W - Postpartum

Question 1

How long does postpartum period last for?
What isit usually caused by?

Answer 1

• 6 wks after delivery
• Caused by: rapid drop in estrogen & progesterone

Question 2

What are the uterus changes? (3)
How do clinicians track progress of uterine involution? (1)

Answer 2

1. Uterus begins to return to its nonpregnant state (size and position) = uterine involution
2. Placenta is delivered → uterine muscle fibres constrict uterine BVs ⇒ prevents postpartum haemorrhage
3. Contractions continue during postpartum (further help uterine involution) = afterpains sharp pain in the abdomen

• By palpating on the top part of the uterus = fundus
  
  • 12h after delivery → fundus can be palpated at 1 cm above the umbilicus
  • Normally descends by about 1 cm (1 fingerbreadth) per day → reaches pelvic cavity by D-14

Question 3

Whats the vaginal discharge after birth? When should nurses assess lochia volume on pad?

Answer 3

○ Stain < 2.5 cm = scant amount of lochia
○ Stain < 10 cm = light amount
○ Stain < 15 cm = moderate amount

• Complete saturation of perineal pad in 60 minutes = heavy lochia
• Complete saturation of perineal pad in 15 minutes = excessive lochia
• Irregularities in the duration, quality, and amount of lochia = can be infection / uterine subinvolution: uterus fails to return to its pre-pregnancy state
• Assess lochia volume on perineal pad every 60 minutes!!!!

Question 4

What changes will occur to the Cervix & Vaginal walls? (3+3)

Answer 4

CERVIX
After baby delivered → cervical trauma can occur ⇒ results in edema, bruises, lacerations

After delivery
- Internal os of the cervix fully closes
- External os remains slightly open at about 2-3 centimetres at 2 to 3 days post-delivery
- End of W1 → narrows to <1 cm, appears as a transverse slit

VAGINAL WALLS
After baby delivered → trauma to vaginal walls ⇒ results in edema and lacerations
- After delivery, vagina loses folds and ridges of the vaginal walls = vaginal rugae
- Start to reappear 3-4 weeks after delivery.
- 6 weeks after delivery, the vagina reaches a near pre-pregnant size

Question 5

Gastrointestinal (2)

Answer 5

1. Most common = constipation tgt with flatulence & abdominal fullness

BECAUSE:
- progesterone levels from pregnancy remain elevated right for several days after delivery
- hormone reduces gastrointestinal tone and motility

2. If client had episiotomy or perineal laceration during delivery → may avoid defecating because of pain and discomfort
   - Normal gastrointestinal motility usually returns at 2 to 3 days post-delivery

Question 6

Cardiovascular changes (5)

Answer 6

1. Blood that used to supply uterus returns to systemic circulation → temporary increase in cardiac output that eventually returns to pre labour values (1h after delivery)
2. Plasma volumes ⇒ also decrease after delivery
   - Normal delivery related blood loss
   ○ 200-500 ml for vaginal delivery
   ○ 600 - 800 for caesarean delivery
3. Aldosterone & oxytocin production ↓ ⇒
   ↑ diuresis and fluid loss through urine + increased sweating ⇒ decrease plasma volume and return it to pre-pregnancy by 6 weeks
4. Hematocrit (% of blood volume made up of red blood cells) & coagulation levels normalise
   ■ Over 4-6 weeks
   ■ During this period, client remains in a hypercoagulable state = increased tendency to clot more than normal -> DVT, pulmonary embolism, stroke or other clotting disorders
5. First 24 hours, WBC levels ↑ up to 30,000 cells per mm3.
   - increase in white blood cell count is a physiologic response
   ○ Not associated with an active infection
   ○ Takes ~ 1 week for body to normalise the white blood cell count

Question 7

Renal (3)

Answer 7

1. Kidneys typically return to normal position over next 4 weeks
   - Diuresis fully restores within 12 h after delivery
2. Urinary retention
   - loss of bladder tone and elasticity ⇒ can result in overdistension and subsequent retention of urine
   - result of the pressure exerted by the foetus during delivery → decreases sensation in the urinary tract
   - trauma to the bladder, urethra, or urinary meatus
   can

can be also caused by:
○ Medications
○ Anaesthesia
○ Lack of privacy

Complications
- Interfere with uterine involution
- elevated or laterally displaced uterus
- provides an environment for bacterial growth and the development of urinary tract infections.

