Pain Management, Postpartum Physiological Assessments & Transition to Parenthood

Question 1

Gate Control Theory of Pain

Answer 1

alternate activity can replace travel of the pain sensation

Question 2

Nonpharmacologic Pain Management

Answer 2

• childbirth education
• cutaneous, thermal and metal stimulation
• presence of a support person
• breathing and relaxation techniques
• complementary therapies

Question 3

Pharmacological Pain Management

Answer 3

• sterile water papules
• analgesia: morphine, nubain, fentanyl, nitrous oxide
• anesthesia: local, pudendal, epidurals, spinal, and general

Question 4

Sterile Water Papules

Answer 4

• cleanse area with alcohol
• inject 0.15ml of sterile water intradermally in each site
• watch for a wheal to form

distracts pain receptors

Question 5

Administration of Systemic Analgesia

Answer 5

• 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

Question 6

Routes of Administration

Answer 6

• oral pain meds are not used d/t delayed gastric emptying, good chance mom has n/v as well
• IV is preferred

Question 7

Sedatives

Answer 7

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

Question 8

Narcotics

Answer 8

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

Question 9

Regional Anesthesia

Answer 9

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

Question 10

Epidural: Advantages and Disadvantages

Answer 10

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.

Question 11

Epidural: Nursing Assistance

Answer 11

• 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

Question 12

Epidural Block: SEs

Answer 12

Common:

• inadequate or unilateral block, block failure
• pruritus
• Temperature elevation
• HA
• hypotension
• Urinary retention

Question 13

Spinal Block: Advantages and Disadvantages

Answer 13

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

Question 14

General Anesthesia

Answer 14

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

Question 15

Pudendal Block

Answer 15

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

Question 16

Local Infiltration Anesthesia

Answer 16

used for laceration and episiotomy repairs

advantages: least amount of anesthetic agent, onset w/in a few minutes
disadvantages: burning sensation w/ injection

Question 17

Postpartum Period

Answer 17

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

Question 18

Postpartum Physical Adaptations: Uterus

Answer 18

uterus needs to shrink down in size = involution

uterus needs to contract to decrease the risk of postpartum hemorrhage

Question 19

Uterus: Nursing Action

Answer 19

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.

Question 20

Fundal Positon

Answer 20

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

Question 21

Issues w/ Involution

Answer 21

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)

Question 22

Endometrium

Answer 22

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

Question 23

Lochia

Answer 23

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

Question 24

Cervical Changes

Answer 24

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

Question 25

Vaginal/Perineal Changes

Answer 25

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)

Question 26

Perineal Care

Answer 26

• 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

Question 27

Breasts

Answer 27

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

Question 28

Cardiovascular Changes

Answer 28

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)

Question 29

Vital Signs

Answer 29

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)

Question 30

Respiratory System

Answer 30

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)

Question 31

Immune System

Answer 31

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

Question 32

Urinary System

Answer 32

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

Question 33

Endocrine System

Answer 33

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

Question 34

Muscular System

Answer 34

Diastasis recti abdominis: separation of abdominal muscles

Striae: stretching, rupture of elastic fibers in skin (never completely gone)

Question 35

GI System

Answer 35

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

Question 36

Neurologic Changes

Answer 36

HA are common
Migraines that were better during pregnancy return

*Pt’s w/ MS and Guillain-Barre syndrome more likely to have symptoms PP

Question 37

Weight Loss

Answer 37

~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)

Question 38

Postpartum Physical Exam

Answer 38

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

Question 39

Discharge Teaching

Answer 39

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

Question 40

Rubin’s Maternal Phases

Answer 40

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

Question 41

Factors affecting transition through Rubin’s Maternal Phases

Answer 41

medication
complications
c-section
pain
pre-term infants
mood disorders
lack of support
adolescents
lack of financial resources
cultural beliefs

Question 42

Bonding Behavior

Answer 42

en face
calls baby by name
cuddles infant
talks/sings to baby
kisses baby

Question 43

Attachment Behavior

Answer 43

responds to infant cry
provides comfort measures
stimulate and entertain when awake
“cue sensitive” to infant behavior