Lactation and puerperium

Question 1

Definition of puerperium?

Answer 1

6 weeks after completion of labour

Question 2

Name 3 normal symptoms a woman might have in the puerperium

Answer 2

Afterbirth pains a few days after labour
Lochia - red/brown/mucus-y vaginal discharge up to 1 month after birth
Increased urination (need to lose fluid built up during preg)

Question 3

Name 5 components of breast milk

Answer 3

Fat
Sugar
Protein (including IgA antibodies)
Minerals
Enzymes, growth factors
Cellular material (leukocytes, antibodies)

Question 4

Name 5 benefits of breastfeeding to the baby

Answer 4

Nutrition
Reduced obesity and HT
Higher IQ
reduced SIDS (can’t overfeed and aspirate and die)
Decreased NEC in preterm
Decreased immunological disease (atopy, infection)

Question 5

Name 3 benefits of breastfeeding to the mother

Answer 5

Faster return to pre-pregnancy weight
Oxytocin release = faster involution of uterus, less blood loss
Reduction in breast and ovarian cancer
Contraception
Economic AND environmental benefits (!!!)

Question 6

What are the WHO guidelines for breastfeeding?

Answer 6

Exclusive breastfeeding for first 6 months

Question 7

Name 2 contraindications for breasteeding

Answer 7

HIV
Antineoplastic agents (cross into breastmilk)

Question 8

Name 3 non-pharmacological strategies to improve breast feeding

Answer 8

Antenatal education
Early breast feeding after delivery
Demand feeding
Avoid supplemental feeds and dummies
Encourage rooming in

Question 9

Go through the physiology of lactation (in terms of breast enlargement, milk production and release, and maintenance of production)

Answer 9

Hormones during pregnancy = breast enlargement (oestrogen, progesterone, prolactin, HPL). Fall in progesterone after delivery = allows release of milk driven by oxytocin release upon suckling. Feeding increases prolactin and oxytocin = more milk production (+ve feedback cycle)

Question 10

What is the name of the fluid that is released in the first few days of breastfeeding? What is it enriched in? When does normal breastmilk start to be released?

Answer 10

Colostrum - rich in Igs. Normal milk usually released by 3-4 days after birth

Question 11

Name 5 common breastfeeding problems

Answer 11

Engorgement (filling of breasts with milk) - is normal, but can be painful so women don’t breastfeed
Low supply
Sore nipples (babies suck hard)
Mastitis
Blocked ducts (infection, surgery - breast implants)

Question 12

Name 3 behaviours of a baby that suggests the mother may have low supply

Answer 12

Baby feeds more often but takes less time in each feed
Baby swaps between breasts a lot
Unsettled baby, settles better on formula
Growth slows after 3 months

Question 13

What is mastitis? Name 3 signs of mastitis. If a woman has mastitis, should she keep breastfeeding or stop?

Answer 13

Mastitis = blocked duct leading to infection of breast tissue.

Indurated, painful area around nipple +/- fever, swelling (could be breast abscess)

She should keep breastfeeding - helps rid the infection

Question 14

What is the usual management of a well, post-partum woman depending on her mode of delivery, in terms of length of stay, and monitoring?

Answer 14

Vaginal - 2 days inpatient
LUSCS - 4 days inpatient

Monitor for general appearance, vitals, uterus involution (palpation, lochia), wound appearance, urinary and bowel function, breast nipple symptoms and signs, allied health review

Question 15

Name 5 postpartal complications

Answer 15

Postpartum sepsis (endometritis, wound infection, mastitis, UTIs) - T > 38 24 hrs after delivery. Often caused by infection of uterus or retained POC
Postpartum depression
Genital tract trauma
C/S complications

Question 16

What hormonal contraception can you offer a woman breastfeeding? What can’t you offer and why?

Answer 16

Can offer progesterone-only medications; combined OCP = reduced milk production, and can cross milk into baby

Question 17

When would you recommend a woman recommence other forms of contraception after she stops breastfeeding?

Answer 17

21 days after cessation - ovulation takes minimum 25 days to recommence after breastfeeding

Question 18

Name 3 risk factors for postpartum sepsis

Answer 18

PROM
Instrumentation (forceps, ventouse, catheters)
C/S
Trauma during delivery (lacerations)
Prolonged labour
PPH

Question 19

What is a non-infectious case of postpartum pyrexia?

Answer 19

VTE

Question 20

Name 2 common causes of secondary PPH. When after birth does it usually happen?

Answer 20

Infection, retained POC

Often happens in 2nd week postpartum

Question 21

Name 3 signs of secondary PPH on examination

Answer 21

Uterine enlargement/tenderness
Fever/tachycardia
Blood, necrotic placenta in cervix
Cervical dilatation
Purulent discharge

Question 22

Name 3 aspects of management of secondary PPH

Answer 22

Restore haemodynamic status - give fluid, blood, correct coagulation deficits
Get rid of cause of bleeding - antibiotics, uterotonics or D&C, embolisation
If really bad - hysterectomy

Question 23

Name 3 ways to prevent secondary PPH

Answer 23

Active management of 3rd stage
Careful inspection of placenta
Antibiotics during labour if woman at risk of endometritis

Question 24

What is the difference between postpartum blues and postpartum depression?

Answer 24

Postpartum blues - affects 80% women, usually a few days after pregnancy, become emotionally labile

Postpartum depression - happens later (weeks after pregnancy), symptoms are worse and affect quality of life

Question 25

Name the 4 degrees of perineal lacerations

Answer 25

First degree - lac of vag mucosa
Second - vag mucosa + perineal skin or body
3rd - vag mucosa, perineal body + external anal sphincter
4th - vag mucosa, perineal body, external anal sphincter + anal canal or rectal mucosa

Question 26

Name 2 short term and long term consequences of genital tract trauma

Answer 26

Short term - pain, wound infection, anaemia

Long term - dyspareunia, anal incontinence

Question 27

Name 5 complications of a C/S

Answer 27

Anaesthetic - aspiration, hypotension, spinal headache
Bleeding - uterine atony, placenta praevia/accreta in next preg, laceration
Endomyometritis
Wound infection
General post-op comps: atelectasis, ileus, UTI, VTE