OB Exam 5

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foxyt14
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271101
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OB Exam 5
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2014-04-19 17:33:48
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OBGYN
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Exam 5 for OB
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  1. If a pt is bleeding lots PP what do I check?
    fundus and bladder....pee!!
  2. How long is the PP period (Puerperium)
    1st 6 weeks after delivery
  3. Involution
    returning of uterus to pre pregnancy size/condition
  4. Describe the uterus immediately post delivery, then after
    • immediately it is btwn pubic symphysis and umbilicus
    • then....
    • it goes above the umbilicus
  5. How much does the fundus descend each day and when should it be no longer palpable?
    • 1cm/day
    • 10th day
  6. What influences involution of the uterus?
    • full bladder
    • multigravida uterus
    • breast feeding
    • pitocin
  7. How does the multigravida uterus effect involution?
    it will be more painful cuz it is stretched so much
  8. How much Pitocin to help with involution
    20units
  9. Breastfeeding helps with involution cuz....
    it secretes oxytocin which helps with contractions to shrink uterus
  10. Describe lochia by day
    first 3 days....rubra which is red...heavy when 1st get out of bed

    days 3-11....serosa which is pink....will be home...made of leukocytes, blood and mucus

    3 to 6 weeks....alba which is white/cream made of leukocytes
  11. Teaching about lochia
    it is abnormal to have large clots, foul odor and increase changing pads once hit alba stage.

    if start to bleed again....rest, if it doesn't stop call doctor
  12. Hormones that increase and decrease to cause milk production at 2-5 days after birth
    • increased prolactin
    • decreased progesterone, estrogen and placental lactogen
  13. What helps with engorgement for breast feeding moms
    cabbage
  14. How do you help non breast feeding moms with engorgement?
    binding the breasts and put ice in the bra
  15. Result of engorgement
    slight increase in temperature....but if it is less than 100 it is ok
  16. Blood loss for c section and vaginal deliveries
    • vaginal=500cc
    • c section=1000

    up to these amounts
  17. Why is cardiac output increased for 48 hrs after delivery?
    cuz blood is returning from the uteroplacental unit back to the heart

    extracellular fluid is moving in to vascular departments
  18. What happens with plasma volume after delivery?

    when will it be at a normal level?
    it decreases due to diuresis and diaphoresis which rids the body of excess fluid

    4-5 days
  19. What happens with fibrinogen after delivery?
    it is still increased so there is still an increased risk for thrombus formation
  20. What happens with leukocytes after delivery?
    they can increase to btwn 20,000-30,000 from pain, stress and inflammation

    normal levels around 3-7 days
  21. How long will it take for hormonally induced skin changes to revert back to pre-pregnancy states?
    months!!

    it takes a while for hormones to decrease...especially melanocytic stimulating hormone
  22. What will happen to stretch marks pp
    turn silvery
  23. What happens with urinating and the pp patient?
    temporary incontinence due to trauma and edema

    **be with patient the first time they get up to urinate.....give them call light and tell them!!
  24. What does diuresis occur after delivery
    within 12 hrs
  25. What can cause a pp patient to have a hemorrhage?
    increased incidence of urinary retention....this displaces the uterus to the side so it cant contract...bleeding
  26. What determines how a person does cardio wise with their delivery and pp?
    • family hx
    • age
  27. When do cardiac events/myopathy occur after delivery?
    within first few days
  28. What hormone allows the ligaments and cartilage to return to pre prego position?  How is this felt?
    • Relaxin
    • Fatigue/joint aches
  29. How long will it take the musculoskeletal system to get back to pre prego shape?
    1 year
  30. Which abdominal muscle has a really hard time getting back to pre prego site?
    diastasis recti....longitudinal muscle that separates
  31. What is common post partum?:
    headaches/fatigue
  32. Post epidural feelings....
    • dizzy
    • lower extremity sensations
    • headache
  33. What is a sign that PIH is worsening
    • blurred vision
    • photophobia
    • ABDOMINAL PAIN
  34. What hormone initiates milk production within 2-5 days of delivery?
    prolactin from the pituitary gland
  35. What causes milk let down from the alveoli in to the lactiferous ducts?
    oxytocin...from pituitary gland
  36. If a person isn't breastfeeding how long will it take for prolactin to disappear?
    2 weeks
  37. Menstruation is hormonally controlled....how long till non nursing moms get it back?
    nursing moms?
    • non at 2-3 months
    • nursing it depends on the breastfeeding frequency....women who feed 6+ times/day will menstruate later than those who breast feed less often
  38. How much is lost with the delivery of the fetus, palcenta, AF and blood?
    12 lbs
  39. During the first few weeks what causes weight loss and how much usually?
    diuresis, diaphoresis and shrinking reproductive organs

