OB Lecture 1 Exam 1 (postpartum period)

what does NSVD stand for

normal spontaneous vaginal delivery

what does LTCS stand for

low transverse cesarean section

what does VBAC stand for

vaginal birth after cesarean; have to be a TOLAC first (trial of labor after caesarian)

what does R-LTCS stand for

repeat low transverse cesarean section (in clinical setting, might see a p or primary or first c-section)

what does FAVD stand for

forceps assist vaginal delivery

what does VAVD stand for

vacuum assist vaginal delivery

what does multipara mean

an individual who has completed two or more preganncies at 20 weeks gestation of greater

what does multigravida mean

an individual who has been pregnant two or more times

what does primipara mean

an individual who has given birth to a baby after 20 weeks gestation

what does primigravida mean

an individual is pregnant for the first time or has not birthed a baby who reached 20 weeks gestation

what does nulligravida mean

an individual who has never been pregnant

what does gravida mean

the number of times an individual has been pregnant

what does para mean

the number of births >20 weeks gestation

what does the G of GTPAL stand for

how many times pregnant

what does the T of GTPAL stand for

term birth >37 weeks gestation

what does the P of GTPAL stand for

preterm birth <37 weeks gestation but >19.6 weeks gestation

what does the A of GTPAL stand for

abortions (elective or spontaneous)

what does the L of GTPAL stand for

living children (current)

at what number of weeks is a fetus viable

24 weeks

what prenatal labs need to be done for patients

CBC/plt, type and screen plus Rh factor, hep B, rubella, RPR/VDRL/syphillis, HIV, chlamydia and gonorrhea, GBS

when is a syphilis test done

at 1st prenatal visit and upon admission to the hospital; also done at 32 weeks gestation for high risk

what is GBS test done

between 36 and 38 weeks

when is CBC test done

on first visit and upon readmission to hospital

what level of CBCs is considered neutropenic

<150,000

when is type and screen odne

first visit and readmission

what is done if a patient has rubella

nothing, have to wait to give MMR since it is a live vaccine

what is done if a patient has GBS

nothing; treatment is delayed until patient is back to give birth since it is transient. Penicillin is given in at least 2 doses and there is a high risk for harm of baby with GBS. need 36-48hr observation for monitoring of baby

why might someone get a cesarean section

HTN, active HSV, HIV, DM, malpresentation (breech of shoulder) of fetus, cephalopelvic disproportion, placental issues such as previas, multiple gestational prolapse

how is the presence of HSV determined

speculum exam for lesions' have to have c section if lesions present

can a patient with HIV have a vaginal birth and breastfeed

yes, if viral load is undetectable

what type of c-section is ineligible for trial of labor

vertical incision or T

what is the acronym used for postpartum assessment

BUBBLE-EAR

what does BUBBLE-EAR stand for

breast, uterus/abdomen, bowel, bladder, lochia, episiotomy/laceration, extremities, attahcment/emotions, rubella/Rhogam

what must be measured in postpartum assessment

quantitated blood loss

each time you enter a room, what must be confirmed

name, DOB, MRN for both patient and baby

hugs and kissess bands often used for security

bowel sounds should always be listened to but for what postpartum patients is it most pertinent for

those who had c-sections

if the patient urinated 2 hrs ago, should you begin assessment

no, have them void first if its been over 2hrs

if birthing person is Rh neg and fetus is Rh pos, what needs to be done

Rhogam needs to be given to avoid creation of antibodies

if birthing person is Rh neg and fetus is Rh neg, what needs to be done

nothing, no Rhogam needed

what should be inspected when it comes to the breasts

size, shape, tenderness, temperature and color, whether soft, filling, or firm

what should be inspected when it comes to the nipples

everted, flat, inverted, red, blistered, cracked, bleeding

recommendations for breastfeeding

hydration, massage and frequent feeds

recommendations if not breastfeeding

tight-fitting bra, avoid heat, use cold packs, NSAIDs

signs and symptoms of mastitis plus treatment

flu like symptoms, fevers, chills, malaise, red streaks, hot to the touch

treat with antibiotics

position of the fundus immediately after birth

midline at the umbilics; then descends 1 fingerbreadth per day

what is done for a boggy uterus

fundal massage

assessment for fundus

consistency; firm with massage, soft boggy, location. looking for proper involution

what is involution of the uterus an how does it progress

shrinking of uterus back to prepregnancy size. in a week uterus will be half size it was just after giving birth, after two weeks will be back inside the pelvis, by about 4 weeks it should be close to its pre-pregnancy size.

