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exam two: self paced modules Flashcards

1
Q

period of abstinence recommended after birth

A
  • 4-6 weeks is normal in our culture
  • up to 6 months or a year
  • recommend women avoid until 6 weeks but can resume within 2-4 weeks when bright red bleeding has stopped, and their perineum has healed.
  • Abstinence allows for: healing, preventing infection, and promotes child spacing
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2
Q

diminished libido after birth

A
  • Very common and can last up to a year
  • Causes:
  • decreased lubrication especially if BF
  • Pain from laceration or episiotomy c section incision
  • Fatigue
  • Body self-image
  • Feeling of putting out constantly in terms of taking care of the newborn who is dependent can lead to emotional exhaustion and no emotional energy leftover for connecting with a partner
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3
Q

return of menstruation and fertility after birth

A
  • Difficulty to predict return to fertility
    o As soon as 4 weeks or not delayed for years until weaning occurs
    o First cycle:
     May be very heavy
     May or may not ovulate
  • Don’t ovulate= just have a period and ovulate the second cycle
  • Ovulate before first period = risk they will get pregnant prior to the first period unless using some form of contraception
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4
Q

why does all of this matter

A

-Unplanned pregnancies are associated with increased risks for moms and babies
-Risk of unplanned pregnancy in teens
-Closely spaced pregnancies (where conception occurs within 0-18 months following a birth) increases risks for complications

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5
Q

Unplanned pregnancies are associated with increased risks for moms and babies

A
  • Delayed initiation of prenatal care= Late education, Late screening, Late prenatal vitamins
  • Increased incidence of PPD
  • Reduced likelihood of breastfeeding
  • Increased risk of physical violence during pregnancy
  • Increased risk of birth defects
  • Increased risk of low birth weight babies
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6
Q

Risk of unplanned pregnancy in teens:

A

o Associated lifetime lower educational attainment
o Lower incomes
o Increased risk for their own children:
 Sons are more likely to be incarcerated
 Daughters are more likely to be become teen mothers

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7
Q

Closely spaced pregnancies (where conception occurs within 0-18 months following a birth) increases risks for complications

A
  • Early pregnancy loss
  • Placental abruption or previa
  • Anemia
  • Cervical incompetence
  • Uterine rupture
  • Preterm birth
  • Low birth weight
  • Pre-eclampsia
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8
Q

Healthy People 2020 goals

A
  • Increase the number if pregnancies that are planned to 56%
  • Decrease the incidence of pregnancies that have a short interconceptual interval from 33.1% to 29.8%
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9
Q

What can we do to help meet the HP2030 goals

A
  • Closely spaced pregnancies and unplanned pregnancies are public health issues
  • Providing women with education and means to control their fertility are important steps in addressing both of these issues
  • Set aside personal views on contraception, be aware of the issues, and work to improve health outcomes
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10
Q

Considerations in choosing postpartum contraception:

A
  • effectiveness
  • method of feeding infant
  • desires and previous experience with contraception
  • the timing of initiating birth control after birth
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11
Q
  • Effectiveness
A
  • Effectiveness and failure rates often reported as those rates related to perfect use
  • Typical use: provides us a more accurate picture about effectiveness as a typical user. This is what we will use
  • Failure rates: percentage of women experiencing an unintended pregnancy within the 1st year of use
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12
Q
  • Method of feeding infant- breastfeeding
A

o Avoid estrogen containing products as they may decrease the milk supply
o Increased vaginal dryness due to lower levels of estrogen during breastfeeding so its recommended that they use a water based lubricant to increase her comfort during intercourse

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13
Q

Method of feeding infant- bottle feeding

A

o Any method can be used
o Avoid estrogen in the first 6 weeks due to the risk of DVT

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14
Q
  • Desires and Previous experience with contraception
A
  • Previous contraception use:
    o Was she able to use it correctly
    o Any side effects experienced
    o Why she stopped using it
    -If she experienced a side effect with one method that was bothersome to her, consider another method that doesn’t have the same types of side effects. Also, if she has a history of something like painful heavy periods don’t give her a form that has that same side effect. Find something she will use correctly, with minimal side effects and based on needs and desires even if there is something more effective. If she is taking something that is bothersome then she is likely to stop taking it and have a unplanned pregnancy.
  • What method does she want?
  • Future desires for fertility:
    o Does she want more and when?
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15
Q
  • Initiating birth control after birth (timing of initiation)
A
  • Best time to initiate birth control is still debatable
  • For legal reasons most manufacturers recommend waiting 6 weeks
  • Need to consider the patients desires and how likely she is to resume intercourse and be at risk for pregnancy if she does not have protection.
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16
Q

lactation amenorrhea method

A
  • fertility based method
  • short term option for the first 6 months.
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17
Q

lactation amenorrhea method effectiveness

A

98 % effective if the following are true:
- Exclusive breastfeeding- no supplementation, no solids, and minimal pacifier use
- Breastfeeding on demand at least Q 4 hours during day and Q 6 hours at night
- Menstruation has not resumed- once first period not acceptable
- Baby under 6 months

