The Postpartum Period

1. Definition
2. Haemorrhage
   
   • Primary Haemorrhage
3. • Secondary Haemorrhage
4. Perineal Trauma
5. Maternal Collapse
6. Sepsis
7. Lactation
   
   • Structure of the Breast
   • Prolactin
   • Oxytocin
   • Advantages of Breastfeeding
   • Mastitis
8. Mental Health Changes in the Post-Partum Period
   
   • ‘Baby blues’
   • Post-Partum Depression
   • Puerperal Psychosis
   • Post Traumatic Stress Disorder
9. Sex and Contraception
10. Quiz

• The post-partum period is the six weeks following the delivery of the placenta.
• Post-partum haemorrhage can be primary (within 24 hours) or secondary (after 24 hours).
  • Primary PPH causes include the 4 T’s - tone (uterus can’t contract well enough), trauma, tissue (retained placenta), thrombin (hypocoagulable state).
  • Secondary haemorrhages are commonly caused by retained placental tissue or endometritis (inflammation of the endometrium commonly caused by infection).
• Perineal trauma is a common result of vaginal birth, either through accidental tears or through interventions such as episiotomies.
• Maternal collapse can be caused by hypovolaemia, hypoglycaemia, or amniotic fluid embolism.
• There are many possible sources of infection that could lead to sepsis during childbirth, such as the urinary tract, genital tract or breast tissue (called mastitis).
• Breast development is completed during pregnancy, with oestrogen and progesterone triggering this. Prolactin and human placental lactogen help stimulate milk development.
• Prolactin release is prompted by suckling; this action inhibits the dopamine release, which normally stops the release of prolactin, allowing prolactin to be released. Oxytocin has a key role in birth, and causes milk let down.
• There are many advantages of breastfeeding, including increased bonding between mother and baby, improvements to the baby’s immune system and gut flora, and helping to prevent overfeeding. However, breastfeeding may not suit all mothers.
• There are many mental health changes that occur in the post-partum period, ranging from ‘baby blues’ caused by the hormonal changes from pregnancy to post-partum, to post-partum depression, post-partum psychosis and PTSD, which are much more serious, and require medical attention.
• It is important for healthcare professionals to implement contraception soon in the post-partum period. There are many disadvantages to unplanned pregnancy soon after birth, including physical and emotional drains on the mother leading to health problems in both mother and baby.

Definition

The post-partum period is defined as the period 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, and there are many physiological and psychological changes that are made, making this time difficult for many new mums.

So many different things can happen in this time, as the mum and those around her get used to having a new baby, and as the mum heals from the birth. 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 as she recovers from birth and adapts to the changes that have occurred.

Haemorrhage

Post-partum haemorrhage (PPH) is defined as the loss of more than 500ml of blood and occurs in between 5-10% of births (according to the World Health Organisation). There are two main types:

Primary Haemorrhage

Occurs within 24 hours of birth, and is related to the 4 ‘T’s of Primary PPH:

• Tone - inadequate uterine tone can contribute to primary PPHs. Normally, once the baby has been delivered, the uterine walls contract to help cut off the blood supply to the placenta, so this 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 can be rapidly life threatening due to the high flow nature of the vessels required to support the fetus in pregnancy.
• Trauma - laceration (such as episiotomies or tears during childbirth) is the most common cause of primary PPH due to trauma, but it 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, the blood vessels supplying the placenta are prevented from contracting, meaning they are free to bleed heavily.
• Thrombin - hypocoagulability caused by a clotting defect can also contribute to primary PPH, but this is rare and is usually identified and managed beforehand.

Table - The occurrence of the four types of primary post-partum haemorrhage

Source

Secondary Haemorrhage

Occurs any time from 24 hours to six weeks, most commonly at weeks 2-3.

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 commonly caused by an infection following birth. It commonly causes lower abdominal pain, abnormal vaginal discharge, and secondary PPH.

Perineal Trauma

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 is made through the perineum called an episiotomy to help control the direction and depth of the damage.

This has many obvious 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 (if there is involvement of the anal sphincter).

Maternal Collapse

There are many possible causes of maternal collapse in the period following birth:

• Hypovolaemia (e.g. following a PPH)
• Hypoglycaemia
• 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.

Preview the The Postpartum Period quiz