Post Partum Flashcards
Define post partum period
Period from delivery of placenta to 6 weeks after during which the mother’s body returns to a pre pregnancy state
Describe the post natal examination
- at 6 weeks
- most pregnancy induced changes have returned to normal
- assessment of woman’s mental + physical health as well as feeding + behaviour of baby
- direct questions about urinary, bowel + sexual function
- BP, urinalysis, breast, abdominal + pelvic exam
What changes occur to the lower genital tract during the post partum period?
Due to low oestrogen levels:
- vulva, vagina + cervix return to original size
- poor lubrication of vagina
- transformation zone of cervix withdraws into endocervix
- internal os is closed
What changes occur in regards to bleeding in the post partum period?
- bleeding is initially heavy + reduces gradually
- bleeding normally stops by 6th week
- passage of clots is not normal
Positive psychological feelings post partum
- gradual falling in love with baby
- increased closeness to partner (parents now too)
- increased closeness to own mother
- protective feeling towards baby
Negative psychological feelings post partum
- distress over delivery process
- anxiety
- jealous of baby being centre of attention
- fears of harming baby
- overwhelming responsibility
- resentment of loss of freedom
Types of hormones which affect the breast + their role
- mammogenic: promote proliferation of alveolar + duct cells
- lactogenic: promote initiation of milk production
- galactokinetic: promote contraction of myoepithelial cells
- galactopoietic: maintain milk production
What hormones are involved in the full development of breasts during pregnancy?
High levels of oestradiol + progesterone
Gradual increase in levels of prolactin + human placental lactogen
Where is prolactin released from?
Anterior pituitary
Describe the release of prolactin + milk production
- suckling stimulates neurons from spinal cord inhibits dopamine release
- prolactin released by anterior pituitary
- leads to stimulation of milk production by breast
- suckling maintains milk production
What does adequate milk secretion require?
- Intact neuroendocrine axis
- Adequate emptying of breast with infant feeding
Describe the delivery of breast milk
- oxytocin released in response to suckling, seeing/hearing baby
- causes myoepithelial cells to contract
- milk is expelled into milk collecting duct
- ‘let down reflex’
What is oxytocin release inhibited by?
Emotional stress
Anxiety
Positive feedback loop of breast feeding
- baby suckles at breast
- stimulates hypothalamus
- oxytocin released from posterior pituitary
- oxytocin stimulates mammary glands
- more milk produces
- repeats
Where is oxytocin produced + released from?
Produced in hypothalamus
Released by posterior pituitary
How does breast milk volume change over time?
- initially milk volumes are low
- colostrum is produced (high fat + immunoglobins)
- as suckling continues, milk volume increases to ~ 800ml per day
How does the breast milk protect the baby from infection?
- lactoferrin: prevents proliferation of E. coli
- populates neonatal gut with non-pathogenic flora
- presence of bacteriocidal enzymes
- immunoglobins
- T lymphocytes + granulocytes
How does lactoferrin from breast milk protect the baby?
Bind iron which prevents proliferation of E. coli (iron dependent organism)
Types of post partum haemorrhage
- primary: loss of >500ml from genital tract within 24 hours post birth
- secondary: excessibe bleeding from genital tract between 24 hours to 6 weeks post birth
What are the 4 Ts of primary PPH?
- tone: inadequate uterine tone (most common)
- trauma: laceration e.g. tears or episiotomies
- tissue: retained placental tissue
- thrombin: hypocoagulability
How can uterine atony cause primary PPH?
- normally, uterine walls contract to cut off blood supply to placenta
- insufficient tone of muscles > placenta is delivered without cut off blood supply > vessels bleed freely
Causes of secondary PPH
Retained tissue
Endometriosis
Causes of maternal collapse
What can this cause?
- Hypovolaemia after PPH
- Hypoglycaemia
- Amniotic fluid embolism
(Can cause cardiac arrest)
Describe the structure of the breast
- made up of secretory lobules which empty into ductules which converge into mammary ducts
-
ampulla acts as temporary storage of milk until
lactiferous duct secretes milk out of
What problems can occur during the post partum period?
- PPH
- DVT + PE
- retained placental tissue
- perineal trauma
- sepsis
- maternal collapse
- cardiac arrest
- domestic abuse
- mental health issues
Why can breast feeding prevent ovulation?
- high levels of prolactin can disrupt the HPG axis by suppressing GnRH secretion
- low levels of FSH + LH > disrupts ovulatory cycle
What is mastitis?
Inflammation of breast tissue
What is mastitis caused by?
- Infection (staph aureus) entering through skin break
- or due to stasis of milk in breast
Treatment of mastitis
- warm compress
- continue breastfeeding to relieve pressure
What are the post natal baby blues?
- mild depression after birth due to hormonal changes as body returns to non pregnancy state
- feeling tearful, irritable, anxiety
- normally self limiting (<14 days) but provide support + reassurance
What is post natal depression?
Depression symptoms within 4 weeks of delivery, lasting for months
Treatment of post natal depression
- self help
- medications e.g. antidepressants
- support + reassurance
What is puerperal psychosis?
- rare syndrome of anxiety, paranoia, mania + delusions developing within 4 weeks post birth
- psychiatric emergency - high rate of maternal suicide or infanticide
Benefits of preventing unwanted pregnancy in post partum period
- helps improve maternal mental health
- reduces risk of preterm labour
- reduces risk of low weight baby
- reduces risk of maternal anaemia
As allows mother time to reset after birth
Why may breastfeeding mothers go longer without a period than a mother who isnt?
High levels of prolactin inhibit FSH > no egg can be matured
What is the perineum?
The portion of skin between her vagina and anus
What organism most commonly causes mastitis?
Why?
- Staphylococcus aureus
- common skin commensals which can enter breast tissue through crack on nipple
What is the most common cause of primary PPH?
Uterine atony
Medical indications of formula feeding
- severe maternal illness
- maternal HIV
- mothers on medications that are contraindicated when breast feeding
Breast problems in the post partum period
- nipple sensitivity + pain
- mastitis
- breast abscess
- breast lump
What is the difference between foremilk and hindmilk?
- foremilk: at start of sucking |higher water content
- hindmilk: higher fats + iron
