Post-Partum Problems

Question 1

what is the puerperium?

Answer 1

6 weeks following birth

period of repair and recovery

Question 2

how does vaginal discharge change over first 3 weeks of puerperium?

Answer 2

3-4 days = fresh red blood (“rubra”)
4-14 days = brownish-red, watery (“serosa”)
10-20 days = yellow (“alba”)

Question 3

what is uterine involution?

Answer 3

group of changes which occur during puerperium

Question 4

what changes occur in uterine involution?

Answer 4

endometrial lining regenerates by day 7
fundus returns to physiological location within pelvis by 2 weeks
uterine weight decreases to 5% of immediate post birth weight

Question 5

does lower repro tract return to normal after pregnancy?

Answer 5

no

regress but never return to pre-pregnancy state

Question 6

by which month of pregnancy will breasts have fully adapted to produce milk?

Answer 6

5th or 6th month

Question 7

what is colostrum?

Answer 7

first milk a breastfed baby will receive
thick yellowish substance
contains more protein and vitamins than later milk
essential for early immunological protection in newborn

Question 8

how is lactation initiated?

Answer 8

expulsion of the placenta in stage 3 of labour

also the decrease in oestrogen and progesterone levels

Question 9

what inhibits milk production during pregnancy?

Answer 9

high levels of oestrogen and progesterone block release of prolactin from anterior pituitary

Question 10

is prolactin produced in pregnancy?

Answer 10

yes

but its prevented from carrying out its function of milk production

Question 11

how does prolactin cause milk production?

Answer 11

after birth, hormone levels drop abruptly (while prolactin is still being produced at high levels)
prolactin is therefore released triggering milk production by lactocytes in mammary alveoli

Question 12

how is prolactin release maintained?

Answer 12

via a positive feedback mechanism whereby the suckling infant promotes prolactin production by stimulating nipple mechanoreceptors

Question 13

what is the let-down reflex?

Answer 13

mechanism of milk release from the breast during feeding
suckling stimulates production of oxytocin from posterior pituitary > oxytocin stimulates myoepithelial cells which surround breast alveoli > myoepithelial cells contract in response to oxytocin and squeeze milk out of the nipple

Question 14

what else can trigger let down reflex?

Answer 14

pain
alcohol
sight and cry of an infant

Question 15

path of milk from production to leaving nipple?

Answer 15

milk produced in lactocytes in mammary alveoli
myoepithelial cells squeeze milk from alveoli so it drains into lactiferous ducts
milk pools in lactiferous sinus before being discharged through nipple pores

Question 16

is breastfeeding recommended by WHO?

Answer 16

exclusive breastfeeding for first 6 months is recommended
its recommended that breastfeeding should continue past 6 months but alongside introduction of appropriate solid foods for up to 2 years or as long as mother chooses

Question 17

what is mastitis?

Answer 17

inflammation of the breast

can be due to infectious and non-infectious causes

Question 18

most common cause of mastitis?

Answer 18

infectious
staph aureus = most common infecting organism
coag +ve staph = 2nd most common cause

Question 19

what can cause a non-infective mastitis?

Answer 19

duct ectasia (blocked lactiferous duct)
foreign body such as breast implant or nipple piercing

Question 20

how can lactation mastitis occur in breastfeeding?

Answer 20

most commonly linked to improper breastfeeding technique
trauma to breast and subsequent milk stasis and ineffective milk release make the breast more likely to harbour bacteria and therefore more prone to infection

Question 21

risks of maltreatment of lactation mastitis?

Answer 21

can lead to an abscess (usually in peripheral breast in breastfeeding women)

Question 22

what should a focused history of mastitis evaluate for?

Answer 22

MAIDS

• milk stasis?
• abscess present?
• Inflammation?
• discharge from nipple?
• systemic symptoms of infection?

Question 23

how is mastitis diagnosed?

Answer 23

clinical diagnosis

Question 24

empirical treatment of lactation mastitis?

Answer 24

full course of staph aureus sensitive antibiotics as soon as signs of the condition appear
- flucloxacillin 500mg orally every 6 hrs for 7 days
- augmentin 625mg every 8 hrs for 7 days
should examine patient every few days to check therapeutic response
important that breastfeeding continues (can even use a breast pump for infected breast if needed)

Question 25

what is done if patient is showing signs of an abscess?

Answer 25

breast US | aspiration with an 18-guage needle for culture should be performed to confirm the diagnosis

Question 26

PPH definition?

Answer 26

blood loss of 500ml or more after the birth of the baby

Question 27

primary vs secondary PPH?

