Postnatal Mum Flashcards
When is the puerperium considered complete?
First ovulation
Return of normal menstruation
What do most cultural perspectives believe in?
A period of mandated rest.
Nigeria - period of isolation
Muslims - 40 days
Japan - several months rest
Latin America 40 days rest
Postnatal complications
PPH - primary or secondary
Thromboembolism
Sepsis - infection
Mental health disorders
Breast complications - thrush, mastitis, blocked duct.
What physiological changes occur in the postnatal period?
Involution of the uterus and genital tract
Secretion of breastmilk and establishment of lactation
What hormones return to there pre pregnancy state postnatally?
Human placental lactogen
human chorionic gonadotropin
Oestrogen
Progesterone
How long does it take estradiol to return to its normal state?
Within 24 hours decreases to levels less than 2% of pregnancy levels
How long does ostrogen levels take to return to normal?
Return to almost pre pregnant level by 7 days
How long does it take progesterone levels to return to normal?
Levels return to those found in luteal phase of menstrual cycle between 24 - 48 hours.
And follicular phase by 7 days.
How long does it take thyroid hormones to return to normal?
By 4 weeks
When does lactogenesis 1 occur?
Cascade of hormonal changes from early pregnancy to approx day 3, affected by the inhibitory effect of placental hormones.
When does lactogenesis 2 occur?
Occurs from delivery of the placenta and subsequent drop of progesterone, prolactin levels increase prompting milk production.
When does lactogenesis 3 occur?
Around day 10, mature milk supply established and maintained. ‘Galactopoeisis’
How does lactation suppress ovulation?
infant suckling disrupt normal patterns of GnRH from the hypothalamus
Lowering levels of LH and FSH
Regular suckling suppresses LH levels
with decreased lactation frequency, GnRH levels return to ‘normal’ and FSH and LH levels will increase this will lead to ovulation.
Can decrease due to using dummies ‘masking feeding queus’, missing feeds, giving formula between feeds.
What happens to your contractions PN?
During first 24 hours oxytocin stimulates further myometrial contractions causing further retraction.
Can lead to after pains, especially in Multiparous woman.
After pains gradually diminish by 7 days.
oxytocin stimulated by skin to skin, infant feeding and natural hormonal processes.
What is involution?
Decrease in cell size of uterus
return of Myometrium to normal thickness, ischaemia, autolysis and phagocytosis.
Decidua is shed as lochia for endometrial regeneration.
What is ischaemia?
Muscles of uterus contract at end of third stage and constrict blood vessels at placental site to ensure haemostasis.
Uterine blood supply is greatly reduced.
What happens during autolysis?
Breakdown of redundant actin and myosin muscle fibres and cytoplasm by preteolytic enzymes and macrophages
Individual myometrial cells are reduced in size - shorter and thinner.
What happens during phagocytosis?
Excess fibrous and elastic tissue is removed, this is an incomplete process, some elastic tissue remains, doesn’t quite return to nulliparous state.
What are positional changes of the uterus?
Immediately after delivery - feels like a cricket ball 1000g at or below umbilicus
12 hours - relaxed slightly, remains contracted.
In the first week - decreases to 500g
by 2nd week uterus in the pelvis
6th week - 60-80g
Non pregnant uterus 40-50g
What happens to the superficial layer of the decidua?
Granulation tissue, invaded by leukocytes, forms barrier to prevent micro organisms invading remainder of decidua barrier.
Lymphocytes, macrophages, polymorphs.
Becomes necrotic and sloughed away as lochia.
What happens to the basal layer?
Remains intact
Regeneration of endometrium begins at 10 days
Complete by 2-3 wks (except placental site)
What happens to the upper portion of the spongy endometrial layer?
sloughed away when placenta delivers
Remaining reorganised into superficial and basal layers.
What happens to the placental site?
is completely healed by 6 wks
Immediately post delivery - raised roughened area many thrombosed sinusoids.
blood vessels that supplied intervillous spaces invaded by fibroblasts, lumen obscured
Some will alter recanalise
Lochia 1-3 days PN
Rubra
Lochia 4-10 days PN?
Serosa
Lochia 11- 21 days PN?
Alba
What happens to the cervix PN?
Rapidly loses vascularity and returns to normal consistency within 3 days
What happens to the cervical Os PN?
reduced 1cm wide by 10 days and more narrowed by 6 wks.
What happens to your ovaries and fallopian tubes PN?
Return to pelvic cavity with the uterus
What happens to your vulva/vagina/pelvic floor PN?
Reduced progesterone - normal muscle tone.
