OB-Exam 2 Flashcards
Physiological change of uterus postpartum
Shrinks down back to pre-pregnancy state
-Goes from the size of a watermelon back to about a lemon or orange
-Placenta removed (7cm wound on the inside) needs to heal
-contractions help the uterus heal, help stop bleeding
where is fundus found immediately after delivery etc.
found slightly below the umbilicus, and within one hour goes up to the level of the umbilicus
-from there shrinks down one finger a day
When would the uterus be back to the pelvic cavity
around day 9-10, and you can no longer palpate.
What can assist uterine involution
Breastfeeding (releases oxytocin -> causes contraction)
Ambulation (gravity helps bring uterus down)
What can slow down uterine Involution
Having multiple fetuses (twins triplets), having repeated births, and excessive narcotics (analgesics)
What is the cervical os
the opening between the cervix and the upper part of the uterus
Physiological changes postpartum for Cervical os
Nulliparous cervix - has not given birth, little circle
Multiparous cervix- has given birth , wider hole.
Hormones after birth
-progesterone and estrogen decrease right after birth.
-As you breastfeed those hormones will fluctuate as you feed (oxytocin and prolactin)
Around how soon after birth will FSH elevate and what will it cause
around 12 days, and this will return the menses
If you are breastfeeding how soon will menstruation return
4-6 months and if not breastfeeding 6-10 weeks.
When can contraceptives be discussed
after postpartum
Lacogenesis 1
16 weeks gestation process that creates colostrum
Lactogensis 2
triggered by birth, once the baby and placenta are delivered, an increase in oxytocin helps start creating and producing more colostrum
Lactogensis 3
- around day 10 milk supply will strat to stabilize
-the more the mom puts baby on the breast the more stimulation the more milk will be produced
(supply and demand)
Lactogenesis 4
involution- baby will strat weening ff
What could low and high BP postpartum indicate?
-Low BP: if she lost a lot of blood she could be hypovolemic, and she might need a transfusion
-High Bo: 140/90 could be developing pre-eclampsia (check urine for protein)
Postpartum maternal assessment
-slight temp increase due to dehydration
-pulse slightly decreased for about 1 week (due to decreased pressure on the vena cava)
-BP should return to pre-pregnancy BP
-Pain increases after birth
Maternal Assssment Postpartum
(Breast)
-Colostrum present during first 1-3 days ( normal)
-Milk production 3-5 days (supply and demand
-engorgement is common and normal (breast will feel full, tender, and heavy)
Maternal Assssment Postpartum
(Uterus) what are the three things you assess for?
consistency, location, and fundal height
Treatment and Education for breast engorgement
Keep breastfeeding every 2-3 hours or on demand, if the baby skips a feeding you should pump
-warm shower, supportive bra, massage breast, cold compress after feeding to decrease inflammation (no heat causes already increased blood flow)
Engorgement can lead to -> Mastitis (explain)
Infection of the milk duct due to bacteria
-encourage good hand hygiene, keep breasts clean
-cracking and bleeding from nipples could be a source of infection
-make sure the baby has a good latch.
-Make sure antibiotics ordered
If mom does not plan to breastfeed what education can you offer?
Wear a tight supportive bra, avoid any nipple stimulation, use a cold compress, and take analgesics to help with discomfort.
Explain the different assessments of the uterus postpartum
Consistency: Firm (Hard) or Boggy (soft)
location: usually found midline (if deviated to L or R could be due to full bladder)
Fundal Height: document in relation to umbilicus -> measured in fingerbreadths or centimeters
explain different ways of writing where the uterus is located
Number and then U (3/U) how many above the umbilicus
u/u at the umbilicus
u then number (u/1) how many below the uterus
Fundal Exam- postpartum
Mom should be supine laying flat for proper feeling
Lochia postpartum
-bloody discharge after birth
-asses with color, amount, odor, consistency
If the fundus is not firm and mom is actively bleeding what is something you could actively do in that moment?
