Скачати 54.79 Kb.
Physiology of the Newborn
The heart and circulation
Feeding and nutrition
Resuscitation of the newborn
Table 1. Clinical evaluation of the newborn infant (Apgar scoring method) Sign 0 1 2
Advanced life support
Examination of the newborn infant
II. Tests and Assignments for Self – assessment.
Real - life situations to be solved
Bukovinian State Medical University
on methodological meeting
of Department of Obstetrics and Gynecology
with course of Infant and Adolescent Gynecology
“___”______________________ 200_ year
The Head of the department
for practical lesson
“Physiology of puerperium. Physiology of newborn”
Module 1: Physiology of pregnancy, labor and puerperium
Context module 1: Physiology of pregnancy, labor and puerperium
Subject: Obstetrics and Gynecology
4th year of studying
2nd medical faculty
Number of academic hours – 4
Methodological instruction developed by:
assistant Andriy Berbets
Chernivtsi – 2008
Aim: to study the normal puerperium, to diagnose the complications of the puerperium and methods of their prevention.
1.Anatomy and physiology of female reproductive system
2.Changes in the female reproductive organs and all organism of woman during pregnancy, labor and puerperium.
3.The structure and function of breasts.
4.Laboratory tests during puerperium.
Students’ Independent Study Program
I. Objectives for Students’ Independent Studies
You should prepare for the practical class using the existing textbooks and lectures. Special attention should be paid to the following:
1.The definition of the puerperium.
2. The definition of the early and late puerperium.
3.The main processes in the puerperium.
4.Involution of the uterus.
5.What is lochia? The role of the lochia.
6.Changening of the lochia during puerperium.
7. Hygiene of the female reproductive organs in pueperants.
8. Care of the pueperants after episiotomy.
9. Function of breasts in puerperium.
10. Fissures of the nipples. Their treatment and prevention.
11. The rules of breast feeding.
12. The management of the puerperium.
13. Ultrasonic estimation of uterine involution.
14. Medicines stimulants of myometrial contractions.
15. Patients discharge from the hospital after delivery.
Key words and phrases: puerperium, involution, uterus, cervix.
The pueperium consists of the period following delivery of the baby and placenta to approximately 6 weeks postpartum. During the puerperium, the reproductive organs and maternal physiology return toward the pregnancy state although menses may not return for much longer.
Involution of the uterus. Immediate after delivery, the fundus of the uterus is easily palpable on the level of the umbilicus. The immediate reduction in uterine size is the result of delivery of the fetus, placenta and amniotic fluid as well as the loss of hormonal stimulation. Further uterine involution is caused by autolysis of intracellular myometrial protein, resulting in a decrease in cell size but not cell number. Through these changes, the uterus returns.
As the myometrial fibers contract, the blood clots from uterus are expelled and the thrombi in the large vessels of the placental bed undergo organization. Within the first 3 days, the remaining decidua differentiates into a superficial layer, which becomes necrotic and sloughs, and a basal layer adjacent to the myometrium, which contained the fundi of the endometrial glands and is the source of the new endometrium.
Immediately after the delivery of the placenta, the uterus is palpated bimanually to ascertain that it is firm.
This discharge is fairly heavy at first and rapidly decreases in amount over the first 2 to 3 days postpartum, although it may last for several weeks. For the first few days after delivery, the uterine discharge appears red ( lochia rubra) owing the presents of erythrocytes. After 3 to 4 days, the lochia becomes paler ( lochia serosa), and by the tenth day, it assumes a white or yellow- white color ( lochia alba). By the end of the third week postpartum, the endometrium is reestablished in most patients.
Cervix. Within several hours of delivery the cervix has reformed, and by 1 week, it usually admits only one finger (i.e., it is approximately 1cm in diameter). The round shape of the nulliparous cervix is usually permanently replaced by a transverse, fish-mouth shaped external os, the result of laceration during delivery. Vulvar and vaginal tissues return to normal over the first several days, although the vaginal mucosa reflects a hypoestrogenic state if the woman breast-feeds because ovarian function is suppressed during breast-feeding.
^ . Return of the elastic fibers of the stretched rectus muscles to normal configuration occurs slowly and is aided by exercise.
