Week 10 pt 2

Question 1

Define Puerperium

Answer 1

6–8 week period following birth (“4th trimester”)

Question 2

Describe uterine involution

Answer 2

Uterus returns to pre-pregnant size by 6 weeks postpartum
1000g  70g
Reduction in cell size, not #
Uterine hemostasis maintained by contraction of the uterine musculature
Breastfeeding causes uterine contractions that are beneficial in the process of involution

Question 3

List and define the 3 types of lochia

Answer 3

Lochia Rubra
red bleeding, lasts 3-4 days, begins very heavy, then gradually decreases in amount
Lochia Serosa
pink-tinged, lasts until approximately day 10 after delivery
Lochia Alba
thinner, whitish-brown discharge which can last several weeks.

Question 4

Describe the cervix and vagina postpartum

Answer 4

Cervix shape permanently changed to a transverse, fish mouth-shaped external os

Vulvar and vaginal tissues return to normal over the first several days Pelvic floor muscles regain their tone
Kegel exercises to strengthen

Question 5

Describe prolactin after birth

Answer 5

Prolactin levels elevated in lactating women  suppresses ovulation
Prolactin returns to normal in 3 weeks in nonlactating women
Ovulation returns ~ 45 days (nonlactating women)
Women who breastfeed exclusively  amenorrhea for up to 6mos
Increased likelihood of ovulation if frequency and duration of breastfeeding decreases

Question 6

Recommend to avoid intercourse for _____ weeks after birth

Answer 6

six

Question 7

Describe the breasts after birth

Answer 7

Engorgement
Galactocele (milk-filled cyst)
Mastitis- slight fever, chills, develops over 2-4wks, redness, soreness of breast, most commonly caused by staph aureus

Question 8

Describe the abd. wall postpartum

Answer 8

Stretch marks (striae gravidarum) lighten over time
Diastasis recti (separation of rectus muscles and fascia) resolves over time

Question 9

Describe the cardiovasc system postpartum

Answer 9

Marked increase in SV and CO in first hour postpartum  gradual decrease
Return to normal 2-3weeks after delivery

Question 10

Hematopoietic System: ___________ during labor and continues for several days

Answer 10

Leukocytosis

Question 11

Describe the renal system postpartum

Answer 11

GFR increases for the first few weeks postpartum
Urethral edema after vaginal delivery leading to transitory urinary retention

Question 12

Describe Postpartum Care & Teaching

Answer 12

Promote Bonding
Observe/document lochia—monitor for hemorrhage
Monitor VS and edema
Monitor for signs of infection (UTI, lochia, perineal tears/episiotomy)
Endometritis: temp > 100.4, pain, foul d/c.
ADMIT, CBC, cultures, begin IV abx therapy
Encourage activity/ambulation; patients are still hypercoaguable
Monitor for postpartum depression
Discuss feeding preferences; bottle vs breast
Make sure patient is emptying her bladder
Make sure patient has BM before discharge
Perineal care as indicated by degree of trauma
-Ice packs, sitz baths, donut rings, stool softeners
-Ensure no hematoma or dehiscence

Question 13

Describe injections & vaccines post-birth

Answer 13

Rhogam if indicated w/in 72hrs
If mom is Rh neg and baby is Rh positive.
Rubella vaccine while in hospital if mom is non-immune
Tdap (if not given during pregnancy)

Question 14

What is the Avg hospital stay (no complications)?

Answer 14

~48hrs after vaginal delivery
~96hrs after c-section

Question 15

What are the potential postpartum complications?

Answer 15

Amniotic Fluid Emboli
DVT
Cardiac decompensation
Cerebral Bleeds
Postpartum hemorrhage
Postpartum infection

Question 16

Amniotic Fluid Embolism (AFE):
1) What is it?
2) Is it deadly?
3) How many phases?

