Maternal-Infant Health Nursing (OB)
Maternal-Infant Health Nursing (OB) NSG 3323
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Ch. 39: Postpartum Complications OB Exam 3 Chapter 39: Postpartum Complications Postpartum Hemorrhage Early: 1 24 hours o More than 500 mL blood loss in a vaginal birth o More than 1000 mL blood loss in a Csection st Late: after the 1 24 hours S/S*: o Excessive or bright red bleeding (saturation of more than one peripad per hour) o A boggy fundus that does not respond to massage o Abnormal clots o High temperature o Any unusual pelvic discomfort or backache o Persistent bleeding in the presence of a firmly contracted uterus o Rise in the level of the fundus of the uterus o Increased pulse or decreased BP o Hematoma formation or bulging/shiny skin in the perineal area o Decreased LOC Causes: o Early: **Uterine atony: #1 cause Lacerations of cervix, vagina, perineum Hematoma Retained placenta fragments Overdistension of uterus in labor o Late: **Retained placenta fragments: #1 cause Subinvolution Uterine rupture Assessment: o Risk factors o Assess vaginal bleeding q15 x 4, q30 x 2, then qhr o Palpate fundus for firmness, midline, and height o Assess bladder Implementation o **Massage boggy uterus, DON’T overmassage o Document amount, type of lochia, clots, and pad count o VS, encourage frequent voiding, I&Os o Administer Pitocin, methergine, hemabate as ordered o For bleeding with contracted uterus, contact physician o Assess LOC o Replace fluids as needed/ordered o Monitor Hct and Hgb 1 day after delivery o Be prepared for blood transfusion if needed/ordered Uterine Atony 1 Ch. 39: Postpartum Complications OB Exam 3 *Primary cause of early PPH Assessment: soft, boggy uterus, displaced uterus, peripad saturation, pale/clammy skin Management: o Fundal massage** o Empty the bladder o Notify MD/midwife o Oxytocin therapy, if unresolved o Hemabate or Methergine per order Hematoma Collection of blood into tissue after delivery—vulvar Associated with use of forceps, vacuum extractor, operative delivery, injury to a blood vessel Assessment o *Abnormal amount of perineal pain/pressure, rated as severe o Could have bulging mass or discolored skin, or hematoma could be concealed o Difficulty voiding or inability to void o Signs of shock—pallor, tachycardia, hypotension (if blood loss has been severe) o A decrease in the Hgb and Hct levels Interventions o Ice to perineal area after delivery o I&Os o Check voids—first 3 after delivery o Encourage fluids/voiding o Prepare for incision and evacuation of larger hematomas, if necessary o Monitor pain level o Look for S/S of infection and administer antibiotics as ordered Bleeding with a Contracted Uterus Lacerations often the cause Uterus contracted Assessment: bleeding continues, then source of bleeding should be identified o Inspection of perineal area o Lab work Subinvolution Slowed involution process (usually it’s not palpable after 10 days pp) Failure of the uterus to return to normal size—less than 1 cm per day Assessment o Uterus larger than expected o Greater than the normal amount of vaginal bleeding o Possible infection o At risk for bleeding Interventions o VS o Assess fundal height and location of fundus o Monitor and document vaginal bleeding o Encourage voiding 2 Ch. 39: Postpartum Complications OB Exam 3 o Monitor Hct and Hgb o Methergine as ordered, or Pitocin o Uterus should be nonpalpable in 910 days PP Postpartal Infections Occur in the first 10 days after delivery, but can occur in the first 6 weeks after delivery Risk factors: o Csection o PROM o Invasive procedures o Vaginal exams o Preexisting infections o Anemia o Forceps/Vacuum extractor use o Diabetic mother Can extend through circulatory system, lymphatic system and develop into peritonitis and pelvic cellulitis Types (matching)**: o Endometritis—infection of endometrium of the uterus o Metritis—infection of the myometrium o Parametritis—infection of the connective tissue of pelvic structures o Salingitis—infection of the fallopian tubes o Oophoritis—infection of the ovaries o Chorioamnionitis—infection of the fetal membranes o Peritonitis—infection of the peritoneal cavity o Cystitis—infection of the bladder o Pyelonephritis—infection of the kidneys o Mastitis—infection of the breasts Agents responsible for infections o GBS o E. coli o Chlamydia trachomatis o Staph. Aureus o Clostridia o Klebsiella pneumonia Assessment o Temperature—excluding the first 24 hours, temp >100.4 on 2 days of first days pp, chills o Foul smelling lochia o Pelvic pain, abdominal tenderness o Dysuria, burning with urination o Tachycardia o Increased WBC o Delayed involution—subinvolution o Anorexia Implementation o Prevention—handwashing o VS q2h 3 Ch. 39: Postpartum Complications OB Exam 3 o Obtain cultures if necessary o Administer IV antibiotics o Provide routine PP care—stress handwashing o Pain medication as prescribed o Hydration, encourage intake of fluids if not contraindicated (30004000 mL/day) o Have family to help with infant care—mom should rest CSection Wounds (REEDA) o Redness o Edema o Ecchymosis o Discharge o Approximation Mastitis Breast connective tissue infection Usually 23 weeks after delivery Usual causes: E.coli, Staph aureus Possible Causes o Cracked nipples o Engorgement o Poor hygiene Assessment o Reddened