Milk production

A healthy mother will produce about 500-800 ml of milk a day to feed her infant with
about 500 Kcal/day. This requires about 600 Kcal/day for the mother which must be
made up from the mother's diet or from her body store. For this purpose a store of
about 5 kg of fat during pregnancy is essential to make up any nutritional deficit during
lactation. With the exception of iron and calcium, almost all other nutrients are provided
in a well balanced diet.

Stimulation of lactation -
Mother is motivated as regard the benefits of breast feeding since the early pregnancy.
No prelacteal feeds (honey, water) are given to the infant.
Following delivery important steps are -
- To put the baby to the breast at 2-3 hours interval from the first day.
- Plenty of fluids to drink.
- To avoid breast engorgement .
- Early and exclusive breast feeding in correct position are encouraged.

Que. - What is the cause of lactation failure or inadequate milk production ?
Ans. - It may be due to infrequent suckling or due to endogenous suppression of prolactin
          (pyridoxin, diuretics or retained placental bits). Unrestricted feeding at short interval
          is helpful in milk production.

Drugs to improve milk production -
Metoclopramide (10 mg thrice daily) increases milk volume about 60-100% by increasing
prolactin levels. Sulpuride (dopamine antagonist) has also been found effective.

Scheme of amenorrhoea in lactating mother

Lactation after delivery

For the first two days following delivery, no further anatomic changes in the breasts occur. The secretion from the breast called colostrum which starts during pregnancy becomes more abundant.

                 Percentage composition of colostrum and breast milk

	Protein	Fat	Carbohydrate	Water
Colostrum   Breast milk	8.6      1.2	2.3      3.2	3.2          7.5	86       87

Advantages -
- The antibodies provides immunological defence to new born.
- It has laxative action on the baby because of large fat globules.

Physiology of lactation -
Although lactation starts following delivery, the preparation for effective lactation starts during pregnancy. The physiological basis of lactation is divided into four phages:
a) Preparation of breast (Mammogenesis).
b) Synthesis and secretion from the breast alveoli (Lactogenesis).
c) Ejection of milk (Galactokinesis).
d) Maintenance of lactation (Galactopoiesis).

Mammogenesis -
Pregnancy is associated with a remarkable growth of both the ductal and lobulo-alveolar systems. An intact nerve supply is not essential for the growth of the mammary gland during pregnancy.

Lactogenesis -
Milk secretion actually starts on 3rd or 4th day after delivery. Around this time, the breasts become engorged, tense, tender and feel warm. Inspite of a high prolactine level during pregnancy, milk secretion is kept in abeyance. Probably, the steroids estrogen and progesterone circulating during pregnancy make the breast tissue unresponsive to prolactin. When the estrogen and progesterone are withdrawn following delivery, prolactin begins its milk secretory activity in previously fully developed mammary glands.

Galactogenesis -
Discharge of milk from the mammary glands depends not only on the suction exerted by the baby during suckling but also on the contractile mechanism which expresses the milk from the alveoli into the ducts.
During suckling, a conditioned reflex is set up. The ascending tackle impulses from the nipple and areola pass via hypothalamus to synthesize and transport oxytocin to the posterior pituitary. Oxytocin produces contraction of the myopithelial cells of the alveoli and the ducts containing the milk. This is the 'milk ejection' or 'milk let down' reflex the milk is forced down into the ampulla of the lactiferous ducts, wherefrom it can be expressed by the mother or sucked out by the baby.

Galactopoiesis -
Prolactin appears to be the single most important galactopoietic hormone. For maintenance of effective and continuous lactation, suckling is essential. It is not only essential for the removal of milk from the glands, but it also causes the release of prolactin. Secretion is a continuous process unless suppressed  by congestion or emotional disturbances. Milk pressure reduces the rate of production and hence periodic breast feeding is necessary to relieve the pressure which in turn maintains the secretion.

