Puerperium Flashcards
(51 cards)
1
Q
why is puerperium care important?
A
- Applicable to all women who deliver
- Physiological changes of labour, delivery and iatrogenic interventions revert to non pregnant state
- Complications could be life threatening and life changing for the mother
2
Q
define puerperium
A
- Period from delivery of placenta through first few weeks after delivery
- Approximately 6 weeks in duration
- Physiological changes of pregnancy, labour and delivery revert to non pregnant state
3
Q
cardiovascular changes during pregnancy
A
- Increased circulatory/vascular volume in pregnancy (blood volume increases by 30% / plasma volume increases by 45%)
- Cardiac output increases by 30-50%
- Stroke volume increases by 25%
- Heart rate increases by 15-25%
- Peripheral vascular resistance decreases by 15-20%
4
Q
cardiovascular changes after birth
A
- Dramatic change
- Stabilisation of increased cardiac output
- Diuresis days 2-5 postpartum dissipates extra volume
- Normalisation from 2 weeks postpartum
5
Q
coagulation system changes in pregnancy and puerperium
A
- Hypercoagulable states in pregnancy
- Profound physiological changes in blood and coagulation after birth
- Remains high for 10-14 days before normalising
- Resulting haemostasis protects against haemorrhage
- Increased risk of VTE
- Virchows triad – vessel wall injury, stasis, hypercoagulability
6
Q
describe changes to uterus in the puerperium period
A
- Involution occurs
- Fundus palpable at maternal umbilicus immediately postpartum, approx. 20 weeks size pregnancy
- Returns to true pelvis within 2 weeks
- Recedes to only slightly larger than pre-pregnancy at end of puerperium
- Restoration of endometrium by 16th day except at placental attachment site
- Changes at placental bed site results in production of lochia (rubra, serosa, alba)
7
Q
describe changes to cervix in puerperium period?
A
- Reverts to non pregnant state
* External os closes such that a finger cannot be easily introduced
8
Q
describe changes to vulva, vagina and perineum in puerperium period?
A
- Resolution of increased vascularity and oedema by 3 weeks
- Restoration of vagina rugae variable depending on breast feeding status (6-10 weeks)
- Swelling and engorgement of already stretched and traumatised vulva/perineum
- Tears and episiotomies heals in couple of weeks
- Pelvic muscle tone regained by 6 weeks depending on extent of damage
9
Q
describe changes to abdominal wall in puerperium?
A
- Laxity in tone of abdominal wall muscles
- Diastasis recti – split/gap in rectus abdomini muscles
- Usually resolves with exercises
10
Q
describe changes to ovaries in puerperium
A
- Resumption of normal ovarian activity and resulting menstruation variable
- Greatly influenced by mode of baby/newborn feeding
- High levels of prolactin inhibit ovulation
- Lactational amenorrhoea up to 6 months (upto ¾ women)
- Formula feeding could result in ovulation as early as 28 days post partum
- Mean time to first menses is 7-9 weeks
11
Q
describe changes to breasts in peurperium?
A
- Changes to breasts in preparation for lactation occur throughout pregnancy
- Development of the ablity to secrete milk occurs as early as 16 weeks gestation
- High levels of circulating progesterone activates mature alveolar cells in the breast
- Rapid decline in progesterone after delivery triggers the onset of milk production
- Swelling, or engorgement, of breasts in postpartum period
- Colostrum high in protein and antibody (first 4 days after delivery)
- Removal of milk from breast stimulats more milk production (autocrine process)
- Breast milk matures over the first 7 days
12
Q
describe the process of lactation
A
- Process of continued secretion of copious milk
- Requires regular breast emptying
- Prolactin release from anterior pituitary gland
- Suckling causes nipple stimulation
- Oxytocin release from posterior pituitary gland
- Contraception of myoepithelial cell of breasts
- Milk flow -> alveolar lumens -> ducts and the nipple
13
Q
describe how the breast responds to formula feeding as opposed to breast feeding/expressing?