area, warm, painful area on breasts o Enlarged lymph nodes o Fever, malaise—flu like symptoms o Elevated temperature Implementation o C&S—give abx if necessary o Breast comfort—support bra, local heat/cold o Hydration and rest o Handwashing, breast hygiene o Antibiotics, pain meds as ordered o VS, antipyretic for fever o Continue breast feeding, unless contraindicated o Empty breast with breast pump at least q4h o Teach breast care/feeding Thromboembolic Complications Thrombophlebitis—inflammation of vessel wall (red line going up the leg) Thrombus—blood components combine to form a clot Embolism—clot that dislodges, travels to lungs and obstructs blood flow to lungs Superficial thrombophlebitis—saphenous vein, midcalf pain, tenderness, redness along vein Deep vein thrombosis (DVT)—muscle pain, Homan’s sign is positive, edema Pelvic thrombophlebitis—2 weeks after delivery, chills, malaise, stiffness, pain (aka septic pelvic thrombophlebitis), seen in conjuction with other reproduction tract infections Pulmonary embolism—sudden intense chest pain, severe dyspnea followed by tachypnea, apprehension, cough, tachycardia, hemoptysis, temperature, high mortality rate Predisposing factors 4 Ch. 39: Postpartum Complications OB Exam 3 o History of thrombophlebitis o Obesity o History of Csection o History of forceps use o Multiparity o Maternal age >35 years Implementation o Support hose for women with varicose veins o Prevent venous stasis o Assess leg for edema, tenderness, varices, increased skin temp o Homan’s sign o Strict bedrest o Anticoagulant therapy as ordered—vitamin K available as antidote for warfarin, Protamine sulfate available as antidote for heparin o When on anticoags, observe and report petechial, bleeding from mucous membranes, bloody stool, hematuria o No estrogens given o Observe for S/S of pulmonary embolism o Non aspirin analgesics for pain o Measure extremities Psychiatric Disorders Baby blues, PP blues, short lived and requires no medical intervention, usually goes away after a week PP depression, PP psychosis, and PP onset panic disorder are others Baby Blues o 5075% affected o Hormone changes o Lack of sleep o Stress of new family member o Occurs within 35 days PP, and lasts up to 14 days o Mom is able to care for herself and baby o Feels overwhelmed, unable to cope, fatigued, irritable, and oversensitive PP Depression or PP Major Mood Disorder o Depression/anxiety during pregnancy o Inadequate social support o Stresses o Uncontrolled crying, anxiety, fear, inability to concentrate, inability to care for self/baby, decreased affection with infant, severe, thoughts of harm to self/baby o Requires psychiatric interventions PTSD o Fear, helplessness o Need sensitive caregivers o Additional support/information PP Psychosis o Variant of bipolar disorder—most serious of PP mood disorders o Occurs in 12 women in 1000 births o Can begin as early as 3 days PP, usually in the first 14 weeks 5 Ch. 39: Postpartum Complications OB Exam 3 o Require immediate hospitalization o Mood swings, agitation, confused thinking, strange thoughts, disorganized behavior, depressed or elated moods+ 6 Maternal-Infant Nursing Chapter 1 Perinatal Nursing time and process of giving birth or being born Antepartal Nursing Intrapartal Nursing Postpartal Nursing Newborn Nursing Pregnancy 9 months 10 lunar months 280 days 40 weeks TRIMESTERS o 1 trimester: 0-3 months o 2ndtrimester: 4-6 months o 3 trimester: 7-9 months Contemporary Maternity Nursing and Women’s Health Care Maternity Nursing: focuses on the care of childbearing women and their families through all stages of pregnancy and childbirth, as well as the first 4 weeks after birth. Women’s health care focuses on the physical, psychological, and social needs of women throughout their lives. Their overall experience is emphasized. Issues and Trends related to the health and health care of women and infants Problems with the U.S. health care system o It’s fragmented, inefficient, and wasteful o Disparities in access to care o Errors High cost of health care o Spends more than any of the other countries that make up the WHO, yet ranks 37 in quality due to shift in demographics, increased emphasis on high-cost technology, and the liability costs of a litigious society, increased number of low birth rate babies in neonatal intensive care units o Midwifery helps to contain some costs, as do early postpartum discharge programs. Limited access to care o EX: inability to pay, lack of transportation, dependent child care. Status of nursing o National nursing shortage, evolution of role from primary care giver to leader of interdisciplinary care team. Integrative health care o Encompasses complementary and alternative therapies in combination with conventional Western modalities Childbearing Changes from a even a decade ago Disparities among races for prenatal care; choosing physicians or midwives; use of labor rooms, delivery rooms, birthing centers, at home; changes in nd conduct during 2 stage of labor (delayed pushing, less episiotomies, methods of analgesia); increasing use of assistive reproductive technology; family-centered care; childbirth education and parenting classes; LDR (labor- delivery-recovery) and LDRP (labor-delivery-recovery-postpartum) rooms; couplet or mother-baby care; lactation consultants; early