    8 lbs
  40. Normal pre prego weight takes
    6-12 months
  41. PP assessment and nursing care for all births
    • VS
    • IV Fluid check
    • Breasts
    • Fundus
    • Lochia
    • Bladder
    • Perineum
    • Lower extremity
    • Deep tendon reflexes
    • Pain
    • Meds
  42. How often take VS after delivery?
    • q 15min x 1hr
    • q 30 min 2-4 hrs
  43. Why is a new mom at risk right after birth for orthostatic hypotension?
    there is a rapid decrease in intrabdominal pressure which leads to dilation of visceral blood vessels
  44. Nanda for new mom
    Risk for injury
  45. If give methergen for pp contractions what do I watch for
    high BP
  46. Sign that the bladder is distended....
    • fundus is displaced to the left or right
    • suprapubic distention
  47. What do I assess on the perineum after an episiotomy/laceration?
    • Redness
    • Edema
    • Ecchymosis
    • Discharge
    • Approximation
  48. How does a mom care for her episiotomy/lacerations in perineum
    1st 24 hrs ice....after that a warm bath to help with healing
  49. How do you evaluate a hematoma in the perineum?
    patient side lying, knees bent and look at from behind.....ask about pain level
  50. Pain and the new mom....
    never assume it is just in the abdomen....can be anywhere and we need to ask to describe
  51. Hemorrhoids are a sign of
    PIH
  52. Why do we do a deep tendon reflex on pp mom?  problem and what dx it?
    • checking for PIH
    • 3/4...hyperactive reflexes
  53. Rubella and the nursing mom
    If they need the vaccination they will still get it even though it will cross over to the breast milk
  54. Additional focused assessment for a mom who had a c section
    • Respirations
    • abdominal incision
    • I&O
    • Mobility/immobility
    • Comfort
  55. Complications after all deliveries
    • fever
    • localized area of redness or swelling
    • pain in the breast not relieved by analgesics
    • abdominal tenderness
    • pelvic fullness/pressure
    • persistent perineal pain
    • frequency, urgency, burning with urination
    • abnormal change in character of lochia
    • localized tenderness, redness or warmth of the legs
  56. Benefits of breast feeding for the infant
    • no allergies
    • immunity
    • easily digested by infant
    • vitamins/nutrients
    • bonding/attachment
    • decreased constipation
    • no overfeeding
    • decreased gas
    • decreased ear infection
  57. Benfits of breast feeding for the mom
    • no heating milk
    • bonding/attachment/contact
    • decrease cost
    • causes uterus to contract
    • mom can rest
    • weight loss
    • decrease stinky diapers to deal with
  58. Bendfits of breast feeding for the dad
    • no heating milk
    • bonding/attachment/contact
    • decreased cost
    • decrease stinky diapers to deal with
  59. State benefits of formula feeding
    • anyone else can feed baby
    • mom can eat anything
    • no meds passed to baby that mom took
    • measurement is for sure
    • employment
    • maternal medical condition
  60. 3 phases of breast milk
    • Colostrum
    • Transitional
    • Mature
  61. Colostrum milk
    • increase protein
    • fat soluble vitamins and minerals
    • low in calories
    • fat
    • increase in IMMUNOGLOBULINS
    • laxative effect 1st week
  62. What do the immunoglobulins received in the 1st phase of breast milk do for the baby?
    colostrum helps to establish the normal flora of the intestines
  63. Transitional milk
    • comes in at 4-10 days
    • increase in calories, lactose and fat
  64. Mature Milk
    after two weeks of lactation this is present and provides sufficient nutrients

