Patient Scenario, Chapter 25, Nursing Care of a Family Experiencing a Postpartum Complication AN ADOLESCENT WITH A POSTPARTAL COMPLICATION Pamela Barth is a 17-year-old, G1P1 woman transferred to the postpartal service following the birth of a 9 lb 4 oz infant boy. CHIEF CONCERN: “Should I be bleeding this much?” HISTORY OF PRESENT CONCERN: The client gave birth to a 9 lb 4 oz boy under epidural anesthesia at 7:25 AM following a 14-hour labor. Membranes had been ruptured for 26 hours. Modified Crede’s maneuver was used to deliver placenta. Fifteen units of Pitocin in 500 ml of lactated Ringer’s were administered intravenously following birth. Blood loss from birth is estimated at 750 ml. At present, the client reports vaginal bleeding is so heavy she is saturating a perineal pad every 20 minutes. FAMILY PROFILE: She lives with mother, two older sisters, and two nieces in a three-bedroom house. The family income is from social security and additional government subsidies. The family members are vegetarians because “meat is too expensive.” Pamela has “borrowed” supplies for baby from sisters. The father of child is said to be supportive but did not come to be with her in labor. HISTORY OF PAST ILLNESS: She had chickenpox at age 5 years. She had facial acne since she was 12 years old. She had no major illnesses and no hospitalizations. GYNECOLOGIC HISTORY: Menarche was at age 10 years; cycle duration: 29 days; menstrual flow duration: 5 days. She has no STIs. She is not using a contraceptive before present pregnancy. OBSTETRIC HISTORY: She had no previous pregnancies. This pregnancy was not intended but was not unwelcome. She has no complications during pregnancy except for minimal edema; proteinuria of 2+ and blood pressure increase to 140/98 mmHg for last 2 weeks. REVIEW OF SYSTEMS: Neurologic: Treated for 5 years when younger for “small seizures”; no longer takes medication for this Mouth: Severe malocclusion treated with oral braces since age 14 years Breasts: Mild breast engorgement; pleased to be breastfeeding PHYSICAL EXAMINATION: General appearance: Apprehensive-appearing, slender teenager; temperature: 98.6°F; BP: 100/60 mmHg. HEENT: Integument: five black comedones present on forehead; mouth: full upper and lower metal braces present; no ulcerations or abrasions on gumlines Chest: Heart rate: 100 beats/min; no murmurs present; lungs: rhonchi present in upper lobes; respiratory rate: 22 breaths/min Abdomen: Soft; fundus palpated at 2F above umbilicus and boggy; massaged and large firm clot 5 cm in diameter expelled vaginally; fundus somewhat firmer following massage but height did not change Perineum: Intact perineum; no external hemorrhoids; lochia: continuous bright red vaginal flow present; no clots LABORATORY RESULTS: Hemoglobin: 8.9 g/dl WBC: 25,000/mm3 Pamela is diagnosed as having mild uterine atony. STUDY QUESTIONS: 1. Which factor in Pamela’s health history makes her high risk for hemorrhage during the postpartal period? a. Her placenta was implanted on the posterior uterus. b. Her baby weighed more than 9 lb at birth. c. Pamela has a history of seizure activity. d. Pamela has been eating vegetarian diet for an extended period. Rationale: You may have uterine atony if your uterus is stretched or enlarged (also called distended) from giving birth to twins or a large baby (more than 8 pounds,13 ounces). 2. To estimate postpartum blood loss, you assess Pamela’s perineal pads. A saturated perineal pad typically contains approximately how much blood? a. 10 to 20 ml b. 25 to 50 ml c. 100 ml d. 250 ml Rationale: Weighing pads to determine the weight (1 gm = 1 mL) is as an effective way to determine the amount of blood in a pad (about 25 to 50 mL). 3. There is a need for Pamela’s uterus to contract postpartally to prevent or control bleeding. As her nurse, you should anticipate the administration of what drug? a. Levodopa b. Prilosec c. Oxytocin d. Meperidine Rationale: to intiate uterine tone and halt the bleeding 4. Massaging a uterus is a measure to control postpartal bleeding. To do this safely and effectively, you should perform what action? a. Use a light rapid effleurage technique to do this. b. Place one hand in the vagina to steady the cervix. c. Always massage from side to side to decrease pain. d. Place one hand at the base of the uterus to anchor it. Rationale: Massaging a uterus is a measure to control postpartal bleeding. To encourage contraction. 