OB EXAM 2 NOTES ALL ANSWERS 100% CORRECT FALL -2022 LATEST SOLUTUION GUARANTEED GRADE A+

Normal Postpartum (3/25/15) 1) Postpartum Care a) Of all the aspects of birth, the postpartum period is the least anticipated and prepared for. b) This is especially true for a first baby. c) The illusion that once the baby comes, the world will once again be a sane and happy place deludes most first time parents. d) The full impact of sleepless nights, physical soreness, and the 24x7 responsibility for a new baby, are difficult concepts to imagine prior to their occurrence. 2) Physical Changes a) It takes approximately six weeks for the uterus to go through the process of involution and return to an almost pre-pregnant condition. b) During this period the woman undergoes many physiologic and emotional changes. c) Anticipatory guidance can make this period easier. d) The following suggestions will help the woman plan ahead for her care and the baby’s after the birth. e) Sleepless nights f) Baby is brand new and can't take care of itself g) You're tired yet you won't fall asleep due to the anxiety of the possibility that something can happen to the baby h) Be sure to tell parents that babies should NEVER sleep in the same bed as them. 3) Postpartum or Puerperium Care a) Fourth Stage Care - Vaginal Delivery i) Vital signs – q15min for the 1st hour ii) Fundus checks q15min iii) Lochia checks – the wall of the uterus will shed like a menstrual cycle iv) Episiotomy and perineal care (ice packs prn) v) Bonding and breastfeeding if desired vi) Rest and nutrition (1) Encourage lots of fluids especially if breast feeding vii) Give Pitocin to force contraction helps with involution viii) Can fill the uterus between the pelvis and umbilicus ix) It moves 1 cm below the umbilicus for every 24h postpartum b) Fourth Stage - Cesarean delivery (major surgery) i) Vital signs - q5min for the first 15min then q15min when stable ii) Oxygen status - pulse ox, TDBC (turn, deep breath and cough) iii) I & O – NPO (about an hour postop), IV, Foley (no blood) iv) Incision and pressure dressing v) Fundus and lochia checks vi) Assess post anesthesia state - epi/gen vii) After a C section, we check mom's vitals every 5 minutes for 15 minutes. Then every 15 minutes. Keep mom NPO for a while.Introduce some ice cubes over times and progress to sips of water as tolerated. viii) Look at the dressing for drainage. If you see drainage, put your name and the time next to the drainage and circle area. If another nurse comes in later, she can tell if drainage has increased dramatically by comparing to the circled parameters. ix) Check the fundus in the post C section mom. Don't be discouraged by mom's reluctance, you have to do your assessment x) Assess the post anesthesia state. Assess for movement and sensation. They have to be able to move their knees to move everything, get out of bed, etc. xi) If mom has too muchvpain, she may need morphine drip. xii) Mom's temperature may increase after birth because of the sudden fluid loss associated with birth. The body thinks it is dehydrated. Nothing above 100.4 though (above that may indicate infection or other complication) xiii) Monitor mom's blood pressure. PIH may continue after birth. Also be aware of orthostatic hypotension (get up slowly, watch for dizziness, etc) c) It'll take approximately 6 weeks for everything (body wise) to get back to normal d) After birth, the uterus disinflates and goes down to a level between the umbilicus and symphysis pubis. It will feel hard because it is "toning up." This process of shrinking is referred to as involution. After a few hours, the uterus should rise back upto the umbilicus. e) Fundus should go down about 1cm (or one finger breath) every 24 hours. f) By the 10th day, it should no longer be felt (but it isn't completely back to pre-pregnancy state either). It goes behind the pubic bone. g) We give a lot of fluids postpartum and open pitocin (induce contractions) to help keep the uterus firm and hard. You do NOT want the uterus to be soft (boggy) because it will hemmorhage. It is now mandatory to give pitocin. h) If the uterus feels boggy after assessment, the nurse can massage it to help it become firm. i) First couple of hours after delivery, everything is checked every 15 minutes. This includes lochia (uterine shedding), fundus firmness (if not