13 - The puerperium and breast feeding

Question 1

What is the puerperium?

Answer 1

The time after childbirth (after placental delivery) lasting about 6-8weeks

Question 2

What occurs during the puerperium?

Answer 2

• physiological and anatomical changes take place in the reproductive, urinary and cardiovascular systems
• The woman and her family are adjusting to parenthood and its roles and responsibilities including psychological adjustments

Question 3

What are the involution of the uterus during the puerperium time?

Answer 3

o Returning to pre-pregnancy size
o Process lasts around 6 weeks
o Fundus cannot be palpated from 10 days after delivery as it has reduced in size to blot the symphysis pubis
o Myometrium changes
o Decidual changes as superficial layer is shed as locia and basal later remains intact and is the source of new endometrium

Question 4

How does the myometrium change during puerperium?

Answer 4

 Ischaemia – vasoconstriction and reduction of blood supply
 Autolysis – self ingestion of myometrial cells
 Phagocytosis – phagocytes engulf and remove waste produces of autolysis which can then be removed by the kidneys

Question 5

What is lochia?

Answer 5

Blood loss after the baby is born

Question 6

What are the characteristics of lochia?

Answer 6

Lochia rubra
Lochia serosa
Lochia alba

Question 7

What is lochia rubra?

Answer 7

 Red
 Up to day 3
 Decidual debris

Question 8

What is lochia serosa?

Answer 8

 Pink
 Up to day 10
 Necrotic decidua

Question 9

What is lochia alba?

Answer 9

 Yellow-white
 Diminishes over 3-6 days
 Serous fluid and leukocytes

Question 10

What are the haematological changes that occur during the puerperium?

Answer 10

o Increase in coagulation maximising clot formation on the 1st day
o Gradual reduction in plasma volume, returning to normal 1 week after delivery
o Haemoglobin increases on the 1st day postpartum

Question 11

What are the cardiovascular changes that occur during puerperium?

Answer 11

o Reduction to normal blood volume by 10 days
o Reduction in cardiac output after 1-2 days and returning to normal levels by 2-6 weeks
o Decrease in progesterone leads to removal of excess tissue fluid and tissues return to normal vascular tone

Question 12

What are the respiratory changes that occur during puerperium?

Answer 12

o Reduction in compression of lungs due to reduction in uterine size
o No more shortness of breath
o Less oxygen demand as reduction in cardiac work and circulatory volume

Question 13

What are the renal changes that occur during the puerperium?

Answer 13

o Dilation of renal tract resolves and renal organs return to pre-pregnant state
o Displaced bladder and stretched urethra return to pre-pregnant state
o Increased diuresis and excretion of breakdown products following pregnancy places extra work on kidneys
o Risk of infection if distension remains

Question 14

What are the hormonal changes that occur during puerperium?

Answer 14

o Body quickly returns to normal hormonal state after the delivery of the placenta
o Reduction in production of oestrogen, progesterone and hPL
o Increase in prolactin and oxytocin which triggers milk production and release

Question 15

What are the changes that occur in the perineum during the puerperium?

Answer 15

o Damage may have occurred in childbirth

o Pelvic floor exercises important to improve continence

Question 16

What are the psychological changes that occur during the puerperium?

Answer 16

o Mood swings – blues, depression, psychosis

o Influenced by hormonal changes and lifestyle adaptations and adjustments to motherhood

Question 17

What does the breast consist of?

Answer 17

o	15-25 lobes
o	20-40 lobules
o	Alveoli 
o	Milk ducts 
o	Lactiferous sinuses

Question 18

What is mamogenisis?

Answer 18

mammary duct growth and development

Question 19

What are the steps of mammogenesis?

Answer 19

o From 6th week the increase in hormones leads to breast enlargement and development
o Oestriogen leads to growth of lactiferous ducts and tubules
o Progestrone, prolactin and hPL lead to proliferation and enlargement of alveoli and stimulate fat deposition
o By 12th week nipple and areola become more pigmented
o By 16th week colostrum is formed by HPL and prolactin
o Milk formation prevented by oestrogen and progesterone
o By 24th week secondary alveoli have formed

Question 20

What is lactogenesis?

Answer 20

initiation of milk secretion in alveoli

Question 21

What are the 3 steps of lactogenesis?

Answer 21

o 1 = initiation of milk secretion during pregnancy
o 2 = production of colostrum following fall in progesterone and high levels of prolactin
o 3 = begins at day 10 and is the maintenance of established lactation and removal of milk by the baby
o Prolactin secreted from the anterior pituitary gland and transported to milk producing cells

Question 22

What is the difference between galactopoiesis and and galactokinesis?

Answer 22

• Galactopoiesis = maintenance of lactation
• Galactokinesis = removal of milk from gland
o Oxytocin – secreted in posterior pituitary gland triggered by sight, smell, sound and touch of baby and is transported to the breast and causes milk ducts to make milk flow

Question 23

What are the advantages of breast feeding?

Answer 23

o Natural food designed for your baby – contains the right balance of nutrients
o Protects baby from infections and diseases
o Less risk of sudden infant death syndrome, childhood leukaemia and cardiovascular disease in adulthood
o Less likely to develop atopic diseases such as eczema and asthma
o Less likely to become obese
o Free
o Available whenever baby needs a feed
o At the right temperature
o change of diarrhoea, vomiting and constipation
o Fewer chest and ear infections
o Reduces

Question 24

What are the advantages of breastfeeding to the mother?

Answer 24

o Lowers ovarian and breast cancer risk
o Lowers osteoporosis risk
o Uses up 500 calories per day so speeds up weight loss
o Saves money
o Builds strong physical and emotional bond between mother and baby
o Sense of achievement

Question 25

What are the disadvantages of breastfeeding?

Answer 25

o Unable to measure amount of milk baby is getting
o Difficult, tiring, stressful
o Unable to leave baby for long periods of time
o Father unable to feed baby
o Difficult to wean baby off breast
o Maternal infection such as HIV
o Certain medications can affect the baby

Question 26

What is the positioning for breastfeeding?

Answer 26

o Hold baby close to breast
o Baby should be on their side with head, neck and body in a straight line
o Nose to nipple
o Baby’s whole body supported

Question 27

How does the attachment occur during breastfeeding?

Answer 27

o	C – close to mum facing breast 
o	H – head free able to tilt back 
o	I – in line
o	N – nose to nipple
o	Wide open mouth 
o	Suckling and swallowing 
o	Head is free 
o	Not painful for mother

Question 28

What are the problems that can occur with breastfeeding?

Answer 28

o	Sore nipples
	Friction 
	Incorrect positioning and attachment 
o	Engorgement 
	Build up of milk in ducts 
	Breast feels hard, lumpy, painful 
	Caused by insufficient emptying of the breast due to incorrect positioning 
o	Mastitis 
	Milk stasis and infection if milk is not removed