At time of delivery, the drop of estrogen and other placental hormones is a major factor in removing the inhibition of the action of prolactin. also, suckling by the infant stimulates release of oxytocin from the neurohypophysis. On approximately the second day after delivery, colostrum is secreted. After about 3 to 6 days, the colostrum is replaced by mature milk.
^ is also important during breast-feeding. The nipples should be washed with water and exposed to the air for 15 to 20 minutes after each feeding. A water-based cream such as lanolin or vitamin A and D ointment may be applied if the nipples are tender.
Mastitis is an uncommon complication of breast-feeding and usually develops 2 to 4 weeks after beginning breast-feeding. The first symptoms are usually slight fever and chills. These are followed by redness of a segment of the breast, which becomes indurated and painful. The etiologic agent is usually Staphylococcus aureus, which originates from the infant’s oral pharynx. Milk should be obtained from the breast for the culture and sensitivity, and mother should be started on a regimen of antibiotics immediately. Because the majority of staphylococcal organisms are penicillinase-producing, a penicillinase-resistant antibiotic, such as dicloxacillin, should be used. Breast-feeding should be discontinued, and an appropriate antibiotic should be continued for 7 to 10 days. If a breast abscess ensues, it should be surgically drained. A breast pump can be used to maintain lactation until the infection has cleared, but the milk should be discarded. The infant, along with other family members, should be evaluated for staphylococcal infections that may be source of reinfection if breast-feeding is resumed.
The transition to the extrauterine life Lungs
Expansion of the lungs at birth presents a considerable challenge to the newborn infant. In fetal life, lung liquid is actively secreted into the alveolar space and the lung is a fluid-filled organ. During term labour lung liquid production ceases, high fetal blood concentrations of thyroid hormone, adrenaline and corticosteroids cause the direction of fluid flow to be permanently reversed, preparing the airspaces forairbr eathing. The majority of lung liquid is absorbed into the pulmonary lymphatics and capillaries with a small amount squeezed out of the lungs as a result of high vaginal pressure during the second stage of labour.
In response to a number of stimuli following birth which include the change in environmental temperature, audiovisual, proprioceptive changes, touch and physiological hypoxia which occurs when the umbilical cord is clamped a healthy term baby usually takes the first breath within 60 s. The first breaths must generate high pressure within the lungs to overcome several factors, such as the surface tension at the air–liquid interface of collapsed alveoli, the high flow resistance and inertia of fluid in the airways and the elastic recoil and compliance of the lungs and chest wall. Therefore initial respiratory effort results
in both large inspiratory breaths which create high negative pressures (20 cmH20) within the lungs and forced active expiration producing pressure ranging from 20–100 cmH2O. Replacement of lung liquid by airis largely accomplished within a few minutes of birth although this may be delayed if the delivery occurs before the onset of labour or the respiratory drive is compromised by such factors as prematurity, surfactant deficiency, perinatal hypoxia and general anaesthesia.
Once expanded, lung compliance is much improved and the pressure required for normal tidal breathing is only about 5 cmH2O. Failure to reabsorb lung liquid may produce transient tachypnoea in a term baby.
Expanded alveoli must be prevented from collapsing again and this depends on the surfactant system. Surfactant, a complex mixture of mainly phospholipids, with smaller amounts of neutral lipids and proteins is produced by type II alveolarcells. These cells can be identified from about 24 weeks gestation. However, surfactant production is limited until much laterin gestation. It is the phospholipids notably dipalmitoyl phosphatidylcholine (DPPC) which forms a monolayerat the alveolarair –tissue interface thereby significantly reducing surface tension and preventing alveolarcollapse. The foursur factantassociated proteins SP-A, SP-B, SP-C, and SP-D each have essential roles; SP-B and C aid spreading, adsorption and recycling of the phospholipids, SP-A has a dual role in improving surfactant function and with SP-D is part of the innate host defence mechanism against infection.
Surfactant production and release increases during the latterpar t of pregnancy undercontr ol of hormones such as corticosteroids and thyroid hormone. Maturation of the surfactant system can be stimulated by numerous agents including maternal glucocorticoids. Babies born preterm may fail to clearlung liquid orpr oduce surfactant so that pulmonary compliance remains low and the high negative intrathoracic pressures required for lung inflation during the first breath persist. These infants develop respiratory distress and may require ventilation and surfactant replacement.
