Postpartum Study Guide

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					Postpartum Study Guide

Chapter 19 (pp. 467-477)
Non-pharmacological pain management

1. What are three neurological origins for pain in labor?
Visceral and somatic:
Visceral: dominates 1st stage [dilation] and comes from organs: cervical changes, distention
of lower uterine segment, and uterine ischemia [caused by compression of the arteries
supplying the muscle during uterine ctx]. This hurts in the lower abdomen. Transmitted by
nerves T1-12.
Referred Pain: pain from uterus going back to the low back, hips, butt and thighs.
*visceral and referred pain should occur only during ctx, but sometimes back pain remains
during rest periods
Somatic Pain: second stage [push it out]. Intense sharp pain due to your tissue being
stretched and torn asunder. Bladder and bowel might also feel squished and angry.
Transmitted by pudendal nerve to S2-4.

2. What is the gate control theory of pain and how might you use that as a nurse in L & D?
The idea is that the channels sending pain signals can only send so many signals at a time,
and if you add other signals the pain messages are disrupted: so massage, sound,
concentrating on breathing, images and other input help. When woman move the messages
are similarly disrupted. As pain increases you have to work harder.

3. How can you tell when a person is hyperventilating? Why don‟t you want them to do that?
You don‟t want them to because they will blow off their CO2, and may enter respiratory
alkalosis [due to hypocapnia]. Not good: blow off Co2, may faint. Common in transition
and pushing phases. We don’t like it. Sometimes we will put a paper bag on her to
rebreathe a little.

4. Several methods of minimizing pain in labor are discussed in this chapter. What are some
advantages and disadvantages compared to the use of medications? Does it have to be

It‟s not her level of pain but her pride in coping with the pain that equals her feelings about
her birth experience. Women should try a variety of options, even pharma, when other
strategies run out. Nothing‟s as effective as an epid.

Usually taught in prenatal classes. Cheap and have few side effects if any—it‟s just that no
one is paying for the research on their effectiveness.
   1. Childbirth prep ed: usually teach Dick-Read, Lamaze, and husband coaching [Bradley
       method]. Birthing from Within and Birthworks assist in women gaining confidence at
       their natural instinct for birthing.
   2. Relaxation: key because women save energy for 2nd stage and reduce their
       sympathetic response which can slow labor.
          a. Attention Focusing: chosen focal point plus a breathing technique
          b. Distraction
          c. Imagery: meditate on pleasant scene, color, or activity
          d. Feedback: coaching to relax tense muscles and tense mind
   3. Breathing: loosens up friction and pressure in abd during 1st stage with open relaxed
       breathing. In 2nd stage, breathing is used to increase pressure and push.
          a. Cleansing breaths to greet and blow away ctx
          b. Slow breathing is good earlier
          c. Complex breathing patterns are good when pain is intense and it takes more
              concentration to override pain signals
          d. Transition is a bitch and it‟s hard to maintain breathing
          e. Always watch for hyperventilation [and don‟t breath at more than twice the
              normal rate
          f. We like plenty of O2 during pushing, so long breaths in are great, and little
              open glottis pushes are good too.
   4. Touch:
          a. effleurage for pain-gate
          b. counterpressure for back labor
          c. laying on of hands
          d. back, head, hand and foot massage
          e. in late labor women may only tolerate her hands and feet being touched
   5. Music: promotes relaxation and lifts spirits, helps encourage movement—can help
   with breathing rythyms
   6. Water!
          a. Buoyancy and warmth help
          b. Reduced anxiety, Stimulates nipples, which causes increase in oxytocin and
              endorphins. Does not overstimulate the uterus.
          c. Mom can move easier in the water
          d. Positions to relieve back labor are do able
          e. Most MD‟s say only w/ VS WNL. No internal monitors. “BOW may be intact
              or ruptured.” No mec, or only lightly stained w/ mec.
          f. If FHR or mom‟s temp increase, labor can slow.
          g. Water is best in active phase of dilation—during the latent phase of dil can slow
          h. Mom can stay in as long as she likes.
          i. Taking ½ to 1 hr dips with breaks may be more effective than prolonged
          j. Bath at body temp
          k. Fluids and cool face cloth are good
   7. TENS: like mom had: buzzes your back, best for low back pain and back labor. No
      risk to kiddo, mom‟s find relief „good‟ or better. Might just be placebo effect.
   8. Accupressure/puncture:
          a. apply heat, cold, or pressure to areas of dense nerves.
          b. Breathing with mom is better
          c. May be pain-gate and placebo effect
          d. No lube
          e. Spot at ankle and meat between thumb and forefinger are good for getting labor
             going w/o pain [right]
   9. Heat and cold: Blankets, ice, compresses, heat packs, warm water
          a. Wamth reduces ischemia and increases blood flow
          b. Heat is best for back pain from anything
          c. Cold is good on face, chest, back, or pain spots.
          d. Cold helps reduce muscle temp and relieves spasms
          e. Cold and heat are best used alternating, never do it on ischemic or drugged
             areas because damage can occur. Use a cloth to cover hot or cold packs to avoid
   10. Hypnosis: positive research on its effectiveness, but we need more
   11. Biofeedback: requires a lot of education for mom. The idea is that she can take
      control of her body better and encourage her labor with her own responses to pain.
   12. Aromatherapy: smells that increase relaxation. She should pick the scent.
   13. Intradermal water block: for low back pain, best in early labor, relieves back pain for
      1-2 hrs.