3. Stress urinary incontinence
   - involuntary urine leakage during exertion, like laughing, coughing, and sneezing
   - due to trauma/weakened pelvic floor muscles and the bladder sphincter -> can’t properly support the bladder & urethra

• resolve stress urinary incontinence with Kegel exercises that strengthen the pelvic floor muscles

Question 8

Endocrine (3)

Answer 8

After placenta delivery:
1. placenta hormones (oestrogen, progesterone, hCG, human placental lactogen) decrease;
2. anterior pituitary gland continues prolactin secretion (triggers milk production, prevents ovulation)

3. prolactin prevents ovulation → causes lactational amenorrhea (no period) while mother breastfeeds
   - breastfeeding clients: 10wks - 6 months to start ovulating & menstruating again
   - 6-10 wks for non-breastfeeding clients

** both breastfeeding and non-breastfeeding clients should consider the use of contraceptive methods to prevent closely spaced pregnancies

Question 9

Integumentary (2)

Answer 9

1. Hyperpigmentations and cutaneous vascular changes like spider angioma, telangiectasia, and palmar erythema fade away after delivery.
2. Purple to red stretch marks: striae gravidarum fade away to a white-ish shade, but never fully disappear

Question 10

Musculoskeletal (3)

Answer 10

During labour, muscles are under a lot of stress ⇒ muscle fatigue (affects neck, shoulders, arms)

1. Hormone relaxin - loosens pelvic ligaments and joints in preparation for labour disappears
2. After delivery, uterus relieves pressure on abdominal wall and resolves previous separation of muscles (diastasis recti)
3. Might require additional abdominal exercises to fully restore the muscle tone of the abdominal wall and return it to the prelabor state

Question 11

Neurological

Answer 11

Headaches → due to changes in fluid and electrolyte balance / regional anaesthesia & dural punctures from spinal anaesthesia (**anaesthesia can cause severe headaches)

Question 12

Postpartum assessment:

What are the complications & clinical manifestations of injuries to genital tract?

Answer 12

Complications (signs and symptoms, observable)
1. Haematomas = localised collections of blood that commonly affect the vulva, vagina, and perineum

2. Large haematomas can cause haemodynamic instability + hypovolemic shock

Clinical Manifestations (additional, adverse, conditions that may develop as the disease progresses or remains untreated)

1. deep, severe pain and feelings of pressure that are not relieved by the usual pain-relief options.
2. intermittent bleeding, painful or difficulty emptying their bladder,
3. discoloured, tender swelling over & around the hematoma.

Complications
Lacerations = tears in body tissue
- can affect uterus, cervix, vagina, perineum

1st degree lacerations
= Tear doesn’t go past the fourchette (where the two labia minora meet posteriorly)

2nd degree lacerations
- extend past fourchette

3rd degree lacerations
- may extend as far as the internal anal sphincter

4th degree lacerations
- reach all the way to rectal mucosa

Clinical Manifestations
- excessive uterine bleeding that continues even when the fundus contracts firmly
- vaginal and perineal lacerations typically cause bleeding, pain and difficulty voiding.

Question 13

What are the complications (1) & clinical manifestations (4) to thrombembolic?

Answer 13

Complications (signs & symptoms, observable)
1. Deep vein thrombosis → blood clot develops in one of the major veins, typically those of the lower leg
- lot can break off and get lodged in other vessels -> potentially life-threatening complications like pulmonary embolism.

Clinical Manifestations (additional, adverse, conditions that may develop as the disease progresses or remains untreated)
1. swollen, red, and painful lower leg;
2. pulmonary embolism can cause:
A. dyspnea:
blockage in the pulmonary arteries reduces blood flow to the lungs, impairing oxygen exchange -> SOB

B. cough: PE -> irritated airway and surrounding tissues in the lungs, which may trigger a cough. This cough may be dry or, in some cases, may produce mucus.

