NSG210 Week 10 Lecture: OB Lecture 4 - Postpartum, Newborn, and Women’s Health

The October 28 OB lecture (OB Lecture 4 on Canvas, syllabus Lectures 6-7) covers postpartum physiology and nursing care, postpartum hemorrhage, cesarean recovery, breastfeeding, maternal role attainment and postpartum mood disorders, newborn transition and assessment, the high-risk neonate, and women’s health. This is Exam 3 content.

Source: OB Lecture 4 slide deck (90 slides); slide numbers are given in each heading. Many slides are diagrams; their text was recovered from the deck itself. Textbook: Durham & Chapman, 4th ed., Ch. 12-14 (postpartum), Ch. 15-17 (newborn), Ch. 18-19 (women’s health). Places where the slides and Durham differ are marked “Slide vs text” and collected in nsg210-exam-3-lecture-vs-textbook. Expanded class notes from the same lecture: nsg210-week-10-class-notes.

Postpartum Physiology (slides 1-10, 15, 22-23; Durham Ch. 12)

Involution (slides 4-5, 10) is the uterus returning to its pre-pregnancy size, tone, and position. It begins when the placenta delivers and takes about 6 weeks.

• Right after delivery, the fundus is halfway between the symphysis pubis and the umbilicus.
• At 1 hour, it is at or 1 cm above the umbilicus (where it was at 20 weeks).
• It descends about 1 cm per day and is in the pelvis by day 14. The slides put it at the pubic bone by 1 week.

Lochia (slides 7, 15):

Assess color and odor. A foul odor suggests infection.

Fundal assessment schedule (slide 7): every 15 minutes for 1 hour, every 30 minutes for 1 hour, every 4 hours until 24 hours, then every shift. Check more often if findings are not within normal limits. Assess location, position, and tone.

Bladder (slides 2, 7): a distended bladder displaces the uterus and causes atony, so a boggy, displaced fundus calls for having the patient void. Lower urinary tract tone may cause retention. Hematuria right after a vaginal birth is usually bladder trauma.

Other changes (slides 2-3, 6, 8, 22):

Afterpains are uterine contractions felt low in the abdomen. Hemorrhoids come from IVC pressure, weight gain, hormones, and increased blood volume.

Perineum (slide 9): lacerations are graded by depth:

A midline episiotomy heals faster and is less painful. A mediolateral episiotomy is cut at 45 degrees. The main complication of both is infection.

Comfort measures (slide 23): ice or a cold pack to the perineum for 10-20 minutes, witch hazel pads, sitz baths 15-20 minutes two to four times a day, NSAIDs, lidocaine spray, docusate (Colace), a pillow for sitting, front-to-back cleansing with a peri-bottle, gentle perineal exercises after 12 hours, and rest.

Postpartum Hemorrhage and Subinvolution (slides 11-17; Durham Ch. 14)

PPH (ACOG definition) (slide 13): a cumulative blood loss of at least 1000 mL, or blood loss with signs of hypovolemia within 24 hours of birth, regardless of route. The most common cause is uterine atony (a boggy uterus).

• Rule of 30: a 30% fall in Hct, a 30 mm Hg fall in systolic BP, or 30% blood loss.
• Signs of blood loss often appear late, after substantial loss. Tachycardia, hypotension, or ongoing bleeding means a loss of 1500 mL or more.

PPH treatment (slide 17):

1. Fundal massage, and empty the bladder (Foley).
2. Uterotonics: oxytocin IV, methylergonovine (Methergine), misoprostol (Cytotec), carboprost (Hemabate).
3. Tamponade if uterotonics fail.
4. Tranexamic acid when first-line measures fail. It reduces mortality when given within 3 hours of birth.
5. Fluid resuscitation, arterial embolization, and the massive transfusion protocol (RBCs, platelets, plasma). Rapid transfusion can cause hypocalcemia, which worsens coagulopathy, because calcium is needed to activate clotting factors.

