Week 2 Learning outcomes-study aid

Question 1

1. Discuss signs and symptoms of impending labor.

Answer 1

A few weeks before labor, changes occur that indicate the woman’s body is preparing for the onset of labor. These changes are also referred to as premonitory signs of labor.
● Lightening: This refers to the descent of the fetus into the true pelvis approximately 2 weeks before term in first-time pregnancies. The woman may feel she can breathe more easily but often experiences urinary frequency at this stage from increased bladder pressure. In subsequent pregnancies, this may not occur until labor begins.
● Braxton-Hicks: These contractions are irregular UCs that do not result in cervical change and are associated with “false labor.” Braxton-Hicks contractions are usually not painful, don’t happen at regular intervals, don’t get closer together, may stop with a change in activity or position, and do not feel stronger over time. These contractions begin to coordinate the many muscle layers of the uterus to perform when true labor begins. True labor is characterized by regular uterine contractions that result in progressive dilation and effacement of the cervix and fetal descent into the pelvis
● Cervical changes. The cervix ripens, becomes soft, and may become partially effaced and begin to dilate. The woman may lose her mucous plug or have a change in discharge.
● Nesting. Some women experience a burst of energy or feel the need to put everything in order, which is sometimes referred to as nesting.
● Less commonly, some women experience a 1- to 3-pound weight loss and others experience diarrhea, nausea, or indigestion preceding labor.
● The woman may experience low backache and sacroiliac discomfort due in part to the relaxation of the pelvic joints.
● The woman may experience a brownish or blood-tinged cervical mucus discharge referred to as bloody show.

Question 2

2. Distinguish between true and false labor.

Answer 2

True labor contractions occur at regular intervals and increase in frequency, duration, and intensity
● True labor contractions bring about changes in cervical effacement and dilation.
● False labor is characterized by irregular contractions with little or no cervical change

Question 3

3. Differentiate among the four stages of labor and typical maternal behaviors during each stage.

Answer 3

Labor and birth is divided into four stages:
● The first stage begins with onset of labor and ends with complete cervical dilation.
● The second stage begins with complete dilation of cervix and ends with delivery of the baby.
● The third stage begins after delivery of the baby and ends with delivery of the placenta.
● The fourth stage begins after delivery of the placenta and is completed 4 hours later; it is the immediate postpartum period

Question 4

First stage more detailed

Answer 4

The first stage of labor is defined as the progression of cervical changes. This stage is divided into three phases: latent phase, active phase, and transition. Characteristics of the first stage of labor are as follows:
● It begins with onset of true labor and ends with complete cervical dilation (10 cm) and complete effacement (100%).
● Stage 1 is the longest stage, typically lasting 12 hours for primigravidas and 8 hours for multigravidas.
● There are normally tremendous variations in lengths of labor
● The bag of waters or fetal membranes usually ruptures during this stage.
● The woman’s cardiac output increases.
● The woman’s pulse may increase.
● Gastrointestinal motility decreases, which leads to increase in gastric emptying time (Mattson & Smith, 2011).
● The woman experiences pain associated with UCs that result in the dilation and effacement of the cervix.
● The first stage has three phases: the latent, active, and transition phases
-Latent phase- Characteristics of this phase are:
● Cervical dilation from 0 to 4 cm with effacement from 0% to 40%.
● Mild intensity contractions occur every 5 to 10 minutes, lasting 30 to 45 seconds. Women often describe them as feeling like strong menstrual cramps.
Women in this phase are usually both excited and apprehensive about the start of labor. They are talkative and able to relax with the contractions.
-Active phase behaviors- Women in this phase may have decreased energy and experience fatigue. They become more serious and turn attention to internal sensations. As labor progresses, most women turn inward
-Transition phase- In transition, women are easily discouraged and irritable, and may be overwhelmed and panicky. They often feel and act out of control

Question 5

Second stage - more detail

Answer 5

The woman enters the second stage of labor when cervical dilation is complete (10 cm) This stage ends with the birth of the baby. Women in the second stage may have a burst of energy, be more focused, and feel like they can actively participate in facilitating birth with active pushing efforts. Phases of the second stage of labor are as follows:
● Latent or resting phase is characterized by a period of rest and relative calm. The urge to bear down is usually not well-established, particularly for women with regional analgesia/anesthesia. The fetus can passively descend in the pelvis during this time without maternal expulsive efforts.
● Descent or active phase is characterized by increasing intensity of uterine contractions and strong urges to bear down with the activation of Ferguson’s reflex. During this phase, bearing-down efforts are most effective for promoting birth.
● Physiologic processes of the second stage of labor are the normal bodily function by which the fetus traverses the pelvic outlet and is expelled from the uterus through the force of strong uterine contractions, voluntary and involuntary bearing down, and stretching of the soft tissues of the female reproductive tract. The process involves numerous hemodynamic changes that may affect the reproductive, cardiac, respiratory, gastrointestinal, and renal systems. Changes in maternal physiology during the second stage of labor may also be influenced by maternal position and energy level, pain, and hydration.
Characteristics of this stage include the following:
● Typically lasts 50 minutes for primigravidas and 20 minutes for multigravidas, although a second stage of several hours is normal.
● Woman may feel an intense urge to push or bear down when the baby reaches the pelvic floor.
● Studies have shown that bearing down in the second stage is less tiring and more effective when started after the woman has the urge to do so rather than before. Nulliparous women with epidurals who delayed their efforts until feeling the urge to push (Ferguson’s reflex) had 27% shorter pushing time. This decreased maternal fatigue, provided increased maternal satisfaction in the birth experience, and allowed women to fully participate in postpartum activities

