Session 10

Question 1

Normal anatomy of the uterus?

Answer 1

Hollow pear shaped organ
Situated in pelvic cavity Anteverted, anteflexed
Non-pregnant measures Length = 7.5cm Width = 5cm Depth = 2.5cm
Weighs 60gms
Consists of corpus and cervix

Question 2

Uterine muscle fibres

Answer 2

3 layers - use panopto

Question 3

Define labour and its stages

Answer 3

oLabour is the process where the fetus, placenta and membranes are expelled through the birth canal.
oNormal labour is spontaneous in onset at term (37-42 weeks), with the fetus presenting by the vertex and is usually completed within 18 hours with no complications arising.
oLabour is divided into three stages:
o1st Stage is the onset of regular contractions until the cervix is fully dilated (latent and active).
o2nd Stage begins when the cervix is fully dilated to the birth of the baby.
o3rd Stage is from the birth of the baby to the delivery of the placenta and membranes and bleeding is controlled.
No abrupt change between sages. all three overlap slightly.

Question 4

Define latent phase of labour, established/active labour and transition

Answer 4

oLatent phase: a period of time, not necessarily continuous when there are painful contractions and cervical effacement and dilatation up to 4cms.
oEstablished/Active labour: is when there are regular painful contractions and progressive dilatation from 4cms.
oTransition: usually from 8cm to 10cm.

Question 5

What is Pre-labour?

Answer 5

• Lightening occurs 2-3 weeks prior to the onset of labour
• Expansion of the lower segment • Fetal head engages • Symphysis pubis widens, sacro-iliac joints relax • Pelvic floor relaxes • Increased vaginal secretions • Frequency of micturition • Braxton Hicks contractions • Taking up of the cervix
oFrom 24 weeks cervical cells gradually change in collagen content Take up more water
oGap junctions formed between cells act as electro-chemical signalling systems between cells Facilitates coordinated contractions
oUp regulation of oxytocin receptors in each myometrial cell Myometrium more sensitive Fergusons reflex: contractions fetal head presses on the cervix release of oxytocin from posterior pituitary gland contractions (positive feedback loop)

Question 6

Theories of how labour is initiated

Answer 6

• Theories:

* Mechanical • Hormonal • Prostaglandins • Neurological • Other

Question 7

Mechanical initiation of labour

Answer 7

• Uterus grows and stretches detected by stretch receptors in the wall of the uterus critical degree of stretch contractions
• Contractions are caused by stimulation of the cervix – pressure from presenting part

Question 8

Hormonal initiation of labour

Answer 8

oJust before labour level of progesterone decreases and oestrogen levels rise Stimulates production of prostaglandins from the placenta Decidua and membranes also produce prostaglandins
oOxytocin is released from the posterior pituitary gland
oCombined action of oxytocin and prostaglandins brings about uterine contractions.

Placental Oestrogen levels increase in the last few weeks (Jackson, Marshall & Brydon 2014) Oestrogen thought to stimulate:• An increase in oxytocic receptors in myometrium • An increase in gap junctions in myometrium • Placenta to release prostaglandins leading to production of collagenases –digest collagen in cervix-help to soften (Tortora & Grabowski 2011) Balance between oestrogen and progesterone facilitates myometrial activity Fetal membranes Involved in the synthesis of Prostaglandins Decidua Gustavvi theory (1977) . Decidual cells responsible for production of prostaglandin

Question 9

Prostaglandin initiation of labour

Answer 9

• Reduction of prostaglandins inhibiting substances prior to term
• Facilitates liberation of calcium ions from intracellular stores in myometrium – increases cell contractile activity
• In cervix facilitates production of enzymes reduce collagen by digestion glycoaminolcans increases cervical ripening