Subinvolution (slide 12) is failure of the uterus to involute as expected. It happens when vessels at the placental site do not close and slough properly.

• Causes: retained placental fragments, infection, an overdistended uterus (large baby).
• Signs: prolonged or excessive bleeding, abdominal pain and distension, back pain.
• Treatment: conservative medical care, uterine artery embolization (fertility-sparing), or hysterectomy.

Cesarean Recovery (slides 18-19)

• Maternal morbidity is doubled compared with a vaginal birth.
• Hospital stay is about 3 days; full recovery takes 6 weeks or longer.
• Complications: infection, hemorrhage, anemia, DVT/PE, bladder trauma, and spinal headache.
• Assess involution and bleeding.
• Prevent atelectasis and pneumonia: cough, deep breathing, incentive spirometry.
• Use sequential compression devices for VTE prevention.
• Watch for ileus, persistent nausea and vomiting, and obstruction.
• Give IV fluids, analgesics, and antibiotics, and advance activity.
• After neuraxial morphine, monitor sedation level and respirations, and watch for allergic reaction, spinal headache, and prolonged numbness in the legs.
• If a DVT is suspected, tell the patient not to massage her legs. The slides list a positive Homans sign (calf pain on dorsiflexion) as a sign; it is a classic but unreliable sign, so rely on unilateral swelling, pain, warmth, and redness.

Lactation and Breastfeeding (slides 20, 24-25; Durham Ch. 16)

Milk production (slides 2, 20):

• After the placenta delivers, estrogen and progesterone fall and prolactin rises.
• Colostrum (first 2 days) is thick and yellow, with more protein, minerals, and immunoglobulins and less fat and sugar than mature milk.
• Mature milk comes in by about day 3 and is fully established by the end of week 2.
• Production is 500-800 mL/day, which needs about 700 extra kcal/day.

Engorgement (days 3-5) is relieved by frequent feeding. Fever, breast tenderness, and redness raise the question of a clogged duct vs mastitis.

Breastfeeding basics (slide 25):

• Position: belly to belly, with the head, shoulder, and hip aligned.
• Latch: nose, cheek, and chin touch the breast, with part of the areola in the mouth. A good latch does not hurt and produces slow, deep sucks with pauses.
• Removing the baby: break suction with a finger in the corner of the mouth.
• Frequency: 8-12 feedings per 24 hours.
• When: feed at early hunger cues. Crying is a late sign and makes latching harder.
• Duration: the AAP recommends exclusive breastfeeding for 6 months.

Breastfeeding vs formula (slide 24):

After Discharge (slide 21)

• Bleeding: heavy bleeding with uterine tenderness and fever suggests endometritis.
• Perineum: tears take weeks to heal. Report fever or increasing pain.
• Voiding: every 3-4 hours, because the bladder can overfill without symptoms. Use stool softeners for constipation.
• Ovulation: in a breastfeeding mother, prolactin suppresses FSH and LH and ovulation returns at about 6 weeks. In a non-breastfeeding mother it can return within a few weeks.
• Contraception if breastfeeding: progestin-only, after 6 weeks. Estrogen reduces milk supply.
• Contraception if not breastfeeding: no estrogen before 3 weeks, because of thromboembolism risk.

Maternal Role Attainment and Mood (slides 26-31; Durham Ch. 13-14)

Rubin’s phases (slide 29):

Bonding vs attachment (slides 27-28):

• Bonding is the mother’s feelings toward the infant. It forms over hours to weeks after birth and continues through the first year. It is measured with self-rated questionnaires (MIBS, PBQ).
• Attachment is the child’s emotional bond to the caregiver, used as a secure base. It forms over a longer time and is measured with the Strange Situation test at 1 year.

Blues vs depression vs psychosis (slide 31):

Screening (slide 30):

• Edinburgh Postnatal Depression Scale (EPDS): scored 0-30. It focuses on psychological symptoms and leaves out fatigue, appetite, and psychomotor change, which overlap with normal postpartum recovery. A higher score means more severe depression. The slides give bands of 0-6 none, 7-13 mild, 14-19 moderate, and 19-30 severe, plus 10 or more for minor depression and 13 or more for major. The bands overlap; see the comparison page.
• PHQ-9: scored 0-27. 0-4 minimal, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe.