A
- Absence of milk removal
- Elevated intramammary pressure due to accumulation of milk within alveolar lumen
- Alveolar distention restricts blood flow to alveoli
- Interference with milk production
- Increase in pressure triggers inhibitor of lactation
- Mammary involution within 2-3 weeks
14
Q
describe perineal pain in peurperium
A
- Usually immediate/early presentation
- Could be due to swelling, bruising, repair from tears or episiotomies
- Requires regular analgesia
- Important to examine to R/O infection, haematoma
- Perineal swabs and antibodies if suspected infection
- Haematoma will need evacuation
15
Q
describe micturition in peurperium
A
- Urinary retention (maybe secondary to pudendal nerve damage) may need catheterisation
- 50% will develop urinary incontinence
- Usually stress incontinence
- May persist after pregnancy
- Pelvic floor exercises should be taught and encouraged
16
Q
describe bowel problems in peurperium?
A
- Constipation may due to regular use of opioids for perineal trauma or pain
- Stool softeners may be useful
- Haemorrhoids may be more painful after birth than before
- Can occasioanlly appear for first time
17
Q
mastitis
A
- May result from failure to express milk from one part of the breast
- It can be treated by ensuring all milk is expressed, feeding on affected side first so this side is emptied effectively
- May be complicated by infection with staphylococcus aureus and require treatment with flucloxacilin
18
Q
backache in peurperium
A
- May persist after birth and affects approxiately 1/3
- Could last several months
- If early presentation with associated headachein woman who had regional anaesthesia needs to rule out complications such as dural tap
19
Q
anaemia in peurperium
A
- This is common and may easily be overlooked
- FBC to confirm diagnosis
- Require iron tables and rarely haemotransfusion
20
Q
psychological problems in peurperium?
A
- Baby blues – days 3-5 postpartum
- Significant proportion of women become temporarily sad, anxious, iritable and emotional
- Precise cause unknown and may involve hormonal changes, reaction to reality of motherhood and doubts by the mother about her ability to care for the child
- Management consists of an explanation and reassurance; feelings should go within a few days
21
Q
VTE in peurperium
A
- Leading cause of maternal mortality in UK (MBRRACE 2013-15)
- Puerperium is the time of highest risk (20 fold increased risk)
- Increased risk in overweight, age >35 years of caesarean section
- Treat with LMWH
- Start treatment immediately on suspicion of thromboembolism
Reducing risk
• Proactivity
• Risk assessment
• Prevention (thromboprophylaxis)
22
Q
diagnosing DVT in peurperium
A
- Leg pain, swelling (unilateral), tender and painful calf muscles on firm palpation
- Lower abdominal pain or thigh pain and tenderness, low grade fever
- Clinical signs are unreliable (and D-dimer cannot be used in pregnancy and puerperium), so confirmation is needed with compression duplex ultrasound
- Treatment is with LMWH start immediately
- If ultrasound is negative but DVT is still suspected, LMWH can be stopped but ultrasound repeated on days 3-7
23
Q
diagnosting and managing PE in peurperium
A
- Dyspnoea, haemoptysis, pleural pain, cyanosis may develop later. Massive PE may present with collapse
- Friction rub may be heard in chest
- ECG performed. Abnormal in 41% but may suggest an alternative diagnosis, such as CHD
- CXR – abnormal in under 50% but may suggest alternative diagnosis, such as pneumothorax
- If DVT suspected, PE may be diagnosed and treatment started if DVT confirmed on compression duplex ultrasound
- If DVT is not suspected, a ventilation/perfusion scan or computerised tomography pulmonary angiogram should be performed
- Treat with LMWH (IV unfractionated heparin bolus followed by infusion with or without thrombolysis for massive PE)
- Self administered LMWH or oral warfarin is continued for at least 3 months
- LMWH is associated with significantly lower risk of post thrombotic syndrome compared with warfarin
24
Q
post partum haemorrhage
- definition
- types
A
- Blood loss of more than 500mL from female genital tract after delivery of fetus (or >1000mL after caesarean)
Second leading direct cause of maternal deaths in UK MBRACE 2013-15
Leading cause of maternal mortality in world - Primary post partum haermorrhage- loss of more than 500mls of blood from genital tract within 24 hours of delivery / atonic uterus 76-80%
Secondary postpartum haemorrhage – abnormal bleeding after 24 hours up until 6 weeks postpartum
25
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PRIMARY POSTPARTUM HAEMORRHAGE
poor uterine tone
1. clinical findings