Question 10

Other theories of how labour is initiated

Answer 10

oNeurological element- maybe determined by the 1st trimester
oOestrogen synthesis may be mediated by fetal adrenal gland activity
Cortex – produces different hormones at different stages of pregnancy 3rd trimester produces cortisol – associated with the maturation process (fetal lungs)
Fetal theory–Hypothalamus/pituitary /adrenal axis
?Onset due to ACTH from fetal pituitary leading to:
1. Increase in fetal cortisol from the fetal adrenal glands. Converts progesterone to oestrogen. Increases uterine sensitivity to prostaglandins and oxytocin Stimulates release of prostaglandins from placenta and myometrium
2. High concentrations of oxytocin found in umbilical circulation. Thought to arise from the fetus and transferred to maternal circulation to induce labour.
However fetal death/ brain /adrenal malformation does not prevent labour
oTime of onset of labour may be determined by the release of corticotrophin-releasing hormones (CRH) CRH is released from the hypothalamus and produced by the placenta
oMaternal levels of CRH begin to rise before the onset of labour CRH stimulates production of prostaglandins by the placenta and potentiates the effect of oxytocin and prostaglandins
oImmune response
oPlacenta produces: Cytokines- cells of immune system communicate Interleukin 8 (IL8) – inflammatory mediator attracts neutrophils to local areas local inflammation
oImmune rejection theory Placenta rejected like a donated organ During pregnancy progesterone facilitates a degree of immunosuppression

oNitric Oxide
Placenta produces nitric oxide Nitric Oxide maintains relaxation of uterus during pregnancy Reduction of Nitric Oxide at term increases the excitability of the uterus.

Question 11

Hormones involved in labour

Answer 11

Progesterone Oestrogen Prostaglandins Oxytocin Endorphins Adrenaline/ Noradrenaline

Question 12

How long does labour normally last?

Answer 12

• The duration of established labour varies from woman to woman, and is influenced by parity. • Progress is not necessarily linear. • In established labour, most women in their first labour will reach the second stage within 18 hours without intervention. • In their second and subsequent labours, most women will reach the second stage within 12 hours without intervention.

Question 13

Working together?

Answer 13

slide 28

Question 14

How does uterine activity give the pushing power aspect of labour?

Answer 14

oMyometrial tone must change to allow co-ordinated contractions of the myometrial body
oWeak, irregular contractions build up to 3-4 contractions every 10mins. They become strong and last around 1min.
oFundal dominance – contractions begin at the cornua and remain strongest at this point. They spread out and down towards the lower segment in waves.

Question 15

Polarity in labour

Answer 15

• Upper and lower poles of the uterus work in unison.
• The upper pole contracts and retracts whilst the lower pole dilates allowing expulsion of the fetus.
• The upper segment of the uterus thickens and shortens propelling the fetus downwards.

Question 16

Normal muscle contraction vs uterine/myometrial muscle contraction

Answer 16

Normal muscle
Contracts and relaxes Returns to the original size E.g. biceps in the arm

Uterine/myometrial muscle
Contracts and retracts Does not return to its original size Permanent partial shortening of muscle fibres Remain shorter than they were originally Resting tone 4-10mmHg

Question 17

Effacement

Answer 17

oThe gradual merging of the cervix into the lower uterine segment convert the cervix from a function of support into the function of a birth canal.
o Effacement usually occurs before dilatation on a primigravida. oProstaglandins implicated- change the collagen content of the cervix.

Question 18

effacement in primigravida compared to effacement in a multigravida

Answer 18

slide 37/38 use panopto

Question 19

Dilatation during labour

Answer 19

oIncreased pressure from the presenting part is said to aid dilatation Ferguson’s Reflex
oCrucial that regular contractions are co-ordinated with cervical dilatation
o10cms is considered to be ‘full dilatation’ when the largest diameter of the presenting part can pass through.

Question 20

Fergusons reflex

Answer 20

slide 40

Question 21

What happens to the mucus plug during dilation of the cervix?

Answer 21

• As the cervix dilates the plug of mucus (Operculum) comes away.
• This may be streaked with blood.
• Not always indicative of the imminent onset of labour

Question 22

Factors hat affect dilatation of the cervix during labour?

Answer 22

oAs the lower uterine segment stretches, the chorion becomes detached.
oThe well flexed head fits snuggly against the cervix trapping a small pocket of fluid = forewaters.
oThe remaining fluid remains behind the fetus = hindwaters.
oFetal axis pressure is exerted down the long axis of the fetus from the fundus ensuring flexion.
o The smallest circumference is evenly applied to the cervical os.
possible include slide 43

Question 23

Spare

Answer 23

spare

Question 24

What might be the effects of labour on the mothers physiology?

Answer 24

slide 47

Question 25

Define second stage of labour. describe its duration

Answer 25

The second stage of labour is traditionally defined as the phase between full dilatation of the cervical os to the birth of the baby
There are four sub stages: Transition, Latent Phase, Active Phase, Perineal Phase
• Nulliparous women should be expected to birth their baby within three hours from the start of the active phase • Parous women should be expected to birth their baby within two hours from the start of the active phase
A diagnosis of delay should be made after two hours for nulliparous women and one hour after parous women and appropriate referral to an obstetrician should be made

Question 26

4 stages of the second stage of labour?

