Pain Management, Postpartum Physiological Assessments & Transition to Parenthood Flashcards
Gate Control Theory of Pain
alternate activity can replace travel of the pain sensation
Nonpharmacologic Pain Management
- childbirth education
- cutaneous, thermal and metal stimulation
- presence of a support person
- breathing and relaxation techniques
- complementary therapies
Pharmacological Pain Management
- sterile water papules
- analgesia: morphine, nubain, fentanyl, nitrous oxide
- anesthesia: local, pudendal, epidurals, spinal, and general
Sterile Water Papules
- cleanse area with alcohol
- inject 0.15ml of sterile water intradermally in each site
- watch for a wheal to form
distracts pain receptors
Administration of Systemic Analgesia
- appropriate when woman is uncomfortable and desires med
- must understand benefits/side effects of meds (fetus is exposed to meds)
- well established labor pattern is important cause meds can knock out labor and they work best the first time so if they aren’t good labor pattern when you use it again it won’t work as well.
- vitals must be stable
- contraindications = drug allergies, respiratory compromise
- must know what other meds are being administered
Routes of Administration
- oral pain meds are not used d/t delayed gastric emptying, good chance mom has n/v as well
- IV is preferred
Sedatives
can be used for early latent phase for relaxation and sleep (therapeutic rest)
common meds:
- sedative: ambien (shorter half life to help induce sleep)
- benzodiazepines: valium
- H1-receptor antagonists: phenergan, vistaril, benedryl (also works as antiemetic)
*morphine and phenergen: last about 12 hours, cause CNS depression and relax smooth muscle contractions. Helps knock out garbage contractions that are causing exhaustion. When she wakes back up she could kick back into labor or stop and days or week later she could go into labor again
Narcotics
Used in active phase pain management
primary action is on sites in brain
common meds:
- nubain: lasts ~2-3hrs.
- demerol: more fetal effects (reverses all other narcotic or opioid effects - do not use in woman with drug hx)
- fentanyl: rapid onset, limited placental transfer, short half life
IM injection of meds lasts longer in system than IV
Regional Anesthesia
temporary reversible loss of sensation
typically narcotic agent + anesthesia
ex: epidural (continuous dose from catheter), spinal (one time dose and wears off),
combined epidural/spinal
less risk than general
required informed consent
Epidural: Advantages and Disadvantages
Advantages: good analgesia, woman fully awake during labor (no altered cognition), continuous, works by gravity
Disadvantages: maternal hypotension -> uteroplacental insufficiency (late decels). Preload with fluid to minimize risk (500-1000m;), seizures, meningitis, cardiorespiratory arrest, need skilled personal, costly, may take up to 30 min for analgesia onset.
Epidural: Nursing Assistance
- have pt empty bladder (won’t sense emptying, so get foley)
- preload w/ fluids
- positioning (works by gravity so don’t have her laying supine or she may lose breathing)
- monitor UC
- monitor BP
After block:
- head of bed 25 degrees, lateral uterine tilt
- q5min vitals
Epidural Block: SEs
Common:
- inadequate or unilateral block, block failure
- pruritus
- Temperature elevation
- HA
- hypotension
- Urinary retention
Spinal Block: Advantages and Disadvantages
Advantages: immediate onset, relative ease of administration (don’t need to thread catheter), smaller drug volume
Disadvantages: hypotension is common, greater potential for fetal hypoxia, intrauterine manipulation difficult
General Anesthesia
unconscious
indications: time sensitive, contraindications to regional, failure to successfully insert regional
Complications: fetal depression, reaches baby in 2min
-potential for chemical pneumonitis: decrease in GI motility, acidic gastric secretions
Breast feeding concerns:
- slower to initiate breastfeeding
- need more assistance with breastfeeding
Pudendal Block
perineal anesthesia: use in second stage of labor, birth, episiotomy repair
advantages: ease of administration, no maternal hypotension
disadvantages: urge to bear down may be decreased, complications
Local Infiltration Anesthesia
used for laceration and episiotomy repairs
advantages: least amount of anesthetic agent, onset w/in a few minutes
disadvantages: burning sensation w/ injection
Postpartum Period
Lasts about 6wks for vaginal delivery (8wks for cesarean) or until body returns to pre-pregnant state.
Women are at risk for infection and hemorrhage
nursing care: fundal height in preventing hemorrhage and prevent infection
Postpartum Physical Adaptations: Uterus
uterus needs to shrink down in size = involution
uterus needs to contract to decrease the risk of postpartum hemorrhage
Uterus: Nursing Action
assess uterus location and position and tone of fundus:
- q15min x 1hr
- q30min for 2nd hour
- q4h for remainder of 1st 24hr after delivery
- q shift after 24 hours or per hospital policy
*do this as frequent checks allow for the identification of potential complications such as uterine atony (decreased tone) which can lead to postpartum hemorrhage. Greatest risk in 1st hour.