Question 6

Third stage more detail

Answer 6

The third stage of labor begins immediately after the delivery of the fetus and involves separation and expulsion of the placenta and membranes. As the infant is born, the uterus spontaneously contracts around its diminishing contents. This sudden decrease in uterine size is accompanied by a decrease around placental implantation. This results in the decidual layer separating from the uterine wall. Placental separation typically occurs within a few minutes to less than a half hour after delivery. Once the placenta separates from the wall of the uterus, the uterus continues to contract until the placenta is expelled . This process typically takes 5 to 30 minutes post-delivery of the baby and occurs spontaneously. Signs that signify the impending delivery of the placenta include:
● Upward rising of the uterus into a ball shape
● Lengthening of the umbilical cord at the introitus
● Sudden gush of blood from the vagina
Active management of the third stage of labor (AMTSL) includes uterotonic drugs (oxytocin is the gold standard), controlled cord traction, and late cord clamping performed 1-3 minutes after delivery. These interventions decrease postpartum hemorrhage (PPH) and cause uterine contractions and placenta expulsion. The placenta, membranes, and cord are examined by the care provider for completeness and anomalies.

Question 7

Fourth stage more detail

Answer 7

The fourth stage begins after delivery of the placenta and typically ends within 4 hours or with the stabilization of the mother. After the placenta delivers, the primary mechanism by which hemostasis is achieved at the placental site is vasoconstriction produced by a well-contracted myometrium. During this stage, the nurse is caring for both the woman and her newborn child (see Table 8–1). This stage also begins the postpartum period.
An important goal during the fourth stage is the newborn-family attachment. This is promoted by allowing early contact with the newborn and encouragement of eye contact and touch. The baby is placed skin-to-skin on the mother and covered with a warm blanket. Positive maternal bonding behaviors include making eye contact, touching and talking to the baby, smiling and cuddling the newborn, and similar actions. This is often the best time to institute breastfeeding. The newborn may remain in the labor and delivery room with the family for the immediate recovery period.

Question 8

4. Identify the three phases of the first stage of labor and typical maternal behaviors during each phase.

Latent phase

Answer 8

-Latent phase- Characteristics of this phase are:
● Cervical dilation from 0 to 4 cm with effacement from 0% to 40%.
● Mild intensity contractions occur every 5 to 10 minutes, lasting 30 to 45 seconds. Women often describe them as feeling like strong menstrual cramps.
The latent phase is the early and slower part of labor with an average length of 9 hours for primiparous and 5 hours for multiparous women. Women in this phase are usually both excited and apprehensive about the start of labor. They are talkative and able to relax with the contractions. Many women choose to stay home during this phase, although some are admitted to the birth center.

Question 9

Active phase

Answer 9

The active phase (dilation to 7 cm) of labor averages three to six hours. It is typically shorter for multigravidas (see Table 8–1). Women in this phase may have decreased energy and experience fatigue. They become more serious and turn attention to internal sensations. As labor progresses, most women turn inward. Characteristics of this phase include the following:
● The consortium on safe labor reviewed more than 19,000 births and determined that nulliparous and parous woman dilate at a similar rate between 4-6 cm, much slower than Friedman (1955) determined in the 1950s: “6 is the new 4” (Zhang et al., 2010). The older standard was cervical dilation progression from 4 cm to 7 cm with effacement of 40% to 80%.
● Fetal descent continues.
● Contractions become more intense, occurring every 2 to 5 minutes with duration of 45 to 60 seconds.
● Discomfort increases; this is typically when the woman comes to the birth center or hospital if she has not done so already.

Question 10

Transition phase

Answer 10

The transition phase (dilation to 10 cm), is usually the most difficult but shortest of the first stages of labor (see Table 8–1). In transition, women are easily discouraged and irritable, and may be overwhelmed and panicky. They often feel and act out of control. Characteristics of this phase are:
● Cervical dilation from 8 to 10 cm with complete (100%) effacement
● Intense contractions every 1 to 2 minutes lasting 60 to 90 seconds
● Exhaustion and increased difficulty concentrating
● Increase of bloody show
● Nausea and vomiting
● Backache: Woman complains of back pressure, hand goes over hip, rubbing and pressing on area.
● Trembling
● Diaphoresis, especially upper lip and facial area
● May have a strong urge to bear down or push, more vocal with primal noises and facial expressions.

