CASE STUDY 5 – QUESTIONS

1. Why is it important to breastfeed immediately after birth? Does breastfeeding help with
postpartum?

Timely initiation of breastfeeding guarantees that infants receive the colostrum, 'the
first breastmilk', which contains antibodies that protect the newborn against diseases.
Breastfeeding within the first hour of life prevents newborn death due to sepsis,
pneumonia, diarrhea and hypothermia. Breastmilk provides the perfect nutrition to match
the baby's needs for growth and development. Colostrum, the breastmilk produced in the
first few days after birth, is very rich in the nutrients and immune components of
breastmilk which help to protect the baby from infection.

The oxytocin released when the baby nurses helps your uterus contract, reducing
post-delivery blood loss. Plus, breastfeeding will help the mother’s uterus return to its
normal size more quickly—at about six weeks postpartum, compared with 10 weeks if
one doesn’t breastfeed. Studies have also showed that women who breastfed report fewer
instances of postpartum.

2. What is breast engorgement? What caused breasts engorgement after delivery?

Breast engorgement is breast swelling that result in painful, tender breasts. It’s
caused by an increase in blood flow and milk supply in the mother’s breasts and it occurs
in the first days after childbirth. Breast engorgement is the result of increased blood flow
in the breasts in the days after the delivery of a baby. The increased blood flow helps the
breasts make ample milk, but it can also cause pain and discomfort.

3. What are your management for breast engorgement?

For those who are breastfeeding, treatments for breast engorgement include:

 using a warm compress, or taking a warm shower to encourage milk let down
 feeding more regularly, or at least every one to three hours
 nursing for as long as the baby is hungry
 massaging the breasts while nursing
 applying a cold compress or ice pack to relieve pain and swelling
 alternating feeding positions to drain milk from all areas of the breast
 alternating breasts at feedings so the baby empties the supply
 hand expressing or using a pump when mother can’t nurse
 taking doctor-approved pain medication
 For those who don’t breastfeed:

 using a cold compress or ice packs to ease swelling and inflammation

 taking pain medication approved by the doctor
 wearing a supportive bra that prevents the breasts from moving significantly

4. What is the level of the fundus after delivery? How do you check fundus after delivery?

Immediately after delivery, the upper portion of the uterus, known as the fundus,
is midline and palpable halfway between the symphysis pubis and the umbilicus. By
approximately one hour post-delivery, the fundus is firm and at the level of the umbilicus.
Check the fundus after delivery by palpating the uterine fundus to determine uterine size,
degree of firmness, and rate of descent, which is measured in fingerbreadths above or
below the umbilicus.

5. Determine the amount and characteristic of lochial discharges. Is it scanty, moderate or

heavy? Explain the 3 stages of postpartum bleeding:
a. Lochia Rubra
b. Lochia Serosa
c. Lochia Alba

Lochia for the first 3 days after delivery is dark red in color which we refer to
Lochia Rubra. A few small blood clots, no larger than a plum, are normal. For the fourth
through tenth day after delivery, the lochia will be more watery and pinkish to brownish
in color which is known as lochia serosa. From about the seventh to tenth day through the
fourteenth day after delivery, the lochia is creamy or yellowish in color and this is the
Lochia Alba. One might notice increased lochia when she gets up in the morning, when
she is physically active, or while breastfeeding. Moms who have cesarean sections may
have less lochia after 24 hours than moms who had vaginal deliveries. The bleeding
generally stops within 4 to 6 weeks after delivery.

Postpartum bleeding is heaviest the first few days after baby is born. As time goes
by the blood flow will lighten and eventually one will experience occasional spotting of
blood.
6. What are the types of episiotomy? What is the reasons/rationale of performing
episiotomy? What are possible complications of episiotomy?

There are two types of episiotomy the midline (median) incision and mediolateral
incison. A midline incision is done vertically. A midline incision is easier to repair, but it
has a higher risk of extending into the anal area while mediolateral incision is done at an
angle. Episiotomy is done to speed prolonged labor, assist with a vaginal delivery, and
delivery of a large baby, to prevent tearing, release pressure from fetal head, widen the
passage and substitute a clean cut than zigzag. The possible complications of episiotomy
are painful sexual intercourse in the future, infection, swelling, hematoma (collection of
blood at the site) leaking of gas or stool due to tearing of rectal tissue, and bleeding.

7. What are some common postpartum complications? Enumerate and discuss briefly.
a. Infection or sepsis - A puerperal infection occurs when bacteria infect the uterus
and surrounding areas after a woman gives birth.
b. Cardiomyopathy - Peripartum cardiomyopathy is a weakness of the heart muscle
that by definition begins sometime during the final month of pregnancy through
about five months after delivery, without any other known cause. Most
commonly, it occurs right after delivery.
c. Thrombotic pulmonary embolism - A blockage in one of the pulmonary arteries in
the lungs often caused by blood clots that travel to the lungs from the legs.
Women with a history of blood clots, varicose veins, or deep vein thrombosis are
at a higher risk than normal for a pulmonary embolism while pregnant.
d. Hemorrhage - Postpartum hemorrhage (also called PPH) is when a woman has
heavy bleeding after giving birth. A PPH occurs when there is more than 1000
mL of blood lost during or after a vaginal delivery or cesarean section.
e. Preeclampsia - Preeclampsia is a hypertensive disorder of pregnancy that is
diagnosed when you have elevated blood pressure (Systolic blood pressure greater
than or equal to 140mmHg OR Diastolic blood pressure greater than or equal to
90mmHg) with proteinuria
f. Mastitis - Mastitis is an infection that develops in breast tissue. The painful
condition causes one breast to become swollen, red and inflamed. In rare cases, it
affects both breasts. Mastitis is a type of benign (noncancerous) breast disease.

