19 - Post Partum Period

Question 1

What is the most common cause of a post-partum haemorraghe?

Answer 1

- Primary: uterine atony

- Secondary: Infection (endometriosis) and/or retained products of conception

• 4 T’s

Question 2

What is the definition of the post partum period?

Answer 2

Period from delivery of the placenta to six weeks after this where the body returns to the pre-pregnancy state

Question 3

What medical input does a new mother get?

Answer 3

• Initially home visits by community midwife who provides advice on contraception, breastfeeding and checks episiotomy
• After few weeks health visitor will take over at home
• Specific clinics once a week for 6 weeks so can assess mother and baby health and developmental progress (e.g immunisations and weight)
• From 6 weeks to 5 years few visits every so often
• At 6 weeks mother has to visit GP to get her B.P, breast, abdomen, pelvis and abdomen examined as well as her mental health

Question 4

What are some changes that occur in the post-partum period?

Answer 4

• Lower genital tract may reduce is size, internal os will close and may be poorly lubricated all due to low oestrogen
• Haemotologically may have high white cell count and platelet
• Endocrine changes back to normal like thyroid and prolactin if not breast feeding
• CVS goes back to normal along with skeletal muscle and ligament laxity

Question 5

What is bleeding post-partum called and what is abnormal?

Answer 5

• Lochia
• Only 1 in 10 women still bleeding after 6 weeks but should get gradually lighter and should be no clots

Question 6

When does menstruation return after pregnancy?

Answer 6

• Usually by 6 weeks if not breast feeding but delayed by several months if breast feeding
• Discuss contraception with mother in health visits

Question 7

What are some mental feelings the mother may have after birth?

Answer 7

• Elation
• Protectiveness
• Anxiety
• Overwhelming responsibility
• Rejection of baby

Question 8

Label the following parts of the lactating breast.

Answer 8

• Lobules empty into ducts which then empties into the wider ampulla
• 15 - 20 lobules in each breast and each lobule is help by suspensory ligaments

Question 9

What are some common issues in post partum?

Answer 9

Question 10

What are some mental health issues that may arise in the post-partum period?

Answer 10

• Postnatal blues
• Post partum depression
• Puerperal Psychosis
• PTSD (1.5% of women)

Question 11

What are the characteristics of postnatal blues (baby blues)?

Answer 11

• Mother feels more tearful and anxious and this is norml for 2 weeks following delivery
• Usually peaks about day 4/5 and occurs in 85% of women
• Reassurance and support

Question 12

What are the characteristics of postpartum depression and how do we treat it?

Answer 12

• Occurs within 4 weeks of delivery with similar symptoms to depression
• 13% of women
• Management depends on severity but pharmacological treatments if symptoms great than a month

Question 13

What is puerperal psychosis?

Answer 13

• Within 4 weeks of delivery but rare psychological emergency
• 30% of cases are women with pre-existing mental illness
• Anxiety, mania, paranoid thoughts and delusions
• Suicide risk is 5% and infanticide risk is 4%
• Need specialist care

Question 14

What hormones stimulate the development of the breast in pregnancy?

Answer 14

• High levels of oestradiol and progesterone
• Gradual increase in prolactin and hPL

Question 15

What are the different classes of hormones that act on the breast?

Answer 15

Question 16

What is the let down reflex?

Answer 16

• Prolactin released from anterior pituitary when suckling stimulus. Suckling also inhibits dopamine to maintain milk production. Prolactin makes sure there is a store
• Oxytocin released on suckling that causes myoepithelial to contract and eject milk. GnRH also inhibited

Question 17

How does milk production change over time?

Answer 17

• Volumes initially low and colostrum produced with high fat and immunoglobulins
• When suckling continues more millk made, up to 800mk a day

Question 18

How does breast milk protect the baby from infection?

Answer 18

• Lactoferrin binds iron to stop e.coli
• Populates neonatal gut with non-pathogenic flora
• Bacteriocidal enzymes
• Contains specific immunoglobulins (IgA)
• Contains lymhocytes and granulocytes

Question 19

When would formula feeding be encouraged?

Answer 19

• Severe maternal illness
• Maternal HIV
• Medications that contraintradict breastfeeding

Question 20

What is puerperal mastitis?

Answer 20

• Milk accumulation in breast leads to inflammation, usually if mother doesn’t use a breast build up on lactiferous fucts
• If infection usually staph aureus and leads to abscess
• Continue feeding and use unused side. If not change in 24 hours give antibiotics
• Make sure you consider breast cancer

Question 21

How does lactation cease and how can we artificially cease it?

Answer 21

• Accumulation of milk in alveoli causes distension and atrophy of glandular epithelium
• Can give dopamine agonist like bromocriptine

Question 22

Why are women encouraged to think about contraception after birth?

Answer 22

• Ferility can return before first menstruation
• Reduces maternal and infant deaths
• Reduces risk of pre term birth and low birthweight babies

Question 23

Why may a woman not want to have sex after birth?

Answer 23

• Perineal trauma
• Dyspareunia due to low oestrogen
• Worried about being pregnant again
• Altered perception of body

Question 24

What hormones stimulate lactation?

Answer 24

• Decreased progesterone and oestrogen allow breast to be sensitive to prolactin
• Increased oxytocin and prolactin