When is the best time to gather history on patient when in active labor?
between contractions - NOT WHEN CONTRACTING
How childbirth pain differs from other pain
childbirth pain is part of the normal birth process.
The woman has seveal months to prepare for pain management.
It is self-limiting and rapidly declines after birth.
Pain is usually a symptom of injury r illness, yet pain during labor is an almost universal part of the normal process of birth. Pain can be beneficial. It often motivates the mother to assume ifferent body psoition, which can facilitate the normal descent of the fetus. Birth pain lasts forhours, as opposed to day or weeks. labor ends with the birth, followed by a rapid and nearly total cessation of pain.
pain thresshold (pain perception)
pain threshold & pain tolerane are oftn used interchaneably to describe pain, although they hve different meanngs.
pain threshold (pain perception) is the least amount of sensation taht a person perceives as painful, is fairly constant and it varies littleunder differnt conditions.
ain tolernce- is the amount of pain one is willing to endure. Unlike the pain threshold, one's pain tolerance can chnge under different conditions.
sources of pain during labor
dilation & stretching of the cervix
reduced uterne blood supply during contractions (iscemia)
pressure of the fetus on pelvic structures
stretching of the vagina and perineum
posterior back pain
non-pharmacologic methods to help relieve labor pain
If the woman did not have childbirth prep. classes the nurse teachessimple breathing andrelaxation techniques. If the woman is extremely anxious and out of control, she will not be able to comprehend verbal instructions. It may be necessary to make close eye contact with her and to breathe with her through each cntraction until she can regain control. The nurse minimizes environmental irritants as much as possible. The lights should be lowered and the woma kept reasonably dry by reg. changing the underpads on bed. The temp. should be adjusted, the nurse provides a warm blanket if that offers the most comfort. when talking with mother, keep it short and sweet. other methods are soothing music, yoga, walking, breathing -do not harm mother nor baby
pharmacological pain management
methods include analgesics, adjunctive drugs to improve he effectiveness of analgesics or to counteract their side effect and aesthetics.
Demerol (drug of choice) meperidine - given to mothers in labor eith i with 5-10 min peak of action or intramuscularly with 50 in peak of action
Narcan (naloxone) - an opioid antagonist that acs within minutes to help resuscitate a newbor who has respiratory deprssion because of narctic sedation of the mother during labor, also relieves itching as a meternal side effect of narcotics
mother needs to know the side effects of the narcotics and what affect it has on her bab-because they cross the pacental barrier. pg 165
used for vaginl births; although its use has become less common b/c epidural block more popular. done through vagina "trumpet" used to protect mom's tissues (needle guide). adv. efeccts: few if woman not allergic,vagnal hemaoma sometimes occur, abscess may develop (not common)
Te two puendal nerves on each side of the pelvis are injected to numb the vagina and perineum.
woman in a side lying osition, or sitting upright, back straight, needle penetrates epidural space (between the dura mater and the inside bony covering of the spinal cord).16-18 gauge needle used, numbness or loss movement after small test does indicates dura mater punctured and drug injected into subarchnoid space (subarchnoid block). numbness around mouth, ringing in ears (tinnitus), visual distrubances, or jitteriness suggest injection into vein.
dural puncture lies below epidural space sometimes punctured "wet trap", large amount of spinal fluid can leak result in headache.
limitation of epidural block:abnormal blood clotting, an infection in area of injection or a systemic infection, hypovolemia
subarchnoid (spinal) block
injection of local anesthetic drug under the dura and arachnoid membranes to block transmission of pain impulses tobrain; used primarily for csection and usually admin. by anesthesiologist
observe for hypotension and urinary retention as with epidural block ( interventions are the same) suspect posspinal headache (usu. during postpartum pd) woman complins of a headache that is worsewhen is in an upright pos.; give oral fluids and analgesics ordered.