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18
Q

lactation amenorrhea method other considerations

A

-New method needs to be initiated if ANY of these are not met

-Modern practices in the U.S. affect effectiveness (returning to work, pumping, supplementation, decrease in co sleeping)

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19
Q

barrier methods

A
  • condoms
  • diaphragm
  • sponge
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20
Q

condoms effectiveness

A

Failure rate 20% for typical use: increased effectiveness when combined with a spermicide

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21
Q

condoms other considerations

A

-water based lubricant strongly recommended due to decreased vaginal lubrication and increased friction from condoms which can be painful for the women
-do not use both male and female condoms at the same time friction can cause tears
-also decreases risks for STI’s

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22
Q

diaphragm effectiveness

A

-failure rate: 12% with typical use
-in order to be effective the correct size is required: it takes at least 6 weeks for the vagina to achieve the size/shape that will be her new normal, needs to be sized by a trained healthcare provider at 6 weeks and for every 20 lbs weight change

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23
Q

diaphragm other considerations

A

-use with spermicide increases effectiveness

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24
Q

sponge

A

Disposable single time use method that is placed in the vagina

Covers the cervix and works by blocking the sperm and releasing spermicide

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25
Q

sponge effectiveness

A

Failure rate: 25%

Higher with women who have had children so not recommended for use by women who have had children

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26
Q

combined estrogen and progesterone methods

A
  • pill
  • patch (ortho-evra & Xulane)
  • vaginal ring (Nuva)
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27
Q

pills

A

-one active pill with estrogen and progesterone is taken each day for 21-24 days
-the 4th week of the cycle (placebo pill or pill free week) is when she will have a menses.
-may take active pills continuously for 3 months at a time = 0nly 4 menses/year
-best if taken at the same time each day—associate with a daily routine or use an app to remind her to take it can help

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28
Q

combination contraception effectiveness

A
  • failure rate with typical use: 9%
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29
Q

side effects of combined contraception methods

A

-breast tenderness
-nausea/vomiting

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30
Q

other considerations with the combined contraception method

A

-estrogens effect on milk supply (decreases it so not recommended for BF mom)
-not recommended in immediate PP period as increased risk for DVT especially in first 6 weeks
-delay initiation for 6 weeks PP

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31
Q

what contraceptive method can you not use while breastfeeding

A
  • combined
  • anything with estrogen
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32
Q
  • Patch (ortho-evra & Xulane)
A

-transdermal patch containing estrogen and progesterone
-can be worn on back, butt, belly, and arms; important to rotate the site
-a new patch is applied to the skin weekly for the first 3 weeks of the cycle
-the 4th week you are patch free and she will withdrawal bleeding (menses)
-repeat

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33
Q
  • Vaginal Ring (Nuva ring)
A

-women inserts the nuva ring into her vagina near the cervix
-it is left in place for 21 days and then removed for 7 days. During these 7 days she will have a period and then the ring is replaced after the 7 days
-she should be educated to frequently check to ensure it is still in place (like prior to having intercourse)

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34
Q

how do combined contraceptive method work

A

All have same mechanism of action- prevents ovulation, blocks sperm

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35
Q

progesterone only options

A
  • mini pills
  • emergency contraception
  • Depo-Provera
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36
Q

mini pill

A

-an oral contraceptive pill that contains only progesterone
-needs to be taken at the same time each day every 24 hours
-begin at 2 weeks PP

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37
Q

mini pill effectiveness

A

failure rate= 9% with typical use and more effective if she is exclusively breastfeeding and in the first 6 months PP

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38
Q

mini pill S/E

A

-irregular bleeding
-bleeding between periods

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39
Q

S/E of all progesterone only contraception

A

*all progesterone only have increased risk for depression but depo-provera has greatest risk

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40
Q

emergency contraception

A

“morning after pill”
-Plan B= one brand
-pill contains a large dose of progesterone and can be taken up to 72 hours after unprotected intercourse to prevent pregnancy (more effective if taken within 24 hours)