5. If perineal lacerations occur, they are categorized by category. Which of the following would be true of a fourth-degree tear? a. Invades the anal sphincter b. Is a tear extending to the urethra c. Includes only the vaginal wall d. Is a tear into the labia majora Rationale: because 4th degree laceration is the entire perineum, rectal sphincter, and some of the mucous membrane of the rectum. 6. Which factor in Pamela’s history puts her at highest risk for postpartal infection of the uterus? a. Birth from a lithotomy position b. Rupture of membranes over 24 hours before delivery c. Birth of a 9-lb infant d. Breastfeeding her infant on demand Rationale: because bacteria may have started to invade the uterus. 7. If Pamela developed a postpartal infection of the uterus, you would read about what problem in her electronic health record? a. Vaginitis b. Cystitis c. Endometritis d. Cervicitis Rationale: because it is an infection of the endometrium, the lining of the uterus. 8. Pamela develops a perineal hematoma. You should recognize which of the following as the most likely cause of this health problem? a. A clotting defect from the injection of epidural anesthesia b. Bruising of the perineum from a vertex fetal presentation c. Bleeding from the placing of perineal episiotomy sutures d. Urine seeping into the perineum from the anterior bladder Rationale: because a vein was punctured during repair. 9. Pamela has a WBC of 25,000/mm3. For a postpartal woman, how should you interpret this assessment finding? a. An active infection, probably of intrauterine origin b. A result of immunodeficiency related to her young age c. A count usual for a woman who has undergone the stress of labor d. Unusual unless it consists of only lymphocytes Rationale: because normal count of WBC is 11,000/mm3 thus, this signify an infection in the untrauterine. 10. Which of the following oral temperatures most clearly suggests the presence of a postpartal infection? a. 101°F at 8 hours postpartum b. 102°F immediately after birth c. 99°F at 2 weeks postpartum d. 101.2°F on the third postpartal day Rationale: A temperature over 100.4°F (38°C) after the first 24 hours is suggestive of postpartal infection. 11. All women in the postpartum period are at high risk for thrombophlebitis. When explaining this risk to Pamela, you should be aware of what causative factor? a. Placental toxins may lead to anticoagulation. b. Vaginal tears can lead to minimal infections. c. Fetal blood mixes with maternal blood at birth. d. Stasis of lower extremity vessels lead to dilation. Rationale: Stasis in dilated vessels leads to increased clotting. 12. If a woman develops a deep vein thrombus in the femoral vein, you should include what intervention in her plan of nursing care? a. Keep her legs in a dependent position. b. Apply alcohol over the inflamed site. c. Apply moist heat over the affected site. d. Use a syringe to sterilely aspirate the clot. Rationale: Moist heat helps to decrease inflammation and prevent further clotting. 13. Warfarin (Coumadin) is sometimes prescribed for deep vein thrombus. Which factor in Pamela’s history would make you question an order for this drug postpartally? a. She is breastfeeding her newborn. b. She is less than 25 years of age. c. She has no history of a previous blood clot. d. She is a vegetarian so may lack vitamin B12. Rationale: because coumarin-derived anticoagulants are passed in breastmilk. 14. The antidote for excessive dosages of warfarin (Coumadin) is: a. Acetylsalicylic acid. b. Vitamin K. c. Heparin. d. Serotonin. Rationale: Coumadin blocks the hepatic synthesis of vitamin-K-dependent clotting factors, supplying vitamin K increases these factors and counteracts the effect of the drug. 15. When teaching Pamela about the potential complication of mastitis, you should explain that it often results in: a. Thyroiditis. b. Pain on breastfeeding. c. Fibrocystic breast disease. d. Development of breast cancer. Rationale: if left untreated a breast infection can be localized abscess. If an abscess forms, breastfeeding on that breast is discontinued. 16. If Pamela does develop mastitis, you should recommend what intervention to relieve pain? a. Apply ice compresses to breasts. b. Apply topical morphine. c. Take an anticoagulant consistently. d. Insert a catheter to drain breast milk. Rationale: can reduce the swelling and pain in your breast. 17. Urinary retention is yet another possible postpartal complication. Which factor marks Pamela as high risk for urinary retention postpartally? a. She ate a high-fiber meal prior to birth. b. She is under age 25 years and female. c. Her large size fetus caused bladder edema. d. She has a history of constipation. Rationale: because bladder sensation for voiding is decreased because of bladder edema caused by the pressure of birth. 