2. investigation
3. management
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1. abdominal palpation - uterus relaxed, boggy and soft. uterine fundus - felt above umbilicus if uterine cavity filled with blood and clots
2. FBC, coag, U+E. if not responsive to fluid and blood - abdominal USS to exclude uterine rupture or intraperitoneal bleeding
3. uterotonic agents - oxytocics, prostaglandins, ergot alkaloids. uterine balloon tamponade. haemostasis
26
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PRIMARY POSTPARTUM HAEMORRHAGE
tears or trauma
1. clinical findings
2. investigation
3. management
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1. bleeding, uterine rupture, extension of uterine angles, tears during caesarean, extragenital causes (subscapular live rupture or rupture of ovarian or spenic vessels)
2. inspect during C.section, ultrasound to identify free fluid
3. management - repair of trauma, pelvic arterial embolisation (in cases of broad ligament or supralevator haematoma)
27
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PRIMARY POSTPARTUM HAEMORRHAGE
retained tissue
1. clinical findings
2. investigation
3. management
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1. retained placenta and membranes - identified during bimanual examination
2. examine under anaesthesia
3. manual removal - of placenta or retained products of conception under regional or general anaesthetic
28
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PRIMARY POSTPARTUM HAEMORRHAGE
coagulopathy
1. clinical findings
2. investigation
3. management
```
1. continuing bleeding, contracted uterus
2. U+E, FBC, coag
3. medical - immediate replacement of blood and coag factors and platelets. surgical - only with trauma or atonic haemorrhage unresponsive to medical treatment
29
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SECONDARY POSTPARTUM HAEMORRHAGE
endometritis
1. clinical findings
2. investigation
3. management
```
1. uterine tenderness, guarding and rebound tenderness
2. ultrasound to exclude retained products of conception, pelvic abscess. high vaginal swabs
3. oral antibiotics, admit for IV antibiotics if unwell or haemodynamically unstable
30
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SECONDARY POSTPARTUM HAEMORRHAGE
pseudo-aneurysm, uterine artery
1. clinical findings
2. investigation
3. management
```
1. profuse bleeding, shock (24hr after birth)
2. doppler uss, MRI, pelvic angiography
3. medical - antibiotics, correction of blood volume. surgical - uterine artery embolisation
31
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SECONDARY POSTPARTUM HAEMORRHAGE
retained tissue
1. clinical findings
2. investigation
3. management
```
1. foul smelling or offensive vaginal discharge, fever, uterine tenderness
2. USS- confirm retained products of conception and exclude pelvic abscesss
3. medical - oral antibiotics or admit for IV antibiotics if haemodynamically unstable
surgical- evacuation of retained products of conception.
32
describe the significance of mental health problems in postnatal period?
* Highest risk of severe mental illness when pregnant and soon after than at other time in life
* Between 2009-2013 there were 101 maternal deaths due to suicide in UK
* Screening questions for depression and anxiety should be considered in early postnatal period
* 10-15% of women experience postnatal depression which may present at any time during the first year after delivery
33
signs and symptoms of postnatal depression
* Feeling very low or despondant, that life is long, hopeless
* Feeling tired and very lethargic
* Not wanting to do anything or take an interest in outside world
* Feeling sense of inadequacy or unable to cope
* Feeling guilty about not coping, or about not loving their baby enough
* Being unually irritablle, which makes guilt worse
* Wanting to cry/cry a lot or constantly
* Having obsessive and irrational thoughts which can be scary
* Loss of appetite which may go with feeling hungry all the time but being unable to eat
* Difficulty sleeping – not getting to sleep, waking early or having vivd nightmares
* Being hostile or indifferent to their partner and/or baby
* Having difficulty in concentrating or making decisions
* Experiencing physical symptoms such as headaches
* Having obsessive fears about babys health or wellbeing or about themselves and other members of family
* Having disturbing thoughts about harming themselves or their baby
* Having thoughts about death/suicide
34
postpartum psychosis
incidence
presentation
* Affects 1-2/1,000 women following delivery and usually appears as mania or depression
* Can present with apparent schizophrenia.
