Women's Health 3 Flashcards
Purposes of prenatal care
- patient education and reassurance
- patient comfor with provider of delivery services
- medical services: BP, detection of preeclampsia
First visit should include (5)
- complete assessment
- gestational age assessment
- Pap smear, cultures
- prenatal panel
- discussion of breast feeding
How long is the standard pregnancy?
40 weeks
How many weeks is considered “term”?
37-40 weeks gestation
How many weeks is “preterm”?
20-36+6 weeks
How many weeks is considered abortion?
20 weeks
What is happening when G does not = P?
patient is pregnant!
Two most important genetic risk assessment factors for the patient
advanced maternal age (>35)
drug exposures
What genetic RF should you think of in ethinic backgrounds (esp AA)
Sickle cell
Recommended schedule for routine antepartum OB visits
Every 4 weeks until week 28
Every two weeks until 35-36 weeks
Recommended schedule for postpartum OB visit
2-6 weeks after delivery
more frequent visits PRN
4 parts of a gestational age assessment
- LMP
- Pelvic US (ideally in 1st trimester)
- Physical exam, fundal height
- Naegle’s rule
What is the formula for Naegle’s Rule and what is it for?
Calculates the Estimated Date of Conception (EDC)
LMP + 7 days - 3 months +1 year
How many week pregnancy is Naegle’s Rule based on?
40 weeks (10 months!)
What’s a useful tool for determining Naegle’s Rule?
Pregnancy wheel
gives current gestational age
The first trimester US takes what measurement?
Crown-Rump Length (CRL)
What # weeks should the first OB visit happen?
8 weeks
Do you need a Pap on the first OB visit?
only if patient is >21
Name some things the prenatal panel contains
Blood type/screen CBC Hepatitis B surface antigen Syphilis Early 1-hour glucose tolerance test Rubella immunity status HIV Urine C&S B-hcG, P4 Hep C Igg Carrier testing for CF, Fragile X, SMA
What is BhCG useful for?
Only establishing viability. It peaks at 10 weeks, then sharply declines and is back to baseline at about 15-17 weeks
What type of fetal assessment happens at <12 weeks?
transvaginal US for “viability” or “dating”
What type of fetal assessment happens at >8 weeks?
Fetal heart tones
What type of fetal assessment happens at >16 weeks?
Fetal movement
When assessing fundal height, when does the uterine fundus begin to grow out of the pelvis?
12 weeks
When assessing fundal height, when does the uterine fundus reach the umbillicus?
20 weeks
when measuring fundal height, when do the gestational weeks equal the measurement in cm?
beyond 20 weeks
When does the uterine fundus reach the xyphoid process?
36 weeks
When does genetic screening take place?
12 weeks
Does genetic screening detect neural tube defects?
no
Ex: spinal bifida
GBS colonizes in the vaginal and rectal areas in what percent of women
30%
What happens to the baby if the mother is infected with GBS?
neonate may become infected during delivery»_space; fever, sepsis
When do you do a vaginal/rectal swab for GBS?
35 weeks
How is the fetal presentation classified?
the anatomical part of the fetus lying over the pelvic inlet: the presenting body part of the fetus
When the baby’s head is presenting
Vertex presentation
When the baby’s feet/bottom are presenting
Breach presentation
When the baby’s shoulder is presenting
Shoulder presentation
What is fetal lie?
relation of the long axis of the fetus to that of the mother
What are the different fetal lies?
Longitudinal
Oblique
Transverse
Common complaints in antepartum care
N/V Heartburn/reflux Fatigue Round ligament pain Leg cramps, muscle pain Low back pain Dyspnea
What causes maternal N/V?
increased hCG/P4
What causes maternal Heartburn/GERD
decreased GI motility increased stomach emptying time reduced GE sphincter tone increased intra-abdominal pressure horizontal lie of the stomach as the uterus enlarges
What causes maternal dietary cravings?
PICA
What causes maternal constipation?
reduced GI motility
What causes maternal hemorrhoids?
elevated venous pressure
increased pelvic blood flow
pressure from constipation
Cardiac output increases _____% in the first 20 weeks of pregnancy
50%
What cardiac finding is normal in pregnancy, not normal otherwise
S3 gallop, systolic ejection murmur
IVC syndrome is common in pregnancy. What is it?
Compression of the IVC by gravid uterus. Causes dizziness, light-headedness, syncope
Hormonal changes cause what MSK change in mom?
