Third stage & Puerperium Flashcards
Definition of the third stage
From the delivery of the baby to the delivery of the placenta
Can be physiologically or actively managed
Definition of Puerperium
The 6 weeks after birth where the genital track returns to normal - the immediate post-natal period
Characterised by lactation, lochia and involution of uterus
Lochia
Post birth vaginal discharge including blood, mucus and uterine tissue
Rubra - 3-5days, serosa -1-2wks, alba - 3-6wks,
Physiological management of the third stage
Less than 60mins, also known as ‘passive’
No prophylatic oxytocin, no cord clamping until pulsation ceased
Placenta delivered by maternal effort
Assisted by gravity, empty bladder and mobilisation
Active management of the third stage
Less than 30mins
10iu of syntocinon/5iu of syntometrin IM thigh at delivery of anterior shoulder
CCT to deliver placenta with uterine guarding
Clamp cord early (immediately)
Use of Delayed cord clamping
if you wait >30second to clamp the cord there is reduced risk of anaemia in the fetus, esp if preterm
30% increase in blood volume
Recommended if simple pregnancy (eg no PPH)
Features to consider when deciding between active and passive management of the 3rd stage
Time - passive about 10mins longer
Blood loss - passive about 16% over 500ml
Increased incidence of MROP if passive
Side effects of drugs
NICE and RCOP recommend active management
MROP
Manual removal of the placenta
Contraindications of physiological management
Epidurals or opiates Induction of labour Instumental delivery or CS Multiple pregnancy Anaemia and risk of PPH
Summary of third stage managements
Physiological - Longer, requires maternal effort, increased blood loss, CI in assisted/operative delivery, multiple birth or risk of PPH
Active - Faster, less effort for mother, risk of drug side effects and retained placenta
Mechanical prevention of PPH
in 1st stage uterine contractions reduce placental blood flow - uterus reduces in size and volume
contractions of the myometrium close spiral arteries
Cord clamping retains blood in retroplacental clot
Endocrine prevention of PPH
Pulsatile release of oxytocin during labour
Prostaglandins from placental tissue & fetal membranes are strong myometrial contractors
Drop off after placental separation
Coagulative prevention of PPH
Pregnancy is a hyper coagulable state with increased concentration of clotting factors
Fibrinolytic action increases after placental separation - higher risk of bleeding
Epidemiology of PPH
Defined as loss of >500ml in 24hrs after vaginal or >1L after CS - 6th cause of maternal death in Uk
1st cause worldwide
Risk factors for PPH (AAOTPPP, 7)
Antenatal - abruption, placental previa,twins etc, PE, previous PPH, obesity, anaemia
Intrapartum - IOL, retained placenta, operative delivery/CS, long labour, big baby, pyrexia in labour, age >40
Cause of PPH (4 ‘T’s)
Tone (80%) - 1L/min to placental bed, uterine inversion,
Trauma - soft tissue laceration
Tissue - retained placenta blocks contraction/placenta accreta
Thrombosis - 3% - coagulopathy
Management of minor PPH (<1000mls)
Call for help, senior midwife, obstetrician etc
IV fluids, FBC & G+S
Rub up contraction and examine for height of uterine, tone and any vaginal/perineal tears
consider catheter
Management of major PPH (>1000mls)
Immediate, life-saving treatment is required
Call for help, stabilise - estimate blood loss - lie women flat - give blood and fluids
Rub up contraction/bimanual massage
2nd dose syntometrine then 40iu syntocinon in 500ml infusion - Pray
Post natal mortality (4)
Will present with either secondary haemorrhage, pyrexia (>38 in 14 days), depression, thromboemboism
Post-partum sepsis
commonest direct cause of maternal death
Post partum up to 6 weeks postnatally
Endometritis or general (UTI/chest etc)
Bacteria causing post-partum sepsis (6)
Group A strep or E coli
Staph aureus/MRSA or Strep Pneumoniae
Clostridium septicum or Morganell morganii
