OB Final (NURS 354-Liberty University)

Self exam of breasts should occur when?

Every month during the week after menses and before ovulation

Position for breast self exam?

Lying flat on the back with one arm over head and pillow or towel under other shoulder

OR

standing in shower

When should a menopausal woman do a breast self exam?

Does not matter as long as it's consistent

ex: First of the month or birthday (21st of every month)

Clinical breast exams should be done how often?

Every 2-3 years between 20 and 39 years old and yearly over 40 years of age

Mammography should be how often?

Every two years over 40 years of age unless the woman has fibrous breasts

5 main benign breast conditions

1. Fibrocystic breast change (benign breast disease-BBD)

2. Fibroadenoma

3. Intraductal papillomas

4. Duct ectasia

5. Mastodynia/Mastalgia

Fibrocystic breast change

Most common in 20-50 year olds

No risk of cancer

Pea sized lumps with bilateral cyclic breast pain

Tx: Restrict sodium and take mild diuretic/analgesic before period

Fibroadenoma

Common in teens-35 years

Solid, moveable, quarter/golf ball size, asymptomatic, Non-tender, possible bilateral galactorrhea (unilateral is probably cancer)

Intraductal papillomas

Unilateral bloody discharge post-menses. Tumor in terminal portion of duct, solid and ball like but not palpable

Remove because it may increase risk of cancer

Duct ectasia

aka comedomastitis

Inflammation of ducts behind nipple in nursing moms

Thick sticky discharge/burning pain/swelling/redness

Tx: Excise pus, use warmth to relieve pain

Mastodynia/Mastalgia

Tender, swollen breasts related to menses

Most important thing to remember about contraceptives

Consistency is more important than reliability

6 categories of contraceptives

1. Fertility awareness based

2. Spermicidal

3. Barrier method

4. Hormonal

5. Sterilization

6. Long-acting reversible contraception

Fertility awareness based methods require

That the woman to monitor her fertile window

Natural family planning/Standard days method/Calendar rhythm method

Only works for women with regular periods and are not breastfeeding

Don't have sex during fertile window (days 8-19)

Billings ovulation method

Assessment of cervical mucous changes

Clear- no sex

Can be used by women with irregular cycles

Symptothermal method

Recording indicators of fertility - including cycle length, frequency and timing of colitis, cervical mucous changes, secondary signs of ovulation (increase sex drive, bloating, mittelschmerz) and changes in basal body temp

Basal body temperature method

Abstain from sex for an entire cycle

Take temp every morning at the same time

Temp rises and remains elevated after ovulation

Use contraception on day of temp rise and 3 days after

May be at risk for pregnancy of had sex right before temp rise

Spermicidal method

Nonoxynol-9

Used before sex

Comes in gel, foam, cream, vaginal film, cervical sponge, and suppository

Minimally effective on its own

Barrier methods includes

Condoms, diaphragm, cervical cap, cervical sponge

Diaphragm, cervical cap and female condom should NOT be used with

Oil-based products

Female barriers can be kept in for how long and should be kept in for how long after intercourse?

Total of 24-48 hours

At least 6-8 hours

Female condoms

Thin sheath with a flexible ring at each end-one fits over the cervix and the other covers some of the perineum

Do not twist sheath when inserting because it will make it impossible for penetration

May be put in 8 hours before sex, great protection against STI's

Cannot be used with male condom

Diaphragm

Steel ring covered with latex or silicone that covers the cervix

Spermicidal cream placed around edges and must be fitted and rechecked after childbirth or weight change of 10-15 lbs.

Add more spemicide q6hr

Do not leave in more than 24 hours

Periodically check for tears and holes

Lasts several years and should be washed, dried, and stored (NO TALC POWDER)

Cervical cap

Smaller version of diaphragm

Cervical/Vaginal sponge

Available without prescription

Contains N-9 and releases spermicide, after wetting it, for 24 hours

Must leave in for 6 hours after last coitus

Only last 24 hours

Long-acting reversible contraception includes

1. Nexplanon subdermal implants

2. Intrauterine Contraception (IUD/IUC)

Nexplanon

Implanted in non-dominant upperarm

Lasts for 3 years

Causes thickened cervical mucous

Intrauterine contraception (IUC/IUD)

Device placed in uterus for 3-10 years

Must be removed if pregnant, must check string each week after menses

Sterilization falls into what two categories?