Pharmacological interventions: they work, but there are usually risks involved. When you
use drugs in combo w/ nonpharm techniques, less drugs are needed. Drugs are very very
popular with patients—few patients have totally unmedicated births.
   1) Sedatives: for relaxation, sleep, reduce n/v, augment analgesics.
         a. Barbiturates (seconal): bad SE‟s of resp depression, esp w/ another CNS
             depressant like opiates. But pain worsens w/ barbs if no other analgesic. These
         b. Phenothiazines (Phenergan): mellow you out, potentiate opiates so lowered
             doses are used, reduce n/v
           c. Benzos (ativan, etc): potentiate opiates, less n/v, but sedation isn‟t always
              desireable to a laboring woman
Analgesia: loss of pain w/o loss of conciousness
Anesthesia: loss of pain and conciousness of varying degrees—also relaxation and loss of
    2) Systemic Analgesia: dope the whole body. Not so popular b/c regional is so much
       better. These drugs get to the baby—and they cross baby‟s BBB better than they do
       mom‟s, they have a longer half life in baby‟s blood, and babies are just tiny. PCA‟s
       can be set up to minimize total drug usage
           a. Opioid Agonist Pain killers: For persistent severe pain, cause euphoria. Women
              feel better w/ epids. Oddly assoc w/ shorter labors, less Pit, less intrumental
              births than epids—maybe b/c of relaxation? Hopefully you deliver w/in 1-4 hrs
              of admin to minimize fetal resp depression.
                  i. Dilaudid [1st choice]
                 ii. Demerol [more SE‟s]
                iii. Fentanyl, Sufentanyl work hard and fast for a short period. Sufentanyl is
                     better: less gets to baby, works faster than fentanyl.
           b. Opioid Agonist-Antagonist Pain Killers: moderate analgesia w/ less SE‟s on
              mom and baby, but sedation might be more than straight opioids. Not ok for
              opiate-using moms.
                  i. Stadol
                 ii. Nubain
           c. Opioid Antagonists: Narcan, to bail your ass out when mom is overdoped, or
              given to baby. Prophylactic use is controversial, hitting mom with narcan
              during delivery is controversial
    3) Nerve Block: mostly use cocaine relatives, so things ending in „caine‟ mean local
       [lidocaine, etc] These interrupt nerve impulses.
           a. Local Perineal Infiltration Anesthesia: for epis cutting or suturing. Injected into
              skin and subQ. Sometimes epinephrine is in the mix to slow bleeding.
           b. Pudendal Nerve Block: for late second stage if epis or instruments are to be
              used, or for 3rd stage repair operations. Almost impossible to feel a bearing
              down reflex. Few fetal complications. But that is just so close to the clitoral
           c. Spinal Block:
                  i. Into 3rd 4th or 5th lumbar space, into the subarachnoid space
                 ii. Problems: hypotension, poor placental perfusion, poor breathing patterns
                     on mom‟s part, allergies.
                iii. Good b/c: no fetal hypoxia unless mom‟s BP drops, mom‟s not sedated,
                     pain is controlled well
      iv. Intrumental birth increases b/c lack of pushing response. More likely to
           have bladder and uterine atony, and headache [PDPH-postdural punture
       v. Use a lot for cesareans—more common than epid—causes numbness
           from nipple to feet
      vi. Low block can be used for vaginal, but not ok during labor
     vii. Bump up her IV fluids to manage BP.
    viii. Monitor her VS and FHR q 5-10 mins
      ix. Emergency: severe low BP, fetal distress [bradycard, low variability, late
           decals]. You do: more IV fluid, O2, elevate legs, lay her on her side, call
           for help.
       x. She cannot sense her ctx, must be coached to bear down. Oddly if you
           add an opioid, she has better motor control.
d. Epidural Block [p 484]
        i. Btwn 4th and 5th L space
       ii. Lumbar Epi Anesth and Analges:
              1. Most commonly used for labor pain in US.
              2. 2/3 of women choose this
              3. for either C/S or vaginal birth
              4. diffusion of med depends on position, depth of needle, dose
              5. Woman cannot move during placement, must lie or sit w/ spine
                  curved—better laying dying b/c of uterine pressure on the vena
              6. Risk for low BP: use incr fluids and O2
              7. She may not be aware of the progress of labor: need to monitor
                  baby and progess
              8. PCeA is most common form of block; not doing intermittent
                  blocks anymore: offers control, less meds used
              9. Good: woman is alert and comfy, relaxed, no risk to airway, partial
                  motor paralysis, no GI slowing, no excess blood loss. Rare fetal
                  comp due to rapid absorbtion of the meds OR mom low BP. Dose
                  can be modified to allow other positions, feeling to push, even
                  walking—or increase for surg or instrumental birth
              10.Bad: instrumental birth, c/s prolonged labor, incr PIT. Cause
                  hypotension which may be prevented by fluid bolus. IV and
                  EFM restrict control/movement. Med injected into vein causes
                  coked out behav and convulsions, resp arrest if injected into
                  subarachnoid space [b/c of high dose of med]. Higher rate of
                       11. Sever hypotension [more than 20% lower than baseline] is due to
                          sympathetic blockade, causing lack of blood to baby. Urinary
                          retention or incontinence also occur postP, maybe due to prolonged
                          and/or instrumental births.
                       12. No confirmation of higher C/S rates w/ epid.

