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Reproductive system > Lecture 21- The postpartum period > Flashcards

Lecture 21- The postpartum period Flashcards

1
Q

when is the postpartum period

A

from the delivery of the placenta to the 6th week postnatally (6/52)

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2
Q

features of the postpartum period

A
  • The period when the changes that occurred as a result of pregnancy revert to the pre-pregnancy state
  • A period of great change in lifestyle psychology, activities, relationships, responsibility
  • Period of stepdown of medical input
  • Potential for problems to occur
  • Period of continued optimal management of any pre-existing medial conditions
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3
Q

Post-natal care

A
  • Midwives have a statutory responsibly to visit the women and her baby at home as required
    • For a period of not less than 10 days post delivery
    • But can lost longer than 28 days
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4
Q

at 6 weeks post partum

A

GP exam (or obestetrician if antenatal period or delivery is complicated)

  • Most pregnancy induced changes in maternal physiology have returned to normal and appropriate time for assessing mother infant interact
  • Requires assessment of women’s mental and physical health as well as feeding and behaviour of the baby
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5
Q

features of the 6 week check up

A
  • Questions and exam
    • Urinary
    • Bowel
    • Sexual function
      • Dyspareunia or anxiety about sexual intercourse are issue women will not disclose voluntarily
    • Blood pressure
    • Urinalysis
    • General breast abdominal and pelvic/ perineal exam
  • Importance of post natal care
    • Contraception discussed-
    • Cervical smear if require
    • Excellent opportunity to discuss adjustment to parenthood and any anxieties
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6
Q

bleeding in the days/week following labour

A
  • Bleeding initial heavy flow (lochia rubra)
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7
Q

lochia rubra changes from

A

red-brown/red-pink –> heavy white (lochia alba)

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8
Q

what is not normal in bleeding after birth

A

clots

  • except those passed on D3/4
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9
Q

anatomical changes to the lower genital tract after labour

A
  • Changes secondary to low oestrogen levels
    • Reduction in size of vulva, vagina and cervix
    • Poor lubrication of vagina
    • Transformation zone of the cervix withdraws in the endocervix
    • Internal os is closed
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10
Q

what regulates lactation

A

endometrium

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11
Q
  • If no lactation
A

,new endometrium by 3rd week, 1st period due by 6 weeks

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12
Q
  • If lactation,
A

ovarian activity suppressed, therefore menses delayed by several months

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13
Q

skeletal changes in post partum period

A
  • Divarication of the recti, resolves depending on pre-pregnancy laxity, parity, level of physical activity
  • Ligament laxity resolves
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14
Q

cardiovascular changes in pregnancy

A
  • Reversal of pregnancy changes by 6 weeks
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15
Q

psychology in post partum period- positive feelings

A
  • Earl puerperium- hours after birth – postnatal ‘high’
  • A degree of elation is normal , esp if women satisfied with birth experience
    • Satisfaction
      • Closeness to partner
      • To mother
      • Feeling of falling in love with baby
      • Protectiveness towards the baby
      • Changes relationship with partner
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16
Q

psychology in post partum period- negative feelings

A
  • Dissatisfaction with delivery process
  • Anxiety about the baby
  • Rejection or ambivalence about the baby
  • Jealousy about the baby being the centre of attention
  • Fears of harming the baby
  • Physical discomfort and anxiety about physical damage during birth
  • Overwhelming responsibility
  • Resentment at loss of freedom
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17
Q

postpartum haemoglobin

A

day 3 post partum usually characterised by

  • diuresiis, a reduction in plasma volume and increase in Hb levels
  • Hb normally at least 1.0 g/Dl higher by six weeks postpartum, irrespective of iron supplementation
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18
Q

postpartum WBC

A
  • very high levels in the immediate post partum period
  • pregnnancy related changes are still present 6-8 weeks after delivery
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19
Q

postpartum platelet count

A
  • usually rises rapdily back to non pregnant values
  • after operative or caesarean delivery it may rise to high levels
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20
Q

postpartum ferritin, transferrin and iron

A

levels all signif decreased at term, irrespective of iron supplementation

  • will return to normal levels by 5-8 weeks postpartum, irrespective of iron supplementation
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21
Q

postpartum glutaryl transferase, aspartate transmainase and alanine transaminases