C. Hemoptysis (Coughing up Blood): when a blood clot lodges in a pulmonary artery -> tissue damage & bleeding in the lung -> cough blood

Question 14

Infections (2)

Answer 14

• usually only causes fever, malaise, tachycardia, foul smelling vaginal discharge
• if left untreated → infection can progress to potentially life-threatening septic shock or disseminated intravascular coagulation

Question 15

Hypertensive disorders

Answer 15

Preeclampsia, eclampsia

Question 16

Placenta

Answer 16

Complications
● Retained placenta → when the placental delivery takes more than 30 minutes
● Placenta accreta → placenta grows into the uterine wall

Clinical Manifestations
- placenta cannot be removed manually
- can cause severe postpartum haemorrhage -> hypovolemic shock

Question 17

Common Risk Factors
for developing postpartum complications? (9)

Answer 17

1. teenage pregnancy, age over 35,
2. Grand multiparity (≥ 5 previous deliveries)
3. Uterine overdistention
4. Multiple gestation or polyhydramnios
5. Preterm delivery, premature rupture of membranes
6. Using certain medications
   - tocolytics: relax the uterine muscles -> harder for the uterus to contract effectively after delivery -> uterine atony & increased risk of postpartum hemorrhage.

• oxytocin: used to stimulate uterine contractions to induce labor & after birth, to help the uterus contract to reduce bleeding.
• Prolonged / high doses of oxytocin can desensitize the uterus to the hormone -> uterine atony (loss of muscle tone in the uterus) after birth -> Without effective contractions, the uterus may not clamp down on blood vessels properly -> increasing risk of postpartum hemorrhage.

7. Previous c-section
8. Use of operative procedures (vacuum extraction, forceps use)
9. postpartum complications also tend to be more common in individuals with preexisting health conditions (diabetes, heart disease)

Question 18

Diagnosis of postpartum complications? (3)

Answer 18

1. Past medical history & physical examination
2. Labs
   Complete Blood Count → low haemoglobin & hematocrit in case of haemorrhage; or high WBC count, with an infection
   - Inflammatory markers (CRP, ESR) → elevated with an infection
   - Coagulation panel: blood test that measures ability of the blood to clot and can help diagnose thromboembolic events like DVT / pulmonary embolism (PE).
   - thromboembolic event = blood clot (thrombus) forms and then moves (embolizes), blocking blood flow to other areas of the body.
3. Imaging studies
   - Pelvic ultrasound → identify placental complications
   - CT scan chest → can help identify or rule out pulmonary embolism.

Question 19

Treatment? (6)

Answer 19

• Depends on the type of complication & addressing underlying cause

1. Severe haemorrhage → blood transfusions

Other options
2. Uterotonic medications
3. Incising and draining large haematomas
4. Suturing lacerations
5. Removing retained placental fragments from the uterine cavity

More complex surgical procedures
6. Hysterectomy
- might be needed when uterine bleeding cannot be controlled with other measures

For Infections:
7. antibiotics are typically given and for thromboembolic events, medications like thrombolytics can be used to dissolve clots

Question 20

Nursing Care? (6)

Answer 20

1. Monitor for complications associated with postpartum period:

Assessment
2. Vital signs (pulse can be lower than normal at first, as body compensates for the loss of placenta + decrease in intra-abdominal pressure after foetus

3. Blood pressure can be a little lower due to the normal blood loss that occurs after delivery, or it may be slightly elevated due to emotional excitement
4. Report HR >100 bpm or hypotension → may indicate haemorrhage OR elevated BP 140/90 mmHg on 2 or more occasions → may indicate preeclampsia
5. Normal for client’s temperature to be as high as 100 °F or 37.8 °C → sign of infection
6. Ask for level of pain

Question 21

Hygiene — Perineal Care:

What is the perineal area (2) and how many times is perineal care done? (2)

Answer 21

• area between the anus and, either the vaginal opening or the root of the penis
• close to the sites of faecal and urine excretion
• Perineal care done once daily during bath
• for specific clients, like those with diarrhoea, faecal or urinary incontinence, or vaginal bleeding or discharge, perineal care might be needed more regularly.
• encourage client to do their own

Question 22

Why does perineal care need to be done? (3)

Answer 22

• Sanctuary for germs to flourish
• need to be kept clean to prevent infections, skin irritation
• get rid of unpleasant body odours

Question 23

Hygiene - Urinary catheter care
When is a catheter used? (5)

Answer 23

1. before, during, or after an operation to keep the bladder empty
2. accurately measure amount of urine produced by critically ill clients or clients receiving IV therapy
3. for clients with wounds or pressure ulcers that need to be protected from contact with urine
4. clients with urinary obstruction or retention
5. to collect sterile urine samples.

