The Post-Partum Period

Question 1

What is the post partum period?

Answer 1

The period form the delivery of the placenta. To 6 weeks postnatal.

It is the period when the change that occurred as a result of pregnancy to revert to the pre-pregnancy state

Question 2

Why is the post partum period important?

Answer 2

It is a period of great changes / modifications in lifestyle, psychology, activities, relationships, responsibilities ect.

Period of step-down of medical input if any required during pregnancy.

Potential for problems to occur.

Period continued optional management of any pre-existing medical conditions

Question 3

What is post-natal care in the UK?

Answer 3

From birth to 10-28 weeks after birth

A postnatal exam is carried out 6 weeks after birth - physical and mental health, smear, contraception

Question 4

What things get checked in the post natal examination?

Answer 4

This occurs 6 weeks after delivery.

Includes assessment of mental an physical health

Smear test, BP, Urine analysis, pelvic exam

Contraception

Urinary, bowel and sexual function.

Question 5

What anatomical changes occur post-partum?

Answer 5

Lower genital tract - low oestrogen.

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

Question 6

What physiological changes occur post-partum?

Answer 6

Bleeding - initial heavy flow (Lochia rubra)
Changes from red-brown / red-pink heavy white (Lochia alba)
Duration of bleeding is variable - only 1 in 10 women still bleed 6 weeks post partum
Passage of clots is not normal - except for one passed on day 3/4
Endometrium regulates - if no lactation, new endometrium after 3 weeks and period is due 6 weeks after birth. If lactation, ovarian activity is suppressed so menses may be delayed by several months.

Question 7

What other changes occur?

Answer 7

Skeletal muscle - devarication of the recta resolves depending on pre-pregnancy laxity, parity, level of physics activity.

Skeleton - ligament laxity resolves

Cardiovascular function - the increased PR at term and increased cardiac output reverses by 6 weeks post partum

Question 8

How does blood change post-partum?

Answer 8

Haematological indices should start to become normal.

Hb - Hb increases
WBCs - Very high immediately after birth. Changes are persistent for longer than 8 weeks postpartum.
Platelets - rise rapidly to pre-pregnancy values
Fe - Deceased at term but normal by 5-8 weeks postpartum.

Question 9

How do hormone levels change post partum?

Answer 9

GGT AST, ALT - Increase after delivery

Cholesterol and triglyceride - Elevated at term fall slowly over many months irrespective of lactation.

Prolactin - elevated if lactating. If not, fall to pre-pregnant range in 2-3 weeks.

Thyroxine - Return to non-pregnant after 6 weeks.

Question 10

What positive psychological feeling can people feel after birth?

Answer 10

Satisfaction
Closer to partner
‘Falling in love’ with baby
Protective towards baby

Question 11

What negative psychological feelings can people have after giving birth?

Answer 11

DIssatisfaction, disappointment or distress over the delivery process.

Anxiety about the baby

Rejection of ambivalence about the baby

Jealousy - baby centre of attention

Guilt - breastfeeding

Physical discomfort and anxiety about physical damage during birth

Fears of harming the baby

Overwhelming responsibility

Loss of freedom

Question 12

What hormones help promote lactation?

Answer 12

Progesterone
Oestrogen
Prolactin

Question 13

Why is only minimal milk produced during pregnancy?

Answer 13

Oestrogen and progesterone inhibit effects of prolactin and placental lactogen by blocking the dopamine receptors.

Question 14

How is milk produced and secreted?

Answer 14

Dependant on the frequency and duration of suckling. Prolactin (therefore milk production) are highest just after birth and reduce slowly and return to normal after weaning.

Also depend on emptying of secreting glands. Milk = distention and atrophy.

Question 15

How is breast milk delivered?

Answer 15

Oxytocin causes contractions of the myoepithelial cells causing alveoli to contract and expel milk into milk collecting ducts.

These ducts then dilate and milk flows to middle.

This leads to the ‘let down’ reflex.

Fist lactation, volumes low and colostrum is produced (high fat and immunoglobulins). Then, amount of milk increases until 800ml a day.

Question 16

What is in breast milk?

Answer 16

Human milk differs from other mammalian milk.

Human milk:
Lower salt 
Higher energy 
Less protein 
More lactose 
More digestible by the human baby. 

Also varies depending when.

Question 17

What are the functions of breast milk?

Answer 17

Protection form infection

• Lactoferrin binds iron to prevent E.coli
• Colonisation of neonatal gut by non-pathogenic bacteria
• Bacteriocidal enzymes present
• Cells part of cell mediated immunity are present
• Immunoglobulins are present - IgA

Question 18

In what circumstances should formula feeding be Vivienne instead of breast milk?

Answer 18

Maternal illness
HIV
Medications

Question 19

What breast problems can present if breast feeding?

Answer 19

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

Question 20

What problems can occur early in post-partum period?

Answer 20

Postpartum haemorrhage (PPH) - primary or secondary - uterus doesn’t contract and have hose like BP bleeding out. Can loose 1L in minutes.

Retained placenta / placental tissue - infection (can cause PPH)

Uterine inversion

Perineal trauma and sequelae

Maternal collapse

Cardiac arrest

Thromboembolic disease

Puerperal pyrexia / sepsis - sources: Genital tract, urinary tract, lactation ducts

Question 21

What mental health conditions can occur perinatally?

Answer 21

Postnatal blue (baby blues) - peaks at D4-5. It is self limiting in 85% of women and is managed by reassurance and support.

Postpartum depression

• Symptoms occur within 4 weeks of delivery
• Affects 13% of women
• Depression symptoms
• 70% risk of recurrence
• If it lasts over 1 month then major

Puerperal psychosis

PTSD

Question 22

What is puerperal psychosis?

Answer 22

rare but 30% occurs in women in pre-existing mental illness.

• Recurrent risk = 25%
• Usually present in 1st month of delivery
• Can be as easily a D4

The risk is to the mother (suicide = 5%) as well as baby (infanticide risk = 4%)
Accurate and timely diagnosis is key
Symptoms include: restlessness, anxiety, mania, paranoid thought and delusions, all easily missed / attributed to other reasons.

Question 23

What is PTSD after childbirth?

Answer 23

1.5% risk ad can occur up to 6 weeks post partum
Required recognition
Management is psychological therapies
Symptoms include: restlessness, anxiety, mania, paranoid thought and delusions (same as psychosis)

Question 24

How does sexuality and sexual function change after pregnancy?

Answer 24

Altered perception of body and changes due to pregnancy
Worried about getting pregnancy again
Perineal trauma
Dyspareunia (painful sex) due to low oestrogen and other causes

Question 25

Why is it important to discuss contraception after a baby?

Answer 25

Important to prevent unintended pregnancy and closely spaced pregnancies after childbirth.

Ask about it after childbirth as it is often ignored.

Can save lives - reduce suicide and other maternal deaths.

Save babies lives - prevent 1 in 10 deaths if space pregnancies more than 2 years apart

Timing of return of fertility is variable and unpredictable.