Newborn Transition (slides 32-42; Durham Ch. 15)

Transition by system (slides 33-35):

Initial assessment (slides 33, 36):

• Apgar at 1 and 5 minutes: heart rate, respirations, tone, reflexes, color.
• General appearance and vital signs.
• Skin (look for polydactyly too).
• Head and neck: molding, fontanels.
• Eyes: light reflex, alignment.
• Ears: position, canal, skin tags.
• Mouth: hard and soft palate intact.
• Abdomen: masses, bowel sounds.
• Genitals and anus: patency, hypospadias, undescended testes.
• Extremities.

S.T.A.B.L.E. (slide 37):

Gestational age: New Ballard (Dubowitz) score (slides 38-40). Add the physical and neuromuscular scores to estimate gestational age.

• Physical maturity (within 2 hours): skin (sticky and red, then smooth, then cracked and peeling); lanugo (absent, then present, then gone with post-maturity); plantar creases; breast tissue; eyes and ear cartilage; genitals (scrotal rugae at term; at term the labia majora cover the clitoris and labia minora).
• Neuromuscular maturity (within 24 hours): posture, square window, arm recoil, popliteal angle, scarf sign, heel to ear.

Newborn medications (slide 41):

• Erythromycin ophthalmic ointment prevents gonococcal and chlamydial eye infection. Slide: within 24 hours. Durham: within 1 hour of birth.
• Vitamin K (phytonadione) IM prevents vitamin K deficiency bleeding (VKDB). The gut has no flora to make vitamin K at birth, and maternal vitamin K is short-lived. Slide: within 6 hours. Durham: within 1 hour.
• VKDB onset: early on day 1, classic on days 2-7, late from day 8 to 6 months.

Screenings (slide 42):

• Metabolic screen within 48 hours. New Jersey tests for 61 disorders, including PKU, hypothyroidism, galactosemia, sickle cell disease, and cystic fibrosis.
• Hearing screen.
• Critical congenital heart disease (CCHD) screen by pulse oximetry, which detects 7 defects: hypoplastic left heart/coarctation, double outlet ventricle, tetralogy of Fallot, pulmonary atresia, transposition of the great arteries, TAPVR, and tricuspid atresia.

The High-Risk Neonate (slides 43-68; Durham Ch. 17)

Cold stress (slide 44):

• Newborns cannot shiver. They burn brown fat and glycogen, which diverts oxygen and glucose from the brain, heart, and growth.
• Signs: mottling or cyanosis, metabolic acidosis, hypoxia, hypoglycemia.
• Related conditions: hypoxemia (PO2 under 50), CNS abnormality or intracranial hemorrhage, hypoglycemia (under 40 mg/dL).
• Care: dry the infant, a neutral thermal environment, cover the head, skin-to-skin contact.

Birth weight (slides 45-46):

• LBW infants have 20 times the risk of death and higher risk of long-term neurologic, language, and chronic disease problems.
• IUGR: symmetrical IUGR starts early (genetic, structural, or infectious cause). Asymmetrical IUGR is more common, spares the head (“brain sparing”), and is caused by uteroplacental insufficiency.

Neonatal jaundice (slides 47-50):

Respiratory problems (MAS slides 51-52, RDS slides 53-54):

Necrotizing enterocolitis (NEC) (slide 55):

• Usually develops in the first 2 weeks, mostly in preterm infants.
• Signs: feeding intolerance, bilious vomiting, distension, bloody stools, temperature instability, lethargy.
• X-ray: air in the bowel wall (pneumatosis intestinalis).
• Causes: immature gut and blood flow regulation, infection, asphyxia, IUGR.
• Treatment: NPO, NG decompression, TPN, antibiotics.