firm, can mean bleeding), episiotomy cuts, etc. j) For severe episiotomies of vaginal/perineal trauma, we may put an ice pack down there. k) After delivery, we want to encourage bonding between mom and baby. l) Hyrdation staus is very important if mom is breastfeeding m) After the first two vital signs, we encourage rest and food (family members can be asked to go get her something special to eat). n) Episiotomy healing (Use the acronym RITA) (A stands for approximation or closure) o) When patients urinate, make sure they clean themselves well and PAT dry. They have to be gentle p) Breastfeeding is every 1 to 2 hoyrs or as needed. More than 2 hours should not pass between feedings because breasts will become hard and engorged. 4) Postpartal Changes a) Vital signs i) Temperature – slight increase in the first 24 hrs due to dehydration intrapartum. (1) Because you become dehydrated because you lost the fluid of the baby and you’ve bled (2) Temperature above 100.4 (38C) considered febrile. ii) Pulse – slightly slower than normal evaluate according to baseline norms of postpartum. iii) Blood Pressure – Compare with pre-birth levels. Above 140/90 consider PIH. Watch for orthostatic hypotension (1) Can get this postpartum b) Breasts – Establishment of milk production i) 1st - 2nd day breasts are soft secretes colostrum (let down reflex) ii) 3rd - 4th day breasts firm or filling milk forms within the breast ducts iii) Beyond 4th day may become engorged. Breasts are taut, shiny and enlarged. c) Uterus – reduction to pre-pregnant state called involution i) Immediately after birth felt halfway between symphisis pubis and umbilicus ii) One hour later rises to level of umbilicus and remains for about 24 hrs iii) After 24 hrs decreases about one fingerbreadth per day. iv) Fundal height assessed by location, height and firmness. (1) Full bladder is the #1 reason for a boggy (soft) uterus so either straight cath or bedpan (2) The bladder pushes on the uterus, causing it to relax (which is undesired). d) Uterus involution – The uterus will ‘shrink’ back below the pubic bone by the tenth day after delivery. This is checked by feeling for the fundus (top) of the uterus each day. e) After pains are common for the first few days after giving birth. i) These are more pronounced in the multigravida and the breastfeeding mother. ii) The mother can get relief from by lying on her abdomen for a brief period. iii) She may experience one strong cramp when she first lies prone and then should get relief. 5) Uterine Involution a) Lochia- uterine flow consisting of blood flow, decidua, white blood cells, bacteria. Measured according to amount. i) Rubra - First 3 - 5 days consists mainly of blood (red) ii) Serosa - About 5 - 10 days consisting of blood and white blood cells (pink) iii) Alba - from 10th day up to 3 -6 wks consisting of mucus and white blood cells mainly (creamy) iv) Amount- scant, light, moderate or heavy (soak a pad in an hour) b) Lochia refers to vaginal discharge during the postpartum period. (The term comes from a Greek word that means "relating to childbirth.") i) It consists of blood, sloughed-off tissue from the lining of the uterus, and bacteria. ii) Lochia discharge typically continues for 4 to 6 weeks after childbirth. c) For the first few days after birth, lochia contains a fair amount of blood, so it will be bright red and look like a heavy menstrual period. i) It may come out intermittently in small gushes or flow more evenly. ii) If you've been lying down for a while and blood has collected in your vagina, you may see some small clots when you get up. d) If everything proceeds normally, you'll have a bit less discharge each day, and by two to four days after you've given birth, the lochia will be more watery and pinkish in color. i) By about ten days after the birth, you should have only a small amount of white or yellow-white discharge, mostly made up of white blood cells and cells from the lining of the uterus. e) The lochia will taper off before it stops, a process that generally takes another two to four weeks, though a small number of women continue to have scant lochia or intermittent spotting for a few more weeks. f) Lochia is the physical evidence of the uterine lining returning to a pre-pregnant state. i) If a woman attempts to be too physically active she will interfere with this process