Question 11

5. Identify pharmacological and non-pharmacological methods to promote comfort during labor
   and birth. Include the following pharmacological methods: systemic medications (narcotics),
   epidural, spinal, general, and local anesthesia. For non-pharmacological methods include:
   effleurage, massage, lighting, soothing sounds, breathing patterns, birth ball, etc. Identify
   which methods are the safest.

Nonpharmacological-

Answer 11

Non pharmacological
● Effleurage is cutaneous stimulation by lightly stroking the abdomen in rhythm with breathing during contractions. Another form of cutaneous stimulation is back massage and/or counter pressure to the sacral area by another. Counter pressure is exerted to the sacral area with the heel of the hand or fist to relieve the sensation of intense pain in the back caused by internal pressure of the fetal head. This increased internal pressure by the fetal head is often associated with the posterior position of the fetus during labor.
● Massage: Multiple studies have shown massage to decrease pain and promote relaxation, which in turn promotes labor progress. A quiet, soothing voice encouraging the woman to imagine a safe place can assist in relaxation. This used in conjunction with aromatherapy has proven to enhance relaxation in laboring women, allowing women to have better control of labor.
Lighting-
Soothing sounds-● Music therapy: Music calms the spirit and decreases stress and distress by diverting attention from the pain receptors and promoting relaxation.
● Relaxation and breathing techniques: Varied breathing patterns that promote relaxation and avoidance of pushing before complete cervical dilation.Most women are taught to take a deep breath at the beginning of the contraction to signal the onset of the contraction and then to breathe slowly during the contraction. As labor pain increases, the woman may need to breathe in a more rapid and shallow manner. On occasion, a woman will experience hyperventilation from this type of breathing. Symptoms are related to respiratory alkalosis and include tingling of the fingers or circumoral numbness, lightheadedness, or dizziness. This undesirable side effect can be eliminated by having the woman breathe into a bag or cupped hands. This causes her to rebreathe carbon dioxide and reverses the respiratory alkalosis. Discuss with the woman and her support team how they plan on managing labor. This will stimulate conversation, facilitate a plan of care to assist them in pain management, and give an opportunity to teach and or support them as needed.
● Birthing ball: This ball (65-cm) originated in physical therapy programs but has been used successfully in the labor suite. It facilitates an upright position, opens the pelvis, and allows the woman to roll or bounce as she deems necessary to manage her contractions and pain.
Hydrotherapy
Self hypnosis
Accupuncture
Aromatherapy
Thermal stimulation-application of warmth or cold
Mental stimulation - imagry, focal points
Support person

Question 12

Pharmacological

Answer 12

pharmacological-
The use of opioids in labor is common. Advantages include availability, ease of administration, and cost. Depending on the dose, route of administration, and stage of labor parenteral analgesia does not illuminate pain but causes a blunting effect, leading to a decrease in sensation of pain and inducing somnolence (Burke, 2014). Opioids cross the placenta and can cause neonatal respiratory depression.
self-administered nitrous oxide for labor analgesia -A recent published review concludes nitrous oxide analgesia is safe for mothers, neonates, and those who care for women during childbirth (Rooks, 2011). In the context of obstetric analgesia, “nitrous oxide” usually refers to a half-and-half combination of oxygen and nitrous oxide gas, called by the trade name “Nitronox.” It is self-administered by the laboring woman using a mouth tube or face mask when she determines that she needs it, about a minute before she anticipates the onset of a strong contraction until the pain eases. Its use can be started and stopped at any point during labor according to the woman’s needs and preferences. It takes effect in about 50 seconds after the first breath and the effect is transient—essentially gone when no longer needed. It is simple to administer and does not interfere with the release and function of endogenous oxytocin, and has no adverse effects on the normal physiology and progress of labor. This analgesia may be of help for women who want to have an unmedicated birth but may need help at some point during labor and want to use a method that is under their control