SI joint relaxation
What causes maternal leg cramps?
electrolyte imbalances
What cause nasal “congestion” in pregnant women?
mucosal hyperemia
What causes maternal dyspnea?
diaphragmatic compression secondary to gravid uterus
What is centering pregnancy?
a model of group healthcare.
Three major components of centering pregnancy?
- assessment
- education
- support
Name a few CCs that can be the clinical presentation of pregnancy
missed period breast tenderness nausea fatigue "purple cervix" Softening and enlargement of the uterus \+ hCG (home or office)
Name some early complications of pregnancy
bleeding pain/cramping hyperemesis change in bowel habits social issues
Name some causes of first trimester bleeding
abortion ectopic pregnancy Hydatidiform mole cervical polyps cervicitis neoplasm
What percent of pregnancies result in spontaneous abortion?`
15-25% of all clinically recognized pregnancies, possibly as high as 50% of all
Most (80%) of miscarriages happen within how many weeks?
the first 12
The likelyhood of spontaneous abortion is lower once…
fetal heart activity is visualized on US
What are the percentages f recurrence associated with 1, 2, 3, and 4 prior losses?
1: 19%
2: 35%
3: 45%
4: 54%
(must be consecutive, live births start from the beginning)
Name 6 reasons etiologies of spontaneous abortion
chromosome abnormalities!! (50-70%) Endocrine abnormalities Reproductive tract abnormalities Immunologic Infection Idiopathic
Chromosome abnormalities are found in what percent of still births? and live births?
5% ; .6%
is alcohol associated with spontaneous abortion?
no, but it’s teratogenic
Is caffeine associated with spontaneous abortion?
possibly
Is trauma associated with spontaneous abortion?
no
Is radiation associated with spontaneous abortion?
Very much, if >10 rads
Is smoking associated with spontaneous abortion?
Yes, if moderate or more
Definition of spontaneous abortion
termination of pregnancy before 20 weeks
Most common etiology of spontaneous abortion
chromosome abnormalities
Definition of threatened abortion
vaginal bleeding in the first trimester, os is still closed, can see pregnancy on US, still have fetal heart tone
Pregnancy may be viable or abortion may follow
What is the most common cause of first trimester bleeding?
threatened abortion
POC in threatened abortion?
NO
cervical os is ____ in threatened abortion
closed
up to _____% of patients have threatened abortion, up to _____% of them miscarry
25%
50%
There is an increased risk of what with threatened abortion
PTD
Threatened abortion S/S
essential bleeding in first trimester; bloody vaginal discharge
Threatened abortion Tx
Supportive: rest, ER return precautions
Serial B-hCG to see if doubling
No medications helpful
EMOTIONAL SUPPORT
Incomplete abortion definition
in the process of aborting, but still have retained products, cervical os is open
pregnancy is not salvagable
POCs in incomplete abortion?
some POC expelled, some still retained
Cervical os is ____ in incomplete abortion
DILATED
Incomplete abortion S/S
HEAVY bleeding
retained tissue
BOGGY uterus
Incomplete abortion Tx
may be allowed to finish
D&C in first, D&E after first
Pitocin
Inevitable abortion definition
pregnancy not salvageable, no POCs expelled yet
Cervical os is _____ in inevitable abortion
progressively dilating
+/- ROM
Inevitable abortion S/S
moderate bleeding >7 days
cramping
Inevitable abortion Tx
Dilation and evacuation in 2nd trimester
Suction curretage in 1st trimester
Missed abortion definition
vaginal bleeding, os is closed, US shows gestational sac, retained products, been in there for awhile. Body did not expel the fetus but there is no fetal heart tone
Fetal demise but still retained in uterus
POCs in missed abortion?
none expelled
Cervical os is ____ in missed abortion
closed
Missed abortion S/S
loss of pregnancy Sx
maybe brown discharge
Missed abortion S/S
D&E (D&C if first trimester)
Misoprostol
Complete abortion definition
complete passage of all products
POC in complete abortion?
all completely expelled
Cervical os is ____ in complete abortion
closed
Complete abortion S/S
pain, cramps, bleeding usually subsides
Septic abortion definition
the retained POC becomes infected, causes infection of the uterus and organs
POC in septic abortion?
some POC retained
Cervical os is ___ in septic abortion
closed
septic abortion S/S
cervical motion tenderness Foul brownish disrcharge fever, chills uterine tenderness spotting >> heavy bleed
When is RhoGam indicated in abortion Tx?
if Rh negative
Definition of elective abortion
termination of intact pregnancy before viability (usually surgical)
Describe medical regiment used for elective abortion (2)
Mifepristone»_space;> Misoprostol 24-72 hours after
OR
Methotrexate»_space;> Misoprostol 3-7 days later
Mifepristone MOA
anti-progestin
Methotrexate MOA
antimetabolit (folate antagonist)
Misoprostol MOA
prostaglandin that causes uterine contractions
Surgical elective abortion can be performed up to _____ weeks from LMP
24
what type of surgical elective abortion is used in weeks 4-12?
