NYU Maternity Exam 2

Feeding postpartum:

how often should you feed?

1st 24 hours, how many mL?

2nd 24 hours, how many mL?

- Feeding should be done q 3-4 hours.

5mL avg in first 24 hours.

10 mL avg in second 24 hours.

What are the signs that the baby is getting enough milk?

- six wet diapers and 2-5 loose stools daily

- steady weight gain

- pale, yellow urine (not dark yellow)

- sleeping well

What are the safe sleeping practices for infants?

- sleep on its back

- less padding in bed

- Avoid co sleeping

What are the safe co sleeping practices?

- firm mattress

- no loose bedding

- sober/alert caregiver

- no smoking

Circumcision care criteria:

what should we observe for?

what to apply?

healing?

- observe for first void

- observe for bleeding

- apply vaseline/neosporin

- heals within 10 days

Umbilical cord care:

cochrane?

cleaning?

when is the clamp removed?

when does it fall off?

baths?

- Cochrane studies: there is no difference in dry cord compared to cords treated with antiseptics (basically - you can let nature take its course)

- Cleaning: allow natural healing, soap and water, alcohol, or iodine

- The clamp is removed once the stump is dry prior to discharge.

- Umbilical cords fall off in 10 days

- Sponge bath until the cord falls off.

Why do we give vitamin K to babies when they are born?

Babies have low clotting factors when they are born, so they need vitamin K to prevent bleeding.

Normal newborn assessment findings:

RR? HR? temp?

posture?cry?reflexes?

skin?

fontanelles/nasal?

- RR 30-60 breaths/min, HR: 110-160 bpm, temp: 97.7-99.5

- Flexed posture, strong cry, present reflexes

- Skin: acrocyanosis, vernix, milia, stork bites (norm)

- Fontanelles have to be soft and flat, no retractions or nasal flaring.

Helping Babies with Physiologic Jaundice:

feeding?

therapies?

Feeding: frequent breast/formula feeding.

Do phototherapy

Hypoglycemia:

criteria?

interventions?

- Glucose < 45 mg/dL in first 72 hours

Interventions: Rapid acting glucose source (Dextrose gel, Breastfeeding, Formula)

When do 2/3 of pregnancy related deaths occur?

Postpartum

Examination of the Fundus:

1st hour?

2nd hour?

first 24 hours?

after 24 hours?

1st hour: q 15 min

2nd hour: q 30 min

1st 24 hours: q 4 hours

after 24 hours: Q every shift

Postpartum Period Changes of the Body:

what does the cervix appear like?

how long do episiotomies take to heal?

abdominal muscle tone?

pelvic floor muscles?

- Cervix: jagged slit-like opening

- Episiotomies take 2-3 weeks to heal

- Abdominal muscle is diminished after birth, exercise to return.

- Pelvic floor tone can take up to 6 months to return, kegel exercises are recommended for return and healing.

Lochia Postpartum:

Lochia rubra?

Lochia serosa?

Lochia alba?

Postpartum hemorrhage?

Lochia rubra: first 3-4 days, blood

Lochia serosa: 2 weeks, old blood/leukocytes

Lochia alba: leukocytes/cells/mucus

Hemorrhage: if pad is completely full in one hour.

What is a fundal involution and how long does it occur in?

What is fundal sub involution? what causes it?

Involution occurs in 6 - 8 weeks postpartum . It is when the uterus is contracted and returned to its normal state.

Sub involution is when the uterus fails to return to its normal state. This can be caused by retained placental fragments or infection.

Perineal Care ?

- ice packs for the first 24 hours.

- peribottle

- sitz bath ( warm water soak after 24 hours )

- avoid straining

- use sitz bath after bowel movement.

Blood Type Issues Postpartum RhoGAM:

- who needs RhoGAM?

- why do you need RhoGAM?

- When should RhoGAM be given if indicated ?

Rh positive mothers do not need RhoGAM.