and her body will tell her by changing the lochia pattern to a return to the bright red heavy lochia. g) Menstruation i) Once the placenta has been delivered the effects of estrogen and progesterone no longer inhibit the FSH hence ovulation will begin. ii) If not breastfeeding menstruation will return in 6-10 wks. iii) If lactating menstruation may return in 3-4 months or even longer. h) In pregnancy, we want a relaxed uterus. After pregnancy, we want to uterus to contract. i) A contracted uterus keeps the blood vessels closed. If it softens, the vessels open and bleeding occurs. This is partucularly bad right after delivery. j) After Pains: Cramps which may feel like contractions and are painful. More common in the multiparous woman (uterus has to work harder to get back down to size). k) Lochia: Shedding of the uterine wall. l) Rubra: First 3 or 4 days - Bright red m) Serosa: 5-10 days - Pink (more white blood cells than red) n) Alba: 10th day to 3-6 weeks o) Heavy bleeding may mean a boggy uterus. Be sure to assess the firmness of the uterus. p) Return fron light colored to drak colored lochia should not occur. May be a bad sign. q) Ovulation begins as soon as you deliver placenta. Breastfeeding hampers ovulation progress and may cause irregular periods, but you are still ovulating and can get pregnant. Patients need to be told that they need to use contraception. 6) Bladder a) Bladder: Her body has accumulated a lot of extra fluids during the pregnancy. i) This protected mom during the process of labor and assisted her kidneys during the pregnancy. b) Now its job is to get rid of the extra fluid. i) To do this she will find that her bladder fills often and holds larger amounts of urine. c) It is not unusual for her to be unaware of the need to void and still be over distended. i) She will have a lack of sensation for several days after the birth and may need reminders to empty her bladder. ii) However once she does she will get immediate relief from cramping d) During pregnancy, mom acumulates a lot of extra fluid and thus, after birth, must get rid of it. She will find that her bladder fills quickly and that she often has the urge to void. e) It is important for mom to be aware of the urge to void 7) Blood clotting a) Blood clotting: New mothers need to be aware of the fact that during their pregnancy their body went through some changes that were meant to protect them from hemorrhage. i) One of these changes was the collection of the increased fluids mentioned in the previous slide and the other one is the development of an increased ability to clot blood. b) She no longer needs this protection and it will soon reverse itself, however, for a few weeks she is at a higher risk for forming blood clots in her legs. i) This is why the nurse or midwife will ask her to flex her foot and ask about pain in her calf. ii) Pain could indicate a possible clot formation which could pose a danger to the mother. c) During this period it is best if the mother does not cross her legs, sit for long periods in one position or wear stockings that bind. (thigh or knee highs) d) For the first few weeks, mom is predisposed to getting blood clots. e) Increased clotting ability is normal in the pregnancy stage. It takes a while for mom to get back to normal f) Nurse assesses for calf pain with foot dorsiflexion g) Mom shouldn't wear stockings that bind her legs or cross them. 8) Lactation a) Establishment of lactation: The mother’s body is ready to breast feed at birth. i) The first milk is called colostrum and is the ideal food for the human baby. ii) The sooner after birth the baby nurses the easier the process becomes for both the mother and the baby. b) Babies have higher amount of catecholamines in their system right after birth, these stimulate the baby to make the necessary changes they need to clear fluid form their lungs and start them on a healthy transition from uterus to outside world. i) They also prepare the baby to begin to breast feed right after birth. ii) If left alone, undisturbed on the mother’s abdomen after birth, the un-medicated baby will crawl to the mothers breast and latch on and begin to breast feed 9) Lactation/Breastfeeding a) Nipple soreness is prevented by good positioning at the breast and knowing how to detach the baby without traumatizing the nipple. i) The mother needs assistance