The Puerperium Flashcards
what is the ‘puerperium’
the 6 weeks following delivery when the body returns to its pre-pregnant state
What physiological changes happen to the genital tract?
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
For how long might ‘afterpains’ be felt after giving birth?
4 days
internal os of the cervix is closed by 3 days
How long is loch (uterine discharge) blood stained for?
4 weeks - but thereafter is yellow or white
When does menstruation occur after pregnancy?
usually delayed by lactation, but occurs at about 6 weeks if there is no lactation
What physiological changes happen to the CVS after pregnancy?
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
What physiological changes happen to the urinary tract after pregnancy?
physiology dilation of pregnancy reduces over 3 months - GFR decreases
What physiological changes happen to the blood after pregnancy?
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 two hormones is lactation dependent on?
Prolactin and oxytocin
Where is prolactin secreted from?
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
Where is oxytocin secreted from?
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
How much milk can be produced per day?
1L
What is Colostrum?
yellow fluid containing fat-laden cells, proteins (igA) and minerals which is passed for the first 3 days before milk comes in
What is the correct positioning for breastfeeding?
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
What is primary postpartum haemorrhage?
loss of >500ml blood <24 hours after delivery, or >1000 ml after C-sectoin
What is MOH?
Massive obstetric haemorrhage - blood loss of >1500ml which is continuing
What are the causes of PPH?
T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)
What is atony (uterine causes) more common with?
Prolonged labour
grand multiparity
fibroids
with over distension of the uterus (due to polyhydramnios or multiple pregnancy)
How is prevention of PPH done?
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
How should the woman be examined after birth?
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
What is the management of PPH?
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
How is PPH bleeding stopped?
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
What is the treatment of 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 can cause of PPH be determined?
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
How is persistent haemorrhage managed?
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
What are the third day blues?
Temporary emotional lability day 3 postpartum - affects 50% women
What % women does postnatal depression?
10% women
In what women is postnatal depression most common in?
Socially or emotionally isolated
Previous history
women who have post pregnancy complications
What are the ddx of pnd?
postpartum thyroiditis
What are the symptoms of PND?
tiredness
guilt
feelings of worthlessness
What is the management of PND?
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.
What is the management of pregnant ladies with pre-existing MH conditions?
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
What % of women does puerperal psychosis affect?
0.2% women
What are the clinical features of puerperal psychosis?
abrupt onset of psychotic symptoms, usually around the 4th day
What are the treatments of puerperal psychosis?
Admission to the mother and baby unit
Cognitive behavioural therapy
Medications (antidepressants, antipsychotics or mood stabilisers)
Electroconvulsive therapy (ECT)
What is secondary PPH?
Excessive blood loss occurring between 24 Horus and 6 weeks after delivery
What is the cause of secondary PPH?
retained products of conception (RPOC) or infection (i.e. endometritis).
How is secondary PPH investigated?
Ultrasound for retained products of conception
Endocervical and high vaginal swabs for infection
How is PPh managed?
Surgical evaluation of retained products of conception
Antibiotics for infection
What is postpartum pyrexia?
Maternal fever >38 degrees in first 14 days - infection is the most common cause
is genital tract sepsis more common after vaginal delivery or c section?
c section
What pathogens most frequently cause sepsis?
Group A streptococcus
staphylococcus
E coli
What are the other common infections that cause postpartum pyrexia?
UTI chest infection mastitis perineal infection wound after C-section
DVT - low grade pyrexia
How long after delivery does pre-eclampsia improve?
24 hours
BP usually peaks 4-5 days after delivery
How should pre-eclampsia be managed postpartum?
pay attention to fluid balance, renal function and urine output, BP and the possibility or hepatic and cardiac failure
BP measurement 5 days postnatally
What issues can occur to the urinary tract?
Retention of urine
Urinary infection
Incontinence
What are the clinical features of urinary retention?
Frequency, stress incontinence or severe abdominal pain
Women or staff may notice lack of voiding, followed by infection, overflow incontinence and permanent voiding difficulties
What is the ix/mx of retention of urine?
post-micturition USS can be used to assess the residual volume non-invasively
treatment is catheterisation for at least 24 hours
What is the clinical presentation of urinary infection
asymptomatic - but often leads to symptomatic infection or pyelonephritis - routine culture is advised
In what % women does incontinence occur in?
10% women - overflow and infection should be excluded using post-micturition USS or catheterisation and MSU
What effects might women experience after perineal trauma?
pain - >8 weeks in 10% women
superficial dyspareunia
What is the management of perineal trauma pain?
NSAIDs
USS
salt baths and mega pulse
What is the presentation of paravaginal haematoma?
excruciating pain in the perineum felt a few hours after delivery, caused by paravginal haematoma
What bowel problems can ensue postpartum?
constipation and haemorrhoids - laxatives are helpful
Incontinence of faeces or flatus - underreported symptom affecting 4% women - mostly transiently
What is the cause of incontinence postpartum?
Pudendal nerve and anal sphincter damage from forceps delivery, large baby, shoulder dystocia and persistent OP position
How are faecal incontinence patients assessed and managed?
anal manometry and USS
managed according to symptoms
formal repair may be required
subsequent pregnancies bust be delivered by C-section
What is mastitis?
inflammation of breast tissue, and is a common complication of breastfeeding. It can occur with or without associated infection
What is the presentation of mastitis?
Breast pain and tenderness (unilateral) Erythema in a focal area of breast tissue Local warmth and inflammation Nipple discharge Fever
What is the managment of mastitis?
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.
