8 - the post partum period Flashcards
when is the post-partum period?
delivery of the placenta to six weeks
is this period characterised by low or high oestrogen levels?
LOW
describe the lactating breast
- series of secretory lobules
- empty into ductules
- ductules combine into a duct which widens at the ampulla
- lactiferous duct carries the secretions to the outside
what are the common problems that can occur during the post partum period?
HAEMORRHAGE
+ primary - baby born up to 24 hrs after
+ secondary - 2/3 weeks later
RETAINED PLACENTA
UTERINE INVERSION
+ obstetric emergency
PERINEAL TRAUMA
+ bruises/ tears
+ sequelae
MATERNAL COLLAPSE
+ amniotic fluid embolism
+ hypoglycaemia
+ hypotension
CARDIAC ARREST + THROMBOEMBOLIC DISEASE
+ risk factors: obesity, just having a baby, surgery, immobility
PYREXIA/ SEPSIS
+ genital tract, urinary tract or lactation ducts
name the hormones involved in the full development of breasts during pregnancy
- oestradiol
- progesterone
- prolactin
- human placental lactogen (hPL)
describe the nature of the hormones that affect the breast
MAMMOGENIC
- promote proliferation of alveolar and duct cells
LACTOGENIC
- promote initiation of milk production
GALACTOKINETIC
- promote contraction of myoepithelial cells
GALACTOPOIETIC
- maintain milk production
what is prolactin and what does it do?
- essential for milk production
- suckling in a powerful stimulus
- it is inhibited by dopamine
- suckling inhibits dopamine - so prolactin increases
what is postpartum haemorrhage?
if inadequate uterine contraction occurs during delivery. emergency!
describe the control of milk let down by oxytocin
- oxytocin is released in response to a variety of sensory inputs (suckling, seeing or hearing the baby) inhibited by stress and anxiety
- there is a 90 minute cycle of ‘let down’ irrespective of suckling as oxytocin is released in a pulsatile manner from the pituitary
- neurones from the spinal cord also stimulate oxytocin release, causing myoepithelial cells to contract and eject milk - “let-down”
- neurones in arcuate nucleus and preoptic area of hypothalamus are inhibited so levels of GnRH fall
- leads to inhibition of the ovarian cycle
how does milk volume change over time?
initially low - called colostrum (high fat and immunoglobulin)
later - 800ml/day
how does breast milk protect the baby from infection?
- contains lactoferrin (bactericidal properties)
- populates neonatal gut with non-pathogenic flora
- presence of bacteriocidal enzymes
- contains specific immunoglobulins
- contains lymphocytes (mainly T cells) and granulocytes that play a role in cell meddiated immunity
what is puerperal mastitis?
when milk accumulates in the breast and can lead to inflammation with or without infection
usually if mother does not breastfeed with both breasts and so milk can build up in the seminiferous ducts of the unused breast
usually staph aureus - can form abscess
treatment: continue feeding and increase frequency esp on affected side
abx if not
describe the mechanisms which produce cessation of lactation
local mechanical factors suppress milk, not hormonal!
once lactation ceases, milk accumulates in the alveoli of the breast causing distention and atrophy of the glandular epithelium
describe the mental health issues that can arise in the post-partum period
POSTNATAL BLUES
- altered mood due to hormonal changes
- tearful anxious
- normal up to 2 weeks following delivery - peaks at day 4/5
- management: reasurrance and support
POST PARTUM DEPRESSION
- usually within 4 weeks of delivery
- psychological treatment considered if more than 4 weeks
PUERPERAL PSYCHOSIS
- usually within 4 weeks
- psychiatric emergency
- 30% of those with pre-existing mental illness
- anxiety, mania, paranoid thoughts, delusions, suicide risk, infanticide risk
- specialist care are
PTSD
- psychological therpaies
list the anatomical and physiological changes that occur in the post partum period
- LOWER GI TRACT (due to low oestrogen)
- reduction in size of vulva, vagina and cervix
- poor lubrication of vagina
- transformation zone of cervix withdraws
- internal os is closed
- BLEEDING
- red-brown/ red-pink heavy white
- pasage of clots not normal except the one on D3/4
ENODMETRIUM REGULATION
- if no lactation - new endometrium by 3/52
- 1st period by 6/52
- if lactating ovarian activity suppressed - menses delayed by months
SKELETAL MUSCLE
- devarication of recti resolves
SKELETON
- ligament laxity resolves
CARDIOVASCULAR FUNCTION
- increased PR and increased CO reverses by 6/52