Epidural anesthesia -Epidural labor analgesia involves the placement of a catheter and injection of a local anesthetic or analgesic agent or both into the epidural space, typically in the lumbar region. Partial loss of sensation may occur.
Morphine sulfate Opioid Respiratory depression Cautious use in 2nd stage.
Butorphanol (Stadol) 2–4 mg IM 0.5–2 mg IV Nalbuphine (Nubain) 10 mg IM or IV-
Opioid agonist–antagonist
No respiratory depression in woman or neonate
Check maternal history for drug abuse. Do not give to drug dependent woman due to possible precipitation of sudden withdrawal response in woman and baby. Monitor effective response.
Sublimaze (Fentanyl) 50–100 mg IM 25–50 mg IM May be used in conjunction with regional anesthesia
Short acting opioid antagonist Crosses the placenta rapidly
Synthetic opioid
FHR changes Hypotension Maternal/fetal/neonatal CNS depression Respiratory depression
Monitor for side effects such as sedation, nausea, vomiting, itching. Monitor respiratory rate and effort.
Types of anesthesia-
LOCAL: Anesthetic injected into perineum at episiotomy site 2nd stage
REGIONAL: Pudendal Block: Anesthetic injected in the pudendal nerve (close to the ischial spines) via needle guide known as “trumpet”-2nd stage
Epidural Block: Anesthetic injected in the epidural space: Located outside the dura mater between the dura and spinal canal via an epidural catheter–first and or second stage of labor
Spinal Block: Anesthetic injected in the subarachnoid space-2nd stage
GENERAL ANESTHESIA: Use of IV injection and/or inhalation of anesthetic agents that render the woman unconscious.-usually used in emergency c-section

Question 13

6. Discuss the physiological and psychological changes that occur in the postpartum woman in the
   immediate postpartum period.

Uterus

Answer 13

After delivery of the placenta, the uterus begins the process of involution by which it returns to its nearly prepregnant size, shape, and location and the placental site heals. This occurs through uterine contractions, atrophy of the uterine muscle, and a decrease in the size of uterine cells. Involution of the uterus takes between 6 and 8 weeks postdelivery.Multiparous women or women who are breastfeeding may experience “afterpains” caused by strong intermittent uterine contractions during the first few postpartum days. Afterpains are moderate to severe cramp-like pains related to the uterus working to remain contracted and/or the increase of oxytocin released in response to infant suckling. The intensity of afterpains will typically decrease after the third postpartum day .. The uterus must be contracted during the postpartum period to decrease the risk of postpartum hemorrhage. The contracted uterine muscle compresses the open vessels at the placental site and decreases the amount of blood loss.

Question 14

Endometrium

Answer 14

The endometrium, the mucous membrane that lines the uterus, undergoes exfoliation and regeneration after the birth of the placenta through necrosis of the superficial layer of the decidua and regeneration of the decidua basalis into endometrial tissue. Lochia is a bloody discharge from the uterus that contains red blood cells, sloughed off decidual tissue, epithelial cells, and bacteria (Cunningham et al., 2014). The placental site heals by exfoliation, which involves the sloughing of necrotic endometrial tissue and the regeneration of the endometrium at the placental site . This process prevents scarring of the endometrial tissue (James, 2014). Lochia undergoes changes that reflect the healing stages of the uterine placental site (Table 12–2). Uterine contractions constrict the vessels around the placental site and help decrease blood loss.

Question 15

Lochia

Answer 15

~Lochia rubra Days 1–3 Bloody with small clots
Normal-Moderate to scant amount Increased flow on standing or breastfeeding Fleshy odor
deviations from normal- Large clots Heavy amount; saturates pad within 1 hour (sign of possible hemorrhage), excessively heavy, saturates a pad in 15 minutes Foul odor (sign of infection) Placental fragments

~Lochia serosa Days 4–10
normal-Pink or brown color Scant amount Increased flow during physical activity Fleshy odor
Deviations from normal-Continuation of rubra stage after day 4 Heavy amount; saturates pad within 1 hour (sign of possible hemorrhage), excessively heavy; saturates pad within 15 minutes Foul odor (sign of infection)

~Lochia alba Day 10
normal-Yellow to white in color Scant amount Fleshy odor
Deviations from normal-Bright red bleeding, saturates pad within 1 hour (sign of possible late postpartum hemorrhage) Foul odor (sign of infection)

Question 16

Vagina and perineum

Answer 16

Vagina and perineum changes-The vagina and perineum undergo healing and restoration during the postpartum period. Immediately after delivery, the vaginal walls are smooth, but rugae are reestablished within 3 weeks of delivery.
● The vagina and perineum experience changes related to the birthing process that may include edema, mild stretching, minor lacerations, major tears, and/or episiotomies.
● A first-degree laceration involves the vaginal mucous membranes and the perineal skin.
● A second-degree laceration involves the vaginal mucous membranes, perineal skin, and the fascia of the perineal body.
● A third-degree laceration involves the perineal skin, vaginal mucous membranes, fascia of the perineal body, and the rectal sphincter.
● A fourth-degree laceration involves the perineal skin and fascia, vaginal mucous membranes, rectal sphincter, and the rectal mucosa and lumen.
● A midline episiotomy is an incision that is midline on the perineum. This type of incision tends to heal more quickly and cause less pain then a mediolateral episiotomy.
● A mediolateral episiotomy is an incision that is made at a 45-degree angle to the perineum.

