Multiple Choice Questions On Puerperium

The term "blues" is the best term to describe the woman's symptoms postpartum. The symptoms of crying, loss of appetite, difficulty in sleeping, and feeling of low self-worth are consistent with the postpartum blues, also known as the baby blues. This is a common condition that affects many women after giving birth and is characterized by mood swings, sadness, and emotional instability. The symptoms typically start within the first few days after delivery and usually resolve on their own within a week or two.

After delivery, the levels of chorionic somatomammotropin (hCS or hPL) decrease. This hormone is produced by the placenta during pregnancy and acts as an antagonist to insulin, leading to insulin resistance. Therefore, a decrease in hCS or hPL levels postpartum would result in a decrease in insulin resistance and a subsequent decrease in insulin requirements for diabetic patients. This is why it is important to check the blood sugar levels immediately postpartum for class C diabetic patients.

After a normal labor and delivery, the uterus should be firm and rounded. This indicates that the uterus has contracted properly and is in a healthy state. A firm and rounded uterus also helps prevent excessive bleeding and promotes the healing process. It is important for healthcare providers to assess the firmness and shape of the uterus after delivery to ensure proper postpartum recovery.

The most likely etiology for the patient's persistent fever on the third day postpartum is endometritis. Endometritis is an infection of the lining of the uterus, which commonly occurs after childbirth. The patient's complicated prenatal course, prolonged labor, and delivery with laceration and episiotomy increase the risk of developing endometritis. Symptoms of endometritis include fever, abdominal pain, and foul-smelling vaginal discharge. Prompt diagnosis and treatment with antibiotics are necessary to prevent complications.

The most likely diagnosis in this case is Sheehan's syndrome (pituitary necrosis). This is supported by the patient's history of significant postpartum bleeding and hypovolemic shock, which can lead to ischemic necrosis of the pituitary gland. The symptoms of breast atrophy, amenorrhea, and hormonal imbalances are consistent with pituitary dysfunction. Additionally, the development of constipation, slurred speech, and nonpitting edema can be attributed to the hormonal deficiencies caused by pituitary necrosis.

The most likely diagnosis in this scenario is uterine inversion. Uterine inversion occurs when the uterus turns inside out and protrudes through the cervix into the vagina. This can result in a red, raw surface at the vaginal introitus. The patient's pale appearance and low blood pressure indicate hypovolemia, which can be caused by uterine inversion due to excessive bleeding. The normal amount of external bleeding suggests that the bleeding is occurring internally, further supporting the diagnosis of uterine inversion.

The most likely diagnosis in this case is retained placental fragments. This is because heavy vaginal bleeding after childbirth can be a sign of retained placental tissue in the uterus. When the placenta does not detach completely from the uterine wall, it can lead to persistent bleeding. Other differentials such as coagulopathies, uterine atony, uterine rupture, and vaginal lacerations may also cause bleeding, but in this scenario, retained placental fragments are the most likely cause based on the patient's history of an uncomplicated vaginal birth.

The given scenario describes a perineal laceration that involves tearing through the skin of the fourchette, vaginal mucous membrane, and the fascia and perineal muscles of the perineal body. However, the anal sphincter or mucosa is not affected. This indicates that the laceration is a second-degree tear.

High dose (≥50 μ gestradiol) oral contraceptive pills can interfere with lactation. The other options, such as Depo-Provera, frequent suckling, Levonorgestrel intrauterine device (IUD), and progestin-only oral contraceptive pill (minipill), do not interfere with lactation.

On average, the blood loss from an uncomplicated vaginal delivery, when carefully measured, is approximately 550 mL.

Staphylococcus aureus is the most likely organism to be found in the breast culture of a postpartum patient presenting with symptoms of engorgement, redness, pain, and fever. Staphylococcus aureus is a common cause of mastitis, an infection of the breast tissue, especially in breastfeeding women. It can enter the breast through cracked or sore nipples and cause inflammation and infection. The symptoms described are consistent with a Staphylococcus aureus infection.

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Immediate replacement of the fundus is the correct answer because the patient is presenting with signs of postpartum hemorrhage, such as a pale appearance, low blood pressure, and a raw surface at the vaginal introitus. The fundus is the upper part of the uterus, and by replacing it, the healthcare provider can help control the bleeding and prevent further complications. This is the initial step in managing postpartum hemorrhage.

During pregnancy, the decidual layer in the uterus is divided into several parts. One of these parts is the zona basalis, which is the layer that remains after a curettage for a retained placenta. This means that the zona basalis is the part of the decidual layer that should not be damaged during the procedure.

Breast binding, ice packs, and analgesics are the simplest and safest methods of lactation suppression. Breast binding helps to reduce milk production by applying pressure to the breasts. Ice packs can also help to decrease milk production by reducing blood flow to the breasts. Analgesics can help to relieve any discomfort or pain associated with engorgement. These methods are non-invasive and do not involve the use of medications, making them safe options for lactation suppression in this situation.

