Lecture 19: Post partum period Flashcards
What is puerperium?
Period from the delivery of the placenta to 6 weeks post natal
- period when the changes that occured as a result of pregnancy revert to the pre-pregnancy state
- period of great changes/modifications in lifestyle
- period of step-down of medical input if any was required during pregnancy
What is the post-natal care in the UK?
Midwives have responsibility to visit the woman and baby for a period of not less than 10 days, but can be for a longer period if midwife considers necessary (28 days)
What is the post-natal examination?
- six weeks postnatal examination by the GP or by the obstetrician if the antenatal period/delivery have been complicated
- by 6 weeks postpartum most of the pregnancy indcued changes in maternal physiology have returned to normal and it is an appropriate time for assessing mother-infant interaction
- requires assessment of mothers mental and physical health as well as feeding and behaviour of the baby
- direct questions about urinary, bowel and sexual function
- BP analysis, urinalysis, breast/abdo/plevic/perineal examination required
- cerivcal smear if required, and contraception discussed
What are the changes to the lower genital tract postpartum?
Secondary to low oestrogen levels
- reduction in size of vulva, vagina, cervix
- poor lubrication of vagina
- transformation zone of cervix withdraws into the endocervix
- internal os closes
- bleeding: initial heavy flow (lochia rubra), changes from red/brown to red/pink to white (lochia alba)
- passage of clots is not normal,except for the one passed on day3/4 postnatal
- enodmetrium regulates: if no lactation, new endometrium by 3 weeks and 1st period by 6 weeks, if lactating ovarian activity is suppressed so menses is delayed by several months
What are some general changes to the body postpartum?
- skeletal muscle: devarication of the recti (depends on pre-pregnancy laxity, level of physical activity, previous pregnancies)
- skeleton: ligament laxity resolves
- cardiovascular function: reversal
What are the psychological changes after giving birth?
- early puerperium: postnatal high
- satisfaction and increased closeness with her partner
- increased closeness to own mother
- feeling of protectiveness/love towards baby
- change in relationship with partner as they are now parents
What are some negative feelings postpartum?
- dissatisfaction, disappointment or distress over delivery process
- anxiety about baby
- rejection or ambivalence about the baby
- jealousy about the baby being the centre of attention
- fear of harming baby
- overwhelming responsibility
- resentment at loss of freedom
- physical discomfort and anxiety about physical damage during birth
How does haemtology change postpartum?
- Hb: diuresis causing reduced plasma volume and an increase in Hb level (no longer dilutional anaemia)
- white cell count: very high levels in imediate postpartum period, can persist for 8 weeks
- platelet count: rises rapidly back to non-pregnant values (dilutional)
- serum ferritin, transferrin and iron: return to normal levels (decreased at term)
- LFTs don’t change in pregnancy, but levels increase after delivery
- plasma levels of cholesterol and triglycerides: levels grossly elevated at term, fall slowly to normal over many months (irrespective of lactation)
- prolactin levels: remain elevated in lactating women, fall to usualy range in 2-3 wks in non-lactating women
- thyroxine levels: return to non-pregnant state by 6 weeks postpartum
How do you prepare for lactation?
- need progesterone and oestrogen to fall to support lactation (although there are high amounts of lactogenic hormones in pregnancy e.g. prolactin and placental lactogen, only minimal amounts of milk are formed due to the inhibitory effects of oestrogen and progesterone on prolactin)
- hypertrophy in pre-existing alveolar-lobular structures in the breast
- formation of new alveolae by budding from the milk ducts with proliferation of milk-collecting ducts
- prolactin is released by the action of suckling at a nipple that has become sensitive post delivery
What are prolactin levels dependent on?
Frequency and duration of suckling
-prolactin levels are at their highest in early puerperium and reduce slowly, only returning to normal after weaning
What is milk secretion dependent on?
Adequate emptying of the secreting glands
-accumulation of milk inside the alveoli will cause distension and atrophy of glandular epithelium
How is the breast milk delivered?
Oxytocin
- released in response to a variety of sensory inputs (suckling, see/hearing the baby)
- inhibited by emotional stress or anxiety
- causes the contraction of myoepithelial cell situiated around the alveolae causing them to contract and expel milk into the milk collecting ducts
- these milk collecting ducts have longitudinal muscle cells which are also stimulated causing them to dilate to improve the free flow of milk towards the nipple= leads to the ‘let down’ reflex
- causes positive feedback
What is the breast milk called as lactation is initiated?
Colostrum
-low volume
-high fat content, high in immunoglobulins
(as suckling continues, the amount of milk increases until, when fully established, 800ml per day is produced)
What is breast milk composed of?
- water
- protein
- carbohydrates/lactose
- fats
- antibodies
- hormones
- immune cells
- bacteria
- human milk oligosaccharides
- vitamins and minerals
What is the difference between the foremilk and the hindmilk?
Foremilk (emerges at start of suckling): higher water content
Hindmilk: higher in fats and iron
What are the functions of breast milk?
- nutrition
- lactoferrin binds iron, preventing the proliferation of E.Coli which is an iron dependent organism
- living lymphocytes, polymorphs and plasma cells are present which may play a part in cell mediated immunity in the neonate
- specific immunioglobulins are present
- bacteriocidal enzymes are present
How is the infant able to defend itself against endemic environmental pathogens?
Large amounts of immunoglobulins are present in breast milk
- immunoglobulin A passes into the infant gut where it remains
- it attaches to specific environmental pathogens to which it was produced in the mother
Should formula feeding be given to breastfed babies?
No, but sometimes it can’t be helped
Why would some mothers formula feed?
- severe maternal illness
- maternal HIV
- mother on medications that are contraindicated when breastfeeding
What are some breast problems?
- nipple sensitivity and pain (in first few days/week or so)
- engorgement (breasts become overly full)
- engorgement can lead to mastitis (inflammationof breast tissue that sometimes involves infection)
- breast abcess
- breast lumps (benign/malignant)
What are some problems of the puerperium?
- postpartum haemorrhage (PPH), primary/secondary
- retained placenta/placental tissue
- perineal trauma and sequelae e.g. loss of faecal continence
- puerperal pyrexia/sepsis: sources- genital tract, urinary tract, lactation ducts
- thromboembolic disease
- maternal collapse
- uterine inversion (uterus turns itself inside out)
- cardiac arrest
- domestic abuse/violence
- mental health problems
What is the 3rd leading cause of maternal death in the UK?
PPH
What are the different types of PPH?
Primary PPH: commonest, loss of >/= 500mls from genital tract within 24 hours of the birth of the baby (due to uterine atony: failure of the uterus to contract after delivery so open venous sinuses release blood/surgical loss)
Secondary PPH: abnormal/excessive bleeding from the genital tract between 24hrs-12 weeks
-can be associated with retained products/tissue and sepsis
How do we control PPH?
Haemostasis
- mechanical measures e.g.bimanula uterine compression
- pharmacologic measures e.g. syntocinon, ergometrine, carboprost
- surgical