* It usually begins abruptly , initially with confusion, anxiety, restlessness and sadness.
* rapid development of delusions or hallucinations
* Any woman with symptoms suggestive of postpartum psychosis should be referred to a secondary mental health service for assessment within four hours. Admission to specialist mother and baby unit.
35
peruperal pyrexia and sepsis
| definition and mortality
• Fever >38 (within 6 weeks postpartum)
in the UK, sepsis in puerperium remains an important cause of maternal death
• The mortality rate related to genital tract sepsis decreased in the UK from 0.63 per 100,000 maternities in 2009-2011 to 0.29 deaths per 100,000 maternities in 2011-2013
36
PUERPERAL PYREXIA AND SEPSIS
| aetiology
* Urinary tract infection -95% caused by Escherichia coli, Proteus spp. and Klebsiella spp.
* Genital tract infection -May be caused by E. coli, other anaerobes, Group A streptococcus (GAS) (also known as Streptococcus pyogenes), Staphylococcus spp. and Clostridium welchii (rare, but serious).
* Mastitis
* Other infections(Chest/viral )
* Deep venous thrombosis(Low grade pyrexia)- venous stasis and hypercoagulability./ Painful, swollen calf.
* Ovarian vein thrombophlebitis (rare cause of persistent puerperal pyrexia).
37
PUERPERAL PYREXIA AND SEPSIS
| caesarean section wound infection
* Lower segment caesarean section-most important risk factor for puerperal pyrexia
* Significantly increased risk of postpartum sepsis, wound problems, urinary tract infections and fever following LSCS.
* In UK (8%) risk of infection following LSCS - appropriate antibiotic prophylaxis before skin incision should be offered routinely
* Prophylaxis reduces endometritis by 66-75% and also reduces rate of wound infection or perineal Wound infection
38
PUERPERAL PYREXIA AND SEPSIS
| caesarean section wound infection
* Lower segment caesarean section-most important risk factor for puerperal pyrexia
* Significantly increased risk of postpartum sepsis, wound problems, urinary tract infections and fever following LSCS.
* In UK (8%) risk of infection following LSCS - appropriate antibiotic prophylaxis before skin incision should be offered routinely
* Prophylaxis reduces endometritis by 66-75% and also reduces rate of wound infection or perineal Wound infection
39
PUERPERAL PYREXIA AND SEPSIS
| signs and symptoms for urgent referral for hospital admission
* Pyrexia > 38 degree celsius
* Sustained tachycardia (≥90 beats/minute).
* Breathlessness (respiratory rate ≥20 breaths/minute).
* Abdominal or chest pain.
* Diarrhoea and/or vomiting - may be due to endotoxins.
* Uterine or renal angle pain and tenderness.
* The woman is generally unwell or seems unduly anxious or distressed.
40
PUERPERAL PYREXIA AND SEPSIS
| clinical assessment and investigations
* Full history and examination (chest, breasts, genital tract, legs)
* Wound swabs
* High vagina swabs(HVS)
* Blood cultures
* Full blood count
* Urine microscopy & cultures
* Throat swabs & sputum cultures
* Radiology(chest X-ray and pelvic ultrasound scan)
41
PUERPERAL PYREXIA AND SEPSIS
| measures for suspeted viral illness, mastitis, wound infection if woman not clinically unwell
* Ice packs may be helpful for pain from perineal wounds or mastitis.
