Postpartum Problemos

Question 1

Normal postpartum blood loss

Answer 1

Under 500mL.

Question 2

Definitions of types of postpartum haemorrhage

Answer 2

Primary: minor = loss of 500-1000ml in 24hrs following delivery, major: loss of over 1000ml in 24hrs following delivery.
If c-section always over 1000ml.
Secondary = excessive blood loss from 24hrs post-delivery to 12 weeks postpartum.

Question 3

Causes of postpartum haemorrhage primary and secondary.

Answer 3

Tone - uterine atony, general anaesthesia, multiple pregnancy, macrosomia, prolonged labour.
Tissue - retained placenta, placenta accreta.
Trauma - episiotomy, perineal tear.
Thrombin - pre-eclampsia.
Secondary = endometritis, gestational trophoblastic disease, retained placenta tissue.

Question 4

Risk factors for PPH

Answer 4

Macrosomia, multiple pregnancy, prolonged labour, maternal pyrexia, operative delivery, shoulder dystocia, previous PPH.

Question 5

Management of a primary PPH

Answer 5

IV access - FBC, blood grouping, coagulation screen.
Warmed crystalloid infusion/fluids, blood transfusion?
IV oxytocin infusion.

Question 6

Management fo secondary PPH

Answer 6

Tranexamic acid.

Admit and consider blood transfusion.1

Question 7

3 postpartum mental health problems

Answer 7

baby blues
Postnatal depression
Puerperal psychosis.

Question 8

Screening for postnatal depression

Answer 8

Edinburgh scale. Includes question on self harm.

Question 9

Baby blues

Answer 9

COMMON. Reassurance, health visitor support.

Question 10

Postnatal depression

Answer 10

Peaks 3months post delivery. Rx with CBT, SSRI e.g. sertraline.

Question 11

Puerperal psychosis

Answer 11

Onset usually within 2-3 weeks of delivery. Mood swings plus disordered perception.
Admit to hospital.

Question 12

Amniotic fluid embolism pathophysiology

Answer 12

Amniotic fluid cells enter maternal circulation - massive immune response. Pulmonary embolism phase where there is a direct blockage and haemorrhage phase where complement pathway is activated.

Question 13

Clinical features of amniotic fluid embolism

Answer 13

Similar to PE. Breathlessness, palpitations, dizzy, seizure, cough, loss of consciousness. Tachycardia, tachypnoea, hypotension, cyanosis, hypoxia, MI.

Question 14

Management of amniotic fluid embolism

Answer 14

ABCDE
100% oxygen, fluid maintenance, correct coagulopathy, deliver baby via c-sec if not already out.
High mortality.

Question 15

Vitamin K

Answer 15

1mg IM, avoid vitamin K associated bleeding disorders

Question 16

Newborn physical examination timings and contents

Answer 16

within first 72hrs and then between weeks 6-8 of age. Include checking heart (rate, sounds, rhythm), head circumference, genitalia, spine, skin, cataracts, hips etc.

Question 17

When is the newborn blood spot

Answer 17

5-8 days old

Question 18

When is the newborn hearing test

Answer 18

By week 4 in hospital or week 5 in community.

Question 19

Classification of perineal tears

Answer 19

1st degree - injury to perineal skin or vaginal mucosa only.
2nd degree - injury to perineal and perineal muscles but not anal sphincter.
Third degree - injury to perineum including anal sphincter.
Fourth degree - injury to perineum incline anal sphincter and anorectal mucosa.

Question 20

Risk factors for perineal tears

Answer 20

Nulliparity
Macrosomia
Shoulder dystocia
Occiputo-posterior position
Prolonged labour stages
Instrumental delivery

Question 21

Perineal protection

Answer 21

Use hands to protect perineum and slow down delivery of head.

Question 22

Management of a perineal tear

Answer 22

Rectal examination.
Adequate analgesia for mother.
Suture ASAP.

Question 23

Breast feeding recommendations

Answer 23

for first 6months of baby’s life. Not for HIV positive women.

Question 24

Sheehan’s syndrome

Answer 24

Postpartum hypopituitarism. Ischaemic necrosis due to blood loss and hypovolaemic shock after birth. Can lead to hypothyroidism, amenorrhea, galactorrhea.

Question 25

When is the puerperium

Answer 25

Delivery to 6weeks after birth

Question 26

Contraindicated post-partum contraception

Answer 26

COCP if breastfeeding.

Question 27

Lochia

Answer 27

Vaginal bleeding after childbirth. Initially red then turns browny. Not pathological. 6 week duration 3 types rubra, serosa and alba

Question 28

Endocrine changes in puerperium

Answer 28

Decrease in hCG, oestrogen and progesterone.

Question 29

Hormones in lactation

Answer 29

Prolactin - milk production | Oxytocin - milk ejaculation

Question 30

Milk at birth

Answer 30

Colostrum - rich in proteins, Vit A, NaCl, lactoferrin and antibodies.

Question 31

Sepsis definition

Answer 31

Infection plus systemic manifestations of infection

Question 32

Severe sepsis definition

Answer 32

Sepsis plus sepsis induced organ dysfunction and tissue hypo-perfusion.

Question 33

Septic shock definition

Answer 33

Persistence of hypo-perfusion despite adequate fluid replacement therapy.

Question 34

Risk factors for puerperium sepsis

Answer 34

``` Obese DM Anaemia Invasive obstetric procedure e.g amniocenteses. Prolonged ROM C-section ```

Question 35

Signs of sepsis

Answer 35

``` 3Ts (white with sugar) Low or high temp tachycardia tachypnoea Hyperglycaemia ```

Question 36

Sepsis 6

Answer 36

``` Blood cultures Urine output Fluid resus Antibiotics Lactate Oxygen ```

Question 37

Where is oxytocin produced

Answer 37

Produced in hypothalamus SECRETED from posterior pituitary gland

Question 38

Where is prolactin produced

Answer 38

Anterior pituitary gland.

Question 39

Findings on examination of uterine atony

Answer 39

Un-palpable uterus

Question 40

Most common cause of primary PPH and its management

Answer 40

Uterine atony. Empty bladder Rub abdomen and bimanual compression of uterus. IV Syntocinon (ergometrine + oxytocin) IM Carboprost. Surgical = B-lynch sutures, internal iliac artery ligation.

Question 41

Most common cause of secondary PPH

Answer 41

Retained placental tissue