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The Post-partum Period Flashcards

1
Q

When is the post partum period?

A

period from the delivery of the placenta to six weeks after this

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2
Q

What occurs in the post-partum period?

A

The body returns to pre-pregnancy state

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3
Q

How is post-natal care of the mother initially delivered?

A

Initially provided at home by the community midwife, where they provide advice on contraception, breastfeeding and checking episiotomy healing

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4
Q

After support from the community midwife, what other support is available for the mother?

A
  • health visitor will support, visiting at home

- encouraged to attend local clinics with babies, one a week for 6 weeks

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5
Q

What is a post-natal examination? What is assessed?

A

At examination performed at 6 weeks after labour.
Mother’s GP assesses woman’s physical health including blood pressure, breast, abdominal, pelvic and perineal examination, as well as her mental health and discussion about adjustment to motherhood.

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6
Q

What changes occur to the mother in the post partum period to revert back to pre-pregnancy state?

A 
Lowered oestrogen levels
Lower genital tract
Haematological and endocrine changes
CVS function
Skeletal muscle changes
Ligament laxity changes 
Reduction in Lochia 
Reduced bleeding
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7
Q

What is lochia?

A

Vaginal discharge post child birth. Consists of blood, fragments of decidua and mucus

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8
Q

In non breast feeding mothers, when does menstruation usually occur?

A

6 weeks post partum

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9
Q

How can menses be delayed post partum?

A

By breast feeding. Suckling intensity and frequency determine the length of anovulation and amenorrhoea

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10
Q

What psychological changes may be seen post partum?

A 
elation
protectiveness
anxiety
overwhelming responsibility
rejection of baby
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11
Q

Describe the ductal system of a lactating breast?

A

The breast consists of a series of secretory lobules, which empty into ductules. These ductules from 15 to 20 lobules combine into a duct, which widens at the ampulla—a small reservoir. The lactiferous duct carries the secretions to the outside

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12
Q

Inadequate uterine contraction can lead to what obstetric emergency?

A

Postpartum haemorrhage

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13
Q

Why does postpartum haemorrhage need urgent management?

A

To prevent major blood loss and CVS shock

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14
Q

What is secondary haemorrhage?

A

Prolonged or excessive bleeding once the mother has returned home.

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15
Q

What typically causes a secondary haemorrhage?

A

Infection (endometritis)

Retained products of contraception

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16
Q

What are the 4 T’s that cause PPH?

A
  • Tone (atony)
  • Tissue (e.g. retained placenta)
  • Thrombin (clotting disorder)
  • Trauma
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17
Q

What are common problems with the post partum period?

A 
Haemorrhage
Retained placenta/placental tissue
Uterine inversion
Perineal trauma
Maternal collapse/cardiac arrest 
Thromboembolic disease
Pyrexia / sepsis 
Mental health problems
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18
Q

What is primary and secondary post natal haemorrhage?

A

Primary (immediately baby born up until 24 hours after)

Secondary (24h – 6 weeks later; most present two or three weeks later with clots)

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19
Q

What post partum problems lead to the maternal collapse/cardiac arrest?

A

Amniotic fluid embolism
Hypoglycaemia
Hypotension/hypovolaemia

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20
Q

What are risk factors for thromboembolic disease?

A

Surgery
Obesity
Post-partum
Immobility

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21
Q

What are the 4 most common mental health problems that can manifest in the post partum period?

A

Postnatal blues
Post-partum depression
Puerperal psychosis
Post-traumatic stress disorder

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22
Q

What is postnatal blues?

A

Altered mood experienced due to hormonal changes that have occurred.
Other feels more anxious or tearful.
Normal for up to 2 weeks following delivery and peaks at day 4/5

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23
Q

What is post-partum depression?

A

Depression that occurs within the 4 weeks following delivery. Similar symptoms to depression outside of pregnancy

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24
Q

How is post-partum depression treated?

A

Management depends on the severity of the condition, and pharmacological treatments can be started if the symptoms are lasting greater than one month.

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25
Q

What is puerperal psychosis?

A

Occurs within 4 weeks of delivery. Psychiatric emergency. Severe symptoms include anxiety, mania, paranoid thoughts and delusions. Suicide risk is 5% while infanticide risk is 4%.

26
Q

What 2 hormones lead to full development of the breasts?

A

Human placental lactogen

Prolactin

27
Q

What are mammogenic hormones?

A

Hormones that promote proliferation of alveolar & duct cells

28
Q

What are lactogen if hormones?

A

Hormones that promote initiation of milk production

29
Q

What are galactokinetic hormones?

A

Hormones that promote contraction of the myoepithelial cells

30
Q

What are galactopoietic hormones?

A

Hormones that maintain milk production

31
Q

What is the main function of prolactin?

A

Milk production

32
Q

What is a powerful stimulus for the production of prolactin?

