Module 3 Part A/B

Question 1

Describe physiologic respiratory changes that occur during the PP period

Answer 1

Removal of pregnancy weight allows for immediate relief of intra-abdominal pressure that allows for elevation of the diaphragm and resolution of shortness of breath. Tidal volume returns to normal.

Question 2

Describe physiologic renal system changes that occur during the PP period.

Answer 2

There is a gradual return to nonpregnant GFR, renal plasma flow, plasma creatinine, BUN and creatinine clearance. Mild proteinura may develop. Natriuesis and diuresis occur over the 3 weeks PP returning to prepregnant blood volume level. Blader tone, size and function returns to normal over 6-8 weeks

Question 3

Describe physiologic hepatic system changes that occur during the PP period.

Answer 3

LFTs return to normal levels by 3 weeks PP, Alkaline phosphate returns to normal within 6 weeks.

Question 4

What PP changes should patients expect concerning the following hyperpigmentation pregnancy-related skin changes? Ex: Linea nigra, melasma, Areola, Striae gravidarum (stretch marks)

Answer 4

Skin changes will gradually fade or regress over 6 months PP. Many do not completely disappear. Ex. striae will turn while in 3 months.

Question 5

Describe PP changes for the following hormones:
Thyroid-binding globulin, triiodothyronine (T3) and thyroxine (T4) levels

Answer 5

Decreasing estrogen causes a drop in T3 and T4 with a gradual return to prepregnant level. PP thyroid dysfunction is typically transient

Question 6

Describe PP changes for the following hormones: Placental hormones human placental lactogen (hPL), human chorionic gonadotropin (hCG), estrogen, and progesterone

Answer 6

There is abrupt drop in estrogen, progesterone, hcg, and hcl when the placenta is expelled.

Question 7

Describe PP changes for the following hormones:
Pituitary function, gonadotropin-releasing hormone )GnRH), FSH, and LH in nonlactating and lactating women

Answer 7

Following birth, FSH and LH levels remain low for the first 2 postpartum weeks, but then rise gradually. Ovarian production of estrogen and progesterone, therefore, also remains low during the first few postpartum weeks. In nonlactating PP patients, ovulation can return within 1-3 months.

Question 8

Outline the major hemodynamic changes that occur in the first few hours of the puerperium that would explain changes in cardiac output, bradycardia, and orthostatic hypotension.

Answer 8

Blood loss at birth causes a decrease in RBC volume and hemodilution. The significant blood loss and autotransfusion causes an 80% increase in cardiac output and stoke volume. Blood volume returns to prepregnant levels by 2 weeks PP.

Question 9

Describe the hemostatic actions that occur within the uterus to minimize blood loss during the postpartum period. How do these relate to afterpains? What role do changes in clotting factors play?

Answer 9

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.

Question 10

Outline the steps in the regeneration of the endometrium, in both the nonplacental and placental areas, giving the time frame

Answer 10

Myometrial cells shrink/autolyse and the uterus is involuted by 50% in 24-48 hours then gradually diminished over 6-8 weeks. Myometrial cells decrease in size**

Question 11

Describe the reorganization of the myometrium.

Question 12

Describe expected fundal height changes over the first two weeks of the puerperium.

Answer 12

The fundus lowers by one fingerbreadth or 1 cm every day. After 14 days PP, the fundus is no longer palpable in the abdomen

Question 13

Consider other reasons why uterine involution may occur more slowly.

Answer 13

Overextended uterus due to fibroids, multiple pregnancy, miltiparas, retained placenta, clots, endometritis

Question 14

Compare and briefly explain (normal vs. abnormal) the values you would expect to see in the late prenatal period with those of the first or second day postpartum for the following lab: Hgb/Hct

Answer 14

A hemoglobin (Hgb) drop of 1 g = 500 mL
A hematocrit (Hct) drop of 1% = 250 mL

Question 15

Compare and briefly explain (normal vs. abnormal) the values you would expect to see in the late prenatal period with those of the first or second day postpartum for the following lab: WBC

Answer 15

WBCs are elevated in labor and gradually return to normal in the puerperium.

Question 16

Compare and briefly explain (normal vs. abnormal) the values you would expect to see in the late prenatal period with those of the first or second day postpartum for the following lab: plts

Answer 16

Normalizes by 12 weeks PP

Question 17

Compare and briefly explain (normal vs. abnormal) the values you would expect to see in the late prenatal period with those of the first or second day postpartum for the following lab: Urinary protein

Answer 17

Mild proteinuria may develop in the first few postpartum days. Will return to prepregnant status in 2-3 days

Question 18

According to the journal’s article on Management of PP Pain, how does estrogen, oxytocin, and perception of the birth experience affect pain sensitivity?

Answer 18

Preclinical studies (using animal models) have demonstrated that estrogen, which is markedly elevated during pregnancy, heightens pain sensitivity through both peripheral and central
mechanisms. Estrogen declines rapidly postpartum following the birth of the placenta, and thus a reduction in pain sensitivity may occur with its decline. Elevated oxytocin levels in the puerperium and while breastfeeding may partially account for the low incidence of persistent, chronic pain even after surgical childbirth.

Question 19

What are potential causes of pain during the postpartum period?

