The Puerperium Flashcards
What is the puerperium?
the time from delivery to 6 weeks / 42 days!
What changes occur in the puerperium?
multifactorial changes:
- Bio
- physical
- endocrine
- immunological
- psychological
- social
Why is the peuerperium important?
- “a woman is most likely to die after her baby is born”
- –>! its the leading cause of maternal death in the UK
- Haemorrhage
- VTE
- sepsis
- pre-eclasampsia/eclampsia
- –>! its the leading cause of maternal death in the UK
What do midwives do for postnatal care?
You get 10 days of midwifery care once home:
- can be every day if needed
- to facilitate and reassure normality for mother and baby
- including bonding and establishing feeding
- identify, investigate and manage abnormality
- consideration during lactation
- e.g. prescribing
- & provide contraceptive advice, if not breastfeeding - have only 30 days until next ovulation!
- if breastfeeding full time for <6 months contraception isnt needed
- make plans for next time
- GET DOING PELVIC FLOOD EXERCISES
- –> PREVENT INCONTINENCE + PROLAPSE
- to facilitate and reassure normality for mother and baby
in the puerperium what are the reversal of changes that happen to the placental hormones?
they fall very quickly
in the puerperium what are the reversal of changes that happen to the uterus?
Uterine involution: –> back in pelvis by 10d
- autolysis
- (the destruction of cells or tissues by their own enzymes),
- bleeding stops
- (can bleed for entire 6wks however),
- resumption of menstruation
in the puerperium what are the reversal of changes that happen to the CVS?
- CO
- TPR
- BP
back to normal by 2wks (14d)
in the puerperium, what are the reversal of changes that happen to coagulation?
- fibrinolysis normal within 30mins;
- pro-coagulant state remains however
- (clotting factors increased)
in the puerperium, what are the reversal of changes that happen to metabolism?
insulin resistance goes immediately
What is lochia?
- Lochia is the vaginal discharge after giving birth, containing blood, mucus, and uterine tissue
- comprised of blood & necrotic decidua
- if continues after 6wks this do an USS
What are the hormonal changes after delivery regarding breast development and the actions that cause these?
breasts contain glandular tissue and supporting stroma
- there is a post-delivery drop in E2
- whcich allows active prolactin to stimulate milk production
Suckling is the action that causes prolactin secretion
- –> milk secretion in glandular cells
- –> milk ejection reflex
- –> oxytocin secretion
- –> aids milk ejection reflex
What are the milk types expected after delivery and at what amount of days?
- Within the 1st 48 hours = colostrum
- @ day 3-4: milk
What is the difference between colostrum produced w/i 48h and milk produced on day 3-4?
Colostrum contains:
- IgA, lysosyme/macrophages e.g. immune stuff
- and is moderatre CHO/fat
Milk contains:
- increased CHO/fat and
- contains lactose and lactalbumin (milk protein) / casein (slow digesting dairy protein)
What are the pros of breastfeeding?
Pro
- easy / free / convenient
- promotes bonding
- reduces atopy
- reduces infections especially GI
- reduces breast cancer
- contraceptive
What are the cons of breastfeeding?
cons:
- not easy / convenient
- embarassing
- painful
- drugs pass through e.g. anti-thyroid
- perinatal infection e.g. HIV
What lactation abormalities can happen?
- failure of lactation (rare)
- blood-stained nipple discharge of pregnancy
- cracked nipples and pain (common)
- galactocele - sterile milk filled retention cyst
- acute mastitis
- breast abscess
What is the presentation of blood-stained nipple discharge of pregnancy?
RF: late pregnancy, early breastfeeding
- typically bilateral
- due to epithelial proliferation
- lasts up to 1w
- is self limiting! = reassure
A new mother presents with cracked nipples and pain (this is common) what do you recommend?
- Pain usually settles spontaneously
- Rx: cracked nipples give local Abx
- Analgesia
- cracked nipple gives increased risk of
- Thrush
- acute mastitis -> breast abscess
- TF rest the nipple
What is a galactocele and its rx?
- sterile milk-filled retention cyst
- resolved spontaneously assisted by massage
- can aspirate or remove surgically
a new mother presents to the GP with a painlful, red, hot breast and has a fever.
How do you manage this condition?
this is acute mastitis
- RF: following on from cracked nipple
- likely infection with S.aureus
Rx: maintain feeding/expressing,
- give abx - flucloxacillin
if actue mastitis remains untreated what can it lead to?
can lead to breast abscess
this is the same management of acute mastitis e.g. maintain feeding/expressing but give Abx flucloxacillin
EXCEPT DO INCISION & DRAINAGE of the breast abcess first
Is it possible to have eclampsia once the placenta has gone e.g. after labour/delivery?
Yes!
50% of eclampsia fits are postnatally!
the puerperium is also the highest risk time for fluid overload
Given the high postnatal risk of eclampsia and fluid overload, how do you maintain a new mothers BP and to what levels?