18. If Pamela develops a urinary infection, you would urge her to do which of the following? a. Remain on bed rest except for breastfeeding. b. Eat high-protein foods to acidify her urine. c. Drink at least 3,000 ml of fluid every day. d. Discontinue any anticoagulant she is taking. Rationale: to help flush the infection from her bladder. 19. Separation of the symphysis pubis can occur with childbirth. If this happens, it can result in which of the following? a. Sharp pain on walking b. Temporary abdominal pain c. Increased vaginal bleeding d. Pain down the lower back Rationale: because her legs tend to rotate externally, giving her a waddling gait. 20. A major complication of the postpartal period is maternal depression. Your best recommendation regarding this for Pamela would be: a. She won’t need treatment; it’s a temporary discomfort. b. This usually occurs in connection with excessive fluid loss. c. This is to be expected because of her changing life role. d. It should not be ignored as it can be a long-term condition. Rationale: because postpartal depression can last for months or even years. OPEN-ENDED QUESTIONS: 21. What if it has been 7 hours since Pamela gave birth and you notice she still has not voided? Would you be concerned? Yes, because maybe it is urinary retention and it occurs as a result of inadequate bladder emptying. After childbirth, bladder sensation for voiding is decreased because of bladder edema caused by the pressure of birth. Unable to empty, the bladder fills to overdistention. 22. What if Pamela later learns she has developed a cystocele and asks you if this will keep her from having any more children. How would you answer her? These uterine displacement disorders may interfere with future childbearing and fertility and may cause continued pain or a feeling of lower abdominal heaviness or discomfort. If the walls of the vagina are weakened, a cystocele (outpouching of the bladder into the vaginal wall) or a rectocele (outpouching of the rectum into the vaginal wall) may occur. FILL IN THE BLANK QUESTIONS: 23. The major cause of postpartum hemorrhage is uterine atony. 24. Endometritis occurs most often after women have had a caesarian delivery. MULTIPLE RESPONSE QUESTION: 25. Thrombophlebitis is a serious complication of childbearing. What are appropriate actions to teach women to prevent this? (Select all that apply.) a. Eat a diet low in animal protein. b. Take in an adequate fluid intake. c. Avoid sitting with knees crossed. d. Always rest in bed in a Sims’ position. e. Ambulate as early as possible post birth. Rationale: Drink adequate fluids to be certain you’re not dehydrated (6-8 glasses of fluid/day). Do not sit with your knees bent sharply. Ambulate as soon after birth as you are able. Early ambulation is the best preventive measure. Patient Scenario, Chapter 17, Nursing Care of a Postpartal Family A POSTPARTAL WOMAN Faye Chang is a 28-year-old, G4P3 woman you care for in a labor-delivery-recovery room following birth of a 6 lb, 13 oz girl. CHIEF CONCERN: “Pain. Sore breasts. Stomach cramps. Is it all right if I get up and walk? Do you know I’m a vegetarian? Don’t want to see any meat on a meal tray.” HISTORY OF CHIEF CONCERN: The client gave birth to a 6 lb 13 oz infant girl, 37 weeks’ gestation, at 1:05 PM with no analgesia. She is concerned new baby is abnormally small because other children both were more than 8 lb at birth. FAMILY PROFILE: The client was married when she was 20 years old, but marriage ended after a trophoblast proliferation pregnancy. She is currently living with her boyfriend and two children in a two-bedroom house; she works as a clerk in a mail-order catalog house. Her boyfriend works as a night club manager. Finances are reported as “okay.” Her boyfriend appeared supportive throughout labor. She voiced pleasure at sex and appearance of new child. HISTORY OF PAST ILLNESSES: Faye had a venomous snake bite at age 15 years while on a camping trip. Antivenin was given immediately; there are no sequelae. Only hospitalization was for two previous childbirths. GYNECOLOGIC HISTORY: Menarche was at age 17 years; cycle duration is 30 days. Menstrual flow duration is 7 days. Both she and sexual partner were treated for chlamydia last year. It was relying on sexual partner to use condoms as method of reproductive life planning prior to this pregnancy. OBSTETRIC HISTORY: Faye had hydatidiform mole pregnancy 8 years ago, followed for 1 year with hCG levels. She never had any elevation in levels. She had three pregnancies: boy, 8 lb 6 oz, vaginal delivery, alive and well, 12 years ago; boy, 8 lb 8 