MIDTERM PERIOD

WEEK 8

1.Methods of Pain Management During Labor and Delivery

2.Signs of Placental Separation

PUERPERIUM
➢ Review of Post Partum Assessment
3. Physiological Changes After Delivery
4.Psychological Changes After Delivery
5.Discharge Planning
 WEEK 8: Introduction
Laboring women often experience intense pain. For most women,
going through labor is probably the worst pain they will experience in their
life. It is also said that labor pain varies from pregnancy to pregnancy,
because of this, it is important for a laboring woman to get hold of the
contractions pain so that she could control the process until the moment
that she delivered her baby. In this case, nursing students should
understand the different pain management so that they can assist their
clients during labor and delivery and they can identify what type of
management is suited for each patient.
Also, recognizing the signs of placental separation is an important
aspect to consider while assisting in labor and delivery. Students must
recognize this process because retained placenta can cause post partum
bleeding and other unwanted side effects. Once physical stability of the
mother and child is established, the focus should turn to assisting the
mother learn to care for herself and her newborn once she is discharged
from the hospital
 I.Methods of Pain Management
1.The Bradley (Partner-Coached) Method
>Stresses the important role of a woman’s partner during pregnancy, labor, and
the early newborn period
> During pregnancy, the woman performs muscle toning exercises and limits or
omits foods rich in preservatives, animal fat ,or salty foods.
>The woman is encouraged to walk during labor

2.The Psychosexual(Kitzinger) Method

>Includes conscious relaxation and levels of progressive breathing that
encourages a woman to “flow with” uterine contractions

3.The Dick-ReadMethod
>Premise is “fear leads to tension, tension leads to pain”
> Achieved through education and focus on abdominal breathing during
contractions
4.TheLamazeMethod
➢Based on the “gating theory of pain control”
>Through stimulation response conditioning, women can learn to
use controlled breathing to reduce pain during labor
> Also termed as psycho prophylactic method because it
focuses on preventing pain in labor

Six major Concepts

1.Labor should begin on its own, not be induced
2.Women should walk, move around and change positions
throughout labor
3.Women should bring a loved one, friend or doula for
continuous support
Doula-a woman, typically without formal obstetric training, who
is employed to provide guidance and support to a pregnant
woman during labor.
4. Interventions that are not medically necessary should be avoided.
5. Women should be allowed to give birth in other positions than on
their back and should follow their body’s urges to push
6. Mother and baby should be kept together after birth , it is best for
the mother, the baby and for breastfeeding

5.Conscious relaxation - RELAXING BODY PARTS

6.BREATHING EXERCISES
a.Cleansing breath
>Breathing in deeply and exhaling deeply
b. Consciously controlled breathing
>Set breathing patterns at specific rates, provides distraction as well
as prevents the diaphragm from descending fully and putting
pressure on the expanding uterus
Level 1:slow deep chest breathing of comfortable but full respirations at a
rate of of 6-12 breaths.min
> Used for cervical dilatation: 0 and 3 cm

LEVEL 2: lighter and more rapid breathing, rib cage expands but be so light
that the diaphragm barely moves
➢rate: up to 40 breaths/min
➢Cervical dilatation : 4 and 6 cm

