Maternal Physiological Adaptations and Assessment

Question 1

Infant Mortality Rate

Answer 1

• Canada ranks 29th & US ranks 31st of industrialized countries
• matter because they are a litmus test of the health of women in society. If healthy babies are not produced, why?
• SDOH. Everything that is contributing to the mother not being able to produce babies that survive

Question 2

Contemporary Issues and Trends

Answer 2

Healthy People 2020 Goals: reduce the rate of fetal and infant deaths, reduce the rate of maternal mortality, reduce preterm births, reduce caesarean births among low-risk women
Sustainable Development Goals: 10 goals related to maternal/infant/child health
Interprofessional Education (IPE): client care will improve when health professionals work together. teamwork and communication are key aspects of IPE, situation, background, assessment, recommendations
The interprofessional collaborative practice competencies include: values/ethics for interprofessional practice, roles/responsibilities, interprofessional communication, teams and teamwork

Question 3

Perinatal Current Issues

Answer 3

• Promoting health and normal birth
• Place of birth and “high-tech” care
• Midwifery
• Baby Friendly Initiative
• Patient safety and risk management
• Community-based care
• Elective C-sections
• Health literacy
• Global perspective

Question 4

Ethical Issues in Perinatal Nursing and Women’s Health Care

Answer 4

• Reproductive technology
• Allocation of resources
• Older-age pregnancies
• Induced ovulation and in vitro fertilization
• HIV-positive women seeking assisted reproduction
• Multifetal pregnancy reduction
• Intrauterine fetal surgery
• Treatment of very low-birth-weight infants (<1000 gms/ 2 lbs 2 oz)
• Indigenous Health
• LGBTQIA2S+

Question 5

Postpartum period

Answer 5

interval between birth and return of reproductive organs to their nonpregnant state.
- referred to as puerperium or “fourth trimester of pregnancy”
- lasts 6 weeks (varies among women)

Question 6

Reproductive System and Associated Structures: Uterus

Answer 6

Fundal height and lochia are indicators of progression of uterine involution
Involution process: return of uterus to tru pelvis after birth. Progresses rapidly. Fundus descends 1 to 2 cm every 24 hr. 2 weeks after childbirth uterus lies in true pelvis

Question 7

Sub involution

Answer 7

failure of uterus to return to non-pregnant state. Common causes are retained placental fragments and infection.

Question 8

Uterus: Contractions

Answer 8

• hemostasis achieved by compression of blood vessels as uterine muscle contracts (pushing and squeezing causes cessation of blood flow) (as opposed to platelet aggregation or clot formation)
• hormone oxytocin, released from pituitary gland, strengthens and coordinates uterine contractions.
• After pains: contractions after delivery
• placental site: vessels close off and cauterize themselves. vascular constriction & thrombosis reduce the placental site

Question 9

Lochia

Answer 9

Post birth uterine discharge
- Lochia Rubra - bright red flow. blood and decidual debris (mucosal lining of uterus). Duration of 3-4 days
- Lochia serosa (pink) - old blood, serum, leukocytes, and debris; median duration of 22 to 27 days
-lochia alba (whitish or brown) - leukocytes decidua, epithelial cells, mucus, serum, and bacteria. Continues 4 to 8 weeks after birth

Question 10

Reproductive System and Associated Structures: Cervix

Answer 10

• Soft immediately after birth
• within 2 to 3 postpartum days, cervix is 2 to 3 cm, and by 1 week it is about 1 cm
• Ectocervix (portion that protrudes into vagina) appears bruised and has small lacerations - optimal conditions to develop infections

Question 11

Reproductive System and Associated Structures: Vagina and Perineum

Answer 11

• Estrogen deprivation: responsible for thinness of vaginal mucosa and absence of rugae (muscular folds on internal wall of vagina)
• Vagina gradually decreases in size and regains tone (never completely returns to pre-pregnancy state)
• Thickening of vaginal mucosa occurs with return of ovarian function
• Dryness and coital discomfort (dyspareunia) may persist until return of ovarian function
• Episiotomies heal within about 2 weeks
• Hemorrhoids are common and decrease within 6 weeks of childbirth
• Pelvic muscular support (supportive tissues of pelvic floor torn or stretched during childbirth. Requires up to 6 months to regain tone. Kegel exercises encourage healing)

Question 12

Breasts: Breastfeeding Mothers

Answer 12

Colostrum: early milk (yellowish fluid expressed from nipples)
- tenderness may persist for 48 hours after start of lactation. Transitions to milk in 72 to 96 hours (lactogenesis). Engorgement comfort measure for lactating mom.