Answer 27

``` primary = bleeding occurs within 24 hrs of delivery secondary = bleeding occurs between 24 hrs and 6 weeks post delivery ```

Question 28

minor vs major PPH?

Answer 28

``` minor = 500 - 1000ml major = >1000ml or signs of cardiovascular collapse or ongoing bleeding ```

Question 29

how can severity of PPH be related to size of patient?

Answer 29

estimate blood volume as equivalent to 100mls per kg and multiple this by patients weight in kg eg a 65kg patients blood volume would be estimated at 6500ml (6.5L)

Question 30

causes of PPH (4Ts)?

Answer 30

tone (uterine atony) = main cause trauma = 2nd most common tissue (retained products of conception) = 3rd most common thrombin = least common cause

Question 31

antenatal risk factors for PPH?

Answer 31

placental problems (praevia, accreta, percreta) previous history of retained placenta, C-section or PPH multiple pregnancy polyhydramnios obesity fetal macrosomnia

Question 32

intrapartum risk factors for PPH?

Answer 32

``` operative vaginal delivery syntocinon/syntometrine use (induced labour) retained placenta c-section labour >12 hrs perineal tear/episiotomy during delivery ```

Question 33

initial assessment and stabilisation of PPH?

Answer 33

``` ABCDE oxygen (15l/min via non-rebreather mask) get IV access bloods cross-match 6 units red packed cells check vital signs every 15 mins determine cause of bleeding consider initiating massive haemorrhage protocol early blood transfusion give tranexamic acid 0.5-1g IV to stop the bleeding (regardless of cause) ```

Question 34

how can you stop the bleeding non-surgically in PPH?

Answer 34

``` uterine massage expel clots manually give 5 units syntocinon insert catheter to minimise bladder pressure on uterus give 500mcg IV ergometrine if no response to syntocinon exclude repair/trauma give carboprost 250mcg IM every 15 mins give misoprostol 800mcg PR ```

Question 35

surgical methods of stopping the bleeding in PPH?

Answer 35

balloon insertion to put pressure on bleeding blood vessels arterial embolisation via interventional radiology "B-lynch" sutures uterine artery ligation internal iliac ligation hysterectomy is a last resort

Question 36

how is fluid replacement done in PPH?

Answer 36

2 large bore IV access rapid fluid resuscitation (crystalloid, 0.9% saline) blood transfusion early (consider O- if life threatening) if DIC/coagulopathy occurs then give FFP, cryoprecipitate, platelets use a blood warmer

Question 37

how can secondary PPH be prevented?

Answer 37

give thromboprophylaxis debrief the couple manage anaemia with iron supplementation

Question 38

how common is perineal tear?

Answer 38

9 in 10 first time mothers

Question 39

what are the 4 degrees of tear?

Answer 39

1 = involves skin only 2 = involving skin and perineal muscles such as levator ani, usually needs stitches 3 + 4 = extend to external anal sphincter muscle, may need surgery as mother may experience faecal incontinence due to overstretching of pudendal nerve branches

Question 40

how as an episiotomy different from perineal tear?

Answer 40

episiotomy is a surgical cut made with patients consent

Question 41

how is anaesthesia used in episiotomy?

Answer 41

local anaesthetic injected along the site of the tear/episiotomy to anaesthetise branches of pudendal nerve (12)

Question 42

blood supply to foetus while in the womb?

Answer 42

via placenta umbilical vein (belonging to foetus) carries oxygenated blood from placenta to two areas (little bit to foetal liver and rest to foetal IVC via ductus venosus) this causes blood to mix as the IVC carries oxygenated blood the mixed blood drains into the right atrium of the heart as the deoxygenated blood from SVC

Question 43

function of foramen ovale in the foetus?

Answer 43

small hole in the septum where blood from the right atrium can pass into the left atrium exists to relieve pressure on the right side of the heart caused by increased pulmonary resistance

Question 44

possible paths of blood flow once it enters right atrium?

Answer 44

can drain into the right ventricle to then be pumped via the pulmonary arteries to the lungs or can pass into the left atrium via the foramen ovale

Question 45

why is there increased pulmonary resistance in the foetus?

Answer 45

alveoli contain fluid rather than air which means they lack oxygen as a result, nearby arterioles vasoconstrict in response to the alveoli's hypoxic state and increase the pulmonary resistance

Question 46

what other structure helps relieve the pressure on the right side of the foetal heart due to increased pulmonary resistance?

Answer 46

ductus arteriosus

Question 47

what does the ductus arteriosus do?

Answer 47

vessel which connects the pulmonary arteries to the aort