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OB > Normal Puerperium & Lactation > Flashcards

Normal Puerperium & Lactation Flashcards

1
Q

a normal puerperium lasts how long?

A

postpartum period lasting 6-12 wks

changes of pregnancy are reversed

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2
Q

immediate puerperium occurs when?

A

first 24 hrs after parturition

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3
Q

early puerperium occurs when?

A

24 hrs to 1 wk postpartum

breast milk comes in

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4
Q

remote puerperium occurs when?

A

period of time required for genital organ involution & return of menses; usually 1st wk to 6th wks

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5
Q

what happens during the immediate puerperium period?

A

dictated by events of delivery, type of anesthesia or analgesia, complications during delivery
BP & pulse every 15 minutes (preeclampsia can occur up to 6 wks postpartum)
maternal temp at least every 4 hrs (big one is endometritis)
post anesthesia care provided by anesthesiologist or obstetrician

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6
Q

why do we take mom’s temp so often after delivery?

A

watching for endometritis

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7
Q

what are some of the physical changes that occur during immediate puerperium

A

placental delivery & involution begins
uterine involution- UCs regular, strong, coordinated, begin to decrease about 12 hrs postpartum
postpartum chills may last up to 60 min

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8
Q

bladder issues during immediate puerperium

A

urinary stasis
proteinuria
incomplete bladder emptying for 1-2 days

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9
Q

after pains

A

cramping that occurs during breast feeding- means uterus is contracting down on self

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10
Q

what occurs during early puerperium

A 
cervix gradually closes
vagina, perineum, pelvic musculature decrease to nml size, increase in tone
episiotomy/tears heal
lochia rubra
lochia serosa
lochia alba
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11
Q

lochia rubra

A

postpartum vaginal d/c heavies in the first 3-4 days

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12
Q

lochia serosa

A

more serous, mucopurulent vaginal d/c from 3-4 days to 2-3 wks postpartum

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13
Q

lochia alba

A

thicker, mucoid, yellowish-white vaginal d/c from 2-3 wks to 5-6 wks postpartum

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14
Q

what occurs during remote puerperium

A

uterine involution complete by 6-8 wks
lochia ceases about 5-6 wks postpartum
striae fade from red to silver but are permanent
hair pattern returns to nml over 6-15 months pp(postpartum)

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15
Q

when does ovulation begin after birth

A

can begin as early as 27 days after delivery
avg. 70-75 days in nonlactating woman
avg 6 mo in lactating woman

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16
Q

when doe menstruation begin after birth

A

at 7-12 wks in nonlacting mothers & as late as 36 mo in breastfeeding mothers

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17
Q

postpartum care

A

encourage early father/partner involvement
skin-to-skin contact w/ baby should occur in <1hr; rooming-in should be encouraged & supported; support & reassurance to new parents is important; imp. for mother to sleep & regain strength, recover from labor; regular diet ad lib; stool softener PRN; early ambulation encouraged to prevent thrombophlebitits; shower ad lib; IV rehydration PRN

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18
Q

care of the vulva

A

teach pt to cleanse vulva from anterior to anus, look for signs of infxn; apply ice bag to perineum 1st 24 hrs post delivery; warm sitz baths beginning 24 hrs after delivery; oral analgesics often required; pelvic muscle exercises may be helpful

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19
Q

care of bladder

A

encourage pt to void as ASAP after delivery; cath placement may be necessary if voiding is too difficult: trauma to bladder during L&D, regional anesthesia, vulvar/perneal pain/swelling or episiotomy

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20
Q

care of breasts

A

if going to bf, it is ideal to begin on-demand bf <1 hr post delivery; well fitting brassiere very important;

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21
Q

what do you do if pt is not going to bf

A

ice packs & analgeisics for engorgement if not bf- lactation suppression meds discouraged
avoid nipple stim
milk prod. should stop w/in a wk

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22
Q

postpartum fever

A

temp >/= 38C (100.4F) on 2 occasions 6 hrs apart
nursery should be notified of maternal fever, esp. in 1st 24 hrs post delivery
look for s/sx of infxns