discharge after delivery requires focused and efficient teaching and followup; neonatal security o Certified Nurse-Midwives (CNMs): registered nurses with education in the two disciplines of nursing and widwifery. Certified midwives are educated only in the discipline of midwifery. o Family Leave: Family and Medical Leave Act of 1993 provides for up to 12 weeks’ unpaid leave to eligible employees for birth, adoption, or foster placement; for care of a child, spouse, or parent who is seriously ill; or for the employee’s own illness. o International concerns: female genital mutilation, infibulation, and circumcision can raise ethical dilemmas Scientific/technological advantages o More care outside hospital o Prenatal diagnosis of birth defects o Improved quality of life for preterm o HIGH TECH BIRTHING Sociologic changes/attitude changes o Mobile families/working mothers o Divorce rates/single parent homes Changes in Healthcare Practices Physician attended births Certified midwife attended births Changes in Birth Experiences LDRP: lactation consultants “Rooming in”: earlier discharge Significant others at birth Trial of Labor Professional Options in Maternal Infant Nursing Nurse Certified RN Nurse Practitioner Clinical Nurse Specialist Certified Nurse Midwife Perinatal Statistics Birthrate—number of live births in 1 year per 1000 population Fertility rate—number of births per 1000 women between the ages of 15 and 44 years (inclusive), calculated on a yearly basis Infant mortality rate—number of deaths of infants under 1 year of age per 1000 live births Maternal morbidity rate— Maternal mortality rate— number of maternal deaths from births and complications of pregnancy, childbirth, and puerperium (the first 42 days after termination of the pregnancy) per 100,000 live births o Significantly lower than they were 25 years ago Neonatal mortality—number of deaths of infants under 28 days of age per 1000 live births Postneonatal mortality—the number of deaths of infants between 28 days and 1 year of age Perinatal mortality rate—number of stillbirths and the number of neonatal deaths per 1000 live births Fetal death—death in utero at 20 weeks’ or more gestation Stillbirth—an infant who, at birth, demonstrates no signs of life, such as breathing, heartbeat, or voluntary muscle movements Abortus—an embryo or fetus that is removed or expelled from the uterus at 20 weeks of gestation or less, weighs 500 g or less, or measures 25 cm or less Vital Statistics World United States Alabama Healthy People 2020 Goals are to increase the quality and years of healthy life and to eliminate health disparities Alabama Vital Statistics at a glance… Infant Mortality Rate Common indicator of the adequacy of prenatal care and the health of a nation as a whole Associated factors: limited maternal education, young maternal age, unmarried status, poverty, lack of prenatal care, smoking, poor nutrition, alcohol use, and maternal conditions such as poor health or HTN A shift from current emphasis on high-tech medical interventions to a focus on improving access to preventive care for low-income families is necessary Vaginal Delivery vs. Cesarean Delivery Rates for State of Alabama Hospitals Summary Very low birth rates are up Prenatal care is down Smoking by mother increases risk of infant death Women who had prior infant death at risk Low maternal weight gain during pregnancy appears to be a factor Deaths for multiple births are up Interventions Fetal-infant Mortality Review Prenatal care for women receiving inadequate or no prenatal care Family planning Interpregnancy care for targeted group Smoking cessation/prevention and second hand smoke OB Exam 1 Women’s Health: Family Planning Chapter 5 Overview 66.4 million U.S. women of childbearing age 62% of these practice contraception Nearly 50% of all pregnancies unplanned 4 in 10 pregnancies terminated Women in Need of Contraception 36,2 million women in need of contraceptive services 137 million women in developing world have unmet need for contraception Maternal morbidity and mortality major challenge Benefits of Family Planning Improved health of women Lower rates of induced abortions Fewer unwanted pregnancies and births Improved socioeconomic status Contraception Any method used that prevents contraception or childbirth Women are at risk for pregnancy almost half of their lives…and estimated 35- 39 years Decisions about contraception should be made voluntarily with full knowledge of advantages, disadvantages, effectiveness, side effects, contraindications, and long term effects Adolescents: a challenge related to contraception o Teen birth has declined in last 20 years o Contraception use has increased o Teen birth is higher than other developed countries o 8 in 10 of teen births are unintended Choosing Contraceptive Method Awareness of: o Advantages and disadvantages o Patient’s age, childbearing plans o Side effects, safety o Contraindications o Partner’s support, willingness to cooperate Choosing influences by: o Cultural practices and religious beliefs o Personality, lifestyle, motivation, self-esteem o Cost and effectiveness o Availability and access to medical care o Misinformation Fertility Awareness-Based Methods Fertility awareness-combined methods 1 OB Exam 1 o Based on an understanding of the changes that occur throughout