Rh-negative mothers need RhoGAM postpartum if

- Their baby is Rh-positive

- They did not already receive RhoGAM during pregnancy

- Why? To prevent Rh isoimmunization, where the mother's immune system creates antibodies against Rh-positive blood cells.

- This can cause hemolytic disease of the newborn.

RhoGAM must be given within 72 hours after delivery if indicated.

Blood type issues:

- Type O Blood moms?

- Infants with A/B blood type and mothers with O blood type?

- Infants born to mothers of Type O blood type need to be tested for jaundice.

- Infants with A or B blood type born to mothers with O blood type are more likely to experience jaundice.

Psych Adaptations:

Taking in phase?

Taking hold phase?

Letting go phase?

- Taking in: right after birth when mom needs others to meet their needs and relives birth process.

- Taking hold: dependent and independent maternal behavior.

- Letting go: patient reestablishes relationships with others.

Breast care if breast feeding:

relieved by ?

warm ?

cold?

- relieved by frequent emptying

- warm shower and warm compress before feeding

- cold compress between feeding

Let down

suckling stimulates oxytocin release which helps milk "let down"

Nipple Care:

expose ?

express?

adequate?

- expose nipples to air after feeding

- express (pump) milk

- adequate latch

Breast care if not breast feeding:

bra?

cold?

avoid?

- wear a tight, supportive bra

- ice breasts

- avoid breast stimulation and expressing (pumping) milk

Formula Feeding Teaching:

gradually?

feeding?

formula type?

- gradually increase the baby's formula

- Feeding (same as breastfeeding)

- Q3-4 hours

- 1st 24 hr: 5mL

- 2nd 24 hr: 10 mL

- Formula must remain consistent

Psych Changes Postpartum:

baby blues (short term), postpartum depression (more long term), and postpartum headaches

Immediate Newborn Interventions:

- airway patency

- proper ID

- thermoregulation

- erythromycin

- vitamin k

How to use APGAR :

what does it stand for?

what are the criteria for each?

- Appearance, Pulse, Grimace, Activity, Respiration

- 1,5,10 min after break

- Appearance:

- blue/pale(0)

- pink body + blue feet/hands (1)

- pink all over (2)

- Pulse:

- No heartbeat(0)

- <100 bpm (1)

- 100+ bpm (2)

- Grimace:

- no response to stimulation(0)

- weak cry/grimace when stimulated (1)

- pulls away/coughs/cries strongly when stimulated (2)

- Activity:

- limp/no movement (0) - some flexing of arms/legs (1)

- active motion (2)

- Respirations:

- not breathing (0)

- weak cry/irregular breathing (1)

- strong cry and regular breathing (2)

APGAR Scoring

7-10 (normal)

4-6 (needs help)

0-3 (emergency resuscitation)

Oxytocin

- Breastfeeding stimulates release of oxytocin

- Oxytocin, released from pituitary gland, strengthens and coordinates uterine contractions

- influences menstruation

Prolactin

- Prolactin levels decline within 2 weeks if not breastfeeding.

- influences menstruation

Menstruation: Follicular Phase:

days?

what occurs here?

hormones?

Follicular Phase

- days 1-14

- Menstruation occurs

- FSH stimulates follicle (egg) growth

- Estrogen rises and thickens lining

Menstruation: Ovulation:

what day is it?

hormones?

what occurs?

Day 14

- LH surges and causes mature egg to be released

Menstruation: Luteal Phase:

Days?

what occurs here?

hormone?

Days 15-28

- Corpus Luteum forms and secretes progesterone

- Progesterone maintains uterine lining for pregnancy

Parameters for Menstruation:

cycle length?

duration?

amount?

too much?

I'm not putting symptoms here if you're a dude idk what to tell you

- Cycle length: 24-38 days

- Duration of flow: 3-7 days Amount of flow: <80mL per cycle,

" too much" - soaking pad in 1 hour

Primary Amenorrhea:

absence of menses by age 15/16

(never got it)

Secondary Amenorrhea

absence of menses for three cycles

( you had it, but then it went away )

What are the causes of primary and secondary amenorrhea?