Dilation and currettage (including suction curettage)
D&C
What type of surgical elective abortion is used in weeks >12
dilation and evacuation
D&E
Definition of ectopic pregnancy
any pregnancy implanted outside the endometrial cavity
Most common place of ectopic pregnancy?
fallopian tubes, especially the ampulla
Ectopic pregnancy RFs
- Previous pelvic infection
- previous tubal surgery
- intrauterine device in place
- previous tubal pregnancy
ADHESIONS from surgery!
Ectopic pregnancy clinical triad:
- unilateral pelvic/abdominal pain
- vaginal bleeding
- amenorrhea (pregnancy)
The ectopic pregnancy triad can also be seen with ___.
threatened abortion
threatened more common than ectopic actually
ectopic pregnancy atypical S/S
vague Sx
menstrual irregularities
severe abdominal/shoulder pain
ruptured/rupturing ectopic pregnancy S/S
severe abdominal pain
dizziness
N/V
signs of shock (from hemorrhage): syncope, tachycardia, hypotension
ectopic pregnancy PE
cervical motion tenderness
adnexal mass
Ectopic pregnancy Dx
- SERIAL quantitative B-hCG
- normally doubles every 48 hours in first trimester - Transvaginal US
- laparoscopy for direct visualization
What would you see on transvaginal US if there is an ectopic pregnancy
absence of gestational sac with B-hCG levels >2000 strongly suggest ectopic or nonviable intrauterine pregnancy`
Ectopic pregnancy Tx
- Surgical: laparascopy with salpingectomy or salpingotomy
- Medical: methotrexate
When would you use surgical versus medical tx of ectopic pregnancy?
Surgical: ruptured or unstable
Medical: unruptured or stable
Methotrexate MOA in ectopic pregnancy
destroys trophoblastic tissue (disrupts cell multiplication)
Indications for methotrexate in ectopic pregnancy (4)
- hemodynamically stable
- early gestation (<4cm)
- B-hCG <5,000
- no fetal tones
CI for methotrexate in ectopic pregnancy
- ruptured ectopic
- history of TB
- B-hCG >5,000
- fetal heart tones present
Do you give RhoGAM in ectopic pregnancy?
Yes, if mom is Rh negative
What is hydatidiform mole?
“molar pregnancy”
a type of gestational trophoblastic neoplasia
Partial mole= identifiable fetal structures
Complete mole= NO identifiable fetal structures
Molar pregnancy S/S
Exaggerated pregnancy symptoms
Threatened abortion Sx
Uterus larger than expected
Molar pregnancy Dx
US: “snowstorm appearance”
Molar pregnancy Tx
Definitive: prompt evacuation of uterine contents, hysterectomy if no wish for future children
In clinic, you’ll probably see more ____ pregnancy, complications. In ER, you’ll probably see more ____ pregnancy complications.
late; early
Women are how many times as likely to be diagnosed with clinical depression?
twice
When does depression most commonly happen in women?
during childbearing years (25-44)
How many women will be dx with depression in their lifetime?
1/8
Do depressed women seek treatment?
less than 1/2 do
Do more men or women get diagnosed with bipolar?
equal
___ times as many women as men experience rapid cycling of bipolar disease
3x
What does research show about women with bipolar?
they have more depressive and mixed episodes than men
Premenstrual syndrome definition
a cluster or general pattern of physical, emotional, and behavioral symptoms with cyclical occurence during the LUTEAL phase of the menstrual cycle
when does PMS occur?
in the LUTEAL phase
1-2 weeks before menses
Remits with onset of menses
How many women experience PMS?