Question 13

Breasts: Non-breastfeeding mothers

Answer 13

• Engorgement resolves in 24-36 hours after milk comes in
• Breast binder/tight bra, ice packs, fresh cabbage leaves, or mild analgesics may be used to relieve discomfort
• lactation ceases within a few days to 1 week

Question 14

Cardiovascular System: Blood volume

Answer 14

• average blood loss range for vaginal birth: up to 500mL
• average blood loss range for Caesarean birth: 500 mL to 1000 mL
• blood volume decreases within a few days as a result of diuresis
• increased BV by 50%

Question 15

Cardiovascular System: Cardiac output

Answer 15

Remains increased for 48 hours after birth
Vital Signs - HR, BP return to normal after 2-3 days. RR returns to normal

Question 16

Cardiovascular System: Blood components and Varicosities

Answer 16

hematocrit and hemoglobin - moderate drop for 2-4 days, then normal by 8 weeks PP
white blood cell count - normal by 10-12 days
coagulation factors - elevated with risk of thromboembolism
- C/S - encourage movement
Varicosities
- total or nearly total regression of varicosities is expected after childbirth

Question 17

Respiratory System

Answer 17

• Immediate decrease in intra-abdominal pressure at birth causing an increase in chest wall compliance
• decreased pressure on diaphragm
• reduced pulmonary blood flow
• rib cage elasticity can take months to return to a pre-pregnancy state
• loss of placenta = decreased progesterone = PaCO2 levels to rise.
• basal metabolic rate returns to pre-pregnancy levels within 1 to 2 weeks after birth

Question 18

Endocrine System: Placental hormones

Answer 18

• Expulsion of placenta = decreased estrogen and progesterone levels
• decreases in human chorionic somatomammotropin (hCS) also known as human placental lactogen estrogens, cortisol, and placental enzyme insulinase reverse effects of pregnancy including reversal of the diabetogenic effects of pregnancy leading to sig. lower blood sugar levels. What does this mean?
• mothers with T1DM often require much less insulin for a few days post birth
• mothers with gestational diabetes often have resolution immediately or within days of birth
• hCG disappears quickly from maternal circulation (detectible for 3-4 weeks post birth)
• hCG: levels double every 48 hours. hormone that indicates pregnancy on pee stick

Question 19

Endocrine System: Pituitary hormones and ovarian function

Answer 19

Prolactin levels are highest during 1st month in women who breastfeed & remain elevated in women who breastfeed.
- influenced by frequency of breastfeeding, duration of each feed and supplementary feeds, strength of infant suck
- ovulation in 27 days after birth for non-lactating women
- ovulation in 70-75 days for lactating women
- BF women - return of ovulation depends on breastfeeding patterns
- may ovulate before first menstrual cycle

Question 20

Urinary System

Answer 20

Urine components:
- Renal glycosuria disappears by 1 week postpartum
- Lactosuria may occur in lactating women
- Blood urea Nitrogen (BUN) increases with autolysis of the involuting uterus
- Ketonuria persists in some women with uncomplicated birth or after a prolonged labour with dehydration
Fluid loss: diuresis of extracellular fluid. profuse diaphoresis often occurs at night for the first 2 to 3 days
Urethra and bladder: excessive bleeding can occur because of displacement of the urethra if the bladder is distended. stress incontinence.
Bladder has been desensitized from baby sitting on top of it
- can be very sweaty

Question 21

Gastrointestinal System

Answer 21

Appetite: most new mothers are very hungry after recovery from analgesia, anaesthesia, and fatigue
Bowel evacuation: spontaneous bowel movements may not occur for 2-3 days after childbirth:
- decreased muscle tone in intestines during labour and immediate puerperium, pre-labour diarrhea, lack of food, dehydration
- discomfort due to perineal tenderness, episiotomy, lacerations or hemorrhoids
- forceps/vacuum/anal sphincter lacerations - increased risk of postpartum incontinence (flatus). should resolve by 6 months
- C/S - abdominal pain from buildup of flatus. encourage mom to move to enhance movement of intestinal system

Question 22

Integumentary System

Answer 22

• Melasma (chloasma/mask of pregnancy): disappears in the postpartum period
• persists in about 30% of women
• Hyperpigmentation of areolae and linea nigra may not regress completely after childbirth
• some women will have permanent darker pigmentation of those areas
• striae gravidarum - stretch marks on breasts, abdomen, and thighs may fade but not disappear
• hair loss during 3 month PP (hormones keep hair that normally would have fallen out, in)
• Fingernails return to pre pregnancy consistency and strength

Question 23

Musculoskeletal System

Answer 23

Adaptations of system are reversed
- take 6 weeks for abdominal wall to return to almost pre pregnancy state (depends on prior tone, exercise)
- Diastasis recti abdoinis = the abdominal wall muscles separate (permanent)
- Joints are stabilized by 6 to 8 weeks after birth
- Ongoing hypermobility of joints
- Change in mother’s center of gravity
- A new mother may notice a permanent increase in shoe size
- hormones cause cartilage to relax (pelvis). can feel loose

Question 24

Neurological System

Answer 24

• Changes with reversal of maternal adaptations to pregnancy and from personal labour & birth story
• headache common in first PP week due to fluid balance
• requires careful assessment
• postpartum headaches may be due to postpartum-onset pre-eclampsia, stress, and leakage of cerebrospinal fluid into the extradural space during placement of the needle for administration of epidural or spinal anaesthesia (supine position)

Question 25

Immune System

Answer 25

Immune system, mildly suppressed during pregnancy
Gradually returns to the pre-pregnancy state.
- no exact timeline
This rebound of immune system can trigger “flare-ups” of autoimmune conditions (MS)

Question 26

Sign of Puerperal Sepsis

Answer 26

an increased maternal temperature to 38 degrees or higher after the first 24 hours postpartum (or recurrent or persistent over the subsequent two days) may be a sign of peurperal sepsis