oz, vaginal delivery, alive and well, 10 years ago; girl, 6 lb 13 oz, vaginal delivery, 2 hours ago, no anomalies at birth. This pregnancy was not intended but not unwelcome. She doesn’t drink alcohol but did smoke “occasionally” during pregnancy. She took daily prenatal vitamin. REVIEW OF SYSTEMS: Essentially negative PHYSICAL EXAMINATION: General appearance: Distressed-appearing; young adult Asian woman HEENT: Hair: unwashed; oily; some postpartal hair loss beginning Chest: Heart rate: 70 beats/min; no murmurs present; lungs: no adventitious sounds present; respiratory rate: 22 breaths/min Abdomen: Soft; fundal height 1 F under umbilicus and firm and midline; linea nigra and striae present Perineum: Edematous; mediolateral episiotomy line intact; lochia: rubra, moderate, no clots Extremities: Homans’ sign negative; no edema over tibia Ms. Chang is diagnosed as having a usual postpartal course. STUDY QUESTIONS: 1. Ms. Chang is 4 hours postbirth and appears to be most concerned about her own care at the present time. When planning her immediate care, you would choose your assessments and interventions in the knowledge that she is in which postpartal stage? a. Taking in b. Taking hold c. Letting go d. Containment Rationale: The taking-in phase, the first phase experienced, is a time of reflection. During this 2- to 3-day period, a woman is largely passive. She prefers having a nurse minister to her (such as bringing her a bath towel or a clean nightgown) and make decisions for her, rather than do these things herself. 2. Based on her current health status, the best nursing diagnosis for Ms. Chang would be which of the following? a. Anxiety related to unexpected care of new infant b. Pain related to breast and abdominal discomfort c. Deficient fluid volume related to poor oral intake d. Impaired parenting related to inexperience Rationale: When abdominal pain and breast tenderness occur together, the cause is often related to changes in hormone levels. 3. You are planning nursing interventions that will address Ms. Chang’s pain. Which would be the best expected outcome for Ms. Chang? a. Client voices that her pain has diminished to a tolerable level. b. Client sleeps an acceptable amount of time and states that she feels rested. c. Client states that she knows her pain medicine will be effective. d. Client states that her pain is minimal and cares for self and infant. Rationale: It is good to know that there has been change and met the patients need. 4. During your interactions with Ms. Chang, you notice that she rarely looks directly at her newborn. How would you document this in Ms. Chang’s electronic health record? a. Client does not assume an enface position with newborn. b. Client appears not to enjoy holding her new newborn. c. Ms. Chang is having difficulty accepting mothering. d. New mother does not hold her infant comfortably. Rationale: Looking directly at her newborn’s face, with direct eye contact (termed an en face position), is a sign a woman is beginning effective interaction. So in that case the client does not assume an enface because she rarely look at her infant. 5. You have selected interventions that will promote Ms. Chang’s attachment, or relating well, to her newborn. This behavior is frequently described as which of the following? a. Negotiation b. Bonding c. Concern d. Fortitude Rationale: because in bonding she begins to express more warmth, touching the child with the palm of her hand rather than with her fingertips. She smoothed the baby’s hair, brushes a cheek, plays with toes, and lets the baby’s fingers clasp hers. Soon, she feels comfortable enough to press her cheek against the baby’s or kiss the infant’s nose or mouth; she has become a mother tending to her child. 6. Ms. Chang asks you if her older children should visit her in the hospital. Thinking of the QSEN competency of patient-centered care, what advice is most appropriate? a. “It’s better if older children see their new sibling first in their own home.” b. “Seeing a sibling in a hospital could make them think the newborn is ill.” c. “Seeing their new brother or sister immediately should help bonding.” d. “It’s important that your son and daughter do what makes you happiest.” Rationale: It can help to relieve some of the impact of separation. It helps to make the baby a part of the family. 