Chapter 7: The Nurse’s Role in Pharmacological Technique: Keep bed rails up, maintaining close observation and having naloxone (NARCAN) ready to reverse respiratory depression Observe for hypotension and respiratory depression The Woman needing Pain Management during Labor: If woman has signs of hyperventilation (dizziness, numbness, or tingling sensations, spasms of hands and feet), have her breathe into her cupped hands, a small bag or a washcloth placed over her mouth Occurs when breathing rapidly, because of exhaling too much carbon dioxide, these measures help conserve carbon dioxide Adverse Effects of Epidural Block: Maternal hypotension & urinary retention Fetal heart rate & blood pressure should be monitored and documented every 5 mins for 15 mins then 30 mins for 1 hr A full bladder can delay birth & cause hemorrhage after birth SA: Epidural block is administered when dilated 4cm Adverse Effects of Subarachnoid Block: Maternal hypotension & urinary retention Postspinal headache may occur bcs of spinal fluid loss May be advised to remain flat for several hours to decrease pain Blood patch: 10-15 ml of blood from vein and injected in epidural area of subarachnoid puncture may provide dramatic relief from postspinal headache Blood clots forms a gelatinous seal that stops spinal fluid leakage Limitations of Epidural Block: Not used when woman have the following Abnormal blood clotting Infection in area of injection or systemic infection Hypovolemia (inadequate blood volume) Nonpharmacological Techniques: Effleurage: abdomen or other areas are massaged during contractions Stroking abdomen with fingertips in a circular motion (circles or figure eights) Sacral Pressure: firm pressure against lower back helps reduce some pain of back labor Positioning: upright positions favors fetal descent, hands and knee position helps reduce the pain of back labor (NO supine position) breathing techniques, diverse and distraction, relaxation techniques, & skin stimulation Walking, sex, stimulating nipples, classical music, quiet environment Non-Pharmacological Techniques (breathing): Cleansing breath: each breathing pattern begins and ends with a cleansing breathe, which is a deep inspiration and expiration similar to a deep sigh Helps woman relax and focus on relaxing Second-stage breathing: when it's time to push, woman takes a cleansing breathe and then takes another deep breath and pushes down while exhaling to a count of 10 Box 7.2 How to Recognize and Correct Hyperventilation: S&S Dizziness, tingling of hands and feet cramps and muscle spasms of hands, numbness around nose and mouth, & blurring vision Corrective measures: Breathe slowly in exhalation, breath into cupped hands, moist washcloth over mouth and nose while breathing, hold breath for a few seconds before exhaling Analgesics and Adjunctive Drugs: Opioids (narcotic analgesic): used in small doses to avoid causing fetal respiratory depression Naloxone/Narcan (narcotic antagonist): used to reverse respiratory depression Usually used in infant, caused by opioid drugs such as meperidine Opioid antagonist that acts within minutes to help resuscitate a newborn who has respiratory depression Analgesic blocks pain but anesthetic blocks pain for both pain and motor responses Adjunctive drugs: not pain relievers but given to relieve nausea and vomiting Benzodiazepines: reduces anxiety and nausea & flumazenil reduces sedation and respiratory technique Methods of Anesthesia Administration for Childbirth: Epidural Block (vaginal & c-section) : administered by physician when cervix is 4cm dilated Observe for hypotension & urinary retention General anesthesia: rarely used for vaginal births Used when womens refusal of regional block, contraindication for regional block, emergency cesarean when there is not time to establish regional block At risk for aspiration of gastric contents Subarachnoid (spinal) block: used primarily for cesarean birth, observe for hypotension & urinary retention Gate Control Theory: Stroking & massaging palm or foot rubbing, pressure or gripping a cool bed rail will stimulate nerve fibers that interfere with a transmission of pain impulses to brain Chapter 8: Terbutaline: administered subcutaneously to stop uterine contractions within minutes Betamethasone: speeding fetal lung maturation (fetal maturation) Oxytocin: increases contractions in labor Magnesium Sulfate: prevents seizures in eclampsia, protects fetus from cerebral palsy Calcium Gluconate: reverses effects of magnesium sulfate Tocolytics: drugs that reduce uterine contractions Contraindications to Inductions: Placenta previa Umbilical cord prolapse Active herpes infection externally or in the birth canal, which the infant can acquire during birth Non-Pharmacological Stimulate Contractions: Walking: stimulates contractions, if woman does not feel like walking she can sit, squat, kneel while facing the raised head of the bed for support, or maintain other upright positions Nipple: improves quality of contractions, applying suction with a breast pump & sexual intercourse Indications for Induction: Gestational hypertension Ruptured membranes without spontaneous onset of labor Infection