The Puerperium and Breastfeeding

Question 1

Define ‘puerperium’

Answer 1

The time after childbirth (from delivery of placenta) to 6-8 weeks later, during which physiological and anatomical changes take place, particularly in the reproductive, urinary and cardiovascular changes

Question 2

What key physiological changes occur during the puerperium?

Answer 2

Involution of uterus (return to normal size and tone), lochia, cardiovascular changes, hormone effects, renal function and urinary structure adaptations, lactation and breastfeeding

Question 3

Describe the process of involution of the uterus

Answer 3

Changes to myometrium to return normal thickness (ischaemia, autolysis and phagocytosis)) and changes to the endometrium (lining shed as lochia and there is regeneration of the endometrium, superficial layer sloughs off in lochia)

Question 4

What is lochia?

Answer 4

The normal discharge from the uterus after childbirth.

Question 5

What type of lochia is present up to 3 days post-partum?

Answer 5

Lochia rubra; a red discharge, variable amount of fresh blood, with decidua like debris

Question 6

What type of lochia is present up to 10 days post-partum?

Answer 6

Lochia serosa; a pink discharge which has small red cells, leukocytes and necrotic decidua

Question 7

What type of lochia is present after 10 days post-partum?

Answer 7

Lochia alba; a yellow-white serous fluid with leukocytes and sweetish odour

Question 8

Describe the haematological changes that take place in the puerperium

Answer 8

Transitional increase in coagulation to maximise clot formation on the 1st day afer birth, thereafter there is a reduction in plasma volume to resolve the haemodilution present in pregnancy and Hb concentration increases on the 1st day after birth to prevent any further anaemia

Question 9

Describe the cardiovascular changes that take place in the puerperium

Answer 9

Reduced CO within 48 hours due to oestrogen withdrawal (reduction in plasma volume), increased peripheral vascular resistance, removal of excess tissue fluid resulting in return of tissues to normal vascular tone due to progesterone withdrawal

Question 10

Describe the respiratory changes that take place in the puerperium

Answer 10

Reduction in compression of the lungs, no more shortness of breath and less oxygen demand

Question 11

Describe the renal changes that take place in the puerperium

Answer 11

Dilatation of kidney ceases and return to their pre-pregnant state, but there is increase in diuresis and excretion of breakdown products following pregnancy which puts extra work on the kidneys

Question 12

Describe the hormonal changes that take place in the puerperium

Answer 12

Once the placenta is delivered, there is a reduction in oestrogen, progesterone and prolactin production

Question 13

Define mamogenesis

Answer 13

mammary duct-gland growth and development

Question 14

Define lactogenesis

Answer 14

initiation of milk secretion in the alveoli

Question 15

Define galactopoeisis

Answer 15

maintenance of lactation

Question 16

Define galactokinesis

Answer 16

removal of milk from the gland

Question 17

Describe the process of mamogenesis

Answer 17

In pregnancy, oestrogen stimulates growth of lactiferous ducts and tubules and progesterone, prolactin and hPL stimulate enlargement of alveoli and promote fat deposition. Thereafter the nipples and areola become pigmented and colostrum is formed under influence of hPL and prolactin but high oestrogen and progesterone levels prevent the formation of milk

Question 18

Describe the process of lactogenesis

Answer 18

Initiation of milk secretion in breast tissue in pregnancy –> production of colostrum and transitional milk following fall in plasma progesterone and high levels of prolactin –> maintenance of established lactation of removal of milk by the baby (~10 days after birth)

Question 19

Describe the role of prolactin in lactogenesis

Answer 19

secreted in the anterior pituitary gland, and impulses from the nipple go to the brain during feeding and causing prolactin secretion

Question 20

Describe the process of galactokinesis

Answer 20

This is the milk let-down reflex performed by oxytocin secreted by the anterior pituitary gland in response to suckling and causes contraction of the myoepithelial cells surrounding the alveoli to propel the milk into the ducts and out of the nipple to feed the baby

Question 21

What are the advantages of breastfeeding for the baby?

Answer 21

Provides immunity, less chance of D&V, fewer infections, less chance of constipation, less likely to be obese in later life and reduces allergy incidence

Question 22

What are the advantages of breastfeeding for the mother?

Answer 22

Lowers risk of breast and ovarian cancer, facilitates faster weight loss, saves money, helps to forma stronger bond and provides a sense of achievement

Question 23

What are some of the disadvantages of breastfeeding?

Answer 23

Unable to measure the amount of milk a baby is getting, some women find it difficult, tiring and stressful, it’s difficult to leave the baby for long periods except for when expressing, father is unable to feed the baby, sometimes it’s difficult to wean baby off the breast

Question 24

What are some of the medical reasons for not breastfeeding?

Answer 24

Maternal infection such as HIV or certain medications which may affect the baby

Question 25

What causes sore nipples in breastfeeding?

Answer 25

Due to friction as a result of incorrect positioning and attachment, and this can be resolved by use of correct attachment, and can rub the milk around the nipple after a feed for protection and leave to dry

Question 26

What causes engorgement in breastfeeding?

Answer 26

Build up of milk in the ducts, causing the breast to feel lumpy, hard, painful and can result in a flat nipple. This is caused by insufficient emptying of the breast, due to incorrect positioning or restricted feeding.. This can be resolved by hand expressing, correct attachment and massage.

Question 27

What causes mastitis in breastfeeding?

Answer 27

If milk is not removed from the breast, it will backtrack and this can lead to the development of infection, causing breast pain, swelling, discharge and tenderness. In the first instance continue to feed as normal to try and resolve milk blockage, but antibiotics should be supplied if there is no improvement in 12-24 hours