NU 321 OB Exam 3

When is the fourth stage of labor?

4-6 hours post-delivery

Includes recovery, freq VS, and fundal exam

Describe involution of the uterus

• Process of uterus returning to pre-pregnancy stage/size

• Immediately after delivery: 2#

• 1 wk: 1#

• 6 wk: 2 oz
  

Oxytocin is excreted from the

posterior pituitary

Describe uterine/placental healing

• Placental attachment is 3-4” in diameter

• Heals via exfoliation/sloughing without scar

• Autolysis: self digestion

  • Proteolytic enzymes released into endometrium = cells loosen protein and shrink

  • Same # of cells, just smaller

What is locia

Postpartum vaginal discharge - uterine shedding lining (decidua) including blood, tissue, and mucus

Describe changes in lochia

• Days 1-3: Lochia Rubra

  • Bright or dark red

  • Mainly blood, decidual tissue, fetal membranes

  • Small clots

  • Heaviest flow

• Days 4-10: Lochia Serosa

  • Pink or brown

  • Blood, mucus, WBC

  • Flow is moderate

• Days 10-6 wks: Lochia Alba

  • Whitish or yellowish

  • Mucus, leukocytes, epithelial tissue

  • Flow is scant

How many weeks does it take vaginal rugae to return

4 weeks

What does dyspareunia mean?

Painful sex

Describe varying degrees (1-4) of perineal laceration

• First degree: skin, superficial tissue

• Second degree: + muscles

• Third degree: + sphincter muscle

• Fourth degree: + anterior rectal wall

Birthing the placenta reverses the diabetogenic effect of pregnancy, resulting in

Lower BGC

HCG is absent by what day postpartum?

Day 14

For a breastfeeding mom, elevated prolactin occurs for 1. how many months postpartum and 2. suppresses what?

1. 6 months postpartum

2. Suppresses ovulation

For a non-breastfeeding mom, ovulation may be as early as 27 days, but the mean is

• 70-75 days

• Most menstruate within 3 mo

• Prolactin levels reach pre-preg norm within few weeks

Colostrum is continued to be produced in the first [ ] days postpartum before transitioning to transitional milk.

2-4 days

• 2-20mL per feeding

• High in IgA, vitamin A, protein

• Low in fat and sugar (easier for NB to digest)

Circulatory changes: Postpartum moms remain in a hypercoagulable state, and WBCs are elevated due to

Stress of delivery

Describe the components of “BUBBLE” and what it’s used for

Postpartum assessment

• B - breasts

• U - uterus

• B - bowels

• B - bladder

• L - lochia

• E - episiotomy/laceration/incision

How is postpartum hemorrhage defined?

• EBL >1000mL blood loss accompanied by hypovolemia

• <24 h after birth

• 10% change in Hct

• Need for RBC transfusion

• Increased surveillance requires quantitative blood loss (QBL)

PPH is categorized as early/acute/primary or late/secondary. Define

Early/acute/primary: Within 24 h of birth

Late/secondary: More than 24 h but less than 6 wk postpartum

What is the leading cause of (often early) PPH

Uterine atony

Uterine atony is defined as

marked hypotonia

Treatments for uterine atony include

• Pitocin

• Methergine - Don’t give to those with HTN**

• Hemabate - Don’t give to those with asthma**

• Cytotec

• Dinoprostone

• Tranexamic acid

• Surgical management - Tamponade

Methergine can’t be given to those with

HTN

Hemabate can’t be given to those with

Asthma

Retained placenta can cause hemorrhage and requires manual removal, hysterectomy, and/or blood replacement. Define the 3 types of retained placenta.

• Placenta accreta: Slight penetration of myometrium by placental trophoblast

• Placenta increta: Deep penetration of myometrium by placenta

• Placenta percreta: Perforation of uterus by placenta

Inversion of the uterus can be complete or incomplete. Describe assessment findings of both

• Complete: large red rounded mass protruding 20-30 cm out of introitus (vaginal opening)

• Incomplete: palpated as a smooth mass through dilated cervix

How to calculate corrected/adjusted age

• Chronological age - weeks premature = corrected age

• Determine weeks premature: 40 weeks - gestational age at birth

• Typically used until 2-3y when most preterm infants catch up developmentally

Describe subinvolution of the uterus

• Delayed or incomplete return of uterus to pre-preg state (involution distrupted)

• Can be caused by retained placenta, endometritis, uterine atony, etc.

• Causes LATE postpartum bleeding

  • Prolonged lochia

  • Hemorrhage

  • Large or boggy uterus

A boggy uterus is…

• Soft, poorly contracted uterus after birth

• Key sign of uterine atony

• Uterine massage is first-line treatment

Signs of hypovolemic shock may not occur until [ ] of blood volume is lost.