a woman’s menstrual cycle and require recording of certain events to identify fertile days o Use of a barrier method during fertile days o Maximum fertility for the women occurs approximately 5 days before ovulation and decreases rapidly the day after o Takes into account the lifetime of sperm (2-7 days) and the ovum (1-3 days) Natural family planning (NFP) o When a couple abstains completely from intercourse during the fertile days o Free, safe, and acceptable to many whose religious beliefs prohibit other methods o Provides an increased awareness of the menstrual cycle, involves no artificial substances or devices, encourages the couple to communicate about sexual activity and family planning, and is useful in helping a couple plan a pregnancy o May interfere with sexual spontaneity, require the couple to maintain records for several cycles before beginning use, may be difficult or impossible for certain groups of women to use, and may not be as reliable as in preventing pregnancy as other methods Basal body temperature method o Used to detect ovulation by temperature changes during the menstrual cycles o Temperature almost always rises and remains elevated after ovulation because of the production of progesterone, a heat producing hormone o At time of ovulation, temperature slightly decreases, then increases 0.4 to 0.8 degrees C. o Fertile period ends 3 days after temperature elevation o Requires that a women take her temperature every morning upon awakening (before any activity) and record the findings on a temperature graph and after 3 to 4 months of regular cycles, she will be able to predict when ovulation will occur o To avoid conception, the couple will avoid intercourse or use a barrier on the day of the temperature rise and for 3 days following Ovulation method o Involves the assessment of cervical mucus changes that occur during the menstrual cycle o The amount and character of cervical mucus change because of estrogen and progesterone Fertile—clear, streatchy, slippery, stringy, FERNING Non-fertile—thick, sticky, cloudy secretions or no mucus o Before using this method, the women must abstain from intercourse for one entire menstrual cycle in which time she assesses her cervical mucus daily for amount, feeling of slipperiness or wetness, color, clearness, and spinnbarkheit o Woman assumes that the peak day of wetness and clear, streatchable mucus is the day of ovulation and should abstain from intercourse from the first sign of mucus becoming clearer, more elastic, and slippery until 4 days after the peak wet mucus day 2 OB Exam 1 Calendar rhythm method o Based on the assumption that ovulation tends to occur 14 days (+/- 2 days) before the start of the next menstrual period o To use this method, the woman must record her menstrual cycle for 6 months to identify the shortest and longest cycles o Fertile phase is calculated from 18 days before he end of the shortest recorded cycle through 11 days from the end of the longest recorded cycle o For effective use, the woman must abstain from intercourse during the fertile phase or use a barrier method o LEAST RELIABLE o Standard days…couples avoid intercourse days 8-19 o Calendar method…shortest cycle—18 days, longest cycles—11 days o Not effective for… Women with short/irregular cycles (25 days) First few years of menarche or few years before menopause Breastfeeding moms or women who have recently given birth Cervical Mucous o Fertile—clear, stretchy, slippery o Non-fertile—thick, sticky, cloudy secretions or no mucous Symptothermal method o Consists of recording various indicators of fertility by the couple for a number of months Cycle length Frequency and timing of coitus Cervical mucus changes Secondary signs of ovulation such as increased libido Abdominal bloting Mittelshmerz (midcycle abdominal pain) Changes in BBT Standard days method o Good for women with regular cycles between 26 and 32 days o Intercourse is avoided, or a barrier method used, between cycle days 8 through 19 Lactational amenorrhea o Based on a woman breastfeeding exclusively for the first 6 months after childbirth o High levels of prolactin in the woman’s body during breastfeeding should prevent ovulation o “pregnancy spacing” Situational Contraceptives Abstinence o Primary—never had sexual intercourse o Secondary—chooses to abstain for time period Coitus interruptus o Pull out method** o Required that the male withdraw from the female’s vaginal when he feels that ejaculation is impending Demands great self-control for the man 3 OB Exam 1 After recent ejaculation, sperm remain in the urethra…so for couples who engage is repeated episodes of sex, the sperm could escape from the penis resulting in unwanted pregnancy o 56% of women used withdrawal at some point…only 3% used as primary form of contraception Perfect use: 4% failure rate Typical use: 27% failure rate Douching o Ineffective, not recommended Spermicides Minimally effective alone Interfere with viability of sperm—prevents sperm from entering cervix Use with barrier method increases effectiveness Not effective against STIs Teaching: o To be applied 30 minutes prior to intercourse and repeated before each subsequent coitus o No douching allowed for 8 hours after intercourse Nonoxynl-9 (N-9) o Approved for U.S. use o Inserted into vagina before intercourse—destroys