Next Lesson - Infections of the Reproductive Tract
Core
The post-partum period is defined as the six weeks after the delivery of the placenta (not the fetus). For most mothers, if they deliver the placenta quickly after birth, this is the period from birth until their baby is 6 weeks old.
During this time, the body tries to return to the pre-pregnancy state. There are many physiological and psychological changes, which can make this time difficult for many new mums.
A lot happens in this time. The mum heals from the birth, and she and those around her get used to having a new baby. There are also lots of hormonal changes occurring in the body of the mother, which can cause anything from elation and protectiveness, to anxiety and feeling overwhelmed. It is therefore important that healthcare professionals look after a new mum’s mental health as well as her physical health. Both need care as she recovers from birth and adapts to the changes in her life.
Post-partum haemorrhage (PPH) is defined as the loss of more than 500ml of blood and occurs in about 6% of births worldwide, with wide variation between regions (based on a 2008 review of studies involving over 3.8 million women). There are two main types:
Occurs within 24 hours of birth, and is related to the 4 ‘T’s of Primary PPH:
- Tone - inadequate uterine tone (uterine atony, where the uterus does not contract well enough) is the most common cause of primary PPH. Normally, once the baby has been delivered, the uterine walls contract to help cut off the blood supply to the placenta, so the placenta can be delivered safely without haemorrhage. However, if there is insufficient tone of uterine muscles, the placenta is delivered without cutting off the blood supply, meaning the blood vessels are free to bleed. This bleeding can be rapidly life-threatening due to the high flow nature of the vessels required to support the fetus in pregnancy.
- Trauma - laceration (a cut or tear, such as an episiotomy or tears during childbirth) is the most common type of trauma that causes primary PPH. Trauma can also include medical emergencies like uterine inversion (where the uterus turns inside out).
- Tissue - as with lack of tone in the uterus, retained placental tissue can be a cause of primary PPH. If part of the placenta is still in the uterus, it stops the uterus from contracting properly. The blood vessels that supplied the placenta are then not squeezed shut, so they can bleed heavily.
- Thrombin - hypocoagulability (blood that does not clot properly) can also contribute to primary PPH. Inherited clotting disorders, such as von Willebrand disease or haemophilia, are rare and are usually identified and managed beforehand. Clotting problems can also be acquired around the time of birth, such as disseminated intravascular coagulation (DIC, where widespread clotting uses up the clotting factors so that bleeding follows).
Table - The occurrence of the four types of primary post-partum haemorrhage
Occurs any time from 24 hours up to 12 weeks after birth (some definitions use six weeks), most commonly at weeks 2 to 3.
The most common causes for secondary haemorrhages are:
- Retained Tissue - similar mechanism to the primary PPH. Retained tissue can stay in the body unnoticed and can cause secondary PPH due to the blood vessels to the placenta remaining open.
- Endometritis - this is an inflammation of the endometrium (the lining of the uterus), commonly caused by an infection following birth. It often causes lower abdominal pain, abnormal vaginal discharge, and secondary PPH.
The perineum is the area between the opening of the vagina and the anus. During vaginal delivery this area is stretched to allow for birth, which can lead to bruising or tearing of the perineum. In some cases, a cut called an episiotomy is made through the perineum. Episiotomy is not done routinely. It is done when there is a clinical need, such as an assisted delivery with forceps or a ventouse (suction cup), or suspected fetal compromise (signs that the baby is not coping).
Perineal trauma has many consequences for a new mother, ranging from pain to severe consequences like PPH. Perineal trauma can also lead in the longer term to painful intercourse and faecal incontinence (leaking of stool from the bowel) if the anal sphincter is damaged. Tears are graded by depth: first degree (skin only), second degree (the perineal muscles, but not the anal sphincter), third degree (the anal sphincter) and fourth degree (the anal sphincter and the lining of the anus).
There are many possible causes of maternal collapse in the period following birth:
- Hypovolaemia (low circulating blood volume, e.g. following a PPH)
- Pulmonary embolism (a blood clot blocking the arteries of the lungs)
- Sepsis (see below)
- Eclampsia (seizures caused by pre-eclampsia)
- Heart problems, such as a heart attack
- Hypoglycaemia (low blood sugar)
- Amniotic fluid emboli - where amniotic fluid gets into the maternal blood stream and blocks a blood vessel.
All of these forms of collapse can lead to cardiac arrest in the mother.
During birth, there are a number of opportunities for pathogens to enter the bloodstream due to the often traumatic nature of labour, which causes many breaks in the skin (vaginal tears/episiotomies, Caesarean sections, placental tissue). Pregnancy is also a state of immunocompromised status, which coupled with the trauma of birth, can leave mothers vulnerable to infections.
Common sources of sepsis in the post-partum period are the genital tract, the urinary tract (e.g. a complication of a UTI), or through mastitis (an infection of breast tissue).
Lactation is another key feature of the post-partum period. It is the process through which the mother produces milk from her breast with which the baby can be fed.