what is uterine inversion

when the uterine fundus collapses into the endometrial cavity, turning the uterus partially or completely inside out. rare complication with vaginal or cesarean delivery, but when it occurs, life threatening obstetric emergency

how should fundus be assessed

have pt empty bladder, lay supine, and palpate fundus, cupping the bottom of it to secure it

what contributes to involution

oxytocin whcih can also be released via breastfeeding

how long should urine be measured for

24 hours

expectation for voiding after birth

pt should be able to spontaneously empty bladder within 6-8 hours after birt and then empty bladder routinely every 2-4hrs. 300mL per void, give up to 8hrs to void if had epidural

education for bladder and voiding

fluids and kegel exercises

recommendations for bowel movements

fluids, fiber, stool softener, early ambulation

what hormone puts patients at risk for constipation

progesterone; progesterone higher after birth

anticipated QBL for vaginal birth

<500mL

anticipated QBL for c-section

<1000 mL

what classifies as PPH

cumulative blood loss of greater than or equal to 1,000mL, or blood loss accompanied by signs or symptoms of hypovolemia, ithin the first six weeks of giving birth

what is lochia rubra and what period does it occur over

bright red, fleshy odor, small blood clots, scant to moderate amount, flow increases with stadning or breastfeeding. days 1-3

whay is lochia serosa and what period does it occur over

pink or brwn, fleshy odor, scant amount, increased flow with activit. days 4-10

what is lochia alba and what period does it occur over

yellow or white, fleshy odor, scant amount. days 10+

first signs of infection as it relates to lochia

foul smelling (spoiled meat), tender uterus, cold like symptoms, bleeding beyond 6 weeks--need to go to hospital immeditately as this could be life threatening

how long is it normal to bleed for

up to 6 weeks

signs of hemorrhage

exceeding 1000mL blood output, going from light color back to dark, pad saturated every hour, symptomatic, loss of 30% of blood volume

what is an episiotomy used for

reserved for instrumentation (forceps or vacuum) or need to expedite birth or maternal exhaustion

what is involved in perineal assessment

sims position or sidelying, ice backs 24hrs, then heat, encourage use of peri bottle, pat dry after urinating, witch hazel/tuck pads, nothing in vagina for 6 weeks or until PP follow up

what does REEDA stand for

redness, edema, ecchymosis, discharge, approximation

1st degree laceration charecteristics

perineal skin vaginal mucous membrane

2nd degree laceration characteristics

skin, mucous membrane, and fascia of perineal body (extends through the perineal muscles)

3rd degree laceration characteristics

skin, mucous membrane. muscle of perineal body and extends to rectal sphincter (through the anal sphincter muscles)

4th degree laceration characteristics

extend into rectal mucosa andn exposed lumen of rectum (extends through the anterior rectal wall)

what needs to be done to prevent 4th degree lac

control contractions, apply presure when giving birth

when does risk of DVT decrease

after 2 weeks postpartum

signs and symptoms of DVT

redness, swelling, warm to the touch

signs and symptoms of PE

diaphoresis, chest pain, difficulty breathing, call 911

where can clots occur

legs all the way up to labia

baby blues v postpartum depression

normal occurence of roller coatser of emotions with weeping and letdown feeling that lasts up to 2 weeks; longer than 2 weeks means postpartum depression

what needs to be done if patient gets MMR vaccine

use protection for 28 days

schedule of Rhogam doses

28 weeks gestation; must be given 72 hrs after birth or post miscarriage

what is the purpose of Rhogam

prevents patient from developing antibodies to Rh positive fetus in the future

what test is performed to measure amount of fetal hemoglobin transferred from a fetus to a postpartum parents bloodstream

Kleihauer Betke

postpartum physiologic adaptations related to heme/metabolism

changes in blood volume, loss of 500-1000mL, insulin needs reduced, circulating estrogen and progesterone signaling the anterior pituitary gland to make prolactin, increased WBCs, increased fibrinogen

postpartum physiologic adaptations as it relates to neuro

alt sleep, fatigue, HA, spinal HA

postpartum physiologic adaptations as it relates to renal

fluid electrolyte shift-diuresis changes in GFR, plasma creatinine, blood urea for 3 months

postpartum physiologic adaptations as it relates to respiratory

returns to pre pregnant state quickly

postpartum physiologic adaptations as it relates to cardiac

increased CO and SV related to hemodynamic changes, diuresis and fluid shifts

postpartum physiologic adaptations as it relates to integumentary

striae gravidarum (stretch marks), laceration, episiotomy

postpartum physiologic adaptations as it relates to immune system

increased WBCs still elevated

postpartum physiologic adaptations as it relates to reproductive system

return of ovulation, lactating, uterus involution 3 weeks, placental site heals, cervix closes and heals, vaginal and labial skin integrity changes, wait for IC until 6wk

postpartum physiologic adaptations as it relates to gastrointestinal system

straining r/t constipation and sutures, abdominal distention

postpartum physiologic adaptations as it relates to musculoskeletal system

relaxin! muscle fatigue, diastasis recti

postpartum self care

ambulation, sleep when baby is sleeping, frequent rest periods, health well balanced meals with increased protein for wound healing, add 500 calories if breastfeeding, drink lots of clear fluids (96-100oz/day), void every 2-4hr or before eah feeding, keep bladder emptu to promote uterine involution, use ice packs 20 minutes at a time, then heat sitz bath, frequent changing of pads, peri bottle, pat dry, good hand hygiene

when does th eintravascular fluid shift occur

5th postpartum day

meds and supplements usually given postpartum

NSAIDs, ibuprofen, toradol, acetaminophen, norco, morphine, dilaudid

tucks, withc hazel, preparation H

what happens at 6 week visit

breatss, perineum if a NSVD, FAVD, VAVD, incision of c section, SVE sterile vaginal exam to ensure cervix has closed and is healed, may perform PAP if due, screening for depression and IPV, pt can resume intercourse and exercise