Describe each

Answer 26

Transition
This period is characterised by • Maternal restlessness • Discomfort • Request for analgesia • A sudden wish for it to all end
Active Phase
• Contractions become stronger and longer but less frequent • Further release of the operculum • Spontaneous rupture of membranes • Draining of liquor allows the fetal head to be applied to vaginal tissue. This aids distention • Fetal axis pressure increases flexion of the fetal head • Smaller presenting diameters • Increases progress • Minimises trauma • Aided by maternal position
Fetal descent leads to • Pressure being applied to the pelvic floor • Nerve receptors are stimulated on the muscles of the pelvic floor and rectum (Ferguson Reflex) • Results in the urge to push • Mother then employs secondary powers of expulsion (contraction of abdominal muscles and diaphragm)

Latent Phase
A period of calm “The resting phase”

Perineal Phase
• The descending fetal head displaces soft tissue • Anteriorly, the bladder is pushed up into the abdominal cavity to prevent damage • This results in stretching and thinning of the urethra • Posteriorly the rectum becomes flattened into the sacral curve and the pressure of the advancing head expels any residual faecal matter • The deep muscles of the perineum (the levator ani muscles) dilate and displace laterally • The perineal body flattens, stretches and thins out
• The head becomes visible at the vulva • Advances with each contraction and recedes following • Crowning then takes place • The head is born • Followed by the shoulders • Then finally the body • A gush of liquor and often blood will follow

Question 27

Signs of the second stage of labour

Answer 27

• Urge to push • Expulsive uterine contractions • SROM • Dilated anus • Anal cleft line • Rhomboid of Michaelas • Blood stained show • Visible presenting part • Definitive diagnosis is by vaginal examination

Question 28

Terms relating to the position of the fetus in labour

Answer 28

• Lie – relation of the long axis of the fetus to the long axis of the uterus • Attitude – relation of the fetal head to the trunk • Presentation – part of the fetus lying at the pelvic brim or lower pole of the uterus • Presenting part – part of the fetus lying over the os and on which the caput forms • Position – relation of denominator to the maternal pelvis (i.e. occiput) • Engaging diameter – diameter of fetal head presenting at the pelvic outlet • Denominator – part of presenting part which determines position

Question 29

Include stuff about pelvis if important

Answer 29

panopto

Question 30

Mechanisms of birth

Answer 30

Descent • Increased abdominal muscle tone • Braxton hicks in late stages of pregnancy • Fundal dominance of the uterine contractions during labour • Increased frequency and strength of contractions during labour • As the head descends, it moves towards the pelvic brim in either the left or right occipito-transverse position • The widest part of the fetal fits through the widest diameter of the pelvic inlet

Flexion
As the fetal head comes into contact with the pelvic floor, cervical flexion occurs. This allows the presenting part of the fetus to sub-occipito bregmatic. In this position, the fetal skull, has a smaller diameter, which assists passage through the pelvis

Question 31

Shoulders during birth

Answer 31

The shoulders are born one after another to reduce the diameters descending into the vaginal orifice.
The anterior shoulder usually escapes under the pubic arch first then the posterior arm sweeps the perineum
The rest of the body is born by lateral flexion as the spine bends sideways through the curved birth canal

Question 32

Third stage of labour

Answer 32

The interval from the birth of the baby to the expulsion of the placenta and membranes

Question 33

Functions of the third stage of labour?

Answer 33

SERPENT
Storage
Endocrine
Respiratory
Protection
Excretion
Nutrition
Transfer

Question 34

Separation and Decent of the placenta

Answer 34

The placenta becomes compressed Blood in the intervillous spaces are forced back into the spongy layer of the decidua basalis
-
Retraction of the oblique muscle fibres constrict the vessels supplying the placenta. The vessels become congested and burst
-
Blood seeps between the spongy layer and the placental surface causing it to separate
-
Separation tends to occur centrally A retroplacental clot may form which may aid separation
slide 75

Question 35

Signs of separation

Answer 35

• Cord lengthening • Rising / tightening of the uterus • Possible separation vaginal bleed • Maternal pressure • Valval bulge
Be aware time – The third stage can take up-to 1 hour. During this time ensure bladder care/ upright position/ control and measurement of blood loss/ maternal physical + psychological wellbeing/ skin-skin if wanted

