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Obstetrics > The Puerperium > Flashcards

The Puerperium Flashcards

1
Q

what is the puerperium

A

6 week period where the body returns to its pre-pregnancy physiological state

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2
Q

what physiological changes to the genital tract occur in the puerperium

A

Uterus contracts and reduces in size over about 6 weeks – after 10 days it is no longer palpable in the abdomen

Contractions or after pain may be felt for 4 days

The internal os of the cervix is closed after 3 days

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3
Q

what is lochia

A

uterine discharge post-delivery

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4
Q

what should lochia look like after labour

A

it may be blood stained up to 4 weeks post delivery but should be yellow/white after

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5
Q

when does lochia require investigation

A

> 6 weeks

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6
Q

when does menstruation return if there is no lactation

A

6 weeks

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7
Q

what physiological changes to the cardiovascular system occur in the puerperium

A

Cardiac output and blood volume decrease after about a week

Odema takes 6 weeks to settle

Transient elevation of blood pressure is usually fixed after 6 weeks

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8
Q

what physiological changes to the urinary system occur in the puerperium

A

GFR decreases over 3 months

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9
Q

what physiological changes to the urinary system occur in the puerperium

A

U+E return to normal

Hb/haematocrit rise

WCC falls

Platelets and clotting factors rise – predisposing to thrombosis

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10
Q

what is the general post natal care delivered

A

Counselling and practical help with breastfeeding is often done

Urine involution, BP, pulse, temperature, lochia and wounds are checked daily

Careful fluid balance check should prevent retention in women who have had an epidural

Analgesia usually prescribed for pain (paracetamol/Ibuprofen)

Psychiatric referral if symptoms/has a psychiatric history

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11
Q

what hormones control lactation

A

prolactin (production of breast milk)

oxytocin (ejection of breast milk)

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12
Q

what is colostrum

A

yellow material high in IgA, fat and minerals passed in the first 3 days of breast feeding

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13
Q

what is the correct positioning for breastfeeding

A

Baby’s lower lip should be planted below the nipple at the time the mouth opens in preparation for receiving milk, so the entire nipple is in the mouth

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14
Q

what are some common complications with breastfeeding

A

Insufficient milk

Engorgement

Mastitis

Nipple trauma

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15
Q

what is the aetiology of primary post partum haemorrhage

A 
uterine causes (atonic uterus) - ~80%
retained placenta - ~2.5%
vaginal causes (tears) - ~20%

Rare:
Cervical tear
Maternal bleeding disorders

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16
Q

what is atonic uterus more common in

A

Prolonged labour (>20 hours in Primips, >14hours in multips)

Grand multiparity (5+ births)

Fibroids

Overdistension of the uterus – multiple pregnancy or polyhydramnios

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17
Q

what is the most effective measure to prevent PPH

A

oxytocin prevents 60% of PPH

Transexamic acid also works

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18
Q

what are clinical features of post partum haemorrhage

A

Bleeding

Enlarged uterus if uterine cause

Tears in vaginal wall and cervix

Collapse if internal bleeding

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19
Q

what is the management for post-partum haemorrhage

A

Support - O2, IV access, Cross matched blood

Restore Blood volume - fluid +/- blood given

Treat any coagulopathy - FFP, cryoprecipitate, TXA

Cessation of blood loss:

  1. Oxytocin ± ergometrine (Prostaglandin injection into myometrium)
  2. Rusch Balloon
  3. If balloon fails – hysterectomy

Identify Cause
Vaginal examination should be performed to exclude uterine inversion
Lacerations are often palpable
Uterine causes common – oxytocin ± ergometrine given IV
If this fails an examination under anaesthetic is usually performed
If the atony persists – PGI2 is injected into the myometrium

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20
Q

what is the maximum time a placenta should remain in the uterus

A

60 mins

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21
Q

what are the 3rd day blues

A

Temporary emotional lability

50% of women

Support and reassurance required

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22
Q

whats the incidence of postnatal depression

A

10%

23
Q

what are risk factors for postnatal depression

A

Socially/emotionally isolated women

Previous history

Pregnancy complications

24
Q

what is an organic differential for post partum depression

A

postpartum thyroiditis

25
Q

what is the treatment for postpartum depression

A

SSRI

Psychotherapy

Social suppoer

26
Q

what SSRI is recommended in pregnancy

A

fluoxetine

27
Q

what are concerning postpartum features that would require an immediate psychiatry referral

A

Significant recent change in mental state

Emergence of new symptom s

Estrangement from infant

Persistent persecution complex about being a mother

28
Q

whats the incidence of puerperal psychosis

A

0.2%

29
Q

what are the clincial features of puerperal psychosis

A

Abrupt onset of psychotic symptoms – usually around the 4th day

More common in primigravid women with a family history

30
Q

how do you treat puerperal psychosis

A

Psychiatric admission

Major tranquillisers

Exclusion of organic illness

31
Q

whats the relapse incidence for puerperal psychosis in subsequent pregnancies

A

10%

32
Q

what are causes of secondary Post partum haemorrhage

A

Endometritis

Retained placental tissue leading to endometritis

Pathology of gestational trophoblastic disease

33
Q

what counts as post partum haemorrhage

A

Excessive blood loss occuring between 24 hours and 6 weeks post delivery

34
Q

what is the clinical presentation of secondary post partum haemorrhage

A

Frank blood loss vaginally

Enlarged and tender uterus

Open internal os

35
Q

what is the management of secondary post partum haemorrhage

A

Vaginal swabs

FBC

Cross match is severe

USS uterus – attempt to visualise retained placenta although it’s hard to differentiate between placenta and blood clots

Heavy acute bleeding = ERPC (evacuation of retained. products of conception)

Chronic bleeding = ABx only

36
Q

whats the definition of post partum pyrexia

A

maternal fever of >38 in the first 14 days

37
Q

what are the most common causes of post partum pyrexia

A

Genital tract sepsis
GAS
Ecoli

UTI (10%)

Chest infection

Mastitis

Perineal infection

Wound infection after C section

38
Q

what are clinical features of post partum infection

A

Offensive lochia

Uterus enlarged

Tender uterus

39
Q

whats an important differential outside of infection for post partum pyrexia

A

DVT/PE may lead to a low level pyrexia

40
Q

what is the leading cause of perinatal mortality

A

DVT/PE

41
Q

when does a PE most commonly strike post delivery

A

10-14 days post discharge

42
Q

when is the risk of pre-eclampsia related mortality highest

A

in the 5 days after delivery

43
Q

how should you assess post-delivery urinary retention

A

post-micturation USS

44
Q

whats the treatment for post delivery urinary retention

A

catheterisation for 24 hours post delivery

45
Q

what % of women have a urinary infection after labour

A

10%

46
Q

what % of women are some level of incontinent post labour

A

20%

47
Q

what is the most commonly used pain relief for perineal trauma after labour

A

NSAIDS

48
Q

what is the common presentation of paravaginal hematoma

A

excruiciating pain in perineum a few hours post delivery

49
Q

how do you identify and treat a paravaginal haematoma

A

vaginal exam and drained under anaesthetic

50
Q

what bowel problems are common after labour

A

haemorrhoids and constipation in 20%

faecal/flatus incontinence - 4% (usually transient)

51
Q

what is usually the cause of faecal incontinence after labour

A

pudendal or anal sphincter damage

52
Q

what are the risk factors for developing faecal incontinence post labour

A

Forceps delivery

Large babies

Shoulder dystocia

Persistent OP position

53
Q

what are the implications if anal repair is required post labour

A

all subsequent labours must be C-section

Obstetrics (16 decks)

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