Neonatal abstinence syndrome (NAS) (slides 56-59):

• Withdrawal after in-utero exposure ends at birth. Timing depends on the substance and its half-life:
  • Alcohol: 3-12 hours.
  • Narcotics: 48-72 hours.
  • Barbiturates: day 1-14.
• Signs: high-pitched or excessive crying, tremors, increased tone, excessive sucking, sneezing, mottling, diarrhea.
• A scoring tool grades severity. Medications are started for seizures, weight loss, dehydration, poor feeding, vomiting or diarrhea, fever, or inability to sleep.
• Opioid withdrawal is treated with methadone, morphine, clonidine, or phenobarbital. Alcohol withdrawal is treated with benzodiazepines.
• Breastfeeding is allowed with maternal methadone; wean gradually.
• Fetal alcohol syndrome: facial anomalies, heart defects, cognitive and behavioral problems, vision and hearing problems.

Circumcision (slide 60) is covered by a linked video only.

Congenital anomalies:

• Cleft lip and palate (slide 61) form at 4-12 weeks of gestation.
  • Lip repair at 1-3 months; palate repair at 12-18 months, before speech develops.
  • Priorities: nutrition, aspiration and airway watch, minimize crying after repair, family support.
• Duodenal atresia (slide 62) is the most common intestinal atresia.
  • Signs: bilious, projectile vomiting in the first 24-36 hours, usually after the first feed.
  • Associated with polyhydramnios and trisomy 21.
• Omphalocele (slides 63-64): abdominal contents herniate through the umbilicus, covered by a membrane. Often has associated cardiac or chromosomal anomalies.
• Gastroschisis (slides 63-64): no membrane, usually to the right of the umbilicus. Associated GI problems such as atresia.
• Neural tube defects (slides 65-68) form in the first month of pregnancy.
  • Spina bifida occulta: a bony gap only, no disability.
  • Meningocele: a fluid sac without cord involvement.
  • Myelomeningocele: a sac containing cord and nerves; the most common and most severe form, causing paralysis and bladder and bowel dysfunction.
  • Anencephaly: the top of the neural tube fails to close, so parts of the skull and brain are missing.
  • Folic acid lowers risk. Risk rises with carbamazepine (Tegretol), valproate (Depakote), uncontrolled diabetes, obesity, and early-pregnancy opioid use.

Women’s Health (slides 69-88; Durham Ch. 18-19)

Menstrual disorders (slides 69-70, 85):

• Amenorrhea:
  • Primary: no menarche by 15.
  • Secondary: 3 months without menses after normal cycles; the most common cause is pregnancy.
• Dysmenorrhea: pain starting 1-2 days before bleeding.
• Endometriosis: functioning endometrial tissue outside the uterus. Ages 30-40; causes pain, dyspareunia, and infertility. Treated with NSAIDs, oral contraceptives, or surgery.
• PCOS: chronic anovulation with obesity, hyperinsulinemia, type 2 diabetes, dyslipidemia, hirsutism (excess testosterone), and ovarian cysts.
  • Most common cause of female infertility.
  • Raised risk of breast, ovarian, and endometrial cancer from unopposed estrogen.
• Abnormal uterine bleeding: heavier, longer, more frequent, or between-cycle bleeding. Causes include fibroids, endometrial cancer, and infection.
• PMS: luteal-phase symptoms (bloating, irritability, mood swings).
• PMDD: severe depression, anxiety, and lability in the luteal phase, gone by the last week of the cycle.
• Ovarian cysts: benign; treated with NSAIDs, oral contraceptives, or surgery.
• Uterine fibroids (leiomyomas): benign tumors of the uterine muscle wall. They cause heavy bleeding and dyspareunia.

Pelvic organ prolapse (slides 71-74):

• Weak pelvic floor support from vaginal birth (large baby, difficult delivery), menopausal atrophy, obesity, chronic constipation, or strain.
• Types:
  • Cystocele: bladder into the vagina.
  • Rectocele: rectum into the vagina.
  • Enterocele: small bowel into the vagina.
  • Uterine prolapse; vaginal vault prolapse after hysterectomy.
• Symptoms: pelvic pressure, dyspareunia, voiding problems (retention, UTIs, incontinence), constipation, back pain.
• Treatment: Kegel exercises, vaginal estrogen after menopause, a pessary, or surgery.

