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128 Cards in this Set
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- Back
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what are the components of the initial post partum exam
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vitals (htn should have resolved); thyroid (should not be enlarged);
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breasts of non breast feed @6 weeks
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(engorgement resolved, breasts soft, with small amount of milk able to express);
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breasts of lactating @6weeks
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(well established milk supply, cracked nipples? blocked duct? persistent engorgement?); talk about mastitis;
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abdomen @6weeks
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(stretch marks, diastasis ‘supine knees up, raise up head’ described in finger berths, usually resolved by 6wks, may be prolonged in multips and sedentary moms, may respond to abd exercises); assess csection wound;
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funduss @6wks
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should be below symphsis;
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vaginal assessment @6wks
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assess rectal vaginal wall; defer bimanual until 6 weeks; check cystolsele and rectosele (have them bare down while inside, kegals to firm up); vagina (walls still smooth, rugge appear 3 weeks PP); episiotomy should be healing well; cervix (should be closed and a transverse slit)
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what are the components of the 6 week physical exam
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vitals, thyroid, brests, abdomen, complete pelvic exam (include pelvic), extremities,
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red flags @6wk visit
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lochia still red or copious or foul smelling; open cervical os (retained placental products); uterus above symphisis or tender; abnormal vital signs; Screening: pap, GC, check rubella, H/H with blood loss, GTT if GDM, depression
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when can sex activity be resumed
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when lochia has stopped and episiotomy has healed, as early as 2 weeks
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how reliable is breast feeding for birth control?
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if amenorrea 96% protected
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what is the optimal time between pregnancies
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18-23 months. less than 6 months associated with premature delivery
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contraception for lactating women?
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progestin only. avoid estrogen
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when does postpartum eclampsia happen
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48 hours or more
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what is the prodrome for eclampsia
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severe persistent occipital headache, scottomatta spots, blurry, photophobia, epigastric or RUQ pain
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complication of eclampsia?
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seizures
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s/s of perineal or vaginal hematomoas
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severe pain, perineal pressure, bruising, maybe hypovolemic shock
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vaginal hematoma DDX
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abscess
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PE vaginal hematoma
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fluctuating tender mass felt on vaginal exam, maybe asymmetrical size of area
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vaginal hematoma management
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ice pack, maybe surgical evac
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VTE after PG complication
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pulmonary embolism
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Etiology of VTE
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1st week post partum, 35 or older, leg pain
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s/s sub involution
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uterus doesn’t involute, painless excessive bleeding, chills, fever, pain, larger than expected uterus
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labs for sub involution
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cbc, esr, lochia cultura, quantitative beta hcg, pelvic US,
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treatment for sub involution
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methergine, doxycycline
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endometritis background
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infection of uterus wall, most common cause post partum morbid, risk factors prolong ROM, prolonged labor, Csection, multiple pelvic exams, use of fetal monitoring
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endometriitis s/s
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fever higher than 100.4, no other causes of fever, boggy uterus and tender, cervical motion tenderness, foul smelling lochia, leukocytosis
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management of endometritis
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hospitalization for IV fluids and antibiotics
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stress incontinence background
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due to relaxed musculature, increased abdominal pressure, loss of urine when abdominal pressure is increased
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stress incontinenece PE
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insert fingers, have her cough, bare down, look for prolapse that contributes
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stress incontinence treatment
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pelvic floor excersizes
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post partum blues background
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2-3 days after delivery, worse on 5th day, no more than 2 weeks
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s/s post partum blues
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insomnia, crying, low energy, decreased appetite
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management post partum blues
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reassurance, support, sleep, watchful waiting, distinguish from depression (EPDS), lorazepam at night, more than 2 weeks? more eval
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s/s of postpartum depression
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anxiety, lack of interest in baby, guilty, insomnia, can’t sleep when baby does, rapid weight loss, doesn’t enjoy food, can’t get out of bed
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diagnosis criteria for post partum depression
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at least 5 every day for two weeks **depressed mood or **loss of interest, weight loss/gain, insomnia/hypersomnia, psychomotor agitation/retardation, feeling worthless or guilty, difficult concentrating, thoughts of death
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EPDS score of 10? 13?
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10 is possible depression, 13 likely depression
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post partum psychosis s/s
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obvious mood swings, hallucinations, delusions, suicidal thoughts, impaired function
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when is post partum loss worst?
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at 2-4 months
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how long should lochia rubra last? serosa? alba?
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rubra 2-3 days, serosa 3-7 days, alba ends 35 days post partum
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hardness or lumpiness in a woman’s breast who is breast feeding suspect what?
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suspect clogged milk duct
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hardness, lumpiness, and redness in woman’s breast during breast feeding, suspect what
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abscess formation
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the transformation zone of a younger person vs older
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younger, you can visualize the area around the os. older, the zone is within the endocervical canal
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screening guidelines for pap/hpv test
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no one under 21, 21-29 pap q3yrs w/ reflex HPV, 30-64 pap q3yrs w/ co-hpv-test or hpv q5years, >65 d/c pap if not at risk and previous screen negative
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oder of pap smear
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collect for wet mount in posterior fornix of vagina, collect pap smear, collect GC with cervical swab
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colposcopy comes back with CIN II, III what happens?