Question 24

Types of catheters? (3)

Answer 24

1. straight
   - inserted into the bladder through the urethra
   - TEMPORARY! removed once the urine is drained
2. indwelling
   - inserted into the bladder through the urethra
   - remains in the bladder and lets the urine drain continuously into a drainage bag.
3. suprapubic catheters.
   - “supra-” = above
   - “pubic” = pubic bone, so it is inserted into the bladder through a surgical incision made above the pubic bone.

Question 25

Signs & symptoms that require further assessment? (7)

Answer 25

1. changes in the color, clarity, or odor of the urine
2. presence of blood or particles in the urine, which might indicate urethral injury
3. urine not flowing freely through the tubing, which can cause infection
4. complaints of pain, burning, or irritation related to the catheter
5. redness, swelling / discharge from the catheter insertion site, which can indicate infection; or
6. urine leaks = replace indwelling device
7. patient pee less or more from their baseline -> tell HCP -> can be due to changes in kidney function or dehydration

Question 26

Psychosocial changes - Postpartum:

How long is the post partum period?
What are the most important psychosocial changes? (5)

Answer 26

Birth of baby - 6 wks

1. Bonding
2. Attachment
3. Maternal touch
4. verbal behaviours
5. Adaptation & maternal role attainment

Question 27

What’s bonding for maternal & paternal role?

Answer 27

• intense connection that parents develop for their baby

Maternal
○ Promote skin-to-skin contact
○ Breastfeeding

Paternal
○ Enhanced with methods including
■ Presence during labour and delivery
■ Bathing baby
■ Changing diapers
■ Bottle feedings

Question 28

Bonding process can be delayed due to? (1)
What nursing care can you provide to improve the bonding process? (4)

Answer 28

Bonding process can be delayed due to:
- neonatal complications that might require admission to NICU

Nursing care:
- provide information,
- encourage bedside visitation
- involvement in baby’s care
- coordinating resources to support the family

Question 29

What’s attachment? (4)

Answer 29

1. enduring linkage between the parents and their child
2. Reciprocal relationship where the baby receives food, warmth, cuddling, and gentle interaction, and develops feelings of security and trust.
3. Babies can anticipate that their parents or caregivers will be available to support them in times of need.
4. In turn, the baby demonstrates reciprocal attachment behaviours, including making eye contact, tracking their parent’s face or grasping their finger.

Question 30

Whats the difference between bonding & attachment? (3)

Answer 30

Bonding ≠ attachment

1. One-way or two-way r/s?
   - Bonding: One way
   - Attachment: Reciprocal relationship
2. Nature of r/s
   - Bonding: Instinctive, initial emotional connection
   - Attachment: Deeper, mutual connection built through consistent care and interactions.
   - infant grows to rely on caregiver for security and comfort.
3. Duration
   - Bonding: first hrs/days
   - Attachment: long-term

Question 31

What’s maternal touch? (4)

Answer 31

1. Right after delivery → mothers usually use fingertips to touch baby.
2. Time passes → feel more comfortable, stroke baby’s hair or chest with palm of hands
3. Hold their baby close, rub the nose against baby’s nose, or rub their cheek against baby’s cheek
4. mothers typically use a high-pitched voice to interact with their baby

Question 32

What’s adaptation? (3)

Answer 32

3 main phases

1. Talking-in Phase
   - time for the mother to recover from the labour regain strength & reorganise their thoughts.
   - focused on their own physical needs like sleep and nourishment.
   - passive, prefer to rely on a partner or HCPs for decision-making.
2. Taking-hold phase
   - more active, takes more responsibility for her own care, and does not rely on others for - adapt and begin focusing on the baby.
   - At first insecure about skills & competence as a parent.
   ○ An ideal time for the nurse to provide positive reinforcement for caregiving activities, and to encourage the partner’s participation
3. Letting go phase
   - “let go” of the previous life, embrace their new role and responsibility + life changes that come with a new baby.
   - applies to other family members, such as the client’s partner and other children.
   - arrival of the baby can change the relationship dynamics with their partner, and they also need to adapt and settle into their new role as a parent.
   - Greater partner involvement with caregiving like diaper changing or feeding -> greater acceptance of new role.