50-80% of women of reproductive age
What is premenstrual dysphoric disorder?
severe PMS with functional impairment
PMS physical S/S
bloating breast swelling and pain HA bowel habit changes fatigue muscle/joint pain
PMS emotional S/S
depression hostility irritability libido changes aggressiveness
PMS behavioral S/S
food cravings
poor concentration
noise sensitivity
loss of motor senses
Most common Sx of PMDD
irritability
DSM-V criteria for PMDD
A. 5 or more Sx in most menstrual cycles in the past year
B. One or more of the following: affective libility, irritability or increased interpersonal conflict, depressed mood or hopelessness or self-depricating thoughts, and anxiety
C. One or more of the following: decreased interest in usual activities, difficulty concentrating, decreased energy, change in appetite, hypersomnia or insomnia, feeling overwhelmed or out of control, physical symptoms
D. Clinically significant distress
E. not an exacerbation of another disorder
F. Prosective daily fatings during 2 symptomatic cycles
G. NOT due to substance use or another med
PMS Dx
- Sx initiate during the luteal phase (1-2 weeks before menstruation)
- relieved with 2-3 days of the onset of menses
- at least 7 Sx-free days during the follicular phase
PMDD Dx
Daily charting of Sx for 2 months
T/F: women with or vulnerable to PMDD have abnormal hormone levels
FALSE. Research shows women vulnerable to PMDD do NOT have abnormal levels of hormones, they have a particular SENSITIVITY to normal cyclical hormonal changes
PMDD pharmacologic Tx
SSRIs are first line
Other options: OCPs containing drospirenone, GnRH agonists (leuprolide), Danazol (a synthetic androgen)
How long does it take for SSRIs to work for PMDD?
a few days, FAST!
When should you start to consider another option if the SSRI isn’t working a for a patient’s PMDD?
after 3 menstrual cycles with no improvement
PMDD non-pharmacologic Tx
- Lifestyle Mods: exercise, sleep, decreased caffeine, decreased EtOH/tobacco
- Nutritional supplements: Ca, Vit B6
- Herbal supplements: no evidence for this
2 keys for follow up for PMDD
- continue daily charting after Dx to determine Tx effectiveness
- Tx for at least 12 months to cover relapse
T/F: the pregnant state is protective for mood disorders
False
Theory behind hormones and mood of postpartum depression
Theory: some women are more sensitive to changes in hormone levels»_space; increased susceptibility for mood disorders via NT changes
What hormone changes happen with delivery?
plummeting of both estradiol and progestin
Spectrum of postpartum mood changes
Postpartum blues >> Postpartum depression >> Postpartum psychosis
What dose the following describe: mother is tearful, irritable, and anxious about the new responsibilities of being a mother, but experience SOME joy, sleeps when the baby sleeps, and eats well
Sx DO NOT impair the woman’s ability to care for herself or baby
Baby blues
Onset of baby blues
about 3 days after delivery, usually resolves by 2 weeks postpartum
Baby blues Tx
support and reassurance
What is one of the most common complications of childbirth?
Postpartum depression
Postpartum depression Dx
Same DSM-V criteria as MDD (SIGECAPS), but onset of episode within 4 weeks postpartum
What does the following describe: mom has guilt, appetite change, agitation, anxiety, cannot sleep even when baby is sleeping, has obsession and compulsions about the baby
Postpartum depression
PPD screening
Edinburgh postnatal depression scale (EPDS)
10 item self report scale
Score of 10-12 is positive
If positive, conduct a brief clinical interview to establish the Dx of depression
PPD RF
- previous episode of depression
- Severe PMS
- anxiety during pregnancy
- depression during pregnancy, particularly 3rd trimester
- prior episode of PPD
- FHx of depression/anxiety/bipolar
- Poor marital support
- Trauma
- isolation of mother
- increased life stressors
- prefectionism
- work/financial pressures
- lack of maternal self-care
Most important RF for PPD
prior episode of PPD
Three components of PPD recovery
- medical intervention
- social support
- psychotherapeutic intervention
Moms MUST get uninterupted sleep for at least ____ hours _____ nights per week
4-6 hours; 2 nights/week
PPD pharmacologic Tx
SSRIs first line
PPD prophylactic Rx
for high risk women, no longer than 17 weeks
Untreated PPD may lead to the following problems: (4)
- interrupted bonding with baby
- contributes to family/marital discord
- can lead to psychosis, SI, tragedies
- interferes with the normal child development
Children who grew up with a mother who suffered from depression have shown an increased incidence of:
- childhood psychiatric disturbances
- behavior problems
- poor social functioning
- impaired cognitive and language development
In normal interactions, mothers and infants engage in _____ mismatching states which leads to trust in the partner and sense of mastery (“we can overcome problems”).