Fundal massage, if it doesn’t work call for help think hemorrhage
How many mLs of blood is normal after vaginal and C-section delivery and what’s considered a hemorrhage
Vaginal: should be less than 500 mLs anything over is considered hemorrhage.
C-Section: should be less than 1000 mLs anything over = postpartum hemorrhage
Explain different types of lochia
Lochia rubra: bright red blood, 1-3 days postpartum
Lochia Serosa: pinkish brownish 4-10 days postpartum
Lochia alba whitish can last up to 6 weeks after birth
Measuring the amount of lochia
Scant: less than 2.5 cm
Light: 2.5cm - 10cm
Moderate: >10cm
Heavy: One pad saturated in 2 hours
Excessive: One pad saturated in 15 minutes (check for hemorrhage)
Perineum assessment postpartum
Could be edematous (swollen with fluid), tender, ecchymosis (bruising), tearing
Offer Car and comfort, witch hazel pad, numbing spray, and hydrocortisone cream for hemorrhoids.
types of tears
1st degree- tear through skin and epithelium
2nd degree- tear through fascia and muscle
3rd degree- fascia + muscle and anal sphincter
4th degree- fascia + muscle and internal and external anal sphincter
Bladder assessment postpartum
encourage frequent urination
-If they had a foley make sure they urinate within 6 hours ( a full bladder can cause the uterus to deviate and not contract properly)
Postpartum bowels
Increase fiber and doffer stool softener. Avoid straining
If they have hemorrhoids hydrocortisone cream can be given to help.
Cesarean section nursing care postpartum
-Incision site: could be closed with staples, steri-strips, dressing, or glue.
-Measure output with Foley and make sure they can void,
-Make sure to have DVT prophylaxis
encourage them to try to stand and walk
-Require pain management IV toradol for the first 24 hours
surgical site: note any redness, swelling, pus, etc,
-Auscultate for bowel sounds and make sure they are passing gas
Education for C-sections for moms
make sure the incision stays clean and dry
no harsh or scented soaps
pain management
education on signs of infection
Rho(D) immune globulin (RhoGAM)
Rh+ has Rh antigen on the surface
Rh- does not have antigen
If mom is Rh - and Bbay is Rh + it could cause complications
-If mom is Rh- she is gonna get RhoGAM during her pregnancy as well as any procedures that could mix her blood with babies blood
-automatically get it at about 26 weeks
- Postpartum if the baby is Rh+ then she’ll get RhoGam again after delivery within 72 hours
Postpartum Maternal Attachment
Bonding
should happen immediately after delivery for both mom & dad
-make eye contact, touching baby, looking at the baby, feeding the baby
Phases of Maternal Adjustment
Taking in: focused on her own needs but excited, talking
Taking hold: focused on maternal role, wants to take charge, wants to learn and practice, hands-on
Letting go: family starts to settle into their roles, settling into family life
Postpartum blues
A huge shift in hormones
-It is normal for a mom to start crying within the 1st-2 weeks but should subside
Postpartum blues education
- encourage support, rest, proper nutrition, educate on PPD, and follow-up with the provider
Postpartum Depression
Persistent sadness that goes on past those 1-2 weeks
-intense mood swings, irritability, not taking care of herself or baby, feelings of guilt and anxiety
-Edinburgh will be due before discharge and then again at 4 weeks
Postpartum depression education
Recommend counseling, antidepressant medications, family/community support, rest & Nutrition
postpartum Psychosis
medical emergency, considered a crisis
-intrusive thoughts, seeing things, hearing voices
What are the 4 critical factors that influence labor and what is a way to remember them?
The 4 P’s
1. passage 2. passenger 3. powers 4. psych
The birth passage
the way the fetus takes to exit the uterus
What sections is the pelvis divided into
inlet, pelvic cavity, outlet
What are the different types of pelvis with an explanation
- Gynecoid: Nice opening (wide heart)
- Android: Triangle shape (narrow heart)
- Anthropoid: Good shape (long heart)
- Platypelloid: difficult to get into but can be done (squished heart)
Which type of pelvis is most favorable for delivery?
gynecoid and anthropoid.