    Bluish in color
  65. How do you combo breast/formula feed?
    Wait till the baby is 3-4 weeks old to introduce formula because breastfeeding is based on supply and demand
  66. What decreases a womans risk of breast cancer?
    less number of menstrual cycles
  67. Breastfeeding decreases a mom's risk of developing which 2 types of cancers?
    breast and ovarian
  68. Breastfeeding and a mom's bones
    makes them stronger in life
  69. Formula fed babies are more at risk to be....
    obese later in life
  70. Nutrition for the nursing mom
    • increase calories 500/day
    • 2-3 litres of fluid/day
    • avoid foods that make infant fussy
  71. Comfort measures for engorgement
    • wear fitted bra for support
    • ice packs
    • warm shower before breast feeding
    • cabbage leafs
  72. LATCHON
    • LIPS FLANGED OUTWARD
    • ALL OF NIPPLE IN AND @ LEAST 1IN OF AREAOLA IN THE MOUTH
    • TONGUE OVER LOWER GUM AND SCOOPED
    • CHIN AND NOSE TOUCHING MOMS BOOB
    • HEAR AUDIBLE SWALLOWING
    • OBSERVE JAW GLIDE AND EAR WIGGLE
    • NO PAIN, DIMPLING OF CHEEKS, SOUND OF AIR ESCAPING
  73. The golden hour promotes....
    bonding and attachment
  74. Bonding
    a UNIDIRECTIONAL attraction from PARENT to child

    It encourages time together/touch...especially in first 2 hours when baby is alert
  75. Attachment
    RECIPROCAL bond through interaction BETWEEN parent and infant through MUTUALLY satisfying experiences
  76. When does attachment start?
    during pregnancy and continues after birth
  77. How does an infant reciprocate attachment?
    • eye contact
    • grasp
    • response to voice
    • be consoled
  78. Finger tipping
    first touch experiencing between mom and newborn when the mom explores the infant's body mainly with her fingertips
  79. Stroking
    done with palm
  80. Enfolding
    mom uses entire hand to touch infant
  81. Verbal behaviors seen when bonding with baby
    talks to infant
  82. 3 maternal role adjustments
    • Taking in
    • Taking Hold
    • Letting GO
  83. Describe taking in
    • 1st day
    • mom focuses on her own physical needs
    • content letting others do things and make decisions
  84. Describe taking hold
    Mom is independent and is taking care of herself and baby...she is also ready to learn
  85. When is a good time for patient education?
    Taking Hold phase
  86. Describe Letting Go
    relinquish fantasy of infant and birth and realize old care free life is OVER
  87. 3 Placental abnormalities
    Placenta accreta-superficial penetration of uterine muscle

    Placenta increta-partial penetration

    Placenta Percreta (perforated) complete penetration
  88. What will be a sign that a pregnant person has placenta Percreta?
    bleeding during pregnancy
  89. What can Placenta Accreta, Increta and Perceta precipitate?  Then....
    • Uterine Inversion
    • Hemorrhage
  90. What is Uterine Inversion?  How does this happen?
    • when the uterus turns inside out, either partially or completely
    • happens cuz dr. pulled on cord before detachment, from fundal pressure during or after birth, abnormally adherent placenta
  91. Result of Uterine Inversion
    risk for Hemorrhage
  92. Placenta accrete/increta/percreta and uterine inversion all put mom at risk for
    hysterectomy
  93. When a patient is bleeding we want to know
    Where blood is coming from....the episiotomy?  Or hemorrhaging?
  94. Sign that a patient has uterine atony
    increased lochia rubra
  95. Subinvolution
    when the uterus doesn't contract down or does it slower than expected...will have late PP hemorrhage
  96. S/S of Uterine Atony
    • soft/boggy or difficult to find fundus
    • uterus gets firm with massage, but loses its firmness when massage is stopped
    • fundus located above expected level/displaced
    • excessive lochia/clots
    • tachycardia/tachypnea/decreased BP
    • Cool pale skin, hypovolemic shock
    • Change in LOC
  97. What is considered to be excessive lochia and clots?
    >1 pad in 15 min
  98. S/S of a hematoma....and can cause
    • unrelieved deep perineal/rectal pain
    • bulging mass or discoloration
    • firm fundus

    hemorrhage
  99. What do I do if a patient is hemoraghing?
    • Fluid Bolus...may need 2nd line
    • Supine position
    • VS q 15min
    • O2
    • Foley to assess for bladder distention
    • Meds to help contract uterus
    • Bimanual compression of uterus
    • Manual removal of placental parts
    • Prepare OR for D&C
  100. Meds given to help with contractions
    • Pitocin 20u
    • Methergine 0.2mg IM...can take orally at home
  101. What lab do I need to monitor when a patient is hemoraghing?
    Platelets....can go in to DIC
  102. 2 times patients are at risk for hemorrhage?
    right away and 6 weeks pp
  103. Subinvolution
    slower than expected return of uterus to pre-pregnancy size....problem after discharge home
  104. S/S of subinvolution
    • prolonged lochia discharge
    • excessive uterine bleeding
    • pelvic pain, backache, persistent malaise....less O2 to the brain=tired
    • uterus feels larger/softer than expected for time
  105. What causes subinvolution
    • retained placental fragments
    • pelvic infection
    • uterine tumors
  106. Therapeutic management for subinvolution
    • **focus on patient ed since this happens after mom goes home....teach when to call Dr and go to ED
    • Methergine
    • Antimicrobial therapy
    • D&C
  107. Thrombophlebitis
    development of thrombus when a vein wall is inflamed...platelets & thrombin collect on vessel wall....can be seen in

