Lecture 5 Postpartum and postpartum complications

Question 1

Attachment behaviors can be easily observed during _

Answer 1

Infant feeding sessions.

Question 2

Postpartum “pinks”

Answer 2

The emotions surrounding the first day or two after birth, characterized by heightened joy and feelings of well-being.

Question 3

Postpartum “blues”

Answer 3

A period after the postpartum “pinks” in which the new mother may be emotionally labile and often cries easily for no apparent reason.
Peaks around the fifth day and subsides by the tenth day.
Experienced by 50-80% of women of all ethnic and racial groups. Can also be experienced by the father.
Other symptoms: Depression, a let-down feeling, restlessness, fatigue, insomnia, headache, anxiety, sadness, and anger.

Question 4

Postpartum depression

Answer 4

A more severe and long-lasting form of postpartum blues experienced by 10-15% of women. Can also be experienced by the father.
Symptoms: Intense fear, anger, anxiety, despondency, irritability (hallmark symptom), ruminations of guilt/inadequacy. May also have psychotic features (rare).

Question 5

After giving birth to a healthy infant boy, a primiparous client, 16 years of age, is admitted to the postpartum unit. An appropriate nursing diagnosis for her at this time is “Deficient knowledge of infant care.” What should the nurse be certain to include in the plan of care as he or she prepares the client for discharge?

Answer 5

Provide time for the client to bathe her infant after she views a demonstration of infant bathing. [Having the mother demonstrate infant care is a valuable method of assessing the client’s understanding of her newly acquired knowledge, especially in this age group, because she may inadvertently neglect her child. Although verbalizing how to care for the infant is a form of client education or providing written information might be useful, neither is the most developmentally appropriate teaching method for a teenage mother.]

Question 6

Puerperium

Answer 6

“The fourth trimester of pregnancy” - the period between birth and the return of the reproductive organs to their normal nonpregnant state. Length traditionally given as 6 weeks. End is marked by the full involution of the uterus.

Question 7

Involution

Answer 7

The return of the uterus to a nonpregnant state after birth. Begins immediately after expulsion of the placenta with contraction of the uterine smooth muscle (oxytocin modulated).

Question 8

Lochia

Answer 8

Postbirth uterine discharge, may last for several weeks. Occurs in this order:

1. Lochia rubra (starts right after birth, heaviest during the first 2 hours) - red - contains blood, small clots, trophoblastic debris.
2. Lochia serosa (changes around day 3 or 4) - pink or brown - old blood, serum, leukocytes, tissue debris.
3. Lochia alba (changes around day 10 to 14) - yellow to white - leukocytes, decidua, epithelial cells, mucus, serum, bacteria.

Question 9

Return of ovulation - lactating vs. nonlactating

Answer 9

1. In lactating women, the mean time to ovulation is 6 months - due to increased levels of prolactin which suppress ovulation.
2. In nonlactating women, the mean time to ovulation is 7 to 9 weeks - may occur as early as 27 days.

Question 10

Typical blood loss during delivery

Answer 10

Vaginal delivery (single fetus): 300-500 mL.
Cesarean delivery: 500-1000 mL.

Question 11

In the puerperium, maternal bradycardia (40-50 bpm), leukocytosis (WBCs as high as 25,000), night sweats, low-grade fever, and bilateral frontal headaches are all _

Answer 11

Normal findings.

Question 12

A woman gave birth to an infant boy 10 hours ago. Where does the nurse expect to locate this woman’s fundus?

Answer 12

1 centimeter above the umbilicus. [The fundus descends approximately 1 to 2 cm every 24 hours. Within 12 hours after delivery the fundus may be approximately 1 cm above the umbilicus. By the sixth postpartum week the fundus is normally halfway between the symphysis pubis and the umbilicus. The fundus should be easily palpated using the maternal umbilicus as a reference point.]

Question 13

The most common causes of subinvolution of the uterus are _

Answer 13

Retained placental fragments and infection.

Question 14

Which statement regarding the postpartum uterus is correct?

Answer 14

After 2 weeks postpartum, it should be abdominally nonpalpable. [The uterus does not return to its original size. At the end of the third stage of labor, the uterus weighs approximately 1000 g. After 2 weeks postpartum, the uterus weighs approximately 350 g. The normal self-destruction of excess hypertrophied tissue accounts for the slight increase in uterine size after each pregnancy.]