within the uterus Placental insufficiency Oxytocin Induction or Augmentation: Induces labor Strengthens uterine contraction Controls bleeding after birth Preparations for Cesarean Birth: Laboratory studies are performed to identify anemia, blood clotting, or abnormalities Complete blood count, coagulation studies, and blood type and history screening are common and appropriate consents is obtained Mom has to be NPO only clear liquids Risk of Cesarean Birth: Risk related to anesthesia, respiratory complications, hemorrhage, blood clots, injuring to urinary tract, delayed intestinal peristalsis, & infection Speeding Fetal Lung Maturation: If it appears that preterm birth is inevitable, physician may give steroid drugs (glucocorticoids) to increase fetal lung maturity if gestation is between 24-34 weeks Betamethasone may be administered in two IM 24 hrs apart Complications of Augmentation of Labor: Fetal compromise and uterine rupture & water intoxication Safety Alert: Tachysystole is most often evidenced by contractions greater than every 2 mins; five or more contractions within 10 mins, durations longer than 90 secs; or resting intervals shorter than 60 secs. Nursing Care for Episiotomy and Laceration: Cold packs applied to perineum for at least 12 hrs to reduce pain, bruising, and edema After 12-24 hrs of cold application warmth in the form of heat packs or sitz bath which increases blood circulation, enhancing comfort & healing Contraindications for Cesarean Birth: Not performed if fetus is dead or premature to survive or if mother has abnormal blood clotting Nursing Care After Cesarean Birth: Support lower uterus with one hand, the fingers of the other hand are gently “walked” from the side of the uterus toward the midline Hypertonic Labor: may occur before 4 cm of cervical dilated Hypotonic Labor: after 4 cm of cervical dilation Woman with Hypotonic Labor: upright positions enhance fetal descent, walking strengthens labor contractions; walking when membranes are ruptured and fetal station is high could lead to umbilical cord prolapse Macrosomia: large fetus that weighs more than 4000g Chapter 9: Perineum Nursing Care: REEDA: redness, edema, ecchymosis, discharge, approximation Patient teaching: Start w ice pack/ chemical ice pack is applied for first 12-24 hours, to reduce edema, bruising, and numb perineal area & when ice melts wait 10 mins before applying another Then after 24 hrs, heat in form of chemical warm pack, a bidet, or sitz bath increases circulation and promotes healing Apply medicated ointments or sprays as directed, do not apply perineal pads for 1-2 mins (medication will be absorbed Mother is taught to do perineal care after each void or bm, its filled with warm water & squirted over perineum (front to back) or at least every 4 hrs Promote Bonding & Attachment: Bonding: a strong emotional tie that forms as soon after birth between parents and newborn Attachment: affectionate tie that occurs through time as the newborn and caregivers interact If difficulty in bonding, it should be recorded and a referral to social services should be considered Fatigue: Best time to rest is when baby is asleep Nurse should assess level of maternal fatigue, initiate relief measures, like taking care of NB for few hours Descent of Uterine Fundus: Uterus can be felt at midline, at or below the level of the umbilicus, as a firm mass (size of grapefruit) After 24 hrs it descends about 1 cm each day By 10-12 days should no longer be palpated Full bladder interferes w uterine contraction Nursing tip: If uterus is soft, massage it & expel clots so it can remain contracted, if bladder is full massage uterus until firm then address emptying bladder (control bleeding first) Nurse should assess fundus each shift & teach mother of expected changes Characteristics of Uterine Atony: If bladder is full the uterus will be higher and pushed to one side rather than midline of abdomen Massage first, then void wait 3 mins Bladder distention, overdistention of uterus, multiparity, oxytocin Assisting mothers to breastfeed: breastfeed for 15 mins then switch breast, start on opposite of the ended on (8-10x a day) Breastfeed every 2-3 hrs Pharmacology: Methylergonovine: helps stop bleeding and maintain contractions Oxytocin: given for contractions & milk production via IV after birth Rho (D) Immune Globulin: The Rh-negative mother should receive a dose of Rh0D immune globulin (RhoGAM) within 72 hrs after giving birth to a positive newborn Given to mother, not fetus Even if had an abortion Lochia: Rubra is red, lasts 3 day Serosa is pinkish, lasts 3-10 days Alba is clear and colorless and white, lasts 10 days until 21st day Screening tests (to identify abnormalities): PKU, hypothyroidism, galactosemia, sickle cell disease thalassemia, maple syrup urine disease, congenital hearing loss & blood glucose test on side of heel (to avoid nerves, blood vessels, and bony areas) Breastfeeding and Secretion of Oxytocin: From the posterior pituitary gland causes the milk to be delivered from the alveoli through duct sys to the nipple Cold applications between feedings and heat just before feedings may help reduce discomfort and engorgement Table 9h