Question 17

Breasts

Answer 17

Breasts– After delivery, there is a decrease in estrogen and progesterone and an increase in prolactin . Prolactin stimulates breast milk production. When the infant suckles, the posterior pituitary releases oxytocin, resulting in the milk ejection reflex, also called the let-down reflex
Immediately after delivery, breast fullness is normal. While breast tissue may be swollen, it is soft and nontender (James, 2014). Around the third postpartum day, both breastfeeding and nonbreastfeeding women experience some degree of primary breast engorgement, an increase in the vascular and lymphatic system of the breasts that precedes the initiation of milk production. The woman’s breasts become larger, firm, warm, and tender, and the woman may feel a throbbing pain in the breasts. Primary engorgement subsides within 24 to 48 hours (Box 12–3).

Question 18

Cardiovascular

Answer 18

Cardiovascular–Women experience an average blood loss of 200 to 500 mL through vaginal birth. This has a minimal effect on a woman’s system due to pregnancy-induced hypervolemia. Stroke volume and cardiac output increase during the first few post-partum hours as blood that was shunted through the utero-placental unit returns to the maternal system. Cardiac output is elevated for 24 to 48 hours after delivery and returns to prepregnant levels within 10 days). After delivery, plasma volume initially decreases due to blood loss, then increases due to shifts from the extracellular to vascular space . Along with a decrease in the total blood volume, this often results in a transient anemia that typically resolves by 8 weeks after delivery . White blood cell (WBC) levels may increase to 30,000/mm within a few hours of birth as the result of the stress of labor and birth, and return to normal levels within 7 days .
Women are at risk for thromboembolism related to the increase of circulating clotting factors during pregnancy . Clotting factors slowly decrease after delivery of the placenta and return to normal ranges within the first 2 postpartum weeks.

Question 19

Respiratory

Answer 19

Respiratory system-Chest wall compliance returns after the birth of the infant as diaphragm pressure is reduced. The respiratory system returns to a prepregnant state by the end of the postpartum period.

Question 20

Immune system

Answer 20

Immune system-The immune system, which is suppressed during pregnancy, returns to normal in the postpartum period . It is common for the postpartum woman to experience mild temperature elevations during the first 24 hours postbirth related to muscular exertion, exhaustion, dehydration, or hormonal changes. A temperature greater than 100.4°F (38°C) after the first 24 hours on two occasions may be indicative of postpartum infection and requires further evaluation.

Question 21

Urinary system

Answer 21

The urinary system-Women are at risk for urinary complications after birth. Transient stress incontinence associated with impaired pelvic muscle function involving the urethra may occur in the first 6 weeks postpartum.. Many factors are associated with stress urinary incontinence, including pregnancy, multiparity, perineal trauma, infant size, length of second stage labor, and pushing techniques that increase pressure on the pelvic floor. Primary complications are bladder distention and cystitis.
Bladder distention, rapid bladder filling, incomplete emptying, and inability to void are common during the first few days postbirth . These are related to administration of intravenous fluids in the postdelivery period, decreased sensation of the urge to void due to anesthesia or analgesia, edema around the urethra, perineal lacerations or episiotomy, operative vaginal delivery, or bladder trauma . Diuresis caused by decreased estrogen levels occurs within 12 hours after birth and aids in the elimination of excess tissue fluids. During this time urine output may be 3,000 cc or more per day

Question 22

Endocrine system

Answer 22

endocrine system-Abrupt changes occur in the endocrine system after the delivery of the placenta. Estrogen, progesterone, and prolactin levels decrease. Estrogen levels begin to rise after the first week post-partum. For nonlactating women, prolactin levels continue to decline throughout the first 3 postpartum weeks. Menses begins 7 to 9 weeks postbirth. The first menses is usually anovulatory. Ovulation usually occurs by the fourth cycle. The average time for women who are not breastfeeding to return to ovulation is 10 weeks postpartum. In women who are lactating, prolactin levels increase in response to the infant’s suckling. Lactation suppresses menses, likely due to hormonal changes, including elevated prolactin levels. Return of menses depends on the length and amount of breastfeeding. Ovulation is suppressed longer for lactating women than for nonlactating women. The mean time to return to ovulation for women who breastfeed is 17 weeks

Diaphoresis occurs during the first few postpartum weeks in response to decreased estrogen levels. This profuse sweating, which often occurs at night, assists the body in excreting the increased fluid accumulated during pregnancy.

Question 23

Muscular and nervous system

Answer 23

Muscular and nervous system-After birth, the abdominal muscles experience reduced tone and the abdomen appears soft and flabby. Some women experience a separation of the rectus muscle, which is no ted as diastasis recti abdominis . This separation becomes less apparent as the body returns to a prepregnant state. Women may experience muscular soreness related to the labor and birth experience. Lower body nerve sensation may be diminished for women who have received an epidural during labor. Delay ambulation until full sensation returns.