Answer 16

1) RARE obstetric emergency causing cardio-respiratory collapse.
2) Maternal mortality rate ~ 80%; most patients die within an hour of onset
3) Two phases

Question 17

Amniotic Fluid Embolism (AFE): Describe the 2 phases

Answer 17

1) In Phase I, pulmonary artery vasospasm with pulmonary hypertension and elevated right ventricular pressure cause hypoxia and SOB
2) Women who survive these events may enter phase II, a hemorrhagic phase characterized by massive hemorrhage with uterine atony and DIC.

Question 18

What are the risk factors for DVT/PE?

Answer 18

Increased parity, obesity, operative delivery, previous DVT, thrombophilias

Question 19

DVT/PE
1) Sx?
2) Workup?
3) Tx?

Answer 19

1) Pain, edema, redness or paleness of limb, abdominal pain
May or may not have SOB…not very specific in pregnancy
2) Venography, doppler, MRI (especially if doppler US negative)
Assess for thrombophilia (pregnancy may reveal otherwise asymptomatic women)
3) Heparin, rest, monitor for clot resolution

Question 20

Cardiac Decompensation:
1) Who may it occur in?
2) What does clinical eval include?

Answer 20

1) May occur in a patient with previously stable or even undiagnosed heart disease
2) Heart sounds, rate, lung sounds, particularly basilar evaluation for rales, dullness to percussion

Question 21

Cerebral Bleeds:
1) What are most assoc. with?
2) What is outcome dependent on?

Answer 21

1) Pregnancy induced HTN, sinus thrombosis, or subarachnoid hemorrhage due to rupture of aneurysms or AV malformations
2) Degree of insult and remainder of medical status

Question 22

Postpartum Hemorrhage (PPH): How common is it?

Answer 22

Prevalence of PPH is 4-6%
140,000 women die of PPH yearly worldwide

Question 23

Risk Factors for Postpartum Hemorrhage include what?

Answer 23

Prolonged labor
Augmented labor
Rapid labor
History of postpartum hemorrhage
Episiotomy (esp. mediolateral)
Preeclampsia
Overdistended uterus  leading to uterine atony
Prior uterine surgery and other risk factors for abnormal placentation
Operative delivery
Asian or Hispanic ethnicity
Chorioamnionitis

Question 24

PPH: Describe uterine tone

Answer 24

Is the bladder empty?
Did she have a big baby? Long labor?
Is the uterine fundus firm to the touch (boggy=atony)
If not, bimanual massage/ meds as indicated

Question 25

PPH: 1) Describe tissue 2) Describe trauma 3) Describe thrombin

Answer 25

1) Is there placenta or membranes left (TISSUE)? 2) Could her cervix be lacerated (TRAUMA)? 3) Could she have a clotting problem (THROMBIN)?

Question 26

Describe how to Dx/ Tx PPH

Answer 26

Evaluate excessive bleeding immediately Assess/Treat based on patient status Notify OB team Monitor and maintain circulation Review clinical course for possible cause Notify OR and have them on standby *Identify patients who are high risk before any bleeding episodes

Question 27

Describe how to assess and Tx PPH based on pt status

Answer 27

Bimanual exam: assess for atony, check for retained placenta Bimanual uterine massage usually successful on own to cause uterine contraction Inspect perineum (laceration?) Assess clotting (CBC, PT/INR, PTT, fibrinogen, H/H, T&C) Administer uterotonics (oxytocin)

Question 28

Active management of the third stage of labor reduces the incidence of PPH by as much as 70%.; describe how this is done

Answer 28

1) Gentle traction on the umbilical cord 2) Uterine massage to expedite expulsion of the placenta 3) Administration of a uterotonic agent (oxytocin) 4) Manually remove the placenta

Question 29

Maternal death rates associated with __________ = ~0.6 maternal deaths per 100,000 live births.

Answer 29

infection

Question 29

Other sources of postpartum infections include what?

Answer 29

Postsurgical wound infections (C/S or episiotomy) Perineal cellulitis Mastitis Respiratory complications from anesthesia Retained products of conception UTIs Septic pelvic phlebitis (temp days after delivery with no response to abx…. Needs CT)

Question 30

If symptoms of infection are present (elevated WBC, fever, pain, purulence), what do you do?

