Session 10: The Post-Partum Period

Question 1

Definition of post-partum period.

Answer 1

Period from delilvery of the placenta to six weeks after.

Question 2

What happens during the post-partum period?

Answer 2

The body returns to a pre-pregnancy state

Question 3

How is a new mother looked after?

Answer 3

Advice on contraception, breastfeeding and checking episiotomy healing.

Encourage to attend specific clinics locally with their child once a week until 6 weeks of age.

Post-natal examination 6 weeks after.

Question 4

What does a post-natal examination include?

Answer 4

BP

Breast exam

Abdominal exam

Pelvic exam

Perineal exam

Mental health

Question 5

What hormone is the post-partum period characterised by?

Answer 5

Low levels of oestrogen

Question 6

Give examples structure that change back to their original state in the post-partum period.

Answer 6

Lower genital tract

Haematological

Endocrine

Cardiovascular

Skeletal

Ligament laxity

Question 7

What does the time period of absence of menstruation depend on?

Answer 7

Whether the mother breast feeds or not.

Question 8

When does menstruation usually return in the case of no breast feeding?

Answer 8

Six weeks post-partum

Question 9

Which psychological changes might occur during the post-partum period?

Answer 9

Elation (euphoria)

Protectiveness

Anxiety

Overwhelming responsibility

Rejection

Question 10

Explain the route of breast milk.

Answer 10

Secreted by secretory lobules that empty into ductules. The ductules from 15-20 lobules will then combine into a duct.

The duct will widen at the ampulla which is a small reservoir.

It will then be excreted via the lactiferous duct.

Question 11

Answer 11

Question 12

What is Postpartum Haemorrhage?

Answer 12

An obstetric emergency that will require urgent management to prevent major blood loss and cardiovascular shock.

Question 13

What might suggest that PPH occurs?

Answer 13

Inadequate uterine contractions after delivery

Question 14

Causes of PPH.

Answer 14

The 4 Ts

Tone (atony)

Tissue (retained placenta)

Thrombin (clotting disorder)

Trauma

Question 15

What are secondary haemorrhages from PPH usually caused by?

Answer 15

Infection like endometritis or retained products of conception like the placenta.

Question 16

Give common complications that might occur in the post-partum period.

Answer 16

Haemorrhage (primary/secondary)

Retained placenta or other tissue

Uterine inversion (obstretic emergency)

Perineal trauma

Maternal collapse/cardiac arrest

Thromboembolic disease

Pyrexia/sepsis

Mental health problems.

Question 17

Causes of maternal collapse.

Answer 17

Amniotic fluid embolism

Hypoglycaemia

Hypotension/hypovolaemia

Question 18

How can you differ between menstruation and secondary haemorrhage?

Answer 18

Secondary haemorrhage is defined as 24h - 6 weeks after birth.

It is most present two or three weeks later.

Question 19

Give examples of mental health issues in the post-partum period.

Answer 19

Postnatal blues (baby blues)

Post-partum depression

Puerperal psychosis

PTSD

Question 20

Explain postnatal blues.

Answer 20

Common after delivery and occurs in 85% of women.

It usualyl peaks at 4/5 days and is an altered mood due to hormonal changes.

It is presented by the mother being more tearful or anxious.

Question 21

Explain post-partum depression.

Answer 21

Usually occurs within 4 weeks of delivery.

Similar symptoms to depression outside of pregnancy.

Occurs in 13% of women.

Important to ask the mother about her feelings.

Question 22

Treatment of postnatal blues.

Answer 22

Managed by reassurance and support

Question 23

Treatment of post-partum depression.

Answer 23

Depending on the severity.

Might require pharmacological treatments if the symptoms lasting longer than a month.

Question 24

What is puerperal psychosis?

Answer 24

Usually occurs within 4 weeks.

Rare but psychiatric emergency, also happens in 30% of women with pre-existing mental illness.

Severe symptoms such as anxiety, mania, paranoid thoughts and delusions.

Question 25

Risk of puerperal psychosis.

Answer 25

Suicide (5%)

Infanticide (4%)

Question 26

Management of puerperal psychosis.

Answer 26

Specialist care and primarily pharmacological.

Question 27

What causes full development of the breasts?

Answer 27

High levels of oestradiol

High levels of progesterone

Gradual increase in levels of prolactin.

Gradual increase in levels of hPL

Question 28

What kinds of hormones is involved in the development of the breasts?

Answer 28

Mammogenic (proliferation of alveolar and duct cells)

Lactogenic (initiation of milk prod)

Galactokinetic (contraction of myoepithelial cells)

Galactopoeitic (maintain milk prod)

Question 29

Role of prolactin in breast feeding.

Answer 29

Milk production and its maintenance.

Question 30

Explain the release of prolactin.

Answer 30

Usually inhibited by dopamine.

Suckling stimulates neurons from the spinal cord to inhibit dopamine release. This leads to an increase in levels of PRL.

This means that suckling maintains milk production. Suckling in one feed orders the next feed.

Question 31

Role of oxytocin in breast feeding.

Answer 31

Contraction of myoepithelial cells to contract and eject milk. This is the let-down reflex.

Question 32

Explain the release of oxytocin.

Answer 32

Suckling leads to stimulation of neurons from the spinal cord.

This stimulate oxytocin release.

Question 33

Explain why anovulation and amenorrhoea occurs during breast feeding.

Answer 33

Neurons in the arcuate nucleus and preoptic area of the hypothalamus are inhibited. This leads to a fall in GnRH.

Inhibition of the ovarian cycle ensues and this means that the suckling intensity and frequency both determine the length of anovulation and amenorrhoea.

Question 34

Explain the contents of the milk in the beginning of breast feeding.

Answer 34

Milk volumes are low and colostrum is produced.

Question 35

What does colostrum contain?

Answer 35

High amounts of fat and immunoglobulins.

Question 36

How does the milk contents change?

Answer 36

When the milk production is established the contents change and 800 ml of milk per day.

Question 37

How does the breast milk protects the baby?

Answer 37

From infection by:

1 - Lactoferrin

2 - Populates the neonatal gut with non-pathogenic flora

3 - Bacteriocial enzymes

4 - Contains specific immunoglobulins

5 - T cells and granulocytes that play a role in cell-mediated immunity

Question 38

The feedback cycle of breast feeding.

Answer 38

Question 39

What is puerperal mastitis?

Answer 39

A condition where milk accumulation in the breast can lead to inflammation, with or without infection.

Question 40

Why might puerperal mastitis occur in the absence of infection.

Answer 40

Occurs if the mother does not breastfeed with both breasts. Therefore milk can build up in the lactiferous duct of the unused breast.

Question 41

Puerperal mastitis with infection.

Causative organism (most common) and potential complication.

Answer 41

S. aureus

Can lead to abscess formation

Question 42

Treatment of puerperal mastitis.

Answer 42

Continue feeding and increase the frequency especially on the affected side.

Antibiotic can be given after 24 hours if there is no improvement.

Question 43

Explain the cessation of lactation.

Answer 43

Milk accumulates in the alveoli of the breast causing distention and atrophy of the glandular epithelium.

This means that the local mechanical factor suppress milk secretion rather than hormonal changes.

Question 44

What can you give in order to artificially supress lactation?

Answer 44

Dopamine agonist to surpress PRL.

An example is bromocriptine.