Answer 19

Perineal tear/episiotomy, C/S pain, afterpain, breast pain, hemorrhoids

Question 20

How does the degree of perineal trauma affect perineal pain following birth?

Answer 20

Perineal pain is experienced in some women even if they have an intact perineum, with the severity usually related to the degree of tissue trauma.

Question 21

Describe dosages, administration routes, frequency, adverse effects, maximum dose/day, and breastfeeding safety for the following pain medication: Acetaminophen

Answer 21

Inhibits cox-3, can get 325-650 every 4-6 hours for a max of 4gm in 24 hours due to risk of liver toxicity. There is a risk of overdose due to combination products. Tylenol is considered safe with BF.

Question 22

Describe dosages, administration routes, frequency, adverse effects, maximum dose/day, and breastfeeding safety for the following pain medication: Ibuprofen

Answer 22

Ibuprofen is a true NSAID. It can be given 400-800 mg every 4-6 hours With a max of 2.4g in 24 hours for pain and 3.6 g in 24 hours for fever. This works well for pain and inflammation and is considered safe for BF.

Question 23

Describe dosages, administration routes, frequency, adverse effects, maximum dose/day, and breastfeeding safety for the following pain medication: Toradol

Answer 23

Toradol is an IV NSAID and very similar to ibuprofen slide

Question 24

Describe dosages, administration routes, frequency, adverse effects, maximum dose/day, and breastfeeding safety for the following pain medication: Acetaminophen/Codeine No. 3

Answer 24

The risk with Tylenol 3 is for those that are ultra-rapid metabolizers. There has been a neonatal demise due to OD of a baby of opioids through breastmilk of an ultra-rapid metabolizer

Question 25

Describe dosages, administration routes, frequency, adverse effects, maximum dose/day, and breastfeeding safety for the following pain medication: Hydrocodone/acetaminophen

Answer 25

This is the most commonly prescribed oral opiod. Essentially the same info as tylenol and tylenol 3

Question 26

What medications does the American Academy of Pediatrics recommend be used for breastfeeding women who require opioids for pain relief?

Answer 26

The American Academy of Pediatrics’ Committee on Drugs states that morphine, hydromorphone, and butorphanol are preferred agents for breastfeeding women who require opioids for pain relief.

Question 27

What are some common care practices following a c/section?

Answer 27

-Oral analgesics for pain control.
-Ambulation to prevent DVT

Question 28

What is the benefit of unrestricted oral intake following a c/section?

Answer 28

Unrestricted oral intake after cesarean birth accelerates the return of gastrointestinal function, and bowel sounds should be audible within 12 to 24 hours after surgery.

Question 29

What is included in pre-op and post-op care following a vaginal birth and tubal ligation?

Answer 29

No additional restrictions or instructions are needed for the postpartum tubal sterilization.

Question 30

Describe PP changes in the following laboratory values
-Hgb
-Hct
-WBC

Answer 30

-H/H: Decreases due to Blood loss and returns to normal range by 4 weeks
-WBCs are elevated in labor and gradually return to normal in the puerperium.

Question 31

What recommendations would you give for advancing activity levels?

Answer 31

Early initiation of ambulation is recommended to prevent DVT.

Question 32

Describe options for postpartum follow-up during the mid-postpartum period including areas assessed.

Question 33

What are common experiences reported by women during the PP period?

Answer 33

Baby Blues, pain, anxiety, stress

Question 34

What are four common needs women identify as needing during the PP period?

Answer 34

..

Question 35

What is an important therapeutic technique when a traumatic birth has occurred?

Answer 35

Using compassionate questions like “How did your birth go?”

Question 36

Define postnatal fatigue, associated risks, factors that increase PP fatigue, and potential strategies for reducing fatigue

Answer 36

Can contribute to baby blues, can cause irritability, stress.
Family and friends can help with household chores and care of the baby so the mother can rest.

Question 37

Based on the results from the study “Balancing Work and Family after Childbirth: A Longitudinal Analysis:
How did the duration of maternity leave affect breastfeeding duration?

Answer 37

Eave duration was correlated with breastfeeding and breastfeeding declined with time from a high of 72% at 5 weeks, to 58% at 11 weeks, and 37% at 6 months.

Question 38

Based on the results from the study “Balancing Work and Family after Childbirth: A Longitudinal Analysis: How did job spillover into home life and home spillover into work affect mental health?

Answer 38

Women more frequently experienced job spillover than home spillover; more than half reporting either medium or high levels at 6, 12, and 18 months and approximately one third reported comparable levels of home spill during the same time periods. pecifically, women who reported high levels of job spillover into home experienced lower mental health, as did women who reported medium and high levels of home spillover into work.

Question 39

Based on the results from the study “Balancing Work and Family after Childbirth: A Longitudinal Analysis: What impact did supportive coworkers have on mental health levels?

Answer 39

A majority of women reported positive work experiences in terms of supervisor and coworker support, and it is plausible that their high level of perceived support blunted conflict. Most women also reported a supportive workplace, which suggests that our inability to find many significant associations may be related to low variability.

Question 40

Based on the results from the study “Balancing Work and Family after Childbirth: A Longitudinal Analysis: What is the potential impact of flexible work arrangements?

Answer 40

Findings also revealed that flexible work arrangements were associated with poorer postpartum mental health scores, which may reflect unintended consequences, such as increasing the amount of work brought home.