OB Exam 2

• Protein and non-protein nitrogens
• Carbs
• Fats
• Vitamins & Minerals
• Live Cells: WBC & T cells to protect immune system
• Not homogenized

• Best nutrition for appropriate growth and development
• Active protection against infection (bacterial & viral); any illness less frequent & less severe
• Lower risk of oral and dental problems
• Builds trusting relationship with Mom

• SIDS
• DM Type 1&2
• Lymphoma/Cancer
• Allergic dx/ skin dx
• Chronic digestive dx (Crohns)
• Childhood/adult obesity
• Chronic high blood pressure

• Dec PP bleeding, rapid uterine involution
• Lactational amenorrhea
• Earlier to return to pre-pregnant wt
• Improved bone remineralization PP
• Reduced risk of breast & ovarian cancer (esp premenopausal)
• Emotional linkage to baby
• Lower costs for health care & food for baby

• Physician apathy, misinformation
• Insufficient prenatal breastfeeding education
• Disruptive hospital policies, interruption of breastfeeding
• Early hospital discharge: milk hasn't come in
• Lack of timely routine follow-up: within 3-5 days
• Maternal employment: not there
• Lack of broad societal support
• Normalization of not breastfeeding, Commercial promotion of ABM

• At each prenatal visit
• Open-ended questions

• Lack of confidence
• Embarrassment/ harrassment/ sexuality
• Loss of freedom
• Lifestyle restrictions
• Influence of family and friends

• Has the right to research-based info: informed choice, not guilt
• Target interests, expectations, and concerns
• Id risk factors
• Social, economic, practice issues important

• Breast exams: 1st tri- nipple trauma; 3rd tri- glandular growth
• C-sec, multiples, premature
• Breastfeeding classes
• Groups and community support

Additional breast tissue in a line pattern extending from armpit to vagina that can leak with breastmilk

• Acute infectious disease
• Venereal warts
• Toxoplasmosis
• Mastitis

• Hepatitis A,B,C
• Tb
• Herpes viruses
• Lyme disease

• HIV
• HTLV-1

• PKU: monitor closely
• Galactosemia: cannot bf, cannot digest

• Drug-by-drug assessment
• The more protein based the better
• Take things baby would nmlly get
• No pseudoephedrine, estrogen: dry up milk

• Conception to Stage 3 Labor
• Breast cellular growth

• Stage 3 to Day 3-4
• Endocrine driven: does not rely on sucking
• Drop in progesterone releases prolactin, driving milk synthesis, dev of prolactin receptors

• Aka Galactopoeisis
• Day 7 until you stop
• Autocrine driven "supply and demand"
• Develops gradually
• Infant sucking, cellular pressure of milk, important in supply
• Continues even as prolactin levels dec

• Medications
• Overhydration: edema, engorgement, excessive fluid (false wt loss in baby), impacts milk supply
• Cranial trauma can pinch sucking nerves: inside FHR mon, forceps
• C-section: mom cannot sit up to nurse

• Inhibit development of full milk supply
• Give depo at least 1 week after

• 40 weeks
• Less stamina, fewer fat reserves
• Underdeveloped neurologic reflexes
• Underdeveloped critical organs (lungs, GI)
• Inc risk for re-admit r/t feeding

• Promote good birth
• Maternal baby bonding
• Breastfeeding

• Early: rooting, sucking on hands, other objects, mewling cry
• Late: crying, breast fullness

• q1.5-3h during day
• At least 1x/ night
• Minimum 140 minutes active feeding per 24h
• Stomach grows up to 1.5 to 2 oz by 10 days of age (feed small)
• Finish first breast first for fat
• 15-30 minutes feeding, 10-15 min audible swallowing

• 1 stool day 1, 2 on 2, 3 on 3
• Stool: size of a quarter
• Void: 1-3 tbsp liquid
• Slows as gut matures
• After first week: 3-5 void, 1 stool minimum
• 7-10% wt loss, back to birth wt by 2 weeks