LEVEL 3: more shallow and more rapid breathing

➢rate:50 to 70 breaths/min
➢Respirations are faster but exhalation must be a little stronger to allow
good air exchange and to prevent hypoventilation
➢Woman should say “out” with each exhalation
➢Cervical dilatation:7 and 10 cm
Level 4: effective for transition contractions
>“PANT BLOW” pattern , or taking three or four quick breaths
(in and out) then a force full exhalation
>Sounds like a train sound: breath-breath-breath-huff, and
sometimes referred to as “choo-choo” or “hee-hee-hee-hoo”
breathing
Level 5: continuous, very shallow panting at about 60
breaths/minute
> Can be used for very strong contractions or during the second
stage of labor to prevent the woman from pushing before full
dilatation
Comfort and Nonpharmacologic Pain Relief Measures
1.Doula
> A woman who is experienced in childbirth and postpartum support
> Provides physical, emotional and informational support prenatally,
during labor and birth and even at home in the postnatal period
2. Relaxation
3.Focusing and imagery
4. Breathing Techniques
6. Herbal Preparations
7. Aromatherapy and essential oils
8. Heat or Cold Application
➢ Heat and cold can help some women during labor.
➢ Heat can help the muscles relax, and both heat and cold can
act as a nerve distractor because it provides a new
sensation, which can reduce the perception of pain.
9. Bathing or Hydrotherapy
➢is immersion in warm water during labor.
➢It can be used during any part of labor, including early labor
and active labor, as well as the late (“pushing”) phase.
➢Hydrotherapy is offered as a comfort measure, providing
relaxation and pain relief.
10. Therapeutic Touch and Massage
➢Studies have shown that massage therapy performed during
labor can significantly reduce pain.
Benefits:
a.Releases Endorphins.
➢Pregnancy massage stimulates the body’s release of
endorphins, which are chemicals produced by the pituitary
gland.
➢These act as a natural painkillers and provide welcome relief
from labor pain, stimulating a positive outlook on the whole
experience.
b. Regulates Hormones
➢Another of the benefits of pregnancy massage is that it
produces and regulates neurohormones that make the labor
experience less painful.
➢Scientific evidence backs up the claims that it raises the levels
of happy-brain chemicals while lowering stress-producing
chemicals.
3. Relaxes Muscles
➢Labour raises anxiety levels. Even people who have never, or
will never, experience labor, have some fear or anxiety
surrounding it.
➢So naturally, when you are actually going through it, you are
going to feel all kinds of emotions. Labor is very much the
rollercoaster woman describe it as being.
d.Decreases the need for medical intervention
➢Research has shown that mothers who go through massage therapy
are less likely to require medicinal in the course of labor because
massage triggers the natural body processes required for a smooth
childbirth experience.
➢When conducted by an experienced therapist, this type of massage
stimulates contractions. That reduces the need an epidural or any other
drug associated with labor induction.

11. Yoga and Meditation

> can improve the outcomes of pregnancy and childbirth. They
can be used as part of the care protocol along with childbirth
preparation classes to reduce the complications of pregnancy
and childbirth.
12. Reflexology
➢Reflexology techniques to stimulate the uterus and ovary reflexes
as well the production of Oxytocin to help bring on labor naturally.
13. Hypnosis
> Hypnobirthing is a birthing method that uses self-hypnosis
and relaxation techniques to help a woman feel physically,
mentally and spiritually prepared and reduce her awareness of
fear, anxiety and pain during childbirth.
II. TWO PHASES INVOLVED
1.Placental separation
2.Placental expulsion
SIGNS OF PLACENTAL SEPARATION
> Placing a clamp on the cord near the perineum makes it easier
to appreciate this lengthening
1.Lengthening of the umbilical cord
2.Sudden gush of blood from the vagina
3.Placenta is visible at the vaginal opening
4. Uterus contracts and feels firm again
PLACENTAL EXPULSION
➢ The fetal side of the placenta is shiny because of the apposed amniotic
membrane (Schultze mechanism)
➢ The maternal side of the placenta is dull and is subdivided into as
many as 35 lobes (Duncan mechanism)
 PLACENTAL EXPULSION