Labor is a series of events affected by the coordination of the four essential factors. One factor is the pelvis. What are the other three factors?
Fetus (passenger), Contractions (power), Psychological Response (psych)
Passenger ( the fetus and placenta)
Passenger needs to cooperate for effective labor
factors affecting the ability of passenger to exit the pelvis.
Fetal presentation: part of the fetus that enters the pelvic cavity first (how the fetus will present itself)
Fetal Lie: maternal longitudinal axis and fetal longitudinal axis (how are they lying in the womb? prefer up & down)
Fetal Attitude:Relation of fetal parts to one another (what degree of flexion? We want high tucked like a ball)
Fetal Position: Position of fetus in relation to the maternal pelvis
Station: Fetal descent in relation to ischial spines (How far down is the baby descending into the pelvic cavity)
Passenger: presentation
the way baby will present itself: Head, Butt, Shoulder
Head: Occiput (favorable what we want)
Butt: Breech
Shoulder: Transverse
Where is the occiput?
hand on neck then pus up a little
Passenger: Presentations
Types of Breech
Knees extended -> toes to head Frank Breech
Knees flexed -> pretzel ball complete breech
Neither hips or knees flexed, foot out -> footling breech
Passenger: Lie
Looking at the fetal axis in relation to mothers
Transverse: fetal axis horizontal
Longitudinal: fetal axis parallel
Fetal Attitude
degree of flexion in the fetus
What we want (full flexion) is the head to be flexed forward with the chin almost resting on the chest and arms and legs flexed.
Moderate flexion there is some space between the chin and chest
Partial flexion: they are looking up meaning the brow will be the presenting part
Fetal Position
We want to know where the baby’s occiput is in relation to the mom’s pelvis.
posterior slightly higher than the anterior
important to know where to put the fetal heart monitor
Passenger: Engagement
Floating: head directed down toward pelvis but can still easily move away from inlet
Dipping: The fetal head dips into the inlet but can be moved away
*Engaged: when baby’s head is in the inlet of the pelvis
Passenger: station
The way nurses measure as the baby comes down into the pelvic cavity. (Feel for ischial spine)
Anything above the ischial spine is - anything below is + if it is at 0 it’s engaged
+3& +4 means crowning
Upon completion of a vaginal examination on a laboring woman, the nurse records 6cm, 80%, -1. Interpret the data above.
6cm dilated, 80% effaced (thinned out), 1cm above ischial spines
Powers: Physiologic forces of labor
muscles for contraction - primary force
Mom using abdominal muscles to push: secondary force
What is a true contraction?
starts at the top of the uterus which is the fundus and then sweeps down.
Braxton hicks contractions
Not true labor will not help the mom push the baby down and start dilation and effacement.
Characteristics of contractions
big wave not little wave
explain progesterone and estrogen’s role in labor.
Helps start labor. Helps to dilate and start contractions.
Progesterone: causes relaxation of smooth muscle tissue
Estrogen: causes stimulation of uterine muscle contractions
*connective tissue loosens and allows softening, thinning, and opening of the cervix
Premonitory signs of labor- Pre-laborism
Lightening: fetus descends into pelvic inlet
Braxton Hicks contractions: pain contractions do not cause cervical pain
Cervical Changes: cervix begins to soften and weaken
Bloody show:loss of cervical ucous plug. Blood-tinged discharge
Rupture of membranes: 1 in 4 labors begin with SROM
Nesting: Burst of energy. usually occurs 24-48 hours b4 start of labor
True Labor
Contractions produce cervical dilation
-discofort begins in back and radiates to front of abdoen
-contractions increase in duration and intensity
-walking intensifies contractions
-resting in warm water does not decrease intensity
False Labor
contractions produce no effect on the cervix
- contractions lessened by walking, or warm water
-discomfort primarily in abdomen
ROM
Rupture of Membranes
-can be spontaneous or artificial
-Prolonged ROM (>24hrs) can lead to infection
- If ruptured: note color, odor, consistency and test with Nitrazine papers to confirm
What color will nitrazine paper turn if it is positive for amniotic fluid?