Increased vascularity - episiotomy, tears, bruising/ trauma usually heal well and oedema re absorbed by 3-4 days.
Reggae - 3 weeks but less prominent than pre pregnancy.
What happens to menstruation and ovulation PN?
Wide variations of return time, influenced by lactation.
1st menstrual cycle is usually anovulatory - 25% ovulate.
Earliest ovulation is around 21 days PN
if there is no disruptions to ovulation then menstruation usually returns by 5 weeks PN.
What happens to your cardiovascular and respiratory systems PN?
Reduced oestrogen - diuresis first 48hrs - plasma volume & haematocrit return to normal.
Reduced progesterone - removal of excess tissue fluid and return to normal vascular tone
Cardiac output and BP return to pre pregnant levels
Respiratory - lungs can full inflate again and tendency to hyperventilate disappears, CO2 levels return to normal.
What happens to the renal system PN?
Kidneys need to cope with excretion of excess fluids and an increase in breakdown products of protein.
decreased progesterone resolves dilation of renal tract and organs can return to pre pregnant state
Bladder displaced and urethra stretched in labour - consider tone/bruising/ pain during micturition.
The bladder can over distend and retention of urine can occur
What happens to the alimentary tract PN?
Reduced progesterone - smooth muscle tone returns to normal
Rapid return to normal carbohydrate metabolism and fasting plasma insulin levels return to non pregnant values between 48hrs and 6wks
Common complications PN?
Wound healing and infection
Breast complications
venous thromboembolism
Mental health
When does postnatal infection occur?
From 24 hours post birth
What are endogenous organisms?
originate from the commensal organisms present in own body
What are exogenous organisms?
Transmitted from other sources (people, surfaces, environment)
Why are PN women at increased risk of infection?
At birth normal protective barriers against infection are temporarily broken down
Owing to presence of placental site, tissue trauma and decidua and lochia being culture medium for bacterial growth.
What is sepsis caused by?
Inappropriate immune response to an infection, immune system goes into overdrive and chemical released into blood to combat infection trigger inflammation
This leads to small blood clot formation
And Leaky blood vessels that block blood flow to vital organs.
What are common breast complications?
breast refusal
Painful nipples
Perception of insufficient milk supply
Full breasts and engorgement
Thrush
Mastitis
Breast abscess
What is the leading cause of direct maternal death within the UK?
Pulmonary embolism
What does NICE estimate that LMWH reduces VTE risk by?
60-70%
What does the risk for VTE increase with?
Gestational age, reaching a maximum after delivery.
What does prophylactic management include?
TTO LMWH, TED’s, intermittent pneumatic compression devices, early mobilisation.
10 days - intermediate risk women
6 weeks - high risk women
What are the affective disorders?
Baby blues - normal transient emotional reaction to childbirth experienced by over 50% of women.
Usually lasts between 3-7 days.
post natal depression - non psychotic illness occurring within the first year of childbirth.
Postpartum (puerperal psychosis) - a mood disorder accompanied by feelings such as loss of contact with reality, delusions and hallucinations and abnormal behaviours.
What contraception methods don’t really on you remembering to take them?
Contraceptive implant
IUD - intrauterine device
IUS - intrauterine system
Contraceptive injection
Sterilisation
Contraception methods that you have to think about
Contraceptive patch
Contraceptive vaginal ring
Combined pill
Progesterone only pill
External condom
Internal condom
Diaphragm/ cap with spermicide
Fertility awareness methods
What are the 4 stages of wound healing?
Haemostasis
Inflammation
Proliferation
Maturation
What happens during haemostasis?
Vasoconstriction, platelet aggregation, to stop bleeding.
What happens during inflammation?
Chemotaxis, increased vascular permeability, limits further damage and closes the wound, removes debris and bacteria, fosters cellular migration.
What happens during proliferation?
Formation of granulation tissue, re epithelialisation, neovascularisation.
What is maturation?
Remodelling where wound achieves maximum strength as it matures
How do wounds heal?
By primary intention
By secondary intention
What is healing by primary intention?
Minimal destruction of tissue, edges of wound are on close apposition, stages overlap.
Inflammation
Proliferation
Maturation
What is healing by secondary intention?
Follows destruction of a large amount of tissue or where edges cannot suppose
Stages similar to primary healing, time taken depends upon size and effective removal cause.
Describe the process of the breast crawl after birth
Christmas
Reindeer
Are
More
Magical
Running
For
Santa
Clause
Cry
Recover
Awaken
Mouthing / suckling
Motor movements
Rest at the breast
Familiarise with the breast
Self latch/feed
Come off and sleep
