastitis
- C-section wound infection: lower segment c-section is the most important risk factor for puerperal pyrexia, 8% risk of infection following lower segment c-section in the UK, offer prophylactic antibiotics before skin incision - reduces risk of endometritis by 66-75% and reduces rate of wound infection
- Can also be caused by chest/ viral infection
- Pyrexia can also be caused by DVT and ovarian vein thrombophlebitis
Postpartum thyroiditis
Transient destructive lymphocytic thyroiditis
Any time during first year
2 phases
- Thyrotoxicosis 1-4months post partum (TSH low)
- Hypothyroidism (TSH high)
Treatment: usually self limiting, beta blockers if hyper severe, thyroxin if hypo severe
Contraceptive methods in the peurperium
Non-breastfeeding <21 days since birth: POP, implant, barrier methods
Avoided: COCP, copper coil, mirena (unless IUD inserted at time of delivery or >4weeks after), sterilisation (unless done at time of c-section)
Non-breastfeeding >21 days since birth: COCP, POP, implant, barrier
Avoided: sterilisation, copper coil/ mirena coil unless inserted at time of birth or after 4 weeks
Breastfeeding <6 weeks since birth: lactational amenorrhoea, POP, implant, barrier
Avoided: COCP, copper/ mirena coil see above, sterilisation
Postpartum care - NICE
- Offer information to enable women to promote theirs and their baby’s health
- At first postnatal contact advise women of signs and symptoms of haemorrhage, infection and VTE etc and appropriate action to take
- Encourage breast feeding
- Advice re contraception during first postpartum week
- Ask about emotional wellbeing, ask about social support and coping strategies
- Encourage women to talk about any changes in their mental state
What is lochia?
Loss consisting of decidual and trophoblastic debris, gradually decreases in volume and becomes less blood stained
Why might involution not occur?
Retained products, infection
Common problems during the puerperium
Perineal pain
Micturition: retention or incontinence
Bowels: constipation due to pain releif
Mastitis: treat conservatively for 24hrs then give antibiotics
Backache
Anaemia
Psych
What is Sheehan syndrome?
Avascular necrosis of anterior pituitary due to PPH
Failure to lactate, loss of pubic hair, hypothyroidism, adrenal insufficiency