Other children
- some children may experience fear of replacement, acting out, or regression,
- others may have an easier time accepting the baby’s arrival.
- assess their reaction and help them adapt by accepting their feelings, and teaching them to interact with the baby

Question 33

What are the factors affecting adaptation during postpartum period? (5)

Answer 33

● Maternal age
● Previous experiences
● Maternal and infant temperament
● Adaptation might be different in clients who undergo caesarean birth than those who have had a vaginal delivery
● Neonatal complications

Question 34

Whats maternal role attainment? (4)

Answer 34

4-stage process where confidence in the maternal role is achieved

1. Anticipatory Stage
   - Begins during the pregnancy and includes seeking role models,
   - Fantasise about future maternal role,
   - Attend childbirth classes
2. Formal Stage
   - Recover frm labour
   - Learns more about her baby’s unique features, cues, & ways of communicating.
   - Learn from others
   - replicate the behaviour of HCPs
   - gain caregiving competence
3. Informal Stage
   - Learned baby’s cues
   - develops unique mothering methods to fit the baby’s needs
4. Personal Stage
   - Develop competence
   - internalise new maternal role.

Question 35

What are the most common maternal concerns? (3)

Answer 35

1. Body image
   - Concerns due to unrealistic expectations about weight loss after pregnancy.
   - Educate clients: No rigid diets during this period -> deficiency of nutrients can decrease their energy levels & impair body’s ability to return to pre-pregnant state.
   - Encourage balanced diet & light daily exercises
2. Postpartum blues (baby blues / maternal blues)
   ○ Begin several days after delivery and usually resolve within 2 wks
   - Exact cause is unknown → might be associated with emotional letdown after delivery, postpartum discomfort, body image concerns, and anxiety about the ability to take care of their baby

○ Nurse to validate mother: significant change in life that comes with having a new baby + provide reassurance that ambivalence & having emotional ups and downs are normal

3. Perinatal depression

Question 36

What are the signs & symptoms of postpartum blues? (5)

Answer 36

• Fatigue
• Mood swings
• milder feelings of depressed mood
• irritability
• crying outbursts

Question 37

What are the signs & symptoms of perinatal depression? (8)

Answer 37

• less common than postnatal blues, but more severe symptoms

1. extreme sadness, hopelessness, irritability, and anhedonia/unable to enjoy everyday activities they used to enjoy -> significantly impair daily functioning
2. Symptoms last for at least two weeks,
3. may negatively affect both parents, the baby, and the process of attachment and bonding.
4. increase / decrease in appetite -> weight gain or loss
5. sleeping too much or too little + lack of energy & extremely tired
6. difficulty concentrating
7. psychomotor retardation / slowing down of a person’s thoughts & reduction in physical movement
8. emotional lability, feelings of worthlessness; excessive guilt + recurrent thoughts of death or suicide

Question 38

Treatment of PD? (3)

Answer 38

Some cases:
- symptoms resolve on their own

Milder cases:
- psychotherapy like cognitive behavioral therapy
- healthy lifestyle changes: more physical activity + meditate, yoga, deep-breathing exercises, and acupuncture

More severe cases:
- serotonin reuptake inhibitors/SSRIs, like fluoxetine and sertraline
- norepinephrine reuptake inhibitors /SNRIs, like venlafaxine can be used.

Question 39

Risk factors of perinatal depression? (8)

Answer 39

1. family or personal history of trauma, like sexual abuse
2. history of depression, premenstrual syndrome, or premenstrual dysphoric disorder
3. Age: < 25 yrs
4. single / unwanted pregnancy
5. struggle with stressful life events before or after delivery
6. inadequate social or financial support; 7. smoking
7. difficulty breastfeeding

Question 40

What client and family education should you provide? (8)

Answer 40

• individualized teaching on baby & self-care
• how to self-administer prescribed medications
• typical postpartum recovery
• newborn sleep-wake cycles
• encourage client to lessen fatigue by resting whenever baby sleeps
• stay well hydrated & eat a healthy diet to help their body recover from childbirth.
• assist them with breastfeeding if desired
• ensure they have a lactation consult referral to help build their confidence in breastfeeding

Question 41

Differences betw postnatal blues & perinatal depression?