Answer 30

Culture everything (blood, urine, lochia) Treat with broad spectrum abx until cultures finalized if taken Re-evaluate for improvement in 24-36 hrs

Question 31

Postpartum Endometritis: 1) What is it? 2) How common is it?

Answer 31

1) Infection of the lining of the uterus 2) 0.2-2% incidence after vaginal delivery 1.5-18% incidence after C/S; depending on whether or not prophylactic antibiotics are given pre-procedure

Question 32

Postpartum Endometritis: 1) Sx? 2) PE? 3) Dx?

Answer 32

1) Fever, malaise, tachycardia 2) Lower abdominal pain, uterine and adnexal tenderness on bimanual, foul-smelling lochia 3) Diagnosis is clinical: Fever, Pain or tenderness (uterine or abdominal), Purulent drainage from the uterus

Question 33

What tests should you do with postpartum endometritis?

Answer 33

CBC Urine Culture +/- Blood Cultures +/- gonorrhea/chlamydia culture Should show clinical improvement within 36-48 hrs.

Question 34

Describe what you should do for refractory postpartum endometritis and why

Answer 34

Blood cultures (if +, consult Infectious Disease) Obtain pelvic CT to rule out septic thrombophlebitis Under-treated or untreated endometritis can cause fatal septic shock

Question 35

Stratify the severities of Sheehan syndrome

Answer 35

1) Severe: lethargy, anorexia, weight loss, and inability to lactate during the first days or weeks after delivery 2) Moderate: failure to lactate and failure to resume menses in the weeks to months after delivery, milder fatigue, weight loss, anorexia 3) Mild: possible delay in many years after inciting event

Question 36

What is Less common in developed countries due to improvements in OB care?

Answer 36

Sheehan syndrome

Question 37

What do all the severities of Sheehan syndrome have in common?

Answer 37

1) Can result in a loss of all anterior pituitary hormones like GH, prolactin, gonadotrophin, TSH, ACTH deficiency 2) Eventual development of small pituitary within normal sized sella “Empty sella” seen on brain MRI

Question 38

Describe eval for Sheehan syndrome

Answer 38

ASAP when suspected after delivery associated with usually heavy blood loss If severe blood loss and hypotension, patients should be evaluated for adrenal insufficiency immediately. Other hormonal deficiencies can be evaluated 4-6 weeks later

Question 39

Describe Tx for Sheehan syndrome

Answer 39

1) Same as for other causes of hypopituitarism, replace the hormones! -ACTH = daily hydrocortisone, TSH = levothyroxine -LH and FSH = estrogen and progesterone -GH = no current recommendations for replacement 2) Prolactin deficiency = inability to breastfeed, no treatment available

Question 40

Postpartum Depression: Give the general Management

Answer 40

Initial therapy should include antidepressant therapy and/or psychotherapy Combination therapy is the most effective

Question 41

Describe the use of antidepressants in postpartum depression

Answer 41

1) SSRIs are most commonly used 2) TCAs can also be used as can other classes 3) All cross the placenta! -However, SSRIs are not associated with specific patterns of congenital anomalies, and the risk of untreated psychiatric disease is felt to outweigh the risk of congenital anomalies. -Only SSRI that should be avoided = paroxetine  linked to fetal cardiac defects -Can also be used in breastfeeding

Question 42

1) What is the most severe form of mental derangement that occurs after birth? 2) How common is it? 3) Describe the onset

Answer 42

1) Postpartum psychosis 2) 0.1-0.2% of women following birth 3) Onset is typically sudden, most often in first 2 weeks BUT can occur any time in the first year.

Question 43

Postpartum psychosis: 1) Who is it most common in? 2) How is it treated?