A
  • no signif changes in pregnancy
  • levels all icnrease after delivery, esp after caesarean section
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22
Q

plasma level of choelsterol and reiglycerises

A
  • levels grossly elevated at term
  • only fall slowly to normal non-pregnant levels over many months
  • irrespective of lactatio
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23
Q

prolactin levels

A
  • remain eleevated in lactating women postpartum
  • fall into the usual non pregnant range by 2-3 weks postpartum in lon-lactating women
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24
Q

thyroxine level

A

should return to the non-pregnant state by 6 weeks postpartum

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25
Q

hormonal preparation for lactation

A
  • Progesterone and oestrogen will fall in order for prolactin to increase- supporting lactation
  • Growth factor and adrenal steroids needed for hypertrophy of the breast
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26
Q

formation of breast tissue able to lactate

A
  • 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
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27
Q
  • Although there are high level of lactogenic hormones (prolactin and placental lactogen) in pregnancy, only minimal amounts of milk are formed, because
A

oestrogen and progesterone inhibit their effect

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28
Q

what stimulates the release of prolactin after birth

A
  • Prolactin is released by the action of suckling at a nipple that has become exquisitely sensitive post delivery
29
Q
  • Prolactin levels and milk production are dependent on the frequency and duration of
A

suckling.

30
Q

Prolactin levels are at their highest in the

A

early puerperium and reduce slowly, only returning to normal after weaning.

31
Q
  • Milk secretion is also dependent on adequate
A

emptying of the secreting glands. Accumulation of milk inside the alveoli will cause distention and atrophy of the glandular epithelium.

32
Q
  • Therefore, adequate milk secretion requires an
A

intact neuroendocrine axis and adequate emptying of the breast with infant feeding.

33
Q

hormone responsible fordelivery of breast milk

A

oxytocin

34
Q

oxytocin in release in response ot a variety of sensory inputs

A

. suckling, seeing or hearing the baby

35
Q

what will inhibit oxytocin release

A
  • Readily inhibited by emotional stress or anxiety.
36
Q
A
37
Q

oxyctin affect on breast tissue

A
  • Contraction of the myoepithelial cells situated around the alveolae to cause them to contract and expel the milk into the milk-collecting ducts.
  • These milk-collecting ducts have longitudinal muscle cells, which are also stimulated, causing them to dilate and improve the free flow of milk towards the nipple along these dilated ducts. This leads to the ‘let down’ reflex
  • There also seems to be a 90 minute cycle of ‘let down’ irrespective of suckling, because oxytocin is released in a pulsatile manner from the pituitary.
38
Q

what is the first breast milk called

A

colostrum

39
Q

colostrum

A
  • high fat content, high in
  • immunoglobulins.
40
Q
  • As suckling continues, the amount of milk
A

increases until, when fully established, approximately 800 ml per day are produced

41
Q

composition of breast milk

A
  • Human milk differs from other mammalian milk.
  • much lower salt content
  • has a higher energy content
  • has less protein
  • has more lactose
  • is more digestible by the human baby.
42
Q

constituents of breast milk vary

A
  • Even more interestingly, constituents differ in early rather than late lactation, vary from feed to feed, and even from the beginning to the end of a feed.
43
Q

The so-called ‘foremilk’ that emerges at the start of suckling has a

A

higher water content.

44
Q

The ‘hind milk’ is higher in

A

fats and iron.