In the fetus, oxygenated blood from the placenta is preferentially streamed through the ductus venosus to the right atrium and across the foramen ovale into the left atrium. Here it mixes with the small quantity of pulmonary venous blood, then passes to the left ventricle from where it is pumped into the aortic root and to the cerebral and coronary circulations. A small proportion of inferior vena cava blood enters the right atrium and mixes with the poorly oxygenated blood returning through the superior vena cava, passing to the right ventricle and pulmonary artery. In the fetus, pulmonary vascular resistance is extremelyhigh and very little blood passes from the pulmonary artery into the lungs. Most blood passes though the patent ductus arteriosus to the aorta and supplies the lower body and placenta.
The fetal pattern of circulation is dependent on high pulmonary vascular resistance, the presence of the patent ductus arteriosus and the low-resistance placental component of the systemic circulation. At birth, expansion of the lung and the onset of air breathing increase the local oxygen concentration within the lungs which causes a dramatic fall in pulmonary vascular resistance, effected by a complex series of vasoactive mediators which include prostaglandins and nitric oxide.
The fall in pulmonary resistance allows pulmonary artery pressure to decrease, and thus right atrial pressure falls below left atrial pressure, so stopping the flow of blood from right to left atrium, and promoting mechanical closure of the foramen ovale. This process is aided by the increase in systemic vascular resistance (and thus left heart pressures) caused by clamping of the umbilical cord with the sudden loss of the low-resistance placental circulation.
Increased oxygenation of arterial blood induces closure of the arterial and venous ducts, largely by inhibition of the dilatorpr ostaglandins PGE2 and PGI2. This system may be immature in the preterm infant and the ductus arteriosus may not close.
Lung expansion and oxygenation are thus essential to the circulatory changes at birth, allowing both a fall in pulmonary vascular resistance and the closure of the ductus arteriosus. Situations of impaired respiratory function are frequently associated with pulmonary hypertension leading to a physiological right to left shunt and exacerbation of hypoxaemia. This is evident in respiratory distress syndrome when the pulmonary artery pressure is high, and in conditions such as meconium aspiration or diaphragmatic hernia persistence of the fetal circulatory pattern is the majorclinical problem.
In the term infant, the haemoglobin concentration is high, between 16 and 18 g/dl. Of this 80% is fetal haemoglobin (HbF). HbF has a loweraf finity for2,3-diphosphoglycerite which shifts the haemoglobin–oxygen dissociation curve to the left, leading to maximum oxygen transfer at lower pO2 levels. The proportion of HbF falls gradually during the months afterbir th and by six months only 5% haemoglobin is HbF. The relatively high total haemoglobin concentration also declines after birth. Haemoglobin is removed through the formation of bilirubin which is removed by the liver; hepatic immaturity frequently leads to jaundice in the normal newborn infant. Excessive haemolysis or liver impairment can lead to levels of unconjugated bilirubin sufficiently high to cause neurological damage.
Human breast milk is the preferred nutrition source for both term and preterm babies; it is associated with a significant reduction in both morbidity and mortality. Every effort should be made to encourage a mother to breastfeed. There are few genuine contraindications to breastfeeding; these include some rare inborn errors of metabolism in the baby such as galactosaemia. It is not the practice to encourage HIV-positive mothers to breastfeed. Breastfeeding is generally safe for the baby if the mother requires medication; rarely breastfeeding is absolutely contraindicated. When prescribing for a breastfeeding motherit is wise to check that the drug prescribed is safe. Often alternative drugs can be prescribed and breastfeeding continued.
Human breast milk is a complex bioactive fluid that alters in composition over time. Colostrum has a greater concentration of protein and minerals than mature milk and provides a largenumber of active substances and cells. Term colostrums contains approximately 3 million cells perml, of which about 50% are polymorpholeucocytes, 40% macrophages, 5% lymphocytes and the remainder epithelial cells. Colostrum also contains antibodies, humoral factors, growth factors and interleukins.