Operative and non-operative

Operative sterilization includes what two procedures?

Vasectomy and tubal ligation

Non-operative sterilizations

Essure- a micro-insert that causes scar tissue in fallopian tubes

Hormonal contraception uses what two hormones

Estrogen and progestin

Combination hormonal contraceptives do what to prevent conception

Inhibits release of ovum, creates atrophy of endometrium and maintains thick cervical mucous (slows sperm)

Combination Oral Contraceptives (COC's)

Aka Birth control

Most popular option because it is safe, rapidly reversible, and creates a "scheduled bleed"

Requires prescription

Effectiveness decrease with abx and anticonvulsants

Contraindications: Hx of blood clots, stroke, heart problems, breast CA, current pregnancy, smoking, over 198 lbs

Transdermal hormonal contraception

Progesterone and ethynyl

Weekly skin patch

Wear patch for 3 weeks and break for period on fourth week

Better compliance since it is not daily

Cannot use if over 198 lbs

Nuva ring

Vaginal ring inserted for three weeks and removed for 7 days and replaced the same day every month

Must be fitted and replacements must be refrigerated

Progestin-only contraceptives

"Mini pill"

Nexplanon

Depo-Provera

"Mini pill"

Used by nursing mothers since it doesn't affect breast milk

Used in medical conditions exacerbated by estrogen

Ex: HTN, thrombophlebitis, etc

Slightly less effective than "the pill"

Depo-Provera

Injectable contraceptive

4 injections/year and is irreversible

Safe with breastfeeding

Return of fertility may take 10 months

Must take Calcium and Vit D to prevent bone loss

Post-coital emergency contraceptives (EC) aka

Morning after pill

EC

Taken within 72 hours but up to 5 days

Not medical abortion

Prevents fertilization

Bacterial Vaginosis

Not an STI

Tissue trauma

Excessive, thin, watery, fishy smelling discharge

Tx: Metronidazole

Vulvovaginal Candidiasis

aka yeast infection

75% of women get at least one

Thick, curdy, white discharge with itching and white patches on vaginal walls

Tx: Topical antifungals and probiotics/yogurt

Cotton underwear, loose clothes, no douching, void before and after intercourse

Trichmoniasis

Most curable STI

Yellow-green, frothy, odorous discharge

Dysuria, itching, strawberry-like red marks

Tx: Flagyl or Tinidazole

NO INTERCOURSE until both partners are cured (7 days)

Chlamydia

Most common STI

Often asymptomatic

Thin, pucopurulent discharge, burning/frequent urination, lower ABD pain, PID

Tx: Broad spectrum abx (Zithromax, Amoxicillin, Erythromycin)

Gonorrhea

2nd most common STI

Often asymptomatic until complications such as PID

Yellow-green vaginal discharge, dysmenorrhea, lower abd pain, vulva and vaginal red and irritated

Tx: Cephtriaxone

Group B Strep

Doesn't make woman sick unless immunocompromised BUT will pass to baby during delivery and is the leading cause of neonatal sepsis and mortality

Tx: Penicillin/ampicillin over 4 hours while in labor to protect baby from getting it

HPV

aka veneral wart/condyloma acuminate

Linked to cervical and anorectal cancer (99% of cervical CA is due to HPV)

Gray/pink cauliflower with stress (usually asymptomatic)

Tx: Podophyllin, TCA/BCA, cryocautery, surgical removal

Prevention with Gardasil vaccine

TORCH consists of what?

