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NCTC Maternity 3
| Question | Answer |
|---|---|
| involution | Uterus undergoes rapid reduction in size and weight |
| Decidua | endometrium) is shed after delivery of placenta |
| Immediately after the delivery of the placenta, the uterine fundus can be located | midway between the umbilicus and symphysis |
| Lochia rubra: | red, immediately pp, 1-3d |
| Lochia serosa: | pink-brown, serosanguinous, 3-10d |
| Lochia alba | whitish mucus, 10-14d |
| Scant: | 2 inch stain is 10 ml |
| Light | 4 inch stain is 25 ml |
| Moderate: | 6 inch stain is 50 ml |
| Large or heavy: | 6 inch stain or saturating a pad within 2 hours 80 ml |
| Excessive: | Saturating a pad in 15 minutes |
| Determining amount of bleeding: | Apply a fresh pad Recheck in 15 minutes Weigh pad: 1 gm = 1 ml of blood |
| Massage boggy uterus until firm to prevent hemorrhage | Avoid pushing downward on uncontracted uterus to prevent inverting it |
| Teach lochial changes to expect and report the following: | Foul-smelling lochia, with or without fever Lochia rubra that persists beyond the third day Unusually heavy lochia Lochia that returns to bright red color after it has progressed to serosa or alba |
| Cervix | Regains muscle tone but never closes as completely Constant trickle of bright red lochia is associated with lacerations of cervix or vagina Particularly if fundus is firm |
| Vagina | Rugae reappear 3-4 weeks pp |
| Perineum | Episiotomy and perineal lacerations described by amount of tissue involved |
| First degree: Episiotomy and perineal lacerations described by amount of tissue involved | superficial vaginal mucosa or perineal skin only |
| Second degree Episiotomy and perineal lacerations described by amount of tissue involved | involves the vaginal mucosa. perineal skin, and deeper tissues of the perineum |
| Third degree: Episiotomy and perineal lacerations described by amount of tissue involved | includes the above and the anal sphincter |
| Fourth degree: | extends through the anal sphincter into the rectal mucosa |
| REEDA: | R - redness without excessive tenderness (pain indicates infection) E - edema is common E - ecchymosis, or bruising, is common D - discharge from the perineal suture line is abnormal A - approximation of the suture line is intact (should not be separated) |
| Ice to perineum | 12-24 hours Allow 10 minutes between reapplication of ice for maximum benefit |
| Warm sitz bath | after first 24 hours |
| Perineal care | Removal of peri pad from front to back Perform cleansing after each toileting Warm water bottle rinse from front to back Blot dry with paper from front to back Apply new pad front to back |
| Topical medications reduce inflammation and numb the perineum | Epifoam (hydrocortisone and pramoxine) Americaine or Dermoplast (Benzocaine) |
| Hemorrhoid relief | Tucks pads Sitz baths Oral analgesics |
| Return of ovulation and menstruation | Ovulation may occur at any time after birth, with or without menstrual bleeding, and pregnancy is possible |
| Changes in the breasts | Breasts are usually soft for the first 2-3 days postpartum Assess: consistency, size, shape, symmetry Non-nursing mothers should wear tight bra or binder to suppress lactation Avoid stimulation of nipples with clothing or shower water |
| Visible shaking and trembling | usually decrease after 20 minutes Believed to be caused by nervous system response or vasomotor changes Reassure that it is normal and apply warm blankets |
| Rh Immune Globulin | Rhogam is given to Rh negative mom of Rh positive babe within 72 hours Consent is signed and injection is administered IM in buttocks of mother |
| Rubella vaccination | Vaccine given immediately in pp period when the woman is not pregnant Protects against getting rubella in future pregnancies |
| Rubin's psychological phases: Taking in: | Passivity, conversation on labor and delivery, wonder of the baby ( no more than 24 hours) |
| Rubin's psychological phases: Taking hold: | Mother initiates action of self-care, interest in caring for baby, may occur within a few hours after delivery Excellent time for teaching |
| Rubin's psychological phases: Letting go: | Redefines her role of mother and may involve some grief and is ongoing after discharge Expected to experience conflicting feelings Known as "postpartum blues" Usually self-limiting |
| "Postpartum depression" | may require intervention Onset of motherhood may activate unresolved issues of depression Persistent depression is not expected and should be reported to the physician - Can go into post partum psychosis -truly psychotic can harm self or baby |
| BREAST FEEDING- Advantages | Ideal food that contains a full range of nutrients Easily digested by immature digestive system Does not cause infant allergies Provides immunity provided by mom Promotes elimination of meconium – rarely causes constipation Promotes mouth development |
