The Post-Partum Period

Question 1

Define the post partum period

Answer 1

The period from delivery of the placenta → 6 weeks after this

Question 2

How is a new mum looked after at home following birth?

Answer 2

Statuatory visits from midwives for at least 10 days post delivery, up to 28 days if necessary

Question 3

What kind of things are checked at the 6 week post natal examination?

Answer 3

• Asssess woman’s mental and physcial health
  
  • BP, breasts, abdominal, pelvic and perineal examination
• Questions about urinary bowel and sexual function
• Any issues of anxiety from the mother

Question 4

What 2 important things should be discussed with a post partum mother regarding their health?

Answer 4

• Perform a cervical smear if one was due whilst pregnant
• Contraception

Question 5

What drives the anatomical and changes in the post partum period?

Answer 5

Low oestrogen

Question 6

What anatomical changes occur in the lower genital tract the post partum period?

Answer 6

Reverting to pre-pregnancy state:

• Reduction in size of vulva, vagina and cervix
• Poor lubrication of vagina
• Transformation zone of the cervix withdraws into endocervix
• Internal os closes

Question 7

How does post partum bleeding change?

Answer 7

• Initially bleeding is heavy (lochia rubra)
• Changes from red-brown → red pink → heavy white (lochia alba)
• Passage of clots is not normal
• Menstrual bleeding usually returns by 6th week post partum but can be delayed several months if breastfeeding

Question 8

How do levels of prolactin change in the lactating women vs the non lactating women, post birth?

Answer 8

If lactatating levels of prolactin remain elevated

If non-lactating levels of prolactin fall to normal by weeks 2-3 post partum

Question 9

What are 4 of the causes of Post partum haemorrhage?

Answer 9

‘The 4 Ts’

• Tone e.g. inadequate uterine category
• Tissue e.g. retained placenta
• Thrombin (clotting disorder)
• Trauma

Question 10

How does secondary haemorrhage occur post partum?

Answer 10

Typically presents in priary care as prolonged/ excessive period once mother has returned home.

Typicallu caused by infection (endometritis) and/ or retained products of conception

Question 11

What is the difference in time period between primary and secondary haemorrhage?

Answer 11

Primary: from birth til 24hrs after

Secondary: 24hrs to 6 weeks later

Question 12

What is the postnatal high?

Answer 12

The hours after childbirth characterised by a degree of elation

Question 13

What is the baby blues?

Answer 13

A period after delivery where mood is altered due to hormonal changes that occur

Usually peaks at day 4/5 and occurs in 85% of women

Question 14

What is post-partum depression?

Answer 14

Occurs within 4 weeks of delivery with similar symptoms of depression outside of pregnancy

Occurs in 13% of women

Question 15

What is puerperal psychosis?

Answer 15

A rare psychiatric emergency including symptoms of anxiety, mania, paranoia and delusions

Occurs within 4 weeks of delivery, 30% of cases occur in women with pre-exisiting mental illness

Question 16

How common is PTSD in post partum women?

Answer 16

Occurs in 1.5% of women

Question 17

Identify the features of the lactating breast

Answer 17

Question 18

How do hormonal changes affect the the breast post partum?

Answer 18

Progesterone, oestrogen, prolactin, growth hormone and adrenal steroids cause hypertrophy of pre existing alveolar-lobar structures in the breast

Formation of new alveolae by budding from the milk ducts and proliferation of milk collecting ducts

Question 19

What is the main driver for prolactin release?

Answer 19

Action of baby suckling at the nipple

Question 20

Which hormone cases milk let down and how?

Answer 20

Oxytocin

Causes contraction of the myoepithelial cells around the alveolae so they expel milk into milk collecting ducts

Question 21

What is colostrum?

Answer 21

The initial milk volume that is produced that is high in fat and immunoglobins

Question 22

How does beast milk protect a baby from infection?

Answer 22

It contains:

• Lactoferrin - binds Fe²⁺ to prevent proliferation of E.coli
• Populates neonatal gut with non-pathogenic flora
• Contains bacteriocidal enzymes
• Contains immunoglobins
• Contains lymphocytes (mainly T cells) and granylocytes

Question 23

The immunoglobins that are present in breast milk are formed where?

Answer 23

In the Peyer’s patches of the mothers gut

Question 24

Which is the main immunoglobin passed to the baby by breastfeeding?

Answer 24

IgA

Question 25

Explain the let down reflex in the delivery of breast milk

Answer 25

1. Baby suckling stimulates mechanoreceptors in the nipple releasing oxytocin
2. Ascending sensory information sent to the hypothalmus
3. Neurones in the arcuate nucleus and preoptic area of the hypothalmus are inhibited and GnRH levels fall → inhibits ovarian cycle
4. Prolactin inhibiting hormone is inhibited causing levels of prolactin to rise
5. Prolactin increases milk secretion in the breast

Question 26

What medical indications are there for formula feeding?

Answer 26

• severe maternal illness
• maternal HIV
• mothers medication contra indicated when breastfeeding

Question 27

What is puerperal mastitis?

Answer 27

A condition where milk accumulation in the breast can lead to inflammation (+/- infection)

Occurs when the mother does not breastfeed with both breasts so milk builds up in the lactiferous ducts of the unused breast

Question 28

Which organism typically causes infection in puerperal mastitis?

Answer 28

Staphylococcus aureus

Can cause abscesses

Question 29

Which hormone antagonises prolactin?

Answer 29

Dopamine