Fundal Positon
Immediately after placental delivery: midway between symphysis pubic and umbilicus
12hrs later: rises to level of umbilicus or 1cm and remains there for ~1 day
after 24 hours: decreases 1cm or 1 fingerbreadth per day
back in pelvis by day 14
reaches prepregnant size by 5-6wks
Issues w/ Involution
if uterus is deviated to the right, soft or elevated above the umbilicus it may indicate a distended bladder (full bladder interferes with involution)
*if uterus feels boggy, nurse should perform fundal massage to stimulate uterus to contract (may also admin oxytocin if ordered =10u in IV or IM)
Endometrium
undergoes exfoliation and regeneration
lochia (bloody discharge from uterus):
- lochia rubra: day 1-3 (dark red or maroon)
- lochia serosa: day 4-10 (pink)
- lochia alba: day 10+ (yellow/beige)
musty stale odor but not offensive
Lochia
scant: <1in
light: <4in
moderate: <6in
heavy: pad saturated w/in 1 hour
may have clots when blood pools
large clots should be weighted, 1 g= 1ml
Cervical Changes
following birth:
spongy, formless, bruised (takes time to recover and firm back up)
shape of os permanently changed and now has dimple to slit appearance
Vaginal/Perineal Changes
dependent on birthing process:
- ranges from mild stretching and minor laceration to major tears and episiotomies
- common to have edematous, bruised appearance from trauma
REEDA scale (redness, edema, ecchymosis, discharge, approximation of edges)
Perineal Care
- assess for discomfort, pain meds as ordered
- ice
- encourage side lying to reduce pressure on perineum
- peribottle
- warm baths after 24hrs
- topical anesthetics as ordered
- encourage frequent peripad changes
Breasts
start to fill and have primary engorgement 2-4 days PP
breasts enlarge, become firm, warm and tender and subsides in 24->48hrs
women that breastfeed experience subsequent engoregements related to distention of milk glands that is relieved by having the baby suckle or by expressing milk
colostrum: clear, yellow, precedes milk production. higher in protein and lower in carbs. contains IgA and IgG
Cardiovascular Changes
average blood loss:
- vaginal: 200-500ml
- cesarean: 800-900ml
hct drops 3-4% per each 500ml loss
WBC increases to 25000 as result of stress from birth (normalizes in a week)
Vital Signs
assessed along with fundal check and lochia assessment schedule
BP: may rise 5%
HR: bradycardia is common d/t decreased blood volume (>100 may indicate excessive blood loss, fever or infection)
RR: 16-24
Temp: mild elevation r/t muscular exertion, exhaustion, dehydration and hormonal changes (temp of >100.4 or 38 on two occasions may mean infection)
Respiratory System
pulmonary function returns to pre-pregnant state by end of PP period
assess breath sounds for women that:
- received large amounts of IV fluids, oxytocin, magnesium sulfate, or terbutaline
- have infection or preeclampsia (at risk for pulmonary edema)
- had cesarean delivery (post-op risk for pneumonia)
Immune System
assess woman’s immunization status regarding:
- rubella titer
- tdap
- flu
- hep B
assess Rh status:
-Rh negative women with Rh positive baby are screened for anti-Rh antibodies (via indirect Coomb’s test), if negative for antibodies than they are given Rhogam prior to discharge
Urinary System
decreased sensation of filling and sensitivity to pressure -risk of: overdistention incomplete emptying residual urine -> risk of UTI
hematuria occasionally occurs
woman should void w/in 4-8 hours of birth, if they haven’t voided by 12 hours they will need cath (important to not have distended bladder to keep uterus contracted)
foley is recommended if inability to void is d/t edema
Endocrine System
nonbreastfeeding moms: menstruation reoccurs 7-9 weeks after delivery
breastfeeding moms:
- prolactin levels increase in response to breastfeeding and suppress menstruation
- menses: can return after 3 or more months depending on length and amount of breastfeeding.
- reduces risk of pregnancy
Muscular System
Diastasis recti abdominis: separation of abdominal muscles
Striae: stretching, rupture of elastic fibers in skin (never completely gone)
GI System
bowels tend to be sluggish for 1-2wks d/t dehydration, decreased movement, pain, fear
-increase hydration, fiber, stool softeners, ambulation
hemorrhoids:
-constipation measures, position on side, sitz bath
flatulence (even more after cesarean):
-simethicone, peppermint or chamomile tea
Neurologic Changes
HA are common
Migraines that were better during pregnancy return
*Pt’s w/ MS and Guillain-Barre syndrome more likely to have symptoms PP
Weight Loss
~12lb initial loss after delivery
-Puerperal diuresis and uterine involution = another 5-8lb loss
return to prepregnant weight ~6-8wks PP (if they gained recommended amount)
Postpartum Physical Exam
empty bladder
q4hr for first 24hr after delivery
q-shift after 24hrs
BUBBLE-HE
- breasts
- uterus
- bladder
- bowel (BM? flatus?)
- lochia
- episiotomy or laceration
- homan’s
- emotions
Discharge Teaching
s/sx of complications
self promotion:
-hygiene and breast care
-nutrition and fluids (increase of 500 calories + 2L of fluid per day for nursing)
-activity and exercise (gradual increase, postpartum exercise, Kegels)
contraception (pregnancy can occur before first menstrual period)
refrain from sexual activity until lochia has ceased and laceration has healed
Rubin’s Maternal Phases
taking in: period of dependent behaviors in first 24-48hrs, focusing on own needs, sleep, food, etc.
taking hold: movement from dependent (nurse helping) to independent behaviors moving focus to infant
letting go: movement from independence to role of mother is fluid and they are responsive to infant
Factors affecting transition through Rubin’s Maternal Phases
medication complications c-section pain pre-term infants mood disorders lack of support adolescents lack of financial resources cultural beliefs
Bonding Behavior
en face calls baby by name cuddles infant talks/sings to baby kisses baby
Attachment Behavior
responds to infant cry
provides comfort measures
stimulate and entertain when awake
“cue sensitive” to infant behavior
