The Puerperium Flashcards
what is the puerperium
6 week period where the body returns to its pre-pregnancy physiological state
what physiological changes to the genital tract occur in the puerperium
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
what is lochia
uterine discharge post-delivery
what should lochia look like after labour
it may be blood stained up to 4 weeks post delivery but should be yellow/white after
when does lochia require investigation
> 6 weeks
when does menstruation return if there is no lactation
6 weeks
what physiological changes to the cardiovascular system occur in the puerperium
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
what physiological changes to the urinary system occur in the puerperium
GFR decreases over 3 months
what physiological changes to the urinary system occur in the puerperium
U+E return to normal
Hb/haematocrit rise
WCC falls
Platelets and clotting factors rise – predisposing to thrombosis
what is the general post natal care delivered
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
what hormones control lactation
prolactin (production of breast milk)
oxytocin (ejection of breast milk)
what is colostrum
yellow material high in IgA, fat and minerals passed in the first 3 days of breast feeding
what is the correct positioning for breastfeeding
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
what are some common complications with breastfeeding
Insufficient milk
Engorgement
Mastitis
Nipple trauma
what is the aetiology of primary post partum haemorrhage
uterine causes (atonic uterus) - ~80% retained placenta - ~2.5% vaginal causes (tears) - ~20%
Rare:
Cervical tear
Maternal bleeding disorders
what is atonic uterus more common in
Prolonged labour (>20 hours in Primips, >14hours in multips)
Grand multiparity (5+ births)
Fibroids
Overdistension of the uterus – multiple pregnancy or polyhydramnios
what is the most effective measure to prevent PPH
oxytocin prevents 60% of PPH
Transexamic acid also works
what are clinical features of post partum haemorrhage
Bleeding
Enlarged uterus if uterine cause
Tears in vaginal wall and cervix
Collapse if internal bleeding
what is the management for post-partum haemorrhage
Support - O2, IV access, Cross matched blood
Restore Blood volume - fluid +/- blood given
Treat any coagulopathy - FFP, cryoprecipitate, TXA
Cessation of blood loss:
- Oxytocin ± ergometrine (Prostaglandin injection into myometrium)
- Rusch Balloon
- 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
what is the maximum time a placenta should remain in the uterus
60 mins
what are the 3rd day blues
Temporary emotional lability
50% of women
Support and reassurance required
whats the incidence of postnatal depression
10%
what are risk factors for postnatal depression
Socially/emotionally isolated women
Previous history
Pregnancy complications
what is an organic differential for post partum depression
postpartum thyroiditis
what is the treatment for postpartum depression
SSRI
Psychotherapy
Social suppoer
what SSRI is recommended in pregnancy
fluoxetine
what are concerning postpartum features that would require an immediate psychiatry referral
Significant recent change in mental state
Emergence of new symptom s
Estrangement from infant
Persistent persecution complex about being a mother
whats the incidence of puerperal psychosis
0.2%
what are the clincial features of puerperal psychosis
Abrupt onset of psychotic symptoms – usually around the 4th day
More common in primigravid women with a family history
how do you treat puerperal psychosis
Psychiatric admission
Major tranquillisers
Exclusion of organic illness
whats the relapse incidence for puerperal psychosis in subsequent pregnancies
10%
what are causes of secondary Post partum haemorrhage
Endometritis
Retained placental tissue leading to endometritis
Pathology of gestational trophoblastic disease
what counts as post partum haemorrhage
Excessive blood loss occuring between 24 hours and 6 weeks post delivery
what is the clinical presentation of secondary post partum haemorrhage
Frank blood loss vaginally
Enlarged and tender uterus
Open internal os
what is the management of secondary post partum haemorrhage
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
whats the definition of post partum pyrexia
maternal fever of >38 in the first 14 days
what are the most common causes of post partum pyrexia
Genital tract sepsis
GAS
Ecoli
UTI (10%)
Chest infection
Mastitis
Perineal infection
Wound infection after C section
what are clinical features of post partum infection
Offensive lochia
Uterus enlarged
Tender uterus
whats an important differential outside of infection for post partum pyrexia
DVT/PE may lead to a low level pyrexia
what is the leading cause of perinatal mortality
DVT/PE
when does a PE most commonly strike post delivery
10-14 days post discharge
when is the risk of pre-eclampsia related mortality highest
in the 5 days after delivery
how should you assess post-delivery urinary retention
post-micturation USS
whats the treatment for post delivery urinary retention
catheterisation for 24 hours post delivery
what % of women have a urinary infection after labour
10%
what % of women are some level of incontinent post labour
20%
what is the most commonly used pain relief for perineal trauma after labour
NSAIDS
what is the common presentation of paravaginal hematoma
excruiciating pain in perineum a few hours post delivery
how do you identify and treat a paravaginal haematoma
vaginal exam and drained under anaesthetic
what bowel problems are common after labour
haemorrhoids and constipation in 20%
faecal/flatus incontinence - 4% (usually transient)
what is usually the cause of faecal incontinence after labour
pudendal or anal sphincter damage
what are the risk factors for developing faecal incontinence post labour
Forceps delivery
Large babies
Shoulder dystocia
Persistent OP position
what are the implications if anal repair is required post labour
all subsequent labours must be C-section