- pregnancy/breast feeding

- anatomic abnormalities

- HPO axis dysfunction

Primary Dysmenorrea: what is it and what is it caused by?

- painful menstruation in absence of underlying pelvic pathology; caused by prostaglandin production

Secondary Dysmenorrhea: what is it and what is it caused by?

- menstrual pain due to underlying pathology (eg. endometriosis, adhesions, fibroids, PID etc)

Presentation and Associated Risks in PCOS:

condition?

s/s?

major cause?

associated with ?

treatment?

- Hormonal condition

- S/s: menstrual irregularity, excess androgens (hirsutism, alopecia, obesity, acne)

- Major cause: insulin resistance (metformin)

- Associated with: obesity, diabetes, mood disorders, infertility

- Treatment: metformin, lifestyle changes, clomid (fertility tx), semaglutides.

Structural Causes of Abnormal Uterine Bleeding (AUB)

"PALM"

- polyp, adenomyosis, leiomyoma, malignancy

Non Structural Causes of Abnormal Uterine Bleeding (AUB)

"COEIN"

- coagulopathy, ovulatory, endometrial, iatrogenic, not classified

Vaginal Environment:

what is the normal pH?

what is the good bacteria and how does it maintain the vaginal environment?

bacterial vaginosis?

candidiasis?

- Normal pH: 3.8-4.5

- Good Bacteria: lactobacilli blocks pathogens and disruptions in flora (sex, use of feminine products, STDs, contraceptives)

Bacterial vaginosis: fishy, itchy, thin white discharge, sexually associated.

Candidiasis: chunky white cottage cheese, yeast

What is the percentage of unintended pregnancies?

What do unintended pregnancies end in?

What are the risks of unintended pregnancies?

43% of pregnancies are unintended, higher in low income/education, 18-24 yrs.

42% end in abortion, 58% end in birth.

Risks: delay prenantal care, violence, mental health issues

Sexual History: CDC's 5 P's

partner, practices, protection, past history of STIs, pregnancy intention

Oral Contraceptives:

MOA?

Risks?

Benefits?

Side effects?

MOA: prevent pregnancy by inhibiting ovulation, thickening cervical mucus, and altering endometrial lining.

Risks: DVT/venous thromboembolism, inc BP, breast/cervical cancer risk.

Benefits: effectiveness is 99% when taken properly, regulates cycle, dec. cramps, reduces acne, reduce heavy/painful periods.

Side Effects: mood changes, amenorrhea w long use.

LARC Method IUDs:

benefits?

risks?

side effects?

benefits: long lasting, effective, no user error, rapid return to fertility, can reduce heavy/painful flow

Risks: insertion risks (perforation, expulsion), pelvic infection, ectopic pregnancy

Side effects: irregular bleeding, light/absent periods, heavy/more painful periods, weight gain, mood change.

Chlamydia:

symptoms?

what can it lead to?

what is it associated with?

-Dysuria/discharge/ bleeding OR asymptomatic

- 10-15% of women with untreated chlamydia develop PID

- Associated with ectopic pregnancy/infertility

Gonorrhea:

symptoms?

what can it lead to?

what is it associated with?

-Dysuria/discharge OR asymptomatic

- can develop PID

- Associated with ectopic pregnancy/infertility

HSV:

what are the types?

symptoms?

what can trigger recurrences?

Herpes Simplex Virus

• Two types: HSV-1 and HSV-2

• Symptoms: painful vesicular lesions, prodromal symptoms may precede outbreaks

• Stressful events may trigger recurrences

HPV:

prevention?

what does it affect?

HPV 6,11: how serious? what do they cause?

HPV 16,18: how serious? what can they cause?

- VACCINATE

- Genital types have specific affinity for genital skin and mucosa

- HPV 6,11:

- non-oncogenic

- causes genital warts

- HPV 16,18:

- dangerous, oncogenic

- cause cervical, anal, penile, vulvar cancers.