The majority of the immunoglobin (Ig) in milk is secretory IgA, with specific antibodies against antigens recognized by the mothers’ intestinal mucosa which protect against the extrauterine environment. However, most circulating immunoglobulin in the human infant is acquired transplacentally.
Healthy term infants feeding on demand usually suckle 2 to 4 hourly. On the first day of life they require about 40 ml/kg of milk, and some 20–30 ml/kg more each day until they take approximately 150 ml/kg per day by the end of the first week. Infants weighing 1.5–2.0 kg need approximately 60 ml/kg, again increasing to 150 ml/kg per day after1 week. Feeding infants smaller than 1.5 kg often requires specialized practices such as gavage or parenteral feeds.
Body composition, fluids and electrolyte metabolism
During pregnancy total body water declines from 94% in the first trimester to about 70% at term. Extracellular fluid decreases from 65% body weight at 26 weeks to 40% at term. Administration of intravenous fluids to a mother or Caesarean section increases the infant’s body water after birth.
Following birth, an abrupt contraction of the extracellular compartment occurs; term infants lose about 5% and preterminfants 10–15% of body weight by diuresis during the first 5 days. This important adjustment to extrauterine life is interrupted by stress which causes secretion of anti-diuretic hormone; infants with respiratory problems show little weight loss until the lung condition improves. However, infants who are sick from many causes may also show excessive weight loss and loss of more than 10% in a term infant is cause for concern.
The glomerular filtration rate is low in newborn infants and only reaches mature levels by the end of the first year. Thus infants initially require little water, and 40–60 ml/kg per 24 h is adequate. Infants have a concomitant obligatory sodium loss and do not require dietary sodium until weight loss is complete. In a sick or pre term infant, fluid great care as well as frequent measuring of weight and blood electrolyte concentrations.
The placenta is a heat exchanger which transfers heat generated by metabolism from fetus to mother. After birth the newborn infant functions as a homeotherm, maintaining deep body temperature at 37◦C. Heat control places a large demand on neonatal metabolism and physiology because a large surface area to volume ratio and wet skin make the newborn baby vulnerable to excessive heat loss.
Newborn infants have a specialized organ for heat production: brown adipose tissue, which allows nonshivering thermogenesis. Catecholamines are released in response to cold, stimulating oxidative phosphorylation in these cells, where uncoupling energy metabolism from ATP generation allows chemical energy to be converted into heat. Non-shivering thermogenesis is impaired in the first few hours of life in sick infants and after maternal sedative administration.
Despite this, the newborn infant has a limited capacity to maintain core temperature. At environmental temperatures below 32◦C non-shivering thermogenesis increases oxygen consumption and maintains core temperature. However, at environmental temperatures below 24◦Cheat production is inadequate and the body temperature will fall. It is therefore important to ensure the environmental temperature in delivery rooms and theatre is 20◦C for a term baby and at least 23◦C if a preterm delivery is expected to prevent initial hypothermia.
Preterm infants are at particular risk of hypothermia because of lack of brown fat, small energy reserves, high evaporative heat loss through immature skin and a higher surface area to volume ratio. Sickness places extreme demands on the infant’s homeothermic capacity and an unstable core temperature frequently accompanies severe illness. While a healthy term infant can be adequately cared for by dressing and wrapping in warm blankets, sick or preterm infants require incubators or radiant heaters to maintain a normal core temperature.
Assessment and simple resuscitation at birth
Most infants born at term and without specific indicators of high risk during pregnancy do not need resuscitation. Almost all those who do can be resuscitated by simple methods using bag and mask ventilation.A small number of term infants and the many extremely preterm infants require resuscitation involving endotracheal intubation. Thus, while having equipment for resuscitation ready, the first task of the attendant is to decide whether resuscitation is required or not.
Assignment of American Pediatric Gross Assessment Record (APGAR) scores as described in Table 1. can be helpful.
Heart rate Absent Slow (below 100 beats/min) Over 100 beats/min
Respiratory effort Absent Weak Good; strong cry
Muscle tone Limp Some flexion of extremities Active motion; extremities well
(response to stimulation
of sole of foot) No response Grimace Cry
Colour Blue;pale Body pink;extremities blue Completely pink
The Apgar score is obtained by assigning the value of 0, 1 or 2 to each of five signs and summing the result.