Pg 484

Chapter 22

   1. In the process of involution, where is the fundus right after birth and
      then where would it normally be located 12 hours later?
After birth the uterus is in the midline, about 2 cm below the level of the
umbilicus, with the fundus resting on the sacral promontory. Within 12
hours, the fundus may be approx 1 cm above the umbilicus.

2. What purpose do uterine contractions have in the postpartum period?
Postpartum homeostasis is achieved primarily by compression of
intamyometrial blood vessels as the uterine muscle contracts.

3. What effect does breast-feeding have on uterine contractions?
Sucking stimulates oxytocin release. Oxytocin strengthens and coordinates

4. What three colors does lochia come in? How would you describe the
amount of bleeding (p. 597)?
Lochia rubra, serosa, and alba.
Lochia: goes from really bloody to not so bloody. We like to
pretend that there’s no blood in it. Which is odd.
Rubra, [don’t call it red, b/c red means blood.]
Serosa [don’t call it pink].
Alba [don’t call it white.]
If given oxytocin, The flow of lochia is often scant until effects of the
medication wears off. Flow of lochia usually increases with ambulation and
breastfeeding. It tends to pool in the vagina when the woman is lying in bed;
upon standing, the woman may experience a gush of blood.
5. You are working nights (yikes!) and a woman who delivered yesterday
puts on her light and is worried she may have an infection because she is
diaphoretic. What‟s going on?

