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NM 717 Comps > Module 6 Postpartum Canvas > Flashcards

Module 6 Postpartum Canvas Flashcards

1
Q

Describe PP uterine involution, including where the fundus is expected by day.

A

Return of the uterus. Fundus descends at a rate of 1cm per day.

Immediately PP, the fundus is at the umbilicus

By day 10-14, the uterus is no longer palpable abdominally

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2
Q

Over what time period does involution occur?

A

The uterus involutes by approximately 50% in the first 24-48 hours PP and then gradually diminishes to the nonpregnant size over the next 6-8 weeks.

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3
Q

At what time frame PP is the uterus no longer palpable abdominally?

A

By 10-14 days, the uterus is no longer able to be palpated abdominally

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4
Q

What is the normal length of time we expect lochia postpartum?

A

Begins Immediately at birth and continues for approximately 4-8 weeks.
mean total duration- 33 days

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5
Q

Describe lochia rubra and when it is expected?

A

primarily blood, red or brownish-red in color.
3-5 days PP

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6
Q

Describe lochia serosa and when it is expected?

A

primarily wound exudate and leukocytes with some blood
pinkish brown color
mean duration is 22 days

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7
Q

Describe lochia alba and when it is expected?

A

primarily leukocytes
white or yellowish-white in color
thru day 33-ish

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8
Q

What is eschar bleeding and when is it expected?

A

transient increase in bleeding from the placental scab
day 7-14

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9
Q

How dilated is the cx at 1 week PP?

A

1 cm

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10
Q

How much of a drop in Hgb and Hct is expected from a 500 cc blood loss?

A

Hgb: 1 pt
Hct: 3%

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11
Q

When does the H&H return to prepregnant values?

A

4-6weeks PP

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12
Q

Why is PP physiologic diureses so crucial?

A

It returns the body to normal cardiovascular function

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13
Q

When does ovulation return PP for non-lactating women?

A

ovulation returns sometime between PP day 45 and 94
many women may be fertile prior to their 1st PP visit (a 6-week visit)

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14
Q

What is lactogenesis?

A

the ability to secrete milk

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15
Q

Describe lactogenesis 1.

A

secretory initiation
starts during the second half of pregnancy
by the 2nd & 3rd trimesters, veins become increasingly visible on the skin surface of the breast
By 16-18 weeks GA, colostrum leaking from nipples

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16
Q

Describe lactogenesis 2.

A

secretory activation- Onset of COPIOUS milk production
occurs in the first PP days
triggered by the drop in hormones once the placenta is expelled
approx 3-40hours after birth, rapid milk volume increase

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17
Q

What hormones does neonatal suckling affect?

A

suckling = increase prolactin = increase milk secretion
suckling = increase oxytocin = contraction of myoepithelial cells = milk ejection

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18
Q

What can cause a delayed onset of lactogenesis 2?

A

obesity
diabetes
PCOS
and other biologic conditions associated with increased androgen levels
cesarean birth,
retained placental fragments
hypothyroidism
certain types of breast surgery
severe maternal anemia
Prematurity & Newborn Illness
Newborns with ineffective or weak suck, palate abnormalities, tongue-tie, and congenital heart defects

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19
Q

Describe lactogenesis 3.

A

lactation is fully established- Ongoing Milk Synthesis
nipple stimulation via infant suckling = prolactin release= hypothalamus increase oxytocin
milk removal stimulates milk synthesis (supply and demand )
when milk is not removed, milk production slows

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20
Q

Describe lactogenesis 4.

A

mammary gland involution that occurs when breastfeeding ceases
no infant sucking = decrease in prolactin levels
milk production ends
mammary epithelial cell apoptosis
Involution take approximately 6 weeks after milk removal ceases
the human breast never fully returns to a prepregnant condition

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21
Q

What is the fourth stage of labor?

A

the 1st hour after the placenta is expelled

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22
Q

How often should the uterus be evaluated immediately PP?