in positioning the baby, getting the baby to latch on correctly, taking the baby off the breast at the end of a feeding, encouragement in demand feeding and confidence in her supply and demand system. b) When a new mother asks how often, and for how long, she needs to feed her baby I often tell her that the baby was used to getting continuous feedings from the umbilical cord for nine months, we now need to reattach him/her to the breast and slowly get him/her used to shorter feeding times! i) If the baby is hungry it is time to feed. If mom is full, it is time to feed. c) For C-section mom it is best to use the football hold d) Moms who have had C sections may prefer "football hold" e) Tickle baby's cheek to stimulate rooting reflex (they turn head towards your finger and open their mouth), then put them on breast (latch on). Breastfeeding should not be painful. If mom is experiencing pain, tell her not to pull baby off (will crack nipple). Baby can be safely removed by putting your pinkie on the edge of their mouth. 10) Other Reproductive Organs a) Cervix - Following a vaginal birth the external ostium will contract by the 7th day. i) It remains slightly open with a slit like shape. b) Vagina- The hymen is permanently torn. Immediately after birth the mucosa is soft with few rugae. i) Thickened walls or dryness is due to decreased estrogen and may cause dyspareunia (painful intercourse) c) Perineum - maybe swollen, tender or bruised from trauma of birth and pushing. i) Kegel exercises helpful ii) Perineal care d) Labia majora & minora - remain atrophied and soft e) Dyspareunia: Painful sex. May be caused by vaginal dryness. Teach moms to use water based lubricants. 11) Gastrointestinal Changes a) If not under the influence of anesthesia, the mother is usually very hungry and thirsty. b) May have hemorrhoids i) Solution is a Sitz Bath a basin with a tube c) Due to the effects of relaxin bowels may be sluggish. d) Pain from an episiotomy or hemorrhoids may cause or hinder bowel movement. i) Give them Colace (stool softener) e) Constipation may haunt the new mother for a period after the birth. i) Although it is not unusual not to have a bowel movement for several days after the birth (especially following a long labor if food has been withheld from the mother, as often happens as a routine in hospital births) ii) If then mother has been given narcotics during labor this will increase her constipation problems. f) Hemorrhoids can also cause pain and increase fear. i) For several days after the birth the mother’s hormones are still readjusting. ii) It takes three to five days for the bowels to return to normal function. g) Suggestions to help the mother deal with delayed peristalsis and gas include i) Avoid iced and carbonated drinks which increase flatulence ii) Ambulation increases peristalsis iii) Avoid narcotic pain relief iv) Respond to the urge to defecate v) Take something to read to the bathroom! vi) Try hot prune juice and lots of hot water vii) Eat healthy, high fiber and fluids h) Mom is very hungry after birth. During labor, they are kept NPO.. sometimes on an ice chip diet. i) Dulcolax or stool softerners given to mom (narcotics, anesthesia, pregnancy, etc all slow bowels) j) Birth and pregnancy can cause hemmorhoids. Best treatment for hemmorhoids is a sitz bath k) Avoid carbonated drinks, they cause flatulence l) Avoid narcotics afterwards to prevent constipation m) Don't hurry when you go to the bathroom n) Increase fiber and fluids 12) Integumentary Changes a) Striae - appear reddened and more prominent. i) This will fade into pale white streaks in Caucasians or darker pigmentation in African Americans. ii) Linea negra and cholasma will also disappear (6 weeks to go away) b) Diastasis recti - overstretching and/or seperation of the musculature i) Area appears indented or bluish tinged 13) Family Considerations a) Maternal-infant attachment (skin to skin) b) Maternal adjustment and role attainment (reva rubin) i) Taking-in phase ii) Taking-hold phase iii) Letting-go phase c) Paternal adjustment d) Sibling adjustment e) Grandparent adjustment 14) Postpartum Psyche a) According to Reva Rubin there are three phases: i) Taking in - seen in first few days ii) Taking hold iii) Letting go b) Taking In Phase i) passive ii) wants to be catered to iii) has others make decision s for her