Case Scenario # 5: Post Partum

This is the case of Belle G1P1, delivered via NSVD to a live baby girl, with IVF of D5LR
1L at 30 gtts/min. Patient was awake, lying on bed with her baby beside her. With
noticeable choloasma on her face and neck.

Assessment done with the following results.

Breast symmetrical in size, verbalized a feeling of fullness, able to breastfed newborn at
regular episode at 2-3 hours or as needed. No masses or dimpling noted. Areola darker in
color. Nipples are erect with no cracks noted.
She complained of moderate pain on both breast. Breast engorgement noted. Encouraged
to do frequent breastfeeding.

Fundus at midline, palpable with one fingerbreadth below the umbilicus. Occasional
cramping or discomfort experienced as claimed, strengthens during breastfeeding due to
uterine contraction.

Hypoactive bowel sounds and able to pass out flatus. Abdomen not distended. Prominent
striae gravidarum and linea nigra.

Urinated once at approximately 300 cc urine, MIO done and recorded.

With moderate lochial discharges, perineal pad moderately soaked with reddish mucus
streaked discharges, no large blood clots and no offensive odor.
Mediolateral episiotomy with stitches about 2 inches long, slightly bruised and perineum is
slightly swollen. Still with moderate pain at a scale of 6/10 as claimed.

There was no edema on both lower extremities, absence of calf pain upon dorsiflexion of
patient’s ankle.

Patient was accommodating, and attentive, confident in handling the newborn. She
performs pericare, as instructed, puts on clean pads and gowns and settles back to bed.
Very eager to take care of her newborn.

Vital signs checked and recorded

BP- 110/70 mmHg
PR- 79 bpm
RR- 19 bpm
T- 37.2 C
Hematology
CBC
Results Normal Values

Hemoglobin 11.8 12.3-15.3 g/dl

Hematocrit 0.34 0.37-0.7

RBC 4.41 4.5-6.1 x 10 12/L

WBC 10 4.4-11.0x10^9/L

Neutrophils 0.55 0.54 – 0.58

Eosinophils 0.03 0.01-0.04

Basophil 0.01 0.00-0.01

Lymphocyte 0.28 0.25-0.33

Monocyte 0.05 0.03-0.07

MCV 86.5 76.0-96

MCH 29.5 27.0-32

Platelet Count 375 150-450x10^9/L

Urinalysis

Results

Color Pale amber

Transparency Hazy

pH Acidic 6.4

Specific Gravity 1.015

RBC +1

Pus Cells 0

Epithelial cells 0

Cast 0
 Glucose (-)

Protein (-)

Medications as ordered:
1. Co- Amoxiclav 625 mg 1 tablet BID for 7days
2. Mefenamic Acid 500 mg 1 tablet every 6 hours prn for pain
3. Obimin Plus 1 tablet OD for 1 month
4. Ferrous Sulfate 1 tablet OD for 1 month
5. Methergine 1 tablet TID x 9 doses

After 2 days postpartum the patient was discharged with her newborn, above medications
to continue at home.

Questions:
1. Why is it important to breastfeed immediately after birth? Does breastfeeding help with postpartum?
Breastfeeding in the first hour or so after birth also confers benefits both to the mother and the baby, such as
improved lactation and less loss of blood. Breastmilk provides the perfect nutrition to match on 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 help the uterus contract, reducing post-delivery blood loss. Through breastfeeding,
the uterus of the mother will heal faster. The hormones (prolactin and oxytocin) that produces milk can also affect
the uterus to contract.

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

Breast engorgement is breast swelling that results in painful, tender breasts. It’s caused by an increase in blood
flow and milk supply in your breasts, and it occurs in the first days after childbirth. Breast engorgement is the result
of increased blood flow in your breasts in the days after the delivery of a baby. The increased blood flow helps your
breasts make ample milk, but it can also cause pain and discomfort.
Milk production may not occur until three to five days postpartum. Engorgement may occur for the first time in the
first week or two after delivery. It can also reoccur at any point if you continue to breastfeed.
3. What are your management for breast engorgement?
The treatments for breast engorgement will depend on whether you’re breastfeeding or not.
For those who are breastfeeding, treatments for breast engorgement include:
1. using a warm compress, or taking a warm 2. shower to encourage milk let down
3. feeding more regularly, or at least every one to three hours
4. nursing for as long as the baby is hungry
5. massaging your breasts while nursing
6. applying a cold compress or ice pack to relieve pain and swelling
7. alternating feeding positions to drain milk from all areas of the breast
8. alternating breasts at feedings so your baby empties your supply
9.hand expressing or using a pump when you can’t nurse

4. What is the level of the fundus after delivery? How do you check fundus after delivery?
The level of the fundus is usually midway between the umbilicus and symphysis pubis within 1 to 2 hours after
delivery, 1 cm above or at the level of the umbilicus 12 hours after delivery, and about 3 cm below the umbilicus by
the third day after delivery. In checking the fundus, nurses can attempt to feel it by gently pressing patients or Belle's
abdomen. We should always remember that the uterus shrinks at about the rate of one cm. per day.