Question 15

The nurse should be cognizant of which postpartum physiologic alteration?

Answer 15

Respiratory function returns to nonpregnant levels by 6 to 8 weeks after childbirth. [Stroke volume increases and cardiac output remains high for a couple of days. However, the heart rate and blood pressure quickly return to normal. Leukocytosis increases 10 to 12 days after childbirth, which can obscure the diagnosis of acute infections, producing false-negative test results. The hypercoagulable state increases the risk of thromboembolism, especially after a cesarean birth.]

Question 16

Which condition, not uncommon in pregnancy, is likely to require careful medical assessment during the puerperium?

Answer 16

Headaches. [Headaches in the postpartum period can have a number of causes, some of which deserve medical attention. Total or nearly total regression of varicosities is expected after childbirth. Carpal tunnel syndrome is relieved in childbirth when the compression on the median nerve is lessened. Periodic numbness of the fingers usually disappears after childbirth unless carrying the baby aggravates the condition.]

Question 17

Which description of postpartum restoration or healing times is accurate?

Answer 17

Vaginal rugae reappear by 3 weeks postpartum. [Vaginal rugae reappear by 3 weeks postpartum; however, they are never as prominent as in nulliparous women. The cervix regains its form within days; the cervical os may take longer. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.]

Question 18

Which statement, related to the reconditioning of the urinary system after childbirth, should the nurse understand?

Answer 18

Fluid loss through perspiration and increased urinary output accounts for a weight loss of more than 2 kg during the puerperium. [Excess fluid loss through other means besides perspiration and increased urinary output occurs as well. Kidney function usually returns to normal in approximately 1 month. Diastasis recti abdominis is the separation of muscles in the abdominal wall and has no effect on the voiding reflex. Bladder tone is usually restored 5 to 7 days after childbirth.]

Question 19

Postpartum hemorrhage (PPH)

Answer 19

The loss of 500 mL or more of blood after a vaginal birth and 1000 mL or more after cesarean birth.
Causes/risk factors: Overdistended uterus (large fetus, multiples) leading to uterine atony, high parity, prolonged labor, oxytocin-induced labor.

Question 20

1st degree perineal laceration

Answer 20

Extends through the skin and vaginal mucous membrane but not the underlying fascia and muscle.

Question 21

2nd degree perineal laceration

Answer 21

Extends through the fascia and muscles of the perineal body, but not the anal sphincter.

Question 22

3rd degree perineal laceration

Answer 22

Involves the external anal sphincter.

Question 23

4th degree perineal laceration

Answer 23

Extends completely through the rectal mucosa, disrupting both the external and internal anal sphincters.

Question 24

Medications used to treat PPH

Answer 24

Uterotonic medications: Oxytocin, Cytotec, Methergine, Hemabate.

Question 25

If a woman experiences PPH (and placenta is expelled) and palpation reveals a boggy uterus, the next actions are to _

Answer 25

Empty the urinary bladder and administer a uterotonic medication.

Question 26

If a woman experiences PPH (and placenta is expelled) and palpation reveals a firm uterus, the next actions are to _

Answer 26

Assess for cervical/vaginal lacerations/hematoma and anticipate repair.

Question 27

If a woman experiences PPH and the placenta has been retained, the next actions are to _

Answer 27

Anticipate need for anesthesia and administer a tocolytic medication (e.g., terbutaline/Brethine).

Question 28

The major contraindications to giving Methergine are _

Answer 28

Hypertension/preeclampsia (BP above 140/90) and cardiac disease.

Question 29

The major contraindication to giving Hemabate is _

Answer 29

A history of asthma (this medication can cause bronchoconstriction).

Question 30

The most objective and least invasive assessment of adequate organ perfusion and oxygenation is _

Answer 30

A urine output of at least 30 mL/hr.

Question 31

Disseminated intravascular coagulation (DIC)

Answer 31

A pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, causing widespread external bleeding, internal bleeding, or both and clotting.
Postpartum patient - most often triggered by the release of large amounts of tissue thromboplastin, which occurs in placental abruption.
Lab findings: decreased platelets, prolonged PT and PTT.

Question 32

Endometritis

Answer 32

Infection of the lining of the uterus - most common postpartum infection. Usually begins as a localized infection at the placental site but can spread to the entire endometrium. Increased incidence with cesarean birth.