iv) wants to talk about the pregnancy, labor and birth (1) Encourage her to talk about the birth (2) Encourage rest v) Not a good phase to teach vi) It’s all about her! c) Taking Hold Phase i) Begins to initiate action and make decisions ii) Assumes care of the infant and shows more interest (1) Offer reassurance and praise (2) Give guidance or instruction as needed iii) Taking hold of her life again d) Letting Go Phase i) Mother adjusts to her new role. ii) Establishes and accepts the new image of her baby, family and role. iii) At home you won’t see it in the hospital e) Rubin's Phases f) Taking in phase i) Is passive and wants to be catered to "can you pleeeease grab that for me, honey" ii) Wants to talk about pregnancy nonstop (1) Hard to teach them during this phase (2) You have to allow her to pass through this phase. It's normal (3) Encourage rest g) Taking hold phase i) Mom is no longer "passive and sweet" ii) Mom is making decisions and taking hold iii) She shows more interest in things other than the baby and is willing to learn iv) Guide guidance and instruction h) Letting go (after she gets home) 15) Emotions after birth a) Baby Blues – when you think of all the new mother has experienced in the last few weeks of pregnancy and the labor and birth, it is no wonder that she will experience a period of let down b) It is probably more amazing that not all mothers experience the blues then the fact that some do experience it. i) The Baby Blues usually manifest themselves shortly after the birth and quickly resolve as the mother is allowed to get adequate rest c) First 5 to 10 days, not supposed to last 10 days d) Baby Blues: period of let down after birth. Quickly resolves as mom is allowed to get rest. Should not last more than 10 days. e) If the baby blues goes over 10 days, the mom now has post-partum depression. f) Regardless of day (depression can occur before 10 days), if mom shows rejection or fears that she may harm the infant, immediate intervention is required. 16) Emotions a) When she begins to feel that she cannot “get over it”; she shows signs that she is not dealing with reality, or she is unable to care for herself or her baby, then she is no longer experiencing the traditional simple Baby Blues. i) Now she has postpartum depression b) Women who have had emotional problems prior to their pregnancies, experience high stress levels or feel out of control in their situations, are at greater danger of experiencing serious postpartum emotional trauma. i) Women with serious emotional problems need medical referral as well as support 17) Postpartum Blues/Baby Blues a) Reduction of progesterone, delayed prolactin release and changes in other placental hormones may trigger emotional instability b) Body image changes and dependency needs may contribute c) Over concern re infant and self, and emotional liability are “normal” during the first 5-10 days after delivery 18) Postpartum depression a) Rejection of infant, or fears that she may harm infant; call for immediate intervention. b) Remind mom during postpartum teaching that these feelings sometimes occur and help is available 19) Postpartum psychosis a) Postpartum Psychosis is a rare illness, compared to the rates of postpartum depression or anxiety. b) It occurs in approximately 1 to 2 out of every 1,000 deliveries, or approximately 0.1% of births. c) The onset is usually sudden, most often within the first 4 weeks postpartum. d) If depression is not noticed, post-partum psychosis may occur (usually at 3 or 4 weeks) e) Hearing things and seeing things f) Moms may drown children, kill hearslf and them, abandon or neglect baby, kill husband, etc. Anything can happen. Whatever the voices tell her to do. g) Symptoms of postpartum psychosis can include: i) Delusions or strange beliefs ii) Hallucinations (seeing or hearing things that aren’t there) iii) Feeling very irritated iv) Hyperactivity v) Decreased need for or inability to sleep vi) Paranoia and suspiciousness vii) Rapid mood swings viii) Difficulty communicating at times 20) Postpartum warning signs to be alert for a) Signs of emotional maladjustment i) loss of reality ii) unable to care for self physically iii) unable to care for infant iv) unable to “feel better” after adequate rest and nutrition b) Signs of urinary tract infections i) burning on voiding ii) painful voiding