sperm by disrupting the cell membrane o May require up to 30 minutes to dissolve and will not offer protection until it has done so o Insert high into vaginal and remain in supine position o Available as: Jelly Foam Vaginal film Suppository Barrier Methods Prevent the transport of sperm to the ovum, immobilize sperm, or are lethal against them Male condom o Small, lightweight, disposable, inexpensive, has no side effects (if not allergic to latex), requires no medical examination or supervision, and offers visual evidence of effectiveness o Thin sheath of rubber material that fits over erect penis o All condoms except for natural skin condoms protect against STIs (consistent use of comdoms results in 80% reduction of the incidence of HIV) o Disadvantages: misplacement, risk of breakage, perineal or vaginal irritation, and dulled sensation o Teaching: Roll sheath onto erect penis, leave enough slack at the end of penis to receive semen Addition of spermicide increases effectiveness should be applied before penetration 4 OB Exam 1 Failure rate in first year around 14% Latex allergy? Should not be stored in hot conditions because heat accelerates their deterioration, making them more susceptible to breaking Avoid placing in car glove box or in a man’s wallet in a rear pants pocket Female condom o Thin polyurethane sheath with flexible ring at each end o Condom may be inserted up to 8 hours before intercourse o Spermicide should be added prior to sex o Not designed to be used with a male condom o Disadvantages: high cost, noisiness during intercourse, and the cumbersome feel of the device Diaphragm o Steel band that forms a ring and is covered with latex or silicone so that when inserted, the ring lodges high in the vagina with the latex or silicone covering the cervix o Dome shaped o 3 types: flat spring, coil spring, and the arcing spring o Teaching: Diaphragm should be rechecked after each childbirth and whenever a woman has gained or lost 10 to 15 lbs or more Use spermicidal jelly/cream in dome Leave in place 6-8 hours after intercourse Clean, store dry, dust with cornstarch Check for holes or defects Inserted before intercourse with approximately one tsp or spermicidal jelly placed around its rim and in the cup Should NOT remain in the vagina for more than 24 hours Cervical cap (FemCap) o Looks like small sailor’s cap o “dome” of cap fits over cervix while the soft “brim” flares out slightly Lea’s Shield o Reusable, silicone, one-size-fits-all vaginal barrier method that completely covers the cervix o Spermicide should be used with it and it should not be worn for more than 48 hours Vaginal sponge o Pillow shaped, soft, absorbent synthetic sponge containing a spermicide o Acts as contraception by releasing the spermicide N-9 gradually over a 24 hour period o Can be worn up to 24 hours and should be left in place for at least 6 hours after intercourse and then removed and discarded o Advantages: professional fitting not required, can be used for multiple acts of coitus for up to 24 hours, one size fits all, and it acts as both a barrier method and a spermicide agent o Disadvantages: difficult to remove, irritation , allergic reactions, and vaginal dryness 5 OB Exam 1 o Failure rate comparable to that of a diaphragm for a women who has never had a baby o Failure rate it high in a woman who has had a baby because of the changes in shape of the cervix Intrauterine Devices (IUDs) T shaped medicated device that is inserted into the uterine cavity by physician Prevents fertility Signs of potential problems: reports PAINS, period late, abdominal pain, infection, not feeling well, string missing Copper IUD (ParaGARD T380A) o Provides protection for 10 years o Has a local inflammatory effect on the endometrium and impairs sperm from functioning properly o Small T-shaped device that has copper covering parts of its stem and arms—not an option for women allergic to copper Mirena Levonorgestrel Intrauterine System (LNG-IUS) o Provides protection for 5 years o Causes the lining of the uterus (endometrium) to become atrophic—it also produces thick cervical mucus that is “hostile” or unfriendly to sperm o Small T-shaped frame with a resivoir that releases levonorgestrel on a daily basis o After 3 months of use, cleeding and lengths of menstrual cycles are reduced 14-20% of women have amenorrhea o Excellent choice for women who are allergic to copper or who have heavy menses and desire amenorrhea Advantages: o High rate of effectiveness o Continuous contraceptive protection o Noncoitus-related activity o Relative inexpensiveness over time Possible adverse effects: o Increased and intermenstrual bleeding o Increased risk for pelvic infection o Perforation of the uterus during insertion o Dysmenorrheal o Expulsion of the device Combined Oral Contraceptives (COC) Contain estrogen and progestin Methods of administration o Day one start o Sunday alert o Quick start Packaging o 21 or 28 pills o Extended use Absolute contraindications: 6 OB Exam 1 o Pregnancy o Previous hx of thromboembolic disease o Acute or chronic liver disease o Presence of estrogen-dependent carcinomas o Undiagnosed uterine bleeding o Heavy smoking o Gallbladder disease o Hypertension, diabetes o Migraine with visual disturbances o Hypercoagulable disorders o Hyperlipidemia Relative contraindications: o Migraine headaches without visual disturbances o Epilepsy o Depression o Oligomenorrhea o Amenorrhea Teaching: o Take at the same time every day o Periodic checkup during use o Report ACHES: abdominal pain, chest pain, SOB, HA, eye problems, severe leg pain Side Effects of COC due to Estrogen o Alterations in lipid metabolism o Breast tenderness o Fluid retention, weight gain o Headache and hypertension o Nausea o Thromboembolic complications o Chloasma Side Effects of COC due to Progestin o Acne o Breast tenderness o Decreased libido o Decreased high-density lipoprotein (HDL) o Depression and fatigue o Hirsutism, weight gain, amenorrhea Noncontraceptive Benefits of COC o Relieve menstrual symptoms, premenstrual syndrome o Decrease cramps and flow o Reduce incidence of: Ectopic pregnancy Pelvic inflammatory disease (PID) Ovarian, endometrial, colorectal cancer Iron deficiency anemia Benign breast disease COC Education o Contact healthcare provider if: Become depressed 7 OB Exam 1 Develop breast lump Become jaundiced Severe abdominal pain, chest pain, shortness of breath Severe headache, dizziness, change in vision Other Hormone Contraceptives Combination estrogen-progestin o Transdermal Weekly contraceptive skin patch Roughly the size of a silver dollar, but square Applied weekly for 3 weeks on one of four sites (abdomen, buttocks, upper outer arm, or trunk) During the 4 week, no patch is applied and menses typically takes place Highly effective in women who weigh less than 198 lbs Better rate of compliance o Contraceptive Ring: Vaginal ring, NuvaRing Flexible, soft vaginal ring Inserted into vagina for 3 weeks—removed for 1 week—new ring inserted Progestin ONLY o Minipill Used primarily by breast feeding mothers because it does not interfere with breast milk production Major problems: amenorrhea or irregular bleeding patterns Slightly less effective than a COC and must be taken consistently at the same time everyday o Long-acting injectable progestin Depo-Provera Provides highly effective birth control for 3 months after administration with subsequent injections scheduled every 10 to 14 weeks Side effects: menstrual irregularities, HA, weight gain, breast tenderness, hair loss, and depression Return of fertility may be delayed for an average of 9 months Associated with bone demineralization, especially during first 2 years—rate of calcium loss slows after time, and bone loss is reversible after discontinuation All women should exercise and take 1200 mg of calcium with Vit. D Implanon Single capsule inserted substernally in the woman’s upper underarm Impregnated with ptogestin Good as a contraceptive methos for 3 years—prevents ovulation 8 OB Exam 1 Side effects: spotting, irregular bleeding or amenorrhea, ovarian cysts, weight gain, HA, fluid retention, acne, hair loss, mood swings, and depression Postcoital Emergency Contraception Combined oral emergency contraceptive (EC) o May cause nausea and vomiting o Initiate within 72 hours of unprotected intercourse Progestin-only contraceptive (Plan B) o More effective than combined postcoital EC o Initiate within 72 hours of unprotected intercourse st nd o Take 1 dose asap after intercourse and the 2 dose 12 hrs later o Woman should have normal menses 2 weeks after taking EC Intrauterine devices (IUD) o Place within 5 days of unprotected intercourse Sterilization Operative o Vasectomy Male sterilization Surgically severing the vas deferens in both sides of the scrotum’ Takes about 4 to 6 weeks and 6 to 36 ejaculations to clear the remaining sperm Rechecked at 6 and 12 months to ensure that fertility has not been restored by recanalization Side effects: pain, infection, hematoma, sperm granulomas, and spontaneous reanastomosis ( reconnection) o Tubal ligation Female sterilization Can be done at any time although the postpartal period is ideal Tubes are ligated, clipped, electrocoagulated, banded, or plugged—this interrupts the patency of the fallopian tube, thus preventing the sperm and ovum to meet Complications: coagulation burns on the bowel, bowel perforation, pain, infection, hemorrhage, and adverse anesthesia effects Nonoperative o Essure Under hysteroscopy, a stainless steel microinsert is placed in the proximal section of the fallopian tube Within 3 months, these microinserts create a benign tissue response that occlude the fallopian tubes Women allergic to nickel should consult healthcare provider before placement Nursing Care Management Nurse usually working with women Birth control attitudes Professionalism in practice o Patient teaching—have resources on hand 9 OB Exam 1 o Patient outcomes—advantages, disadvantages o Content—cite warning signs to report o Teaching method—show correct procedure o Evaluation Surgical Pregnancy Termination st 1 Trimester (less tndn 13 weeks) o Safer than 2 trimester o Dilation—vacuum curettage o Major risks: perforation of the uterus, laceration of the cervix, systemic reaction to anesthetic agent, hemorrhage, retained products of nd conception, and infection 2 Trimester (greater than 13 weeks) o Dilation and evacuation o Woman will need to labor and pass the fetus in the hospital Nursing management o Support—post procedure support; encourage woman to verbalize their feelings; provide support before, during, and after the procedure o Education—accurate