Repro20 - The Post-Partum Period

Question 1

Definition of the postpartum period

Answer 1

First 6 weeks after delivery where the body returns to pre-pregnancy state
- this period is characterised by low oestrogen levels

Question 2

3 features of post-natal care

Community Midwife
Clinics
Post-Natal Examination

Answer 2

1. ) Community Midwife - provide care at home
   - provide advice on contraception, breastfeeding, checking episiotomy healing
2. ) Clinics - mother attends once a week for 6 weeks
   - health visitors offer support to mother and assess the baby’s health and development progress
3. ) Post Natal Examination - performed at 6 weeks
   - assessment of the woman’s physical health: inc. her BP, breast, abdominal, pelvic, and perineal examination
   - also assess her mental health

Question 3

7 changes that occur in the post-partum period

Lower Genital Tract x3
Bleeding x3
Haematological x3
Cardiovascular x2
MSK x2
Endocrinology
Psychological x3

Answer 3

1. ) Lower Genital Tract - secondary to low oestrogen
   - reduction in size of vulva, vagina and cervix
   - cervix transformation zone withdraws into endocervix
   - internal os closes
2. ) Bleeding - initial heavy flow (lochia rubra) changes from red-brown to red-pink (lochia alba)
   - 10% of women still bleeding 6 weeks post-partum
   - menstruation returns by the 6th week post-partum
3. ) Haematological - can take > 8 weeks to re-adjust
   - diuresis –> increase in haemoglobin level
   - white cell count is still very high during post-partum
   - platelet count and iron levels rise back to normal
4. ) Cardiovasular - increased HR and CO reverses
5. ) MSK - ligament laxity resolves and devarication of the rectus abdominus (return to midline)
6. ) Endocrinology
   - thyroxine levels return to normal by 6 weeks
   - prolactin levels remain high in lactating women
   - cholesterol and triglycerides can take months to fall to pre-pregnancy levels
7. ) Psychological - postive or negative feelings
   - elation, protectiveness, satisfaction
   - anxiety, overwhelming resposibility. rejection of baby

Question 4

3 features of postpartum haemorrhage (PPH)

Complication
Secondary Haemorrhage
Causes x4

Answer 4

1. ) Complication - obstetric emergency
   - needs urgent management to prevent major blood loss and cardiovascular (haemorrhagic) shock
2. ) Secondary Haemorrhage - prolonged or excessive bleeding once the mother has returned home
   - caused by infection (endometritis) and/or retained products of conception e.g. placenta
3. ) Causes of PPH - the 4T’s
   - Tone (uterine SM), Tissue (e.g. retained placenta)
   - Thrombin (clotting disorder), Trauma

Question 5

3 features of the microstructure of the lactating breast

Adipose Tissue
Secretory Lobules
Duct System

Answer 5

1. ) Adipose Tissue - lots of fat present
   - surrounds the duct system

2.) Secretory Lobules - secrete breast milk into ductules

3. ) Duct System - ductules and lactiferous duct
   - ductules from 15-20 lobules combine into a duct which widends at the ampulla
   - lactiferous duct eject secretions to the outside

Question 6

6 features of lactation and breast feeding

Development of the Breast
Hormones affecting the Breast x4
Prolactin
Oxytocin
Inhibiting Menstruation
Supressing Milk Secretion

Answer 6

1. ) Development of the Breast - occurs during pregnancy
   - due to oestrogen, progesterone, prolactin and hPL
2. ) Hormones Affecting the Breast - different categories
   - mammogenic: proliferation of alveolar and duct cells
   - lactogenic: initiation of milk production
   - galctokinetic: contraction of myoepithelial cells
   - galactopoietic: maintain milk production
3. ) Prolactin (PRL) - essential for milk production
   - suckling stimulates PRL release from anterior pituitary
   - suckling inhibits dopamine so it can’t inhibit PRL
4. ) Oxytocin - ‘let down reflex’, oxytocin release responds to suckling, seeing, or hearing the baby
   - can be inhibited by emotional stress or anxiety
   - release is pulsatile so 90 minute cycle
   - oxytocin is galactokinetic so stimulates milk release
5. ) Inhibiting Menstruation - caused by lactation
   - suckling inhibits neurones in the hypothalamus so levels of GnRH falls, inhibiting the ovarian cycle
   - suckling intensity and frequency determines the length of amenorrhoea and anovulation
6. ) Suppressing Milk Secretion - not hormonal
   - due to local mechanical factors when lactation stops
   - milk accumulates in the alveoli of the breast causing distension and atrophy of the glandular epithelium
   - dopamine agonists (e.g. bromocriptine) can be artificially given to suprress lactation (inhibits PRL)

Question 7

4 features of breast milk

Colostrum
Protection from Infection
Components
Formula Feeding

Answer 7

1. ) Colostrum - small volume initially produced before milk production is fully established (800ml per day)
   - contains lots of fat and immunoglobulins
2. ) Protection from Infection
   - contains lactoferrin which binds to iron, preventing proliferation of iron-dependent organisms (e.g. E.coli)
   - also populates neonatal gut w/ non-pathogenic flora
   - contains IgG, lymphocytes, bacteriocidal enzymes
3. ) Components - differs from mammalian milk
   - more digestible by the baby and also has more energy content and lactose
   - however, contains less salt and protein
4. ) Formula Feeding - should only be done if chosen by the mother herself or for medical reasons:
   - severe maternal illness, maternal HIV, medications

Question 8

3 features of puerperal mastitis

What is it?
Common Cause
Treatment

Answer 8

1. ) What is it? - inflammation of the breast due to milk accumulation +/- infection (often S.aureus)
   - infection can lead to an abscess

2.) Common Cause - mother not breast feeding with both breasts so milk builds up in unused breast

3. ) Treatment - increase feeding on affected side
   - antibiotics if no improvement after 24 hours

Question 9

8 common problems of the post-partum period

Answer 9

1. ) Haemorrhage - primary (first 24 hrs) or secondary (24h-6w, often 2-3 weeks later)
2. ) Retained Placenta - can lead to infection or bleeding
3. ) Uterine Inversion - obstetric emergency
   - occurs when delivering the placenta
4. ) Perineal Trauma - bruises and tears
   - episiotomy to enlarge opening for the vagina
5. ) Cardiac Arrest
   - hypoglycaemia, hypotension, amniotic fluid emoblism
6. ) Thromboembolic Disease - risk factors
   - surgery (C-section), immobility, obesity, labour
7. ) Fever/Sepsis - infection of genital tracts, urinary tracts or lactation ducts
8. ) Mental Health Problems

Question 10

4 mental health conditions during post-partum

Answer 10

1. ) Postnatal/Baby Blues - very common, peaks at day 4/5
   - altered mood due to hormonal changes
   - mother is more tearful or anxious
2. ) Postpartum Depression - similar symptoms to regular depression and occurs within 4 weeks of delivery
   - management depends on severity and length
3. ) Psychosis - rare and often occurs within 4 weeks
   - symptoms: anxiety, mania, paranoia, delusions
   - 30% occurs in women with pre-exisiting mental illness
   - there is increased suicidal and infanticide risk
4. ) PTSD - occurs in 1.5% of women
   - managed using psychological therapies