A

evaluate the uterus for position and tone q 5 - 15 min immediately after birth

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23
Q

How can a patient improve afterpains postpartum?

A

empty bladder
heating pads
lying prone (on the stomach) with a pillow or blanket roll under the lower abdomen
NSAIDS for 48-72 hours

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24
Q

What causes afterpains?

A

caused by the continuing sequential contraction of the uterus.

Note: painful cramping more common in multips

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25
Q

When do the majority of PPH occur?

A

In the 4th stage of labor. Key evaluate bleeding every 5-15m

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26
Q

When should the bladder be assessed for distention and urinary retention PP?

A

30m PP

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27
Q

What is first lime treatment for PP hemorrhoids?

A

Increase fiber (25-30 mg/day)
Drink more water (6-8 glasses a day)
Mild Stool Softener

Don’t strain
Don’t spend too long on the toilet

Warm water spray or sitz baths
Ice packs
Cold sitz baths
Warm water compresses

OTC ointments: Preparation H, etc.
Witch Hazel compress (Tucks pads)
Hydrocortisone suppository

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28
Q

What RX can be given for PP hemorrhoids?

A

Topical corticosteroids
Rx products containing Hydrocortisone

Adodan-HC 10 mg rec supp or 0.5%/0.5% ointment
Anusol HC 25 mg rec supp or 2.5% cream
Local anesthetic
Lidocaine/xylocaine jelly 1.00 mm 2%

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29
Q

What vital signs are considered abnormal PP?

A

greater than 38 degrees C or 100.4
higher than 140/90 or lower than 85/60
higher than 100 bpm

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30
Q

How does ibuprofen help with PP pain?

A

NSAIDs are anti-prostaglandin (prostaglandins cause cramping)

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31
Q

Why should we be cautious with codeine and hydrocodone for breastfeeding moms?

A

individuals with polymorphism of CPY2D6 are ultra-rapid metabolizers and we dont know who these patients are

4-5% in the US are

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32
Q

Describe the assessment for diastasis recti.

A

midline separation of the rectus abdominus muscle
palpate by placing 1 or 2 fingers parallel to the abdominal midline
ask the woman to lift her head while lying supine (on her back)

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33
Q

At what point PP is the uterus no longer palpable abdominally?

A

By approximately 2 wks PP, the uterus can no longer be palpated abdominally

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34
Q

What is subinvolution?

A

when the uterus doe not return to its prepregnant size and position within the expected time frame (typically complete by 6w PP)

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35
Q

What can cause subinvolution?

A

retained placental fragments
leiomyomas
infection

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36
Q

When can most women resume regular exercise?

A

by 6 wks PP, most women can resume regular exercise routines
women should get at least 150 minutes of moderate exercise per week

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37
Q

How do nutritional needs change PP for BF women?

A

lactating women use 500-700 calories more per day than nonpregnant women
AAP recommends that breastfeeding women supplement if their diet is deficient in DHA (or eat 2 servings of fish/week)

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38
Q

What supplementation is needed for BF babies?

A

all breastfed infants need oral supplement of vitamin D 400 IU per day

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39
Q

How does kegels benefit women PP?

A

promotes long-term perineal comfort and strength
reduces stress urinary incontinence
increase circulation to the area
promotes healing
restores

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40
Q

What are the PP warning signs for the mother?

A

Sudden HA, vision changes, epigastric pain
Fever/chills
Redness, heat, firmness/pain in one breast
Increased abd or vulvar pain
Calf pain/heat/swelling
Marked changes in mood

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41
Q

What are the PP warning signs for the newborn?

A

Feeding problems
Yellowing skin
Fever
Inability to console
Insufficient wet/dirty diapers
>6stools per 24h/bloody or watery stools
Listless behavior, not alert when awake
Resp. problems, turning blue

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42
Q

What limitations are associated with PP phone assessments/calls when assessing a newborn?

A

Limitations of PP phone calls include the inability to directly screen for neonatal hyperbilirubinemia and excessive weight loss

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43
Q

When is it recommended for PP women to resume sexual activity?