7. Ms. Chang’s boyfriend tells you Ms. Chang has cried several times since the birth of the baby. What factor most likely accounts for this emotional lability? a. An increase in estrogen b. An increase in prolactin c. Loss of blood volume d. A decrease in estrogen Rationale: During the postpartal period, as many as 50% of women experience some feelings of overwhelming sadness. They may burst into tears easily or feel let down or irritable. This temporary feeling after birth has long been known as the “baby blues.” This phenomenon may be caused by hormonal changes, particularly the decrease in estrogen and progesterone that occurs with delivery of the placenta. 8. You have assessed Ms. Chang’s uterus and have noted that it is beginning to return to its prepregnant state. How should you document this phenomenon in the electronic health record? a. Atrophy b. Involution c. Retrographic change d. Endometrial discharge Rationale: involution is the process whereby the reproductive organs return to their nonpregnant state. 9. Ms. Chang is breastfeeding. What effect should the nurse anticipate that this will have on uterine size during the postpartal period? a. It slows the process of involution by approximately 25%. b. It promotes diuresis and limits the amount of lochia. c. It aids uterine contraction because of oxytocin release. d. It causes the cervix to expand because of estrogen release. Rationale: Because oxytocin which is released with breastfeeding, stimulates uterine contraction. 10. When Ms. Chang is 1 day postpartum, which of the following descriptions of lochia would you identify as being normal? a. Pink with occasional red streaking b. White because of mucous infiltration c. Brown because blood is now old d. Red with occasional small clots Rationale: For the first 3 days after birth, a lochia discharge consists almost entirely of blood, with only small particles of decidua and mucus termed as lochia rubra. 11. Assessing uterine size is important during the postpartum period. If Ms. Chang is 1 day postpartum, you would expect to locate her uterus at what location? a. 1 cm under her rib cage b. 3 cm below her umbilicus c. 1 cm below her umbilicus d. 3 cm above her symphysis pubis Rationale: On the first postpartal day, it will be palpable one fingerbreadth below the umbilicus. 12. You are preparing to palpate Ms. Chang’s abdomen for uterine position. What nursing action should you perform? a. Place a hand at the base of the uterus to prevent uterine inversion. b. Insert one hand vaginally to slow the vaginal flow while palpating. c. Mark the point of the fundus on the abdomen with a pen or marker. d. Place ice on the abdomen to cause contraction prior to palpation. Rationale: because this usually causes the uterus to contract and become firm immediately. 13. Suppose Ms. Chang were 3 days postpartum. What would be an expected outcome when you are assessing her lochia? a. Lochia is red with pinpoint clots present. b. Lochia appears yellow because of serum. c. Lochia’s color is now white, and texture is firm. d. Lochia is pink with no strong odor. Rationale: For the first 3 days after birth, a lochia discharge consists almost entirely of blood, with only small particles of decidua and mucus termed as lochia rubra. 14. Ms. Chang tells you she seems to be voiding a large amount of urine. What is the usual amount of urine women in the postpartum period void each 24 hours? a. 500 to 1,200 ml b. Approximately 1,000 ml c. 2,000 to 3,000 ml d. 4,000 to 5,000 ml Rationale: voids a minimum of 100 ml by 2 hours is the common measures. 15. Ms. Chang worries she will develop a thrombophlebitis. When assessing her, you should be aware of what risk factor for this problem during the postpartal period? a. They develop fatty plaques from the stress of labor. b. Involution causes the uterus to obstruct blood vessels. c. Their fibrinogen level is still elevated from pregnancy. d. Amniotic fluid mixing with plasma causes rapid clotting. Rationale: this is a protective measure against hemorrhage. However, this high level also increase the risk of thrombus formation. 16. On her first day postpartum, Ms. Chang’s temperature is 38°C (100.4°F). How should you interpret this assessment finding? a. She must be developing a postpartal infection. b. This is a normal finding for the first day postpartum. c. Her temperature should be mildly hypothermic for 24 hours. d. She must be developing a stress reaction to parenting. Rationale: Most women demonstrate a slightly elevated temperature in the first 24 hours following birth. Postpartal infection is not suspected unless it rises more than 38°C. 17. On the third day postpartum, Ms. Chang tells the home care nurse that her breasts feel warm and tender. How should the nurse interpret this assessment finding? a. She is experiencing breast engorgement, which is normal. b. Her infant must be a particular vigorous feeder. c. This suggests that mastitis may be developing. d. She needs to drink more fluid to reduce inflammation. Rationale: it fades as the infant begins effective sucking and empties the breast of milk. 18. If Ms. Chang had an episiotomy with perineal pain, what would be the preferred pain-relief measure for her on the third day postpartum? a. Perineal application of ice b. Topical hydrocortisone c. Oral hydromorphone (Dilaudid) d. Perineal heat application Rationale: Dry heat in the form of a perineal hot pack or moist heat with a sitz bath is an effective way to increase circulation to the perineum, provide comfort, reduce edema, and promote healing. 