30-40%

Describe DIC

• Consumption of clotting factors = widespread bleeding

• Vascular occlusion of small vessels d/t clots

• Caused by stillborn, severe pre-e, sepsis, CV arrest, etc.

• Observe bleeding from IV and puncture sites, petechiae (such as under BP cuff)

Postpartum infection is defined as

• Clinical infection of genital canal occurring <28 days after miscarriage, abortion, or childbirth

• Risk factors: prolonged labor, internal monitoring, DM, immunosuppression

• Such as endometritis, mastitis

Risk of postpartum infection is 10-15x higher with…

C-sections

Define endometritis and provide s/sx

• Begins as localized infection at placental site, spreads to endometrium

• Fever, chills, pelvic pain, foul smelling discharge

Describe mastitis

• Most are first time breast feeders

• Usually unilateral

• Develops after flow of milk established

• Staph aureus

• Initially nipple fissure, then duct is involved

• Edema obstructs flow of milk

• Can progress to abscess

  • May require surgical drainage

PPH is a leading cause of death in US

• 4.3%

• 70,000 maternal deaths annually globally

Afterpains are caused by

• Oxytocin constricting blood vessels at point of placental separation

• Impeded by full bladder

The cervix takes [ ] weeks to heal postpartum

6

• Swelling, bruised, red, slit-like appearance

The perineum recovers in

6-8 wk

Describe postpartum changes caused by decreasing estrogen and progesterone

Decreasing estrogen: Diuresis, breast engorgement r/t milk production, postpartum mood changes/depression

Decreasing progesterone: Milk production, return of menstrual cycle, uterine involution

What are typical EBLs of both vaginal delivery and c-section

V: 200-500mL

C: 500-1000mL

Early postpartum has a/n [ ] in platelets, causing a [ ] state

Increase in platelets = hypercoagulability

What are the 4 T’s of PPH

• 1. Tone (uterine atony)

• 2. Trauma (lacerations)

• 3. Tissue (retained placenta)

• 4. Thrombin (coagulation dysfunction)

Two most common/initial s/sx of hematoma formation

Pain

Shock

empty

Occurrence of postpartum infection is [ ]%

5-7%

Puerperal sepsis is one of the top 5 causes of maternal deaths worldwide, causing [ ]% of deaths in the postpartum period

10-15%

Endometritis is the most common postpartum infection, affecting [ ]% of vaginal and [ ] of c-section deliveries

V: 1-3%

C: 5-10%

2-4% of women develop what type of infection postpartum?

UTI

1% of women will develop…

Mastitis

Neonate is a term used for infants aged…

Birth through 28 days

The postpartum “Transition Period” lasts how many hours?

6-8

How do contractions alter PO2, PCO2, and pH?

PO2: Decreased

PCO2: Increased

pH: Decreased

Cord cutting [increases/decreases] prostaglandins

Decreases

How often and how long can respiratory pauses be and still be considered normal?

Normal is 30-60 pauses of 15 seconds

• Typically occur during REM

• Longer than 20 seconds is a problem

What causes the closure of the foramen ovale?

First extra-uterine breaths

• Initial breathing occurs against increased alveolar capillary distention

• Increased pulmonary blood flow causes a closure of the foramen ovale

• May have transient murmurs until closure

Where is neonate cardiac PMI?

Fourth intercostal space and to the left of the midclavicular line

Is it recommended to routinely obtain 4 point BPs?

No

When should a nurse obtain a 4 pt BP?

• Tachycardia

• Persistent murmur

• Abnormal pulses

• Poor perfusion

• Abnormal precordial activity

What are normal BP values for a NB?

Systolic 60-80

Diastolic 40-50

When is a NB considered hypotensive? What about hypertensive?

Hypotensive: Mean BP less than gestational age

Hypertensive: Mean pressure exceeds 50-70

What is a neonate’s blood volume?

• 85mL/kg

• 300mL at birth

• If delayed cord clamping, increases by 100mL

Causes of NB persistent tachycardia

• Anemia

• Hypovolemia

• Hyperthermia

• Sepsis

Causes of NB persistent bradycardia

• Congenital HB

• Hypoxemia

A significant difference between upper and lower extremity BPs is an early sign of…

Coaractation of aorta

Pathologic jaundice occurs within 24 hours of birth and can be caused by…

ABO or Rh issues

Leukocytosis is [normal/abnormal] at birth

Normal

A NB with sepsis is likely to display [increased/decreased] WBCs

DECREASED WBCs!

What is the normal NB temp range?

• 97.8-98.8 

  • Slightly higher may be ok if it makes sense clinically (eg wrapped in blankets)

What are the four methods of heat loss?

