The puerperium Flashcards
What is the puerperium?
The 6 week period following delivery when the body returns to its prepregnant state
What happens to the genital tract immediately after the placenta has separated from the uterus?
The uterus contracts and the criss-cross fibres of myometrium occlude the blood vessels that formerly supplied the placenta.
How long does it take for the uterus to shrink again?
Uterine size reduces over 6 weeks: within 10 days the uterus is no longer palpable abdominally
Do you get any pain after labour?
Contractions or ‘after pain’ may be felt for 4 days
Is discharge normal after pregnancy?
Lochia, a discharge from the uterus, may be blood stained for 4 weeks, but thereafter is yellow or white.
When does menstruation start again after pregnancy?
It is usually delayed by lactation, but occurs at about 6 weeks if the woman is not lactating
How does the cardiac output and plasma volume change after delivery?
They decrease to pre-pregnancy levels within a week
What hormones is lactation dependent upon?
Prolactin and oxytocin
What does prolactin do and where is it secreted from?
It is from the anterior pituitary gland and stimulates milk secretion
What stimulated the first milk secretion after delivery and why?
Levels of prolactin are high at birth, but it is the rapid decline in oestrogen and progesterone levels after birth that causes milk to be secreted, because prolactin is antagonised by oestrogen and progesterone
What does oxytocin do and where is it from?
From the posterior pituitary and stimulates ejection in response to nipple suckling, which also stimulates more prolactin release and therefore milk secretion.
How much milk can be produced in a day?
Over 1L, dependent on demand
How can emotional and physical stress effect lactation?
Since oxytocin release is controlled via the hypothalamus, lactation can be inhibited by emotional or physical stress
What is colostrum and when is it released?
It is a yellow fluid containing fat-laden cells, proteins (IgA) and minerals, is passed for the first 3 days, before the milk ‘comes in’
What are the advantages of breastfeeding?
Protection against infection in neonate Bonding Protection against breast (mother) Cannot give too much Cost saving
When is postnatal contraception started again?
Usually 4-6 weeks after delivery, but COCP is contraindicated during breastfeeding
What is primary postpartum haemorrhage? (PPH)
The loss of >500mL blood <24h of delivery.
What are the risk factors for primary PPH?
previous PPH prolonged and induced labour pre-eclampsia increased maternal age polyhydramnios emergency Caesarean section placenta praevia, placenta accreta macrosomia ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis) Coagulapathy/anticoagulant therapy Instrumental/Caesarean delivery Multiple pregnancy Grand multiparity Obesity
How does retained placenta cause PPH?
Partial separation can cause blood to accumulate in the uterus, which will rise. Collapse may occur in the absence of external loss
What are the uterine causes of PPH?
The uterus fails to contract properly, either because it is ‘atonic’ or because there is a retained placenta, or part of the placenta.
What are the risk factors for uterine atony?
Prolonged labour, with grand multiparity and with overdistension of the uterus and fibroids
How do you prevent PPH?
Routine use of oxytocin in the third stage of labour reduces the incidence of PPH by 60%.
What are the clinical features of PPH and how do they identify a cause?
An enlarged uterus suggests a uterine cause.
The vaginal walls and cervix are inspected for tears. Occasionally, blood loss may be abdominal: there is collapse without pain or over bleeding.
How would you manage PPH caused by retained placenta?
The retained placenta should be removed manually if there is bleeding, or if it is not expelled by normal methods within 60 minutes of delivery.
How would you manage PPH?
ABC including two peripheral cannulae, 14 gauge
IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
IM carboprost
if medical options failure to control the bleeding then surgical options will need to be urgently considered
the RCOG state that the intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
What is secondary PPH?
occurs between 24 hours - 12 weeks after delivery
What causes secondary PPH?
Endometritis, with or without retained placental tissue, or, rarely, incidental gynaecological pathology.
What are the findings on examination in secondary PPH?
The uterus is enlarged and tender with an open internal cervical os.
How do you manage secondary PPH?
Identify and remove and retained placenta, give antibiotics
What are some problems of the puerperium?
Postpartum pyrexia Thromboembolic disease Psychiatric problems Hypertensive complications Urinary retention or incontinence Perineal trauma Bowel problems
What and how common is the third day blues?
It consists of temporary emotional lability, it affects 50% of women. Support and reassurance are required
What are the risk factors for postnatal depression?
Socially or emotional isolation; a previous history; after pregnancy complications
How does postpartum depression feel?
Tiredness, guilt and worthlessness
When does puerperal psychosis present?
Abrupt onset of psychotic symtpoms, usually around the fourth day.
How do you treat puerperal psychosis?
Psychiatric admission and major tranquilisers, after exclusion of organic illness
What urinary complications are common after delivery?
Urinary retention, infection and incontinence
How long does perineal pain usually last for?
It persists for more than 8 weeks in 10%. Superficial dyspareunia is common, even years later.
What can be used to treat perineal pain?
The anti-inflammatory diclofenac
What bowel problems are common after delivery?
Constipation and haemorrhoids; incontinence of faeces or flatus
What are the main risk factors for incontinence in the puerperium?
Forceps delivery, large babies, should dystocia and persistent occipito-posterior positions
