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