Demoral (mepeidine) (narcotic)
given to mothers in labor either IV with 5-10 min. peak of action or intramuscularly with a 50 min peak of action.
maternal responses may incude hypotension, sedation, nausea and vomiting, pruritus, fetal responses can incl. decrease in fetal heart varability. can cause respiratory depression and sedation in newborn if delivery occurs within 2 hr. after the last dose is admin.
giving at beginning of contraction - more to mom - less to baby
Narcan (naloxone ) narcotic antagonist
is used to reverse respiratory depression, usually in the infant caused byopioid drugs such as Demeral (meperidine). it can be given by the IV route or it may be given through the endotrachael tube during resuscitation. IV naloxone can be given to the neonate immediately after birth via the umbilical corc vein. the use of naloxone in a woman who is drug dependent can cause withdrawal syndrome in themother or the neonate.
rapid onset and short duration of action. can cause respiratory depression, often used with epidural analgesia
comb. opioid agonist-antagonist
Butorphanol (Stadol & Naibuphine (Nuban) mixed narcotic and narcotic antagonist effect. both drugs reduce pain and are thought to cause less respiratory depression than Demoral (meperidine). Should not be used in women who are drug addicts.
Ataractic (analgesic potentiators)
Promethazine (Phenergan) & Hydroxyzine (Vistaril) reduce anxiety and potentiate the effects of narcotic drugs, lowering the dose of narctoic needed for pain reliefe. also have antinausea and antiemetic effects. may decr. beat to beat variability in fetal heart rate.
uterine stimulants -
...primarily prescribed to induce labor, vaginal inserts and gels and oral dosage forms of prostoglandins are being tested as adjunctive therapy to help ripen the cervix
Dinoprostone (cervidil, prostin, prepidil) - prostoglandin
prostoglandins are a natural chemical in the body that causes uterine and gastrointestinal smooth muscle stimulation. PLAYS AN ACTIVE ROLE IN CERVICAL SOFTENING AND DILATION 9CERVICAL RIPENING0 unrelated to muscle stimulation - in prregnancy produces cervical softening and dilation - in higher dose increases frequency and strengths -naterine contractions.
common adverse effects -nausea, vomiting, diahrrea, thermo-regulation (chills and shivering) may occur in patients receiving this.
misoprostol (cytotec) -synthetic prostaglindin E
induces uterine contractions in the pregnant uterus - also as a CERVICAL RIPENING AGENT for induction of labor nd for serious postpartum hemmorhage in the prescence of uterine atony - not used in women who had a previous C section delivery.
common & serious adv. effect - misoprostol for short term obstetric use. mmeber of prostoglandin(e) family-
adv. effect: orthostatic hypotension
rare - uterine yperstimulation with subsequent fetal hypoxia, uteine rupture & amniotic fluid embolism have been reported.
ergonovine maleate & methylergonovine
Ergonovine & methylergonovine ar tructurally similar ergot deriatives that share similar actions. both drugs directly stimulate uterine contractions
small dose= contraction w/ normal resting
intermediate= cause more forceful & prolonged contractions w/ elevated resting muscle tone
large doxe= severe, prolonged contractions Because of this sudden intense uterine activity which is dangerous to the fetus these agents CANNOT BE USED FOR INDUCTION OF LABOR
uses: produce more sustained contractions than oxytocin and are used in small doses in postpartum pts. to control bleeding & maintain uterine firmness - DO NOT USE IN PATIENTS WHO WISHES TO BREAST FEED!!! methlergonevine may be used as alternative because it will not inhibit stimulation of milk production by prolactin.
hypertension & headaches may dvelop inpts. who have received Caudal or spinal anesthesia followed by dose of ergonovine or methylergonovine
monitor blood pres., heart rate and rhythm
THERAPEUTIC OUTCOME: REDUCED POSTPARTUM BLOOD LOSS
aDV. EFFECTS: nausea, vomiting, abdominal cramping
serious adv. effect: hypertension
drug interactin:macrolide antibitics (erythromycin,clarithromycin) these enhance therapeutic and toxic effects.
hormone produced in hypothalamus and stored in pituitary gland. When released stimulates smooth muscle of uterus, blood vessels and mammary glands - when administeredduring 3rd timester active labor may be initiaged
Drug of choice for inducing labor at term and for augmenting uterine contractions during 1st and2nd stages of labor - routinely administered immediately postpartum to control uterine atony and postpartum hemmorrhage. uterine contractions should be monitored by both tocho and fetal heart monitor. contraction longer than 90 sec. require flow rte of oxytocin to b slowed or discontinued.
