THE COMFORT AND PAIN RELIEF NEEDS
ANTEPARTUM, INTRAPARTUM, & POSTPARTUM PATIENT
Pregnancy and Pain
One of the miracles of nature is Pregnancy. Two cells that cannot be seen by the naked eye join and create a human being that walks, talks, thinks, loves, and lives. For women this stage of their life is a time of happiness and sometimes of concern. They realize that now they are in charge of their lives and the life of a new individual. While most pregnancies run a normal smooth course, some others can become high risk pregnancies. Mothers become aware of the many changes occurring in their bodies and with those changes come discomfort, pains, and concerns. Mothers need to understand is what is normal, what is not normal, which warning signs they should look for, and when to pay attention and contact a healthcare provider. The purpose of this paper is to explore some of the signs and symptoms that can be experienced during the antepartum, intrapartum, and postpartum periods of pregnancy, and explore pain relieving measures and techniques.
Antepartum, Intrapartum, Postpartum
Pregnancy is considered a 280 day process or 40 weeks from conception to delivery. However, it is more than that, it is also divided in many periods and stages which it covers more than the time of gestation. For example a pregnancy can be observed in four periods, the period before conceiving or getting pregnant – getting ready for pregnancy - a stage that not every woman plans for. After conception/fertilization there is the Antepartum period or prenatal period – normally termed pregnancy- or the time when the fetus develops and grows inside a woman’s uterus. This is the 40 weeks time period. The Intrapartum period or the time when the baby is born is also referred to as labor and delivery. This period can last from 1 hour to several days. And the last period, the Postpartum period after the birth of the baby, it is the time when a woman’s body returns to its pre-pregnant stage and it can last approximately six weeks. (Wikipedia)
Each period can also be observed and divided into stages. The prenatal period can be observed and divided into trimesters, or weeks of gestation. The intrapartum can be divided into stages of labor that indicates how the birth and delivery are progressing. The Postpartum period can be seen as weeks when the woman’s body and the hormones return to a pre-pregnancy state.
During all these periods and stages the woman can feel many discomforts as her body changes, the hormones change, there is an increase in blood volume, and as the fetus grows inside her. Just like the periods or stages of pregnancy are different, so are the symptoms of discomfort and pains a woman can experience. Every pregnancy is different and the events and discomfort are also different, even for women that have had more than one child. That is why it is so important for women to plan pregnancies, and once pregnant to follow a routine and care by a professional healthcare provider.
The recommended visits with a healthcare provider for a pregnant woman are: one visit to the healthcare provider every four weeks up to 28 weeks of gestation, then every two weeks up to 36 weeks of gestation and finally every week up till delivery. Following such schedule the woman has an opportunity to discuss with the healthcare provider any signs or symptoms of discomfort or pain and pain relieving methods as needed. While most pregnancies are considered normal, the woman also needs to know which warning signs she should look out for and which of these symptoms require an immediate phone call to the doctor or healthcare provider. For a woman following the healthcare provider’s advice and following a pregnancy routine, this can be a time of joy, happiness, and less stress. Let’s explore some areas that can cause pain in each period of pregnancy.
The Antenatal/Antepartum Period
While the antenatal or prenatal period can be considered a 280 day process or 40 weeks from conception to delivery, sometimes it can be up to 42 weeks and many count the time as months – 9 months. It is also divided into trimesters and weeks of gestation. Each trimester is composed of approximately 12-14 weeks. During that time there are many body changes and many opportunities to feel discomfort and pain.
There are discomforts that are normal changes of pregnancy, and there are discomforts and pains that require immediate intervention by a healthcare provider as they can be dangerous and risk the fetus life and/or the mother’s life. While women would want to be pain or discomfort free it is important to mention that no drug can be considered 100% safe to use during pregnancy. Healthcare providers and pregnant women will need to weigh the risks of taking any medications during pregnancy. Because many pains and discomforts can occur during the pregnancy, women will experience many different complaints along the way. This paper will only discuss a few such as breast tenderness, constipation, leg cramps, and hemorrhoids.