19. Ms. Chang reports she is afraid to have a bowel movement because that may cause perineal pain. How should you advise her? a. This problem will resolve spontaneously. b. The use of a stool softener may be indicated. c. She should eat soft foods for the next several days to increase bowel peristalsis. d. She should avoid having a bowel movement until her perineum has begun to heal. Rationale: To prevent constipation, many women are prescribed a stool softener such as docusate sodium, beginning with the first day after birth. If a woman has not moved her bowels by the third postpartum day, a mild laxative or cathartic may be prescribed. OPEN-ENDED QUESTIONS: 20. What if Ms. Chang tells you in the hospital that she knows she had a perfect baby so should be happy but she can’t stop crying? At what point would you suggest counseling for her? “Postpartal blues” are a normal accompaniment to childbirth. You can assure a woman that her feelings are normal and offer supportive care until the emotion passes. 21. What if Ms. Chang’s boyfriend tells you their new baby looks nothing like him and asks you how soon he can request a DNA analysis to establish if he’s the father or not? How would you advise him? Another common feeling parents may experience is disappointment in the baby. All during pregnancy, they pictured a chubby-cheeked, curly-haired, smiling girl or boy. They have instead a skinny baby, without any hair, who seems to cry constantly. It can be difficult for parents to feel positive immediately about a child who does not meet their expectations in this way. It can cause parents to remember their adolescence, when they felt gangly and unattractive, or to experience feelings of inadequacy all over again. You can never change the sex, size, or look of a child, but in the short time you care for a postpartal family, you can help to change the feelings of a mother or father about their infant. Handle the child warmly, to show that you find the infant satisfactory or even special. Comment on the child’s good points, such as long fingers, lovely eyes, and good appetite. During periods of crisis such as childbearing, it is possible for a key person such as a nurse to offer support to tip a scale toward acceptance or at least help a person involved to take a clearer look at his or her situation and begin to cope with the new circumstances. FILL IN THE BLANK QUESTIONS: 22. The process of a uterus returning to its prepregnant state is termed Involution. 23. The uterine discharge after birth is termed Lochia. MULTIPLE RESPONSE QUESTIONS: 24. Which of the following are important assessments to make in the postpartal period to keep a woman safe from hemorrhage? (Select all that apply.) a. Blood pressure and pulse b. Uterine tone and consistency c. Ability to walk steadily d. Tympanic temperature e. Assessment of appetite Rationale: Blood pressure and pulse should be monitored carefully during the postpartal period, because a decrease in this can indicate bleeding. Uterine tone and its consistency should also be monitored in order to know if there’s possible problem. 25. Ms. Chang will be busy after she returns home because she works outside the home in addition to caring for two other children. What discharge instructions should you include in your health teaching? (Select all that apply.) a. She should try to maintain a smoke-free house rather than return to smoking. b. She should try to breastfeed for a minimum of 6 months even while working. c. She should call and make an appointment for a health visit at 4 to 6 weeks. d. She needs to plan rest times as exhaustion can lead to postpartal depression. Rationale: Before discharge, make sure a woman is aware that she must return for an examination 4 to 6 weeks after birth, and that she should make an appointment to take her baby to a primary care provider for an examination at 2 to 4 weeks of age. A woman should plan at least one rest period each day and try to get a good night’s sleep.