adverse effects: nausea, vomiting
serious adv. effects - fetal distress - normal more than 120-160 beats/min-indicate fetal distress, tachy (more than 160 beats/min followed by brady less than 120 beats/min.
hypertension, hypotension, water intoxication, dehydration, postpartum hemmorhage
magnesium sulfate(uterine relaxant)uterine relaxants are also known as tocolytic agents and are used primarily to delay or prevent pre term labor and delivery.Tocolytic agents act by inhibiting uterine muscle contraction. they are most commonly used toinhibit labor for 2 to 7 days in order for corticosteroids to b administered to mature fetal lungs, and to transport the mother to a hospital with a neonatal intensive care unit. Although not approved, agentts that are mos commonly used are magnesium sulfate and terbutaline.
magnesium sulfate - is an ion normally found in the blood inconcentration of l.8 to 3 mEq/L - when administered parenterally in doses sufficient to produce levels higher than 4mEq/L the drug may depress the central nervous ys. and block peripheral nerve transmission, producing anticonvulsant effects and smooth muscle relaxation.
Uses: is used in obstetrics primarily to inhibit premature labor. It may also be used to control seizure activity assoc. wit preeclampsia or eclampsia. -
blood levels should be maintained at 4 - 8 mEqL
pts. maintaned at a mag. serum level between 3 and 5 mEq/L rarely show an adv. effect from hypermagnesemia. At a level of apprx 5 to 8 mEq/l pts begin to SHOW INCREASING SIGNS OF TOXICITY THAT CORRELATE FAIRLY ELL TO SERUM LEVELS - EARLY SIGNS OF MATERNAL TOXICITY ARE COMPLAINTS OF 'FEELING FLUSH ALL OVER' and being thirsty all the time, FLUSHED SKIN AND DIAPHORESIS. pts. may then becme hypotensive and have depressed patellar, radial and biceps reflexes and flaccid muscles.
later signs of hypermagnesemia are CNS depression shown first by anxiety then confusion, lethargy and drowsiness. If serum levels increase cardia depression and respiratory paralysis may result
Should be admin with extreme caution to pts with impaired renal function and whose urine output is lesss than 100mL over the past 4 hrs.
erious adv effects: DEEP TENDON REFLEXES
Overdose: The antidote fr magnesium intox. is calcium gluconate
selective relaxant properties on uterus,causing a reduction in the intensity & frequency of uterine contractions terbutaline is used to arrest premature labor in situation in which it has been determined that there is no iunderlying pathology indicating that pregnancy should not be allowed toprogress to completion.
serious adv. effects: cardiovascular: tachycardia, palpitation, hypertension, hypotension.most symptoms are dose related, alteration should be rpted. to doctor. monitor the maternal and fetal heart rates and rhythms at reg. intervals throughout therapy.
CNS neurologic- tremors, nervousness, anxiety, restlessness, headache, gastrointestinal, nausea, vomiting,metabolic- hyperglycemia - diabetc or prediabetic pts must be monitored fr the dev. of hyperglycemia.
hematologic - electrolyte imbal.
the neonate: uncommon, but hyperglycemia followed by hyglycemia, hypocalcemia, hypotension and paralytic ileus have been rptd.
drugs that enhance toxic effects: tricyclic antidepressents
drugs tht reduce ther. efffects: beta-adrenergic blocking agents (propranolol, nadolol, pinolol
corticosteroids: concurrent use may rarely result in plumonary edema
antihypertensive agents: sympathomimetic agents may red. the ther. effects of antihypertensive agents.
anesthetics: concurrent use with genl anesthetics may reult in add'l hypotensive effects.
clomid (clomiphene citrate)
is a chemical compound tat is structurally similar to natural estrogens.It is used to induce ovulation in women who are not ovulating because of reduced circulating strogen levels. Preg. occurs in 25% to 30% of pts. treated. ovulation of more than one per cycle with potential fertilization of multiple ova may occur in 5 to 10% of pts. treated.
