Post-partrum Period

Question 1

When is the post-partum period? What occurs during this time? What needs to be checked at the end of this period?

Answer 1

From delivery of the placenta to 6/52 postnatal

Changes that occurred due to pregnancy revert to pre-pregnancy state

Potential for problems

Midwife visits no less than 10 days post delivery and up to 28days as necessary

6 weeks postnatal examination by the GP or obstetrician if the antenatal period or delivery have been complicated (check urinary/ bowel/ sexual/ mental health/ feeding/ baby/ Bp/ urinalysis/ great/ abdo/ pelvic/ perineal/ cervical smear if due), contraception discussed

Question 2

What anatomical and physiological changes may have occurred after pregnancy in the lower genital tract?

Answer 2

Secondary to low oestrogen levels:

• reduction size vulva, vagina, cervix
• poor lubrication of vagina
• transformation zone of the cervix withdraws into the endodocervix
• internal os closed

Question 3

When and how does mensuration come back after pregnancy?

Answer 3

Initial heavy flow (lochia rubra)

Changes from red-brown to heavy red-pinky white (lochia alba)

Only 1/10 women still bleeding 6/52 post partum

Passage of clots is NOT normal except for the one passed on D3/4

If no lactation new endometrium by 3/52, 1st period due by 6/52
If lactation, ovarian activity suppressed therefore menses delayed by several months

Question 4

What changes occur to skeletal muscle post-partum?

Answer 4

Divarication of the rectus- abdominus resolves depending on pre-pregnancy laxity, parity, level of physical activity

Skeleton-ligament laxity resolves

Question 5

What changes occur to cardiovascular function post-partum?

Answer 5

Increased PR (by15bpm) at term and increased cardiac output reverses by 6/52

Question 6

What changes occur to haematology post-partum?

Answer 6

HEmoglobin: D3 usually characterised diuresis, reduction plasma volume and increase Hb at least 1g/Dl higher by 6 weeks postpartum irrespective of iron supplementation

White cell count: v high immediate postpartum - 25x10^9/ litre normal

Platelet count - rises flails back to non-pregnant levels (post operative/ caesarean May be high)

Serum ferritin/ transferrin/ iron: significantly decreased at term, irrespective iron supplementing but will return normal 5-8 weeks porstpartum

Question 7

What changes occur to endocrinology post-partum?

Answer 7

Gamma glut Arya transferase, aspartate transmainase and alanine transaminases: no significant changes in pregnancy, levels increase after delivery (especially post caesarean)

Plasma cholesterol/ triglycerides: grossly elevated at term, fall slowly to normal levels over many months

Prolactin: remain elevated in lactating women (58-178microgram) but fall normal by 2-3 weeks PP in non-lactating

Thyroxine: thyroid function should return to non-pregnant state by 6 weeks PP

Question 8

How does the onset and maintenance of lactation occur?

Answer 8

Progesterone, oestrogen, prolactin, growth hormone and adrenal steroids = hypertrophy in preexisting alveolar-lobular structures in breast + formation of new alveolae by budding from milk ducts with proliferation of milk-collecting ducts = pregnancy

Although high levels of lactienic hormones (prolactin and placental lactogen) in pregnancy minimal amounts of milk - oestrogen and progesterone inhibit

Suckling at now v sensitive nipple -> releases prolactin

‘Let down reflex’
suckling/ visual/ auditory baby stimuli -> Oxytocin (inhibited stress/ anxiety) - contraction of myoepithelial cells around alveolae -> contracting alveolae-> expel milk into milk collecting ducts (longitudinal muscle cells dilate)

Question 9

What occurs if milk accumulates inside alveoli?

Answer 9

Distension and atrophy of glandular epithelium -> poor milk secretion

Question 10

How does the volume and contents of lactation change during the feeding period and during a singular feed?

Answer 10

throughout feeding period: initiated - volumes low and colostrum produced (high fat/ immunoglobulins) -> milk increases -> max 800ml per day produced

Singular feed: foremilk higher water contents and hind milk higher fat and iron

Question 11

Components of breast milk compared to other mammalian milk

Answer 11

Lower salt 
Higher energy
Less protein 
More lactose 
More digestible to humans

Question 12

How does breast milk help protect the baby?

Answer 12

Protection:

• lactoferrin - binds iron preventing proliferation E.coli (iron dependent)
• non-pathogenic flora- encourages colonisation of neonatal gut competitively inhibit
• bacteriocidal enzymes
• lymphocytes/ polymorphs/ plasma cells - CMI
• immunoglobulins

Question 13

How are specific immunoglobulins made and passed to the baby in breast milk?

Answer 13

Specific environmental organisms -> mum’s peyer’s patches in gut -> immunoglobulins

E.g. Immunoglobulin A then -> thoracic duct + lymphatics -> breast milk -> infant gut -< attaches specific environmental pathogens to which it was produced in mum

Question 14

When should formula feeding be given?

Answer 14

Not unless chosen by mum or medically indicated e.g.

Severe maternal illness
Maternal HIV
Mothers meds contraindicated

Question 15

Breast problems that can occur

Answer 15

Nipples sensitivity and pain

Engorgement (overfilled fluid)

Mastitis (inflammation)

Breast abscess (collection of pus)

Breast lumps (benign/ malignant) - must always be investigated

Question 16

Problems of early puerperium

Answer 16

• postpartum haemorrhage - primary (straight away) or secondary (infection) _<500mls normal
• retained placenta/ placental tissue - (could prevent uterus contracting/ could lead to the above or infection)
• uterine inversion
• perineal trauma and sequelae
• maternal collapse
• cardiac arrest
• thromboembolic disease (3rd cause maternal death)
• puerperal pyrexia/ sepsis - sources: genital tract, urinary tract, lactation ducts
• domestic violence/ abuse

Question 17

Perinatal mental health (during pregnancy and first year after)

Answer 17

Postnatal blues peaks D4/5 self-limiting 85% not to be confused with

Postpartum depression - within 4/52 of delivery 13% women, risk recurrence 70%, if lasts >1/12 regarded major = pharmacological treatment

Question 18

How common is puerperal psychosis? Risks, symptoms

Answer 18

Rare but 30% occurs in women with ore-existing mental illness, recurrence 25%, usually 1st month of delivery, can be as early as D4

Suicide risk - 5%
Baby death - 4%

Symptoms: restless, anxiety, mania, paranoid thoughts, delusions

Leading cause direct maternal death pregnancy or up to one year after = suicide