Question 24

Gastrointestinal system

Answer 24

Gastrointestinal system-Gastrointestinal muscle tone and motility decrease postbirth with a return to normal bowel function by the end of the second postpartum week.
● Constipation
● Women are at risk for constipation due to decreased GI motility from the effects of progesterone, decreased physical activity, dehydration and fluid loss from labor, fear of having a bowel movement after perineal lacerations or episiotomy, and perineal pain and trauma.
● Hemorrhoids
● Women commonly develop hemorrhoids during pregnancy and/or the birthing process. Hemorrhoids often slowly resolve but can be painful. Sometimes hemorrhoids persist postpartum.
● Appetite
● Women are hungry after the birthing experience and can be given a regular diet, unless they are on a prescribed diet such as for diabetes. Women are exceptionally hungry during the first few postpartum days and may require snacks between meals.
● Weight loss
● Most women will experience significant weight loss during the first 2 to 3 weeks postpartum. Immediately after birth, women lose approximately 11 to 12 pounds as the result of delivery and blood loss.
● Diuresis results in the loss of approximately another 5 to 8 pounds postdelivery
● The average American woman at the end of 6 months postpartum is approximately 3 pounds above her prepregnancy weight

Question 25

Bonding

Answer 25

Bonding make sure the family is interacting with the baby and concerned about caring for the baby.
In some cultures the mother does not change the diaper or do much of the care because the family wants her to rest after childbirth. However the mother would still show signs of affection toward her baby,
Sometimes it is too painful for mothers who have just had a C/S to lift their baby or stand and lean over the crib to change the diaper. So be careful about judging bonding too quickly.
When bonding is not occurring it is usually obvious and often associated with drug abuse. A mom may be crashing from a methamphetamine high or withdrawing from other drugs.

Question 26

Postpartum blues

Answer 26

Postpartum blues is normal and is due to hormonal changes particularly with estrogen progesterone and cortisol. Moms may be teary and weepy and not be able to express why. They can be moody and irritable and tired.
. The blues do not cause the mom not to be able to care for the baby.

Question 27

Postpartum depression

Answer 27

Postpartum depression is much more severe. Appears on or after two weeks and is associated with strong feelings of inadequacy, guilt, and worthlessness. Sleep disturbance can be severe and suicidal thoughts can occur.
It is important to teach the mom and her partner or family members what signs and symptoms to watch for because postpartum depression requires treatment.

Question 28

Postpartum psychosis

Answer 28

Postpartum psychosis is less common but include delusions, agitation and bizarre behaviors. It usually occurs later in the postpartum period.
People who already have mood disorder are more at risk

Question 29

7. Identify the critical components of the postpartum assessment in the first 2 hours after delivery.

Answer 29

●determine how much blood was lost
● Assess the uterus for location, position, and tone of the fundus.

● After the third stage of labor, assess the uterus:

● Every 15 minutes for the first hour.

● Every 30 minutes for the second hour.
● Assist the woman to the bathroom and encourage her to void within 2 to 4 hours post birth.

● Rationale: Early voiding decreases the risk of cystitis and prevents bladder distention, which could lead to uterine atony and postpartum hemorrhage

● monitor labs, vitals, signs of eclampsia (headache, facial edema, blurry vision, high bp)- hematocrit change by 10% can indicate hemorrhage

Question 30

8. Discuss the physiological and psychological changes that occur in the postpartal woman.

Answer 30

After delivery of the placenta, the uterus begins the process of involution by which it returns to its nearly prepregnant size, shape, and location and the placental site heals.

The endometrium, the mucous membrane that lines the uterus, undergoes exfoliation and regeneration after the birth of the placenta through necrosis of the superficial layer of the decidua and regeneration of the decidua basalis into endometrial tissue.

The vagina and perineum experience changes related to the birthing process that may include edema, mild stretching, minor lacerations, major tears, and/or episiotomies.

After delivery, there is a decrease in estrogen and progesterone and an increase in prolactin
Women who breastfeed experience subsequent breast engorgement related to distention of milk glands that is relieved by having the baby suckle or by expressing milk. Colostrum, a clear, yellowish fluid, precedes milk production and is secreted after delivery.

Cardiac output is elevated for 24 to 48 hours after delivery and returns to prepregnant levels within 10 days

Chest wall compliance returns after the birth of the infant as diaphragm pressure is reduced. The respiratory system returns to a prepregnant state by the end of the postpartum period.

The immune system, which is suppressed during pregnancy, returns to normal in the postpartum period

Transient stress incontinence associated with impaired pelvic muscle function involving the urethra may occur in the first 6 weeks postpartum
Bladder distention, rapid bladder filling, incomplete emptying, and inability to void are common during the first few days postbirth

Diaphoresis occurs during the first few postpartum weeks in response to decreased estrogen levels. This profuse sweating, which often occurs at night, assists the body in excreting the increased fluid accumulated during pregnancy.