A

wait until the birthing person feels comfortable and ready to resume sex

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44
Q

On average, when do non-lactating women resume ovulation?

A

39 days

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45
Q

When can an IUD be inserted?

A

Varney p. 1196, “Insertion of an IUD may be performed safely after delivery of the placenta, although expulsion rates are higher than if insertion is performed later than 4 weeks PP.

Delayed insertion (after 6-8 weeks) = lower expulsion rates

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46
Q

Discuss IUD insertion immediately PP after delivery of the placenta.

A

After vaginal delivery, IUD insertion can be accomplished manually or with a ring or Kelly forceps.
The IUD is removed from the inserter and the strings are cut to 10 cm.
The wings of the IUD are grasped gently with a ring forceps, and the IUD is passed through the cervix and placed at the fundus.
Ultrasonographic guidance may be used.
In the setting of cesarean delivery, the IUD is inserted after removal of the placenta and after the uterus has become hemostatic.
After initiating closure of the uterine incision, the IUD is placed at the fundus with the inserter, manually, or with a ring forceps, and the string gently placed manually or with ring forceps into the cervix.
After this is accomplished, hysterotomy closure can be completed.
Immediate postpartum insertion is contraindicated among women in whom peripartum chorioamnionitis, endometritis, or puerperal sepsis is diagnosed

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47
Q

Aside from an IUD, what other contraceptive can be given prior to d/c PP?

A

DMPA

48
Q

What contraceptives are contraindicated PP and why?

A

Estrogen-containing methods

CONTRAINDICATED until 3-4 weeks PP (check MEC)
due to hypercoagulation state

49
Q

What contraceptives should be avoided but are not contraindicated for BF?

A

CHC, OCPs, patches or rings, or high -dose progestins (DMPA) d/t concern about milk supply

50
Q

What occurs in subsequent pregnancies for an Rh - mother with a + fetus?

A

these antibodies can cross the placenta and bind to fetal RBCs
causes hemolytic disease of the fetus and newborn
approx 17% of Rh D negative women who are NOT immunized will become alloimmunized.

51
Q

What amount of fetal-maternal hemorrhage is covered by a 300mcg dose of rhogam?

A

sufficient to treat a fetal-maternal hemorrhage containing 15 mL of RBC or 30 ML of whole blood

52
Q

What test should be performed to determine if more rhogam is needed?

A

a Kleihauer-Betke test is performed to determine the amount of fetal hemoglobin present.

Note: a rosette test only shows if there is fetal blood present in maternal blood

53
Q

What immunizations can/should be given PP if not previously received/nonimmune?

A

HPV, Flu, TDAP, Rubella, Varicella

54
Q

When do Hgb/Hct return to normal levels PP?

A

4-6w PP

55
Q

When do WBCs return to normal levels PP?

A

by 6d PP

56
Q

When is urinary retention considered out of the CNM/APRN scope?

A

When it is COMPLICATED

*MANAGEMENT OF UNCOMPLICATED URINARY RETENTION IS WITHIN THE MIDWIFERY SCOPE OF PRACTICE.

57
Q

Describe uncomplicated urinary retention

A

The inability to void at all
covert PP urinary retention (the birthing person can void, but has a residual bladder volume of 150 ml+)

58
Q

How should PP urinary retention be treated?

A

maintaining privacy
adequate analgesia
warm-water immersion
peppermint oil in toilet water or bedpan
sound of running water

If unsuccessful: urinary catheterization. If indwelling, use for shortest period possible

59
Q

How should the CNM/APRN respond to any PP patient presenting with S/S of infection?

A

PHYSICIAN consultation and/or REFERRAL is indicated for women who require evaluation for any postpartum infection.

60
Q

Describe the S/S of endometritis:

A

typically develops within 2-4 days PP or as late as 2-6 wks PP

Classic Triad: Fever, Tachycardia, Uterine Tenderness

61
Q

When endometritis is suspected, what other infections must be ruled out?