Menopause:

how long without menses?

average age?

perimenopause?

symptoms?

management?

• 12 months without a menstrual period

• Average age: 51

• Perimenopause: 2-8 years prior, menstrual irregularity, decreasing/fluctuating estrogen

• Symptoms: Vasomotor sx (hot flashes), genitourinary syndrome, and more!

• Management Pharmacological (hormone therapy), CAM, Lifestyle

What are the causes of bleeding in early pregnancy?

implantation, ectopic pregnancy, spontaneous abortion, gestational trophoblastic disease

Implantation bleeding: what is it?

bleeding in early pregnancy, bleeding after fertilization

Spontaneous Abortion:

nursing care?

- bleeding in early pregnancy

- monitor bleeding

- monitor for products of conception

- RhoGAM if Rh neg

Ectopic Pregnancy:

nursing considerations ?

interventions?

- causes of bleeding in early pregnancy

- Nursing:

- hemodynamic stability, Rhogam if Rh negative, CBC, hCG.

- Interventions: methotrexate or surgery

Gestational Trophoblastic Disease:

nursing considerations?

- causes of bleeding in early pregnancy

Nursing:

- immediately evacuate contents of uterus

- long term follow up + hCG monitoring

Other causes of bleeding in early pregnancy...

- Lesions, infections, polyps, fibroids, cancer

What is placenta previa ?

Improper implantation in lower uterine segment, overlying the os.

Placenta Previa: low lying

os?

low lying?

- <2cm away but not overlying oz: low lying

Placenta previa:

- s/s?

- when does it occur/how often?

- how do you confirm?

- what NOT to do?

- Management?

s/s:

- PAINLESS bright red vaginal bleeding

- occurs at >20 weeks gestation, recurrent

- Sonographic confirmation

- NO VAGINAL EXAMINATIONS

- Management: bed rest, pad count q 4 hours, betamethasone, fluids

Placental Abruption:

what is it?

S/S?

management ?

- Premature separation of placenta from uterine wall leading to compromised fetal blood supply.

• Presentation:

- dark red vaginal bleeding

- abdominal pain/ uterine contractions

- rigid/tender uterus

- hypotension

- FHR abnormalities

- Nursing Management:

• Continuous fetal monitoring

• Labs

• Oxygen therapy

Shoulder Discotia Nursing Interventions

• Call for help

• McRoberts maneuver (thighs flexed up onto abdomen)

• Suprapubic pressure (not fundal)

• Help roll patient to hands and knees

Umbilical Cord Prolapse:

what is it?

Nursing interventions?

- Cord exits cervix before fetus, can lead to hypoxia

Nursing Interventions:

• Assessment with ROM

• Elevate presenting part!

• Knee-to-chest position

• Emergency Cesarean

Fetal and Maternal Indications for C Sections

- Labor dystocia

- Abnormal FHR

- Fetal malpresentation

- Multiple gestations

- Fetal macrosomia

- Placenta previa

- Previous uterine surgery - Herpes (active)

- Maternal medical conditions

Vacuum Extraction:

indications ?

nursing care?

• Indications:

- analgesia or exhaustion

- limits ability to push effectively

- non-reassuring fetal heart tracing

Nursing Care:

• Pump vacuum to appropriate level

• FHR assessed every 5 minutes

• Caput will disappear in 2-3 days

Forceps: indications

• Indications:

- analgesia or exhaustion

- limits ability to push effectively

- non-reassuring fetal heart tracing

Caput:

what is it?

characteristics?

when does it go away?

- benign edema, from long labor or vacuum

- crosses suture lines, soft, boggy, poorly defined borders

- presents at birth goes away in 48 hours.

Cephalohematoma:

what is it?

characteristics?

when does it go away?

- blood collection

- does not cross suture lines, firm

- hours or days after birth and disappears in weeks or months.

Gestational Diabetes (GDM):

management?

risk factors?

