Concepts in Reproductive Health Exam 2

indications for c-section

labor dystocia, abnormal or indeterminate FHR tracing, fetal malposition, multiple gestation, suspected macrosomia

maternal indications for C-section

previous c-section, placental abnormalities, cephalopelvic disproportion, mechanical impediment of progress of labor or arrest of active labor, previous uterine surgery, medical conditions such as cardiac disease, severe diabetes, preeclampsia, current genital herpes outbreak at time of labor

classification of c-sections

scheduled vs. unscheduled. Arrest of labor or abnormal/indeterminate FHR are main reasons for unscheduled. Scheduled: previous c-section, cephalopelvic disproportion, fetal malposition, active genital herpes, provider preference

emergent c-section: immediate need to delivery for reasons that arise suddenly during labor (prolapsed cord, premature separation of placenta, rupture of uterus, abnormal FHR patterns/fetal distress, failure to progress)

risks related to c-section

increased risk for postpartum hemorrhage, VTE, maternal death. More blood loss than vaginal birth. Newborn may have higher risk of respiratory difficulty after birth, possible alterations to newborn gut microbiome. Most significant risk with repeat c-section is placenta accreta. Placenta accreta is when placenta grows too deeply into uterine wall, fails to separate from uterine wall after delivery which can lead to excessive hemorrhage. Hysterectomy usually needed.

postoperative care

recovery time following c-section is longer than vaginal delivery, full recovery from surgery can take 6 weeks or longer. Maternal morbidity rate increased 2x compared to vaginal delivery.

post-op nursing care

monitor vitals, assess fundus and lochia, assess abdominal dressing incision and abdominal pain, monitor level of sensation, monitor intake output, remove Foley, assess breathing, encourage deep breathing and coffee, assess bowel sounds, facilitate skin to skin contact with newborn, assist with ambulation. Avoid lifting anything heavier than the baby for 6 weeks.

postpartum period

generally considered to be 6-8 weeks after delivery, when most body systems have returned to pre-pregnancy state. Shift to define postpartum period as the 12 months after birth.

uterus postpartum

involution: uterus begins process of returning to pre-pregnancy state. Takes 6-8 weeks. Assess uterus often, usually every 15 minutes, in first hour postpartum. Risk for hemorrhage is the highest. Have patient bladder. Lower head of bed. Locate fundus and use gentle downwards pressure, use other hand to support lower uterine segment.

Measure distance between fundus and umbilicus with finger. In next 12 hours, fundus rises to level of umbilicus and starts to descend 1 cm/day, returns back to midway between umbilicus and symphysis pubis by 1 week postpartum.

Boggy uterus (uterine atony) is a sign that uterus is not contracted and is most common cause of postpartum hemorrhage. Uterine massage is first intervention for boggy uterus. Educate on afterpains, usually decrease after day 3 postpartum and are more common in multiparous women.

lochia

normal vaginal discharge occurring after giving birth. Assess amount, color, presence of clots.

Stages: rubra (red and bloody, first 3 days)

serosa: pink or brown, scant amount, days 4-10

alba: white or clear, scant, day 10 up to 6 weeks

amount:

scant: less than 1 inch on pad

light: less than 4 inches on pad

moderate: less than 6 inches on pad

heavy: saturates pad in 1 hour of less

perineal assessment postpartum

REEDA: redness, edema, ecchymosis, discharge, approximation of edges of laceration or episiotomy

apply ice to perineum, cold sitz baths for first 24 hours

warm sitz baths after 24 hours

side lying position to take pressure off

use peri-bottle with warm water after using bathroom

breasts postpartum

breast engorgement: tenderness, firmness, warmth, enlargement. Frequent feedings, warm compresses and massage, supportive bra, express milk manually or with pump.

Assess nipples for signs of irritation and breakdown.

Non-breastfeeding women can have engorgement in first few days after delivery. Supportive bra, avoid stimulating breasts or expressing milk, use ice packs, analgesic for pain.

Lactation suppresses menses due to hormonal changes, 40% of women exclusively breastfeeding

cardiovascular system postpartum

preeclampsia can onset postpartum. Increased risk for thromboembolism for first few weeks after delivery. Assess lower extremities for unilateral tenderness, edema, warmth, redness, pulses, encourage early and frequent ambulation. Increased risk for orthostatic hypotension for first week postpartum. Postpartum shivering in first hour is common, offer warm blanket and reassurance.

urinary system postpartum

bladder distension, rapid bladder filling, incomplete emptying, etc common postpartm. Get rest of slide

discharge teaching

stress importance of going to postpartum visit at 4-6 weeks. Educate on signs of complications that need to be reported to provider.

Lactating women need to increase calories by 500-1000 calories per day, drink 2-3 L water.

When to resume sexual activity: when lochia has stopped or returned to alba, perineum has healed, patient feels ready, has effective contraception available.

Discuss plans for contraception prior to discharge.

Ibuprofen and tylenol are common for pain, safe for breastfeeding women

transition to parenthood

provide environment conducive to rest, provide private time for bonding, provide positive feedback for parents’ infant care, provide info on parenting classes and support classes, provide info on infant care, involve partners, family members in teaching. Cluster nursing cares to promote bonding.

risk factors for delayed bonding

maternal illness, neonatal illness that necessitates being separated from parents, prolonged or complicated labor, fatigue, postpartum discomfort, age, developmental age of patient, outside stress such as finance.

postpartum or baby blues

several mild depressive symptoms that are temporary, sadness, crying, irritability, trouble sleeping, exhaustion, mood lability. Does not require a number of symptoms to be present for diagnosis. Onset of symptoms usually 2-3 days postpartum. Characterized by severe depression that occurs within first 12 months postpartum.

perinatal anxiety disorders

range of anxiety disorders experienced during pregnancy or postpartum period. GAD occurs in 6-8% in first 6 months postpartum. Excessive worry, difficulty controlling anxious thoughts, racing thoughts, intrusive thoughts. Panic, shortness of breath, rapid pulse, dizziness, chest pains, fear of dying.

postpartum PTSD

in general OB population, average incidence of 4%. Higher prevalence in high risk populations (complicated pregnancy or birth, history of physical/sexual abuse)

postpartum psychosis

alteration in perception of reality. Onset of hallucinations, disorganized speech, disorganized or bizarre behavior. Can onset within a few days postpartum. May experience paranoia that often involve delusions associated with the baby. 0.1-2.6 per 1000 births. Emergency, requires hospitalization.

screening recommendations perinatal mental health

Edinburgh postnatal depression scale (EPDS) is gold standard. PHQ-9 is depression only, GAD-7 is anxiety only.