Blue
How many stages are there of labor and general description?
First Stage: Latent, Active, Transition (effacement & Dilation)
Second stage: Pushing, delivery of baby
Third Stage: Delivery of Placenta
Fourth stage: Recovery
First Stage: Latent Phase
Very beginning, regular contractions
-cervical effacement and dilation begin (0-5cm)
First Stage: Active phase/ Transition Phase
*Physiological Changes
Nursing Interventions: monitor FHR, watch contractions, do vaginal checks, ask mom about bladder distention
-Begins at 6c and ends at 10cm
- Fetus begins to descend into the pelvis
First Stage: Active phase/ Transition Phase
*psychological Changes
- Excitement & Fear
-Fear of loss of control
-Anxiety increases
Transition - locked in in the zone
Second Stage *Physiologic Changes
-Begins with complete cervical dilation and ends with the birth of an infant
-Perineum begins to bulge, flatten, and move anteriorly as the fetus descends
Second Stage *Psychological Changes
May feel a sense of purpose and may feel out of control or frightened
Third Stage * physiologic changes
-Placental separation: The uterus contracts and the placenta begins to separate
-Placental delivery: The woman bears down and delivers the placenta (the doctor can put slight traction on the cord to assist delivery of the placenta
Third Stage * psychological changes
Women may feel relief at the completion of birth, the woman focuses on the infant and may not recognize the pain, etc.
Fourth Stage *Physiologic Changes
-Increased pulse and decreased blood pressure
-uterus remains contracted and located between the umbilicus and symphysis pubis
-Women may experience shaking
- Urine may be retained
Psych. feeling of euphoria and energized at childbirth
What is the recovery & postpartum assessment
BUBBLE-HE
Breast, Uterus, Bowel, Bladder, Lochia, Episiotoy/ Tear, Hemorrhoids, Emotional state
Cardiovascular changes (intrapartum) Mom
cardiac output increases
blood pressure will increase with each contraction may rise with pushing may decrease with epidural
Respiratory changes (intrapartum) Mom
increase in O2 demand & consumption
Increase RR
Mild respiratory acidosis (can occur by tie of birth)
Gi changes (intrapartum) Mom
- Decreased Gastric Motility
-Prolonged gastric emptying
-loose bowel movements as contractions strengthen
Renal changes (intrapartum) Mom
-Edema may occur at bladder due to pressure of fetal head
Immune changes (intrapartum) Mom
spike in WBC normal and could have a drop in glucose
Types of pains in mom (intrapartum)
First stage: Pain comes from dilation of the cervix and stretching of the lower uterine segment, shell feels pressure
Second Stage: Due to contractions and perineum pain
Third Stage: Pain fro detaching placenta
Fetal responses (intrapartum, )
BP decreases at peak of each contraction to long of a contraction can hold blood in the baby
-can experience edema and carpet
-can experience an increase in HR
Leopold Maneuvers
The most important part is finding the fetal back
-palpate the top of the fundus and determine if it’s the head or the bum, Paulick’s grip to pinch babies head and determine if its engaged with the pelvis
After doing Leopold’s maneuvers, the nurse determines that the fetus is in the ROA position. To best auscultate the fetal heart tones, the Doppler is best placed
Below the umbilicus on the right side
Remember: if you hear the heartbeat the loudest above the mothers umbilicus baby ay be breach
Assessing a contraction
We can palpate a contraction
- We can feel the fundus and determine the frequency, duration, and intensity
Cool way to determine the intensity of contraction
Intensity (mild, moderate, or strong)
Mild- nose
Moderate-Chin
Strong-Forehead
Cervical Assessment
Determine dilation & effacement evaluated by vaginal exam
How do you gauge dilation
insert index and middle fingers against the cervix and determine the opening size.
Before labor begins the cervix is long and the sides feel thick. The canal is closed
