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Obstetrics > Third stage & Puerperium > Flashcards

Third stage & Puerperium Flashcards

1
Q

Definition of the third stage

A

From the delivery of the baby to the delivery of the placenta
Can be physiologically or actively managed

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2
Q

Definition of Puerperium

A

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

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3
Q

Lochia

A

Post birth vaginal discharge including blood, mucus and uterine tissue
Rubra - 3-5days, serosa -1-2wks, alba - 3-6wks,

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4
Q

Physiological management of the third stage

A

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

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5
Q

Active management of the third stage

A

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)

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6
Q

Use of Delayed cord clamping

A

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)

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7
Q

Features to consider when deciding between active and passive management of the 3rd stage

A

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

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8
Q

MROP

A

Manual removal of the placenta

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9
Q

Contraindications of physiological management

A 
Epidurals or opiates
Induction of labour
Instumental delivery or CS
Multiple pregnancy
Anaemia and risk of PPH
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10
Q

Summary of third stage managements

A

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

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11
Q

Mechanical prevention of PPH

A

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

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12
Q

Endocrine prevention of PPH

A

Pulsatile release of oxytocin during labour
Prostaglandins from placental tissue & fetal membranes are strong myometrial contractors
Drop off after placental separation

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13
Q

Coagulative prevention of PPH

A

Pregnancy is a hyper coagulable state with increased concentration of clotting factors
Fibrinolytic action increases after placental separation - higher risk of bleeding

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14
Q

Epidemiology of PPH

A

Defined as loss of >500ml in 24hrs after vaginal or >1L after CS - 6th cause of maternal death in Uk
1st cause worldwide

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15
Q

Risk factors for PPH (AAOTPPP, 7)

A

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

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16
Q

Cause of PPH (4 ‘T’s)

A

Tone (80%) - 1L/min to placental bed, uterine inversion,
Trauma - soft tissue laceration
Tissue - retained placenta blocks contraction/placenta accreta
Thrombosis - 3% - coagulopathy

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17
Q

Management of minor PPH (<1000mls)

A

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

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18
Q

Management of major PPH (>1000mls)

A

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

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19
Q

Post natal mortality (4)

A

Will present with either secondary haemorrhage, pyrexia (>38 in 14 days), depression, thromboemboism

20
Q

Post-partum sepsis

A

commonest direct cause of maternal death
Post partum up to 6 weeks postnatally
Endometritis or general (UTI/chest etc)

21
Q

Bacteria causing post-partum sepsis (6)

A

Group A strep or E coli
Staph aureus/MRSA or Strep Pneumoniae
Clostridium septicum or Morganell morganii

22
Q

Thromboembolic disease in pregnancy

A

Factors VII,VIII, IX, X increased in pregnancy - most significantly is fibrinogen - normalises 15 days after pregnancy
D-dimer always raised in pregnancy

23
Q

Risk factors for VTE post natally

A

Slight - dehydation, CS, immobilisation
Moderate - age>35, parity>4, obesity,
High - thrombophilia, surgery, Hx of VTE

24
Q

Post natal mental health

A

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

25
Q

Breast feeding

A

Its really good for several reasons but it can cause mastitis and can be hard. women may have not enough milk or poor technique

26
Q

Post-natal contraception

A

safe for 21 days but after this breast feeding is no reliable - consider risks of contraception within the frame of puerperium

27
Q

Theraputics of PPH (5)

A

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

28
Q

Uterine physiology after birth

A

~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’

29
Q

Ovarian physiology after birth

A

Ovulation suppressed by prolactin from breastfeeding - time to ovulation generally 45-94 days but can be as soon as 25-27 days

30
Q

Vaginal physiology after birth

A

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

31
Q

Pelvic floor physiology after birth

A

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

32
Q

Breast physiology after birth

A

Breasts are capable of lactating from 16wks, initation is placental delivery (crash in Estrogen & progesterone while prolactin remains high)

33
Q

Colostrum

A

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

34
Q

Post natal care

A

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

35
Q

Breast feeding

A

Not easy or essential

establish by 36-96hrs

36
Q

Post natal discharge information

A 
Where to get support and information
Perineal and wound care
Breast feeding support
'Lifecourse advice'
Birth control
37
Q

Post natal complications

A

Haemorrhage (Primary or secondary)

Sepsis (endometritis, pelvic collections, wound infections, mastitis, UTI)

38
Q

Primary postpartum haemorrhage

A

Up to 24hrs after delivery. Problem if >500ml VD or >1000ml CS
4 Ts –> Tone (atonia), Tissue (retained placenta),Trauma (tears), Thrombin (Coagulopathy)

39
Q

Secondary postpartum haemorrhage

A

24hrs to two weeks

Due to infection, retained products or coagulopathy

40
Q

Management of Post partum haemorrhage

A

ABCDE
Examine for cause
Treat with abx, uterine repair or emptying etc

41
Q

Post natal sepsis

A

Endometritis (1-3% of VD, 5-15% of CS)

Risk is increased if there was a prolonged or early rupture of membranes

42
Q

Causes of endometritis and post natal sepsis

A

Day 1-2 –> Group A strep or enterococcus (25%)
Day 3-4 –> E coli
Day 7 –> Chlamydia

43
Q

B-lynch Brace Sutures

A

A form of compression suture used to treat PPH secondary to an atonic uterus

44
Q

Risks of Manual removal of Placenta

A

Endometritis – fever, irregular bleeding.

Retained products will not cause fever but are more likely after premature labour

45
Q

Mendelson’s syndrome

A

Aspiration pneumonitis - the most common cause of maternal anaesthetic death –> aspiration of sterile stomach contents leads to inflammation and can be fatal.

46
Q

How to treat endometritis?

A

Referred to hospital for IV abx (clindamycin and gentamicin until afrebrile for >24hrs)

Obstetrics (13 decks)

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