Management:

- insulin

- metformin

- glyburide

- dieting

- lifestyle

Risk factors:

- PMH

- BMI>30

- PCOS

- age>35

- previous infant >4000g

GDM Maternal Risks

- preeclampsia

- HTN

- difficult labor

- polyhydramnios

- UTI, vaginitis

- Type 2 DM

GDM Fetal Risks

- trauma

- hypoglycemia

- resp distress

- inc. billirubin

- obesity/diabetes longterm.

Gestational Hypertension:

when does it occur?

bp?

protein in urine?

organ involvement?

- after 20 wks

- BP >140/90

- NO protein in urine

- NO organ involvement

Preeclampsia:

when does it occur?

bp?

protein in urine?

organ involvement?

can lead to?

seizures? coma ? hyperreflexia?

- after 20 wks

- bp >140/90

- Protein present in urine

- organ involvement is present

- can lead to eclampsia causing complications.

- No seizures, no coma, no hyperreflexia

Preeclampsia with severe features:

bp/diagnosing criteria?

protein in urine?

organ involvement?

can lead to?

seizures? coma ? hyperreflexia?

- BP >160/110 on 2 occasions at least 6 hours apart while on bedrest

- Protein present in urine

- organ involvement is present

- NO seizures/coma,

- hyperreflexia is present

- HELLP (hemolysis, elevated liver enzymes, low platelets)

Eclampsia:

bp?

can lead to?

seizures? coma ? hyperreflexia?

other severe s/s?

- >160/110

- seizures/coma present, hyperreflexia present

- HELLP, renal failure, cerebral damage.

Maternal preeclampsia/ eclampsia risk

- seizure

- organ failure

- HELLP

- stroke

Fetal preeclampsia/ eclampsia risk

- preterm

- IUGR

- low birth weight

- placental abruption

- distress

- death

Eclampsia/ Preeclampsia meds?

Management?

Meds:

- magnesium sulfate: seizure prevention

- antihypertensives

- corticosteroids PRN

- seizure management PRN

Management:

- bed rest/ quiet

Preterm Labor Meds

- Tocolytic therapy (nifedipine, terbutaline, indomethacin): slow contractions

- corticosteroids (betamethasone, dexamethasone): fetal lung maturity

- Mg Sulfate: fetal neuroprotection

- Antibiotics: GBS

Perineal Lacerations 1st Degree

injury to epithelium + vaginal skin only

Perineal Lacerations 2nd Degree

injury to perineal muscles but not anal sphincter

Perineal Lacerations 3rd Degree

injury to perineum involving anal sphincter complex

Perineal Lacerations 4th Degree

injury to perineum involving anal sphincter and anal/rectal mucosa

Management of Perineal Lacerations

• Ice pack in first 24 hours

• Peribottle

• Sitz bath

• Topical anesthetic

• Oral pain medication

• Assess for hematoma and signs of infection

• Prevention of constipation (docusate, fluid, fiber, ambulation)

Respiratory Distress:

signs and symptoms?

- Grunting : Flaring

- Retractions

- Tachypnea

Infant Sepsis:

management?

signs and symptoms?

Management:

- Q 4 hour vital signs for 48 hours

- Head to Toe assessment q 8 hours

Signs and symptoms:

- respiratory distress

- pallor

- temperature instability

Infant Jaundice:

s/s?

management?

Signs and symptoms:

- encephalopathy

- kernicterus

- jaundice, yellow skin

- increased bilirubin.

Management:

- Universal Screening •

- No risk factors: 48 hours

- Risk factor present: 12 hours, 24 hours, and 48 hours

- Phototherapy

Infant Hypoglycemia:

blood sugar?

screening?

causes?

signs?

- Blood glucose level less than 45mg/dL in first 72 hours

- Screening: Q 3-4 hours blood glucose checks q 12 hours

- Causes: GDM, LGA, SGA/IUGR/preterm

- signs: jittery, lethargy, cyanosis, apnea, seizures, high pitched/weak cry, HYPOTHERMIA , poor eating