Answer 41

1. Symptoms
   - PB: sleep or appetite changes, mood swings, fatigue, crying outbursts, milder feelings of depressed mood
   - PD: extreme sadness, anhedonia, suicidal thoughts, significantly impair daily functioning, sleep too much or too little, difficulty concentrating, psychomotor retardation, feelings of worthlessness, constant guilt
2. Duration
   - PB: < 2 wks
   - PD: 2 wks or more
3. Diagnosis?
   - PB: symptoms are mild & last for short time - less than 2 wks
   - PD: history & physical assessment, must meet certain criteria in DSM-5, check serum TSH levels & anti-thyroid peroxidase antibodies
4. Treatment
   - PB: emotional support
   - PD: symptoms can go away spontaneously, more exercise
   - more severe: SSRIs, SNRIs

Question 42

Whats postpartum hemorrhage and the types?

Answer 42

SIGNIFICANT loss of blood after delivery

1. Early/Primary PPH = first 24 hours after delivery
   - normal: >500ml
   - C-section: >1000ml
2. Late / secondary postpartum hemorrhage = 6 - 12 wks after birth

Question 43

Causes of PPH?

Answer 43

early causes can easily be remembered as the 4 Ts: Tone, Trauma, Tissue, and Thrombin.

1. Tone
   - lack of uterine tone = uterine contraction is weak/absent = uterine atony
   - most common cause of PPH
   - Repeated distention of the uterus due to multiple previous pregnancies or overstretching from multigestational pregnancy can interfere with effective uterine contractions after birth -> uterine atony after birth
   - uterine muscles become fatigued after prolonged labor
   - urine retention causes a distended bladder that interferes with uterine involution.
2. Trauma
   - damage to any reproductive structures, like the uterus, cervix, vagina, or perineum during delivery.
3. Tissue
   - part of the placenta retained in uterus after birth, prevent the uterus from contracting effectively -> Without proper contraction, blood vessels remain open -> increase risk of ongoing bleeding -> PPH
4. Thrombin
   - mother having some condition that prevents blood clots from forming normally
   - eg: coagulation disorder like von Willebrand disease -> inability to form blood clots.

Question 44

Risk of PPH? (6)

Answer 44

1. history of PPH in previous pregnancies
2. placental disorders like placenta previa, placenta accreta or placental abruption
3. overdistended uterus due to polyhydramnios = excessive amniotic fluid volume -> uterine cant contract effectively after delivery -> uterine atony, blood continues to flow from the open vessels -> PPH, multiple gestation, or macrosomic infant
4. infection,
5. prolonged labor,
6. cesarean section.

Question 45

Clinical manifestations of PPH? (5)

Answer 45

1. overt, in which a large amount of blood loss can be assessed
2. occult blood pools up somewhere inside the body or inside a hematoma
   - within the uterus or in the pelvic or abdominal cavity
3. lochia rubra = vaginal discharge after delivery
   - abnormal with large amounts of fresh blood and numerous large blood clots
4. Severe bleeding can cause signs and symptoms of hypovolemic shock = significant loss of blood or fluids in the body -> organ failure and death
   - orthostatic hypotension, dizziness, tachycardia, palpitation, shortness of breath, and cold, clammy skin
5. severe backache with a feeling of pelvic heaviness due to hematoma formation.

Question 46

How to diagnose PPH? (5)

Answer 46

1. history and physical assessment
   - A steady or heavy flow of blood is usually noticed first
2. CBC
   - done at intervals to assess hemoglobin and platelet count
   - specific tests to look for coagulopathies (disorders that make it too easy or too hard to form clots -> excessive bleeding/clotting)
3. ultrasound: identify retention of the placenta, which usually looks like a hyperechoic intrauterine mass.
4. Abdominal inspection
   - uterine fundus to be above the expected level = internal bleeding and formation of hematoma
   - With uterine atony, palpation can reveal a boggy, soft and enlarged uterus instead of a firm, contracted one
5. Vaginal examination
   - bright red discharge with numerous blood clots = uterus is the source of the bleed, and not a cervical or vaginal laceration.
6. close inspection of the placenta after delivery can show some of the placenta has been left behind.