Question 33

What is the primary nursing responsibility when caring for a client who is experiencing an obstetric hemorrhage associated with uterine atony?

Answer 33

Performing fundal massage. [The initial management of excessive postpartum bleeding is a firm massage of the uterine fundus. Although establishing venous access may be a necessary intervention, fundal massage is the initial intervention. The woman may need surgical intervention to treat her postpartum hemorrhage, but the initial nursing intervention is to assess the uterus. After uterine massage, the nurse may want to catheterize the client to eliminate any bladder distention that may be preventing the uterus from properly contracting.]

Question 34

If nonsurgical treatment for late PPH is ineffective, which surgical procedure would be appropriate to correct the cause of this condition?

Answer 34

Dilation and curettage (D&C). [D&C allows the examination of the uterine contents and the removal of any retained placental fragments or blood clots. Hysterectomy is the removal of the uterus and is not the appropriate treatment for late PPH. A laparoscopy is the insertion of an endoscope through the abdominal wall to examine the peritoneal cavity, but it, too, is not the appropriate treatment for this condition. A laparotomy is the surgical incision into the peritoneal cavity to explore it but is also not the appropriate treatment for late PPH.]

Question 35

A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle feed. During the assessment, the nurse notices that both breasts are swollen, warm, and tender on palpation. Which guidance should the nurse provide to the client at this time?

Answer 35

Apply ice to the breasts for comfort. [Applying ice packs and cabbage leaves to the breasts for comfort is an appropriate intervention for treating engorgement in a mother who is bottle feeding. The ice packs should be applied for 15 minutes on and 45 minutes off to avoid rebound engorgement. A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk. A bottle-feeding mother should continuously wear a well-fitted support bra or breast binder for at least the first 72 hours after giving birth.]

Question 36

Minimum allowed hospital stays after birth

Answer 36

48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth.

Question 37

What information should the nurse understand fully regarding rubella and Rh status?

Answer 37

Women should be warned that the rubella vaccination is teratogenic and that they must avoid pregnancy for at least 1 month after vaccination. [Women should understand that they must practice contraception for at least 1 month after being vaccinated. Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated. Rh immunoglobulin is administered intramuscular (IM); it should never be administered to an infant. Rh immunoglobulin suppresses the immune system and therefore might thwart the rubella vaccination.]

Question 38

Parents who have not already done so need to make time for newborn follow-up of the discharge. According to the American Academy of Pediatrics (AAP), when should a breastfeeding infant first need to be seen for a follow-up examination?

Answer 38

48 to 72 hours after hospital discharge. [Breastfeeding infants are routinely seen by the pediatric health care provider clinic within 3 to 5 days after birth or 48 to 72 hours after hospital discharge and again at 2 weeks of age. Formula-feeding infants may be seen for the first time at 2 weeks of age.]

Question 39

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. What is the nurse’s highest priority at this time?

Answer 39

Massaging the woman’s fundus. [The nurse should first assess the uterus for atony by massaging the woman’s fundus. Uterine tone must be established to prevent excessive blood loss.]

Question 40

Postpartum assessment mnemonic

Answer 40

BUBBLEHE:
Breasts
Uterus
Bladder
Bowel
Lochia
Episiotomy
High risk clots
Emotional

Question 41

Episiotomy assessment mnemonic

Answer 41

REEDA:
Redness
Edema
Ecchymosis
Discharge
Approximation

Question 42

The pelvic rest period (no sex, tampons, douching, etc.) after childbirth usually lasts for _

Answer 42

6 weeks.

Question 43

Idiopathic thrombocytopenic purpura (ITP)

Answer 43

Autoimmune disorder, decreases lifespan of platelets resulting in low platelet count, capillary fragility and increased bleeding time. Increased risk of postpartum uterine bleeding and vaginal hematomas. Neonatal problems possible.

Question 44

von Willebrand Disease (vWD)

Answer 44

A type of hemophilia; defect in von Willebrand factor. Symptoms: Nosebleeds, bruises, prolonged bleeding time, factor VIII deficiency. Increased risk for bleeding up to 4 weeks postpartum.

Question 45

Uterine involution after delivery

Answer 45

12 hours after = 1 cm above the umbilicus.
24 hours after = 1 cm below the umbilicus.
2 days after = 2 cm below the umbilicus.
3 days after = 3 cm below the umbilicus.
7 days after = palpable at the symphysis pubis.
10 days after = non-palpable.