A

pneumonia: chest x-ray
mastitis: breast exam
pyelonephritis: urine culture
surgical site infection: abdominal exam

61
Q

How should endometritis be treated?

A

** CONSULTATION should be obtained rapidly for any woman who has signs or symptoms that indicate she is at risk for severe morbidity such as: HYPOTENSION, TACHYPNEA, O2SAT less than 95% or Shortness of Air. *****

Broad-spectrum antibiotics
Gold Standard: IV Clindamycin and Gentamicin administered until afebrile for 24-48 hours.

62
Q

Describe the S/S of PP wound infections.

A

low-grade temp, <38.3 degrees C.
localized pain and edema
red, inflamed repair edges
exudate and wound separation or dehiscence
dysuria (perineal wound infections)

63
Q

How should perineal wound infections and laceration dehiscence be treated?

A

Removal of sutures, opening, debriding & cleansing the wound
allows the area to heal by granulation
PHYSICIAN CONSULT INDICATED
ABX

Note- we would NEVER re-suture!!! that would cause a secondary infection.

64
Q

How should we respond to PP C/S site infections/large hematomas?

A

PHYSICIAN CONSULTATION REQUIRED

Seromas/hematomas may need to be drained
Abx
Culture
Debreidement and packing

65
Q

Describe the presentation of UTI/Pyelo PP.

A

urinary frequency, urgency, dysuria, or lower abdominal pain
low-grade fever
flank pain
CVAT
nausea and vomiting
HOWEVER: PP women often DO NOT have, dysuria, frequency or urgency
ANY PP woman with a fever has to be evaluated for a UTI

**E-Coli is the most common cause

66
Q

When is an U/S indicated PP?

A

When retained products of conception are suspected

Secondary PPH may be an indication

67
Q

Describe the S/S of vaginal hematomas.

A

perineal, vaginal, urethra, bladder or RECTAL PRESSURE
severe pain
tense, fluctuant swelling
bluish or blue-black discoloration of tissue.

***EXTREME PAIN out of proportion to what is expected

68
Q

How are vaginal hematomas treated?

A

PHYSICIAN CONSULT IS NECESSARY for evaluation and plan

Vaginal packing for counterpressure
or incision to evacuate blood and blood clots to ensure closure of the cavity
may need blood replacement and antibiotics

69
Q

What is a key risk factor for a secondary PPH?

A

PRIMARY PPH!! (If she had an immediate PPH- you have to watch her like a hawk!)

70
Q

When does a secondary PPH most commonly present?

A

2nd week PP
increase or return of lochia rubra or frank hemorrhage

71
Q

If bleeding is heavier than usual, but not markedly so, AND the woman is stable, AND the uterus has the expected size and shape, AND there is no indication of infection OR retained placental fragments…THEN:

A

methylergonovine (Methergine) 0.2 mg PO q 3-4 hours x 24-48 hours

72
Q

What abx may be ordered for a PP pt with signs of infection?

A

broad-spectrum antibiotics: ampicillin-sulbactam or cefoxitin
if chlamydia is suspected: azithromycin 1g PO (one dose) added to the above regimen
IV or PO depending on the severity of her symptoms

73
Q

How many maternal deaths secondary to HTN occur PP?

A

75%

74
Q

What are the most common S/S of Pre-E PP?

A

neurological indicators- visual disturbances, headache
nausea and vomiting

HTN and Proteinuria are not always present!

75
Q

What patients with HTN should receive a physician consultation?

A

ALL OF THEM

*PHYSICIAN CONSULTATION indicated for ANY degree of hypertension PP

76
Q

How should the CNM/APRN respond to peripartum cardiomyopathy?

A

PROMPT referral to Physician, preferably a cardiologist

77
Q

What are the S/S of peripartum cardiomyopathy?