| Frequency and duration of feeding | Start with the side used last for at least 10 minutes Change sides and continue nursing for at least 15 minutes Do no continue to switch sides during the same feeding |
| FORMULA FEEDING | Keep nipple full of formula to prevent swallowing air Leftover formula should be discarded due to contamination from microorganisms of the mouth Do not prop bottle and leave infant Causes aspiration and dental caries |
| Danger signs | Heavy bleeding, or return to lochia rubra Breast or leg pain or redness Elevated temp Dragging backache Persistent abdominal or pelvic pain Discharge or inflammation of suture line Persistent lochia rubra or lochia that has a foul odor S/S UTI |
| SHOCK | condition in which the cardiovascular system fails to provide essential oxygen and nutrients to the cells |
| Tachycardia | usually the first sign of inadequate blood volume |
| Early postpartum hemorrhage causes: | Uterine atony: lack of normal muscle tone |
| Normal postpartum changes | Uterus if firm, size of grapefruit, at or slightly below umbilicus Lochia rubra no more than 1 pad per hour, with some small clots |
| Characteristics of uterine atony: | Uterus is boggy soft Fundal height above umbilicus Located on one side of midline May or may not have palpable bladder Lochia is increased and may contain large clots |
| Correct bladder distention | Assist to void or cath If boggy, massage until firm, then assist with bladder emptying |
| Drugs to increase uterine tone: | oxytocin (Pitocin) methylergonovine (Methergine) Increases B/P so should not be given in PIH prostaglandin F2alpha MD must determine and correct source of bleeding |
| Lacerations of the reproductive tract | Blood loss is usually brighter red and flows in continuous trickle, but the uterus is firm |
| Late postpartum hemorrhage | Occurs later (24 hours - 6 weeks) after delivery Usually due to: Retention of placental fragments or disrupted placental site scab Subinvolution of the uterus Usually occurs after discharge from hospital Bleeding begins suddenly and may be profuse |
| Ultrasound to determine presence of placental fragments | D&C Antibiotics to prevent infection Teaching during discharge: Persistent red bleeding Return to lochia rubra after bleeding has turned pinkish or white |
| Superficial vein thrombosis | Painful, reddened, warm vein that is easily seen - mom can still breast feed usually tylenol,or asprin |
| Deep vein thrombosis | Pain, calf tenderness, leg edema, color changes, and dorsiflex pain (Homan's) in deep vein thrombosis Primary risk is that clot will break off and travel Can't breastfeed with Coumadin - |
| PUERPERAL INFECTION | Temp > 100.4 Achiness Redness Malaise Edema Loss of appetite Pain WBCs : 20,000-30,000 Fever may call and just complain of cramping constantly for several days |
| PUERPERAL INFECTION - Nursing care | Fowler's position to promote drainage of infected lochia Regular perineal care and hygiene Administer antibiotics as ordered |
| Breast infection (mastitis) | Redness and heat in the breast Tenderness Fever and chills May continue to breastfeed unless abscess is present; then pump and discard Cold between feedings heat during feedings |
| SUBINVOLUTION OF THE UTERUS | Def - slower-than-expected return of uterus to nonpregnant state Causes: Retained placental fragments Infection Signs of subinvolution: Fundal height greater than expected for the amount of time since birth |
| Postpartum depression | Manifested within 4 weeks of delivery and affects 10-20% of postpartum women Onset may interfere with mom’s ability to respond to infant’s cues and bonding |
| Monthly breast-self examination (BSE) | Should be performed by all women after age 20 Should be performed q month about 1 week after the beginning of menses |
| Mammography | Screening test can detect breast cancer long before a lump can be palpated Should be scheduled following menses when breasts are less tender Should be q 1-2 years for women 40 and over May begin earlier with family history of breast cancer |
| Pelvic examination | Should be scheduled between menses No intercourse or douching for at least 48-72 hours before Pap |
| Amenorrhea | Primary - failure to menstruate by age 16 if she has breast or pubic hair development Failure to menstruate by 14 if she has not developed any secondary sex characteristics |
| Abnormal uterine bleeding | Defined as bleeding that is too frequent (metrorrhagia), too long, or excessive(menorrhagia) |
| Mittelschmerz | Harmless pain that is experienced around the time of ovulation Mild analgesics may be effective |
| Dysmenorrhea (cramps) | Spasmodic pain at or soon after the onset of menses May radiate to lower abdomen, back, or down the legs May be accompanied with diarrhea, nausea, and vomiting Common among nulliparas |
