The puerperium

Question 1

What is the puerperium?

Answer 1

The 6 week period following delivery when the body returns to its prepregnant state

Question 2

What happens to the genital tract immediately after the placenta has separated from the uterus?

Answer 2

The uterus contracts and the criss-cross fibres of myometrium occlude the blood vessels that formerly supplied the placenta.

Question 3

How long does it take for the uterus to shrink again?

Answer 3

Uterine size reduces over 6 weeks: within 10 days the uterus is no longer palpable abdominally

Question 4

Do you get any pain after labour?

Answer 4

Contractions or ‘after pain’ may be felt for 4 days

Question 5

Is discharge normal after pregnancy?

Answer 5

Lochia, a discharge from the uterus, may be blood stained for 4 weeks, but thereafter is yellow or white.

Question 6

When does menstruation start again after pregnancy?

Answer 6

It is usually delayed by lactation, but occurs at about 6 weeks if the woman is not lactating

Question 7

How does the cardiac output and plasma volume change after delivery?

Answer 7

They decrease to pre-pregnancy levels within a week

Question 8

What hormones is lactation dependent upon?

Answer 8

Prolactin and oxytocin

Question 9

What does prolactin do and where is it secreted from?

Answer 9

It is from the anterior pituitary gland and stimulates milk secretion

Question 10

What stimulated the first milk secretion after delivery and why?

Answer 10

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

Question 11

What does oxytocin do and where is it from?

Answer 11

From the posterior pituitary and stimulates ejection in response to nipple suckling, which also stimulates more prolactin release and therefore milk secretion.

Question 12

How much milk can be produced in a day?

Answer 12

Over 1L, dependent on demand

Question 13

How can emotional and physical stress effect lactation?

Answer 13

Since oxytocin release is controlled via the hypothalamus, lactation can be inhibited by emotional or physical stress

Question 14

What is colostrum and when is it released?

Answer 14

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’

Question 15

What are the advantages of breastfeeding?

Answer 15

Protection against infection in neonate
Bonding
Protection against breast (mother)
Cannot give too much
Cost saving

Question 16

When is postnatal contraception started again?

Answer 16

Usually 4-6 weeks after delivery, but COCP is contraindicated during breastfeeding

Question 17

What is primary postpartum haemorrhage? (PPH)

Answer 17

The loss of >500mL blood <24h of delivery.

Question 18

What are the risk factors for primary PPH?

Answer 18

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

Question 19

How does retained placenta cause PPH?

Answer 19

Partial separation can cause blood to accumulate in the uterus, which will rise. Collapse may occur in the absence of external loss

Question 20

What are the uterine causes of PPH?

Answer 20

The uterus fails to contract properly, either because it is ‘atonic’ or because there is a retained placenta, or part of the placenta.

Question 21

What are the risk factors for uterine atony?

Answer 21

Prolonged labour, with grand multiparity and with overdistension of the uterus and fibroids

Question 22

How do you prevent PPH?

Answer 22

Routine use of oxytocin in the third stage of labour reduces the incidence of PPH by 60%.

Question 23

What are the clinical features of PPH and how do they identify a cause?

Answer 23

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.

Question 24

How would you manage PPH caused by retained placenta?

Answer 24

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.

Question 25

How would you manage PPH?

Answer 25

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

Question 26

What is secondary PPH?

Answer 26

occurs between 24 hours - 12 weeks after delivery

Question 27

What causes secondary PPH?

Answer 27

Endometritis, with or without retained placental tissue, or, rarely, incidental gynaecological pathology.

Question 28

What are the findings on examination in secondary PPH?

Answer 28

The uterus is enlarged and tender with an open internal cervical os.

Question 29

How do you manage secondary PPH?

Answer 29

Identify and remove and retained placenta, give antibiotics

Question 30

What are some problems of the puerperium?

Answer 30

Postpartum pyrexia
Thromboembolic disease
Psychiatric problems
Hypertensive complications
Urinary retention or incontinence
Perineal trauma
Bowel problems

Question 31

What and how common is the third day blues?

Answer 31

It consists of temporary emotional lability, it affects 50% of women. Support and reassurance are required

Question 32

What are the risk factors for postnatal depression?

Answer 32

Socially or emotional isolation; a previous history; after pregnancy complications

Question 33

How does postpartum depression feel?

Answer 33

Tiredness, guilt and worthlessness

Question 34

When does puerperal psychosis present?

Answer 34

Abrupt onset of psychotic symtpoms, usually around the fourth day.

Question 35

How do you treat puerperal psychosis?

Answer 35

Psychiatric admission and major tranquilisers, after exclusion of organic illness

Question 36

What urinary complications are common after delivery?

Answer 36

Urinary retention, infection and incontinence

Question 37

How long does perineal pain usually last for?

Answer 37

It persists for more than 8 weeks in 10%. Superficial dyspareunia is common, even years later.

Question 38

What can be used to treat perineal pain?

Answer 38

The anti-inflammatory diclofenac

Question 39

What bowel problems are common after delivery?

Answer 39

Constipation and haemorrhoids; incontinence of faeces or flatus

Question 40

What are the main risk factors for incontinence in the puerperium?

Answer 40

Forceps delivery, large babies, should dystocia and persistent occipito-posterior positions