- labetolol or
- slow release nifedipine
- to control HTN aiming for BP <150/100, may need HDU
- often needed for 1-2 wks postnatally
- do home BP monitoring every 2 days
- halve the dose of labetolol/SR nifedipine when BP is <140/90
- if still needing the drug Rx of HTN at 6 weeks postnatally –> specialist assessment needed
A new mother has a waddling gait when walking and is experiencing pain, O/E pain is over the pubic region and an interpubic gap is palpable.
What is the rx for this condition?
This is
symphysis pubic diastasis
(e.g. spontaneous separation of symphysis pubic –> happens in 1/800 vaginal deliveries)
Rx:
- bed rest,
- pelvic corset => support and stability
- anti-inflammatory agents,
- and physiotherapy
What are the RF/associations with causing synphysis pubis diastasis?
Associations:
- Forceps,
- rapid 2nd stage of labour
- or severe abduction of thighs during delivery
WHAT is the biggest cause of meternal mortality and when is this risk highest?
-
PE is the biggest cause of maternal mortality
- [NB Pregnancy-induced hypercoagulability is probably a physiologically adaptive mechanism to prevent post partum hemorrhage]
- highest risk = 10-14 days post-delivery (e.g. ~2wks)
What prophylactic measures do we give post-partum women (new mothers) regading VTE/PE?
- TED stockings,
- LMWH,
- early mobilisation,
- adequate hydration,
- education
What is the Rx for post-partum VTE/PE?
- formal anti-coagulation
- with heparin & warfarin
What factors/thresholds indicate significant puerperal pyrexia?
- Temp >38c
- on any 2 of the first 10 days post-partum (excluding the first 24 hours);
- pyrexia + tachycardia warrants investigation
NB: Have high index of suspicion for wound infection in C-section patients
What are the common causes for significant puerperal pyrexia?
(2 x >38o w/i 10d postpartum, exluding 1st 24h)
commonly
- infective or
- VTE (can cause fever)
examine from head to toe
e.g. as can be multiple possible infective causes endometritis, peritonitis, uti, wound infection, RTI, mastitis, epidural sites
When looking for a cause of puerperal pyrexia what should be considered at each of the following sites in the head to toe examination?
- genital tract
- pelvis
- UTI
- wound
- respiratory
- breast
- other
Genital tract - endometritis/perneum
Pelvis - peritonitis (ascending infection)
UTI - especially if catheterised
Wound - perineum or CS scar
Respiratory - especially GA
Breast - mastitis/abscess
Other - venflon sites, epidural sites, concurrent infection e.g. flu
What is the most likely infective site post-partum causing puerperal pyrexia and how do you Rx it?
endometritis is most likely (endometrial inflammation)
Do the sepsis 6 & broad spectrum antibiotcs
What are the chest complicatinos assoc. with puerperium?
- atelectasis (partial collapse or incomplete lung inflation)
or following GA –>
- aspiration pneumonia (mendelsons syndrome)
What is Mendelsons syndrome (of aspiration pneumonia)?
a chemical/aspiration pneumonitis caused by aspiration (gastric juices, blood, bile, water) during anaesthesia - esp. during pregnancy
Sy are post GA…
- spiking temp
- wheezing
- SOB!
A post-partum woman is presenting with cough, purulent sputum and SOB. What investigations and managment should be done?
?pneumonia
TF investigate w/
- sputum MC&S
- CXR
manage:
- physiotherapy
- abx
A post-partum woman is presenting with sore throat, cervical lymphadenopathy. What investigations and managment should be done?
?tonsilitis
Ix: throat swab
Rx: abx
A post-partum woman is presenting with headaches, neck stiffness & had an epidural/spinal during delivery.
What investigations and managment should be done?
?meningitis
Ix: lumbar puncture
Rx: abx
A post-partum woman is presenting with dysuria, loin pain and loin tenderness.
What investigations and managment should be done?
?pyelonephritis
Ix: urine MC&S
Rx: abx and increased fluid intake
A post-partum woman is presenting with a secondary PPH, she has a tender, bulky uterus.
What investigations and managment should be done?
?endometritis or retained placental tissue
Ix: clinical diagnosis +/- pelvic USS
Rx: abx and/or uterine evacuation
A post-partum woman is presenting with pelvic pain/tenderness or calf pain/tenderness.
What investigations and managment should be done?
?DVT
Ix: doppler/venogram of veins
Rx: heparin
A post-partum woman is presenting with chest pain and dyspnoea.
What investigations and managment should be done?
?PE
Ix: CXR, ABG, V/Q perfusion scan [?not CTPA?(IDK maybe do that)], angiogram
Rx: heparin
A post-partum woman is presenting witha painful engorged breast.
What investigations and managment should be done?
?mastitis or breast abscess
Ix: clinical exam, MC&S of expressed milk
Rx: express milk, abx, incision and drainage