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23
Q

what are some s/sx of infxn w/ a postpartum fever

A 
enometritis
mastitis
UTI
thrombophlebitis
infected tear/ surgical site
complications of anesthesia
*labs: CBC, UA, others as indicated
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24
Q

suggestion for icing perineum

A

frozen giant maxipad with witch hazel frozen into it

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25
Q

common postpartum (pp) complications

A 
uterine hemorrhage
preeclampsia/eclampsia
infxns
urinary retention
thromboembolism/thrombophlebitis 
pelvic musculoskeletal pain
neuropathy (pudendal nerve damage)
sweat a lot/ pee a lot (way to get rid of extra fluid)
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26
Q

pp IMZ

A

300 mcg of anti-Rh(D) IG (RhoGAM) w/in 72 hrs of delivery if mother is Rh(D)-neg & baby is Rh(D)-pos;
MMR postpartum if not already
Tdap if due
Hep B may be given

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27
Q

when can combination OCs be used in NON-bf women?

A

2-3 wks pp

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28
Q

what type of OC is safe in bf women?

A

progestin-only- depo-provera, levonorgestrel

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29
Q

tubal ligation

A

2nd MC method of contraception used in US

may be performed at time of c/s, 24-48 hrs after vaginal delivery, or immediately pp in women w/ epidural in place

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30
Q

when can IUD insertion be done pp?

A

at first pp visit (4-6 wks pp)

copper IUD or prgestin-containing IUD

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31
Q

hospital stay times

A

48 hrs for vaginal delivery
96 hrs for c/s
doesn’t include day of delivery

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32
Q

short stay criteria for early d/c

A 
mother afebrile, VSS
amt & color of lochia appropriate
firm uterine fundus
adeq. urine output
no evid of infxn in wound/repair sites
mother able to ambulate w/ ease
no abnormal physical/emotional findings
mother able to eat & drink
pp f/u care arranged
mother ready to care for self & baby
pp hgb or hct nml
ABO & Rh type are known
IMZ have been administered PRN
mother instructions for home care & f/u
support persons are avail. in home
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33
Q

minimal caloric req. for adequate milk prod. on avg is?

A

1800 kcal/day

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34
Q

pp nutrition general info

A

fluid intake important
balanced, nutritious diet ensures healthy mother & baby
vit. supplements routinely not needed; may recommend to continue PNV
Ca2+, vit B 12, vit D most imp
iron given only PRN

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35
Q

pp considerations

A

no sex sooner than 2wks pp
contraception methods reviewed
at d/c mother should be given contact info if she has any questions/problems

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36
Q

pp d/c discussion should include

A

condition of newborn
immed. needs of newborn
feeding techniques, skin/umbilical cord care
recognition of neonatal illnesses
supprot systems available
instructions in case of emergency/complications
importance of CH IMZ

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37
Q

pp f/u care

A

support & reassurance are extremely important in pp period
involvement of the newborn’s father & extended family
community & hospital support should be easily available for mother & newborn

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38
Q

pp visits for mom time fram

A

visit & exam 4-6 wks after uncomplicated vaginal delivery
visit & exam 7-14 days after c/s or complicated delivery
most women may resume regular work & activities by 4-6 wks pp

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39
Q

pp visits for mom should include?

A 
interval hx: PE, wt, BP, thryroid, extremities, breasts, abdomen, pelvic
adaptation to newborn
bf issues discussed
OCP reviewed
pp depression eval
labs PRN (Hgb, pap, TSH)
counseling/education PRN- HPV vaccine?
40
Q

what type of changes during pregnancy & puerperium do mammary glands undergo?

A

proliferation of alveolar epithelial cells
formation of new mammary ducts
develop. of lobular architecture
epithelium differentiates for secretory activity
increase in breast size (gain 400g each)
hypertrophy of blood vessels, myoepithelial cells, connective tissue

41
Q

3 stages of lactation

A

mammogenesis
lactogenesis
galactopoisesis
*multiple, complicated hormonal interactions involved in lactation

42
Q

mammogenesis

A

mammary growth & development

requires estrogen & progesterone

43
Q

lactogenesis

A

initiation of milk secretion

requires prolactin

44
Q

galactopoiesis

A

maintenance of milk secretion

requires prolactin, oxytocin (suckling)

45
Q

when is lactation initiated?

