The puerperium Flashcards
What is the puerperium?
The 6 week period following delivery, when the body returns to its pre-pregnant state.
What are the psychological changes in the genital tract in the puerperium?
The uterus contracts as soon as the placenta is separated to occlude blood vessels.
Uterine size reduces over 6 weeks and stops being palpable abdominally at 10 days.
Contractions/after pains may be felt for up to 4 days after.
Internal os closed by 3 days.
Lochia, a discharge from the uterus, may be blood-stained for 4 weeks, but is thereafter yellow or white.
Menstruation is delayed by lactation, but occurs at 6 weeks if a woman is not lactating.
What are the cardiovascular changes in the puerperium?
Cardiac output and plasma volume decrease to pre-pregnant levels within a week.
Loss of oedema can take up to 6 weeks.
If transiently elevated, blood pressure is usually normal within 6 weeks.
What are the urinary tract changes in the puerperium?
Physiological dilatation of pregnancy reduces over 3 months and glomerular filtration rate decreases.
What are the changes to blood in the puerperium?
Urea and electrolytes return to normal because of the reduction in GFR.
In the absence of haemorrhage, haemoglobin and haematocrit rise with haemoconcentration.
White blood count falls.
Platelet and clotting factors rise, predisposing to thrombosis.
What is done when a woman has a history of psychiatric illness?
Psychiatric referral.
What is lactation dependent on and what is the mechanism for it?
Lactation is dependent on oxytocin and prolactin.
Prolactin is released from the anterior pituitary and its levels are high in circulation at birth, but it is the decline of progesterone and oestrogen after birth that causes milk to be secreted.
Oxytocin from the posterior pituitary stimulates ejection in response to nipple suckling and also stimulates prolactin release and therefore more milk secretion.
Why can emotional or physical stress prevent lactation?
Because stress inhibits the hypothalamus which is what causes oxytocin release.
What is the fluid secreted in the first 3 days of lactation called and what does it contain?
It is called colostrum. It contains fat-laden cells, proteins (including immunoglobulins) and minerals. It is passed on for the first 3 days before milk comes along.
What is the correct positioning for breast feeding? What problems does the correct positioning reduce?
The baby’s lower lip should be planted below the nipple at the time that the mouth opens in preparation for receiving milk - this could prevent the main problems such as insufficient milk, engorgement, mastitis and nipple trauma.
What are the advantages of breast feeding?
Protection against infection in neonate. Bonding. Protection against cancers (mother) Cannot give too much Cost saving
What postnatal contraception is recommended?
Contraception is not required until around 6 weeks post-partum.
COCP is contra-indicated in those who are breast feeding.
POP is fine when a woman is breast feeding.
IUD is inserted either in the first 24 hours after with or 6 weeks later.
What is primary postpartum haemorrhage and how common is it?
Primary postpartum haemorrhage (PPH) is the loss of >500mL of blood <24 hours of delivery.
It occurs in 10% of women and remains the major cause of maternal mortality.
What are the causes of primary postpartum haemorrhage?
Retained placenta
Uterine causes (account for 80%). The uterus fails to contract properly, either because it is atonic or because there is retained placenta. Atony is more common with multiple pregnancies, polyhydromnios, prolonged labour and fibroids.
Vaginal causes (account for 20%). Bleeding from a perineal tear is obvious, but a high vaginal tear must be considered.
Cervical tears and coagulopathy are rare.
How is primary postpartum haemorrhage prevented?
The routine use of oxytocin in the third stage of labour reduces the incidence of PPH by 60%.
