puerperium and breast feeding

Question 1

what is the puerperium?

Answer 1

time after childbirth lasting approximately 6-8 months

Question 2

what are the key hormonal effects and physiological changes?

Answer 2

• Involution of the uterus
• Characteristics of lochia
• Haematological changes
• Cardiovascular changes
• Respiratory and metabolic changes
• Renal function, urinary structures and H2O metabolism
• Changes in GIT, neuromuscular, and integumentary systems
• Lactation & Breastfeeding

Question 3

what is involution of the uterus?

Answer 3

when the uterus returns to its pre-pregnant state

Question 4

why cant you palpate the fundus of the uterus 10 days after birth?

Answer 4

its reduced in size below the pubic symphysis

Question 5

how long does involution last?

Answer 5

6 weeks

Question 6

what does involution of the uterus involve?

Answer 6

changes to the myometrium and endometrium

Question 7

how does the myometrium return to its normal thickness?

Answer 7

• ischaemia - contraction of the empty uterus = reduction of blood supply to the uterus = deoxygenation and ischaemia
• autolysis - proteolytic enzymes self-ingest myometrial cells –> removal of redundant muscle fibres and cytoplasm
• phagocytosis: phagocytes engulf and remove waste products from kidneys

Question 8

what layer is a new source of the endometrium?

Answer 8

basal layer adjacent to the myometrium which remains intact

Question 9

what layer is removed in locia?

Answer 9

superficial decidua layer

Question 10

what is locia?

Answer 10

consists of RBCs, lucocytes, shreds of decidua and organism

Question 11

what are the different types of locia?

Answer 11

o Lochia Rubra (Red) Up to 3 days
o Lochia Serosa (Pink) Up to 10 days
o Lochia Alba (Yellowish-white) Diminishes over 3-6 weeks

Question 12

what haematological changes occur during puerperium?

Answer 12

• increase in coagulation
• Hb and haematocrit levels increase in the first few days post-partum
• increase in WBCs
• withdrawal of oestrogen = reduction in plasma volume

Question 13

how long does it take for plasma volume to return to normal?

Answer 13

1 week after delivery

Question 14

what cardiovascular changes occur during puerperium?

Answer 14

• reduction in plasma volume = reduction in blood circulatory volume
• Reduction in CO, HR and SV to pre-labour value
• decrease in progesterone –> removal of excess tissue fluid –> tissues return to normal vascular tone by 2 weeks

Question 15

what respiratory changes occur during puerineum?

Answer 15

• no more shortness of breath bc reduction in lung compression bc reduction in uterine size –> allows for full inflation of lungs
• no more hyperventilation - less O2 demand bc reduction in cardiac work and circulatory volume
• all respiratory values return to normal within 6 weeks

Question 16

why do you experience no more shortness of breath after delivery?

Answer 16

Reduction in compression of lungs due to reduction in uterine size –> full inflation of the lungs

Question 17

why do you no longer experience hyperventilation after delivery?

Answer 17

Less oxygen demand bc reduction in cardiac work and circulatory volume

Question 18

what renal changes occur?

Answer 18

• Dilatation of renal tract resolves
• Renal organs return to their pre-pregnant state
• Displaced bladder, dilated ureters and renal pelvis return to normal size within 8 wks.
• Increased diuresis (physiological diuresis) occurs between 2nd & 5th day

Question 19

what GIT changes occur?

Answer 19

• GI motility, food absorption and lower oesophageal sphincter pressure are decreased during pregnancy
• Slower gastric emptying time during labour –> gastric volume is increased
• GI changes go back to non-pregnant state within 6 weeks

Question 20

what neurological changes occur?

Answer 20

CNS and PNS are more sensitive

returns to normal 36hrs postpartum

Question 21

what changes occur to the integumentary syste,s?

Answer 21

• Relaxin causes ligamentous relaxation + softening of collagenous tissues –> lordosis during pregnancy. (up to 5 months to return back to normal. )
• Abdominal wall and ligaments and hyperpigmentation of certain body parts e.g. face, beck and midline of the abdomen, require about 6 weeks to return to non-pregnant state

Question 22

what hormones prevent lactation during pregnancy and how?

Answer 22

oestrogen and progesterone

inhibit milk synthesis

Question 23

describe the anatomy of the breast

Answer 23

• 15-25 lobes
• 20-40 lobules
• Alveoli
• Milk ducts
• Lactiferous sinuses
• They contain – glandular & connective tissue, myoepithelial cells, blood, lymph, nerve & fat.

Question 24

what is mamogenesis?

Answer 24

Mammary duct-gland growth & development

Question 25

what is lactogenesis?

Answer 25

Initiation of milk secretion in alveoli

Question 26

what is galactogenesis?