A

when plasma estrogens, progesterones, and human placental lactogen levels fall after delivery

46
Q

how do you maintain established milk secretion?

A

requires suckling & emptying of mammary ducts & alveoli

47
Q

how long does it take for prolactin levels to return to nonpregnant levels in absence of suckling?

A

2-3 wks pp

48
Q

colostrum general info

A

premilk secretion present in 1st 2-3 wks pp: yellowish alkaline secretion, may begin in last months of pregnancy

49
Q

make up of colostrum

A

higher specific gravity, protein, vit A, Ig, Na, Cl content than mature breast milk
lower carb, K, fat content than mature breast milk
normal laxative action

50
Q

what drives milk production?

A

prolactin

others: insulin, cortisol, etc

51
Q

substrates for milk are derived from?

A

maternal gut & liver

52
Q

what is the principal carb in breast milk?

A

lactose

53
Q

mature human milk contains what?

A 
7% CHO as lactose
3-5% fat
0.9% protein
minerals
vit
enzymes
H2O
60-75 kcal/dL provided to infant
54
Q

immune support & bf

A

maternal transfer of Ig thru breast milk provides immunologic defense for the newborn as the immune system develops:
highest output during first wk
all classes of Ig in breast milk (90% IgA)
breast milk is highly anti-infective (primarily leukocytes)
other factors that help protect the infant from dz & develop a nml immune system

55
Q

what is the avg milk production in bf mother?

A

120 mL by the second pp day & increases to 300 mL/d by pp days 10-14

56
Q

what are some things that may increase milk yield?

A

crying baby
positive family or provider support of bf
anticipation of nursing
sexual stimuli (CNS modulated release of oxytocin)

57
Q

bf recommendations

A

exclusive up to 6 months
partial bf 6-12 mo or longer
WHO suggests up to 2yrs or beyond
ongoing practitioner support increases proportion of mothers who bf
giving formula to new mothers at d/c from the hospital has been shown to discourage bf

58
Q

maternal advantages of bf

A 
convenient, economical
emotionally satisfying/ bond w/ infant
aids in uterine involution
improves GI motility & abosrption
delays ovulation
may protect against ovarian CA
increased wt loss pp
59
Q

maternal disadvantages of bf

A

inconvenient for some
yield may decrease if pumping a lot
nipple tenderness, mastitis possible

60
Q

what are CI to bf?

A 
illicit drug use
excess alcohol intake
human T-cell leukemia virus type 1
HIV
active breast CA
active TB or varicella infxn
galactosemia of newborn
maternal intake of certain meds
61
Q

advantages of bf in infants

A

easily digestivle, ideal composition & temp

free of contamination; good source of Ig; improved cognitive development & intelligence

62
Q

infants have a decreased incidence of what with bf?

A 
diarrhea
lower RTIs
necrotizing enterocolitis
invasive bacterial infxns
SIDS
obesity
CH allergies
Type 1 DM
Crohn's dz
UC
lymphoma
63
Q

disadvantages of bf to infants

A

slightly increased risk of neonatal jaundice in 1st few wks
not usually possible for infants that are weak, ill, or very premature (cleft palate, choanal atresia, PKU- may be fed expressed breast milk); mothers w/ CF have high Na content in milk

64
Q

when is it ideal to begin bf?

A

within 1-2 hrs of delivery

65
Q

when does milk usually come in?

