The Puerperium

Question 1

The puerperium is the period of about six weeks after childbirth during which the mother’s reproductive organs return to their original non-pregnant condition.

What physiological changes occur in the puerperium?

Answer 1

• by 6 weeks most changes of pregnancy, labour + delivery have resolved
• uterus: 1000g → 50-100g; endometrial lining rapidly regenerates (16days); contractions normal for 4 days post-delivery; lochia may be bloody for up to 4wks; menstruation delayed (12wks)
• platelets + clotting factors rise increasing risk of thrombosis

Question 2

What is postnatal depression?

Answer 2

• depressive episode within first 12 months postpartum
• usually peaks 2 months after childbirth
• different from baby blues - a period of low mood + irritability, starts 3-4 days after birth and lasts for 7 days
• urgent referral to specialist mental health services if severe
• social support + psychological treatments appropriate
• consider breastfeeding if severe/needs medication
• seek advice from perinatal psychiatry services

Question 3

What is postpartum (puerperal) psychosis?

Answer 3

• extremely severe, needs to be recognised early
• starts within days-weeks of delivery
• 1 in 1000
• prev episode of postpartum psychosis = 50% chance of it recurring in next pregnancy
• features: confused, distracted, quiet, withdrawn, agitated, distressed, paranoia, grandiose delusions, auditory hallucinations, sleep disturbance
• prompt assessment by Specialist Mental Health services
• risk assessment - suicide, harm, self-neglect, baby
• treat under MHA
• take 6-12 months to recover fully

Question 4

MLGI

What are the 4 stages of lactation?

Answer 4

1. mammogenesis → growth of breasts
2. lactogenesis → functional change of breast tissue allowing it to secrete milk
3. galactopoesis → maintaining production of milk
4. involution → termination of milk production

Question 5

What are the roles of different hormones in the physiology of lactation?

Answer 5

• progesterone → high levels inhibit lactation, before birth + then drop
• oestrogen → stimulates milk duct system then drop after birth allowing lactation
• prolactin → differentiation of ductal structures, role in regulating milk production
• FSH, LH + hCG are essential
• growth hormone contributes to galactopoiesis
• oxytocin contracts smooth muscles to squeeze milk into duct system
• at birth, abrupt withdrawal of progesterone in the presence of high prolactin level stimulates copious milk production
• colostrum is the first milk a breastfed baby receives, containing higher amounts of WBCs + antibodies, esp IgA

Question 6

What are advantages of breastfeeding?

Answer 6

• promotes bonding
• free, no prep
• protection from infection
• cannot over-feed
• nutrients, healthy digestive system, strengthens immunity, may boost IQ
• reduces malginancy risk
• helps uterus shrink faster + weight loss

Question 7

What are disadvantages of breastfeeding?

Answer 7

• embarrassment/stigma
• discomfort
• unable to measure baby’s intake
• nipple trauma, mastitis
• care with medication, caffeine, alcohol
• can impact return to work

Question 8

What drugs are safe in mothers who are breastfeeding?

Answer 8

• antibiotics → penicillins, cephalosporins, trimethoprim
• endocrine → glucocorticoids (avoid high doses), levothyroxine
• epilepsy → sodium valproate, carbamazepine
• asthma → salbutamol, theophyllines
• psych drugs → tricyclic antidepressants, antipsychotics (bar clozapine)
• hypertension → beta-blockers, hydralazine
• anticoagulants → warfarin, heparin
• digoxin

Question 9

What drugs should be avoided in breastfeeding?

Answer 9

• antibiotics → ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
• psych drugs → lithium, benzodiazepines
• aspirin
• carbimazole
• methotrexate
• sulfonylureas
• cytotoxic drugs
• amiodarone

Question 10

What factors are involved in mother-child bonding?

Answer 10

• pregnancy → bonding beings around 18-25wks + mother can feel foetus moving which enhances bonding
• childbirth → enhances maternal bond but negative exp in pregnancy may strain mother-child bond
• breastfeeding → oxytocin, produced during lactation, relieves anxiety + helps to enhance bonding; touch, mutual gazing + response also fosters bonding