OB final Flashcards
What assesment should be done on a postpartum mother in addition to the Head-to-toe assessment?
BUBBLEHEN
Bubblehen
B
Bilateral breast assesment:
- symmetry, shape, size
- asses for consistency - soft? firm? masses?
- nipples: shape? observe for bruising, cracks, and/or discharge
- use the back of the hand to asses temperature
- no stimulation for bottle feeders
Breast
bUbblehen
U
Check fundus using two hands ( one supporting bottom of the uterus while one palpates the fundus)
- should be firm and midline
- boggy –> fundal massage
- a boggy funud can be indicative of hemorrhage
- shifted left –> tell patient to urinate
Uterus
buBblehen
B
Ask patient when was the last time they voided was, they should attempt to void every 2-3 hours
bladder
bubBlehen
B
Ausculate for bowel sounds (C-section patients may have hypoactive bowel sounds), ask when the last time they ate or drank was, ask when the last time they had a bowel movement was, if 3 days with no bowel movement take laxative
Bowel
bubbLehen
L
Check pad and ask when they last changed it (if there is a lot of blood in a short amount of time, may indicate hemorrhage), should be bright red for first 3 days (lochia rubra), coin-sized blood clots normal, educate patient on progression of what the lochia should look like and when to be concerned, if there is a strong smell it may indicate infection
Lochia
bubblEhen
E
Not as common anymore but if she does have a laceration be sure to assess
(REEDA: redness, ecchymosis, edema, drainage/discharge, approximation),
there shouldn’t be any drainage
bubbleHen
H
DVT assessment, support the knee and dorsiflex foot back (if there is pain there MAY be a DVT but further testing would be necessary), most DVTs are asymptomatic so pay attention for redness, edema, and heat, pedal pulses should be palpable
Homan’s
bubblehEn
E
Observe relationship with baby, support system, comments regarding concerns, interaction with baby, three phases:
- taking in: more about mom and her needs - hungry, tired, pain
- taking hold: interest shifts to baby and the baby’s needs
- letting go: don’t typically see in hospital but it is when they establish routine - usually happens when they get home
- EDUCATE on the signs of postpartum depression and psychosis and make sure to educate on resources to seek if it occurs
Emotion
bubbleheN
N
How they are eating, ask when the last time they ate or drank was, do they have an appetite, if they are eating is it settling well, do they have any nausea or vomiting, more calories necessary when breastfeeding, consider cultural influences
Nutrition
the postpartum period
bith to six week from the birth of the infant
- time for the body to heal and to get back to its pre-pregnancy state
- involution: the process of healing during the six week period
PP vagina
- maybe swollen, have lacerations or be edematous
- Does not regain nulliparous size
- estrogen effects: aids in the healing process by helping the vaginal wall to become thick again after delivery
PP Perineum
- may be edematous or bruised
- educate to practice kegal exercises
PP cervix
- flabby, edematous, wide open, may have lacerations
- uterine bleed: dark red blood
- cervical laceration: bright red blood
- foul smell to blood is a sign of infection
PP Uterus
trying to heal (involution) occuring in three steps d/t oxytocin:
1. contraction of the muscle fibers
2. reduction of the cellular wall size
3. regeneration of the epithelial wall of the uterus (2-3 wks)
PP Breast
little to no change the first 24 hours
days 1-2: soft
days 2-3: filling
days 3-5: full
what is shoulder dystocia?
Head is delivered but the anterior shoulder cannot pass under the pubic arch.
what are s/s of shoulder dystocia?
slowing of progression of 2nd stage, turtle sign, and external rotation DOES NOT occur.
What is turtle sign?
When the head of the baby is delivered but then retracts because the shoulder is stuck.
What are maternal complications of shoulder dystocia?
Postpartum hemorrhage and trauma to vagina, perineum and/or rectum
What are fetal complications of shoulder dystocia?
