Session 10: The Post-Partum Period Flashcards
Definition of post-partum period.
Period from delilvery of the placenta to six weeks after.
What happens during the post-partum period?
The body returns to a pre-pregnancy state
How is a new mother looked after?
Advice on contraception, breastfeeding and checking episiotomy healing.
Encourage to attend specific clinics locally with their child once a week until 6 weeks of age.
Post-natal examination 6 weeks after.
What does a post-natal examination include?
BP
Breast exam
Abdominal exam
Pelvic exam
Perineal exam
Mental health
What hormone is the post-partum period characterised by?
Low levels of oestrogen
Give examples structure that change back to their original state in the post-partum period.
Lower genital tract
Haematological
Endocrine
Cardiovascular
Skeletal
Ligament laxity
What does the time period of absence of menstruation depend on?
Whether the mother breast feeds or not.
When does menstruation usually return in the case of no breast feeding?
Six weeks post-partum
Which psychological changes might occur during the post-partum period?
Elation (euphoria)
Protectiveness
Anxiety
Overwhelming responsibility
Rejection
Explain the route of breast milk.
Secreted by secretory lobules that empty into ductules. The ductules from 15-20 lobules will then combine into a duct.
The duct will widen at the ampulla which is a small reservoir.
It will then be excreted via the lactiferous duct.
What is Postpartum Haemorrhage?
An obstetric emergency that will require urgent management to prevent major blood loss and cardiovascular shock.
What might suggest that PPH occurs?
Inadequate uterine contractions after delivery
Causes of PPH.
The 4 Ts
Tone (atony)
Tissue (retained placenta)
Thrombin (clotting disorder)
Trauma
What are secondary haemorrhages from PPH usually caused by?
Infection like endometritis or retained products of conception like the placenta.
Give common complications that might occur in the post-partum period.
Haemorrhage (primary/secondary)
Retained placenta or other tissue
Uterine inversion (obstretic emergency)
Perineal trauma
Maternal collapse/cardiac arrest
Thromboembolic disease
Pyrexia/sepsis
Mental health problems.
Causes of maternal collapse.
Amniotic fluid embolism
Hypoglycaemia
Hypotension/hypovolaemia
How can you differ between menstruation and secondary haemorrhage?
Secondary haemorrhage is defined as 24h - 6 weeks after birth.
It is most present two or three weeks later.
Give examples of mental health issues in the post-partum period.
Postnatal blues (baby blues)
Post-partum depression
Puerperal psychosis
PTSD
Explain postnatal blues.
Common after delivery and occurs in 85% of women.
It usualyl peaks at 4/5 days and is an altered mood due to hormonal changes.
It is presented by the mother being more tearful or anxious.
Explain post-partum depression.
Usually occurs within 4 weeks of delivery.
Similar symptoms to depression outside of pregnancy.
Occurs in 13% of women.
Important to ask the mother about her feelings.
Treatment of postnatal blues.
Managed by reassurance and support
Treatment of post-partum depression.
Depending on the severity.
Might require pharmacological treatments if the symptoms lasting longer than a month.
What is puerperal psychosis?
Usually occurs within 4 weeks.
Rare but psychiatric emergency, also happens in 30% of women with pre-existing mental illness.
Severe symptoms such as anxiety, mania, paranoid thoughts and delusions.
Risk of puerperal psychosis.
Suicide (5%)
Infanticide (4%)
Management of puerperal psychosis.
Specialist care and primarily pharmacological.
What causes full development of the breasts?
High levels of oestradiol
High levels of progesterone
Gradual increase in levels of prolactin.
Gradual increase in levels of hPL
What kinds of hormones is involved in the development of the breasts?
Mammogenic (proliferation of alveolar and duct cells)
Lactogenic (initiation of milk prod)
Galactokinetic (contraction of myoepithelial cells)
Galactopoeitic (maintain milk prod)
Role of prolactin in breast feeding.
Milk production and its maintenance.
Explain the release of prolactin.
Usually inhibited by dopamine.
Suckling stimulates neurons from the spinal cord to inhibit dopamine release. This leads to an increase in levels of PRL.
This means that suckling maintains milk production. Suckling in one feed orders the next feed.
Role of oxytocin in breast feeding.
Contraction of myoepithelial cells to contract and eject milk. This is the let-down reflex.
Explain the release of oxytocin.
Suckling leads to stimulation of neurons from the spinal cord.
This stimulate oxytocin release.
Explain why anovulation and amenorrhoea occurs during breast feeding.
Neurons in the arcuate nucleus and preoptic area of the hypothalamus are inhibited. This leads to a fall in GnRH.
Inhibition of the ovarian cycle ensues and this means that the suckling intensity and frequency both determine the length of anovulation and amenorrhoea.
Explain the contents of the milk in the beginning of breast feeding.
Milk volumes are low and colostrum is produced.
What does colostrum contain?
High amounts of fat and immunoglobulins.
How does the milk contents change?
When the milk production is established the contents change and 800 ml of milk per day.
How does the breast milk protects the baby?
From infection by:
1 - Lactoferrin
2 - Populates the neonatal gut with non-pathogenic flora
3 - Bacteriocial enzymes
4 - Contains specific immunoglobulins
5 - T cells and granulocytes that play a role in cell-mediated immunity
The feedback cycle of breast feeding.
What is puerperal mastitis?
A condition where milk accumulation in the breast can lead to inflammation, with or without infection.
Why might puerperal mastitis occur in the absence of infection.
Occurs if the mother does not breastfeed with both breasts. Therefore milk can build up in the lactiferous duct of the unused breast.
Puerperal mastitis with infection.
Causative organism (most common) and potential complication.
S. aureus
Can lead to abscess formation
Treatment of puerperal mastitis.
Continue feeding and increase the frequency especially on the affected side.
Antibiotic can be given after 24 hours if there is no improvement.
Explain the cessation of lactation.
Milk accumulates in the alveoli of the breast causing distention and atrophy of the glandular epithelium.
This means that the local mechanical factor suppress milk secretion rather than hormonal changes.
What can you give in order to artificially supress lactation?
Dopamine agonist to surpress PRL.
An example is bromocriptine.
