The Post-partum Period Flashcards
When is the post partum period?
period from the delivery of the placenta to six weeks after this
What occurs in the post-partum period?
The body returns to pre-pregnancy state
How is post-natal care of the mother initially delivered?
Initially provided at home by the community midwife, where they provide advice on contraception, breastfeeding and checking episiotomy healing
After support from the community midwife, what other support is available for the mother?
- health visitor will support, visiting at home
- encouraged to attend local clinics with babies, one a week for 6 weeks
What is a post-natal examination? What is assessed?
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.
What changes occur to the mother in the post partum period to revert back to pre-pregnancy state?
Lowered oestrogen levels Lower genital tract Haematological and endocrine changes CVS function Skeletal muscle changes Ligament laxity changes Reduction in Lochia Reduced bleeding
What is lochia?
Vaginal discharge post child birth. Consists of blood, fragments of decidua and mucus
In non breast feeding mothers, when does menstruation usually occur?
6 weeks post partum
How can menses be delayed post partum?
By breast feeding. Suckling intensity and frequency determine the length of anovulation and amenorrhoea
What psychological changes may be seen post partum?
elation protectiveness anxiety overwhelming responsibility rejection of baby
Describe the ductal system of a lactating breast?
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
Inadequate uterine contraction can lead to what obstetric emergency?
Postpartum haemorrhage
Why does postpartum haemorrhage need urgent management?
To prevent major blood loss and CVS shock
What is secondary haemorrhage?
Prolonged or excessive bleeding once the mother has returned home.
What typically causes a secondary haemorrhage?
Infection (endometritis)
Retained products of contraception
What are the 4 T’s that cause PPH?
- Tone (atony)
- Tissue (e.g. retained placenta)
- Thrombin (clotting disorder)
- Trauma
What are common problems with the post partum period?
Haemorrhage Retained placenta/placental tissue Uterine inversion Perineal trauma Maternal collapse/cardiac arrest Thromboembolic disease Pyrexia / sepsis Mental health problems
What is primary and secondary post natal haemorrhage?
Primary (immediately baby born up until 24 hours after)
Secondary (24h – 6 weeks later; most present two or three weeks later with clots)
What post partum problems lead to the maternal collapse/cardiac arrest?
Amniotic fluid embolism
Hypoglycaemia
Hypotension/hypovolaemia
What are risk factors for thromboembolic disease?
Surgery
Obesity
Post-partum
Immobility
What are the 4 most common mental health problems that can manifest in the post partum period?
Postnatal blues
Post-partum depression
Puerperal psychosis
Post-traumatic stress disorder
What is postnatal blues?
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
What is post-partum depression?
Depression that occurs within the 4 weeks following delivery. Similar symptoms to depression outside of pregnancy
How is post-partum depression treated?
Management depends on the severity of the condition, and pharmacological treatments can be started if the symptoms are lasting greater than one month.
What is puerperal psychosis?
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%.
What 2 hormones lead to full development of the breasts?
Human placental lactogen
Prolactin
What are mammogenic hormones?
Hormones that promote proliferation of alveolar & duct cells
What are lactogen if hormones?
Hormones that promote initiation of milk production
What are galactokinetic hormones?
Hormones that promote contraction of the myoepithelial cells
What are galactopoietic hormones?
Hormones that maintain milk production
What is the main function of prolactin?
Milk production
What is a powerful stimulus for the production of prolactin?
Suckling - stimulates neurones from the spinal cord to inhibit dopamine release from hypothalamus and the levels of prolactin increase
How is prolactin release inhibited?
Normally inhibited by dopamine secreting neurones of the hypothalamus. Stops secretion from the anterior pituitary
Where is oxytocin released to act on breast tissue?
Released from the spinal cord
What action does oxytocin have in the breast?
Cause myoepithelial cells to contract and eject milk from ducts.
Neurons in the arcuate nucleus and preoptic area of the hypothalamus are inhibited post-partum. Why is this?
So that the levels of GnRH fall. This leads to inhibition of the ovarian cycle so that other can continue lactation
Before milk is produced, what is first produced at the breast glands?
Colostrum. This is a thin yellow milky fluid that contains high amounts of fat and immunoglobulins.
How much milk can be produced a day from a lactating mother?
800mls a day.
How does breast milk protect the baby from infection?
- Lactoferrin
- Populates neonatal gut with non-pathogenic flora
- Presence of bacteriocidal enzymes
- Contains specific immunoglobulins
- Contains lymphocytes (mainly T-cells) and granulocytes that
play a role in cell-mediated immunity.
Why is lactoferrin?
An iron-binding protein found in granules of neutrophils. Exerts an antimicrobial activity by withholding iron from ingested bacteria and fungi.
What is puerperal mastitis?
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.
In infective puerperal mastitis, what organism is commonly to blame?
Staphylococcus aureus, can lead to abscess formation
How is puerperal mastitis treated?
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.
What causes cessation of lactation?
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.
How can lactation be artificially suppressed?
Dopamine agonists (bromocriptine)
Why should contraception/family planning be introduced following childbirth?
Reduces both maternal and infant deaths
Reduces the risk of pre-term birth, low birth rate and small-for-gestational age babies.
During the post natal examination, what aspects of the mothers life is asked about?
Urinary/bowel and sexual function
Incontinence
Dyspareunia or anxiety about sexual intercourse
What are the anatomical changes that occur in the lower genital tract?
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
Describe how haematology of the mother changes post-partum
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
What changes occur in preparation for lactation?
Hypertrophy in pre-existing alveolar-lobular structures of the breast.
Formation of new alveoli by budding from the milk ducts
Proliferation of milk ducts
Why is milk not produced during pregnancy>=?
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.
What is foremilk?
Milk that emerges at the start of suckling has a higher water content.
What is hid milk?
Milk that emerges later after that start of suckling that is higher in fats and iron
Which immunoglobulin passes from the mother to the fetus in breast milk?
Immunoglobulin A
Why might formula feeding by advised?
Severe maternal illness
Maternal HIV
Mothers on medications that are contraindicated when breastfeeding
What breast problems may occur post-partum?
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
What is primary PPH?
loss of >/= 500mls from the genital tract within 24hrs of the birth of a baby
When is the time of highest risk of venous thrombosis and thromboembolism?
Post-partum period
What is the leading cause of direct maternal death?
Venous thrombosis and thrombo embolism
What is the most important consequence of VTE?
Pulmonary embolism
How do we manage VTE?
Managed by assessing risk factors, taking preventative measures and then prompt diagnosis.
How is VTE treated?
Treatment is with anti-coagulation- heparin, warfarin ( not to be used during pregnancy) , new anti-coagulants (NOACs)