Brachial plexus injury and phrenic nerve injury, fracture of humerus or clavicle, and asphyxia
What maneuver is done for shoulder dystocia management?
McRoberts maneuver
What is prolapse umbilical cord?
Occurs when the cord lies below the presenting part
What is known as the presenting part?
the part of the baby that leads the way through the birth canal. Most often, it is the baby’s head, but it can be a shoulder, the buttocks, or the feet. Ischial spines. These are bone points on the mother’s pelvis.
What are signs and symptoms of prolapsed umbilical cord?
Variable or prolonged deceleration, reports feeling cord after ROM, cord seen or felt or protruding from vagina
What are maternal complications of prolapsed umbilical cord?
Forceps or vacuum delivery, C/S, inadequate uterine relaxation, bleeding
What are some fetal complications of prolapsed umbilical cord?
Hypoxia, CNS damage, and death
If the umbilical cord is protruding from the vagina what should be done?
Wrap umbilical cord in sterile towel saturated in sterile saline
What is uterine rupture?
Complete nonsurgical disruption of all uterine layers
What is a major risk factor for uterine rupture?
Multiple c-sections, or surgically scarred uterus
What are signs and symptoms of uterine rupture?
Abnormal FHR tracing, constant abdominal pain, uterine tenderness, change in uterine shape, and** cessation of contractions**
What are maternal complications of uterine rupture?
Hemorrhage, hypovolemic shock, laparotomy, hysterectomy, and death
What are fetal complications of uterine rupture?
Fetal hypoxia and death
What is amniotic fluid embolus?
Sudden acute onset of hypoxia, hypotension, cardiovascular collapse, and coagulopathy
What causes amniotic fluid embolus?
Foreign substance initiates the condition and is presumed to be present in the amniotic fluid that is introduced into the maternal circulation
What are signs and symptoms of amniotic fluid embolus?
Respiratory distress, circulatory collapse, hemorrhage
What are maternal complications of amniotic fluid embolus?
Hypoxia, brain injury, and death
What are fetal complications of amniotic fluid embolus?
Hypoxia and death
stages of labor
First stage: 0-10 cm
○ Latent phase: 0-5 cm
■ Contractions that cause cervical change and are painful
■ Will become more effaced
■ Baby will descend more
○ Active phase: 6-10 cm
■ Cervix dilates quickly
■ Baby descends at a faster rate
Stages of Labor
Second stage: 10 cm - birth
○ Latent phase
■ Baby descends and head rotates to anterior position
■ No strong urge to push
○ Active phase (pushing)
■ Oxytocin released leading to contractions
■ Ferguson reflex; strong urge to push occurs
■ Actively pushing
Stages of labor
Third Stage: birth - placenta delivery
○ Signs of placenta separation
■ Globular shaped uterus
■ Fundus rises in abdomen
■ Trickle or gush of blood
■ Umbilical cord lengthens
Fourth Stage: Placenta delivery-1 hour postpartum
○ Recovering from anesthesia
○ Adjusting to not being pregnant
○ Bonding and breastfeeding baby
○ Nurse should do a fundal massage
a way to remember what the different types of decelerations are and what the cause is. Decelerations are not always a bad thing but they can be. Accelerations are what you want to see and that is an increase in HR of at least 15 beats for at least 15 seconds. This tells us the baby is well oxygenated.