5. Determines the amount and characteristic of the lochial discharges. Is it

scanty, moderate or heavy? Explain the 3 stages of postpartum bleeding:
Lochia rubra - The blood will be red and very heavy. It’s also normal to see
clots during this stage. However, clots should not be larger than a small
plum, so if it increasing in size it would recommended to seek advice from a
midwife or healthcare professional as soon as possible
Lochia serosa - A mixture of blood and discharge will change to a light
watery pink. It will be slightly lighter than the previous days. However, as
the placental wound is still healing, blood will still be released.
Lochia alba - lochia changes from pink to a yellow/white colour, with just
the occasional spot of blood. This discharge is mainly made up of white
blood cells leaving the body after they helped heal the mother's uterus
following birth.

6. What are the types of episiotomy? What are the reasons/rationale of

performing episiotomy? What are the possible complications of episiotomy?
There are two types of episiotomy incisions:
•Midline (median) incision. 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.
•Mediolateral incision. A mediolateral incision is done at an angle. A mediolateral incision offers the best protection
from an extended tear affecting the anal area, but it is often more painful and is more difficult to repair.
Episiotomy risks
•Episiotomy recovery is uncomfortable, and sometimes the surgical incision is more extensive than a natural tear
would have been. Infection is possible. For some women, an episiotomy causes pain during sex in the months after
delivery.
•A midline episiotomy puts you at risk of fourth-degree vaginal tearing, which extends through the anal sphincter
and into the mucous membrane that lines the rectum. Fecal incontinence is a possible complication.
7.What are some common postpartum complications? Enumerate and discuss briefly.
Postpartum hemorrhage
Postpartum hemorrhage, also known as a PPH, is the leading causes of maternal morbidity and mortality worldwide.
A PPH occurs when there is more than 1000 mL of blood lost during or after a vaginal delivery or cesarean section.
It’s also important to note that a postpartum hemorrhage can occur up to 12 weeks after your delivery. This is what
we call a secondary PPH.

Postpartum 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 (protein in your urine.)This can develop during pregnancy, and is diagnosed if you meet
the above criteria after 20 weeks of gestation or in the postpartum period.

Postpartum Endometritis
Endometritis is an infection of the endometrium, the innermost lining of the uterus, that occurs after delivery. It
causes fever, tenderness when the uterus is touched, and/or foul smelling vaginal discharge.
DVT and pulmonary embolism
A “DVT” or deep venous thrombosis is a blood clot that forms in one of the lower extremities.
A pulmonary embolism, or “PE” occurs when that blood clot from the lower extremity travels to the lung.
Postpartum increase the risk of developing blood clots due to the high estrogen environment in your body.The high
estrogen state coupled with decreased activity are the major risk factors for developing postpartum clots.

8. Assess emotional state of the patient after delivery. Discuss & explain the following:
- The patient was accommodating and attentive, and she was confident in her ability to care for the newborn. She
does pericare as directed, changes into clean pads and gowns, and returns to bed. She is very eager to care for her
newborn.
Discuss & explain the following:
a. What is post partum depression and “Baby Blues”? How long does it last?
- Postpartum depression or PPD refers to depression occurring during pregnancy or after childbirth. PPD is a serious,
but treatable medical illness involving feelings of extreme sadness, indifference and/or anxiety, as well as changes in
energy, sleep, and appetite. It carries risks for the mother and child. PPD can occur within four weeks to several
months after childbirth, and can last up to a year.
- Although being a mother should be a pleasant occasion, the joy of having a new baby might be overwhelmed by
emotions of despair and mood swing. Many new moms experience these feelings shortly after giving birth, which are
often referred to as the “baby blues.” The baby blues usually appear three to five days after the baby is born, and the
mother usually experiences symptoms for two weeks. Within the first few weeks after childbirth, the mother's
estrogen and hormone changes have a role in the onset of post-baby blues symptoms. Some common symptoms are
crying, anxiety, and feeling restless or overwhelmed; these are often felt by new mothers due to the added stress
and responsibility that a newborn can bring. These symptoms are known as the baby blues and are likely to occur
within four to five days after the birth of the baby.

b. What are the causes of postpartum depression and how can it be prevented?
The specific cause has yet to be determined. Hormone levels fluctuate during pregnancy and after delivery.
Alterations in hormones may cause chemical changes in the brain. This contributes to the development of
depression.
Postpartum depression is more likely to occur if you have had any of the following:
- Previous postpartum depression.
- Depression not related to pregnancy.
- PMS or Severe premenstrual syndrome.
- A difficult or very stressful marriage or relationship.
- Few family members or friends to talk to or depend on.
- Stressful life events during pregnancy or after childbirth (such as severe illness during pregnancy, premature birth,
or a difficult delivery).

It is impossible to prevent or avoid postpartum depression. However, if you have a history of depression or
postpartum depression after giving birth to other children, you can prepare. Keeping your mind and body healthy
could be part of your preparation. During your pregnancy, eat well, exercise, and practice stress-reduction
techniques. Avoid alcohol and caffeine after your baby is delivered. Continue to choose a healthy lifestyle. If you're
worried about postpartum depression, see your doctor earlier in your pregnancy or soon after giving delivery.
9. What are the physiologic changes during postpartum?
- The typical changes in a woman's body following childbirth, during the postpartum period, are referred to as
postpartum physiological changes. These changes signal the resumption of pre-pregnancy physiology as well as
nursing.
- The fundus contracts one centimeter into the pelvis each day after delivery. After two weeks the uterus will have
contracted and return into the pelvis. Women who have previously delivered a child or children may experience
stronger postpartum uterine contractions in terms of sensation and strength.

10. Make a drug study

11. Identify at least 2 nursing problem and make Nursing Care Plan.