Estrogen, progesterone, and prolactin levels decrease. Estrogen levels begin to rise after the first week post-partum. For nonlactating women, prolactin levels continue to decline throughout the first 3 postpartum weeks. Menses begins 7 to 9 weeks postbirth. The first menses is usually anovulatory. Ovulation usually occurs by the fourth cycle. The average time for women who are not breastfeeding to return to ovulation is 10 weeks postpartum

After birth, the abdominal muscles experience reduced tone and the abdomen appears soft and flabby
Some women experience a separation of the rectus muscle, which is no ted as diastasis recti abdominis

Gastrointestinal muscle tone and motility decrease postbirth with a return to normal bowel function by the end of the second postpartum week.

Postpartum depression (PPD) is a mood disorder characterized by severe depression that occurs within the first 6 to 12 months postpartum and affects an estimated 11.5% of postpartum women
Postpartum psychosis (PPP), a variant of bipolar disorder, is the most serious type of postpartum mood disorder. Postpartum psychosis is relatively rare
 Most women experience postpartum blues, which are short-term and require no medical intervention

Question 31

9. Identify the components of the postpartum assessment including assessment of the
   postoperative postpartum patient.

Answer 31

● Vital signs, pain, breath and heart sounds
● Laboratory findings, such as CBC, rubella status, and Rh status
● Breasts Assess the breasts for primary engorgement.
Inspect and palpate the breasts for signs of engorgement: tenderness, firmness, warmth, and/or enlargement.
● Uterus- Assess the uterus for location, position, and tone of the fundus.
● Bladder- Measure voidings postbirth. The woman should be able to void at least 300 cc within 2 to 4 hours of delivery. Assist the woman to the bathroom and encourage her to void within 2 to 4 hours postbirth.
● Bowel
● Assess bowel sounds at each shift.
● Assess for constipation.
● Assess for hemorrhoids.
● Lochia red 3-4 days, pink brown 4-10 days, white yellow 10-28 days. Help pt change pad, watch for clots bigger than eggs, watch for odor, placental fragments, Heavy amount; saturates pad within 1 hour (sign of possible hemorrhage), excessively heavy, saturates a pad in 15 minutes.
● Episiotomy, lacerations, perineum, hemorrhoids
● Lower extremities- Assess lower extremities for venous thrombosis.
● Emotions, bonding with infant, fatigue, psychosocial factors

Question 32

10. Discuss methods for assessing and treating pain in the postpartal period.
    Examples of nonpharmacological interventions include:

Answer 32

• Ice packs
• Warm compresses
• Sitz baths
• Repositioning
• Showering
• Topical treatments, such as witch hazel pads and anesthetic sprays applied to localized perineal discomfort.

Pharmacological interventions may include:
• NSAIDs such as ibuprofen (for mild to moderate pain):
• Ibuprofen (Motrin) may be administered with food or milk to decrease GI upset. Give with a full glass of water.
• Patients with asthma, nasal polyps, or who are allergic to aspirin are at risk for hypersensitivity to ibuprofen.
• Route and dose for ibuprofen: PO; 400 to 800 mg every 4 to 6 hours PRN, maximum 24-hour dose 3,200 mg/day. Assess pain before and 30 minutes after administration.

• Opioid analgesics may be used for moderate to severe pain. These medications are often used in combination with a nonopioid medication for added analgesic effect.

Question 33

11. Describe family-centered care by:

    A.	Identifying factors involved in mother-infant and father-infant bonding (attachment). factors that influence bonding and attachment behaviors are:

Answer 33

● The knowledge base of the couple.

● Past experience with children.

● Maturity and educational levels of the couple.

● Type of extended support system.

● Maternal/paternal expectations of the pregnancy.

● Maternal/paternal expectations of the infant.

● Cultural expectations.

Early contact between the parents and their infant fosters the development of attachment and integration of the infant into the maternal and paternal relationship.

Paternal–Infant Contact- The new father, when holding his child for the first time, may feel awkward and uncomfortable and have a fear of injuring the baby. These feelings will decrease over time with continued contact with the infant.
When expectant fathers participated in the labor and birth of their children in roles that were comfortable for them, they had a greater sense of belonging, which led to deeper engagement in the father role.

Bonding and Attachment Behaviors:
BONDING BEHAVIORS UNIDIRECTIONAL: PARENT → INFANT
En face
Calls baby by name
Cuddles baby close to chest
Talks/sings to baby
Kisses the baby
Breastfeeds the baby or holds the baby close when bottle-feeding

ATTACHMENT BEHAVIORS BIDIRECTIONAL: PARENT ↔ INFANT
Parents respond to the infant’s cry.
The infant responds to the parents’ comforting measures.
Parents stimulate and entertain the infant while awake.
Parents become “cue sensitive” to the infant’s behavior.