Answer 26

Removal of Milk from the breast

Question 27

what hormones are involved in mamogenesis and when do they start to increase?

Answer 27

oestrogen, progesterone, prolactin and human placental lactogen increase from 6th week

Question 28

what does oestrogen do in mamogenesis?

Answer 28

growth of lactiferous ducts and tubules and increase in breast size

Question 29

what do progesterone, prolactin and human placental lactogen (HPL) do in mamogenesis?

Answer 29

proliferation and enlargement of alveoli, promote fat deposition and stimulates development of lobes and lobules

Question 30

describe what happens at 12, 16 and 24 weeks of mamogenesis?

Answer 30

* 12th week – nipple and aerola become more pigmented. Montgomery’s tubercles begin secreting lubricants * 16th week – colostrum (first milk) formed under influence of HPL and prolactin * 24th week – secondary alveoli have formed

Question 31

what is lactation?

Answer 31

physiological completion of the reproductive cycle

Question 32

what are the 3 stages of lactogenesis and what occurs in each of them?

Answer 32

o Lactogenesis I – initiation of milk secretion in breast tissue during pregnancy o Lactogenesis II – following 3rd stage, production of colostrum and transitional milk following the fall in plasma progesterone and high levels of prolactin o Lactogenesis III – begins about day 10 – maintenance of established lactation and removal of milk by baby

Question 33

where is prolactin secreted from?

Answer 33

anterior pituitary

Question 34

where is oxytocin secreted from?

Answer 34

posterior pituitary gland

Question 35

where do milk ejection signals go? what triggers them?

Answer 35

brain to nipple | triggered by sight, sound, smell and touch of baby

Question 36

what are the breast feeding benefits to the baby?

Answer 36

- natural food designed for the baby - protection from infection and disease - less chance of vomiting, diarrhoea and constipation - better survival during first year - right balance of nutrients - less chance of obesity - reduced allergies - free, readily available and right temperature

Question 37

what are the benefits of breast feeding to the mother?

Answer 37

* Lowers risk of breast and ovarian cancer * Naturally uses up to 500 calories a day * saves money * build a strong physical and emotional bond between mother and baby. * can give you a great sense of achievement

Question 38

what are the disadvantages of breast feeding?

Answer 38

* Unable to measure the amount of milk baby is getting * Some women find difficult, tiring and stressful * Difficult to leave baby for long periods except expressing * Father unable to feed baby * Sometimes difficult to wean baby off the breast

Question 39

how should a mother position a baby for successful breastfeeding?

Answer 39

* Mother should hold baby close to breast not breast to baby. * Baby should be on his side, with head, neck & body in a straight line. * Nose to nipple. * Baby’s whole body should be supported.

Question 40

how do you get a baby to attach to the breast?

Answer 40

* C – Close to mum facing breast * H – Head free able to tilt head back * I – In line (baby head and body straight) * N – Nose to nipple – brush top lip with nipple * Wide open mouth * Suckling & swallowing * Head is free * Not painful for mother

Question 41

what problems can occur with positioning and attachment of the baby?

Answer 41

sore nipples from friction engorgement mastitis

Question 42

what is the solution for sore nipples from friction of breastfeeding?

Answer 42

correct attachment – Nipple at top back of mouth

Question 43

what causes engorgement?

Answer 43

build-up of milk in ducts bc of insufficient emptying of the breast bc of incorrect positioning or restricted feeding. Hard for baby to latch on

Question 44

describe the appearance of an engorged?

Answer 44

Breast feels hard, lumpy, painful, shiny and can result in flat nipple

Question 45

what is the solution to engorged breasts?

Answer 45

Correct attachment, massage, hand expressing, unrestricted feeding

Question 46

what is mastitis?

Answer 46

milk stasis and infection – if milk isn’t removed then it will back track

Question 47

what are symptoms of mastitis?

Answer 47

breast pain, swelling, redness, fever, enlargement, changed nipple sensation, discharge, itching, tenderness and/or breast lump

Question 48

what should you do if you have mastitis?

Answer 48

* Continue to feed, affected side first, unrestricted feeding, massage, hand expressing, analgesia, anti-inflammatory, hot/cold packs * Antibiotics if no improvement in 12-24 hours

Question 49

how should the perineum be managed during puerperium?

Answer 49

* Keep clean and dry to aid healing and avoid infection | * Remember pelvic floor exercises

Question 50

how should the bowels be managed during the puerperium?

Answer 50

advice on diets and fluids

Question 51

what can cause haemorrhoids and how are they treated?

Answer 51

* May be caused by the strain of pushing or worsen. * Avoid long periods of standing * Use topical analgesia