PUERPERIUM-KNOWN AS THE POSTPARTAL PERIOD –REFERS TO THE 6-

WEEK PERIOD AFTER CHILDBIRTH
III.PHYSIOLOGIC CHANGES OF THE POSPARTAL PERIOD
a. Reproductive System Changes/Local Changes
1.Uterus-Uterine involution
➢Immediately after birth- wt: 1,000g
➢At the end of the 1st week- wt: 500 g
➢Time involution is complte (6 weeks)- wt: 50g
➢The uterus of a breastfeeding mother may contract more quickly
because oxytocin stimulates uterine contractions
➢Consistency of the postpartal uterus- well contracted fundus feels so
firm
• If soft and boggy in the first hour after delivery-uterine atony-post
partum bleeding
Nursing Mgt:check the bladder, massage the uterus, apply cold
compress over the abdomen, Check the vital signs, administer Oxygen,
notify the physician.
2.The Cervix
➢Immediately after birth – feels soft and malleable to palpation
➢Internal and external os- open
➢End of 7 days- the external os narrowed to the size of a pencil opening,
feels firm and nongravid again
3.The vagina
➢After vaginal birth- feels soft, with few rugae,its diameter is greater than
normal
➢Hymen is permanently torn with small separate tags of tissue
➢Takes the entire postpartal period for the vagina to involute (by
contraction, as with the uterus) until it gradually returns to its
prepregnancy state
➢A woman who is breastfeeding may have delayed ovulation and may continue to
have thin-walled or fragile cells that cause slight vaginal bleeding during sexual
intercourse until about 6 weeks
➢Advice the woman to practice kegel exercise – to strengthen the tone of the vagina
4. The Perineum
➢Immediately after birth – edematous and tender due to the great amount of pressure
experienced during birth
➢Eccymosis patches from ruptures capillaries on the surface
➢Labia majora and labia minora remain atrophic and softened after birth and never
return to its prepregnancy state
➢Advice the woman non pharmacologic comfort measures:
• cold compress within 24H after birth
• warm compress after 24 H after birth
• May sit on a soft pillow or doughnut pad
• Pharmacologic pain relievers as prescribed by the doctor: acetaminophen, ibuprofen
b.Systemic Changes
1.The Hormonal System
➢Decrease in pregnancy hormone as soon as the placenta is no longer
present
*HCG and hPL-almost negligible by 24Hrs
➢By week 1 – progestin, estrogen and estradiol are all at prepregnancy
levels (estriol may take an additional week before it reaches
prepregnancy levels)
➢FSH (Follicle Stimulating Hormone)remains low fo about 12 days and
begin to rise as a new menstrual cycle is initiated
2.The Urinary System
➢During pregnancy- 2,000-3,000ml of excess fluid accumulates in the
body so extensive diaphoresis (excessive sweating) and diuresis
(excess urine production) begin almost immediately after birth to rid
the body of this fluid.
➢Daily urine output-from a normal level of 1,500 to as much as
3,000ml/day during the 2nd to 5th day after birth
➢This marked increase in urine production causes the bladder to fill
rapidly.
➢Advice:
• reassure the mother that this is normal
• Instruct the mother to continue to drink a healthy amount of fluids daily
especially if she is breastfeeding
➢There is a transient loss of tone together with the edema surrounding
the urethra due to the pressure from the fetal head as it passed on the
bladder’s underside
➢This leads to decreased woman’s ability to sense when she has to void
➢A woman who has had an epidural anesthesia can feel no sensation in
the bladder area until the anesthetic has worn off
Management:
1.Asess a woman’s abdomen frequently in the immediate postpartal
period
• Method: Palpation:
• Findings: a full bladder is is felt as a hard or firm area just above the
symphysis pubis
• Method: Percussion:place one finger flat on the woman’s abdomen over
the bladder and tap it with the middle finger of the other hand
• Findings:
• Full bladder- sounds resonant in contrast to the thudding sound of non-
fluid filled tissue
• Results:
• this pressure make a woman feel as if she has to void but unable to do
so
• Inadequate or lack of contraction
Management:
> Assist the woman to the bathroom to urinate
3.TheCirculatory System
➢Presence of reduced blood volume accumulated during pregnancy
• Causes
➢Diuresis (excess urine production) between 2nd and 5th day after birth
➢Blood loss at birth
• Normal blood loss with vaginal birth – 300-500 ml
• Cesarean delivery – 500-1,000 ml
• A 4 point decrease in hematocrit (proportion of RBC to circulating
plasma)and a 1 g decrease in hemoglobin occur per 250 ml of blood lost
• If the woman was anemic during pregnancy, she could be expected an
anemic afterwards
Management: advice woman to eat food rich in iron; administer iron prep
as prescribed
4.The Integumentary System
➢After birth – striae gravidarum still appear reddened and may be more
prominent
• White woman – will fade to a pale white over the past 3-6 mos
• Black woman—may remain slightly darker pigment
➢melasma/chloasma, linea nigra – become barely detectable by 6
weeks
➢Diastasis recti (overstretching and separation of the abdominal
musculature) – appear as slightly indented bluish streak in the
abdominal midline
Management:
• Modified sit-ups to strengthen abdominal muscles and return abdominal
support to its prepregnancy level
• Surgery may be required to correct diastasis recti
5.The Gastrointestinal System
➢Digestion and absorption begin to be active again soon after delivery
unless the woman has had a cesarean delivery