Depressed mothers find it difficult to read and respond to infants’ communications, leading to larger and longer mismatches and less likelihood of _____ repair
repairing; repair
What commonly occurs with PPD
Postpartum OCD
what happens in POCD
intrusive thoughts or images of harming baby or something harmful happening
Are women with POCD more likely to harm their infant?
NO
Explain how a mom with POCD might act
Obsessive thoughts about harm coming to the infant causes them to avoid holding the baby on staircases, bathing the baby, the kitchen area, leaving the house, etc
Important note about women with POCD
These Sx cause shame and embarrassment, women don’t volunteer this info unless you ask!!
What is described by the following: mom has anxiety and agitation, disorganized behavior, confusion, delusions about infant, voices in her head, hallucinations, and thoughts about hurting herself or baby
postpartum psychosis
When does postpartum onset? what about recurrence?
onset is rapid- within 3 days to one week
Recurrence rate is extremely high!
Patients with preexisting Dx of ____ have a 20% increased risk for developing postpartum psychosis
bipolar
Postpartum psychosis Tx
ANTIPSYCHOTICS AND HOSPITALIZATION
PSYCHIATRIC EMERGENCY!!
Risk of suicide and infanticide!!
General rules of treating depression during pregnancy
discuss psychotropic meds and pregnancy when you first prescribe meds for women during their childbearing years
ABRUPT cessation of psyciatric meds during pregnancy makes relapse more likely
What is first line Tx for depression during pregnancy
SSRIs
Any risks for fetus with SSRI?
no risk of malformations
no evidence of being teratogenic
Other Tx options for depression during pregnancy
psychotherapy
ECT
Omega-3s
Bright light therapy
General principals for breastfeeding while on meds (for mom)
breastfeeding not always safe
SLEEP is very important
General principals for breastfeeding while on meds (for baby)
- BBB is porous
- liver enzymes not fully developed
- kidneys partially functioning
Breastfeeding while on SSRIs: drug exposure to infant is ___
low
Normal pregnancy is an average of ___ weeks from the first day of the LMP to the estimated date of delivery
40
Definition of early term
37 0/7 - 38 6/7 weeks
Definition of full term
39 0/7 - 40 6/7 weeks
Definition of late term
41 0/7 - 41 6/7 weeks
Definition of post term
42 weeks and beyond
What term has the lowest incidence of adverse neonatal outcomes?
full term
What are the four warnings of labor?
- the 5-1-1 rule
- spontaneous rupture of membranes
- vaginal bleeding
- decreased fetal movement
What is the 5-1-1 rule of labor?
Contractions occur…
- every 5 minutes (are painful)
- last at least 1 minute each
- go on for at least 1 hour
How many fetal movements should there be at term?
about 10 discrete movements per hour
Explain dilation/effacement/station on cervical exam when a patient is admitted to labor and delivery
Dilation: the opening of the cervix, ranges from 0-10
Effacement: rough estimate of the shortening of the cervix
Station: fetal head location in the maternal pelvis
The reference point for “station” is what?
the ischial spines
what is 0 station
baby’s biparietal diameter is AT the level of the ischial spines
what is minus station?
baby’s biparietal diameter is ABOVE the ischial spines
what is plus station?
baby’s biparietal diameter is BELOW the ischial spines
There is an increased risk of what in spontaneous rupture of membranes?
infection
What is the first stage of labor?
from onset of labor»_space; complete cervical dilation (10cm)
What is the second stage of labor?
from complete cervical dilation»_space; delivery of the infant
What is the third stage of labor?
from delivery of the infant»_space; delivery of placenta
What is happening in the latent phase of the first stage of labor?
cervix effacement with gradual cervical dilation
What is happening in the active phase of the first stage of labor?
rapid cervical dilation, usually beginning at 3-4 cm
What is happening in the passive phase of the second phase of labor?
complete cervical dilation to active maternal expulsive efforts
What is happening in the active phase of the second phase of labor
from active maternal expulsive efforts to delivery of the fetus
What are the three signs of placental separation in the third stage of labor?