Breast milk for premature infant is beneficial by many ways (psychological, nutritional and immunological). Metabolic disturbances like azotemia, hyper amnioacidemia and metabolic acidosis are less with breast milk compared to formula. It gives immunological protection to the premature infant.

Physiological changes after delivery

Pulse -
For a few hours after normal delivery, the pulse rate is likely to be raised,
which settles down to normal during the second day. However, the pulse rate
often rises with after-pain or excitement.

Temperature - 
The temperature should not be above normal temperature within first 24 hours.
Genito-urinary tract infection should be excluded if there is rise of temperature.

Urinary tract -
Dilated ureters and renal pelvis return to normal size within 8 weeks. 'Clean catch'
sample of urine should be collected and sent for examination and contamination
with lochia should be avoided.

Gastro-intestinal tract - 
Increased thirst in early puerperium is due to loss of fluid during labour, in the
lochia, diuresis and perspiration. Slight intestinal paresis leads to constipation.

Weight gain - 
In addition to the weight loss as a consequence of the expulsion of the uterine
contents, a further loss of about 2 kg occurs during puerperium chiefly caused
by diuresis.

Fluid loss - 
There is a net fluid loss of at least 2 litres during the first week. The amount of loss
depends on the amount retained during pregnancy, dehydration during labour and
blood loss during delivery.

Blood values - 
Immediately following delivery, there is slight decrease of blood volume due to
dehydration and blood loss. The blood volume returns to the non-pregnant level
by the second week. RBC volume and haematocrit values returns to normal by
the end of first week.

Menstruation and ovulation -
- The onset of the first menstrual period following delivery is very variable and
  depends on lactation.
- If the woman does not breast feed her baby, the menstruation returns by 6th week 
  following delivery in about 40% and by 12th week in 80% of cases.
- A woman who is exclusively breastfeeding, the contraceptive protection is about
  98% upto 6 months after delivery.
- Non-lactating mother should use contraceptive measures after 3 weeks and the 
  lactating mother after 3 months of delivery.

Lochia: Normal bleeding and discharge after birth

                                                LOCHIA

It is the vaginal discharge for the first fortnight during puerperium. The discharge
originates from the uterine body, cervix and vagina.

Odour and reaction -
It has got a particular offensive fishy smell. Its reaction is alkaline tending to becomes
acid toward the end.

Composition -
Depending upon the variation of the colour of the discharge, it is named as

Name	Colour	Duration	Composition
Lochia rubra	Red	1-4 days	Blood, shreds of fetal membranes and deciduas, vernix caseosa, lanugo and meconium
Lochia serosa	Yellowish or pink	5-9 days	Leucocytes, wound exudates, mucous from the cervix and micro-organisms
Lochia alba	Pale white	10-15 days	Decidual cells, leucocytes, mucous, cholestrin crystals, fatty and granular epithelial cells and micro-organisms

Amount -
The average amount of discharge for the first 5-6 days, is estimated to be 250 ml.

Normal duration -
It may extend up to 3 weeks.

Clinical importance -
The character of the lochial discharge gives useful information about the abnormal
puerperal state. The vulval pads are to be inspected daily to get information.

• Odour :- If offensive, indicates infection.
• Amount :- Scanty or absent - signifies infection. If excessive - indicates infection.
• Colour :- Persistence of red colour beyond the normal limit signifies subinvolution                      or retained bits of conceptus.
• Duration :- Duration of the lochia alba beyond 3 weeks suggests genital lesion.

Puerperium period (Involution of uterus)

Puerperium is the period following childbirth during which the body tissues,
specially the pelvic organs revert back approximately to the pre-pregnant state
both anatomically and physiologically.

Duration -
Puerperium begins as soon as the placenta is expelled and lasts for approximately
6 weeks when the uterus becomes regressed almost to the non-pregnant size.
The period is arbitrarily divided into -
a) Immediate - within 48 hours
b) Early - upto 7 days
c) Remote - upto 6 weeks.