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41
Q

emergency contraception effectiveness

A

Within 24 hours: 95% reduction in pregnancy
Within 72 hours: 89%

*shouldn’t be used as only method

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42
Q

emergency contraception side effects

A

-nausea and vomiting
-irregular bleeding or heavy menses
-headaches
-abdominal pain

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43
Q

Depo-Provera

A

-progesterone only injection IM
-given every 12 week and may be given prior to discharge

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44
Q

depo-provera effectiveness

A

Failure rate: 6% with typical use
-considered one of the very effective methods

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45
Q

side effects of depro-provera

A

-irregular bleeding
-amenorrhea
-1 in 10 women dc from side effects. Make sure she knows what to expect from it.

46
Q

other considerations with dero-provera

A

-increased risk of depression and not easily reversible. Effects continue for 3 months after she gets injection and can’t be turned off. Women who have history of depression or current symptoms or risk factors use with caution.
-delayed fertility up to 18 months after last shot

47
Q

Intrauterine device options

A

-progesterone IUD= hormonal
-copper T IUD= non hormonal

  • all forms of long acting reversible contraception
48
Q

Progesterone IUD

A

-mirena, Kyleena, Lilitta, Skyla all containing varying amounts of progesterone which is slowly released
-Good for 3-7 years depending on which one is used.
-Prevents pregnancy by preventing ovulation and blocking sperm entering into the cervix by causing thick cervical mucus.

49
Q

intrauterine devices effectiveness

A

-over 99% effective with typical use

50
Q

other considerations for intrauterine devices

A

-immediately reversible meaning they can have it taken out and get pregnant the same day
-check string length after each menses or periodically if not menstruating to make sure hasn’t been expelled or moved out of place
-slightly higher rate of expulsion if placed immediately after birth

51
Q

progesterone IUD side effects

A

-amenorrhea
-irregular spotting/bleeding

52
Q

copper t IUD

A
  • “paraguard”- causes an inflammatory reaction that is toxic to sperm and ovum and prevents fertilization and implantation.
  • Provides protection up to 12 years
53
Q

Copper T IUD side effects

A

-bleeding between periods
-heavy menses
-cramps
-severe menstrual pain

54
Q

nexplanon

A
  • long acting reversible contraception

-progesterone containing rod placed in the inner upper arm
-slow release of progesterone
-effective up to 4 years

55
Q

nexplanon effectiveness

A

Less than 0.5 % failure rate with typical use

56
Q

nexplanon other considerations

A

-most common side effect is irregular bleeding/spotting

-can be placed immediate PP within first 48 hours or at 6 weeks

57
Q

permanent methods

A
  • tubal ligation: tying the tubes
    -tubal removal:salpingectomy
    -male sterilization: vasectomy
    -essure
58
Q

tubal ligation

A

suture tied around segment of the tube with removal/cauterization of the ends

59
Q

tubal ligation effectiveness

A

failure rate 0.5%

60
Q

tubal ligation other considerations

A

-requires abdominal incision
-done 24-48 hours after birth for vaginal, during c section, 6 weeks PP
-increased risk of ectopic if she becomes pregnant
-reduction in risk of ovarian cancer

61
Q

tubal removal

A

complete removal of the fallopian tubes

62
Q

tubal removal effectiveness

A

failure rate = almost 0%

63
Q

tubal removal other considerations

A

-requires abdominal incision and can be done within 24-48 hours after vaginal delivery and during a c section
-cannot be reversed
-less risk of an ectopic pregnancy than a tubal ligation
-provides protection against ovarian cancer

64
Q

male sterilization

A

removal or part of vas deferens. Prevents sperm from leaving man’s body

65
Q

male sterilization effectiveness

A

failure rate of 0.5%

66
Q

male sterilization other considerations

A

-require a semen analysis because they continue to be fertile for up to 3 months; should use another method until no sperm noted

67
Q

essure

A
  • voluntarily taken off the market in the U.S in December 1018 and in other countries in 2017 and will totally be unavailable after 12/2019.
    -FDA is continuing to investigate the safety concerns. Metal coils placed into the fallopian tubes using a hysteroscope inserted through the cervix.
    -Done in the clinic
68
Q

essure effectiveness

A

failure rate of 0.1%

69
Q

essure other considerations

A

-causes scarring to block tubes
-complications: perforation and migration, long term pelvic pain, ectopic pregnancy, menstrual changes
-was popular because it didn’t require abdominal incision or anesthesia and could be done in the clinic and was permanent

