Module 3 GRTL Study Guide Questions

Question 1

Describe uterine involution

Answer 1

The process of the uterus returning to a pelvic organ by about 10 days PP

Three processes: 1) Contractions, 2) decreased size of myometrial cells, 3) endometrial regeneration

Question 2

How does fundal height change over two weeks postpartum?

Answer 2

Immediately after birth, it is at the Umbilicus, then decreases by 1 cm each day after birth
It takes 24-48 to involute to half of its size postpartum. Highly efficient for the first two days and then involutes slower.

Question 3

At what point postpartum is the uterus no longer palpable?

Answer 3

10 days to 2 weeks PP

Question 4

How long does the process of involution take?

Answer 4

involution is complete at 6-8 weeks

Question 5

What factor could expedite involution?

Answer 5

BF makes involution more efficient

Question 6

What factors could slow involution?

Answer 6

Uterine overdistention: polyhydramnios, multifetal pregnancy, multips

Question 7

What conditions could cause subinvolution?

Answer 7

Subinvolution: does not return to non pregnant state in expected time (6-8w)
Retained tissue, infection (endometritis), fibroids, uterine laceration, unknown etiology

Question 8

The midwife is performing an exam for a woman at 12 days PP, and the uterus is not palpable. What does she tell the patient?

Answer 8

It is normal to no longer feel your uterus abdominally at this point PP

Question 9

T/F: Subinvolution is always due to uterine infection

Answer 9

False

Question 10

After normal labor and birth, at 10 hours PP, the midwife palpates the uterine fundus at 2 cm above the umbilicus. What does the CNM consider first as a possible cause?

Answer 10

Bladder distention

Question 11

What form does the external cervical os typically take following a vaginal birth?

Answer 11

After birth the cervix is shorter. It is more “slit like”.

Question 12

When do vaginal rugae reappear postpartum?

Answer 12

By week three pp, the vagina has become much smaller and the rugae are beginning to reform on the vaginal walls. By 6 weeks pp, the rugae have returned to approximately the same size they were before birth.

Question 13

What is lochia made up of?

Answer 13

blood, endometrial lining, amniotic fluid, bacteria and microorganisms, any left over fetal membranes, and cervical mucus.

Question 14

Describe the flow and color changes of lochia.

Answer 14

Rubra - bright red/brown color for ~ 3-5 days
Serosa - pink/mucous ~5-22 days
Alba - whitish (from leukocytes) day 10 up to 6wk pp

Question 15

What is eschar bleeding? When does it occur?

Answer 15

Release of the placental site scar that results in bright red VB on pp day 10-12

Question 16

What factors can affect the duration of lochia?

Answer 16

Type of delivery, physical activity, breastfeeding, infection, subinvolution

Question 17

What conditions can increased afterbirth pains?

Answer 17

Multiparous women, full bladder, having had an overextended uterus from multifetal gestation

Question 18

What are some relief measures that can be used for afterpains?

Answer 18

600 mg Ibuprofen q6hr prn, narcotics may be needed the first few days, have pt empty bladder prior to breastfeeding, lying prone, periodically massaging own fundus

Question 19

How long are afterpains typically felt for?

Answer 19

48-72 hours at most

Question 20

What types of perineal trauma can occur during a vaginal birth?

Answer 20

Bruising, hematoma. Lacerations, episiotomy.

Question 21

Describe the typical healing time of perineal injuries

Answer 21

Sutures should absorb by the third week of postpartum, except for the external knot, which will be reabsorbed when the suture underneath is absorbed. Typical healing time is three weeks after giving birth.

Question 22

Describe comfort measures that can be used for perineal injuries

Answer 22

Comfort measures include: kegel exercises, ice packs up to 24 hours after childbirth, cool or warm baths, topical analgesics such as benzocaine spray, and herbal compresses with witch hazel, comfrey, or lavender oil.

Question 23

Describe granulation tissue appearance

Answer 23

Can take up to 4 to 5 weeks. Patients that have sutures in place and the suturing material may take up to 6 weeks or longer for the sutures to be fully absorbed.

Question 24

Describe collagen scar tissue characteristics

Answer 24

This phase can last for years. Many new blood vessels begin to regress. Wound contractors start the action of myofibroblasts.

Question 25

Describe Pelvic floor exercises technique

Answer 25

1) Make sure that the bladder is empty
2) Tighten the pelvic floor muscles and hold for 5-10 seconds
3) Relax the muscle for 5-10 seconds
4) Repeat 10 times and continue to do 10 repetitions three times a day

Question 26

Describe Pelvic floor exercises benefits

Answer 26

Kegel exercise asses for vaginal tone, cystocele or rectocele. Kegel exercise also help increase circulation to the perineum and provide comfort with little movement after initial tenderness. Another benefit of Kegel exercise is to help maintain urinary incontinence and decrease stress incontinence. Kegel exercises can be done shortly after birth and needs to be continued through life. At six weeks the examiner will insert a gloved finger and ask the client to do a kegel exercise. At this time the examiner can assess and give advice accordingly.