- gush of blood
- lengthening of the umbilical cord
- anterior-cephalad movement of the uterine fundus (becomes globular and firmer after the placenta detaches
what is the biggest difference in labor from nulliparas to multiparas women
second stage of labor lasts about 33 minutes in first labor, but only 8.5 minutes in subsequent labors
describe pain in the first stage of labor
diffuse, visceral, not well localized
describe pain in the second stage of labor
pudendal nerve and the anterior divisions of S2-S4 are stimulated by distention of vagina/pelvic floor/perineum
somatic pain, better localized
biggest problem with systemic analgesia as pain management in labor
it crosses the placenta
it also doesn’t really work as well
Best part of neuroaxial (regional) analgesia for pain management in labor
pain relief with minimal maternal and neonatal adverse affects
What women are more likely to elect regional anesthesia?
higher education levels
caucasian
early presentation for prenatal care
what is the apgar score for?
assessing clinical status of newborn
5 components of the apgar score
- color
- HR
- reflexes
- muscle tone
- respiration
when do you report the apgar score?
1 and 5 minutes after delivery
Describe the apgar scores and what they’d mean
1-10 total, assigned 0-2 points in each section
7-10 is reassuring
4-6 is moderately abnormal
0-3 is nonspecific sign of illness
When would you repeat apgar scores
if score <7, repeat at 5 minute intervals up to 20 minutes
When would a baby get a +2 for on the HR section of the apgar?
HR >100
When would a baby get a +2 for color on the apgar score?
pink baby (no cyanosis)
When would a baby get a +1 on for color on the apgar?
acrocyanosis: body is pink, extremities are blue
What’s a normal baseline fetal heart tone?
110-160
What are we looking for when monitoring fetal heart tones?
baseline, long and short term variability, accelerations and decelerations
Two types of fetal monitoring
- External: US
- Internal: same tech as EKG measures R-R interval. Allows for better quality tracing with more continuity
Fetal heart tones are always discussed in increments of ____.
5
What is short term variability in fetal heart tones?
beat to beat irregularity in the HR, represents the push-pull effect of sympathetic and parasympathetic nerve input
What is the dominant nerve of short term variability?
vagus
What is long term variability of fetal heart tones?
the waviness of the tracing. Accelerations.
What is a reactive long-term variability?
2 accelerations every 20 minutes
Why is variability important?
it’s a marker of fetal well-being.
When a fetus is alert and active, the variability is _____. When a fetus is obtunded, variability is _____.
normal or increased; reduced
Name some things that would decrease variability
anything that depresses or reduces brain function!!
sleeping baby drugs fetal anomalies neuro insult immature CNS fetal tachy fetal sepsis
what causes variable decelerations?
compression of the umbilical cord
classic shape of variable decelerations
V
What are early decelerations caused by?
head compression
usual shape of early decelerations
U
What are late decelerations and what is their shape?
begin after onset of contraction; U
What types of decelerations are worrisome
Late, if repetitive
Describe the predictive value of apgar score
1 min 0-3: natta
5 min 0-3: correlates with neonatal mortality in large populations but does not predict individual future neurologic dysfunction
A low 5 minute apgar score confers an increased relative risk of what?
Cerebral palsy
Why does postpartum hemorrhage happen?
failure of uterus to contract after expulsion of contents
How much blood flows through the placenta at term?
600 mL/min
RF for postpartum hemorrhage
Overdistention of uterus (mult gestations, macrosomia) oxytocin-stimulated labor Uterine relaxants Amnionitis manual extraction of placenta
Post partum hemorrhage Tx
Uterine massage
Uterotonics
Surgery
Recommended time frame for umbilical cord clamping
30-60 seconds
What does umbilical cord clamping do for term infants?
increases hemoglobin levels at birth
improves iron stores in first months of life
Name a few things umbilical cord clamping does for preterm infants
- improved transitional circulation
- better establishment of RBC volume
- decreased need for blood transfusion
- lower incidence of necrotizing enterocolitis and intraventricular hemorrhage
When does the postpartum visit usually happen?
4-6 weeks after delivery
Topics to be addressed in the post partum visit
mood and emotional well being feeding sexuality, birth control sleep and fatigue physical recovery chronic disease mgmt health maintenance
What percent of women do not attend a postpartum visit?
40%
Nickname for postpartum care
“fourth trimester”
How many lobes are in one mature mammary gland? what are lobes separated by?
15-25; fat
Each lobe is made up of several ___, and those are made up of large numbers of ______.
lobules; alveoli
what do the alveolar secretory epithelium synthesize?
milk constituents
What are the ducts that open separately on the nipple?
lactiferous ducts
What is the other name for stage 1 of lactation?
mammogenesis
WHen does stage 1 (mammogenesis) of lactation occur?
conception to mid-pregnancy
What is happening in mammogenesis?