• Pumping
• Supplementing with hindmilk at breast
• Lactation Counseling

• Frequent, effective feeds
• Soften breasts with massage, expression, warmth
• Soft breast easier for latch
• Cold compress after feed to reduce edema
• Wear supportive bra

• Bad position and latch
• Tongue tie
• Yeast- tx mom and dad if systemic
• Other skin infections: eczema, rashes

• Unresolved engorgement leads to plugged duct leads to mastitis
• Problem of stasis
• Move milk out of breasts and tx with antibiotics
• May have ductal pain after
• Staph, MRSA more common

• Medicated birth
• Oral anatomy, tongue tie
• Oral trauma
• Oral imprint to non-breast
• Physical discomfort
• Slow/weak suck

• Breast anatomy
• Hormones interfering
• Prolonged severe engorgement causing shutdown
• Metabolic issues: DM, hypothyrodism (delay large milk)
• Mother low fat stores or intake

• Do not delay
• Determine factors limiting milk transfer
• Train baby back to breast: avoid bottles, supplement at breast, early signs
• Stimulate milk production: massage and pump

• Vagina is relaxed
• Perineum is edematous, nml in 6-10 wks
• Hematoma may be present
• Episiotomy & tears heal in 2-3 wks
• Hemorrhoids shrink w/in 6 wks
• Sex in 6-8 wks, use lube

• Ovulation can occur in 27 days for bottle feeding moms
• 2-3 months for breastfeeding
• Menstration starts in 3 months

• Bladder tone returns to nml 5-7 days
• Inc BUN, 1+ protein, trace ketones present 1-2 days
• Kidney fxn returns to nml w/in 1 mo

• Passing gas
• Bowel sounds
• Holding down fluids

• Soft and fill 24-48 hrs up to 4-5 days
• Engorged 3-4 days
• No soap on bf pts nipples

• Blood volume dec 300-400mL in vag, 1000mL in c-sec
• Inflammatory values elevated up to 12 wk
• No utero-placental circulation
• Temp may be elevated from dehydration, and when milk comes in

• Requires careful monitoring
• Report tachycardia, low & high blood pressure, oral temp 100.4 or greater

• Very low H&H: excessive blood loss
• Elevated clotting factors
• WBC: 20-25 first 10-12 days
• Varicosities & hemorrhoids regress after 6 wks

• Diuresis leads to alleviation of carpal tunnel syndrome
• Numbness & tingling of the hands resolves
• H/A: epidural-blood patch, PIH or ecclampsia

• Relaxation and hypermobility of joints reverse to nml
• Joints stabilized by 6-8 weeks
• Feet joints never go back, always bigger

• C-sec delay abdominal exercise for 4 wks
• Rubella vaccine if not immune and no prego w/in 3 mo after
• Document referrals: social services, hearing visits

• Focused breathing and relaxation techniques
• Slow abdominal-paced breathing (latent)
• Pattern-paced breathing (transition) avoid hyperventilation

• Husband coached
• "Natural" darkness, solitude, quiet

• Water therapy
• Hypnosis
• Biofeedback
• Aromatherapy
• Position change
• Application of heat & cold

• Effleurage: gentle stroking mom's belly
• Counter pressure: pressure applied to sacral area
• Acupressure
• Touch & massage
• Healing touch
• TENS

• Based on gate control theory
• Focusing & feedback
• Music
• Breathing patterns

• Mild contractions
• Alternate periods of excitement & rest
• Encourage upright position and support
• Plant seed for meds

• Senses urge to push
• Tries to find adequate breathing pattern
• Inc irritability
• Frequent positioning
• Minimize stress
• Discourage holding breath

• Extreme pain & powerlessness
• Burning sensation
• Inc urge to push
• Encourage "blowing away"
• Warm compress to perineum
• Provide mirror
• No pushing!

