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Exam (elaborations) OB 101 (OB101) OB 101 - OB Final Exam Study Guide.
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1OB FINAL EXAM
Postpartum
• The postpartum or the puerperium period is the period of time following the delivery of the child during which the body
tissues, especially the reproductive system reverts back to the pre-pregnant state, both anatomically and physiologically.
• The puerperium or the postpartum period lasts for 6 weeks.
o 1) Immediate Postpartum: the 24-hour period immediately following delivery.
o 2) Early Postpartum or puerperium: up to 7 days.
o 3) Remote postpartum or puerperium: up to 6 weeks.
Reproductive system
• Involution of the uterus: rapid reduction in size of the uterus to a nonpregnant state following birth.
• Following delivery of the placenta the uterus contracts into a hard mass; the size of a grapefruit
• Exfoliation is a very important aspect of involution; if healing of the placenta site leaves a fibrous scar, the area available for
future implantation is limited, as is the number of possible pregnancies.
• With the dramatic decrease in the levels of circulating estrogen and progesterone following placental separation, the uterine
cells atrophy, and the hyperplasia of pregnancy begins to reverse.
• Factors that enhance involution include:
o an uncomplicated labor and birth
o complete expulsion of the placenta or membranes
o breastfeeding
o manual removal of the placenta during a cesarean birth
o and early ambulation.
• Factors that slow uterine involution include:
o Prolonged labor
o Anesthesia
o Difficult birth
o Grand multiparity
o Full bladder
o Incomplete expulsion of the placenta or membranes
o Infection
o Over distension of the uterus (Overstretching of uterine muscles with conditions such as multiple gestation,
hydramnios, or a very large baby may set the stage for slower uterine involution.)
Uterus
• At delivery fundus is at the umbilicus
• 1-2 hours: midway between umbilicus and symphysis pubis
• 12 hours: 1 cm above or at umbilicus
• After that the height of the uterine fundus decreases (involutes) by approximately 1 cm per day.
• Within 6 to 12 hours after birth, the fundus of the uterus rises to the level of the umbilicus because of blood and clots that
remain within the uterus and changes in support of the uterus by the ligaments.
• A fundus that is above the umbilicus and boggy (feels soft and spongy rather than firm and well contracted) is associated with
excessive uterine bleeding. As blood collects and forms clots within the uterus, the fundus rises; firm contractions of the uterus
are interrupted, causing a boggy uterus (uterine atony). When the fundus is higher than expected on palpation and is not in the
midline (usually deviated to the right), distention of the bladder should be suspected; the bladder should be emptied
immediately and the uterus remeasured.
• If the woman is unable to void, in-and-out catheterization of the bladder may be required.(straight cath)
• After birth the top of the fundus remains at the level of the umbilicus for about half a day. On the first postpartum day, the top
of the fundus is located about 1 cm below the umbilicus. The top of the fundus descends approximately one finger
breadth(width of index, second, or third finger), or 1 cm, per day until it descends into the pelvis on about the 10th day. Breast
feeding hastens this process.
• oversized uterus during the pregnancy(because of hydramnios, [LGA] infant, or multiple gestation), the time frame for uterine
involution process is lengthened.
, 2
• If intrauterine infection is present, in addition to foul-smelling lochia or vaginal discharge, the uterine fundus descends much
more slowly.
o When infection is suspected, other clinical signs such as fever and tachycardia in addition to delayin involution must
be assessed.
o Any slowing of descent is called subinvolution (is the failure of the uterus to return to a nonpregnant state)
o Common causes- retained placental fragments and infection
Lochia- more common in the mornings and multiparous mom tend to have more, also moms who had a vaginal birth VS a Csection
• Rubra- 1-3 days – dark red, bloody, fleshy, musty, stale non-offensive odor; clots, sometimes meconium and vernix. A few clots
(no larger than a nickel is common) LARGE clots are not normal
• Serosa- 4-10 days – pinkish, watery, odorless
• Alba-11-21 days; ( a week or two) yellow to white, possible stale odor
• When the lochia flow stops, the cervix is considered closed, and chances of infection ascending from the vagina to the uterus
decrease.
• Foul smelling lochia: assess for (WBC) count and differential and assessment for uterine tenderness and fever.
• Persistent discharge of lochia rubra or a return to lochia rubra indicates subinvolution or late postpartal hemorrhage
• Continuous bleeding is consistent with vaginal/uterine lacerations. Lacerations should be suspected if the uterus is firm and of
expected size and if no clots can be expressed.
Vaginal changes
• Edematous
• Multiple small lacerations
• Perineal pain can last for up to 2 weeks
• By 6 weeks the nonbreastfeeding woman’s vagina usually appears normal.
• The lactating woman is in a hypoestrogenic state because of ovarian suppression, and her vaginal mucosa may be pale and
without rugae; the effects of the low estrogen level may lead to dyspareunia (painful intercourse), may be reduced by the
addition of lubricant.