- increased proportion of glandular tissue
- increased size of breasts
- darkening and prominent veins
- milk secretion inhibited by the high levels of progesterone and estrogen
What is the other name of the second stage of lactation and when does it occur?
lactogenesis I: mid pregnancy to 2 days postpartum
lactogenesis II: 3-8 days postpartum
What is happening in lactogenesis I?
- stimulation of milk synthesis by prolactin
- milk secretion still inhibited
What is happening in lactogenesis II?
- reduction of progesterone allows for production and secretion of large amounts of milk
What is the other name for Stage three of lactation and when does it occur?
galactopoiesis; 9 days postpartum until involution (stage 4)
what is happening during galactopoiesis?
- maintenance of milk secretion controlled by hormones
- breast size diminishes between 6-9 months, production continues as long as baby sucks
What is the other name for the 4th stage of lactation, when does it occur?
involution, begins about 40 days after last breastfeed
What is happening during involution?
- loss of the secretory function of milk
- epithelial cells no longer needed and are removed by apoptosis and replaced with adipose tissue
Describe the physiology of breastfeeding
- baby sucks, no milk released
- receptors on nipple sense pressure from sucking, send sensory impulses transmitted to the hypothalamus
- nerve signals in hypothalamus stimulate release of oxytocin from posterior pituitary gland and prolactin from the lactotrophs
- oxytcin released into blood, acts on myoepithelial cells causing them to contract. Increase in pressure in alveoli causes the milk to be ejected in the ducts
- 30 seconds to 1 min later, baby is still sucking on the nipple, milk is ejected
When do prolactin levels rise?
5th week of pregnancy
what does prolactin increase do?
causes mammary ducts to mature and alveoli to differentiate into secretory cells
What acute effect does prolactin have?
causes mammary glands to secrete milk into the alveoli
When does oxytocin surge?
with suckling, crying baby
What inhibits oxytocin?
stress
What effect does oxytocin have?
causes milk ejection
what is colostrum?
thick, yellow, high in protein/Ab/vits/minerals type of milk that develops during pregnancy and lasts until a few days after baby is born
what is transitional milk?
white, high fat/calories/protein/lactose/vits milk that replaces colostrum 2 days after birth
what is mature milk?
replaces transitional milk 10-15 days after birth
foremlik or hindmilk
Foremilk vs Hindmilk
foremilk: bluish in color, more water content
hindmilk: more white, higher fat content, essential to baby’s growth/nutrition
Why are the first 2-4 weeks of breastfeeding the hardest?
exhaustion (they eat so freakin much) latching problems lazy/sleepy eaters discomfort milk supply vs demand baby blues
3 nursing positions
cradle
football
lying down
How to latch
bring baby to the breast not breast to baby!!!
nose in line with nipple, brush nipple from nose to upper lip, put areola and nipple into mouth
Breastfeeding recommendations
- exclusive BF for first 6 months
- intro of complementary solid foods with continued BF until 12 months (mom’s milk looses iron, need iron from solid food)
- continue BF until “mutually agreeable” time between mom and baby
Benefits of BF
involution of mom's uterus bonding decreased cancer and T2DM risk in mom decreased infant mortality decreased risks in baby for diarrhea, resp illness, obesity, OM, DM save money portable good nutrition for baby
2 main problems in BF
engorgement
plugged milk ducts
Plugged milk duct Tx
moist heat prior to feeding
massage during feeding
Presentation of mastitis
single area of localized warmth, TTP, edema, erythema in one breast >10 days after delivery
Flu-like Sx: fever, fatigue, N/V, HA
Mastitis Tx
Keflex for 10-14 days (not excreted in breast milk)
continue to nurse
Analgesics
what can happen if there is failure of mastitis to improve after 48-72 hours?
breast abscess
Breast abscess Tx
surgical drainage
Incision corresponding to skin lines (cosmetic)
pack resulting cavity with gauze
what percent of women will elect to never BF for varying reasons?
20%
How to make more milk?
feed the baby!
supply and demand
how long to see a change in supply?
24-48 hours
Name some common Rx contraindicated during lactation
acebutolol aspirin antihistamines bromocriptine ergotamine lithium phenobarbitol primidone sulfasalazine
Alternatives to BR
formula
pumping