Breast tenderness occurs early in pregnancy, the breasts feel sore and swollen in the first weeks of pregnancy. It is due to body changes and hormonal changes. This tenderness tends to ease up relatively quickly.
Constipation can be very uncomfortable and even painful. It is caused by high levels of progesterone that cause the muscles of the intestine to get a little sluggish. Also the bowel mobility can be hindered as the baby grows, because the internal organs get displaced. This could be remedied with and increase in water intake, increase in fiber, and increase in exercise. Walking is one of the best exercises for pregnant women.
Along with the constipation, hemorrhoids can become very uncomfortable. These occur because the pressure from the baby’s head and body can cause the veins of the rectum to swell. The healthcare provider can prescribe an ointment to be applied to the hemorrhoids. Also the use of ice packs can relieve some pain. It is recommended to prevent from straining when having a bowel movement, not sitting for long periods on hard surfaces, and no standing for long periods of time. This discomfort can be more uncomfortable later in the pregnancy and can continue through the postpartum period (Douglas, 2012).
Hip pain and sciatica pain can become common during the second and third trimester of pregnancy. This pain is usually caused by the baby’s head resting on the sciatic nerve in the lower part of the spinal canal. The discomfort could be noticed as pain, numbness, and/or tingling that starts in the buttocks and radiates down the back of the legs. Usually this pain can be relieved by the baby shifting position. Some mothers would kneel on the bed with hands and knees on the bed, facing down, to allow the baby to move from the areas of pressure. Also sleeping on the side, preferably the left side is recommended. This pain is usually not a cause for concern but it should be communicated to the healthcare provider. For some women generalized hip pain can occur, due to the hormonal changes and the softening and shifting of the pelvic bones and the pressure of the fetus/ uterus. Sleeping on the side with pillows between the legs is also recommended, or using a heating pad or sitting in a warm (not hot) bath (Parents, 2001).
Another source of pain is contractions. From the early contractions called Braxton Hicks contractions to the actual labor and delivery contractions that change the cervix and prepare the body for delivery can be uncomfortable. Braxton Hicks contractions are irregular contractions that occur throughout the pregnancy. It is like an athlete getting ready for competition, the body prepares for the main event of labor and delivery by continuously having minor irregular contractions. These contractions can be uncomfortable and sometimes painful, but there is not much you can do about them. It is recommended to do breathing exercises, drink plenty of water and get some rest. (Douglas, 2012)
Mothers are sometimes concerned about certain pains such as abdominal pain and pains associated with Pregnancy Induced Hypertension (PIH). Some abdominal pains may indicate issues with the pregnancy such as a urinary tract infection (UTI), or issues with the placenta. The best recommendation is to discuss these with the healthcare provider to rule out issues. After the 24 week period, there is a chance for PIH in some women. Some of the signs and symptoms that need to be reported are severe headache that feels like a tight band around the forehead, changes in vision, blurry vision and spots in front of the eyes, epigastric pain with nausea and vomiting. These symptoms require the immediate intervention of a healthcare provider and close monitoring of the pregnancy. Pain relief measures can be given by the healthcare provider. With close monitoring by the healthcare provider a decision about when to deliver the baby can be made. The only cure for PIH is delivery. (Oster, p. 192).
Because the antepartum period lasts 40 weeks, the woman can feel many pains and discomforts. What is really important is that she is followed closely by a qualified healthcare professional that will reassure her of normal symptoms of pregnancy changes and those that she must report, such as sharp pains or pain when urinating.
Medication during Pregnancy
The rule of thumb is: No medication is 100% safe to use during pregnancy (Nihira, 2012). While there are some times when the woman might need to take some pain medication, it is best to ask the healthcare provider first as there are some over-the-counter (OTC) mediations, herbs, and home remedies that can be considered dangerous for pregnancy. “The FDA splits the drugs pregnant women might take into five categories: A, B, C, D, and X. Category A drugs are the safest, and Category X drugs are the most dangerous. Category A, B, and C are all drugs for which there is no strong evidence of harm to human babies” (Oster, p.167). The pregnant woman needs to consult with her healthcare provider what medications are OK to take and what meds she needs to find alternatives for. It is also very important for the pregnant woman to tell the healthcare provider what alternative medicines or supplements she takes, even if it says “natural” is not necessarily safe. “Generally, you should not take any OTC medication while pregnant unless it is necessary” (Nihira, 2012).