These scores are conventionally determined at 1 and 5 min and describe cardiorespiratory and neurological depression. There are many causes of depression at birth, and low Apgar scores are neither evidence of birth asphyxia, nor, except in extreme circumstances, a guide to neurological prognosis. Nevertheless, a low Apgar score signifies a problem that needs explanation and management.
It is helpful to commence a time clock at the moment of delivery and some attendants aspirate the nasal passages immediately after delivery to remove fluid and debris from the pharynx and exclude choanal atresia, although many believed this to be excessive for low-risk births.
In an infant who breathes immediately on delivery, it takes minutes for the cerebral oxygenation concentration to reach normal extrauterine levels and there is no reason to believe that a short period of apnoea at birth causes significant injury. At least three quarters of normal term infants breathe within a minute of delivery and most of the rest have breathed before 3 min. The low-risk newborn can thus be safely given immediately to the mother, while drying with a warm towel, which should then be discarded, and the baby then covered in dry warm towels to allow skin-to-skin contact with the mother. The infant can then be observed, and failure to breath by 30 s should persuade the attendant that resuscitation might be needed. Initially drying, orblowing cold airoroxygen overthe face may stimulate respiration. If this fails then resuscitation is appropriate. In many units preterm babies are placed directly in plastic bags without drying. If the bag covers the whole baby except the face better thermal control is achieved and hypothermia, which is known to significantly increase mortality and morbidity, can be prevented.
In infants who have taken a first breath, mask ventilation is highly effective provided the right equipment is used. The mask must be soft so as to form a seal around the airway. Pressurized air or oxygen is provided either by a compressible bag or an interruptible pressurizegas source; both should have a valve which releases pressure at 30 cm of water. After the airway has been adequately cleared by suction, the mask is positioned over the nose and mouth with the baby lying prone and the bag squeezed (orgas provided) to deliversever al long inspiratory breaths followed by regular ventilation at a rate of 30–40 breaths/min. In many cases ventilating with air is as effective as using oxygen. This technique requires practice and obstetricians and midwives should maintain their skills, if necessary, using an appropriate resuscitation dummy.
The best guide to successful resuscitation is the baby’s heartbeat. This can be determined in most cases by feeling the umbilical cordorthe femoral pulsation, orcan be heard through a stethoscope over the chest. A heart rate above 120 usually signifies adequate oxygenation, but a heart rate below this implies a need for more effective therapy. The heart rate provides a more immediate and accurate guide to the baby’s state than respiratory effort or skin colourand, especially forthe occasional orinexper ienced resuscitator, is the best short-term measure of success or failure.
If mask ventilation fails to produce an adequate heart rate check again forevidence of upperair way obstruction and aspirate the nasal passages and nasopharynx. Meconium present in the trachea should have been aspirated under direct vision using a laryngoscope before ventilation, but this may need repeating. If clearing of the airway and reventilation fails to produce a normal heart rate, endotracheal intubation is required. This technique is not difficult but requires practice and carries a considerable danger in inexperienced hands: the endotracheal tube will enter the oesophagus easily and significantly inhibi ventilation. If an infant does not rapidly improve after attempted endotracheal intubation, there is presumptive evidence of the tube being in the oesophagus. It should be removed and intubation repeated. If there is doubt it may be safer to concentrate on bag and mask ventilation while awaiting skilled assistance. Once the endotracheal tube is placed, auscultate the chest overboth lungs to ascertain that breath sounds are equal. Inequality implies that the tube has been inserted too far and entered one lung, but could also suggest majorpr oblems such as pneumothorax orcongenital diaphragmatic hernia. Endotracheal intubation secures access for mechanical ventilation. Initial ventilation should include an inspiratory time of approximately 1 s todistend collapsed alveoli, and peak pressures sufficient to visibly move the chest. Once the alveoli are expanded less pressure is required. Thus the first breaths may require peak pressures of 30 cm of waterormor e in term babies, whereas afterthis it is usually possible to ventilate the lungs with pressures of approximately half this, and a respiratory time of 0.5 s at a rate of 40 breaths/min. If there is evidence or presumption of surfactant deficiency, exogenous surfactant shouldbe administered early. Effective ventilation is enough to resuscitate most infants and only rarely is cardiac massage or the administration of blood because of bleeding required. On very rare occasions, endotracheal adrenaline may need to be administered for persistent bradycardia and if this fails intravenous adrenaline may be given. It is no longer good practice to administer sodium bicarbonate intravenously to infants unless blood gases are measured or circulatory failure is very prolonged. Most low-risk infants who require resuscitation can be extubated within a few minutes and can usually be nursed by their mothers as long as (1) there is no specific problem such as meconium aspiration, prematurity or a history of infection and (2) adequate observation can be maintained. Infants who cannot be extubated successfully in this time or who continue to have respiratory problems require admission to a neonatal unit.