Question 36

Schultze Method

Answer 36

• Separation generally starts at the centre of the placenta, causing this part to descend first
• The fetal surface appears at the vulva
• Any blood loss appears minimal as it is contained within the inverted amniotic sack
• Akiyma et al (1981) found that 80% of placentae separate by this method

Question 37

Mathew Duncan Method

Answer 37

• Less commonly separation commences at the lower edge of the placenta
• The placenta slips down sideways and the maternal surface appears at the vulva
• Separation is accompanied with vaginal blood loss
• No retroplacental clot is formed; leading to a slower separation
• Blood loss is likely to be more profuse

Question 38

Physiological / Expectant management

Answer 38

DO • Maintain a calm and warm environment • Maintain a comfortable, upright position • Facilitate baby and parent discovery • Observe for any adverse signs – excessive blood loss • Be prepared for a large “gush” of blood. Initial loss is heavier than when an uterotonic is given. Midwives must understand physiological blood loss and not rush to administer oxytocic treatment. • Empty bladder • Trailing membranes may be teased out gently

DON’T
• Manipulate the uterus • Apply any traction to the cord • Cut the cord until pulsation has ceased • Administer any oxytocic treatment unless clinically indicated.

Question 39

Achievement of haemostasis after birth

Answer 39

Retraction of oblique (spiral) uterine muscle fibres on torn vessels act as “living ligatures” to stop blood flow
Contraction of the uterus after placental separation leads to an apposition of the uterine walls and pressure on the placental site
Clotting mechanisms cause : 1. Blood clots to form in the torn blood vessels (Increased platelet activity) 2. Production of a fibrin mesh over the placental site 3. (Increased fibrinogen activity)
4. Check for perineal trauma 5. Check bladder

Question 40

Risk factors for haemorrhage

Answer 40

• Induction of labour • Prolonged stage of labour (1st / 2nd/ 3rd) • Intrapartum oxytocin • Precipitate labour • Grand parity • Operative birth or caesarean section • Multiple pregnancy/ polyhydramnios/ macrosomia/ Fibroids / uterine growth • Hb < 100/ haemoglobanopathies • BMI >35 • Previous PPH or retained product • Low lying placenta • Antepartum haemorrhage • Maternal age >35 (

Question 41

Placenta appearence

Answer 41

slide 82

Question 42

Active management after birth

Answer 42

Do • Administer uterotonic drug appropriately • Allow active process time of drug • Palpate the uterus to confirm contracted • Apply counter traction • Observe for signs of separation and decent • Using controlled cord traction (modified Brandt Andrews in UHL) deliver the placenta and membranes
Don’t:
• Attempt traction without signs of placental separation • Continue traction when resistance is felt • Cut the cord earlier than 1 minute unless clinically indicated to

Question 43

Spare

Answer 43

s

Question 44

Spare 2

Answer 44

3

Question 45

spare3

Answer 45

4

Question 46

spare 4

Answer 46

5

Question 47

Define the post-partum period

Answer 47

Period from the delivery of the placenta to 6/52 post natal  The period when the changes that occurred as a result of pregnancy revert to the pre-pregnancy state  A period of great changes/modifications in lifestyle, psychology, activities, relationships, responsibility, etc.  Period of step-down of medical input if any required during pregnancy  Potential for problems to occur  Period continued optimal management of any preexisting medical conditions

Question 48

Post natal care in the uk?

Answer 48

In the UK, midwives have a statutory responsibility to visit the woman and her baby in her home as required, for a period of not less than 10 days post delivery, but also for a longer period as the midwife considers necessary up to 28 days post delivery.

Question 49

Post natal examination

Answer 49

 Six weeks postnatal examination by the GP or by the obstetrician if the antenatal period or delivery have been complicated.  By six weeks postpartum most of the pregnancy-induced changes in maternal physiology have returned to normal and it is an appropriate time for assessing the mother-infant interaction.  Assesses the woman’s mental and physical health as well as feeding and behaviour of the baby.  Direct questions about urinary, bowel and sexual function as well as incontinence,  Dyspareunia or anxiety about sexual intercourse are issues that many women will not discuss voluntarily.  Blood pressure, urinalysis and a general, breast, abdominal and pelvic/perineal as required.

