The Pueperium

Question 0

Main changes in the puerperium

Answer 0

• uterus involutes from 1kg to 100g
  
  • felt at umbilicus after delivery, pelvic organ at 10 days
  • internal os closes by 3 days, external os by 3wks
• lochia is passed PV (endometrial slough, red cells, white cells)
  
  • red for first 3 days (lochia rubra)
  • yellow for next 10 days (lochia serosa)
  • white until 6wks (lochia alba)
• breasts produce milky discharge and colostrum during the last trimester
  
  • milk replaces colostrum 3 days after birth
  • breasts are swollen, red and tender with physiological enlargement at 3-4 days

Question 1

Time frame of the puerperium

Answer 1

6wks after delivery

Question 2

Signs of retained products

Answer 2

• persistent red lochia
• failure of uterine involution
• PPH

Question 3

Puerperal psychosis

Answer 3

1:500 births

Distinguished from mild depression that often follows birth by a high suicidal drive, severe depression, mania and more rarely schizophrenic symptoms with delusions that the child is malformed.

If acute organic reaction is present, suspect puerperal infection.

Presentation by day 7 in 50%, by 3 months in 90%. Onset is usually sudden and deterioration rapid.

Admission to specialist mother and baby unit may be needed.

Question 4

6wk post natal examination

Answer 4

• see how mother and baby relate
• BP and weight
• FBC if anaemic post natally
• arrange cervical smear if due
• check contraceptive plans
• ask about
  
  • depression
  • back ache
  • incontinence
  • resuming intercourse (abstinence or gentle intercourse recommended for first 6wks to prevent fatal air embolism)

Question 5

Contraception after baby

Answer 5

Lactational amenorrhoea (LAM)

• nature’s contraception
• breast feeding delays return of ovulation
  
  • suckling disrupts frequency and amplitude of gonadotrophin surges so ovulation does not occur
• if breast feeding day and night (ie breast milk is baby’s sole nutrient) and are less than 6 months post partum and amenorrhoeic can expect this method to be 98% effective
• average first period at 28wks if breast feeding
• contraceptive efficacy decreases after 6 months, if periods return, if frequency reduces, if baby receives supplements, or if ill/stressed

In UK although 69% of mothers initiate breast feeding only 21% still feed at 6 months

PoP

• can be started anytime post-partum, does not effect breast milk production
• low doses secreted in milk but do not effect babies

COCP

• effect early milk production and not recommended if breast feeding until 6 months
• start at 3wks if not breast feeding

Emergency contraception

• progesterone method suitable for all
• not needed before day21

Depot injections
- not recommended until 6wks if breast feeding

Progesterone implants
- not recommended until 6wks if breast feeding

IUCD
- should be inserted in first 48hrs or delayed until 4wks to minimise risk of uterine perforation

Diaphrams and caps
- will need to keep being refitted

Sterilisation
- best to wait an appropriate time after as immediate postpartum tubal ligation has possible increased failure rare and more likely to be regretted

Question 6

Advantages of breast feeding

Answer 6

• suckling promotes uterine contraction, so avoiding some PPHs
• breast feeding induced oxytocin surges promote trust and diminish fear
• less insulin resistance, HTN and obesity (growth is less rapid) due to increased breast milk long-chain polyunsaturated fatty acids (may also increase IQ)
• breast milk is cheap and clean and gives babies an attractive smell
• colostrum has endorphins - good for birth-associated stress
• IgA, macrophages, lymphocytes (with interferon) and lysozyme protect from infection
  
  • acids in breast milk promote growth of friendly lactobacilli in baby’s bowel
  • gastroenteritis may be less severe if mother makes and transfers antibodies
• infant mortality, otitis media, pneumonia, diarrhoea are less if breast fed
• breast milk contains less Na, K, and Cl than other milk, so aiding homeostasis. If dehydration occurs less risk if fatal hypernaturaemia.
• exclusive breast feeding may reduce risk of:
  
  • type 1 diabetes
  • rheumatoid arthritis
  • IBD
  • food allergy/atopy (if +ve fhx)
• breast feeding helps mothers lose weight, and is contraceptive
• some protection in menopausal years against maternal breast cancer

To reduce allergies, US says to delay weaning till 6months, cows milk till 1yr, egg to 2yrs, and peanuts, tree nuts, fish to 3yrs. (Conflicting evidence)