PUERPERINIUM: Prematurity, PPH, Perineal tear, Postnatal care


Prematurity

Epidemiology


10% are pre-term labour/PTPROM

Causes


Infection- chorio (GBS which crosses placenta; BV), viruses
Anatomical- cervical incompetence, bicorneal uterus
Multiple pregnancy- mono-chorionic, di-amniotic
Polyhydramniosis

Classification


Primary- Bico uterus, Ehlers Danlos syndrome (hypermobility of joints)
Secondary- TOP, cone Bx, D&C

Presentation


Classical- painless, bloodless (birth of live fetus)
PROM
Prospective (U/S)
pHx mid-trim loss

Management


Prolong time in-utero at earlier stages
  • Prophylactic stitch at 13 weeks!! Therapeutic stitch to be placed before 24 weeks
  • Tocolytics (indacid per rectal, anti-prostaglandins) to suppress labour, however >32weeks this is terotogenic, causing premature ductus arteriosis closure
  • Nifedipine (oral) calcium channel blocker 1/1 tds- also at earlier stages
  • Progesterone PV pessaries 200mg daily
  • monitor with Trans-vaginal scan; Rest at home

At later stages, give steroids, deliver and prevent infection ie prevent chorionitis
  • Fetal monitoring with CTG 3 times/week (fetal tachycardia if infection occurs)
  • Erythromycin; swab (if BV give oral Flagil or Clindamycin cream)

Advances to enable survival:
  • steroids to mature lungs e.g. celesteronecromodone 11.4mg
  • surfactant spray
  • oscillator (ventilator without pressure issues)
  • MgSO4 to prevent cerebral palsy

Prognosis


PNM rate (death within 28 days postnatal) is 0.8-1%
PNM = NND + FDIU (mostly growth-restricted babies)
at 28 weeks, 98% survival rate at a NICU (neonatal ICU- MMC, Mercy, Royal Women's)
26 week survival rate 75%
24 week survival rate 40%
However, less than 31 weeks difficult, as head is smaller than body ie head may get stuck!

PERS- perinatal emergency referral service
NET- neonatal emergency transfer



Post-Partum Haemorrhage

Management


  • Resuscitate with drip and cross match 2 units of blood
  • Empty bladder to help uterus contract; place in catheter; (Oxytocin release: baby to breast)
  • Syntocin, Syntometron (contains ergometron, S/E: HT)- 10U on primi, 1 U on mluti (multiparous women have very sensitive uterus which may easily rupture).
Contractions assist with bleeding, as in between contractions, fetus is able to otain blood supply.
Uterus may be atonic, this is the commonest cause of PPH
  • Check completeness of placenta. Manual removal of placenta may be required. Retained products (placenta should be out within 30min) Remove placenta; chord traction. Placenta accreta- placenta grows into muscle of uterus

For sustained bleeding:
  • Repeat syntometron 40IU- 2nd dose (3rd dose is rare)
  • Misoprostol 5 tablet per rectal
  • PG F2alpha 1mg inection into myometrium (NOT in asthmatic)
  • balloon tamponade
  • (Last resort- remove uterus)

Causes


Primary causes within 24 hours
  • Atony, retained products, multiple grand multigravity, placenta previa and abruption, fibroids, polyhydramniosis, instrumental prolonged labour
  • Tone Tissues Trauma, coagulopathies

Secondary causes up to 6 weeks (end of pueperinium)
  • Infection, tissues, coagulopathies

Fiboids
Fibroids can cause infertility, miscarriage, pre-term labour, malpresentation of fetus, PPH

DIC Mx
FFP (fresh frozen plasma, which includes clotting factors)
platelets
blood replacement
PG F2alpha



Perineal lacerations

Classification




1st degree Vaginal mucosa, perineal skin or fourchette only
2nd degree Muscle fo the perineal body
Muscles: superficial transverse perineal, bulbocavernosus, central perineal body, posterior margin of the deep transverse muscle and urogenital diaphragm.
If tear is deep: puborectalis, pubococcygeus muscles
3rd degree Perineal body- whole, plus External anal sphincter
3A if <50% external anal sphincter
3B if > 50% external anal sphincter
3C if [+] internal anal sphincter
4th degree Anal or rectal mucosa


Aetiology


Natural vaginal birth- mostly standing;
3.7kg birth weight;


Investigation


  • Endorectal U/S
loss of 'echogenicity'
  • Manometry (anal pressures)
4 quadrants
  • Pudendal nerve study
pelvic floor; conduction time should be 2.0 + 0.2ms
use ischial spine as bony landmark

Management


Use HRT/oestradiol cream e.g. Ovestin to thicken epithelium
Pelvic floor exercises



Postnatal Care

Breastfeeding



Oestrogens stimulate proliferation of the lactiferous ducts (possibly with adrenal steroids and growth hormones).
Progesterone is responsible for the development of the mammary lobules.
Prolactin (lactogenic hormones) and human placental lactogen also play a role in modulating these changes during pregnancy.
Colostrum
Colostrum is a yellowish fluid secreted by the breast that can be expressed from week 16 gestation.
The proteins are mainly in the form of globulins- esp IgA, which plays an important role in protection against infection. Colostrum is also believed to have a laxative effect, which may help empty the baby’s bowel of meconium.

Breast milk
Major constituents of breast milk are lactose, protein, fat and water.
Prolactin levels increases by 20 fold during pregnancy and lactation.
Oxytocin is released in a pulsatile fashion from the posterior pituitary upon the milk-ejection or let-down reflex initiated by suckling.
Oxytocin contracts the myoepithelial cells surrounding the alveoli as well as the myoepithelial cells lying longitudinally along the lactiferous ducts, thereby aiding the expulsion of milk. Oxytocin cna also stimulate uterine contractions, giving rise to the ‘after-pains’ of childbirth.
Oxytocin is stimulated by visual, olfactory and auditory stimuli e.g. baby cry. Inhibited by stress.
Benefits of breast feeding

Benefits



  • Cheap and readily available (at right temperature)
  • Ideal nutritional value
  • Reduces childhood infective illnesses esp. Gastroenteritis
    • Reduces fertility with amenorrhoea (decreased LH from anterior pituitary)
    • Reduces atopic illnesses, juvenile diabetes, necrotizing enterocolitis, childhood cancer esp. Lymphoma, reduces pre-menopausal breast cancer

Interventions




Dopamine receptor blockers e.g. metoclopramide, sulpiride and domperidone, may be used to treat women who are temporarily unable to breastfeed.
Sublingual or buccal oxytocins may also be used to augment lactation with good effect.
Pelvic floor exercises

Contraception




The combined oral contraceptive pill enhances the risk of thrombosis in the early puerperium and can have an adverse effect on the quality adn constituents of breast milk.
The progesterone only pill (minipill) is therefore preferable and should be commenced about day 21 following delivery.
Women who are not breastfeeding should commence the pill within 4 weeks of delivery, as ovulation can occur by 6 weeks postpartum.


General Post-natal Care




Perinatal death
Post mortem encouraged; register the death with the Registrar of births and deaths; funeral; 6 week postnatal visit at hospital

Postnatal examination
6 weeks postpartum; with GP or obstetrician if complicated
Urinary, bowel and sexual functions