Question 47

Treatment of PPH? (5)

Answer 47

1. maintaining adequate circulating volume is the priority
   - intravenous fluids and blood products ensure that the vital organs are well perfused
2. keep uterus firmly contracted
   - If there is severe bleeding after delivery of the placenta a bimanual uterine massage can promote contractility of the uterus to further reduce bleeding
   - cup one hand & placing it under the uterus at the level of the symphysis pubis and then cupping the other hand over the top part of the uterus = fundus
   - gently but firmly massage the fundus in a circular motion
   - Frequent massaging of the fundus during the postpartum period keeps uterus contracted and reduces bleeding
   - giving uterotonic medications like oxytocin, misoprostol, methylergonovine, or carboprost will also help the uterine muscles contract firmly.

Other options for severe hemorrhage:
3. intrauterine balloon tamponade
-> inflated once it’s positioned inside the uterus -> applies direct pressure against the uterine walls -> compresses blood vessels and placental site -> stops bleeding by controlling the flow of blood from the uterine arteries and veins.
- helps to maintain uterine tone
- temporary measure

4. uterine artery embolization / ligation = selectively blocking the uterine arteries, UAE can reduce blood flow to the bleeding areas in the uterus, stopping the hemorrhage
5. hysterectomy as a last resort.

Question 48

Management of care for a client with postpartum hemorrhage?

Answer 48

Priority goals:
1. control bleeding
2. maintain normal fluid volume
3. provide emotional support.

Assessment
1. Assess height, position,and consistency of your client’s fundus and massage until it is firm
2. check amount of bleeding & clots produced during massage
- Determine how long it takes for one perineal pad to become saturated
3. document amount of blood by weighing the pad
4. maintain IV access, continue the administration of fluids and oxytocin, and titrate it per protocol
5. start second IV, which should be at least 18 gauge.
6. pulse oximetry, provide supplemental oxygen per protocol, and assess their vital signs frequently
7. Insert IDC and check intake and output
8. draw labs for hemoglobin, hematocrit, type and cross-match, and coagulation studies, and compare these values with admission labs.
9. Notify blood bank that packed RBCs may be needed, and confirm that OR staff including an anesthesia provider are available if surgical intervention is needed.

• Assess your client for signs of hypovolemic shock
• Check skin and mucous membranes and check their urine output as well as their vital signs.
• due to the increased blood volume that occurs during pregnancy, traditional signs of hypovolemia are not always evident until
  10-30% of blood is lost.
• bedrest with their legs elevated 30 degrees to increase venous return to the heart maintain cardiac output
• Immediately report to the health care provider if the uterus remains boggy, if hemorrhage continues in spite of interventions, or if signs of shock are evident.
• Increase the IV flow rate, administer blood products,
• administer additional uterotonics: stimulates uterine contractions or increase uterine tone as prescribed
• prepare your client for surgical intervention.
• During care, provide reassurance and support, and keep them informed about your interventions using clear, brief statements.

Question 49

Client & family teaching? (6)

Answer 49

• postpartum hemorrhage is when there’s severe bleeding after giving birth
• Explain plan of care and reassure them that they will be monitored closely and that the team will work together to stop the bleeding.
• after discharge, get plenty of rest, eat a balanced diet and stay well hydrated
• take their prescribed iron supplement as directed.
• monitor the amount and characteristics of their lochia
• seek immediate medical care for signs of heavy bleeding, including a pad saturated within one hour, and presence of numerous blood clots.

Question 50

Postpartum infections:

What are postpartum infections (1) and when do they develop (2)?

Answer 50

• infections of the genitourinary tract, surgical wounds, urinary tract (UTI), & breast (mastitis)
• develop after the first 24 hours OR
• on any two of the first 10 days postpartum

Question 51

Causes of postpartum infections?

Answer 51

• aerobic or anaerobic bacteria

1. stephylocacus A
2. E coli
   Proteus spp, Enterobacter spp, Klebsiella spp, Clostridium spp, Staphylococcus aureus, and Streptococci spp.

less frequent pathogens include Chlamydia trachomatis, Ureaplasma, Mycoplasma, and Gardnerella vaginalis.