70
Q

summary

A
  • Unintended pregnancies and short inter pregnancy intervals are public health issues with significant negative consequences for women and families.
  • Nurses have the potential to educate women and their families about these issues and promote behaviors that can minimize risks
  • A thorough understanding of postpartum sexuality and contraception options Is necessary for nurses who plan to work with childbearing families
71
Q

Long-acting reversible contraception benefits

A

o Effective
o Easy to use
o Immediately reversible
o Safe with breastfeeding
o Can be inserted in the immediate postpartum period (minutes/hours after birth) or at 6 weeks
o Cost effective and covered by most insurance companies

72
Q

Permeant forms of contraception:

A
  • Should be considered permanent and irreversible but most of these are possible to be reversible but is just expensive and risky and not covered by insurance and lower chance it will work.
    o Tubal ligation/tubal removal needs informed consent and counseling before labor if it is going to be done during hospitalization
  • Hormone free and safe with breastfeeding
73
Q

in normal placenta where is the cord

A
  • cord is inserted centrally in the middle part of the placenta
74
Q

velmentous insertion

A
  • the vessels of the cord divide some distance from the placenta in the membranes (blood vessels exposed between the placenta and the cord when should be directly attached)
  • the vessel cord doesnt implant in the placenta correctly and run through the chorion and amnion some distance from the placenta
  • vessels no longer protected bu whartons jelly = can compress
  • can cause hemorrhage in mom and baby if vessel is torn during ROM
75
Q

vasa previa

A
  • velamentous insertion with the unprotected fetal vessels present at/lying over the cervical os
  • if ruptures, causes severe bleeding= high fetal mortality
  • can be ruptured @ the time of SROM or AROM
76
Q

succenturiate placenta

A
  • placenta has one or more accessory lobes
  • blood vessels will run from the main placenta over to accessory lobes
  • risk of postpartum hemorrhage due to retained lobes (if when the placenta is delivered the extra lobes isn’t and is left inside the uterus)
77
Q

what is a big clue that the accessory lobe has not come out with the placenta

A
  • if when the placenta is delivered you see blood vessels that don’t go to anything
78
Q

battledore placenta

A
  • the cord is inserted at the edge or near the margin of the placenta rather than in the center
  • raised firm ridge around the placenta
  • increased incidence of preterm bleeding and labor
79
Q

implantation problems include

A
  1. accreta
  2. increta
  3. percreta
80
Q

accreta

A
  • the placenta implants too deeply into the uterine wall and attaches to the myometrium
81
Q

increta

A
  • the placenta invades into the myometrium
82
Q

percreta

A
  • the placenta invades through the myometrium and may attach to outside organs (most commonly the bladder)
83
Q

implantation problems

A
  • may not be able to see before labor but will know when you have a delayed 3rd stage and placenta doesnt come out and they start to PPH
  • might have to do a hysterectomy especially with percreta if cant get all of the placenta out without destroying uterine wall and other organs
84
Q

implantation problems are more common when

A
  • if woman has had c-sections
  • the more she has the greater the risk she is at for this
85
Q

PROM

A
  • premature rupture of membranes (TERM)
  • rupture of membranes prior to the start of labot
  • > /= 37 weeks
  • incidence: 8-10%
86
Q

treatment for PROM

A
  • induction of labor in 12-24 hours to help reduce chance of infection
  • 85% of women will go into labor spontaneously within 24 hours
  • may depend on GBS status: if positive will give 1st dose of abx then wait four hours then induce
87
Q

PPROM

A
  • pre term premature rupture of membranes
    -rupture of membranes prior to the start of labot
  • <37 weeks
  • incidence is 2-4%
88
Q

treatment of PPROM

A
  • depends on gestational age and presence of infection
  • assessment/treatment:
    1. amniocentesis to r/o infection
    2. ABX just in case cuz infection is usually the cause
    3. corticosteroids for lung maturation and to decrease chance of resp. distress syndrome
    4. fetal assessment and surveillance (EFM) and looking for increased FHR baseline and decelerations
    5. US to determine how much fluid is around fetus

*major source of perinatal deaths (18-20%)