• Convection

  • Heat to cooler ambient air

• Radiation

  • Loss of heat to cooler solid surface (not in direct contact) 

• Evaporation

  • Liquid to vapor 

• Conduction 

  • Loss of heat to cooler surface in direct contact 

Describe convection

Heat loss to cooler ambient air

Describe radiation

Heat loss to cooler solid surface NOT in direct contact

Describe evaporation

Heat loss from liquid to vapor

Describe conduction

Heat loss to cooler surface in DIRECT CONTACT

Infants cannot shiver, and thus have reserves of…

Brown fat, for thermogenesis

• Can increase heat production by as much as 100%

• Reserves gone by few weeks postpartum

• Premature infants have less

What is cold stress?

• Pre-hypothermia

• Increases metabolic and physiologic demands

  • BMR increases

• Respirations increase

• Anerobic glycolysis occurs

  • Increases production of acids

    • Metabolic acidosis

    • Increases risk of hyperbilirubinemia

Describe symptoms of NB hyperthermic sepsis

• Stressed

• Constricted vessels

• Pale

• Hands and feet cold

NBs should void within [ ] hours.

• 98% void within the first 30 hours

• If none in 48 hours, consider renal impairment 

Describe red brick staining

• Caused by washing of uric acid crystals, not blood

• Normal in first days after birth

[ ]% of a NB’s body weight is water. [ ]% of body weight is extracellular.

[75]% of a NB’s body weight is water. [40]% of body weight is extracellular.

Describe NB’s daily fluid requirements in 1) first 2 days and 2) following that

1) First 2 days: 40-60mL/kg

2) Following: 100-150mL/kg/24 hours

Babies lose 5-10% of their body weight in the first [ ] days. They regain birth weight within [ ] days after birth.

Babies lose 5-10% of their body weight in the first [3-5] days. They regain birth weight within [14] days after birth.

Sucking calluses disappear by [ ] months.

12 months

What are epsteins pearls?

• Whitish-yellow “retention cysts” along the gums or on the roof of a NB’s mouth

• Harmless, disappear within weeks

Stomach capacity of a NB is…

30-90mL

Lowest BGC level occurs between [ ] minutes postpartum

30-90 minutes

• 40-80mg/dL

60% of NBs have…

Hyperbilirubinemia

• Can be physiologic or pathologic

Describe kernicterus

• Acute bilirubin encephalopathy 

• Lethargic

• Hypotonic

• Poor suck

• High pitched cry

• Fever 

Nevi, or stork bites, are [blanchable/nonblanchable]

Blanchable

Describe caput succadaneum

• Commonly on occiput

• Edematous swelling of fetal scalp

• Crosses suture lines

• Disappears 3-4 days

• Harmless

• Occur especially with vacuum-assisted

Does caput succadaneum or cephalhematoma cross suture lines?

Caput succadaneum: yes, crosses

Cephalhematoma: no, doesn’t cross

Describe cephalhematoma

• Collection of blood between skull bone and periosteum

• Doesn’t cross suture lines

What is the Ortolani maneuver?

A physical examination technique used to assess for congenital hip dysplasia

Describe NB reflexes: extrusion, fencing, stepping, babinksi

Extrusion: aka “tongue-thrust,” protects from choking. Pushes tongue forward when touching the lips. At birth.

Fencing: asymmetrical tonic neck reflex. Baby extending the arm and leg on the same side their head is turned towards while flexing the limbs on the opposite side. 18 weeks.

Stepping: occurs when held upright and their feet touch a flat surface.

Babinksi: occurs after the sole of the foot has been firmly stroked. The big toe then moves upward or toward the top surface of the foot. The other toes fan out

Describe a NB’s vision

• No tears

• Crossed eyes

• Tracking

• Black and white

• 12 inches of vision

• Prefers patterns

Fluid in the NB’s middle ear can cause…

A failed NB hearing test/false positive hearing loss

Taste develops..

At 25 weeks in utero

Differentiate between caput succedaneum and cephalohematoma

• Caput succedaneum is edema (swelling) of the scalp due to pressure, while cephalohematoma is a collection of blood (hemorrhage) under the scalp

• Cephalohematoma doesn’t cross suture lines while caput succedaneum does.

• Caput succedaneum appears at birth and usually resolves within a few days while cephalohematoma appears shortly after birth and may take weeks or even months to resolve

What four types of factors stimulate the medulla’s respiratory center in order to cause respiration after birth? Give an example of each

• Chemical

  • Contractions causing transient hypoxia and hypercarbia

    • Decreased PO2 and pH & Increased PCO2

• Mechanical

  • Changes in intrathoracic pressure

• Thermal

  • Skin receptors

• Sensory

  • Handling, suction, drying, sights and sounds

Apgar scores are obtained at…

1 and 5 minutes

Apgar is scored from a total of…

0-10