➢Hemorrhoids (distended rectal vein) that has been pushed of the rectum
during pregnancy may be present
➢Bowel sounds are active but passage of stool may be slow because of
the still-present effect of relaxin ( a hormone which softens and
lengthens the cervix and pubic –symphysis for preparation of the
infant’s birth
Management:
> Advice the woman to eat hight fiber diet and increase fluid intake
A. RETROGRESSIVE CHNAGES OF THE PUERPERIUM
➢Retrogressive - declining from a better to a worse state
1. Exhaustion
➢Experienced by the woman for the last several months of pregnancy”
difficulty sleeping
➢Working hard during labor
➢Experiencing “sleep hunger”
2.Weight Loss
➢Due to rapid diuresis and diaphoresis during the 2nd to 5th days after
birth
➢Weight loss of 5 lbs (2 to 4 kg)
➢Due to lochia flow-additional lost of 2 to 3 lb (1 kg)
➢Influenced by the woman’s nutrition, exercise and breastfeeding
3.Vital Sign Changes
a.Temperature- taken orally or tympanically (never rectally)-danger of vaginal
contamination and discomfort
➢Increased temperature- first 24H after birth due to dehydration which
occurred during labor
➢Management: advice the woman to drink adequate fluid
• If with fever-postpartal infection
• Other Causes: breasts fill with milk-happens on the 3rd or 4th day during
lactogenesis-temperature will rise for a period of hours because of the
increased vascular activity, this process is termed engorgement
• If fever lasts longer than few hours, infection maybe the reason
• Mastitis- an infection of the breast/ can interfere with lactation
Management:
1.Notify the attending physician for antibiotic and treatment
2.Advice the woman to continue breastfeeding
3.If the infant refuses, instruct the mother to pump her breasts to maintain flow
and to avoid clogged ducts), then offer the affected breast after 12-24 HRs
4.Once the mastistis is treated-infants will resume breastfeeding after 12-24Hrs
b.Pulse
➢Usually slower than usual during the postpartal period
Causes:
➢During pregnancy- the distended uterus obstructed the amount of venous
blood returning to the heart
➢After birth- to accommodate the increased blood volume returning to the
heart, stroke volume increases that leads to reducing the PR between 6-
70beats/min.
➢By the end of the first week- PR will return to normal
➢During the postpartal period- a rapid and thread pulse could be a sign of
hemorrhage
c.Blood Pressure
➢A decrease may indicate bleeding
➢An elevation above 140/90- may indicate postpartal hypertension
➢Compare the woman’s BP with her prepregnancy level rather than with
standard blood pressure ranges
Causes:
➢Oxytocin administration during the postpartal period-to achieve uterine
contraction, cause contraction of all smooth muscle, including blood vessels
• These can increase blood pressure
Management:
> Always assess the BP before administering- if Bp > 140/90mmHg, withhold the
medication and notify the attending physician-to prevent hypertension and
possible cerebrovascular accident
➢Orthostatic Hypotension- major complication during postpartal period
Cause: woman lost a considerable maount of blood with birth
➢Dizziness that occurs on standing because of the lack of adequate blood volume to
maintain nourishment of the brain cells
To assess:
• Check the woman’s BP and PR while she is lying supine
• Raise the head of the bed fully upright
• Wait for 2-3 minutes and recheck the BP and PR
• If PR is increased > 20beats/min. and BP is < 15 to 20mmHg than formerly- woman is
positive for
Management:
1.Inform the attending physician
2.Advice the woman to sit up slowly and “dangle” her legs on the side of her bed
before attempting to stand and walk
3.If with obvious dizziness, support the woman to avoid falling incident
4.Advice the woman not to attempt to walk while carrying her newborn until her
cardiovascular status adjusts to her blood loss.
B.PROGRESSIVE CHANGES OF THE PUERPERIUM
➢progressive- the building of new tissue
➢Requires good nutrition; caution women against strict dieting that would limit
cell-building ability during the first 6 weeks after childbirth
1.Lactation
➢Driven by hormones from the hypothalamus to the pituitary gland in
order to secrete the lactation hormones
➢This is identified by four phases of lactogenesis (human milk
production)
➢A retained placenta inhibit this process by causing continual circulation
of progesterone – inhibit prolactin and milk production
FOUR PHASES:
LACTOGENESIS 1 – milk synthesis
➢Begins around 16 weeks gestation as the glandular luminal cellsin the breast
begin to secreting colostrum (thin, watery prelactation secretion)
LACTOGENESIS II
➢Triggered at birth by the delivery of the placenta, when the progesterone
(prolactin is no longer inhibited) and other circulating pregnancy hormones
suddenly decrease and oxytocin sharply increases as a result of the infant
sucking.
➢Oxytocin helps the uterus to shrink to its prepregnancy size
➢Some mothers feel uterine cramps initially when breastfeedinguntil the uterus
fully involutes.
➢Often when mothers feel their “milk has come in” (engorgement)-occurs
between birthb to 5 to 10 days postpartum; termed as “transitional milk”
LACTOGENESIS III
➢occur from day 10 until weaning postpartum
➢When the “mature milk” supply is driven by the circulating lactation
hormones oxytocin and progesterone
LACTOGENESIS IV
➢Occurs after complete weaning and the breasts involute to their
prelactation state

