Puerperium Flashcards
Anatomical/ physiological changes seen in puerperium…
Genital tract:
- Uterus decreases in size by about 1cm per day until around day 10-12 when it is no longer palpable
- Contractions felt up to 4 days after
- Cervical os closes in 3 days
- Lochia (discharge from uterus) bloodstained –> yellow –>white (3-4 days)
Cardiovascular system:
- Cardiac output decreases to normal by 1 week
- Oedema decreases over 6 weeks
- BP decreases back to normal by 6 weeks
Vaginal wall:
- Regains tone very quickly
Urinary tract:
- Dilatation of the tract decreases by 3 months
- GFR returns to normal over few weeks
Blood:
- Hb will rise gradually
- Platelets and clotting factors rise - VTE risk!
What is colostrum?
The first milk that is ejected from the mammary glands after birth - yellowish in colour and tends to include more IgA and minerals for the newborn.
What are the different hormones involved in breastfeeding and what are their roles?
- Oestrogen = increasing number and size of ducts in the breast
- Progesterone = increases the number of alveoli (clusters of tissue that secrete milk) in the breast tissue
- hPL = stimulates development of acinar cells (smallest functional unit of the mammary gland)
- Prolactin = stimulates milk production from the alveoli
- Oxytocin = stimulates the ‘let down’ reflex where milk is made available to the baby when suckling on the nipple
Mechanism of breastfeeding…
- Prolactin stimulates lactiferous glands to produce milk
- Baby stimulates tactile receptors on nipple causing posterior pituitary to secrete oxytocin
- Oxytocin stimulates contraction of myoepithelial cells which allows milk produced in alveoli to flow to nipple core
Advantages of breastfeeding…
Mother:
- Reduced risk of ovarian cancer
- Contraceptive effects
- Better bonding with baby - reduces risk of post-partum depression
Baby:
- Increased energy content
- Contains IgA and lymphocytes to boost immunity
- Reduces risk of obesity, diabetes, atopy
Disadvantages of breastfeeding…
- Volume of milk drank is unknown
- Low in Vitamin K - at risk of haemorrhagic disease of newborn
- Transmission of bloodborne viruses
- Transmission of medications
Why is vitamin K supplementation important in breastfeeding babies?
Babies are relatively low in vitamin K which makes them prone to haemorrhagic disease of the newborn (HDN) - breast milk does not provide enough vitamin K so an IM dose is usually recommended
Breastfeeding problems…
- Cracked and sore nipples - will self resolve within a week
- Blocked duct - ‘milk bleb’ - causes pain when breastfeeding, and may need breast massage
- Nipple candidiasis - can give miconazole cream for mother and nystatin suspension for baby
- Mastitis -treat if systemically unwell or symptoms have not resolved within 24 hours of effective milk production
1st line = flucloxacillin 10-14 days
*If left untreated may develop into abscess which needs drainage - Engorgement - pain typically occurs before feeding, hand expression of milk may help to reduce pain
What contraception can women start post-partum?
Non-breastfeeding <21 days post-partum = POP, barrier
Non-breastfeeding >21 days post-partum= COCP, POP, barrier
Breastfeeding <6 weeks post-partum = POP, barrier
Breastfeeding 6 weeks - 6 months post-partum = POP, IUD, injection
What are the main causes of pain in puerperium, and how is it treated?
- Mastitis
- Perineal tear
- Back ache
- Dyspaneuria
Treatment= Paracetamol, NSAIDs
Potential complications in puerperium…
Puerperal pyrexia (temp> 38 deg within the first 14 days):
- Causes: mastitis, genital tract infection UTI, wound infection from C section scar
- Ix: Bloods (FBC, blood culture), urinalysis, vaginal swab, wound swab,
- Tx: SEPSIS 6 if indicated
VTE - need mobilisation and good hydration early on
Postpartum endometritis:
Sx: lower abdominal pain, fever, offensive lochia
Tx: Admission and IV abx if red flags of high temp, tachycardia, tachypnoea
Secondary PPH (bleeding from 24h-6 weeks post-partum)
- Usually caused by endometritis with/ without retained products of conception
- These products may have to be removed if there is heavy vaginal bleeding
Urinary tract problems:
- Retention - will require 24 hour temporary catheter
- UTI - antibiotics
- Incontinence - pelvic floor exercises, then surgical intervention is required
Bowels:
- Constipation and haemorrhoids- laxatives required
- Faecal incontinence - caused by pudendal nerve anal sphincter damage - may require formal repair
What are baby blues, and who is at risk of developing it?
Transient episode of low mood with onset within first 3-5 days post-partum.
RFs = first child, history of depression, poor social circumstances
Symptoms of baby blues…
- Episodes of tearfulness
- Labile mood
- Sleep disturbance
- Feeling distant from baby
- Feelings of depression
Treatment for baby blues…
SELF LIMITING - will usually resolve within 10 days
What is the definition of postnatal depression?
Depression that develops 4-6 weeks after childbirth