Here are some medications that have no known harmful effects during pregnancy when they are taken according to the labeled instructions, for example: Benadryl, Claritin, Colace, Metamucil, Neosorpin, Bacitracin, Caladryl, and Tylenol. However, care must be taken if in the first trimester of pregnancy. Prenatal vitamins and folic acid are safe and important to take during pregnancy. Other alternative measures can be used after discussing it with the healthcare provider such as chiropractic manipulation, acupressure and acupuncture, exercise and hypnosis (Nihira, 2012).
The Intrapartum Period
The intrapartum period could be considered the most painful period, as this is the time when the uterine contractions are effective in opening the cervix to allow the birth of the baby. A baby is considered full term and ready to be born after 37 weeks of gestation, when all the vital body organs are ready to function on their own. Most babies will turn and present “head down” for the birth. In some cases, the baby will be in a breech presentation and will need to be assisted to turn. Other possible painful conditions would be sharp abdominal pain, and/or a rigid uterus with or without vaginal bleeding. These conditions will need to be evaluated right away as they can signal compilations and possible danger for the baby and the mother. Other sources of pain can be caused by complications, episiotomies and cesarean sections.
The intrapartum period is divided into three stages. Labor and Delivery can vary from woman to woman, as well as her tolerance for pain, but she will go through the three stages of labor for a vaginal delivery. Stage one is when labor starts, the contractions are effective to change the cervix and allow for the baby to be born. Usually the phases of the first stage are measured by the opening of the cervix. The cervix will dialate from one to ten centimeters and this phase can take up to 20 hours, more or less. The second stage is considered from full dilatation to the delivery of the baby. This could take up to two hours. The third stage is the delivery of the placenta and it could take 30 minutes. At any time before or during the labor, a decision can be made to do a cesarean section for the safety of the baby or the mother (Bosh, 2012).
According to Dr. Nihira, for pain relief during labor, epidurals are the most effective treatment, but immersion in a warm bath can also relieve tension. Relaxation and breathing techniques, emotional support, self-hypnosis, and acupuncture are widely used in labor and can also work for some women. The most common preparation for labor is the Lamaze class method, using the relaxation and breathing techniques learned in these classes to cope with the discomfort. The epidurals are usually administered once the cervix reaches five centimeters and the labor is well established. Other forms of analgesia are Spinal anesthesia, General anesthesia (rarely used now) and Local anesthesia (Nihira, 2012).
The Postpartum Period
According to Wikipedia, the postpartum period “is the time after birth, a time in which the mother's body, including hormone levels and uterus size, returns to a non-pregnant state”. During this period of time the woman can experience different types of pain.
If the woman had a cesarean section, it is considered major abdominal surgery and incision pain should be expected. Analgesics will be prescribed for relief of pain. It is important to know that most medications will be passed through the breast milk; therefore, the mother needs to consult with her healthcare provider before taking medications that can affect the baby.
If the mother is breastfeeding, it is not uncommon to have sore breasts for the first 3-4 days until the milk flows freely, referred to as engorgement. Sometimes there can be breast infections from blocked tubules. If there is an infection, the breast could be red and sore, called mastitis and antibiotics will be prescribed and analgesics if needed. Also warm compresses and pumping out the milk from that breast will be suggested for pain relief. From breastfeeding, sore nipples are common as the mother and baby adjust to the breastfeeding. It is recommended that the mother changes positions when breastfeeding and use warm moist towels for the breasts and allow them to air dry after breastfeeding.
Abdominal pains are normal and could be uncomfortable as the uterus returns back to its normal state. The afterpains or postpartum contractions are also often felt during breastfeeding as the body produces oxytocin that allows the uterus to contract. The healthcare provider could recommend analgesics (Eisenberg, et al. pp383 – 430).