A

Suckling - stimulates neurones from the spinal cord to inhibit dopamine release from hypothalamus and the levels of prolactin increase

33
Q

How is prolactin release inhibited?

A

Normally inhibited by dopamine secreting neurones of the hypothalamus. Stops secretion from the anterior pituitary

34
Q

Where is oxytocin released to act on breast tissue?

A

Released from the spinal cord

35
Q

What action does oxytocin have in the breast?

A

Cause myoepithelial cells to contract and eject milk from ducts.

36
Q

Neurons in the arcuate nucleus and preoptic area of the hypothalamus are inhibited post-partum. Why is this?

A

So that the levels of GnRH fall. This leads to inhibition of the ovarian cycle so that other can continue lactation

37
Q

Before milk is produced, what is first produced at the breast glands?

A

Colostrum. This is a thin yellow milky fluid that contains high amounts of fat and immunoglobulins.

38
Q

How much milk can be produced a day from a lactating mother?

A

800mls a day.

39
Q

How does breast milk protect the baby from infection?

A
  1. Lactoferrin
  2. Populates neonatal gut with non-pathogenic flora
  3. Presence of bacteriocidal enzymes
  4. Contains specific immunoglobulins
  5. Contains lymphocytes (mainly T-cells) and granulocytes that
    play a role in cell-mediated immunity.
40
Q

Why is lactoferrin?

A

An iron-binding protein found in granules of neutrophils. Exerts an antimicrobial activity by withholding iron from ingested bacteria and fungi.

41
Q

What is puerperal mastitis?

A

Condition where milk accumulation in the breast can lead to inflammation, with or without infection. This typically occurs if the mother does not breastfeed with both breasts, and therefore milk can build up in the lactiferous ducts of the unused breast.

42
Q

In infective puerperal mastitis, what organism is commonly to blame?

A

Staphylococcus aureus, can lead to abscess formation

43
Q

How is puerperal mastitis treated?

A

First line treatment is usually continue feeding and increase the frequency esp on the affected side. Antibiotics can then be given after 24 hours if no improvement.

44
Q

What causes cessation of lactation?

A

Once lactation ceases, milk accumulates in the alveoli of the breast causing distention and atrophy of the glandular epithelium, thus the effects of local mechanical factors suppress milk secretion, rather than hormonal changes.

45
Q

How can lactation be artificially suppressed?

A

Dopamine agonists (bromocriptine)

46
Q

Why should contraception/family planning be introduced following childbirth?

A

Reduces both maternal and infant deaths

Reduces the risk of pre-term birth, low birth rate and small-for-gestational age babies.

47
Q

During the post natal examination, what aspects of the mothers life is asked about?

A

Urinary/bowel and sexual function
Incontinence
Dyspareunia or anxiety about sexual intercourse

48
Q

What are the anatomical changes that occur in the lower genital tract?

A

Changes occur secondary to low oestrogen levels. These are:
Reduction in size of vulva, vagina and cervix
Poor lubrication of the vagina (dyspareunia)
Transformation zone of the cervix withdraws into the endocervix
Internal os is closed

49
Q

Describe how haematology of the mother changes post-partum

A

Haemoglobin: diuresis occurs post partum, resulting in a reduction of plasma volume. There is therefore an increase in Hb level
WCC: very high in the post-partum period.
Platelet count: usually rises rapidly back to non-pregnant values
Serum ferritin, transferrin and iron: decreased at term

50
Q

What changes occur in preparation for lactation?

A

Hypertrophy in pre-existing alveolar-lobular structures of the breast.
Formation of new alveoli by budding from the milk ducts
Proliferation of milk ducts

51
Q

Why is milk not produced during pregnancy>=?

A

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.

52
Q

What is foremilk?

A

Milk that emerges at the start of suckling has a higher water content.

53
Q

What is hid milk?

A

Milk that emerges later after that start of suckling that is higher in fats and iron

54
Q

Which immunoglobulin passes from the mother to the fetus in breast milk?

A

Immunoglobulin A

55
Q

Why might formula feeding by advised?

A

Severe maternal illness
Maternal HIV
Mothers on medications that are contraindicated when breastfeeding

56
Q

What breast problems may occur post-partum?

A 
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
57
Q

What is primary PPH?

A

loss of >/= 500mls from the genital tract within 24hrs of the birth of a baby

58
Q

When is the time of highest risk of venous thrombosis and thromboembolism?

A

Post-partum period

59
Q

What is the leading cause of direct maternal death?

A

Venous thrombosis and thrombo embolism

60
Q

What is the most important consequence of VTE?

A

Pulmonary embolism

61
Q

How do we manage VTE?

A

Managed by assessing risk factors, taking preventative measures and then prompt diagnosis.

62
Q

How is VTE treated?

A

Treatment is with anti-coagulation- heparin, warfarin ( not to be used during pregnancy) , new anti-coagulants (NOACs)

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