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ablate transformation zone with cryosurgery, co2 laser, LEEP, conization of cervix
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what is the most effective form of contraception
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sterilization, intrauterine contraception
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what is a very effective contraception
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hormonal methods (OC, patch, ring, implant)
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what are effective contraceptions
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condoms and diaphragms with spermacide
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what are moderately effective forms of contraception
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cervical cap with spermacide, spermacides, sponge
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types of abstinence
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continuous, interrupted, primary (virgin), secondary (born again virgin)
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advantages of abstinence
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100% efficacy when used perfectly, free, increase self esteem, increase communication and negation skills, reduced risk of sti/cervical cancer, endorsed by cultures and religions
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disadvantages of abstinence
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frustration, sense of rejection, self control, requires argreeeable partner, may not be prepared to contract if intercourse does occur, sexual assault and date rape can occur
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what to do if abstinence failure occurs
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emergency contraception
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risk of typical chance users for PG
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85%
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withdrawal method efficacy
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typical user 27% chance of PG/yr and perfect user 4% change pg per year
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advantage of withdrawal method
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free, always available, no hormones, no devices, no side effects, great back up, no visit required
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withdrawal disadvantages
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no room for error, interrupts sex activity, no sti protection, depends on males ability to recognize orgasm
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best couple for withdrawal method
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experienced couples, good control of orgasm, much trust
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patient education for withdrawal method
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take out before ejactulation, cum anywhere but on the vagina, urinate between sex acts, wash the dick between, mistake? insert spermacide immediately, precum can’t get your PG
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lactational amenorrhea method
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6 month window in post partum, ovulation is suppressed do to increased prolactin levels in breastfeeding women, suppresses GNRH impulses
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LAM efficacy
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typical user 2% chance PG in 1yr, perfect is 0.5% chance PG in year
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Lam advantages
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no cost, available, no sex interruption, breast feed good for baby, no partner participation, protects from breast cancer, delay return of menses,
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LAM disadvantages
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return to fertility not predictable, ovulation can occur prior to menses, decreased vaginal lubrication, no STI protection
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patient EDU for LAM
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temporary form, must breastfeed q4hrs, don’t supplement with formula, no pacifiers, look for signs of return to fertility, must meet all 3: amenorrhea, fully breastfeeding, less than 6 mo postpartum
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contraindications to fertility awareness based contraception
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irregular cycles, annovulatory cycles, cervial erosion, cervisitis, vaginitis, inability to use assessments
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types of FAB
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calendar, standard days, cycle beads, ovulation, basal body temp
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calendar method instruction
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chart cycle for 6-12 months, identify length of shortest and longest cycle. subtract 18 from last day of shortest cycle and 11 from the last day of the longest cycle. cycle must be 26-32 days. abstain from days 8-19
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thick or dry mucus you can have sex on…
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alternative days
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wet mucus you can have sex on…
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don’t have sex. you are fertile
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basal body temp and pregnancy
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basal is the lowest upon wakening, rises at pre ovulation time, take temp before get out to bed, record every day, ovulate is ^ 0.4-0.8 above readings for last 6 days, elevated temp persists for 10 days post ovulation, 3 days after ovulation or rise in temp may resume sex with no chance of pg
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what interferes with basal body temp
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illness, interrupted sleep, sleeping late, alcohol, jet lag
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MOA for progestin
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thickens cervical mucus and blocks sperm from entering cervix, also blocks LH surge to suprees ovulation
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what are androgen symptoms
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increase in LDL, triglycerides, decreased HDL, acne, oily skin, rash, puritis, edema. happens with progestins
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estrogen MOA
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supresses FSH—>suppress ovulation; slows egg transport and thins endometrial lining
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how to select OC
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screen for contraindications, measure BP, if over 35 no estrogen
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what are types of phases for OCs
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mono phase, multiphase, extended cycle
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explain mono phasic OCs
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21-24 active pills, 4-7 placebo pills
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benefits/disadvantages of transdermal hormones
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highly effective, apply x3wks followed by patch free week, high percent of perfect use, no significant weight gain, minor application site reaction, may have minor spotting after first 2 cycles
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transdermal patch contraindications
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>198#
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explain the nova ring
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inserted into vagina for 3 weeks, followed by 1 week ring free, very effective, can be stored at room temp up to 4 months if longer storage put in fridge, can be out for up to three hours without any backup, if out for more than 3 hours need back up for 7 days, rinse and reinsert
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contraindications for hormonal contraception
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HA with focal neuro symptoms, migraine with aura, 35 years smoking more than 15 cigs a day, >160/100, hx of thrombosis, DM, BC, estrogen dependent cancer, endocarditis, a fib, major surgery, cva
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past age 40 and wanting to continue hormonal contraception?