Diagram - Internal structure of the breast
SimpleMed original by Dr. Maddie Swannack
The breast is made up of a series of secretory lobules (clusters of milk-producing sacs called alveoli) which empty into ductules (small ducts, or tubes). These ductules then converge to form the mammary ducts. Milk is made in the alveoli and held there until the baby feeds. Anatomy texts have traditionally shown each duct widening under the areola (the darker skin around the nipple) into a sac called the ampulla (or lactiferous sinus), described as a temporary store of milk. However, an ultrasound study of breastfeeding women did not find these sacs, which suggests that the ducts carry milk rather than store it. During a feed, the lactiferous duct carries the milk out through the nipple.
In the adult female, breast development is not complete until pregnancy. The high levels of oestrogen and progesterone during pregnancy prompt full breast development. Levels of other hormones that act on the breast also rise, namely prolactin (the hormone that drives milk production) and human placental lactogen (a hormone made by the placenta).
Hormones that affect the breast can be categorised by their function:
- Mammogenic hormones promote proliferation of alveolar and duct cells.
- Lactogenic hormones promote initiation of milk production.
- Galactokinetic hormones promote contraction of the myoepithelial cells (contractile cells around the alveoli and ducts) in the breast, which pushes milk out (milk ejection).
- Galactopoietic hormones maintain milk production.
Prolactin is a hormone that is essential for milk production. Suckling (the baby trying to feed on the nipple) is a very powerful stimulus for the production of prolactin.
In the absence of suckling, prolactin release from the anterior pituitary is inhibited by dopamine produced by the hypothalamus. Suckling inhibits this dopamine release removing the inhibition and resulting in prolactin production from the anterior pituitary. As a result, suckling maintains milk production.
High levels of prolactin may also disrupt the hypothalamic-pituitary-gonadal axis (the chain of hormone signals from the brain to the ovaries). This is because prolactin tends to suppress the secretion of GnRH (gonadotrophin-releasing hormone) from the hypothalamus. This decreases the secretion of FSH (follicle-stimulating hormone) and LH (luteinising hormone) from the anterior pituitary, which can disrupt the ovulatory cycle. This is why breastfeeding can suppress ovulation in some mothers, particularly when feeding is frequent and exclusive.
Oxytocin is produced in the hypothalamus and released from the posterior pituitary. Oxytocin has a key role in birth, but also has functions in the breast. Oxytocin causes the basketwork (network) of myoepithelial cells surrounding the alveoli and lactiferous ducts to contract. This squeezes milk out, causing milk let down (the milk ejection reflex). Suckling is the main trigger for let down, but the reflex can also be triggered in other ways, such as by the baby crying.
To the baby:
- Breast milk contains lactoferrin, an antimicrobial protein that binds iron and helps limit bacterial growth; iron in breast milk is efficiently absorbed by the infant.
- Breast milk contains other bactericidal enzymes (enzymes that kill bacteria) to help prevent infections.
- Breast milk contains specific immunoglobulins formed by the mother’s immune system, which allow for the baby to protect itself from some diseases while its own immune system is weak.
- Breast milk contains T lymphocytes and granulocytes (a type of white blood cell) from the mother, which can contribute to immune protection and modulation while the baby’s own immune system matures.
- Breastfeeding can help to reduce the baby’s risk of sudden infant death syndrome (SIDS) and obesity.
To the mother:
- Breastfeeding lowers the mother’s risk of breast cancer, ovarian cancer, osteoporosis (weak bones), cardiovascular disease, obesity and diabetes.
- Breastfeeding can help build a strong emotional bond between mother and baby.
There are circumstances in which breastfeeding is not possible or where the mother chooses not to breastfeed. When considering the different options, it is important to remember that it is the mother’s choice whether to breastfeed or not. Parents who formula feed should be given face-to-face support to do this safely, including how to sterilise feeding equipment and prepare formula feeds.
It is therefore important that healthcare professionals explain the advantages of breastfeeding to the mother and respect any choice that she makes.
Mastitis is inflammation of the breast tissue. It may or may not involve infection. In breastfeeding women it is usually caused by stasis of milk (milk building up in the breast). The built-up milk causes inflammation, which may or may not progress to infection. The most common organism in infective mastitis is Staphylococcus aureus. The woman should continue breastfeeding, including from the affected breast, to keep the milk flowing. Frequent and effective milk removal is the most important step in management. Simple painkillers (paracetamol or ibuprofen) and cold compresses can help ease the pain.
In the UK, current guidance (NICE CKS) advises an oral antibiotic if the woman has an infected nipple fissure (crack), if symptoms have not improved (or are worsening) after 24 hours despite effective milk removal, or if a breast milk culture is positive. Flucloxacillin is usually the first choice. A woman with signs of sepsis (such as a fast heart rate, fever and chills) needs hospital admission.
Mental Health Changes in the Post-Partum Period
‘Baby blues’ refers to a mild depression of mood following birth that stems from the hormonal changes that are occurring in the body as it returns to the non-pregnant state.
Symptoms can include feeling tearful, irritable, low mood and anxiety. It is usually self-limiting (it gets better on its own) and usually goes away within 2 weeks of the birth. It should be managed by reassuring and supporting the mother. If low mood lasts longer than this or gets worse, she should be assessed for post-partum depression. Many mothers will experience some elements of the ‘baby blues’.