Question 34

B. Identifying cultural and ethnic influences on postpartum care and parenting
behaviors.

Answer 34

● The degree of the father’s involvement in infant care.

● The role extended family members have in the care of the infant and new mother.

● The method of infant feeding.

● Foods that are eaten and foods that are avoided during the postpartum period.

● When a woman can bathe and wash her hair.

● When the baby is named and who names the baby.

Question 35

12. Discuss the discharge teaching needs for the postpartal woman and postpartum home care.

Answer 35

Signs of complications that need to be reported to the physician or midwife:
● Heavy lochia (saturating a pad in 1 hour) indicates possible secondary postpartum hemorrhage (James, 2014).
● The return of bright red, heavy bleeding after lochia has diminished or that becomes serosa or alba, or the passage of clots the size of an egg or larger indicates possible secondary postpartum hemorrhage.
● Foul-smelling lochia; indicates possible infection.
● Increased temperature (100.4°F [38°C] or higher); indicates possible infection.
● Pelvic or abdominal tenderness/pain; indicates possible infection.
● Frequency, urgency, or burning on urination; indicates possible cystitis.
● Unilateral breast tenderness, warm reddened area; chills and fever; indicates possible mastitis, which often occurs 3 to 4 weeks after delivery (James, 2014).
● Blurry vision, severe headaches, epigastric abdominal pain, fluid retention; may be associated with preeclampsia.
● Leg pain, swelling, redness may indicate venous thrombosis. Chest pain and difficulty breathing may be associated with pulmonary embolism .
● Thoughts of harming infant or self, difficulty caring for self and/or infant, difficulty sleeping or sleeping too much, and persistent feelings of depression and sadness are associated with postpartum depression .

Expected physical changes
● Uterine involution, afterpains, progression of lochia
● Breast changes, engorgement
● Diaphoresis and diuresis
● Weight loss
● Women can expect to lose approximately 12 pounds immediately after delivery, and an additional 5 to 8 pounds due to fluid losses associated with uterine involution and diuresis (Cunningham et al., 2014).

Self-care
● Hygiene
● Perineal care, continue to change pad frequently and use peri-bottle until lochia has stopped
● Breast care for lactating and nonlactating women
● Pharmacological and nonpharmacological pain control measures

Patient Education Figure
AWHONN Postpartum Discharge Teaching Project: Warning Signs

Call 911 for:

Pain in the chest

Obstructed breathing or shortness of breath

Seizures

Thoughts of hurting yourself or baby Call your provider for:

Bleeding soaking though one pad/hour or passing a clot the size of an egg.

Incision that is not healing

Red or swollen leg that is warm or painful to touch

Temperature of 100.4 or higher

Headache that does not get better even after taking medicine, or bad headache with changes in vision

If you cannot reach your provider, go to an emergency room.

Question 36

13. Identify behaviors that demonstrate the taking in, taking hold, and letting go phases associated with the mothering role.

Answer 36

TAKING-IN PHASE
The taking-in phase, a period of dependent behaviors, occurs during the first 24 to 48 hours after birth and includes the following maternal behaviors:

• The woman is focused on her personal comfort and physical changes.
• The woman relives and speaks of the birth experience.
• The woman adjusts to psychological changes.
• The woman is dependent on others for her and her infant’s immediate needs.
• The woman has a decreased ability to make decisions.
• The woman concentrates on personal physical healing

TAKING-HOLD PHASE
The taking-hold phase, the movement between dependent and independent behaviors, follows the taking-in phase. It can last weeks and includes the following maternal behaviors:

• The focus moves from self to the infant.
• The woman begins to be independent.
• The woman has an increased ability to make decisions.
• The woman is interested in the infant’s cues and needs.
• The woman gives up the pregnancy role and initiates taking on the maternal role.
• The woman is eager to learn; it is an excellent time to initiate postpartum teaching.
• The woman begins to like the role of “mother.”
• The woman may have feelings of inadequacy and being overwhelmed.
• The woman needs verbal reassurance that she is meeting her infant’s needs.
• The woman may show signs and symptoms of baby blues and fatigue.
• The woman begins to let more of the outside world in.

LETTING-GO PHASE
In the letting-go phase, the movement from independence to the new role of mother is fluid and interchangeable with the taking-hold phase. Maternal characteristics during this phase are:

• Grieving and letting go of old relationship behaviors in favor of new ones.
• Incorporating the infant into her life whereby the baby becomes a separate entity from her.
• Accepting the infant as he or she really is.
• Giving up the fantasy of what it would/could have been.
• Independence returns; may go back to work or school.
• May have feelings of grief, guilt, or anxiety.
• Reconnection/growth in relationship with partner