Infertility (slides 75-76) is no pregnancy after 1 year of unprotected intercourse.

• Female causes: ovulatory, tubal, or uterine factors.
  • PID is the leading cause of tubal infertility; it is usually from chlamydia or gonorrhea.
  • Others: PCOS, hyperprolactinemia, endometriosis, prior ectopic pregnancy, fibroids, uterine anomalies, and declining ovarian reserve with age.
• Male causes:
  • Varicocele is the most common correctable cause, usually on the left.
  • Cryptorchidism, Klinefelter (47,XXY), Noonan syndrome.
  • Infections (chlamydia, gonorrhea, mumps), drugs and chemotherapy.
  • Testicular torsion; correct within 6 hours to save the testis.
  • Ejaculatory and erectile disorders.

Contraception (slides 77-79):

Progestins can cause liver dysfunction, so monitor liver enzymes.

Menopause (slide 80) is 12 consecutive months without menses, usually around age 50 (as early as 40). It can also be induced by oophorectomy, chemotherapy, or radiation. Symptoms are vasomotor (hot flashes, night sweats), urogenital, psychological, and cardiovascular.

STIs (slide 81):

• Chlamydia is the most commonly reported STI and is often co-infected with gonorrhea. Most infected people have no symptoms. It causes PID, ectopic pregnancy, and preterm birth in women and epididymitis in men.
• Gonorrhea is the second most common. Its symptoms are similar to chlamydia, plus scrotal pain. A Gram stain identifies it from the male urethra. Untreated, it can cause arthritis and meningitis.
• Herpes is treatable (acyclovir) but not curable. Outbreaks are triggered by illness, sun, stress, or menses. It is dangerous to newborns.
• HPV causes genital warts and cervical dysplasia (abnormal Pap). The vaccine is given at 11-12 years, with catch-up for females through 26 and males through 21.
• Trichomoniasis is caused by a parasite and is curable.
• Bacterial vaginosis is a bacterial imbalance that raises the risk of PID, other STIs, and pregnancy complications.

Breast cancer (slides 82-83):

• Most common type is invasive ductal carcinoma (70-80%).
• Signs: a lump, shape change, skin dimpling, nipple discharge or new inversion, a red or scaly patch.
• Survival is 99% when caught while localized.
• Screening at average risk: mammogram every 1-2 years from 40 to 75.
• High risk: prior breast cancer, a genetic mutation, high-risk lesions on biopsy, or chest radiation before 30.

Reproductive cancers (slides 84-88):

Ethics (slide 90)

The four principles are autonomy, beneficence, non-maleficence, and justice. A provider should question a pregnant patient’s decision only when all three are true:

1. The fetus faces irrevocable harm without treatment.
2. The treatment is properly indicated and likely to work.
3. The risk to the pregnant person is minimal.

Quick Review

• Fundus: at the umbilicus at 1 hour, then down 1 cm/day. Boggy means massage and have her void.
• PPH: 1000 mL or more, or hypovolemia within 24 hours. Most often atony. Massage, oxytocin, then other uterotonics; TXA within 3 hours.
• Lochia: rubra (days 1-4), serosa (4-10), alba (after 10). A foul odor means infection.
• Fever after day 3 means infection until proven otherwise.
• Taking-in is not the time to teach; taking-hold is.
• Psychosis is an emergency; the blues last days.
• Eye ointment and vitamin K: Durham says within 1 hour.
• Jaundice in the first 24 hours is pathologic.
• MAS affects term and post-term infants; RDS affects preterm infants.
• NEC: bloody stool and distension mean NPO, NG tube, antibiotics.
• Do not massage the Depo-Provera site. The IUD is the most effective reversible method.

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