6. What is engorgement and when does it occur?
Swelling of the breasts can occur after birth if woman has not breastfed

7. What can be done for engorgement?
Well fitted, supportive bra, ice packs, cabbage leaves, mild analgesics,
breastfeeding or pumping

8. What would make postpartum women susceptible to orthostatic
Ortho hypotension can develop in the first 48 hrs as a result of the
splanchnic engorgement that may occur after birth. the overfilling or pooling
of blood within the blood vessels of the stomach cavity following the
removal of pressure from the stomach area, as in the removal of a large
tumor, birth of a child, or drainage of a large ...

9. Even though there is blood loss during childbirth, why does her crit go up
in the first couple of days after birth?
She drains off all that water that she was packing around during
pregnancy—her blood becomes more concentrated. During the first 72 hrs
after childbirth, there is a greater reduction of plasma vol than in the number
of blood cells. This results in a rise in hematocrit and HgB levels by the 7th
day after birth.

10. How about that WBC count? What could this level also indicate?
Normal leukocytes of pre gave about 12,000. During the first 10-12 days
after childbirth values between 20,000 and 25,000 are common.
Leukocytosis, coupled with normal increase of erythrocyte sedimentation
rate, may obscure the diagnosis of acute infection at this time.

Chapter 23

1. What is the fourth stage of labor?
1-2 hours after birth: The hour or two after delivery when the tone of the
uterus is established and the uterus contracts down again expelling any
remaining contents. These contractions are hastened by breast-feeding,
which stimulates production of the hormone oxytocin. Watch for bleeding.

2. What kind of physical assessment do we do in the first hour pospartum?
VS, placement of fundus, assess bladder/voiding, lochia, perineum

3. If a woman has an epidural, what do you need to check before she gets up
to go to the bathroom?
Can she move her legs, extend legs off bed, raise buttocks off bed. Make
sure she doesn‟t fall.

4. What‟s early postpartum discharge? What are some advantages and
Discharge before 24 hours. Disadvantages: some med problems don‟t show
up in the first 24 hrs, new mothers have not had sufficient time to learn how
to care for their newborns and identify newborn health problems such as
jaundice and dehydration related to breastfeeding difficulties. Advantages:
reduce health care costs, have less medical intervention and more family
focused experiences

   5. What are the two most important things you can do to prevent uterine
“maintain good uterine tone and prevent bladder distention.”
Uterine atony is a loss of tone in the uterine musculature. Normally,
contraction of the uterine muscle, compresses the severed placental blood
vessels and reduces flow. This increases the likelihood of coagulation and
prevents bleeds. Thus, lack of uterine muscle contraction can cause an acute
hemorrhage. Clinically, 75-80% of postpartum hemorrhages are due to
uterine atony. Many factors can contribute to the loss of uterine muscle tone,

- overdistention of the uterus
- multiple gestations
- polyhydramnios
- fetal macrosomia
- prolonged labor
- oxytocin augmentation of labor
- grand multiparity (having given birth 5 or more times)
- precipitous labor (labor lasting less than 3 hours)
- magnesium sulfate treatment of preeclampsia
- chorioamnionitis
- halogenated anesthetics
- uterine leiomyomata
prevent: Many practitioners actively manage the third stage of labor, gently
pulling the umbilical cord and administering oxytocin to help the uterus
contract and promote delivery of the placenta. The uterus can also be
massaged to help it contract firmly. Many studies show this technique
reduces postpartum hemorrhage and the need for blood transfusions.