• Uterine muscle hypoxia
• Cervical & lower uterine segment
• Stretching
• Pressure on bony pelvis

• Does not relieve pain, induces sleep & dec anxiety
• Rarely used due to neonatal CNS effects

• Stadol: used more, q3-4h
• Nubain: used less
• Do not give close to delivery- neonatal narcosis, resp depression

• Phenergan- good for nausea
• Vistaril
• Enhances opioid effects

• Narcan
• Infant: neonatal narcosis, low RR
• Mom: itching, CNS depression

• Hypotension- early
• Prolong labor- give in Active phase
• Inc need for Oxytocin
• Maternal fever
• Inc risk for C-sec
• Inc use of Operative delivery
• Itching reported
• Bladder distension- late, foley

• Risk in epidural
• Tachycardia
• Numbness of tongue
• Metallic taste
• Inc BP or tinnitus w/in 2-3 min
• Intervention: lie down, place elsewhere

• Risk in epidural
• Immediate upper thoracic sensory loss
• Severe lower extermity motor blockage
• RESP ARREST

• Risk in epidural
• Tx: blood patch, caffeine, supine, rest

• Assess FHR & Uterine activity w/ narcotics- expect some nonreactivity
• Maternal vaginal exam
• Observe for resp depression, give narcan
• Enhance opioid effects with vistaril or phenergan

• Used for Pain relief in Stage 2
• Blocks nerve for relief in lower vagina, vulva, perineum
• Used in complications

• Leopolds for PMI
• Fetal status
• Contractions: frequency, length, strength
• Membranes

• Color
• Thin or thick fluids could cause resp problems
• White flecks in fluid is vernix, okay
• Ferning pattern under microscope: indicative of protein
• Pooling in vaginal vault

• VS
• Pain
• Coping
• Psychosocial

• Platelets at least 100,000 before epidural
• WBC elevated during labor, up to 20,000 after delivery

• Monitoring frequency
• Diet
• IV therapy
• Activity
• VS
• Consults
• GBS

• Latent: 5-30 min, irregular, mild to moderate
• Active: 3-5 min, regular, moderate to strong (if irregular, inc petocin)
• Latent: 2-3 min, strong to very strong (goal is strong 90-100 mmHg)

• Dilation, effacement
• Presenting part
• Membrane status
• Stool in rectum
• (sterile glove if ruptured, ky jelly if not)

• Squatting position
• Inc pelvic diameter & gravity

• Doesn't descend (inc petocin)
• Mom doesn't dilate
• Malpresentation
• Baby too big
• Doesn't deliver after 3-4 hrs in Stage 2

• Meconium- no cry
• Arrest of Progress
• Vaginal Bleeding
• Infection: GBS status (antibiotics), maternal temp, FHR

• Amniotic fluid embolism/ PE
• Prolapse cord: knee-chest position to get pressure off cord, watch for bradycardia
• Vaginal bleeding: PP hemorrhage
• Nonreassuring FHR: 5 min brady, rep late decel (C-sec)

• Infection
• Tear extension
• Hematoma

• During labor: warm compress, perineal massage
• After labor: ice packs

• Firmly contracting fundus
• Sudden gush of blood from introitus
• Lengthening of umbilical cord (delivered before placenta)
• Membranes at introitus- gentle push
• -Must be delivered in 30 min

• Bolus Oxytocin
• Fundal massage
• S/S hemorrhage
• VS
• LOC

• 1. Oxytocin inc & fundal massage
• 2. Methrogen, hemobait
• 3. Emergent hysterectomy

• Intergration of family
• Cultural beliefs
• Support of adolescents

• Breathing
• Adjusting from fetal to nml circulation
• Maintaining body's temperature
• Later: breath, suck, swallow

• Changes in pressure (fluid out of lungs)
• Changes in temperature
• Environmental stimuli (noise, lights)

• Infants: closes up PDA (ductus arteriosus)
• Mom: stop preterm labor

• Convection: baby to air
• Radiation: baby to distant object
• Evaporation: baby tries to evaporate cold moisture, keep baby dry
• Conduction: baby to object in direct contact

• Voiding may be delayed up to 24 hours
• Red brick dust/ uric crystals: nml
• 40-60 mg/kg/day first 2 days
• 100-150 mg/kg/day after