A

3rd or 4th pp day

initial discomfort d/t engorgement

66
Q

baby & getting milk

A

baby must latch on correctly to suckle effectively w/ the mouth entirely covering the areola; the tongue will milk to nipple to express the colostrum

67
Q

bf & supplementation

A

best to avoid supplementing breast milk in the first 6-8 wks unless absolutely necessary-baby is losing wt, severe nipple or breast leasion, pregnant mother, severley ill mother

68
Q

avoid using artificial nipples, which may_______infant’s suckling reflex

A

weaken

may use a dropper or tube

69
Q

preparing to bf

A

wash the hands w/ soap & water

clean the nipples & breasts w/ water

70
Q

comfortable positions for nursing

A

upright or rocking chair
mother lying on her side
using pillow to prop the baby

71
Q

allow infant to feed on demand how often?

A

q 3-4 hrs

always bf on both breasts

72
Q

start bf w/_____min each breast/feeding, working up to________min/side/feeding

A

5 minutes

5-10 min

73
Q

what should you do to stimulate suckling reflex or keep baby awake?

A

stimulate infant’s cheek or mouth

express some milk into mouth

74
Q

how do you remove infant from breast?

A

gently open mouth by lifting outer border of the upper lip to break suction

75
Q

you want to make sure you place the entire_____&_____ in infant’s mouth

A

nipple & areola

76
Q

bf should be initiated when after delivery?

A

< 1 hr post delivery

77
Q

frequency & duration of feeds should be on demand, but may be?

A

every hour, 8-12x’s/day in 1st few wks

typically 10-15 min each breast at each feed- depends on milk supply, efficiency of milk transfer, infant’s behavior

78
Q

feedings initiated based on infant cues

A

sleeping infant making suckling motions of the lips
moving the mouth toward an object
sucking on the hands
irritation & crying
*should wake newborns up to feed every few hrs

79
Q

signs of infant satiety

A

release of the nipple
relaxation of facial muscles, hands
falling asleep while feeding

80
Q

postpartum care concerning bf

A

evaluate mother & baby for adequacy of latchin on, suckling, milk production, and assessment of intake
maternal knowledge & resources should be discussed
ideally a lactation nurse will follow up w/ family 48 hrs after d/c

81
Q

infant assessment of bf

A

urine output: 6 wet diapers/day
stools: >4 soft stools/day
wt gain/loss: expect 5-7% loss initially; regain birth wt @ 2 wks
jaundice

82
Q

mother assessment of bf

A

supplementation
painful nipples
engorgement
mastitis

83
Q

painful nipples

A 
common!
often occur 1st few wks of bf
dry heat/application of expressed milk to nipples bet. feeds may help
vaseline/lanolin/vit A&D ointment
tx candida infxn if present
nipple shields only as last resort
84
Q

engorgement

A

occurs 1st wk pp

d/t vascular congestion & accumulation of milk

85
Q

how do you help and prevent engorgement

A

breast massage & around-the-clock feedings

86
Q

how else can you help relieve engorgement

A

oral analgesics
cool compresses
partial expression of milk before feedings will help relieve discomfort & engorgement

87
Q

mastitis occurs most frequently in?

A

primiparous mother

88
Q

what causes mastitis?

A

coagulase-positive S. aureus

89
Q

what should be suspected in recurrent or bilateral mastitis?

A

neonatal strep infxn

90
Q

what will you see in mastitis?

A

painful, erythematous lobule in an outer quadrant of 1 breast during 2nd or 3rd wk pp; Ab (antibody) coated bacteria in milk

91
Q

in mastitis it is important to continue bf why?

A

prevents milk stasis

92
Q

what Abx are used to tx mastitis

A

cephalosporins
dicloxacillin
methicillin
*local heat, well fitted bras also help

93
Q

what might develop if mastitis is left untreated?

A

breast abscess- pitting edema & fluctuance over the inflamed area; I&D abscess, start Abx; discontinue bf

94
Q

indications for suppression of lactation

A

women who do not desire bf
women who cannot bf
failure of attempted bf
fetal or neonatal death

95
Q

methods of suppression of lactation

A

stop or do not begin bf, milk expression, or pumping
avoid nipple stimulation
wear supportive bra
medical suppression w/ bromocriptine or estrogens is not recommended

96
Q

complications of suppression of lactation

A 
breast engorgement
breast pain
leaking breasts
sx's will generally improve in 2-3 wks
oral analgesics helpful

OB (13 decks)

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