* Rest and adequate fluid intake are required, particularly for mothers who are breast-feeding.
* Oral antibiotics with broad spectrum cover
42
PUERPERAL PYREXIA AND SEPSIS
| management if clinically unwell or signs of severe sepsis
* Admission to hospital
* Antibiotics should be commenced after taking specimens and should not be delayed until the results are available.
* Administration of intravenous broad-spectrum antibiotics within one hour of suspicion of severe sepsis, with or without septic shock, is recommended
* Analgesia may be required. NB: non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided for pain relief in cases of sepsis, as they impede the ability of polymorphs to fight GAS infection.
* Multidisciplinary team approach involving Senior Obstetrician, microbiologist/virologist/intensivist required for severe sepsis /shock.
* Surgical intervention may be required if an abscess has formed.
43
PUERPERAL PYREXIA AND SEPSIS
postpartum thyroiditis
what is it, symptoms, treatment
• Transient destructive lymphocytic thyroidis
• Anytime in first year postpartum
2 phases
• Thyrotoxicosis 1-4 months post partum, low TSH
• Hypothyroidism - increased TSH
Symptoms
• Hyperthyroidism - Anxiety, irritability, rapid heartbeat or palpitations,unexplained weight loss,increased sensitivity to heat, fatigue, tremor, insomnia.
• Hypothyroidism - Lack of energy, increased sensitivity to cold, constipation, dry skin, dificulty concentrating, aches and pains.
Treatment
• Usually self limiting
• Hyperthyroidism (Beta blockers if severe)
• Hypothyroidism (Thyroxin if severe symptoms)
44
when is contraception in puerperium needed
* Great variation in the return to fertility and sexual activity following childbirth
* Earliest known time of ovulation is 27 days after delivery.
* No contraception needed until 21 days postpartum.
* Contraceptive options influenced by breastfeeding
45
CONTRACEPTION IN PUERPERIUM
| non breast feeding women <21 days postpartum
- progestogen only pill
- progestogen only injectables and implants
- barrier methods
46
CONTRACEPTION IN PUERPERIUM
| non breast feeding women >21 days postpartum
- all combined hormonal contraceptive methods
- POP
- progestogen only injectables and implants
- barrier methods
- fertility awareness based methods in previous user
47
CONTRACEPTION IN PUERPERIUM
| breast feeding women <6 weeks postpartum
- lactational amenorrhoea method
- POP
- progestogen only implants
- barrier methods
48
POSTPARTUM CARE
* Women should be offered information to enable them to promote their own and their baby's health and well-being and to recognise and respond to problems.
* At the first postnatal contact, women should be advised of the signs and symptoms of haemorrhage, infection, thromboembolism and preeclampsia/eclampsia and the appropriate action to take.
* All maternity care providers should encourage breast-feeding.
* contraceptive methods and advice about when to start them should be discussed within the first postpartum week
* At each postnatal contact, women should be asked about their emotional well-being, what family and social support they have and their usual coping strategies for dealing with day-to-day matters.
* Women and their families/partners should be encouraged to tell their healthcare professional about any changes in mood, emotional state and behaviour that are outside of the woman's normal pattern.
49
DRUGS AND BREASTFEEDING
| principles
* Almost all drugs pass in breastmilk
* Prescribe only when absolutely indicated
* Choose ones with shorter half lives, less toxicity, those commonly used in infants and those with reduced bioavailability
50
DRUGS AND BREASTFEEDING
| medications with poor bioavailability and low risk
* Heparin.
* Insulin.
* Aminoglycoside antibiotics.
* Third generation cephalosporins.
* Omeprazole and lansoprazole.
* Inhaled steroids and beta agonists.
51
DRUGS AND BREASTFEEDING
| drugs contraindicated in breast feeding women
* Amiodarone.
* Antineoplastic.
* Chloramphenicol.
* Ergotamine.
* Cabergoline.
* Ergot alkaloids.
* Iodides.
* Methotrexate.
* Lithium.
* Tetracycline.
* Pseudoephedrine.