• Tone and contractility of the vaginal orifice may be improved by perineal tightening exercises such as Kegel exercises
• Painful intercourse due to lowered estrogen which leads to decreased vaginal lubrication and vasoconstricition for 6–10
weeks
Perineal changes
• Edematous and bruising
• If episiotomy present ; sore tender, pain subsides in 5-6 days
• Observe for REEDA
• Healing can take up to 2-3 weeks; complete up to 4-6 months
• Perineal discomfort
• Perineal lacerations: place ice pack, sitz bath, or packing
• DO NOT give pt enema or suppository
•
Recurrence of ovulation & menstruation
• In nonbreastfeeding mothers, menstruation generally returns between 4 and 6 weeks after birth.
• nonlactating mothers the average time to first ovulation can be as early as 27 days with a mean time of 70 to 75 days (6-8
weeks)
, 3
• ovulation and menstruation in breastfeeding mothers is usually prolonged and is associated with the length of time the
woman breastfeeds and whether formula supplements are used.
• If a mother breastfeeds for less than 1 month, the return of menstruation and ovulation is similar to that of the
nonbreastfeeding mother.
• Lactating- delayed, but not reliable form of birth control; Exclusive breastfeeding leads wider spacing of pregnancy
• In women who exclusively breastfeed, menstruation is usually delayed for at least 3 months. Suckling by the infant typically
results in alterations in the gonadotropin releasing hormone (GnRH) production, which is thought to be the cause of
amenorrhea
Postpartal Physical Adaptation
• Vital Signs
o During the postpartal period, with the exception of the first 24 hours, the woman should be afebrile.
o Epidural anesthesia for labor, which can interfere with heat dissipation, has a direct effect on maternal temperature but
rarely results in overt fever.
o Maternal temp of up to 38C (100F) may occur after childbirth as a result of exertion & dehydration of labor.
o An increase in temp between 37.8C and 39C (100F to 102.2F) may also occur during the first 24 hours after mothers milk
comes in
▪ FIRST 24 hours after birth- high temp is normal
▪ 24 hours after birth- high temp is NOT normal
o Immediately following childbirth, may women experience a transient rise in both systolic & diastolic BP, which
spontaneously returns to baseline over the next few days
o A decrease may indicate physiologic readjustment to decreased intrapelvic pressure, or it may be related to uterine
hemorrhage.
o Orthostatic hypotension- feelings of faintness or dizziness immediately after standing up can develop in the first 48 hours
as a result of abdominal engorgement that may occur after birth
o A low or decreasing BP may reflect hypovolemia secondary to hemorrhage, but it’s a LATE sign.
o BP elevations may result from excessive use of oxytocin or vasopressor meds
o Puerperal bradycardia with rates of 5-70 bpm commonly occurs during the first 6-10 days of postpartal period
▪ May be related to decrease cardiac effort, the decreased blood volume following placental separation and
contraction of the uterus, and increased stroke volume.
▪ A pulse greater than 100 bpm may be indicative of hypovolemia, infection, fear, or pain and requires further
assessment
• Abdominal
o Loose, flabby- responds to exercise within 2 to 3 months
▪ However, the abdomen may fail to regain good tone & will remain flabby in the grand multipara, in the woman
who’s abdomen is overdistended, or in the woman with poor muscle tone before pregnancy.
o Striae or stretch marks
o Diastisis recti- separation of rectus muscle, may improve depending on the woman’s physical condition, gravidity, exercise
• If diastasis occurs, part of the abdominal wall has no muscular support but is formed only by skin,
subcutaneous fat, fascia, & peritoneum.
• This may be especially pronounced in women who have undergone a C-section.
• This may result in a pendulous abdomen and increased maternal backache.
• Cardiovascular
o Cardiac output returns to prepregnant levels within 1 hour
o Maternal hypervolemia acts to protect the mother from excessive blood loss
o Maternal hypovolemia occurs immediately following birth (POWERPOINT)- didn’t find this in the book.
o Cardiac output declines by 30% in the first two weeks and reaches normal by 6-12 weeks
o Diuresis in the first 2-5 days results in a 3kg weight loss
▪ Failure to diuresis in the immediate postpartum period can lead to pulmonary edema and subsequent cardiac
problems. This is seen more commonly in women with a hx of preeclampsia or preexisting cardiac problems
• Blood values
o Nonpathologic leukocytosis- immediate PP (25,000 – 30,000/mm)
▪ WBC typically return to normal levels by the end of the 1 st postpartum week
▪ Leukocytosis combined with the normal increase in erythrocyte sedimentation rate may obscure the diagnosis of
acute infection at this time
o H&H maybe difficult to interpret in the first two days b/c of the changing volume
▪ This loss of blood in the first 24 hrs accounts for half of the RBC volume gained during the course of the
pregnancy.
o A decrease in 2%-3 % points from hematocrit level at the time of admission indicates a blood loss of 500 ml
o 400 ml blood loss with vaginal & nearly 1000 ml with C-section
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