Normal puerperium

Question 1

Discuss physiological changes postpartum of endocrine and haematological system
-Hb
-WCC
-Platelets
-Ferritin
-Prolactin
-Thyroid
-Cholesterol and triglycerides

Answer 1

1. Haemaglobin
   -diuresis D3 causes drop in plasma volume and increase in Hb
   -Increase in Hb by 6/52
2. WCC
   -Raised PP up to 25 is WNL. Can last 6-8/52
3. Platelets
   -Rise rapidly to pre-pregnancy levels
4. Ferritin
   -Returns to normal 5-8/52 PP irrespective of Fe supplementation
5. Prolactin
   -Increased if breast feeding but if not returns to normal weeks 2-3
6. Thyroid
   -Returns to normal v=by week 6 PP
7. Cholesterol and triglycerides
   -Elevated at term and slow normalisation over months

Question 2

Discuss postpartum physiological changes for the following systems
-Cardiac (1)
-Respiratory (1)
-GIT (1)
-MSK (2)

Answer 2

1. Cardiac output and HR return to normal by 6 weeks PP
2. Respiratory system
   -Functional residual capacity returns to normal by 2 weeks
   -Tidal volume returns to normal over 6-8 weeks
3. GIT
   -Gastric emptying returns to normal day 2-3 postpartum
4. MSK
   -Ligament laxity resolves as progesterone and relaxin levels drop
   -Devarication of the rectus muscle is common and resolution depends on many factors

Question 3

Discuss the postpartum physiological changes to
-The uterus (2)
-The lower genital tract (4)

Answer 3

1. The uterus
   -Uterine involution occurs secondary to muscle contraction and autolysis of the myometrium
   -Fundus should not be palpable above the SP by 2 weeks PP
2. Lower genital tract
   Drop in oestrogen results in:
   -Atrophy of the lower genital tract
   -Decrease in size of the vulva, vagina and cervix
   -Decreased vaginal and cervical secretions
   -Internal os closed by 48hrs PP

Question 4

Discuss lochia
-Types of lochia
-Pattern of lochia
-Timing of development of new endometrium

Answer 4

1. Types of lochia
   Lochia Rubra
   -Dark red blood like a heavy period
   -From birth till D4 PP
   Lochia Serosa
   -Pinkish brown light/moderate flow
   -From 4 to 2 weeks PP
   Lochia Alba
   -Scanty creamy whitish DC
   -From 2 weeks to 3 weeks PP
2. Timing of endometrium regeneration
   -If not breast feeding then fully regenerated in 3 weeks PP

Question 5

Discuss birth spacing
-Definition of interpregnancy interval
-Definition of birth-to-birth interval
-Definition of birth to conception interval
-WHO recommendations for birth spacing

Answer 5

1. Interpregnancy interval - time a woman is not pregnant from last live birth/ pregnancy loss to next pregnancy
2. Birth -to birth interval - time between a live birth and subsequent live birth
3. Birth to conception interval - time between a live birth and the start of the next pregnancy
4. WHO recommendations:
   -24 months after a live birth
   - 6 months after a miscarriage

Question 6

What are the risks associated with a short birth interpregnancy interval (9)

Answer 6

-Maternal anaemia (30% increase if <6/12)
-PTB OR 1.2 if <6/12
-PPROM if <18/12
-Congenital abnormalities if <6/12
-LBW 60% increase
-SGA <10% 10-15% increase if <6/12
-Autism, ADHD, schizophrenia 3.4 times higher if <6/12
-Still birth if <6/12
-Uterine rupture with VBAC