45
Q

functions of breast milk

A
  • protection from infections
  • nutrients
  • hydration
46
Q

how does breast milk protect the infant from infection

A
  • lactoferrin
  • bacteriocidal enzymes
  • living lymohocytes, polymorphs and plasma cells (cell meidated immunity)
  • IgA
47
Q
  • Lactoferrin in breast milk
A
  • binds iron, preventing the proliferation of E.coli, which is an iron-dependent organism
  • encourages colonisation of the neonatal gut by non- pathogenic flora, which competitively inhibit pathogenic strains
48
Q

IMMUNOGLOBULINS

*

A
  • Are present in large amounts in breast milk
  • The immunoglobulin A formed passes into the infant gut where it remains. It attaches to the specific environmental pathogens to which it was produced in the mother and thus the infant is enabled to defend itself against endemic environmental pathogens.
49
Q

formula feeding

A
  • Unless chosen by a woman herself or medically indicated – should not be given to breastfed babies
  • Medical indications include:
    • Severe maternal illness
    • Maternal HIV
    • Mothers on medications that are contraindicated when breastfeeding
50
Q

BREAST PROBLEMS

A
  • Nipple sensitivity and pain
  • Engorgement
  • Mastitis
  • Breast abscess
  • Breast lumps- benign or malignant
51
Q

Breast lumps- benign or malignant

A
  • Breast lump must always be investigated
  • Self-examination- outside menstruation
  • If malignant- requires prompt treatment, surgery+/- radiotherapy, expert oncology care
52
Q

Problems of the puerperium

A
  • Post partum haemorrhage (PPH)- primary or secondary
  • Retained placenta/placenta; tissue
  • Uterine inversion
  • Perineal trauma and sequelae
  • Maternal collapse
  • Cardiac arrest
  • Thromboembolic disease
  • Puerperal pyrexia/sepsis- source: genital tract, urinary tract and lactation ducts
  • Domestic violence/abuse
  • Mental health problems
53
Q

post partum haemorrhage is the

A

3rd leading cause of maternal death in the UK

54
Q

primary PPH

A
  • Commonest
  • Loss of >500mls from the genital tract within 24hrs of the birth of a baby
  • Could be due to atony or surgical loss
55
Q

secondary PPH

A
56
Q

medical intervention: haemostasis

A
  • Abnormal/excessive bleeding from the genital tract between 24hrs- 12/52 weeks post natally
  • Can be associated with retained products/tissue and sepsis
57
Q

Venous thrombosis and thromboembolism (VTE)

A
  • Leading cause of direct maternal death
58
Q

when is the highest risk of venous thromboses

A
  • Post-partum period = time of highest risk
59
Q
  • Deep vein thrombosis (DVT), 1 in
A

700 post partum period

60
Q

most important conseuqence of DVT

A

pulmonary embolism

  • Mat. Mortality, <1%if treated early, > 80%if left untreated
61
Q

DVT managed by

A
  • assessing risk factors, taking preventative measures and then prompt diagnosis.
  • Treatment is with anti-coagulation- heparin, warfarin, new anti-coagulants
62
Q

Sexuality and sexual function

A
  • Last thing on her mind (usually!)…or not
  • Altered perception of body and changes due to pregnancy
  • Worried about getting pregnant again
  • Perineal trauma
  • Dyspareunia due to low oestrogen and other causes
  • Handling these and relationship with her partner (all while caring for a new born!)
63
Q

perinatal mental health

A
  • Postnatal blues (baby blues)
  • Postnatal blues (baby blues)
  • Puerperal psychosis is rare but 30% occurs in women in women with pre-existing mental illness
  • PTSD usually due to events around the birth
64
Q
  • Postnatal blues (baby blues)
A
  • Peak D4-5
    • Self limiting in 85% of women
    • Managed by reassurance and support
    • If symptoms occur within 4/52 of delivery
    • Symptoms are similar to depression outside pregnancy
65
Q
  • Postnatal blues (baby blues)
A

*

66
Q
  • Puerperal psychosis
A

is rare but 30% occurs in women in women with pre-existing mental illness

67
Q

CONTRACEPTION

A

Childbirth presents an opportunity for providing contraception at a time when women are attending a service staffed by healthcare providers with the skills to offer a full range of methods and when women may be highly motivated to start using an effective method

68
Q

contraception can

A
  • Can save mothers’ lives – family planning can prevent more than one-third of maternal deaths
  • can also save babies’ lives –can prevent 1 in 10 deaths among babies if couples space their pregnancies more than 2 years apart
69
Q
  • The timing of the return of fertility after childbirth is
A

variable and unpredictable.

Reproductive system (28 decks)

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