Toxoplasmosis

Other infections

Rubella

Cytomegalovirus

Herpes

Toxoplasmosis

Protozoal infection from raw/uncooked meat and cat feces

Tx: Trisulfapyrimidines

Other infections

Hep A & B

Syphilis

Mumps

Parvovirus B-19

Varicella-Zoster

Rubella

Vaccine should only be given after delivery and wait 1-3 months to get pregnant again

Cytomegalovirus

Part of herpes viral group

Very prevalent in children

No treatment, just wash hands

Herpes genitalis/simplex

Cold sore/genital infection

No cure

"Herpes, unlike love, lasts forever" ~Ms. Drohn

Blister-like vesicles, tingling/itching, dysuria, enlarged lymph nodes, flu-like symptoms

Tx: Acyclovir

Polycystic Ovarian Syndrome (PCOS)

Endocrine disorder affecting reproduction

Menstrual dysfunction is most common sign

Hyperandrogenism (male characteristics), obesity, infertility, often diabetes

Tx: COC's, antiandrogens, metformin, ART

Endometriosis definition

Presence of endometrial tissues outside the uterine cavity most commonly in the pelvic cavity

Endometriosis sx/tx

Pelvic pain & intercourse

Tx: oral contraceptives, progestin, danizol, GnRH analogs, surgery

EPF stands for what?

Early pregnancy factor

What is early pregnancy factor?

An immunosupressant so mom doesn't attack baby, shows in serum 24-48 hours after fertilization

FSH

Follical stimulating hormone- if too low there is no ovulation

LH

Luteal hormone

Estrogen

Increases uterine size and weight

Progesterone

Hormone of pregnancy

Prostaglandins

prevent hemorrhage, vasoconstrict, and ripen cervix

hCG

stimulates estrogen and progesterone production by corpus luteum for first 12 weeks of pregnancy

hPL

ensures good nutrient supply, antagonist of insulin (increased glucose to baby)

Relaxin

softens cervix, relaxes joints and muscles

Menarche

First menstrual period

When does menarche occur?

Two years after breast development

Usually 9-13

Menstruation is the number one cause of what?

Anemia

Hypomenorrhea

Abnormally short duration of menses

Hypermenorrhea

Abnormally long duration of menses

Oligomenorrhea

Infrequent menses

Polymenorrhea

Too frequent menses

Menorrhagia

Excessive menstrual flow

Metrorrhagia

Bleeding between periods

Menometrorrhagia

Bleeding that is excessive in amount and duration, occurring at regular and irregular intervals

Amenorrhea

absence of menses

Primary amenorrhea

No period by 16 years old

Why would someone have primary amenorrhea?

Obstruction, hormonal imbalance, born without a uterus

Secondary amenorrhea

When an established period goes away for more than 3 months

Give a few examples of why secondary amenorrhea would happen?

Hypothalmic dysfunction

Pituitary dysfunction

Ovarian failure

Anatomic abnormalities

Obstruction

Stress

Hormonal substance

Pregnancy

Menopause

Decreased body fat

Strenuous exercise

Breastfeeding

Dysmenorrhea

pain that occurs at or a day before the time of menses and goes away when period is over

Primary dysmenorrhea

Cramps without underlying disease

Secondary dysmenorrhea

Associated with pathology of reproductive tract appearing after menstruation

Causes of secondary dysmenorrhea

Endometriosis

Pelvic inflammatory disease

Cervical stenosis

Uterine fibroids

Ovarian cysts

Tumors (benign or malignant)

Presence of intrauterine device

An-ovulatory cycle

No ovulation

Painless but very heavy bleeding because of lack of prostaglandins

PMS

Behavior and physical changes during luteal phase that is relieved upon menstruation

How do you treat PMS?

Increased vitamins and minerals, grazing, carbs, and protein

Possible oral contraceptives

Avoid: Salt, sugar, caffeine, and nicotine

Premenstrual dysphonic disorder

VERY serious PMS

Treat with serotonin: Prozac or Zoloft

Cycle from day 1-28

1-5: Period

5-14: Follicular phase

14: Ovulation

14-28: Luteal phase

When does ovulation occur in ANY cycle?

14 days before menstruation

Three presentations

Cephalic, breech, and shoulder

Three types of breech presentation

Complete- butt and feet present

Frank- only butt first

Footling- feet first

Four main fetal positions

LOA

LOP

ROA

ROP

What is "back labor"?

When the baby's occiput is posterior

Where does fertilization occur?

The ampulla of the fallopian tube

What is the cell created at conception called?

A zygote

What part of the sperm breaks down the egg wall?

Hyaluronidase