VEAL CHOP
V- variable decelerations ; C - cord compression
E- early decelerations ; H - head compression
A- accelerations ; O - okay / oxygenated
L- late decelerations ; placental insufficiency
Veal Chop
V - Variable decelerations
V - Variable decelerations
● Abrupt decreases in the HR that occur randomly; in the shape of a “V” or “W”
● Intervention: maximize umbilical circulation
Mild- won’t really intervene
Moderate/prolonged-Change maternal position (left side)
Give IV fluid bolus
STOP THE PITOCIN
Palpate uterus for tachysystole
Give O2 by mask at 8-10 L/min
Contact provider
Prepare for internal fetal monitoring if indicated or scalp stimulation (want HR to increase)
C - Cord compression
vEal cHop
E - Early decelerations
E - Early decelerations
● Drop in HR that mirrors the contraction; peak of decel lines up with peak of contraction and HR will return to baseline when contraction ends
● Intervention: nothing; this is an expected finding when the fetal head is being compressed which happens with contractions
H - Head compression
veAl chOp
A - Accelerations
A - Accelerations
Cause: fetal movement or can happen spontaneously- REASSURING
● HR rise at least 15 beats for at least 15 seconds
● Intervention: nothing, this is normal and what we want to see; tells us the baby is well oxygenated
O - Ok/Oxygenated
veaL choP
L - Late decelerations
L - Late decelerations
● Peak of the decel occurs after the peak of the contraction; most worrisome deceleration finding because it indicates baby is using their reserves which can lead to bigger problems
● Intervention: Fix the cause (hypotension, tachysystole) bc of PITOCIN or if cause unknown, maximize oxygenation
Change maternal position (left side)
Give IV fluid bolus
STOP THE PITOCIN
Palpate uterus for tachysystole
Give O2 by mask at 8-10 L/min
Contact provider
Prepare for internal fetal monitoring if indicated or scalp stimulation (want HR to increase)
P - Placental insufficiency
initial visit
o CBC
o Blood type
o Pap smear (if >21 y/o) o Gonorrhea/Chlamydia
o HIV
o Urine culture
o Rubella
o Hbg Ag
o RPR
o Physical and breast exam o Immunization: PPD, Td
o Begin prenatal vitamins
Routine care
o 0-26/28wks = routine care q 4wks
o 22/28—36wks = routine care q 2wks
o 36-40wks = routine care q 1wk
Each visit
o EGA (est. gestational age)
o B/P
o Weight
o Fundal height (after 20wks)
o Fetal heart tones w/ doppler (after 12wks)
o Urine dip for glucose and protein
o Assess for edema and s/s of preterm labor (contractions, vaginal bleeding, leakage of fluids)
o Fetal movement (after 20wks)
16-18 Weeks:
o MSAFP (maternal serum alpha-fetoprotein)
18-20 Weeks:
o Ultrasound for fetal anatomy and placental location (18wks)
26 Weeks:
o 1hr glucose tolerance test (24-28wks)
o CBC or H&H
o Repeat RPR (26-28wks)
28 Weeks:
o RhoGam (if RH-)
o Kick counts (if high risk pregnancy)
o PTL education
o Lactation counseling
36 Weeks:
o Fetal kick counts (begins at 34wks in normal pregnancy)
o H&H
o Gonorrhea
o Chlamydia
o GBS
o Labor education
40-41 Weeks:
o Assess fetal wellbeing by:
▪ Non-stress test (NST) q wk (2x)
▪ Ultrasound w/ biophysical profile (BPP) w/ amniotic fluid index q wk
▪ Consider delivery
True labor
Regular contractions- increase in frequency, intensity, and duration
Activity and walking intensifies contractions
Contractions do NOT decrease with rest
Contractions do NOT decrease with hydration
Progressive cervical dilatation
Discomfort starts in the back and wraps around abdomen
False Labor
Irregular contractions- no increase
Activity and walking does NOT intensify contractions
Rest lessens contractions
Hydration lessens contractions
No cervical change
Lower abdominal and groin discomfort
Normal glucose of a newborn birth to 4hrs of age
greater than or equat to 45
hyperbilirubinemia
Physiologic jaundice
- Peaks 3-5 days & resolves after 1-2 weeks
- Caused by increased levels of unconjugated bilirubin
- Can be associated with breastfeeding
Pathologic jaundice
- Can appear in first 24 hrs.
- Often requires phototherapy
probable signs
chadwick sign
bluish/purple vaginal mucosa & cerrvix
Hegar sign
sofening of the lower uterine segment
probable signs
Goodell sign
sofening of the cervix