Therapeutic outcome: ovulation followed by fertilization and pregnancy
common adv effects: nausea, vomiting, diarrhea, constipation, "hot flashes" abdominal cramps.
serious adv effections - severe abdominal cramps,
no clinicaly sig. drug interactions
glucocorticoid steroid used to accelerate fetal lung maturity to produce surfactant
RhoGAm (Rh(D) immun globulin
suppresses the stimulation of active immunity by Rh pos. foreign red blood cels that enter the maternal circulation at the time of delivery, at the termination of a pregnancy or during a transfusion of inadequately typed blood.
Rh hemolytic disease of the newborn can be prevented in subsequent pregnancies by administering Rh(D) immune globulin antibody to the Rh negative mother shortly after delivery of an Rh positive child.
uses: is used to preventRh immunization of the Rh neg. pt. exposed to Rh pos. blood as the result of a transfusion accidident, during termination of a prgnancy or as the result of a delivery of an Rh pos. infant.
Therapeutic outcomes: is to prevent Rh hemolytic disease.
Antepartum prophylaxis: one standard dose vial IM at about 28 wks gestation. This must be followedd by another vial administered within 72 hrs. of delivery. After amniocentesis, miscarriage, abortion or ectopic pregnancy and less than 13 wks gestation, one microdose vial IM within 72 hr.s ; l3 or more wks of gestation:one standard dose vial IM within 72 hrs.
erthomycin ophthalmic ointment
used prophylactically to prevent opthalmia neonatorum which is caused by N. gonorrhoeae. It is also effective aginst C. trachomatis. primary therapeutic outcome is prevention of postpartum gonorrhea or chlamydia eye infection.
Admin: instill a narrow ribbon of erythromycin ointment along the lower conjunctival surface, begin at inner canthus to the outer aspect of each of the baby's eyes.
common adv effects: mild conjunctivitis
no sig. drug interactions have been reported
Vitamin K (phytonadione)
Vit. K is a fat-soluble vit. necessary for the production of the blood-clotting factors,prothrombin (factorII), proconvertin (factor VII) plasma thromboplastin component and Stuart factor in the liver. Vit. K is absorbed from the diet and is normally prod. by the bacterial flora in the gastrointestial tract, from which it is absorbed and transported to the liver for clotting factor prod. newborns have not yet colonized the colon ith bacteria and are often deficient in Vit. K. They also may be deficient in these clotting factors and are therefore more susceptible to hemmorrhagic disease in the first 5-8 days after birth.
Injected IM in the lateral aspect of the thigh
serious adv effects: bruising, hemorrhage
no drug interactions
is the 6 weeks following childbirth. This period is often referred to as the fourth trimester of pregnancy
refers to changes that the reproductive organs, particularly the uterus undergo after birth to return them to the prepregnancy size and condition. The uterus should return to the prepregnant size by 5-6 wks after delivery If not, called subinvolution
called the endometrium when not pregnant and the decidua during pregnancy - is she when the placenta detaches. The placental site is fully healed in 6-7 wks.
descent of the uterine fundus
the uterine fundus (upper portion of the body of the uterus) descends at apredictable rate as the muscle cells contract to control bleeding at the placental insertion site and as the size of each muscle cell decreases. Immediately after the placenta is expelled, the uterine fundus ca be felt midline at or below th level of the umbilicus, as a firm mass (size of a grapefruit) After 24 hrs the fundus begins to descent about 1 cm (one finger's width) each day. y 10 days postpartum it should no longer be palpable. A full bladder interferes with uterine contraction because it pushes the fundus up and causes it o deviate to one side usu. the rt side.
intermittnt uterine contractions may cause afterpains similar to menstrual cramps. afterpains occur more often in multiparas or in women whose uterus was overly distended. breastfeeding mothers may have more afterpains because infant suckling causes their posterior pituitary to release oxytocin, a hormone that contracts the uterus. mild analgesics may be prescribed. NO ASPININ - intereferes with blood clottng.
vaginal discharge after delivery
lochia rubra - is red because it is composed mostly of blood; it lasts for about 3 days after birth
Apoorly contracted (soft or boggy) uters should be massaged until firm to prevent hemorrhage.
lochia serosa - is a pinkish color becase of its blood and mucus content. it lasts from about 3rd thru 10th day after birth.
lochia alba-mostly mucus, is clear and colorless or white. it lasts from the tenth thru the twenty first day after birth
should not have a foul odor.