Question 27

When should rectal suppositories not be used during PP recovery?

Answer 27

Rectal suppositories should be avoided if the patient has sustained a third or fourth degree laceration.

Question 28

Describe PP cardiovascular changes.

Answer 28

Dramatic fluid shifts cause maternal cardiovascular instability and time of increased risk for pulmonary edema, cardiac failure and death in those with cardiac disease, HTN, or pre-e. 10-15 min PP there is an 80% increase in stroke volume and cardiac output. This effect is hypothesized to be due to increased cardiac preload that results from auto-transfusion of utero-placental blood back into maternal systemic circulation and improved venous return with decompression of the vena cava secondary to removal of mechanical pressure from the gravid uterus. These remain elevated in the first hour. Maternal heart rate decreases, but mean arterial BP is unchanged. Normal return of cardiovascular function depends in part on a physiologic diuresis in the first week postpartum. Without normal excretion of the extracellular fluid into the intravascular system, there is an increased risk of pulmonary edema, particularly among women with cardiac disease or preeclampsia. The increase in stroke volume first during pregnancy and then during the postpartum period leads to a temporary increase in the size of the left atrium of the heart. This physiologic ventricular hypertrophy resolves more slowly than the increase in stroke volume and cardiac output. Left ventricular size does not return to normal until approximately 6 months postpartum.

Question 29

What are patients with cardiac disease higher risk in the immediate pospartum period?

Answer 29

The auto-tranfusion of 10-15% blood volume due to the removal of the placenta increased stroke volume and cardiac output by 80%. The CO is increased within the first 48 hours and slowly retunes to normal over 6-12 weeks PP.

Question 30

Describe PP hematologic changes.

Answer 30

A series of significant and rapid cardiovascular changes occur in the immediate postpartum period—namely, loss of blood, auto-transfusion of 10% to 15% of blood volume secondary to removal of the low-pressure fetal–placental unit, and mobilization of extracellular fluid back into the maternal circulation. Mobilization of extracellular fluid back into circulation in the first few postpartum days also contributes to increased maternal blood volume. This acute increase in blood volume helps compensate for the normal blood loss of parturition. Following the sudden increase in cardiac output immediately after birth, the woman’s blood volume declines to prepregnant levels over a period of approximately 2 weeks. The blood loss that occurs during birth causes a marked decrease in the woman’s red blood cell (RBC) volume. In addition, a period of hemodilution arises in the first postpartum week due to the increase in plasma volume that occurs as interstitial fluid is mobilized. The loss of RBCs combined with this hemodilution leads to a decrease in hemoglobin and hematocrit in the first postpartum week. A woman’s hemoglobin and hematocrit gradually return over a 4- to 6-week period to their prepregnant values as plasma volumes and RBC production return to normal.

Question 31

Explain postpartum diuresis and diaphoresis, factors that impact this process, and comfort measures for diaphoresis.

Answer 31

Women will begin shedding the excess water from pregnancy soon after birth. This usually occurs on days 2–5 but may start as early as 12 hours, and last into the second week, especially if large amounts of IV fluid were used in labor. Within 3 weeks postpartum, the diuresis and diaphoresis is complete. Diuresis of about 3000 cc/day is common. A single void can be 500 cc or more (Blackburn, 2013). Remind women of the importance of keeping the bladder empty and the uterus contracted, and reassure them that the loss of this extra fluid is a natural part of the postpartum recovery process. Diaphoresis is another route for shedding the excess extracellular fluid retained during pregnancy. Remind women of its normalcy and discuss comfort measures. Encourage frequent showering or bathing, wearing natural fibers, and dressing in layers. Keep fluids at the bedside and drink to thirst. Explain that weight loss of 5–6 pounds of fluid during this time can be expected

Question 32

Discuss risks associated with PP sleep disturbances, assessment, and helpful tips to improve sleep.

