Puerperium Flashcards
What are the changes to the genital tract in the puerperium?
- As soon as the placenta has separated, the uterus contracts and the fibres of the myometrium occlude the blood vessels that formly supplied the placenta
- Uterine size reduces over 6 weeks- within 10 days the uterus is no longer palpable in the abdomen
- Contractions or ‘after-pain’ may be felt for 4 days- the internal os of the cervix is closed by 3 days
- Lochia (uterine discharge) may be blood-stained for 4 weeks, but thereafter is yellow or white
- Menstruation is usually delayed by lactation, but occurs at about 6 weeks if there is no lactation
How does the cardiovascular system change in the puerperium?
- Cardiac output and plasma volume decrease to pre-pregnant levels within a week
- Loss of oedema can take up to 6 weeks
- If transiently elevated- BP is usually normal within 6 weeks
How does the urinary tract change in the puerperium?
• Physiological dilation of pregnancy reduces over 3 months- GFR decreases
How does the blood change in the puerperium?
- U&Es return to normal because of the reduction in GFR
- In the absence of haemorrhage- Hb and haematocrit rise with haemoconcentration
- WCC falls- platelets and clotting factors rise predisposing to thrombosis
What is the general postnatal care?
- Counselling and practical help with breastfeeding
- Uterine involution, lochia, BP, temperature, pulse and any perineal wounds are checked daily
- Careful fluid balance check should prevent retention in women who have had an epidural
- Analgesics may be required for perineal pain- also helped by pelvic floor exercises
- Psychiatric referral is suggested in women with a psychiatric history- postnatal plan including the GP should be drawn up
What is lactation dependent on?
o Prolactin from anterior pituitary stimulates milk secretion- levels are high at birth, but it is the rapid decline in oestrogen & progesterone after birth that cause milk to be secreted as prolactin is antagoinsed by them
o Oxytocin from the posterior pituitary stimulate ejection in response to nipple suckling, which also stimulates prolactin release and therefore more milk secretion
What can affect the amount of milk produced?
- As much as +1L of milk per day can be produced
* Since oxytocin release is controlled via the hypothalamus- lactation can be inhibited by emotional or physical stress
What is colostrum?
a yellow fluid containing fat-laden cells, proteins (IgA) and minerals is passed for the first 3 days
then milk ‘comes in’
Why is the correct positioning during breast feeding important?
the baby’s lower lip should be planted below the nipple at the time that the
mouth opens in preparation for receiving milk, so that the entire nipple is drawn into the mouth
Prevents:
Insufficient milk
Engorgement
Mastitis
Nipple trauma
What is primary postpartum haemorrhage?
the loss of >500ml blood <24hrs after delivery ( or >1000ml after C-section) occurs in 10% of women and remains a major cause of maternal mortality
• Massive obstetric haemorrhage (MOH) is best defined as blood loss of >1500ml which is continuing
What is the aetiology of PPH?
Retained placenta
Uterine causes- fails to contract, atonic (prolonged labour, grand multiparty, fibroids, over distension)
Vaginal- perineal tear, high tear, episiotomy
Cervical tear- precipitate labour and instrumental delivery
Coagulopathy- congenital disorders, anticoagulant therapy and DIC. antenatal thromboprophylaxis should be stopped at least 12hrs before labour or delivery
How is PPH prevented?
• The routine use of oxytocin in the 3rd stage of labour reduces the incidence of PPH by 60%
oxytocin is as effective as Ergometrin, which often causes vomiting and is contraindicated in hypertensive women
What are the clinical features of PPH?
- Blood loss should be minimal after delivery of the placenta, an enlarged uterus suggests a uterine cause (above the level of the umbilicus)
- The vaginal walls and cervix should be inspected for tears
- Very occasionally, blood loss may be abdominal- there is collapse without overt bleeding
What is the management for PPH?
- Where blood loss is >1500ml and is ongoing, a MOH protocol should be activated- it has clear algorithms including the use of uncross-matched blood and anaesthetic, haematological and senior obstetric help
- Resucitation- nursed flat, oxygen is given, IV access is obtained and blood is cross-matched- fluid ± blood is given
- Prevent/treat coagulopathy- FFP and cryoprecipitate may be required, tranexamic acid also reduces bleeding
- Retained placenta- should be removed manually if there is bleeding or if it is not expelled by normal methods within 60mins of delivery
How are the causes of PPH identified and treated?
o Vaginal examination is performed to exclude rare uterine inversion
o Vaginal lacerations are often palpable
o Uterine causes are common- oxytocin and/or ergometrine are given IV if trauma is not obvious
o If this fails- an examination under anaesthetic (EUA) is performed
o If uterine atony persists- PGF2a is injected into myometrium
• Persistent haemorrhage-continuation despite medical treatment requires surgery, bleeding from placental bed may respond to placement of a Rusch balloon
if other methods fail then hysterectomy should not be delayed