    legs or pelvis
  108. S/S of thrombus
    • no symptoms or
    • pain in leg/pelvis/abdomen
    • edema, redness
    • cord like vein
    • increased temp/chills/tachy
    • decreased peripheral pulses
  109. What can cause venous stasis which can cause a thrombus?
    • compression of large vessels of pelvis and legs by growing uterus or
    • prolonged time in stirrups
  110. How do you treat a thrombus?
    PREVENT ONE....limit time in stirrups! Only in stirrups when Dr. is there and ready to deliver

    • bedrest with elevated leg
    • apply moist heat
    • analgesics
    • Heparin
    • Elastic hose
    • don't massage
    • know s/s of PE
  111. S/S of Pulmonary Embolism
    • sudden sharp chest pain
    • tachycardia
    • tachypnea
    • rales
    • COUGH
    • SOB
    • PANICKED
    • SITTING IN TRI POD POSITION
    • Decreased O2 sats
  112. Management of PE
    • Rapid Response
    • Crash Cart
    • IV Heparin
    • Thrombolytic Drugs
    • O2
    • Elevate HOB....reduces dyspnea
    • Analgesics
    • Pulse Ox
    • Prepare for respiratory/cardiovascular support
  113. Metritis and complication
    infections of the uterus by staph, strep or e coli

    causes sterility from inflammation of fallopian tubes
  114. When will you see metritis? S/S?
    • 2nd/3rd PP days
    • 100.8 fever +
    • chills
    • malaise
    • anorexia
    • abdominal pain/cramping
    • uterine tenderness
    • purulent/foul smelling lochia
    • leukocytosis
  115. What causes metritis
    • *numerous vaginal exams
    • delivery/c section
    • ruptured membranes for too long causing over colonization of normal bacterial inhabitants
  116. Therapeutic Management of Metritis
    • Differentiate temp from dehydration vs. infection
    • IV antibiotics...then oral
    • antipyretics
    • oxytocics to promote drainage
    • fowlers postion (drainage)
  117. Mastitis
    lactating breast infection
  118. S/S of mastitis
    • PAIN
    • flu like symptoms
    • temp >101
    • headache
    • *localized redness
    • warmth
    • inflammation
  119. What causes mastitis
    • poor handwashing
    • nipple injury
    • skipped feedings/sudden cessation
    • constricting bra
    • decrease in rotation of positioning when feeding
    • lowered maternal immune system
  120. How do you prevent mastitis?
    • wash hands
    • feed correctly with different positions preventing engorgement
    • feed every 2-3 hrs
  121. How do you treat mastitis?
    • continue with feeds
    • apply moist heat before feeding
    • ice between feedings
    • empty breasts to prevent stasis of milk
    • teach how to express milk or use a pump
    • drink 3000 fluids each day
    • admin antibiotics
  122. Postpartum Blues
    usually within 1 week and is normal and to be expected

    transient and due to temporary hormonal adjustment
  123. How do you support a mom with post partum blues?
    let her cry!!
  124. Postpartum Depression
    happens 1 month to 1 yr and lasts at least 2+ weeks
  125. S/S of Postpartum Depression
    • loss of interest in daily life
    • no emotion towards family
    • no pleasure/love
    • sees infant as demanding...can be true
    • feelings of guilt/shame/unworthiness
    • fatigue and cant concentrate
    • appetite and sleep disturbances
    • panic attacks
    • obsessive thoughts
  126. What puts a mom at risk for postpartum depression?
    • hx of depression
    • weak support system
    • 1st time mom
    • sleep deprivation
    • poor diet
  127. Postpartum psychosis
    rare...happens 3 weeks pp

    same s/s as PP depression but person will have delusions and won't know they have a problem.

    poor judgment and infant is at risk...NEVER leave them alone with an infant
  128. What makes you at risk for PP psychosis
    bipolar or manic depressive usually without mania
  129. 3 ways to decrease you likelihood of post partum depression/psychosis
    • eat well
    • get a good nights sleep
    • join a support group
  130. Person with PP depression/blues/psychosis NANDA
    risk for ineffective coping

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