6. Generally, what assists in the healing of an episiotomy or a laceration?
Keep clean, wipe from front to back, use squeeze bottle with warm water or
an antiseptic solution after voiding, change pad from front to back each time
she voids or defecates

7. What kind of interventions can be done to maintain uterine tone?
Stimulation by gently massaging fundus until it is firm, admin of IV fluids
and oxytocic meds

8. What are some problems that can arise (ha ha) with a distended bladder?
A full bladder causes the uterus to be displaced above the umbilicus and well
to one side of midline in the abd. It also prevents the uterus from contracting
normally—causing atony.

What are some things you could do to assist the woman to be able to void (p.
598)? Help the woman empty her bladder spontaneously as soon as possible.
Have her listen to running water, pour water over her perineum, assist
woman into shower, peppermint oil in bedpan, analgesics for pain

9. If a woman is having intense afterbirth pains, but is hesitant to take pain
medications, what kind of advice could you give her?
Inform woman of med, side effects, certain meds are found to be safe during
breastfeeding, teach nonpharm relaxation techniques such as distraction,
warmth, imagery, therapeutic touch, relaxation, interaction with infant

10. What are some signs of a thromboembolism? Complaint of pain in calf
muscles, warmth, redness, or tenderness

11. What do cabbage leaves have to do with engorgement? Help reduce
swelling. Believed that naturally occurring plant estrogens or salicylates may
be responsible for the effects
12. What would be some advantages of giving a woman a rubella
vaccination postpartum? What would be some concerns?
It is recommended in women who have not had rubella or have not been
immunized in the past to prevent the possibility of contracting rubella in
future pregnancies. It should not be given if the mother or other household
members are immunocompromised because the virus is shed in urine and
other body fluids. An allergy to eggs may cause a hypersensitivity reaction
to the vaccine. Her baby‟s immune system is not too succeptible. Must
avoid pregnancy for at least 1 mo after vaccine.

13. What is the Kleihauer-Betke test?
It detects the amount of fetal blood in the maternal circulation. If more than
15ml of fetal blood is present in maternal circ, the dosage of Rh immune
glogulin must be increased.
Used in assessing for Rh Sensitization
   1. Maternal blood Rh negative
   2. Large antepartum bleed

RH isoimmunization
Rh incompatibility is a condition that develops when a pregnant woman has
Rh-negative blood and the baby in her womb has Rh-positive blood.
Rh factor is a protein found on most people's red blood cells. When a person
does not have the factor on their cells they are Rh negative. An Rh negative
mother exposed to blood having the Rh factor will produce antibody
(isoimmunization) to the factor. If her unborn child is Rh positive the
antibody may cross the placenta and bind to fetal red cells which will be
destroyed by the fetal spleen.
During pregnancy, red blood cells from the fetus can get into the mother's
bloodstream as she nourishes her child through the placenta. If the mother is
Rh-negative, her system cannot tolerate the presence of Rh-positive red
blood cells.

First-born infants are often not affected -- unless the mother has had
previous miscarriages or abortions, which could have sensitized her system -
- as it takes time for the mother to develop antibodies against the fetal blood.
However, second children who are also Rh-positive may be harmed.

In such cases, the mother's immune system treats the Rh-positive fetal cells
as if they were a foreign substance and makes antibodies against the fetal
blood cells. These anti-Rh antibodies may cross the placenta into the fetus,
where they destroy the fetus's circulating red blood cells.

Hemoglobin changes into bilirubin, which causes an infant to become
yellow (jaundiced). The jaundice of Rh incompatibility, measured by the
level of bilirubin in the infant's bloodstream, may range from mild to
dangerously high levels of bilirubin.

Rh incompatibility develops only when the mother is Rh-negative and
the infant is Rh-positive. Special immune globulins, called RhoGAM, are
now used to prevent this sensitization. In developed countries such as the
US, hydrops fetalis and kernicterus have decreased markedly in frequency as
a result of these preventive measures.