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yes if low risk factors and not smoking
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estrogen disadvantages
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N/V, HA, mood change, CV complications, glucose intolerance, gallbladder dz, VTEIPV
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which drugs increase CHC hormone levels
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high dose VIT C
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which drugs levels are increased by CHCs
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benzo, steroid, cortsteroid
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what drugs decrease levels of CHC hormone level
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st. johns wart
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how long do you need backup protection when starting CHC
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for the first 7 days unless you start on first day of menstrual period
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how to handle missed CHC pills
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1 missed: take as soon as remembered take the next at regular time; 2 missed pills: take 1 pill as soon as realize, take 1 pill at regular time that day return to regular time and use back up x7 days; happens during week 3 do not take a 7 day break begin new pack of pills on day 22
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what are the ACHES warning signs for CHC
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abdominal: sever upper, chest pain/SOB, headache, eye problems, severe leg pain
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explain quick start for CHC
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most preferred, start day of clinic visit, do it is you’re sure they’re not pregnant, if need EC give that day and start CHC next day, need backup for 7 days
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start CHC when for post partum?
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42 days
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estrogen excess side effects
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breast tenderness, dysmenorrhea, cholasm
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estrogen deficiency side effects
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spotting days 1-9, continuous bleeding/spotting, hypomenorrhea, atrophic vaginitis
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progestin excess side effects
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^ appetite, depression, fatigue, libido decrease, weight gain, hypertension, recurrent yeast
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progestin deficiency side effects
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break through bleeding days 10-21, delayed withdrawal bleeding, dysmenorrhea, hypermenorrhea
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side effect: acne, CHC management?
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increase estrogen or decrease progestin
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side effect: amenorrhea
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increase estrogen
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side effect: breast tenderness swelling chc management?
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decrease estrogen
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side effect: nausea, CHC management?
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take with food at night, decrease estrogen or increase progestin
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side effect: BTB, CHC management?
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increase estrogen
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side effect: irregular painful menses, CHC management?
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increase progestin, derease androgen
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side effect: high risk thrombosis CHC management?
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decrease estrogen
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side effect: BTB 10-21 days, CHC management?
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increase progestin
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MOA progestin only pills
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thickens cervical mucus, inhibits ovulation, decrease tubal motility, atrophic endometrial changes
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advantages of progestin only pills
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no estrogen, scant or no menses, less cyclic discomfort, supress ovulation pain, decreased risk of endometrial cancer, ovarian cancer, PID, less pain with endometriosis, good for nursing moms, pills less confusing, not as confusing, no estrogen, rapid return to fertility, no weight gain
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disadvantages of progstin only contraception
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no protection against STI, weight gain, increased appetite, depression, fatigue, decreased libido, acne
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progestin only pill contraindications
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known PG, BC, undiagnosed bleeding, ALF, chronic malabsorption, meds that interfere with metabolism
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side effects of progestin only pill
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functional ovarian cysts, acne, headache, irritable
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how to take progestin only pills
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take everyday, no break, may start 6wkeeks PP, may start post abortion immediately, start on 1st-7th day of menses, may start anytime PG ruled out
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missed or skipped progestin only pills
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if breastfeeding take asap, don’t double, otherwise use back up for 48-1week and consider EC if intercourse in last 3-5 days, if more than 3 hours late and recent sex consider EC, if 2 or more pills missed, start back up and take 2 pills a day for 2 days
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meds that decrease progestin only pills
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phenytoin rifampin, gris, st johns wart
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repo prover
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extremely effective, only if patient returns on time, no egg released from follicle
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advantages of depo
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less human error, ameonorrhea, no drug interactions, no estrogen, ok for breastfeed, decrease seizure/sickle cell/ endo and ovarian cancer/cysts
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disadvantages
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can’t stop quick, have to come in, spotting, prolonged return to fertility, weight gain, depression, anxiety, decreased libido, excessive hair growth, increase LDL, decrease HDL
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contra for depo
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pg, vag bleed, 160/100, VTE acute viral hep
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when to start depo
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first dose during 5-7 days from start of menses needs no back up, may start anytime during cycle but need backup x7days, start 6 weeks after breast feed
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side effects of implanon
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HA, acne, vaginitis, weight gain, breast tender
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contra for implanon
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throbs, cancers, pg, vag bleed, liver disease
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when to insert implanon
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between 1-5 day of cycle, anytime during placebo week of OC, immediate after 1st trimester abortion, days 21-28 following childbirth or 2nd trimester abortion
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MOA mirena ring
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thickens cervial mucous
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when does newborn return to birthweight?
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14 days, 28 at latest
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formula fed initial weight loss?
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5%
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breast fed initial weight loss?
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10%
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vaccines at 2 month visit?
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Dtap, PCV HIB, Rota, IPV, HBV
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developmental progression at 2 months?
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time on stomach? rolling over? cooing?
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how often breast fed at 2 months?
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q2-3hr
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how often formula fed at 2 months
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q3-4hr, 2-4oz at each feed
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bowel movements at 2 months?
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should be regular
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