Post-partum (or postnatal) depression commonly develops within the first few weeks to months after delivery and can persist for many months. It is characterised by the same symptoms as depression, including low mood and low motivation. It is treated similarly to depression, with self help, psychotherapy (talking therapy, such as cognitive behavioural therapy) and medications such as antidepressants. Many antidepressants are safe to use while breastfeeding, and the doctor will prescribe one that is suitable.
Especially with post-partum depression, it is important for the new mum to get a lot of help and support, so she is able to look after herself and the baby. Post-partum depression is very common, and affects between 10 and 15 in every 100 women having a baby (source).
Risk of occurrence is higher in those women with previous mental health issues. As so many women have this condition, it is key to ask new mothers about their mood.
Puerperal/Post-Partum Psychosis
Post-partum psychosis is a rare but severe mental illness, affecting about 1 in 1000 mothers. It usually starts suddenly within the first two weeks after birth, often within hours or days. More rarely, it starts several weeks after birth. Symptoms can include mania (feeling very high or overactive), low mood, confusion, hallucinations (hearing or seeing things that are not there), delusions (fears or beliefs that are unlikely to be true), paranoia (a fear that others want to cause harm) and anxiety. It is a psychiatric emergency. It can get worse rapidly and can put the safety of both mother and baby at risk, including the risk of suicide and of harm to the baby. NICE advises assessment by a specialist mental health team within 4 hours of referral. If she needs admission, this should normally be to a specialist mother and baby unit.
Post Traumatic Stress Disorder
Post traumatic stress disorder (PTSD) occurs in about 4 to 5% of women following childbirth, and is more common in high-risk groups. It is usually associated with traumatic births. These include physically difficult births, such as an emergency Caesarean section, an assisted (forceps or ventouse) delivery, a severe perineal tear or a PPH. They also include births that the mother experiences as traumatic, even when the delivery itself was straightforward. The main symptom is distressing thoughts about the birth that keep coming back, as flashbacks, intrusive images or nightmares. She may also avoid reminders of the birth, feel very anxious and on edge, and sleep poorly.
It is important to remember that childbirth is a challenging time for many mothers, and that the adaptations to life as a new mum alongside biological changes to the body can be very difficult. Support and reassurance often are very helpful, as is input from a healthcare professional.
There is no right or wrong time to begin having sex again after childbirth; it is a decision to be made as a couple when both parties feel ready again. However, a woman can become pregnant from 3 weeks after giving birth, even if she is breastfeeding and her periods have not returned. She therefore needs contraception from then if she does not want to become pregnant.
As already mentioned in this article, breastfeeding can inhibit ovulation for a number of months through inhibition of GnRH release, which disrupts the ovulatory cycle.
The lactational amenorrhoea method (LAM) uses frequent breastfeeding to suppress ovulation (amenorrhoea means absence of periods). All three conditions are needed: periods have not returned, the baby is under six months old, and feeding is exclusive and frequent, including at night. Exclusive breastfeeding means giving breast milk only. Start another contraceptive method if periods return, the baby reaches six months, other feeds are introduced, night feeds stop or gaps between feeds increase. Expressing milk may make LAM less effective. Ovulation can occur before the first period, so breastfeeding or absence of periods alone must not be treated as reliable contraception.
The introduction of contraception in the post-partum period can sometimes be a difficult topic to approach, but there are many benefits to preventing unwanted pregnancies in this period (source):
- Helps to improve the mental health of the mother by reducing the burden of being pregnant accidentally when dealing with a newborn.
- Reduces the risk of pre-term labour with the second baby. Pregnancy very soon after giving birth is difficult and includes increased risks of pre-term labour.
- Reduces the risk of low birthweight babies because a longer gap between pregnancies allows the mother to lay down the stores needed to grow a fetus.
- Reduces risk of maternal anaemia because it allows the mother to recover from the previous pregnancy.
There are a number of options for contraceptives after birth, but it is important to understand the time limits on them. The contraceptive implant, the contraceptive injection, the progestogen-only pill (a pill containing only a progesterone-like hormone) and condoms can all be started straight after birth. An intrauterine device (IUD, the copper coil) or intrauterine system (IUS, the hormonal coil) can be fitted within 48 hours of birth; otherwise it is usually fitted from 4 weeks after birth. Pregnancy and the immediate postpartum period are considered pro-thrombotic (blood clots form more easily). For this reason, the combined oral contraceptive pill is contraindicated (must not be used) until at least 3 weeks postpartum in women who are not breastfeeding and have no other risk factors for venous thromboembolism (blood clots in the veins). In women with additional risk factors, or those who are breastfeeding, combined oral contraception should not be used until at least 6 weeks postpartum. In contrast to this, male and female condoms have no contraindications surrounding birth, so can be used as soon as both parties feel ready to engage in intercourse.
Edited by: Dr. Ben Appleby
Reviewed by: Dr. Thomas Burnell and Dr. Marcus Judge
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