Prevented by: injection 72 hr postpartum prevents future fetal risk. The Rh
Globulin destroys any fetal blood cells floating in mom‟s blood stream. If
they are lyzed before the immune system can create antibodies, her future
children will be safe. A higher dose of rhogam is needed if a large
transfusion is suspected, using a kleihauer-betke test.

If you get rhogam and rubella vaccines at the same time, you need to have a
rubella titer 3 mo later in case the immune system was too busy to become
immune to rubella.

Chapter 24

1. In Tables 24-1 and 24-2, can you see how the facilitating behaviors might
occur in an upward spiral and the inhibiting behaviors occur in a downward
Right—the cute connected things the baby does to stimulate the parent are
responded to with an engaging parent that stimulates their baby, starting the
cycle over. Vice versa: an uninteresting and disconnected baby leads to a
standoffish parent. (reciprocity)

2. How do parents typically get to know their newborns (this can be very
culturally specific however)?
Bonding, proximity and interaction with infant, identifies with infant as
individual, claims infant as member of family…touch, play, talk, singing.

3. What is the difference between reciprocity and synchrony?
Reciprocity- type of body movement or behavior that provides the observer
with cues. The observer or receiver interprets those cues and responds to
Synchrony- refers to the “simultaneousness” between the infant‟s cues and
the parent‟s response. When the parent and infant have a synchronous
interaction, it is mutually rewarding.

4. What is the en face position?
“face to face,” is a position in which it parent‟s face and the infant‟s face are
approx 8 inches apart and on the same plane

5. A woman had a c-section and ended up in the ICU. It is now five days
after she delivered and she has little contact with her infant. She is in tears
because she read so much about the importance of bonding early with the
baby. What would you discuss with her?
Early close contact may facilitate the attachment process, but this does not
mean that a delay will inhibit the process. Additional psychologic energy
may be needed to. No scientific evidence has demonstrated that immediate
contact after birth is essential for the human-parent relationship

6. What are the 4 stages in Mercer's Becoming a Mother theory? What do
you think might speed up or slow down this process?
1. commitment, attachment, and preparation (pregnancy)
2. acquaintance, learning and physical restoration (first 2 to 6 weeks
following birth);
3. moving toward a new normal (2-4 months),
4. achievement of the maternal identity (around 4 months) achievement is
influenced by mother and infant variables and the social environment

7 What are some causes of the postpartum blues?
50-80% of women experience it. Some causes: depression, a let-down
feeling, restlessness, fatigue, insomnia, headache, anxiety, sadness, and
anger. Biochemical, physiologic, social, and cultural factors have also been
explored—not sure what the root cause is.

8. Why might some new fathers feel “left out of the loop”?
Fathers may express concerns about decreased attention from their partners
relative to their relationship, the mother‟s lack of recognition of the father‟s
desire to participate in the decision making for the infant, and limited time
available to establish a relationship with their infant
9. What are some characteristics of engrossment?
It is the term used for the father‟s absorption, preoccupation, and interest in
the infant. Characteristics include: Some of the sensual responses relating to
touch and eye to eye contact and the fathers keen awareness of features both
unique and similar to himself that validate his claim to the infant.

10. A young Hispanic couple have just given birth to a daughter. The father
is beaming, but refuses to hold the baby? What‟s up and what would you do
in this situation?
Father interactions with infants tend to be characterized by stimulating social
play rather than caretaking. Nurses can arrange to teach infant care when the
father is present and provide anticipatory guidance for fathers about the
transition to parenthood. Hispanic husbands do not expect to see their wives
or infants until both have been cleaned and dressed after birth.

11. As a nurse, what suggestions could you make to a parent to decrease
sibling rivalry?
    Take firstborn on tour of hospital room and point out similarities to
       his/her birth
    Have a small gift from the baby to give to your older child
    Give the child a “I‟m a big brother” t-shirt
    Make sure the older child is one of the first to see and hold the baby
    Plan time for both children
    Have father spend time with other siblings while the mother is taking
       care of the baby and visa versa
    Give preschool or school age children a newborn doll as “their baby”
       to care for