A preliminary examination is made in the delivery room to establish that the baby does not have a major abnormality such as spina bifida and the full examination at a later time. In this way bonding and the initiation of breastfeeding are not interrupted.
A full examination should be carried out on every baby in the presence of the mother before discharge from hospital. Ideally it should take place 24–48 h after birth; however, if discharged before this the examination should still be undertaken. It is then advisable to examine the baby again during the first week of life. Any trained practitioner can carry out the newborn examination. A history should be taken including maternal obstetric and family history to identify problems in the baby that will require further management or follow up.
During examination one relies heavily on observational skills. Note abnormalities of posture and asymmetry of facial or limb movements. Evidence of jaundice, polycythaemia, anaemia orr ashes is noted and choanal atresia excluded.
A systematic search for congenital abnormalities can be rapidly performed by examining along the midline and then passing to the limbs. Starting with the head, the facial features should be noted and thought given to dysmorphic syndromes. The palate needs to be examined visually to exclude a clef palate or bifid uvula which signifies a sub-mucus cleft. The eyes must be examined by ophthalmoscopy to exclude cataracts: in a normal eye the red reflex is immediately obvious. Eye movements may not be fully coordinated in the first week of life and momentary strabismus is common.
Examination should be made of (1) the back of the neck and the spine forskin lesions suggesting spinal dysraphism; (2) the anus; (3) the genitalia; (4) the femoral pulses; (5) hips; (6) the abdomen; and (7) the chest for examination of the cardiovascular and respiratory system (chest). Then the limbs are examined: digits need to be counted and palmar and planter creases examined; the ankles should be examined for talipes. Examination of the cardiovascular system includes not only auscultation of the heart but also palpation of all pulses and the liver. Murmurs are not necessarily evidence of cardiac abnormalities, whereas major heart disease can occur in infants with normal heart sounds. Important signs of cardiac disease include cyanosis, tachypnoea, recession and absent or high-volume pulses.
Respiratory problems also present with cyanosis, recession or tachypnoea, but these two problems can be separated by echocardiography. If this is unavailable a hyperoxia test may be used in which an infant is given 100% oxygen to breathe for 10–20 min and a sample of arterial blood taken from the right arm. Assuming ventilation is adequate, a baby with lung disease will normally have an oxygen tension exceeding 20 kPa whereas in a baby with cyanotic heart disease it normally remains below 15 kPa. The test is now more frequently undertaken with pulse oximetry substituted for arterial blood gas measurement; however, this is prone to error. As the hyperoxia test is not infallible echocardiography is preferred.
Examination of the hip is mandatory to exclude congenital dislocation. The infant lies supine, a femuris held in eitherhand and the hips fully abducted until the femurs lie parallel to the bed. If this cannot be achieved by gentle pressure, the hip is probably dislocated and ultrasound examination is required. The pelvis is then held firmly by one hand while the other grasps the femur in a vertical position, applying pressure downwards and outwards. If the hip is unstable, this will allow the head of the femur to leave the acetabulum. The examiner then abducts the femur, which rides forwards and inwards as it re-enters the acetabularcup producing a low pitched clunk: this signifies a dislocatable hip. High-pitched clicks can also occurbecause of ligamental laxity. It is wise to obtain ultrasound examinations of all suspect hips, in infants born after breech delivery and in those with a family history of congenital dislocation.
