L18: the postpartum period Flashcards
When is the post-partum period?
Defined as the period from the delivery of the placenta to six weeks after this
During this time, the body returns to a pre-pregnancy state
How is a new mum looked after?
Post-natal care is provided at home initially by the community midwife
Mothers are encouraged to attend specific clinics locally with their babies, so health visitors can offer support to the mother and assess baby’s health and developmental progress (continues until age 5)
Post-natal examinations are performed at six weeks at the mother’s GP – physical health, mental health & discussion about adjustment to motherhood
Describe the changes that occur in the post-partum period
Period is characterised by low oestrogen levels
Bleeding post-partum (lochia) gradually reduces, with only 1 in 10 still bleeding at six weeks
Menstruations usually returns by the 6th week if not breast feeding
This period is marked by profound psychological changes which may include elation, protectiveness, anxiety, overwhelming responsibility & even rejection of baby
Describe the anatomy of the lactating breast
Consists of a series of secretory lobules, which empty into ductules
These ductules from 15-20 lobules combine into a duct, which widens at the ampulla
The lactiferous duct carries the secretions to the outside
What is postpartum haemorrhage?
Inadequate uterine contraction after delivery can cause PPH
Obstetric emergency & needs urgent management to prevent major blood loss and cardiovascular shock
Secondary haemorrhage (24 hours-6 weeks later) can occur, which typically presents in primary care as prolonged or excessive once the mother has returned home -> typically caused by infection and/or retained products of conception
Causes of PPH: tone (atony), tissue (retained placenta), thrombin (clotting disorder) & trauma
List some common problems of postpartum period
1) Haemorrhage
2) Retained placenta/placental tissue
3) Uterine inversion
4) Perineal trauma
5) Maternal collapse/cardiac arrest
6) Thromboembolic disease
7) Pyrexia/sepsis
8) Mental health problems
Describe postnatal blues
Common after delivery
Refers to the altered mood experienced due to the hormonal changes that have occurred
Mother typically feels more tearful/anxious, and is considered normal up to two weeks following delivery
Usually peaks at day 4/5 & occurs in 85% of women – managed by reassurance and support
Describe postpartum depression
Usually occurs within 4 weeks of delivery, with similar symptoms to depression outside pregnancy
Important to ask about as mothers may feel reluctant to share how they are feeling
Management – depends on the severity & pharmacological treatments can be started if the symptoms are lasting > 1 month
Describe puerperal psychosis
Usually occurs within 4 weeks of delivery
Rare, but considered a psychiatric emergency
30% of cases occur in women with pre-existing mental illness
Severe symptoms: anxiety, mania, paranoid thoughts & delusions
Management: specialist care and is primarily pharmacological
Describe post-traumatic stress disorder
Occurs in 1.5% of women
Managed using psychological therapies
Describe the hormones which affect the breast
During pregnancy, under the influence of high levels of oestradiol and progesterone & gradual increase in levels of prolactin and human placental lactogen, full development of the breasts occurs
Hormones which affect the breast are:
1) Mammogenic – promote proliferation of alveolar and duct cells
2) Lactogenic – promote initiation of milk production
3) Galactokinetic – promote contraction of myoepithelial cells
4) Galactopoietic – maintain milk production
Describe the role of prolactin in lactation
Essential for milk production and suckling is a powerful stimulus for its release
Suckling stimulates neurones from the spinal cord to inhibit dopamine release, and the levels of prolactin therefore increase
Leads to stimulation of milk production by the breast
Suckling thus maintains milk production
Describe the role of oxytocin in lactation
Neurones from the spinal cord stimulate oxytocin release, which causes myoepithelial cells to contract and eject milk – the ‘let down’ reflex
Neurones in the arcuate nucleus & preoptic area of the hypothalamus are inhibited -> levels of GnRH fall
Leads to inhibition of the ovarian cycle
Initially milk volumes are low, and colostrum is produced, which contains high amounts of fat and immunoglobulins; as milk production is established – content changes and approx. 800ml of milk per day is produced
List ways breast milk protects the baby from infection
1) Lactoferrin
2) Populates neonatal gut with non-pathogenic flora
3) Prescence of bactericidal enzymes
4) Contains specific immunoglobulins
5) Contains lymphocytes and granulocytes that play a role in cell-mediated immunity
What is puerperal mastitis?
Condition where milk accumulation in the breast can lead to inflammation, with or without infection
Typically occurs if the mother does not breastfeed with both breasts & therefore milk can build up in the lactiferous ducts of the unused breast
If infection is present, usually caused by staph aureus & can lead to abscess formation
First line treatment – continue feeding, antibiotics can then be given after 24 hours if no improvement
