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CP2 OBS > The Puerperium > Flashcards

The Puerperium Flashcards

1
Q

what is the ‘puerperium’

A

the 6 weeks following delivery when the body returns to its pre-pregnant state

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2
Q

What physiological changes happen to the genital tract?

A

As soon as the placenta has separated, the uterus contracts and the fibres of the myometrium occlude the blood vessels that firmly supplied the placenta

Uterine size reduces over 6 weeks - within 10 days, the uterus is no longer palpable in the abdomen

Uterine discharge may be blood stained

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3
Q

For how long might ‘afterpains’ be felt after giving birth?

A

4 days

internal os of the cervix is closed by 3 days

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4
Q

How long is loch (uterine discharge) blood stained for?

A

4 weeks - but thereafter is yellow or white

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5
Q

When does menstruation occur after pregnancy?

A

usually delayed by lactation, but occurs at about 6 weeks if there is no lactation

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6
Q

What physiological changes happen to the CVS after pregnancy?

A

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

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7
Q

What physiological changes happen to the urinary tract after pregnancy?

A

physiology dilation of pregnancy reduces over 3 months - GFR decreases

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8
Q

What physiological changes happen to the blood after pregnancy?

A

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

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9
Q

What two hormones is lactation dependent on?

A

Prolactin and oxytocin

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10
Q

Where is prolactin secreted from?

A

Anterior pituitary - levels are high at birth, but it is the rapid decline in oestrogen and progesterone after birth that causes milk to be secreted as prolactin is antagonised by them

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11
Q

Where is oxytocin secreted from?

A

posterior pituitary - stimulate ejection in response to nipple sucking - which also stimulates prolactin release and therefore more milk secretion

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

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12
Q

How much milk can be produced per day?

A

1L

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13
Q

What is Colostrum?

A

yellow fluid containing fat-laden cells, proteins (igA) and minerals which is passed for the first 3 days before milk comes in

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14
Q

What is the correct positioning for breastfeeding?

A

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

this could largely prevent the main problems of insufficient milk, engorgement, mastitis, nipple trauma

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15
Q

What is primary postpartum haemorrhage?

A

loss of >500ml blood <24 hours after delivery, or >1000 ml after C-sectoin

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16
Q

What is MOH?

A

Massive obstetric haemorrhage - blood loss of >1500ml which is continuing

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17
Q

What are the causes of PPH?

A

T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)

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18
Q

What is atony (uterine causes) more common with?

A

Prolonged labour
grand multiparity
fibroids
with over distension of the uterus (due to polyhydramnios or multiple pregnancy)

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19
Q

How is prevention of PPH done?

A

Treating anaemia during the antenatal period
Giving birth with an empty bladder (a full bladder reduces uterine contraction)
Active management of the third stage (with intramuscular oxytocin in the third stage)
Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients

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20
Q

How should the woman be examined after birth?

A

Blood loss should be minimal after delivery of the placenta - an enlarged uterus suggests a uterine cause

The vaginal walls and cervix should be inspected for tears

Blood loss may be abdominal - there is collapse without overt bleeding

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21
Q

What is the management of PPH?

A

Resuscitation with an ABCDE approach
Lie the woman flat, keep her warm and communicate with her and the partner
Insert two large-bore cannulas
Bloods for FBC, U&E and clotting screen
Group and cross match 4 units
Warmed IV fluid and blood resuscitation as required
Oxygen (regardless of saturations)
Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion

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22
Q

How is PPH bleeding stopped?

A

Mechanical
Medical
Surgical

Mechanical treatment options involve:

Rubbing the uterus through the abdomen to stimulates a uterine contraction (referred to as “rubbing up the fundus”)
Catheterisation (bladder distention prevents uterus contractions)

Medical treatment options involve:
Oxytocin (slow injection followed by continuous infusion)
Ergometrine
Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding

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23
Q

What is the treatment of retained placenta?

A

should be removed manually if there is bleeding or if it is not expelled by normal methods within 60 minutes of delivery

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24
Q

How can cause of PPH be determined?

A

Vaginal examination - exclude rare uterine inversion

Vaginal lacerations are often palpable

Uterine causes = common. Oxytocin and/or ergometrine are given IV if trauma is not obvious.

If this fails - EUA

If uterine atony persists, PGF is injected into myometrium

25
Q

How is persistent haemorrhage managed?

A

Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding
B-Lynch suture – putting a suture around the uterus to compress it
Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow
Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life

26
Q

What are the third day blues?

A

Temporary emotional lability day 3 postpartum - affects 50% women

27
Q

What % women does postnatal depression?

A

10% women

28
Q

In what women is postnatal depression most common in?

A

Socially or emotionally isolated

Previous history

women who have post pregnancy complications

29
Q

What are the ddx of pnd?

A

postpartum thyroiditis

30
Q

What are the symptoms of PND?

A

tiredness
guilt
feelings of worthlessness

31
Q

What is the management of PND?