• Breast milk forms in response to the decrease in estrogen, and

progesterone levels that follows delivery of the placenta
• This stimulates prolactin production and milk production and an increase
in prolactin and oxytocin
• Signs and symptoms: breasts become fuller, larger and firmer as blood
and lymph enter the area to contribute fluid to the formation of milk
➢Breasts distention, engorgement with feeling of heat or tenderness
➢Engorgement phase: the breast tissue appear reddened- 3rd or 4th day after
birth- primary engorgement
➢Fades when infant begins effective latching and begins transferring colostrum
followed by milk from the breasts
Factors that Influence successful Breastfeeding:
1.infant’s successful latch
2.Ability to suck
3.Transfer milk effectively
4. Lactation support
5.Milk supply
6.Emplyment
7.Personal habits
8.mother’s view about breastfeeding
3.Return of Menstrual Flow

After the delivery of the placenta production of placental estrogen and progesterone ends

Rise in production of FSH

Ovulation

Return of Normal Menstrual Cycles

> woman not breastfeeding – menstrual flow return 6-10 weeks after birth
> If breastfeeding- menstrual flow may not return for 3 or 4 months (lactational amenorrhea)
IV.Psychological Changes During the Post Partal period

Phases of the Puerperium

a.Taking-in phase
➢ 2 to 3 days postpartum
➢ Woman is dependent and largely passive
b.Taking-hold phase
> 3 days to 2 weeks
Woman initiates actions and makes her own decisions
c.Letting-go phase
> Varied time frame
> Woman redefines her new role
Maternal Concerns and Feelings in the Postpartal Period
1.Abandonment
2.Disappointment
3.Postpartal Blues
V.Discharge Planning
➢ The greatest need of a postpartal woman before discharge
from a hospital is education to prepare her to care for herself
and her newborn at home.
Areas of Concern Before Discharge
1.Rooming In – keeping the infant with the parents
• To make the woman or parents to become acquainted with
their child
• To make the parents more confident in their ability to care for
their baby
• To form a mother-child relationship
2.Sibling Visitation
➢Reduces feelings that their mother cares more about the new
baby than about them
➢To relieve some of the impact of separation
➢Help to make the baby a part of the family
➢Check if siblings are free of contagious diseases
➢Have them wash their hands
➢ Areas of concern:
1.How to bathe and breastfeed the baby
2.Care for the infant’s cord and circumcision
3.A review of how much infant’s sleep during 24 hours
4.Inform a woman that she must return to her physician for an
examination 4-6 weeks after birth; take the baby to the primary
care provider for an examination within the first 3 to 5 days
post partum
5.Maternal Immunizations
➢ Centers for Disease Control and Prevention (CDG) recommend that
each pregnant woman receive a Tdap and seasonal influenza vaccine
with each pregnancy.
• Tdap – Tetanus, Diptheria & Pertussis
➢ Check if this was given prenatally to the women, if not, inform her
physician and if applicable to be given prior to discharge
➢ Other close caregivers: partners, grandparents are also recommended
to be up to date on their Tdap and influenza vaccines
➢ If the woman does not have adequate rubella antibody titer and
anticipates further rpregnancies , she should be asked if she wants a
rubella immunization before discharge
➢ Women who are Rh negative and who have had an Rh-positive infant
will receive Rh0 (D) immunoglobulin (RhIg) or Rh antibodies to prevent
isoimmunization concerns in a future pregnancy
➢ Inform the parents that many healthcare agencies have a
community liaison person, ideally a nurse, who calls or makes a
home visit to women after discharge
• This person helps the new mother assess her own health and that of
her baby and answers questions from families who lose their
instructions or unable to interpret them after they have returned home.
➢ Making telephone calls or visiting a family 24 Hours after discharge is
another way to evaluate whether the family is able to continue self-
evaluation and infant care
6.Postpartal Examination
➢ Check up 4-6 weeks after birth (the end of the postpartal period)
Areas of Concerns: Review of Post Partum Assessment
➢ Breast: check if the woman is breasfeeding- she is free of nipple pain
or damage and has established milk supply
➢ Abdomen/Uterus: check for tone and determine that the uterus
involution is complete and the uterus is no longer palpable abdominally
➢ Returning to work or school
➢ Internal Examination-to be certain involution is complete and any
lacerations sustained during birth have healed