information about cramping, bleeding, and pain that occur; need to know that follow-up is important; info about methods of abortion and associated risks as well as counseling reguarding alternatives Medical Pregnancy Termination Mifepristone (RU-486)/misoprostol o First 7 weeks of pregnancy (up to 49 days after last menstrual period) o Blocks the action of progesterone, thereby altering the endometrium o 14 days after taking the misoprostol, the woman is seen to confirm the abortion was successful o Risks: endometritis Methotrexate o First 7 weeks of pregnancy o Stops the cell division o Not currently approved for this use Nursing Care Management Decision to terminate Verify pregnancy Education o Emotional support o Monitor vital signs o Provide comfort o Patient self-care 10 Method Mechanism of Action Advantages Disadvantages Other Info Fertility AwarenessBased Methods Basal Body Woman records temperature each morning on Inexpensive Reliability can be Avoid intercourse on the day her Temperature (BBT) graph for 34 months Convenient affected by many temperature rises and for 3 days following BBT rises and remains elevated after No side effects variables ovulation r/t progesterone Ovulation Method Daily assessment of cervical mucus changes No cost Assessment of mucus Abstain from intercourse from the time (Cervical Mucus) that occur during menstrual cycle Women with irregular characteristics may be mucus first becomes clearer, more elastic, Follicular phase=end of menses to just before cycles can use it inaccurate and slippery until 4 days after the peak wet ovulation; mucus thick, white & sticky – Woman may feel mucus (ovulation) progesteronedominant & “hostile” to sperm uncomfortable testing her Ovulation=mucus clear, watery, & stretchable mucus (spinnbarkheit) – estrogendominant; fertile Calendar Rhythm Fertile period calculated based on woman’s Most useful when Least reliable Based on assumption that ovulation occurs Method recorded number of days in each cycle combined with BBT Requires accurate record ~ 14 days before onset of next menstrual Longest cycle – 18 days or cervical mucus keeping cycle Shortest cycle – 11 days method Requires compliance Standard Days Method=avoid intercourse Avoid intercourse between those days Inexpensive days 819 Symptothermal Combination of other FAB methods May be acceptable to Unpredictability of cycle This combined approach tends to improve Method Record various indications of fertility for members of religious Restricts spontaneity the effectiveness of FAB as a method of several months:; cycle length, frequency & groups during fertile periods contraception timing of coitus, cervical mucus changes, No drugs or devices Requires periods of secondary signs of ovulation, and BBT Inexpensive extended abstinence Barrier & Spermicidal Methods Male Condom Sheath applied over erect penis Male involved in BC Interruption to put on New condom each time Prevent sperm from entering cervix Safe, no side effects Altered sensation Leave space at tip of condom for sperm Some contain spermicide, ↑ effectiveness (unless latex allergy) Spillage of sperm can Check expiration date Available to anyone cause pregnancy Store in cool, dry place Nonsurgical May occasionally tear Use waterbased lubricants contraception STI protection Female Condom Thin polyurethane sheath with flexible ring at Female involved in Expense/cost OTC, one time use each end BC Noisiness during use May insert up to 8 hrs before Inner ring serves as means of insertion Safe, no side effects Cumbersome feel Do not use with male condom Fits over cervix STI protection Vaginal irritation Rewetting drops or oil/water based Less messy than other Risk for TSS lubricants can ↓noise female methods Diaphragm Steel ring band covered with latex or silicone May be inserted up to Leave in place for 6 hrs Not for women w/ hx UTIs, on menstrual – woman fitted with correct size 6 hrs before after intercourse (not period, or abnormal vaginal discharge Ring lodges high in vagina with latex/silicone intercourse more than 24 hrs) Recheck sizing after each childbirth & with covering cervix Inexpensive Interferes with weight gain or loss of 1015 pounds (or at Inserted before intercourse with one Potential ↓ incidence spontaneity of intercourse least annually @ gyno exam) teaspoonful of spermicidal jelly of cervical gonorrhea Need a different BC if Empty bladder before insertion & after sex & chlamydia intercourse is desired Inspect before each use Protection from HPV again within 6 hours Replace q2 years Risk for TSS Cervical Cap “Dome” fits over cervix, soft “brim” flares out Extended period of Risk for TSS Refit same as diaphragm slightly & conforms to shape of vagina wear No STI protection Not for those w/ abnormal pap smear, those Strap placed over dome permits easy removal Inserted hrs ahead of Not as effective as who find insertion/removal too difficult, Must remain in place for at least 6 hr after sex, time without need for diaphragm in preventing vaginal/cervical infections, latex allergies up to 48 hr addtl spermicide later pregnancy Requires less when initially inserted Vaginal Sponge Pillowshaped, soft, absorbent synthetic Professional fitting Possible rxn to N9 Moisten w/ water before insertion sponge containing spermicide not required No STI protection Leave in place for at