A great deal can be learnt about an infant’s neurological status by observation and assessing posture and tone. A normal term infant when left supine will adopt a position in which the limbs are flexed and adducted. If lifted and held prone the baby will momentary hold its head extended before dropping it forward, with the spine adopting a smooth curvature. Reflexes can also be helpful signs of normality. To elicit the Moro reflex gentle but abrupt neck extension is allowed by moving the head, and this results in sudden extension and abduction of the limbs followed by slower adduction and flexion. Slow rotational movement of the head will also elicit dolls eye movement in which the point of gaze remains relatively
fixed despite the movement. If the cheek is touched gently, a rooting response will be elicited in which the baby turns his head slightly towards the stimulus and gives a unilateral grimace. Sucking is a valuable neurological sign, and babies who suck well and effectively rarely have a severe encephalopathy. A complete examination includes measurement and plotting on standard charts of weight and head circumference; this forms the basis of developmental surveillance in following years. It should also be ascertained that the infant has passed meconium and urine within 24 h of birth.
Choose the correct answer / statement:
1. The puerperium is the period of time following birth during which the reproductive tract returns to its normal, nonpregnant state. This lasts approximately how many weeks?
A - 4;
B - 6;
C - 8;
D - 10;
E – 12.
2. How many weeks does takes it for the uterus to return to its pregnancy position in the true pelvis?
A – 1;
B – 2;
C – 3;
D – 4;
E – 5.
3. On approximately what postpartum day does milk production begin?
A – First;
B – Third;
C – Fifth;
D – Seventh;
E – Ninth.
4. When after delivery is the endometrium reestablished in most patients?
A - First week;
B - Second week;
C - Third week;
D - Fourth week;
E - Fifth week.
5. Breast-feeding in the postpartum period:
A - Markedly diminishes blood loss;
B - Slightly diminishes blood loss;
C - Does not affect the amount of blood loss;
D - Slightly increases blood loss;
E - Markedly increases blood loss.
6. A 23-year-old woman delivers a healthy term boy by normal vaginal delivery after an unremarkable anterpartum course and spontaneous labor. She decides to breast-feed, which is begun satisfactorily during her stay in the hospital. She and her new son are well at the time of discharge. Ten days later, she calls complaining of the slight fever and pain in her left breast. You learn that the segment in the left side of her left breast is redness , which is indurated and painful and feels especially warm to touch. Her temperature is 38°C and she feels generally bad. What is the most likely diagnosis?
III. Answers to the Self- Assessment.
1. B. 2. B. 3. B. 4. C. 5. C. 6. Mastitis.
Students must know:
1.Regime of the pueperium unite.
2. Prevention methods of complication from puerperal genital infection.
3. The physiologic pueperium period.
4. Management of physiologic pueperium period.
5. Principles of breast-feeding.
Students should be able to:
1.Perform the palpation of postpartum uterus for determination its consistency.
2.Examine the external reproductive organs, estimate the character of lochia.
3. Estimate the breast and nipple care, to diagnose crafted nipples.
4.Perform the breast pump, to study how to pump breast.
5.Care of the perineum, perineal lacerations.
6.Take away the sutures from perineal tear.
1. Хміль С.В. Акушерство. – Тернопіль: Укрмедкнига. – 1998. – С. 150 - 158.
2. Danforth’s Obstetrics and gynaecology. - Seventh edition.- 1994. – P. 163- 174.
3. Obstetrics and gynaecology. Williams & Wilkins Waverly Company. – Third Edition.- 1998. – P. 136 - 146.
4. Basic Gynecology and Obstetrics. – Norman F. Gant, F. Gary Cunningham. – 1993. – P. 317 - 320.
5. Obstetrics and gynecology. – Pamela S.Miles, William F.Rayburn, J.Christopher Carey. – Springer-Verlag New York, 1994. – P. 47 - 50 .
|Mina Wayman experience exchange between the Bukovinian State Medical University and Utah Valley State College in relation to preparation of nurses||Bukovinian State Medical University|
|Bukovinian State Medical University||Bukovinian State Medical University|
|Bukovinian State Medical University||Bukovinian State Medical University|
|Bukovinian State Medical University||Bukovinian State Medical University|
|Bukovinian State Medical University||Ministry of health of ukraine bukovinian state medical university|