A

Marked SOA
orthopnea (the sensation of breathlessness in the recumbent position, relieved by sitting or standing.) NIH.gov
tachycardia
palpitations
chest pain
cough
edema

Note: Most patients are not diagnosed until PP

78
Q

What is the gold standard for Dx of peripartum cardiomyopathy?

A

Echocardiogram (echo) (definitive dx)
12 lead electrocardiogram (ECG) (can rule out other causes. 50% of people with PPCM have a normal ECG)

79
Q

What are the S/S of a PE?

A

tachypnea, dyspnea, and sudden onset of sharp chest pain
altered lung or heart sounds
apprehension as blood O2 decreases

80
Q

What is the gold standard for dx of a DVT/PE?

A

Compression ultrasound with or without color Doppler imaging
lab studies: high-sensitivity D-dimer studies (measures fibrin degradation)

HOMAN’S SIGN (eliciting pain of dorsiflexion of the foot) IS NO LONGER RECOMMENDED!! DON’T EVER DO IT!!! Not even as part of your routine PP exam. NEVER do it! NEVER CHART “negative Homan’s”- CAUSE you SHOULDN’t have EVER checked it!!!!

81
Q

What anticoagulant is safe with BF?

A

Coumadin

82
Q

Describe how PP thyroiditis presents.

A

-transient hypothyroidism
-transient hyperthyroidism OR
-hyperthyroidism followed by hypothyroidism

83
Q

Describe the S/S of hyperthyroiditis PP and when it manifests.

A

1-4m PP

Anxiety, fatigue, goiter heat intolerance/sweats, insomnia, irritability, weight loss

Low TSH
thyroid peroxidase antibodies
lack of TSH receptor antibodies

84
Q

Describe the S/S of hypothyroiditis PP and when it manifests.

A

4-8m PP

Constipation, depression, dry skin, fatigue, goiter, impaired concentration

elevated TSH
a positive test for antithyroid peroxidase antibodies

85
Q

Describe the S/S of a thyroid storm.

A

nausea & vomiting
diarrhea
fever (greater than 41 C) 105.8 F!!!!
tachycardia
tremor
women in thyroid storm usually present to the ED acutely ill and may initially be assumed to have preEclampsia
neuropsychiatric symptoms & hyperpyrexia distinguish thyroid storm from PP preE or eclampsia

86
Q

When does breast engorgement occur PP?

A

48-72 hours after birth
(may not appear until up to 7 days PP)

87
Q

Describe the S/S of engorgement.

A

distended breasts, tense, tender to touch
skin warm to touch
visible veins,
skin taught across the breasts
nipples are firmer - difficult for infant to grasp
may cause mildly elevated temp
not greater than 100.4 (38.0 C)

88
Q

What should NOT be done to treat engorgement for those that are NOT breastfeeding?

A

NO ATTEMPT SHOULD BE MADE TO EXPRESS MILK FROM THE BREASTS, EITHER MANUALLY OR BY USING HEAT, AS THIS WILL SIMPLY PROMOTE MILK EJECTION & FURTHER MILK PRODUCTION

Engorgement will improve within 24-48 hours

89
Q

What is delayed lactogenesis II?

A

no obvious signs of milk production 72 hours or more after birth

90
Q

When should a physician/ped referral be done for BF concerns?

A

If infant has lost weight or has signs of hyponatremia

91
Q

What is a galactocele?

A

milk retention cyst that results from a plugged duct (benign)

92
Q

How should nipple trauma be treated?

A

Assess the latch and educate when needed
application of breast milk to the injury
use of breast shield
glycerin gel dressings

93
Q

What are the S/S of candida on the nipples?

A

burning, itching, stinging, “piece of glass” feelings, deep stabbing pain that radiates toward the chest wall.
nipple and areola are shiny and red
flaking of the skin around the nipple
cracks in the areola
pain is OUT OF PROPORTION compared to the physical findings
Baby has thrush or a diaper rash

94
Q

What is the treatment for nipple candida?

A

fluconazole (Diflucan) for mom
infant should be treated as well with topical antifungal

95
Q

Describe the presentation of raynauds on the nipple and its treatment.