89
Q

assessment of PROM and PPROM

A
  • Evaluate for signs of infection
  • evaluate fetal status
90
Q

signs of infection from PROM and PPROM

A
  • maternal fever
  • increased WBC
  • pulse
  • amniotic fluid: clear? ordor? meconium?
91
Q

fetal status evaluation for PROM and PPROM

A
  • baseline HR: tachycardia ususally comes before maternal fever
  • variability
  • decelerations
92
Q

oligohydramnios

A
  • less than normal amount of amniotic fluid
  • amniotic fluid index of less than 5 cm
93
Q

normal amniotic fluid amount

A

> /= 500 ml

94
Q

causes of oligohydramnios

A
  • unknown
  • post maturity (>42 weeks) because the placenta deteriorates = decreased perfusion and shunting of blood to vital organs away from kidneys and they stop peeing
  • renal malformations (renal agenesis): if dont have normal renal tissue not producing urine
  • IUGR: not getting enough perfusion
  • placental insufficiency: like with HTN causing vasospasm and lack of perfusion
95
Q

oligohydramnios significance of first part of pregnancy

A
  • fetal adhesions (amniotic bands): chorion and amnion adhere to fetal parts = amputations
  • skeletal abnormalities: fetus doesnt have room to move
  • skinn abnormalities
  • pulmonary hypoplasia: lungs cant develop if there isnt fluid since baby is breathing in the fluid and what helps to keep the lung tissue open and develop muscles in chest
96
Q

oligohydramnios significance in labor

A
  • FHR changes
  • variable decelerations because there isnt enough fluid around cord = cord compression
97
Q

oligohydramnios treatement

A
  • amnioinfusion
98
Q

when would you not treat oligohydramnios with an amnioinfusion

A
  • if not in labor and pre term
99
Q

amnioinfusion

A
  • sterile, normal saline, or LR solution introduced through the intrauterine pressure catheter into the uterus
  • used to treat variable decelerations: replaces the fluid around fetus
  • 500 ml bolus
  • 250 ml bolus then 75 ml/hr
  • monitor what is going in and what is leaking out onto the chux
100
Q

hydramnios (polyhydramnios)

A
  • greater than 2000 ml of amniotic fluid
  • AFI > 20-24 cm
101
Q

hydramnios (polyhydramnios) causes

A
  • neurologic abnormalities
  • renal abnormalities
  • DM in mom= increased glucose in baby
  • infections (herpes and rubella)
  • can be acute or chornic
  • idiopathic
102
Q

with hydramnios (polyhydramnios) what is the risk and should ROM occur

A
  • baby can float around more and not be as engaged and or be in non vertex position
  • If ROM occurs then high chance for cord prolapse due to the huge pressure change (huge gush)
103
Q

fetal risks of hydramnios (polyhydramnios)

A
  • malpresentation and prolapsed cord
104
Q

maternal risks of hydramnios (polyhydramnios)

A
  • respiratory distress because of the compression on the diaphragm
105
Q

treatment of hydramnios (polyhydramnios)

A
  • removal of excessive fluid by amniocentesis in someone who is not in labor but most the time the fluid will come back
  • someone in labor: AROM by needle amniotomy with a double set up ( take to the OR and have it set up for c section in case of prolapsed cord) : gently allows fluid to leak out very slowly while keeping the hand there to prevent prolapsed cord and huge sudden loss of fluid
  • indomethacin PO to mother: decreases fetal urine output
106
Q

prolapsed umbilical cord

A
  1. The umbilical cord precedes the fetal presenting part
    -Gets trapped between the presenting part and the maternal pelvis: more common with high station and ROM and or non vertex position
    -Blood vessels compressed
  2. Overt
    -Visible in/outside the vaginal introitus
  3. Occult
    - Cord lies just ahead or along the presenting part
107
Q

fetal risks for prolapsed cord

A
  • FHR changes: prolonged decelerations/persistant bradycardia
  • may lead to death
  • EMERGENCY
108
Q

how to prevent prolapsed cord

A
  • no AROM of head is not engaged
109
Q

management of prolapsed cord

A
  • relieve the pressure
  • maternal positioning
110
Q

how to releive the pressure with prolapsed cord

A
  • push the presenting part off of the cord via vagina exam- hold presenting part up off the cord
  • ride the bed with the patient to the OR- do not remove fingers
111
Q

maternal postions to help with prolapsed cord

A
  • trendelenberg
  • knee/chest
112
Q

cord accidents

A
  • nuchal cord: cord around neck- might have to cut cord before rest of baby is born
  • true knot: if knot becomes tight = decreased o2 to fetus and can cause fetal death
    -Cord Issues are common: ~25-35% of births
    -Stillbirth related to these causes:
    -Less than 0.4% of the babies with these issues will die from them

OB (12 decks)

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