| Teaching relief measures for PMS | Diet rich in complex carbs and fiber Reduce intake of caffeine: colas, coffee, tea, foods, medicines Avoid simple sugars in candy, cookies, and cake Reduce intake of salty foods: chips, pickles, fast-food items Exercise |
| BBT - Record temp taken with basal thermometer q am before rising (calibrated in tenths) | Temp rises shortly after ovulation between 0.4 and 0.8 degrees Increase is due to progesterone influence Temp remains higher after ovulation Is better at identifying when ovulation has occurred rather than predicting it |
| Observing cervical mucus (Billing's) | Cervical mucus changes due to levels of estrogen and progesterone After menses, mucus is cloudy and tacky Near ovulation, mucus becomes clear, slippery, and stretches (spinnbarkeit) which enhances sperm mobility |
| Calendar or rhythm method | Notes ovulation occurs about 14 days before next menses Abstains from intercourse CD 10-17 when ovulation and fertility are likely |
| Abstinence | 100% effective in preventing STIs and pregnancy |
| Oral contraceptives | Most popular, effective, and reversible method |
| Oral contraceptives - Benefits | Very low failure rates (0.1% for combined pills and 0.5% for minipills) Reduce risk of ovarian and endometrial cancer Probably no greater risk of breast cancer less cramping and lighter periods May improve PMS symptoms |
| Oral contraceptives - Side effects and contraindications | Does not protect against STD's N/V, headache, weight gain, BTB, depression, breast tenderness generally disappear |
| Risk factors - Oral contraceptives | Thromboembolic disease CVA or heart disease Estrogen-dependent cancer or breast cancer Smoking more than 15 cigarettes per day Impaired liver function Pregnancy Undiagnosed vaginal bleeding |
| Warning signs to report to physician | A - abdominal pain C - chest pain, dyspnea, bloody sputum H - headache, weakness or numbness of extremities E - eye problems (blurring, double vision, vision loss) S - severe leg pain or speech disturbances |
| Medications that interfere with OCP efficacy: | Anti-epileptics, Antibiotics, TB drugs like Rifampin, barbiturates |
| Hormone implants | Etonogestrel (Implanon) Single rod of progesterone implanted under skin of upper arm Can be used during lactation Has rapid return to fertility after removal |
| Intrauterine device (IUD) | T-shaped plastic device with copper Effective for 10 years |
| Transdermal patch | Placed each week for 3 weeks, then one week without patch for withdrawal bleeding Preferred placement is below the waist |
| Vaginal ring | Releases estrogen and progesterone locally in the vagina Worn for 3 weeks then removed for withdrawal bleeding |
| Diaphragm and cervical cap | Block semen from entering the cervix Used in conjunction with spermicidal creams and jellies Fitted and prescribed by physician Diaphragm inserted up to 6 hours before intercourse Left in place for 6-24 hours Cervical cap left in place for up to 48 hours |
| Male condom | Provide good, not perfect, protection against STDs, including HIV |
| Spermicide - OTC contraceptives in foam, jelly, cream, film, and suppository with vaginal applicator | Inserted 15 minutes prior to intercourse and last 1 hour Act to neutralize vaginal secretions, destroy sperm, and block entrance to the cervix Should not be followed by douche for at least 8 hours after intercourse More effective when used with a condom |
| Emergency contraception – “Morning After” pill | Larger than normal dose of OCP with 72 hours of unprotected sex is repeated in 12 hours Copper IUD inserted within 5-7 days of unprotected sex |
| Unreliable contraceptive methods | Withdrawal Douching Breastfeeding |
| Male sterilization (vasectomy) | Alternate forms of contraception are recommended until sperm count is zero (sperm remain in the tract and can cause pregnancy) |
| Female sterilization (BTL) | Procedure done by laparoscopy Local or general anesthesia |
| Evaluation of infertility | Hysterosalpingogram |
| Therapy for infertility Medications | Clomiphne (Clomid) - induces ovulation - can cause multiple ovulation Menotropins (Pergonal) - stimulates ovulation - can give to both genders helps men form sperm |
| Therapeutic insemination | AI (baby-in-a-box) is insertion of partner or donor sperm into the uterus through the cervix using a TB syringe and long, tube-like tip |
| Advanced reproductive techniques | In vitro fertilization - ova are harvested under laproscopy and fertilized with sperm in the laboratory, then transferred to the uterus 2 days later |
| Therapy for osteoporosis | Calcium intake in foods and supplements Exercise Bone mineral density testing Fosamax to help bone growth Raloxifene helps prevent bone loss |
| OTHER FEMALE REPRODUCTIVE TRACT DISORDERS | Uterine leiomyoma Uterine fibroid tumors Grow under the influence of estrogen |
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