Question 52

Risk factors in general (7), UTI (1) and mastitis (1)?

Answer 52

1. colonization of the vagina with group A and B Streptococcus, chorioamnionitis
2. prolonged rupture of membranes
3. prolonged labor
4. retained placenta tissue.
5. internal fetal monitoring
   - fetal scalp electrodes
   - intrauterine pressure catheters
   - repeated vaginal examinations
6. trauma
   - can occur during normal childbirth
   - or when providing medical care
7. immunocompromised
   - HIV infection, cancer, malnutrition, diabetes, - taking immunosuppressant medications like corticosteroids

Risks factors for developing UTI:
1. placement of a urinary catheter and urinary retention

Risk factors for developing mastitis:
1. milk stasis due to blocked milk ducts or inadequate breast emptying

Question 52

Pathology? (3)

Answer 52

1. often starts as an ascending infection = bacteria start by colonizing the vagina -> go up the cervix and uterus -> infects endometrium and myometrium -> endometritis
2. trauma to the abdominal wall or perineum, which allows bacteria from the skin, vagina, or bowel flora to penetrate deeper into the subcutaneous tissue, abdominal and pelvic cavities
3. after delivery
   - urinary retention in the bladder -> bacteria grows
   - trauma to the nipple and areola like small skin cracks -> bacteria from the skin or a newborn’s mouth and nose to penetrate the breast -> develop mastitis while breastfeeding.

Question 53

complications

Answer 53

1. bacteria move up to:
   fallopian tubes -> salpingitis /
   ovaries -> oophoritis /
   peritoneum -> peritonitis.
2. Bacteria move up to:
   - pelvic venous system -> inflammation
   - damage of the venous wall -> thrombus formation / septic pelvic thrombophlebitis
   - its a life-threatening complication -> bacteremia & sepsis -> septic shock and death.
3. Surgical wound infections -> formation of an abdominal or pelvic abscess -> necrotizing fasciitis = infection involves the subcutaneous tissues & fascia
4. Cystitis -> bacteria move up ureters & kidneys -> pyelonephritis.
5. Mastitis -> breast abscess formation.

Question 54

clinical manifestations of postpartum infections in general (4), for endometritis (3), septic pelvic thrombophlebitis (1), UTIs (5) & mastitis (3)?

Answer 54

In general:
- Chills and fever
- oral temperature of 38°C & higher on any two of the first 10 days postpartum
- 38.7°C & higher during first 24hrs
- malaise, loss of appetite, tachycardia

Endometritis:
1. abdominal pain, and foul smelling discharge
2. uterus tender and enlarged -> inability to return to its normal size after delivery,= uterine subinvolution
3. surgical wound infections:
- swelling, tenderness, redness & warmth
- Incisions may burst open with purulent discharge.

Septic pelvic thrombophlebitis:
1. palpable pelvic veins.

Urinary tract infections
1. dysuria or painful urination, increased urination frequency,
2. suprapubic tenderness,
3. costovertebral angle tenderness,
4. cloudy and foul-smelling urine
5. hematuria

Mastitis
1. localized hard lump
2. redness, warmth, tenderness, and swelling, 3. fever and flu-like symptoms

Question 55

Diagnosis? (4)

Answer 55

1. history and physical assessment
2. lab tests
   - CBC may show leukocytosis with neutrophilia, & coagulation studies when septic pelvic phlebitis is suspected
3. uterine, cervical, & wound cultures
   - identify causative microorganism.
4. imaging tests
   - pelvic ultrasound, X-rays, or CT scan
   - visualize deeper structures.

Question 56

Treatment of postpartum infections (5)

Answer 56

1. supportive measures
   - IV fluids, antipyretics & analgesics + broad-spectrum antibiotics like cephalosporins.
2. Once the culture results are available:
   - antibiotic choice can be narrowed down to a specific one
3. For septic pelvic thrombophlebitis
   - anticoagulation therapy
4. Wound infections and abscesses
   - surgical incision and drainage
   - necrotizing fasciitis requires surgical debridement
5. mastitis:
   - emptying of the breasts
   - by breastfeeding or breast pump
   - breast support
   - use moist heat or ice packs.