least 6 hrs after Fits over cervix with loop for easy removal May be used for Potential vaginal dryness intercourse, then discard Gradually releases spermicide N9 over a 24 multiple acts of Difficulty removing hr period intercourse for up to Risk for TSS 24 hours Spermicide Inserted into vagina before intercourse Most are immediately Suppository takes up to N9 available as cream, jelly, foam, vaginal Destroys sperm by disrupting cell membrane – effective 30 min to dissolve (no film, or suppository reduces sperm motility Readily available protection until it does) Insert high into vagina (to reach cervix) & Lack of systemic side Little or no protection remain in supine position effects against gonorrhea, Low local toxicity chlamydia, HIV Intrauterine Devices (IUDs) IUDs (both) Tshaped device inserted into uterus by HCP High rate of ↑ bleeding during Contraindicated with current pregnancy, & left in place for extended period effectiveness menses STI, or pelvic infection 2 strings hang from base to ensure it has not Continuous ↑ risk of pelvic infection Inserted at any time during woman’s cycle become dislodged contraceptive for ~ 3 weeks after Intermittent cramping or bleeding for 26 Thought to prevent the implantation of protection over long insertion weeks after insertion fertilized ovum periods of time Risk for perforation of May have irregular menses Produce spermicidal intrauterine environment Nonintercourse uterus during insertion Check strings for presence after each period related contraception Expulsion of device Remove if become pregnant Relatively inexpensive over time NonHormonal Local inflammatory effects on the Not for women allergic Effective for up to 10 years Copper IUD endometrium to copper (ParaGard) Impair sperm from functioning properly May cause more bleeding/cramping w/in 1st year Hormonal Causes the lining of the uterus (endometrium) Possible STI Effective for up to 5 years Mirena to become atrophic protection r/t thick *Progestin only Produces thick cervical mucus that is “hostile” cervical mucus to sperm Hormonal Methods Cause decreased FSH & LH secretion follicles do not mature & ovulation is inhibited *Estrogen and Progesterone “Hostile” cervical mucus Oral Combined Oral Take pills for 21 days w/ 7 day break ↓ cramps & PMS Review side effects** Women > 35 YO who smoke should not Contraceptives Day 1 start (1st day of cycle)=immediate Lighter, regular cycle Must be taken daily take b/c ↑ risk MI (COCs) protection ↓ incidence of: Improper use can Report ACHES: Abdominal pain, chest “The pill” Sunday start (Sunday after 1st day of ectopic pregnancy; contribute to unintended pain, HA, eye problems, severe leg pain menstrual cycle)=common b/c prevents periods PID; ovarian, pregnancy CI: pregnancy, hx thromboembolic on weekends backup BC needed for 1st 7 endometrial, colorectal Less reliable in obese disorders, acute or chronic liver disease of days of use cancer; iron deficiency women cholestatic type with abnormal LFTs, Quick start (any other time)=backup method anemia; benign breast No STI protection estrogendependent carcinomas, undx needed for 1st 7 days of use disease Fertility rates slightly uterine bleeding, heavy smoking, gallbladder lower first 312 months disease, HTN, DM, migraine w/ visual after discontinuation disturbances, hypercoagulable disorders, hyperlipidemia Transdermal Patch Patch applied weekly for 3 weeks on one of 4 Highly effective in Potential skin irritation S/S r/t COCs Ortho Evra sites: abdomen, buttocks, upper outer arm, or women < 198 pounds Contraindications > 198 pounds or skin trunk (not breasts) Better compliance disorders Apply on the 1st day of their menses or on than COC users Sunday following (7 day backup BC if Sunday) Vaginal Ring Lowdose, sustainedrelease flexible, soft Virtually one size fits Some women may be Do not use if vaginal prolapse NuvaRing vaginal ring inserted up around cervix all uncomfortable placing Replacement rings should be kept Left in place for 21 days, removed for 7, then ring refrigerated replaced Hormonal Methods Inhibit ovulation, thicken and ↓ cervical mucus, thin endometrium, alter cilia in uterine tubes *Progesterone Only Oral Pill Similar to oral COCs, must be taken at the Does not interfere Causes amenorrhea or Slightly less effective than COCs Minipill same time every day with breast milk irregular bleeding patterns Mostly used by nursing mothers production Can be used by women with CI to estrogen in oral COCs Progestin Implanted through incision into upper arm Breakthrough bleeding Risk for ectopic pregnancy if pregnancy Implantable Device Provides 3 years of contraception common occurs during use Implanon No STI protection Minor surgery to implant & remove Injection IM injection providing 3 months of protection Highlyeffective Return fertility delayed ~ All women should exercise daily and take DepoProvera Subsequent injections q 1113 weeks Can be given to 9 months after DC 1200mg Calcium with Vitamin D Initiate during 1st 5 days of menstrual cycle nursing mothers Risk for ↓ bone density Safe, convenient, (highest in first 2 years) private, inexpensive Weight gain & breakthrough bleeding Ch. 27 & 28: LaborRelated Procedures & Complications OB Exam 3 Chapter 27 & 28: LaborRelated Procedures & Complications D
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