IMPORTANCE
 A cervical smear if required  contraception is discussed, if it has not already been initiated.  The postnatal examination is an excellent opportunity to discuss with the mother her adjustment to parenthood and any anxieties she may have

Question 50

ANATOMICAL AND PHYSIOLOGICAL CHANGES during the post partum period

Answer 50

 Lower genital tract- these are secondary to low oestrogen levels  Reduction in size of vulva, vagina and cervix  Poor lubrication of the vagina  Transformation zone of the cervix withdraws into the endocervix  Internal os is closed

 Bleeding- initial heavy flow (lochia rubra)  Changes from red-brown/red-pink-heavy white (lochia alba)  Duration of bleeding is variable, only 1:10 women still bleeding at 6/52 post partum  Passage of clots is not normal, except for the one passed on D3/4  Endometrium regulates  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

OTHER CHANGES  Skeletal muscle- devarication of the recti, resolves depending on pre-pregnancy laxity, parity, level of physical activity  Skeleton- ligament laxity resolves  Cardiovascular function- the increased PR (by 15bpm) at term and increased cardiac output reverses by 6/52

Question 51

Haematological changes after birth for mother

Answer 51

slide 11

Question 52

Endocrinological changes experienced by the mother after birth

Answer 52

slide 12

Question 53

Psychological impacts of pregnancy on the mother

Answer 53

 The early puerperium- the hours after birth, characterised in some women by a postnatal ‘high’.  A degree of elation is obviously normal, especially if the woman is satisfied with her birth experience and has a close partner and family that are supportive and congratulatory.
Positive feelings in the puerperium include:
 satisfaction  an increased closeness to her partner  an increased closeness to her own mother  a gradual ‘falling in love’ with the baby  a feeling of protectiveness towards the baby  changes in the relationship with the partner: now ‘parents’ and not just ‘partners’.

Negative feelings may include:  dissatisfaction, disappointment or distress over the delivery process  anxiety about the baby  rejection or ambivalence about the baby  jealousy about the baby being the centre of attention  fears of harming the baby  physical discomfort and anxiety about physical damage during birth  overwhelming responsibility  resentment at loss of freedom

OLD AND NEW ISSUES
 reactivation of poor relationship with own mother leading to anxiety about repetition through generations.  In some 16% of women, the early elation after childbirth can be extreme and meets the criteria for hypomania. The rapidly falling hormone levels in the early puerperium may also explain this. It is a self-limiting condition

Question 54

ONSET AND MAINTENANCE OF LACTATION

Answer 54

 Progesterone, oestrogen, prolactin, growth hormone and adrenal steroids = hypertrophy in pre-existing alveolar-lobular structures in the breast.  Formation of new alveolae by budding from the milk ducts, with proliferation of milk-collecting ducts.
 Although there are high levels of lactogenic hormones (prolactin and placental lactogen) in pregnancy, only minimal amounts of milk are formed, because oestrogen and progesterone inhibit their effects. Prolactin is released by the action of suckling at a nipple that has become exquisitely sensitive post delivery.

Question 55

MILK PRODUCTION AND SECRETION

Answer 55

 Prolactin levels and milk production are dependent on the frequency and duration of suckling. Prolactin levels are at their highest in the early puerperium and reduce slowly, only returning to normal after weaning.
 Milk secretion is also dependent on adequate emptying of the secreting glands. Accumulation of milk inside the alveoli will cause distention and atrophy of the glandular epithelium. Therefore, adequate milk secretion requires an intact neuroendocrine axis and adequate emptying of the breast with infant feeding.

Question 56

DELIVERY OF THE BREAST MILK

Answer 56

 Oxytocin= contraction of the myoepithelial cells situated around the alveolae to cause them to contract and expel the milk into the milk-collecting ducts. These milk-collecting ducts have longitudinal muscle cells, which are also stimulated, causing them to dilate and improve the free flow of milk towards the nipple along these dilated ducts.

 This leads to the ‘let down’ reflex. Oxytocin is released in response to a variety of sensory inputs including suckling, seeing or hearing the baby but is also readily inhibited by emotional stress or anxiety. There also seems to be a 90 minute cycle of ‘let down’ irrespective of suckling, because oxytocin is released in a pulsatile manner from the pituitary.  As lactation is initiated, the volumes are low and colostrum is initially produced. This has a high fat content and is also high in immunoglobulins. As suckling continues, the amount of milk increases until, when fully established, approximately 800 ml per day are produced

Question 57

COMPONENTS OF BREAST MILK

Answer 57

 Human milk differs from other mammalian milk.  Human milk:  has a much lower salt content  has a higher energy content  has less protein  has more lactose  is more digestible by the human baby.  Even more interestingly, the constituents of human milk differ in early rather than late lactation and will also vary from feed to feed, and even from the beginning to the end of a feed.  The so-called ‘foremilk’ that emerges at the start of suckling has a higher water content. The ‘hind milk’ is higher in fats and iron.

