PUERPERIUM Flashcards
What is the puerperium?
The period from the delivery of the placenta through the first 6 weeks after delivery. This is when the various changes that occurred during pregnancy, labour and delivery revert to the non-pregnant state
Cardiovascular changes during pregnancy?
Increased circulatory volume - plasma volume increases by 45% and blood volume by 30%
CO increases by up to 50%
SV increases by 25%
HR increases by up to 25%
Peripheral vascular resistance decreases by 20%
Cardiovascular changes after birth?
Cardiovascular system reverts to normal during the first 2 postpartum
These changes are dramatic and there will likely be diuresis on days 2-5 postpartum to dissipate the extra volume of fluid
Changes in coagulation system postpartum?
The hypercoagulable state from pregnancy will remain high for up to 2 weeks postpartum before starting to normalise
This is to protect against haemorrhage
But it increases the risk of VTE
Uterus changes in the postpartum period?
After delivery of the placenta, the uterus is the size of a 20 week pregnancy i.e. fundus palpable at maternal umbilicus
It will reduce in size by 1 finger breadth each day and will likely not be able to be palpated by 12th day
By the end of the puerperium it will only be slightly larger than pre-pregnancy
Lochia changes post partum?
First 3-4 days - lochia rubra - bright/dark red and may be small clots
Day 4-10- lochia serosa - watery pinkish brown
Day 10-28 - Lochia alba - yellowish white
Lochia can persist up to 5 weeks postpartum!
What is lochia?
Postpartum bleeding
Changes to the cervix in the puerperal stage?
It will revert to the non pregnant state and external os will close such that a finger cannot be easily introduced
Os will be more “slit-like” compared to the round os it was before
Changes to the vulva, vagina and perineum in the puerperal phase?
Resolution of the increased vascularity and oedema by 3 weeks
Restoration of vagina rugae will be variable dependant on breast feeding status (6-10 weeks)
Tears and episiotomies will heal within a couple of weeks
Pelvic muscle tone will be regained by 6 weeks
How does breastfeeding affect the vagina?
Breast feeding keeps oestrogen levels low
= vaginal rugae take longer to return to pre-pregnant state and vaginal atrophy may occur
What is diastasis recti?
An increased distance between rectus abdominal muscles at the midline caused by weakness in the anterior abdominal wall
Usually back to normal by 8 weeks postpartum
Regular pelvic floor and deep stomach muscle exercise can help
Earliest time of ovulation possible after giving birth?
28 days post partum if formula feeding!
Mean time to first menses post-pregnancy?
7-9 weeks
What is lactation all amenorrhoea?
The absence of periods related to breastfeeding
Breastfeeding disrupts release of GnRH
Changes to the breasts in preparation for lactation to occur throughout pregnancy?
Lactogenesis occurs as early as 16 weeks gestation
High levels of circulating progesterone actives mature alveolar cells in the breast but it does not allow secretion - stage 1 lactogenesis
The rapid drop in progesterone after deliver triggers onset of milk production within 24-48 hours - stage 2 lactogenesis
Regulation of milk production?
Suckling = neuro-endocrine reflex = hypothalamus reduces secretion of dopamine and increases prolactin secretion = more milk is produced
Milk let-down reflex?
Suckling = oxytocin released from pituitary gland = myoepithelial cells are stimulated and squeeze milk out of the breast
Despite suckling being the major stimulus for milk let down, the reflex can be conditioned. The cry or sight of an infant and preparation of the breast for nursing may cause let-down, whereas pain, embarrassment or alcohol may inhibit it.
Maintaining milk production?
Sufficient suckling to maintain pro,actin secretion and remove accumulated milk
If this stops then alveolar distension restricts blood flow to the alveoli and feedback inhibitor of lactation is released = interferes with milk production
Mammary involution would occur within 2-3 weeks
Maternal mortality rates and effects of ethnic minority backgrounds and deprivation?
Maternal death during pregnancy and up to 6 weeks after is 4x higher in black women, 3 times higher in mixed-ethnicity women and 2 x higher in Asian women
Women living in the most deprived areas are 2.5x more likely to die compared to women living in the least deprived areas
When should the first midwife visit occur?
Within 36 hours after transfer of charge from place of birth/ after a home birth
Should be face-to-face
When should the first health visitor visit occur?
7-14 days after transfer of care from midwifery care
What will be done at each postnatal contact?
Ask women about general health and assess general wellbeing e.g. signs of postnatal mental health problems, physical problems, importance of pelvic floor exercises, fatigue, nutrition/diet/physical activity/smoking/alcohol/drug use, contraception, sexual intercourse, safegaurding concerns
Assess woman’s psychoglcial and emotional wellbeing
Assess for signs of infection, pain, vaginal loss, bladder and bowel function, nipple/breast discomfort, signs of VTE/anaemia/pre-eclampsia
For women who had a vaginal birth check perineal healing
For women who had a c-section check wound healing and signs of infection
Inform women of red flags!
What to do if a pregnant woman is experiencing perineal pain following pregnancy?
Analgesia
Examine to rule out infection or haematoma
Perineal swabs and antibiotics if infection suspected
Urticaria evacuation if haematoma infection
What causes urinary retention following pregnancy?
How common is it?
Possible secondary to pudendal nerve damage after vaginal delivery. This is usually stress incontinence.
About 50% of women will develop some urinary incontinence
Managing urinary retention following pregnancy?
May require catheterisation
Pelvic floor exercises should be encouraged
Why is constipation a common puerperal problem?
Regular use of opioids, lack of food and water during labour etc
What is mastitis?
Inflammation of the breast tissue that may indicate infection
Advice about resuming sexual activity after birth?
No rules but most woman its about 6 weeks
Many women need lubricant to make it more comfortable
Remind them its possible to get pregnant as little as 3 weeks after birth
How common is puerperal backache?
Affects 1/3rd of women after birth!
Anaemia in puerperal period?
Common - possible cause is blood loss during or after childbirth
Check FBC and iron studies - likely IDA
What are baby blues?
A period of low mood, anxiety, tearful and irritability that starts 3-4 days after birth, lasts about 7 days and doesnt require treatment
More common in primiparous women
How common is baby blues?
Up to 70% of women
What can cause baby blues?
Sudden drop in oestrogen and progesterone after birth
Management of baby-blues?
Reassurance and support - the health visitor has a key role in this!
What screening tool can we use to screen for postnatal depression?
The Edinburgh scale
It’s a 10 item questionnaire with a max score of 30 that indicates how the mother has felt over the previous week
Score >14 indicated depressive illness of varying severity
How common is postnatal depression?
When does it typically start?
Features?
Affects 10% of women
Most cases start within 1 months and peak at 3 months
Features are similar to depression
Management of postpartum depression?
Reassurance and support
CBT
SSRIs
Which SSRIs are best for postpartum depression?
Sertraline and paroxetine
How common is puerperal psychosis?
When does it typically occur?
Features?
Prognosis?
0.2% of women
Onset within first 2-3 weeks following birth
Severe mood swings and disordered perception e.g. auditory hallucinations. Usually starts with confusion. May appear withdrawn or manic - very variable. Sleep disturbance is very common!
Prognosis is generally good. More women take 6-12 months to recover fully
