Discuss perineal pain PP
-Incidence of perineal trauma
-Incidence of women requiring suturing
-Incidence of ongoing pain at 18months
-Complications (3)
-Management (4)
- Incidence of perineal trauma - 80%
- Incidence of those requiring suturing 60-70%
- Incidence of ongoing pain at 18 months - 10%
- Complications
-Wound break down
-Infection
-Haematoma - Management
-Cold pack - no more than 20 mins
-Topical anaesthetics
-Analgesia (Avoid codeine)
-Continuous suturing - reduces pain
Discuss sexuality post partum
-Incidence of dyspareunia (2)
-Risk factors for dyspareunia (5)
-Usual timing of resumption of sexual intercourse (1)
-Causes of reduced sexual desire (5)
- Incidence
-60% at 3 months
-10% at 1 yr - Risk factors
-Episiotomy
-Operative vaginal delivery
-Excessively tight perineal repair
-Breast feeding with hypoestrogenism - Usual time to resumption of SI
-33% by 6 weeks PP - Causes of reduced sexual desire
-Dyspareunia
-Fatigue
-Physical changes to the body
-Hormone changes
-Transfer of emotional interest to baby
Discuss perineal infection
-Incidence (1)
-Risk factors (6)
-Common pathogens (3)
-Investigations (2)
-Treatment (6)
- Incidence
1-2% - Risk factors
-Instrumental delivery
-Vuval haematoma
-Poor sterile technique
-Poor postpartum hygiene
-Smoking
-Poor nutritional status - Common pathogens
-Staph aureua
-E. Coli
-Streph pyogens - Investigation
-Swabs +/- bloods if systemically unwell - Treatment
-Perineal hygiene
-Adequate hydration
-Analgesia
-Avoidance of constipation
-Antibiotics (Augmentin / cef and Met)
-Don’t re-suture with ongoing infection
Discuss perineal breakdown / dehiscence
-Causes (3)
-Management (4)
-Complications (1)
- Causes
-Infection
-Haematoma
-Poor surgical technique - Management
Assess for infection, necrotic tissue, suture fragments
Limited evidence to guide management early vs delayed repair
-Early re-suturing associated with less pain, less dyspareunia, earlier return to SI
Treat any infection with antibiotics and gentle debridement.
Consider re-suturing once clear and granulation tissue evident - Complications
-Fistulae
Discuss genital haematomas
-Incidence (2)
-Causes (2)
-Presentation (6)
-Sites (3)
-Investigations (3)
- Incidence
1:500 - 1:12 000
Surgical intervention required in 1:1000 deliveries - Causes
-Direct - vessel laceration from operative delivery, epis, pudendal block
-Indirect - spontaneous injury to blood vessel during stretching of birth canal - Presentation
-Excessive perineal pain
-Vulval or vaginal lump
-Shock
-Urinary retention
-Deviated uterus
-Unexplained pyrexia - Sites
-Infralevator
-Supralevator
-Broad ligament - Investigations
-FBC, coags
-USS/CT/MRI (MRI best for location and size)
Discuss infra levator haematoma
-Vessel usually arising from (1)
-Anatomy of location (3)
-Presentation (1)
-Management (2 options)
- Usually arises from internal pudendal artery
- Anatomy of location
-Within the superficial compartment
-Superficial boarder - superficial perineal fascia
-Deep boarder - levator ani fascia/ urogenital diaphragm - Presentation
-Perineal pain and swelling - Management
-If <5cm manage conservatively with: cold packs
prophylactic antibiotics
compression
-If >5cm or unstable surgical management
Open and evacuate blood.
Find bleeding point and ligate
Obliterate dead space with interrupted sutures
Cover with broad spec ABx
Discuss supra levator haematoma
-Vessel injury responsible (1)
-Anatomy of location (3)
-Presentation (6)
-Management (4)
- Vessel responsible
-Descending vaginal branch of uterine artery/ paravaginal plexus - Anatomy of location
-Contained in the paravaginal space
-Cardinal ligaments superior
-Levator ani fascia distal - Presentation
-Rectal pain and pressure
-Lower abdo pain
-Hypovolemia and collapse
-Protruding PV mass
-Fundal deviation
-Urinary retention - Management
-Surgical exploration technically difficult
-Consider USS drainage
-Consider IR or UAE
-Consider vaginal tamponade with balloon
Discuss broad ligament haematoma
-Vessels responsible (1)
-Causes (4)
-Presentation (4)
-Management (4)
- Vessels responsible
-Uterine artery branches - Causes
-Cervical or vaginal laceration
-Uterine rupture
-Extension of uterine incision
-Inadequate closure of angles - Presentation
-Abdo pain
-Hypovolemia
-Pyrexia
-Deviated uterus - Management
-If unstable perform laparotomy, open haematoma, identify bleeding point and secure
-Consider internal illiac artery ligation, embolisation, hysterectomy
Discuss CS wound infection
-Definition (1)
-Incidence (3)
-Types (4)
- Definition
-Infection occurring in part of the body where surgery took place within 30days of procedure - Incidence