The greatest predisposing cause of puerperal infection in this patient is tissue trauma. The patient had a complicated labor, including a mid-forceps delivery with a sulcus laceration and a third-degree episiotomy. These procedures can cause damage to the tissues, increasing the risk of infection. Other factors such as anemia, poor weight gain, and maternal obesity may also contribute to a weakened immune system, making the patient more susceptible to infection. However, in this case, the tissue trauma from the delivery is the most significant factor.

Puerperal infection refers to an infection that occurs after childbirth. Septic thrombophlebitis is a serious complication of puerperal infection. It is most commonly spread through the venous route. This means that the infection originates in the veins and spreads through the bloodstream, causing inflammation and blood clot formation. In this case, the patient had multiple risk factors for infection, including a complicated labor and delivery, which may have contributed to the development of septic thrombophlebitis through the venous route.

Prolactin stimulates milk production and breast development. This hormone is responsible for initiating and maintaining lactation in the postpartum period. It is produced by the pituitary gland in response to the suckling of the baby and helps in the production of breast milk.

Uterine atony is the most frequent cause of immediate hemorrhage in this patient. Uterine atony refers to the inability of the uterus to contract effectively after childbirth, leading to excessive bleeding. Given the patient's history of a previous cesarean section, the risk of uterine atony is increased. It is important to note that while all of the other options can also cause postpartum hemorrhage, uterine atony is the most common cause in this scenario.

Parametritis refers to an infection that spreads to include the supporting connective tissues of the uterus. It is characterized by inflammation and infection of the parametrium, which is the tissue surrounding the uterus. In this case, the patient had a complicated labor and delivery, which may have increased the risk of infection spreading to the parametrium. The other options listed (peritonitis, phlebothrombosis, pyemia, thrombophlebitis) do not specifically involve the infection of the supporting connective tissues of the uterus.

The next best intervention for this patient with postpartum hemorrhage that is not controlled by bimanual massage of the uterus and intravenous oxytocin is prostaglandin F2 (PFG2)-alpha. Prostaglandin F2 (PFG2)-alpha is a medication that can be used to induce uterine contractions and control bleeding. It is commonly used in cases of postpartum hemorrhage when other interventions have failed.

Discharge counseling and plans for a patient following an uncomplicated vaginal delivery would include rubella immunization for nonimmune patients. This is because rubella, also known as German measles, can cause severe birth defects if a pregnant woman contracts the virus. Therefore, it is important to ensure that nonimmune patients receive the rubella vaccine to protect themselves and any future pregnancies. The other options mentioned in the question are not relevant to discharge counseling after a vaginal delivery.

Transfusions should be started if the patient becomes hypotensive despite other volume expanders. This is because hypotension indicates inadequate blood volume and perfusion, which can be life-threatening. Transfusions are necessary to restore blood volume and prevent further complications. The other options are not appropriate in this scenario as they do not address the immediate need for transfusions in a hypotensive patient.

Abdominal rigidity after a vaginal delivery could be indicative of a serious condition such as uterine rupture or internal bleeding. This requires immediate attention and further investigation to rule out any complications. The other findings mentioned, such as leukocytosis, proteinuria, a pulse rate of 60, and a single temperature of 100.4°F, are relatively common and may not be as concerning as abdominal rigidity in this context.

A spiral computed tomography (CT) scan would be the most helpful test to diagnose a pulmonary embolism in this patient. The patient's symptoms of chest pain and dyspnea, along with her history of prolonged labor and postpartum pelvic thrombophlebitis, raise suspicion for a pulmonary embolism. A spiral CT scan is a sensitive and specific test for detecting pulmonary embolisms, as it can visualize the blood vessels in the lungs and identify any blockages caused by blood clots. This test would provide the most accurate and timely diagnosis in this situation.

A hematoma can represent a serious etiology of inability to void in the immediate postpartum period. Hematomas can occur due to trauma during delivery and can compress the urethra or bladder, leading to urinary retention. This can be initially treated with Foley placement to relieve the obstruction caused by the hematoma.

The patient's symptoms of a high fever, tender uterus, and increased lochia without an odor suggest an infection in the postpartum period. The most likely organism causing this infection is beta-streptococcus, also known as Group B Streptococcus (GBS). GBS is a common cause of postpartum infections and is often associated with limited and inconsistent prenatal care. Therefore, the antibiotic choice needs to cover beta-streptococcus to effectively treat the infection.

Peptostreptococcus is the most commonly found anaerobic organism in the endometrial cavities of asymptomatic patients 2 to 3 days postpartum. This suggests that Peptostreptococcus is a normal inhabitant of the endometrial cavity during this time period.