Thromboembolic disease in pregnancy
Factors VII,VIII, IX, X increased in pregnancy - most significantly is fibrinogen - normalises 15 days after pregnancy
D-dimer always raised in pregnancy
Risk factors for VTE post natally
Slight - dehydation, CS, immobilisation
Moderate - age>35, parity>4, obesity,
High - thrombophilia, surgery, Hx of VTE
Post natal mental health
Baby blues –> 50% - anxiety, irritability, weepy - resolves in 14 days
Postnatal depression - 10-15% -depression within 3 months of delivery
Puerperal psychosis - 0.1% - unusual ideas and irrational response to baby in first 4wks
Breast feeding
Its really good for several reasons but it can cause mastitis and can be hard. women may have not enough milk or poor technique
Post-natal contraception
safe for 21 days but after this breast feeding is no reliable - consider risks of contraception within the frame of puerperium
Theraputics of PPH (5)
Syntoinon/syntometrine 10units IM
Ergometrine 250mcg IM x2 (rarely used)
Syntocinon infusion 40units over 4hrs
Carboprost 250mcg IM, up to 8 doses 15mins apart
Misoprostol 600mcg stat PV/PR then surgical means
Uterine physiology after birth
~1000g - fundus is at or above the umbilicus
–> by 2wks 50-100gs and not palpable
The placental site will bleed for 2wks then shed the ‘eschar’
Ovarian physiology after birth
Ovulation suppressed by prolactin from breastfeeding - time to ovulation generally 45-94 days but can be as soon as 25-27 days
Vaginal physiology after birth
Vaginal oedema resolves by 3 weeks - ruggae reappear, may be atrophic during breastfeeding due to low estrogens - can have sex after 3wks
Any tears or episiotomy will heal in 2weeks
Pelvic floor physiology after birth
May have nerve ‘palsy’ from pressure of babies head
Muscle and connective tissue stretch should return to normal by 6wks –> but highly dependant on maternal exercise
Breast physiology after birth
Breasts are capable of lactating from 16wks, initation is placental delivery (crash in Estrogen & progesterone while prolactin remains high)
Colostrum
In the ducts at the end of pregnancy, thick, yellow and full of protein, fat and immunoglobulins. - produced for 2-4 days
Suckling increases release but is not necessary
Post natal care
Go home 2 days post delivery in hospital or 3-5 post CS
After this community midwife support - 6 week check
Particularly check any blood loss or infection, uterus is contracting and mother can void
Breast feeding
Not easy or essential
establish by 36-96hrs
Post natal discharge information
Where to get support and information Perineal and wound care Breast feeding support 'Lifecourse advice' Birth control
Post natal complications
Haemorrhage (Primary or secondary)
Sepsis (endometritis, pelvic collections, wound infections, mastitis, UTI)
Primary postpartum haemorrhage
Up to 24hrs after delivery. Problem if >500ml VD or >1000ml CS
4 Ts –> Tone (atonia), Tissue (retained placenta),Trauma (tears), Thrombin (Coagulopathy)
Secondary postpartum haemorrhage
24hrs to two weeks
Due to infection, retained products or coagulopathy
Management of Post partum haemorrhage
ABCDE
Examine for cause
Treat with abx, uterine repair or emptying etc
Post natal sepsis
Endometritis (1-3% of VD, 5-15% of CS)
Risk is increased if there was a prolonged or early rupture of membranes
Causes of endometritis and post natal sepsis
Day 1-2 –> Group A strep or enterococcus (25%)
Day 3-4 –> E coli
Day 7 –> Chlamydia
B-lynch Brace Sutures
A form of compression suture used to treat PPH secondary to an atonic uterus
Risks of Manual removal of Placenta
Endometritis – fever, irregular bleeding.
Retained products will not cause fever but are more likely after premature labour
Mendelson’s syndrome
Aspiration pneumonitis - the most common cause of maternal anaesthetic death –> aspiration of sterile stomach contents leads to inflammation and can be fatal.
How to treat endometritis?
Referred to hospital for IV abx (clindamycin and gentamicin until afrebrile for >24hrs)