8. Assess emotional state of the patient after delivery. Discuss & explain the following
a. What is post-partum depression and ‘baby blues”? How long does it last?
b. What are the causes of post-partum depression and how can it be prevented?
 Patient was accommodating and attentive, confident in handling the newborn.
She also follows instructions as evidenced by performing pericare as instructed and
very eager to take care of her newborn.

The "baby blues" happen to as many as 70% of women in the days right after
childbirth. The mother may have sudden mood swings, such as feeling very happy
and then feeling very sad. She may cry for no reason and can feel impatient, cranky,
restless, anxious, lonely, and sad. The baby blues may last only a few hours or as long
as 1 to 2 weeks after delivery. Postpartum depression (PPD) can happen a few days or
even months after childbirth. PPD can happen after the birth of any child, not just the
first child. The mother can have feelings similar to the baby blues -- sadness, despair,
anxiety, crankiness -- but she feels them much more strongly. PPD often keeps the
mother from doing the things she need to do every day. When one’s ability to
function is affected, she needs to see a health care provider, such as her OB/GYN or
primary care doctor.

Some things that can raise the chances of postpartum depression include:

 A history of depression prior to becoming pregnant, or during

pregnancy
 Age at time of pregnancy (the younger you are, the higher the
chances)
 Ambivalence about the pregnancy
 Children (the more you have, the more likely you are to be
depressed in a later pregnancy)
 Family history of mood disorders
 Going through an extremely stressful event, like a job loss or
health crisis
 Having a child with special needs or health problems
 Having twins or triplets
 Having a history of depression or premenstrual dysphoric disorder
(PMDD)
 Limited social support
 Living alone
 Marital conflict
 Hormones. The dramatic drop in estrogen and progesterone after
you give birth may play a role. Other hormones produced by your
thyroid gland also may drop sharply and make you feel tired,
sluggish and depressed.
 Lack of sleep. When you're sleep-deprived and overwhelmed, you
may have trouble handling even minor problems.
  Anxiety. You may be anxious about your ability to care for a
newborn.
 Self-image. You may feel less attractive, struggle with your sense
of identity, or feel that you've lost control over your life. Any of
these issues can contribute to postpartum depression.

9. What are the physiologic changes during post-partum?

Involution of the uterus involves two processes. First, the area where the placenta
was implanted is sealed off to prevent bleeding. Second, the organ is reduced to its
approximate pregestational size.
Immediately after birth, a uterine cervix feels soft and malleable to palpation.
Both the internal and external OS are open. Like contraction of the uterus, contraction of
the cervix toward its prepregnant state begins at once.
After a vaginal birth, the vagina feels soft, with few rugae, and its diameter is
considerably greater than normal. The hymen is permanently torn and heals with small,
separate tags of tissue. It takes the entire postpartal period for the vagina to involute (by
contraction, as with the uterus) until it gradually returns to its approximate prepregnancy
state. Thickening of the walls appears to depend on renewed estrogen stimulation from
the ovaries.
Because of the great amount of pressure experienced during birth, the perineum is
edematous and tender immediately after birth.
Pregnancy hormones begin to decrease as soon as the placenta is no longer
present.
During pregnancy, as much as 2,000 to 3,000 ml of excess fluid accumulates in
the body so extensive diaphoresis (excessive sweating) and diuresis (excess urine
production) begin almost immediately after birth to rid the body of this fluid. This easily
increases the daily urine output of a postpartal woman from a normal level of 1,500 ml to
as much as 3,000 ml/day during the second to fifth day after birth. This marked increase
in urine production causes the bladder to fill rapidly.
During pregnancy, as much as 2,000 to 3,000 ml of excess fluid accumulates in
the body so extensive diaphoresis (excessive sweating) and diuresis (excess urine
production) begin almost immediately after birth to rid the body of this fluid. This easily
increases the daily urine output of a postpartal woman from a normal level of 1,500 ml to
as much as 3,000 ml/day during the second to fifth day after birth. This marked increase
in urine production causes the bladder to fill rapidly.
Hemorrhoids (distended rectal veins) that have been pushed out of the rectum
because of the effort of pelvic-stage pushing often are present. Bowel sounds are active,
but passage of stool through the bowel may be slow because of the still-present effect of
relaxin (a hormone which softens and lengthens the cervix and pubic symphysis for
preparation of the infant’s birth during pregnancy) on the bowel.
 After birth, the stretch marks on a woman’s abdomen (striae gravidarum) still
appear reddened and may be even more prominent than during pregnancy, when they
were tightly stretched. Typically, in a White woman, these will fade to a pale white over
the next 3 to 6 months; in a Black woman, they may remain as areas of slightly darker
pigment. Excessive pigment on the face and neck (chloasma) and on the abdomen (linea
nigra) will become barely detectable by 6 weeks’ time. If diastasis recti (overstretching
and separation of the abdominal musculature) occurred, the area will appear as a slightly
indented bluish streak in the abdominal midline. Modified sit-ups help to strengthen
abdominal muscles and return abdominal support to its prepregnant level. Diastasis recti,
however, may require surgery to correct.

10. Make a Drug Study

11. Identify at least 2 nursing problem and make Nursing Care Plan.
 Impaired comfort related to uterine contraction as evidenced by occasional cramping
 Pain related to mediolateral episiotomy as evidenced by slightly bruised and swollen
perineum and a 6/10 pain scale as claimed by the patient