A

sharp, burning pain
pain with breastfeeding or to cool air
blanching or purple color changes to the nipple

Treatment: “Calcium-Channel blockers” (nifedipine) to relieve nipple spasm, avoid cold exposure or warmth

96
Q

Describe the presentation of mastitis and its treatment.

A

breast inflammation
one or more segments of breast are hot, red and inflamed
localized, unilateral area of erythema
fever 38.5 degrees C or 101 degrees F
feelings of malaise
flu-like s/s
fatigue

Treatment:
most resolve within 48 hours with sufficient and frequent breast emptying
adequate fluids and nutrition
antibiotic therapy

97
Q

Describe the treatment of a breast abscess and how it is diagnosed.

A

PE->confirm with U/S

Treatment: drainage/aspiration, abx, and MD referall

98
Q

Describe postpartum blues.

A

50-75% of new mothers experience

Day 2-5 peak
S/S:
crying
anxiety
emotional lability
irritability
fatigue
Key: still finds pleasure in things

99
Q

Describe PPD.

A

major depressive disorder
peak onset is 2nd month after childbirth but can occur up to 1 year PP

Key: no longer finds pleasure in things, thoughts of harming self or baby

100
Q

How should we respond to an EPDS score of 0-4?

A

Requires no treatment, routine F/U

101
Q

How should we respond to an EPDS score of 5-9?

A

Treatment with self-care. Routine F/U

102
Q

How should we respond to an EPDS score of 10-12?

A

Refer for mental health services, and discuss pharmacotherapy. F/U 2-4w or 1-2w if meds started

103
Q

How should we respond to an EPDS score of 13-20?

A

Refer for mental health services, and pharmacotherapy. Immediate/emergency referral for severe depression, psychosis or suicidal ideation. F/U 1-2w/as directed by mental health

104
Q

What question on the EPDS requires immediate response if a positive response is marked?

A

Number 10!!

105
Q

What med is first line for PPD?

A

SSRIs

1st line: Sertraline and paroxetine may be considered
Fluoxitne (Prozac), Citalopram (Celexa), and escitalopram (Lexapro) have higher rates of transfer to breast milk and are more often associated with infant behavioral side effects.

106
Q

Describe the presentation of a bipolar episode PP.

A

overly euphoric, talkative and less in need of sleep
or depressive symptoms associated with the disorder
may also present as PP psychosis
a woman with a hx of BPD exhibiting signs of mania or hypomania should be assessed by a psychiatric clinician

107
Q

What is the treatment for PP psychosis?

A

hospitalization
lithium therapy
benzodiazepines

108
Q

What are the signs of lactogenesis II?

A

breast fullness, tingling and hardness, leaking and change of milk color from yellow/creamy to blue/watery.

109
Q

How much breast milk is produced per day?

A

700-800 mL

110
Q

When is BF contraindicared?

A

Galactosemia, G6PD deficiency, phenylkentonuria, certain maternal infections (HSV with active lesion on breast, HIV, HTLV, cytomegalovuris)

111
Q

What medications may inhibit breast milk production?

A

Parlodel
Dostinex
Estrogen contraceptives
Ergotamnine
Progestins
Sudafed
Testosterone
Tamoxifen

112
Q

How many milk ejection reflexes do most women have per feeding?

A

2

113
Q

What are the signs of BF infant satiety?

A

healthy infants feed on demand
usually, 8- 12x in each 24 hour period
infants need 20-24 ounces of breast milk per day
stomach capacity is less than 1 oz.
cluster feeds -2+ feeds with short periods of sleep or quiet alert state between feeding cues

114
Q

How much weight gain is expected for a BF infant?

A

breastfeeding infants gain an average of 4-7 oz per week

115
Q

How many voids/stools are expected PP?

A

Voids: only a few times in the first days after birth, before lactogenesis is established
Then, approx 6-8x per day

Stool: possibly after ever feed

NM 717 Comps (31 decks)

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