Answer 43

1) Women with preexisting disorders like bipolar illness or schizophrenia 2) Considered a medical emergency and patient should be referred for immediate, often inpatient, treatment

Question 44

Describe Anxiety disorders postpartum

Answer 44

1) Patients with anxiety disorders pre pregnancy and during pregnancy are prone to perinatal depression. 2) Treatment is similar to PPD

Question 45

Describe Bipolar disorders postpartum

Answer 45

1) Onset is often in early adulthood, so preconception treatment planning is wise 2) Manifestations include depression, mania, and psychosis 3) Teratogenic concerns for valproate, carbamazepine, and maybe lithium? 4) Increased risk of peripartum depression and psychosis

Question 46

Describe schizophrenia postpartum

Answer 46

1) Affects 1% of population and symptoms manifest in young adulthood Strong genetic component, 5-10% chance of passing on the disorder 2) Women with schizophrenia are at increased risk of depression and psychosis

Question 47

Describe immediate newborn care

Answer 47

1) Suction to ensure that the baby’s airway is clear 2) Dry the baby to maintain body temperature 3) Delayed cord clamping after 30-60 seconds (unless needs to be done immediately) 4) Warm blankets, skin-to-skin contact with mother 5) Begin breastfeeding within first hour of life (8-12 feedings/day) 6) Monitor infant’s vital signs q 30min until stable x 2hrs 7) Closely monitor for first 6-12hrs to identify any problems that may arise

Question 48

If baby is not responding well in 10-15 seconds after birth, begin true resuscitation efforts; describe these

Answer 48

1) Airway first, then check heart rate 2) Begin compressions if HR < 60bpm 3) Normal newborns breathe within seconds of delivery and establish regular respirations within 1min of delivery

Question 49

Describe appropriate umbilical artery lab values

Answer 49

pH: 7.28 (+/-.5) pCO2: 49 (+/-8) pO2: 18 (+/- 6.2) HCO3: 22 BE: -2.5

Question 50

Blood from the umbilical vein is full of _______________ blood going TO the baby from the mother.

Answer 50

well oxygenated

Question 51

When do you Check Cord Blood Gases?

Answer 51

Cesarean delivery for fetal compromise Low 5-minute APGAR score Severe growth restriction Abnormal fetal heart rate tracing Maternal thyroid disease Intrapartum fever Multifetal gestations

Question 52

What prevents hemorrhagic disease of the newborn?

Answer 52

Vitamin K to promote appropriate clotting.

Question 53

Breastfeeding Advantages (for Baby) include what?

Answer 53

Protects baby from a multitude of infections and other illnesses Decreased incidence of otitis media Higher IQ and cognitive development Believed to be protective against several adult acquired diseases Easier to digest—less reflux, less constipation No worry of contamination

Question 54

Breastfeeding Advantages (for Mom) include?

Answer 54

May delay fertility Decreased lifetime risk of breast cancer Decreased risk uterine and ovarian cancer Promotes uterine involution Promotes weight loss – it takes more calories to breastfeed than it does to be pregnant! Decreased risk of osteoporosis

Question 55

Disadvantages of Breastfeeding include?

Answer 55

Initially can be uncomfortable If returning to work and want to exclusively feed breast milk, pumping must be instituted Causes uterine cramping during first postpartum period due to increased uterine contractions/involution May result in changes in breast texture after weaning

Question 56

Describe how to alleviate sore nipples in breastfeeding

Answer 56

Make sure enough areolar tissue is in baby’s mouth, don’t let baby suck on just the tip of the nipple Allow nipples to air dry after nursing Change baby’s position with each feed Alternate between breasts with each feed

Question 57

Describe how to alleviate low milk supply

Answer 57

Nurse frequently, do not supplement with bottles (supply & demand) Let baby empty both breasts Avoid pacifiers Pump to empty breasts if baby sleeps through a feeding

Question 58

Describe how to alleviate a plugged duct

Answer 58

Painful lump with no redness or fever Nurse frequently. New recs = ice packs, avoid massaging, sunflower lecithin supp. If persists and begins to be an actual mastitis (red, hot, swollen, sore, fever), contact provider to get antibiotics and KEEP NURSING!

Question 59

Describe how to alleviate newborn jaundice

Answer 59

Keep nursing Voiding and stooling will help baby clear the jaundice Need to be sure it isn’t pathologic