A

Mild cases may be managed with additional support, self-help and follow up with their GP
Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy
Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit

The Edinburgh postnatal depression scale can be used to assess how the mother has felt over the past week, as a screening tool for postnatal depression.

There are ten questions, with a total score out of 30 points. A score of 10 or more suggests postnatal depression.

32
Q

What is the management of pregnant ladies with pre-existing MH conditions?

A

recorded at booking visit

psychiatric drugs should be continued in pregnancy - decision should be made after assessment of the risks and benefits.
For depressive illness, SSRIs are preferred

Should be seen by psychiatrist before delivery

Urgent referral if there is a recent significant change in mental state, emergence of new symptoms/thoughts/acts, estrangement from infant or persistent expression of incompetency as a mother

33
Q

What % of women does puerperal psychosis affect?

A

0.2% women

34
Q

What are the clinical features of puerperal psychosis?

A

abrupt onset of psychotic symptoms, usually around the 4th day

35
Q

What are the treatments of puerperal psychosis?

A

Admission to the mother and baby unit
Cognitive behavioural therapy
Medications (antidepressants, antipsychotics or mood stabilisers)
Electroconvulsive therapy (ECT)

36
Q

What is secondary PPH?

A

Excessive blood loss occurring between 24 Horus and 6 weeks after delivery

37
Q

What is the cause of secondary PPH?

A

retained products of conception (RPOC) or infection (i.e. endometritis).

38
Q

How is secondary PPH investigated?

A

Ultrasound for retained products of conception

Endocervical and high vaginal swabs for infection

39
Q

How is PPh managed?

A

Surgical evaluation of retained products of conception

Antibiotics for infection

40
Q

What is postpartum pyrexia?

A

Maternal fever >38 degrees in first 14 days - infection is the most common cause

41
Q

is genital tract sepsis more common after vaginal delivery or c section?

A

c section

42
Q

What pathogens most frequently cause sepsis?

A

Group A streptococcus
staphylococcus
E coli

43
Q

What are the other common infections that cause postpartum pyrexia?

A 
UTI
chest infection
mastitis
perineal infection
wound after C-section

DVT - low grade pyrexia

44
Q

How long after delivery does pre-eclampsia improve?

A

24 hours

BP usually peaks 4-5 days after delivery

45
Q

How should pre-eclampsia be managed postpartum?

A

pay attention to fluid balance, renal function and urine output, BP and the possibility or hepatic and cardiac failure

BP measurement 5 days postnatally

46
Q

What issues can occur to the urinary tract?

A

Retention of urine

Urinary infection

Incontinence

47
Q

What are the clinical features of urinary retention?

A

Frequency, stress incontinence or severe abdominal pain

Women or staff may notice lack of voiding, followed by infection, overflow incontinence and permanent voiding difficulties

48
Q

What is the ix/mx of retention of urine?

A

post-micturition USS can be used to assess the residual volume non-invasively

treatment is catheterisation for at least 24 hours

49
Q

What is the clinical presentation of urinary infection

A

asymptomatic - but often leads to symptomatic infection or pyelonephritis - routine culture is advised

50
Q

In what % women does incontinence occur in?

A

10% women - overflow and infection should be excluded using post-micturition USS or catheterisation and MSU

51
Q

What effects might women experience after perineal trauma?

A

pain - >8 weeks in 10% women

superficial dyspareunia

52
Q

What is the management of perineal trauma pain?

A

NSAIDs
USS
salt baths and mega pulse

53
Q

What is the presentation of paravaginal haematoma?

A

excruciating pain in the perineum felt a few hours after delivery, caused by paravginal haematoma

54
Q

What bowel problems can ensue postpartum?

A

constipation and haemorrhoids - laxatives are helpful

Incontinence of faeces or flatus - underreported symptom affecting 4% women - mostly transiently

55
Q

What is the cause of incontinence postpartum?

A

Pudendal nerve and anal sphincter damage from forceps delivery, large baby, shoulder dystocia and persistent OP position

56
Q

How are faecal incontinence patients assessed and managed?

A

anal manometry and USS

managed according to symptoms

formal repair may be required
subsequent pregnancies bust be delivered by C-section

57
Q

What is mastitis?

A

inflammation of breast tissue, and is a common complication of breastfeeding. It can occur with or without associated infection

58
Q

What is the presentation of mastitis?

A 
Breast pain and tenderness (unilateral)
Erythema in a focal area of breast tissue
Local warmth and inflammation
Nipple discharge
Fever
59
Q

What is the managment of mastitis?

A

Where mastitis is caused by blockage of the ducts, management is conservative, with continued breastfeeding, expressing milk and breast massage. Heat packs, warm showers and simple analgesia can help symptoms.

If infection is suspect (e.g. the woman is febrile), antibiotics should be started. Flucloxacillin is first line, or erythromycin if allergic to penicillin.

Women should be encouraged to continue breastfeeding, even when infection is suspected

A rare complication if not adequately treated, is a breast abscess. This may need surgical incision and drainage.

CP2 OBS (20 decks)

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