-10%
-80% involve superficial tissue of anterior abdominal wall
-20% involve deeper tissue - Types
-Cellulitis
-Haematoma
-Necrotising fasciitis
-Abscess
Discuss prevention strategies for CS wound infection (8)
- Avoid unnecessary CS
- Optimise modifiable RF (smoking, glycemic control)
- Antibiotics prior to skin incision - reduces infection by 60-70%
-Cefazolin +/- Azythromycin if SROM >4hrs - Hair removal at surgical site
- Vaginal preparation RR 0.43 esp in setting of SROM
- Skin prep chlorhex likely better than iodine but limited evidence
- Surgical technique
-CCT to avoid endometritis
-Good haemostasis
-No evidence for irrigation - Consider negative pressure dressing in high risk population but evidence sparse
Discuss the risk factors for CS wound infection
-Pre labour RF (5)
-Labour RF (4)
-CS RF (6)
- Pre labour RF
-Smoking
-GDM/Diabetes
-Immunocompromised
-Obesity
-Previous CS - Labour RF
-Prolonged labour
-Prolonged ROM
-Chorioamnioitis
-Internal fetal monitoring - CS RF
-Emergency CS
-Long incision
-Lack of antibiotic prophylaxis
-Lack of pre-operative vaginal cleaning
-Prolonged operation
-Increased blood loss
Discuss management of CS wound infection
-Diagnosis (3)
-Management (3)
- Diagnosis
-Swabs
-Bloods
-USS/CT for haematoma - Management
-Broad spec Abx
-Drainage of large haematoma
-Debridement if concern for tissue viability
Discuss endometritis
-Incidence (2)
-Pre-existing RF (4)
-Labour RF (7)
-Postpartum RF (2)
- Incidence
1-3% following VB
Up to 30% following CS - Pre-existing RF
-Obesity
-Diabetes
-Immunocompromise
-Anaemia - Labour RF
-Prolonged labour
-Prolonged ROM
-Chorioamnionitis
-Internal fetal monitoring
-IUFD
-Instrumental delivery
-CS - Postpartum RF
-Retained products
-MROP
Discuss endometritis
-Methods to prevent (3)
-Implications of infection (4)
-Common pathogens (4)
- Methods of prevention
-Antibiotic prophylaxis for CS RR 0.5
-Antibiotics for instrumental RR 0.58
-Pre-operative vaginal prep with iodine RR 0.41 - Implications of endometritis
-Intrauterine adhesions
-Dysmenorrhoea
-Subfertility
-Secondary PPH - Common pathogens
-Usually polymicrobial
-Group A and B strep
-Staph
-Many others (Gram -ve, anaerobes, mycoplasma)
Discuss management of endometritis
-Diagnosis
-Management
- Diagnosis
-Bloods
-Swabs
-Consider USS if concern for RPOC but not routinely necessary - Management
-If mild 5-7 days of PO abx
-If systemically unwell IV Abx: Cochrane suggest clindamycin and gent most effective options
-Only evacuate uterus if RPOC on USS and not improving after 24hrs Abx and haemodynamically unstable
Discuss group A sepsis
-Type of organism (1)
-Significance of GAS sepsis (4)
-Transmission (3)
- Type of organism
-Gram + cocci (Strep pyogenes) - Significance of GAS sepsis
-Second most common cause of sepsis after E.coli
-Most common cause of deaths from sepsis (50% of maternal sepsis deaths in NZ)
-20 times increase in invasive GAS in pregnancy
-1:10 is health care related - Spread
-contact or droplets
-5-30% are Asx carriers in skin or throat
-PP GAS is usually from invasion through endometrium to blood
Discuss GAS sepsis
-Presentation (5)
-Criteria of probable Streptococcal toxic shock syndrome
-Criteria of definite strep toxic shock syndrome
- Presentation
-Abdominal pain
-Fevers
-Rapid onset
-Myalgias
-Rash - maccular and erythematous - Criteria for probable STSS
-Isolation of GAS from non-sterile site + hypotension + 2 or more other organs involved - Criteria for definite STSS
-Isolation of GAS from sterile site + Hypotension + 2 or more other organs involved
Discuss puerperal sepsis
-Definition (1)
-Incidence (1)
-Maternal risk factors (6)
-Labour risk factors (9)
-Most common cause (2)
- Definition
-Onset of sepsis from birth to 6/52 PP - Incidence
-5% of maternal mortality in NZ - Maternal risk factors
-Obesity
-Impaired glucose tolerance
-Immunosupression
-Anaemia
-Hx of pelvic infection
-Low SES / Ethnic minority
4 Labour risk factors
-Invasive procedures
-Prolonged ROM
-Prolonged labour
-Use of FSE
-Genital trauma
-CS
-RPOC / MROP
-GAS in close contacts
-Instrumental delivery - Most common cause
-Genital tract and UTI = 90% of all causes
Discuss management of puerperal sepsis (10)
- Measure lactate
- Blood cultures
- Broad spectrum Abx (No consensus) Within first hr
- If lactate >4 or hypotensive give crystalloid
- Consider vasopressors if no response to fluid resus to maintain MAP >65
- MDT input
- Consider IVIG if severe strep or staph infection to neutralise exotoxins
- Consider source control
- Consider ICU admission
- If GAS contact Neonates and place baby on Abx
- Avoid NSAIDS in treatment of GAS