Involution of the uterus - 

Anatomical consideration - 
Uterus -
Immediately following delivery, the uterus becomes firm and retracted with
alternative hardening and softening. The uterus measures about 20*12*7.5 cm
(length, breadth & thickness) and weight about 1000 gm. At the end of 6 weeks,
its measurement is almost similar to that of the non-pregnant state and weight
about 60 gm.

Lower uterine segment -
Immediately following delivery, the lower segment becomes a thin, flabby,
collapsed structure. It takes a few weeks to revert back to the normal shape
and size of the uterus, that is the part between the body of the uterus and
internal opening (os) of the cervix.

Cervix - 
The cervix contracts slowly; the external os admits two fingers for a few days
but by the end of first week, narrow down to admit the tip of finger only.

Physiological consideration - 
The physiological process of involution is most marked in the body of the uterus.
Changes occur in following component -
a) Muscles
b) Blood vessel
c) Endometrium.

Muscles -
There is marked hypertrophy and hyperplasia of muscle fibers during pregnancy
and the individual muscle fiber enlarges to the extent of 10 times in length and
5 times in breadth. During puerperium, the number of muscle fibers is not
decreased but there is number of muscle fibers is not decreased but there is
substantial reduction of the myometrial call size.

Blood vessels -
The changes of the blood vessels are pronounced at the placental site. The arteries
are constricted by contraction of its way and thickening of the intima followed by
thrombosis. New blood vessels grow inside the thrombi.

Endometrium -
Following delivery, the major part of the decidua is cast off with the expulsion of
the placenta and the membranes, more at the placental site. The endometrium left
behind varies in thickness from 2-5 mm. The superficial part containing the
degenerated decidua, blood cells and bits of fetal membranes becomes necrotic
and is cast off in lochia. Regeneration occurs from the epithelium of the uterine
gland mouths and interglandular stromal cells. Regeneration of the epithelium is
completed by 10th day and the entire endometrium is restored by the day 16,
except the placental site it takes about 6 weeks.

Clinical assessment of involution -
The rate of involution of the uterus can be assessed clinically by noting the height
of the fundus of the uterus in relation to the symphysis pubis. The measurement
should be taken carefully at fixed time every day, preferably by the same observer.
Bladder must be emptied beforehand and preferably the bowel too, as the full
bladder and the loaded bowel may raise the level of the fundus of the uterus.
The uterus is to be centralised and with a measuring tape, the fundal height is
measured above the symphysis pubis. Following delivery, the fundus lies about
13.5 cm above the symphysis pubis. During the first 24 hour, the level remains
constant, thereafter there is a steady decrease in height by 1.25 cm in 24 hours,
so that by the end of second week the uterus becomes a pelvic organ.

Episiotomy procedure

A surgically planned incision on the perineum and posterior wall during
the second stage of labour is called episiotomy.

Objectives :-
- To enlarge the vaginal introitus for safe delivery.
- To minimise overstretching of perineal muscles.
- To reduce the stress and strain on the fetal head.

Indication :-
- To in-elastic perineum.
- Big baby.
- Breech delivery.
- Shoulder dystocia.
- Face to pubis delivery.
- Operative delivery.
- Previous perineal surgery.

Timing :-
Just prior to crowning.

Advantages :-
- A clear controlled incision is easy to repair and heal.
- Reduction in the duration of second stage.
- Reduction of trauma to pelvic floor muscles.
- It minimise intracranial injuries of fetus.

Types :-
It has four types -
1. Medio-lateral episiotomy
2. Median episiotomy
3. Lateral episiotomy
4. 'J' shaped episiotomy
Mostly used episiotomy is medio-lateral.

Steps of medio-lateral episiotomy :-
Step 1 (preliminaries) :- Perineum is swabbed with antiseptic lotion.
Step 2 (incision) :-  The incision is made by a sharp scissors.
Step 3 (repair) :- The repair is done soon after expulsion of placenta.