Answer 32

The postpartum period is characterized by a significant lack of sleep for most new mothers. Sleep disturbance can include both sleep deprivation and sleep fragmentation that disrupts the integrity of the sleep cycle. Despite extreme fatigue, insomnia can increase for some postpartum women and further reduce sleep time. Cumulative lack of sleep and sleep fragmentation increasingly worsen up to 3 months postpartum and can significantly affect maternal daytime functioning and mood (Insana et al., 2013). Assessment of maternal sleep duration and quality is essential during postpartum visits. Areas to assess include maternal employment, household assistance, use of medications, alcohol and herbal preparations, sleep duration and quality, and number of nighttime awakenings. Parents may believe that co-sleeping with their newborn improves maternal sleep since the mother can feed without arising out of bed; however, it can result in poorer sleep quality for both the co-sleeping mother and infant (Volkovich et al., 2015). This should be a discussion point when talking to postpartum women about sleep. Sleep deprivation and insomnia are significantly associated with PPD (Lawson et al., 2015). If women continue to have difficulty falling asleep or returning to sleep for more than 2–4 weeks, screening for PPD should be done and referral to a sleep clinical considered.

Question 33

Identify the causes of PP constipation

Answer 33

-limited intake during labor, so they have limited
-stool in the rectum
-BM during delivery (sometimes unaware)
-iron supplementation
-pain medications (opioids)
-Fear of pain with BM and/or tearing sutures (education that BM will not interfere with sutures)

Question 34

How long should it take a PP patient to resume normal bowel habits?

Answer 34

up to a week

Question 35

What relief measures can be used for PP constipation?

Answer 35

-increase fluids
-eat high-fiber foods (fruits, vegetables, etc)
-moderate activity, such as walking
-Over-the-counter stool softeners or mild laxatives (normally prescribed for women who sustain a 3rd or 4th-degree lacerations)

Question 36

What types of activity would you encourage during the early PP period and why?

Answer 36

For both vaginal & c-section deliveries, women should get up and move around soon after birth. Altered clotting factors increase the risk for
Thrombosis. Activity is a preventive practice for DVT.

Activity beyond normal walking or home activities will depend on the woman’s birth recovery. Women should gradually increase exercise, (especially after six weeks PP). Starting at two weeks PP daily walks outside with the baby can fulfill many purposes:
-exercise
-morale
-can help baby sleep

Question 37

What percentage of women resume sexual activity prior to the 6-week PP visit?

Answer 37

Waiting to have sex until after the 6-week postpartum visit has no physiologic basis, 66% will have resumed intercourse in the first month, and 88% by the second postpartum month.

Question 38

What advice would you give regarding the resumption of sexual intercourse?

Answer 38

Consider personal factors when making the decision to resume sex:
-vaginal bleeding
-perineal comfort
-contraception choice
-readiness of both partners

Question 39

How does breastfeeding potentially impact sexual activity?

Answer 39

Breastfeeding is associated with poorer sexual function and decreased satisfaction with sex

Associated with dyspareunia (painful intercourse), decreased sexual desire and nonresumption of sexual intercourse because of hormonal changes and fagitue

Question 40

How would you counsel a patient on the resumption of ovulation and menses?

Answer 40

Average day of return to ovulation for non-breastfeeding women is 6 weeks pp

Often the first menses comes after the first ovulation, so you may not see the warning sign of a period before conceiving

All non-breastfeeding pp people are at risk for unintended pregnancy as early as 3-4wks pp

For breastfeeding people, return to ovulation varies and is impossible to predict - People who exclusively breastfeed who are amenorrheic have a very small chance of becoming pregnant in the first 6 months pp

Question 41

When should contraceptive needs be discussed and why?

Answer 41

Counseling and decision-making should ideally begin during early pregnancy and continue throughout prenatal care (first visit is often 6wks postpartum - may miss opportunity to prevent pregnancy if penile-vaginal intercourse has already resumed
-spacing pregnancies is critical to improving maternal and fetal outcomes in future pregnancies (spacing <6mos associated with preterm birth, LBW, SGA, <18mos associated with less but still increased risk of poor perinatal outcomes)
-Important to allow time to recover physically and emotionally from pregnancy and childbirth and have the opportunity to bond with the new baby and family structure

Contraceptive method should be tailored to the specific needs/preferences of the patient

Fully breastfeeding people would ideally start contraception by 3mos pp and non-breastfeeding people should initiate in the 3rd wk pp.

Question 42

Discuss postpartum baby blues including etiology, incidence, symptoms, onset and duration, and helpful measures.

Answer 42

26-84% of birthing people experience postpartum blues

-Etiology unknown but fatigue, limited support, hormonal changes, social isolation, relationship conflict can all contribute
-Common to cry for unexplained reasons, experience anxiety, experience fatige or insomnia, changes to apetite, have mixed emotions about the birthing experience
-Symptoms that last more than 2 wks indicated need for evaluation for ppd
-Postpartum depression can have onset of weeks or moths after birth
-Clinician - active listening, reassurance and normalization of feelings

Suggest increased support at home with tasks, self care activities, sleep and rest and other coping mechanisms