Question 58

functions of breast milk

Answer 58

Protection Breast milk helps to protect the infant from infection by a variety of mechanisms: lactoferrin in breast milk binds iron, preventing the proliferation of E.coli, which is an iron-dependent organism it encourages colonisation of the neonatal gut by non-pathogenic flora, which competitively inhibit pathogenic strains bacteriocidal enzymes are present living lymphocytes, polymorphs and plasma cells that may play a part in cell mediated immunity in the neonate are present specific immunoglobulins are present.
IMMUNOGLOBULINS  The immunoglobulins that are present in large amounts in breast milk are formed by the mother in Peyer’s patches in her gut. They are formed in response to contact with specific environmental organisms.
 The immunoglobulin A formed in this way is passed to the breast milk via the thoracic duct and the lymphatic system. The immunoglobulin passes into the infant gut where it remains. It attaches to the specific environmental pathogens to which it was produced in the mother and thus the infant is enabled to defend itself against endemic environmental pathogens.

FORMULA FEEDING
 Unless chosen by a woman herself or medically indicated – should not be given to breastfed babies  Medical indications include:  Severe maternal illness  Maternal HIV  Mothers on medications that are contraindicated when breastfeeding

Question 59

Breast problems experienced by mothers

Answer 59

 Nipple sensitivity and pain  Engorgement  Mastitis  Breast abscess  Breast lumps- benign or malignant  Breast lump must always be investigated  Self-examination- outside menstruation  If malignant- requires prompt treatment, surgery+/- radiotherapy, expert oncology care

Question 60

PROBLEMS OF THE PUERPERIUM- EARLY

Answer 60

 Postpartum haemorrhage (PPH)- primary or secondary  Retained placenta/placental tissue  Uterine inversion  Perineal trauma and sequelae  Maternal collapse  Cardiac arrest  Thromboembolic disease  Puerperal pyrexia/sepsis- sources; genital tract; urinary tract; lactation ducts.  Domestic violence/abuse

Question 61

PERINATAL MENTAL HEALTH

Answer 61

 Postnatal blues (baby blues)- peaks at D4-5  Is self-limiting in 85% of women  Managed by reassurance and support  Postpartum depression  Is defined as this if the symptoms occur within 4/52 of delivery  Affects 13% of women  The symptoms are similar to depression outside pregnancy  Risk of recurrence is 70%  If lasts >1/12, is regarded as major and requires pharmacological treatment

PUERPERAL PSYCHOSIS AND PTSD  Puerperal psychosis is rare but 30% occurs in women in women with pre-existing mental illness  Recurrence risk= 25%  Usually present in the 1st month of delivery  Can be as early as D4.  The risk is to the mother (suicide risk=5%) as well as to the baby (infanticide risk= 4%)  Accurate and timely diagnosis is key  Symptoms include: restlessness; anxiety; mania; paranoid thoughts and delusions. All easily missed/attributed to other reasons

Risk of suicide

PTSD
 Can happen as a result of childbirth  1.5% at 6/52 postpartum  Requires recognition  Management is psychological therapies

Question 62

SEXUALITY AND SEXUAL FUNCTION after pregnancy

Answer 62

 Last thing on her mind ( usually!)  Altered perception of body and changes due to pregnancy  Worried about getting pregnant again  Perineal trauma  Dyspareunia due to low oestrogen and other causes  Handling this and relationship with her partner (all while caring for a new born!)
CONTRACEPTION
 Postpartum family planning (PPFP) aims to prevent unintended pregnancy and closely spaced pregnancies after childbirth.  Often ignored and a number of biases and misconceptions have limited its availability.  Childbirth presents an opportunity for providing contraception at a time when women are attending a service staffed by healthcare providers with the skills to offer a full range of methods and when women may be highly motivated to start using an effective method. It is clear from the statistics below that PPFP saves lives:  Can save mothers’ lives – family planning can prevent more than one-third of maternal deaths  can also save babies’ lives – family planning can prevent 1 in 10 deaths among babies if couples space their pregnancies more than 2 years apart. .  The timing of the return of fertility after childbirth is variable and unpredictable. .