Plan of Care for the Intrapartum Period
The best plan for the Intrapartum period starts when the woman plans to get pregnant or finds out that she is pregnant. Routine visits to the healthcare provider are extremely important. Throughout the pregnancy she will have many questions and will also get many answers from well wishing parents, friends, and family. It can be a confusing time and one of concern and stress. The healthcare provider will be her advocate and should be her source of safe and foundational advice.
Currently there are many resources for the mother-to-be to prepare her for the intrapartum period. Hospitals and Clinics offer a variety of classes, from Lamaze training, Breathing and Relaxation Exercises, Cesarean Section classes, Preparing for Baby Delivery classes, and so much more. There are also many books and videos on the market that address this period. One of the series of books that has become almost like a bible for pregnant women is the “What to Expect When You’re Expecting” and “What to Expect the First Year” by Eisenberg, Hathaway, & Murkoff. These books have been written and reviewed by healthcare providers and offer good information for the mother to be. What is important is that the woman discusses the information with her healthcare provider and validates the information obtained from friends, family, books, videos, the internet and social media.
As a nurse, it is important to encourage the woman to seek medical treatment, medical advice, and to prepare for this stage with classes, written information, and sound advice. Most of the books or classes will tell her or show measures to help her alleviate the pain and discomfort during the intrapartum period: positions, use of warm compresses, walking, balls, use of warm baths or showers as allowed, breathing exercises and relaxation exercises, and the use of hypnosis, acupuncture and acupressure. It is very important for the woman to receive emotional and physical support from the father of the baby, family and/or relatives. The nurse’s role is both a supportive one and an educational one.
This paper attempted to explore some of the signs and symptoms and pain that can be experienced during the antepartum, intrapartum, and postpartum periods of pregnancy, and pain relieving measures and techniques. It is a very large topic. There are so many reasons why a pregnant woman would experience pain during her pregnancy, her delivery, and her postpartum recuperation periods. There are entire books written and dedicated to each period, to each complication, to each stage. This paper serves as an overview and introduction.
Pregnancy for a woman should be a time of happiness and preparation for the baby and the changes in her life. Pregnancy is considered a major event in a woman’s life and as such it should be one of joy. During this time the woman will experience many physical and emotional changes and it is important for her to follow a good medical routine treatment, good nutrition, and to educate herself on what to do safely to control pain and discomfort.
Bosh, M. (2012). Antepartum, Intrqpartum, Postpartum Care. Quizlet. http://quizlet.com/15433494/antepartum-intrapartum-postpartum-care-flash-cards/ (Accessed March 2014)
Douglas, A. (2012).Top 10 pregnancy-related aches and pains. Canadian Living Moms. http://www.canadianliving.com/moms/pregnancy/top_10_pregnancy_related_aches_and_pain s.php [Accessed March 2014)
Editors of Parents Magazine. (2001). Pregnancy Symptoms & Complaints: Sciatica and Hip Pain.
[Accessed March 2014)
Eisenberg, A., Hathaway, S, & Murkoff, H. (2002, 3rd Ed.) What to Expect When You’re Expecting. Workman Publishing. New York.
Eisenberg, A., Hathaway, S, & Murkoff, H. (2003) What to Expect The First Year. Workman Publishing. New York
Leverly, A. D. (2013). A Good Birth – Finding the Positive and Profound in Your Childbirth Experience. The Penguin Press, New York.
Nihira, MD, M. A (2012) Taking Medicine During Pregnancy. WebMD A Review July 6, 2012. http://www.webmd.com/baby/guide/taking-medicine-during-pregnancy (Accessed March 2014)
Office on Women’s Health. (2010). Stages of Pregnancy. WomensHealth.gov http://www.womenshealth.gov/pregnancy/you-are-pregnant/stages-of-pregnancy.html (Accessed March 2014)
Oster, Emily. (2013). Expecting Better. The Penguin Press. New York
Stöppler, MD, M. C. Pregnancy Week by Week (First, Second, and Third Trimester). MedicineNet.com A review March 14, 2014 http://www.medicinenet.com/pregnancy/article.htm [Accessed March 2014)
Wikipedia. Post Partum Period. http://en.wikipedia.org/wiki/Postpartum_period [Accessed March 2014)