womean's fundus should be checked for firmness, because an uncontracted uterus allows blood to flow freely from vessels at the placenta insertion site.
abnormal characteristics to be reported:
foul smelling lochia, with or without fever
lochia rubra that persists beyond the third day
unusually heavy flow of lochia
lochia that returns to a bright red color after it has progressed to serosa or alba.
medications that may be given to stimulate uterine contraction include the following:
Oxytocin (pitocin) often routinely given in an IV infusion after birth
methlergonovine (methergne) given IM or orally
an infant suckling at breast has similar effects because natural oxytocin release stimulates contracttions
cervix (after birth)
regains it muscle tone but never closes as tightly as during the prepregnant state. some edema persists for a few wks after delivery. A constant trickle of brighter red lochia is assoc with bleeding from lacerations of the cervix or vagina, particularly if the fundus remains firm
undergoes a great deal of stretching during childbirth. The rugae, or vaginal folds, disappear and the walls of the vagina become smooth and spacious. The rugae reappear 3 weeks postpartum. within 6 wks the vagina has regained most of its prepregnancy form but it never returns to the size it was before pregnancy.
sexual intercourse after pregnancy
it is considered safe to resume sexual intercourse when bleeding has stopped and the perineum (episiotomy) has healed. Kegel exercise help to strengthen muscles involved in burination, bowel function and vaginal sensations during intercourse.
the perineum is often edematous, tender and bruised. An episiotomy (incision to enlarge the vaginal opening ) may have been done or perineal laceration may have occured. women with hemorrhoids often find that these temporrily worsen during the pressure of birth.
The perineum should be assed for normal healing and signs of complications- the REEDA acronym helps the nurse remember the five signs to assess
5 signs to assess the perineum after an episiotomy:
Redness - redness without excessive tenderness is probably the normal inflammation assoc with healing but pain with the redness is more likely to be infection.
Edema- mild edema is common, but severe edema interferes with healing.
Ecchymosis (bruising) -a few small superficial bruises are common. larger bruises interfere with normal healing.
Discharge-no discharge from the perineal suture line should be present
Approximation (intactness of the suture line) - the suture line should not be separated. if intact, it is almost impossible to distinguish the laceration or episiotomy from surrounding skin folds.
an ice pack or chemical cold pack is applied for the first 12 to 24 hrs to reduce edema and bruising and numb the perineal area.
after 24 hrs heat in the form of a chemical warm pack, a bidet, or a sitz bath increases circulation and promotes healing.
topical and systemic medications may be used to relieve perineal pain, reduce inflammation or numb the erineum.
Epifoam (hydrocortisone and pramoxine & benzocain (Americain or Dermoplast) used. Tuck (witch hazel pads ad sitz baths reduce the discomfort of hemorrhoids.
return of ovulation & menstruation
the production of placental estrogen & progesterone stops when the placenta is delivered, causing a rise in the production of follicle stimulating hormone (FSH) and the return of ovulation & menstruation. Menstrual cycle resume in about 6 to 8 weeks if the woman is not breastfeeding. The early menstrual periods may or may not be preceded by ovulation. return of ovulation is more delayed in breastfeeding mother. However ovulation may occur at any time after birth with or without menstrual bleeding and pregnancy is possible
the first 2 or 3 days the breasts are full but soft. by day 3 breasts become firm and lumpy as blood flows increases and milk production begins. Breast engorgement may occur in both nursing and nonnursing mothers. the engorged breast is hear, erect and very uncomfortable. the nipple may be so hard that the infant cannot easily grasp it. the breasts of the nonnursing mother return to their normal size in1 to 2 weeks.
because of a 50% increase in blood volume during pregnancy the woman tolerates the following normal blood loss at deliver:
500mL in vaginal birth
1000 mL in cesarean birth
despite the blood loss there is a teporary increase in blood vol. and cardiac output because blood that was directed to the uterus and the placenta returns to the main circulation.
added fluid movers from the tissues into the circulation further increasing her blood vol. toreestablish normal fluid balance the body rids itself of excess fluid in the following two ways: 1. diuresis (increased excretion of urine) which may reach 3000mL day 2. diaphoresis 9profuse perspiration)