Nursing Management of Pain During Labor and Birth Chapter 7 Nursing Management of Pain During Labor and Birth Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Education for Childbearing (p. 157) Gestational diabetes mellitus Early pregnancy Exercise for pregnant women Infant care Breastfeeding Sibling Grandparent Adolescent childbirth Ideally, educational preparation for childbirth begins prior to conception Discuss content for each of the classes. Review the period in the pregnancy in which each of the classes should be taken. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Variations of Basic Childbirth Preparation Classes (p. 158) Refresher – review material from a previous pregnancy Cesarean birth - anticipated Vaginal birth after cesarean – mother may be more anxious depending on the reason for the Csection Adolescent – separate from adult classes. Can support each other, may be held in a school setting with expectant fathers Review Health Promotion, Types of Prenatal Classes on p. 158. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Content of Childbirth Preparation Classes (p. 158) Changes of pregnancy Fetal development Prenatal care Hazardous substances to avoid Nutrition Common discomforts Work, benefits of exercise Coping with labor and delivery Discuss the availability and cost of prenatal classes in your community. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Childbirth and Pain (p. 159) How childbirth pain differs from other pain Part of a normal birth process Woman has several months to prepare for pain management Is self-limiting and rapidly declines after birth Nurses must remember that each patient’s pain is individualized. Discuss different perspectives concerning the pain and discomfort associated with labor and delivery. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Factors that Influence Labor Pain (p. 159) Pain threshold – least amount of sensation that a person perceives as painful Pain tolerance – the amount of pain one is willing to endure Nursing responsibility to modify as many factors as possible so that the woman can tolerate the pain of labor Identify sources of pain during labor. What maternal factors can contribute to a painful labor and delivery experience? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Factors that Influence Labor Pain (p. 159) Sources of pain during labor Central nervous system factors Gate control theory – impulses to the brain Endorphins – natural body substance similar to morphine Maternal conditions Cervical readiness – how it responds to contractions Pelvis – size and shape Labor intensity – if fast, woman cannot recover from one contraction to another Fatigue – reduces pain tolerance and ability to cope Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Factors that Influence Labor Pain (p. 159) Fetal presentation and position – the fetal presenting part causes effacement and dilation along with uterine contractions. The fetus in an abnormal presentation or position applies uneven pressure to the cervix. This results in less effective effacement and dilation. Will prolong the labor and delivery Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Factors that Influence Labor Pain (p. 159) Interventions of caregivers IV lines Continuous fetal monitoring, especially if it hampers mobility Amniotomy Vaginal examinations or other interruptions Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nonpharmacological Pain Management (p. 161) Advantages Nonpharmacological methods do not harm the mother or fetus They do not slow labor if they provide adequate pain control They carry no risk for allergy or adverse drug effects Nonpharmacological methods of pain management can be used alone for a woman desiring a labor experience without medication or in conjunction with pharmacological methods. Identify the best means to prepare the woman and her partner for the use of nonpharmacological methods of pain management. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Methods of Childbirth Preparation (p. 161) Dick-Read method – fear causes pain Bradley method – father coaches during labor Lamaze method – respond to contractions with relaxation rather than tension The Dick-Read method incorporates the concepts of fear, tension, and pain. The Bradley method emphasizes slow abdominal breathing and relaxation techniques. The Lamaze method uses mental conditioning and breathing techniques to occupy the patient’s mind. Who might be best suited for each of these methods? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nonpharmacological Pain Relief Measures (p. 162) Relaxation techniques Skin stimulation Effleurage Sacral pressure Thermal stimulation Positioning Diversion and distraction Breathing A combination of nonpharmacological relief measures can be utilized by any single patient. Discuss and demonstrate these methods. Ask for class input concerning methods they have used or have seen in the clinical setting. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Question 1 A woman is in the first stage of labor. She reports that she is experiencing moderate back discomfort with every contraction. The best nonpharmacological intervention you can encourage is: diversion. sacral pressure. effleurage. thermal stimulation. Answer: 2 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Breathing (p. 163) First stage of labor – till cervix 10cm dilation Slow-paced – half usual rate of breathing Modified-paced – twice usual rate of breathing Patterned-paced Constant pattern Stairstep pattern Second stage Used when pushing- cleansing breath, deep breath, push down while counting to 10 – open glottis Breathing techniques are most effective when the woman has had the techniques reviewed prior to the onset of labor. Review the timing of implementing breathing techniques. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

How to Recognize and Correct Hyperventilation (p. 164) Signs and symptoms Dizziness Tingling of hands and feet Cramps and muscle spasms of hands Numbness around nose and mouth Blurring of vision Corrective measures Breathe slowly, especially when exhaling Breathe into cupped hands Place a moist washcloth over the mouth and nose while breathing Hold breath for a few seconds before exhaling Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Question 2 A laboring woman reports that she is “dizzy” and experiencing “tingling” in her hands and around her mouth and nose. You recognize that these symptoms are most likely related to: hyperventilation. stroke. anxiety. medication side effect. Answer: 1 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

The Nurse’s Role In Nonpharmacological Techniques (p. 164) Determine if attended childbirth preparation classes Aids in developing appropriate nursing care plan Identify signs of tension Aids in determining appropriate relaxation techniques Minimize environmental irritants Keeping her clean and dry helps her to relax and focus Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Pharmacological Pain Management (p. 164) Analgesics Systemic – affecting the entire body Adjunctive drugs to improve effectiveness or counteract side effects – Phenergan – reduce anxiety and nausea (see Table 7-1 pg 165) Anesthetics Regional: loss of sensation localized General: loss of consciousness and sensation Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Physiology of Relationship of Pregnancy to Analgesia and Anesthesia (p Pregnant woman at higher risk for hypoxia Sluggish GI tract can result in increased risk of vomiting and aspiration Aortocaval compression increases risk of hypotension and shock Effect on fetus must be considered A unique relationship exists between pregnancy and the use of pharmacological pain management techniques. Review the underlying physiological factors that are responsible for these physiological changes. The pregnant woman has an increased risk for hypoxia. Reduced GI activity can promote nausea and vomiting. There is an increased incidence of hypotension and the onset of shock. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Pharmacological Methods (p. 164) Advantages Using medications during labor allows the mother to be more comfortable and relaxed. Increased relaxation will aid in her ability to work through contractions. Lessens “stress response” which, if not controlled, could lead to fetal acidosis. Review misconceptions that exist concerning the use of medications in labor. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Pharmacological Methods (cont.) (p. 164) Limitations Important factor to consider—two people are being medicated, mother and fetus Any medication used must be considered for its potential impact on the condition of the fetus Can slow labor if given too early What is the relationship of timing of medication administration to the stage of the woman’s labor? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Analgesics and Adjunctive Drugs (p. 165) Narcotic (opioid) analgesics Avoid if birth anticipated within 1 hour Narcotic antagonist: reverses respiratory depression - Narcan Adjunctive drugs: relieves nausea/vomiting – Phenergan Two persons are medicated- mother and fetus Narcotics are used most frequently. What are two commonly used narcotics? Name a narcotic antagonist. Adjunctive drugs enhance the actions of analgesics and reduce nausea. Name an adjunctive medication used for the laboring patient. What can cause withdrawal syndrome in the mother or neonate? Naloxone (Narcan) in the narcotic drug-dependent woman/fetus. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Regional Analgesics and Anesthetics (p. 166) Regional anesthesia usually involves placement of anesthetic in epidural or subarachnoid space The meninges around the spinal cord Dura mater Arachnoid mater Pia mater Regional analgesia is the administration of an anesthetic in the epidural or subarachnoid space. Compare and contrast analgesics and anesthetics. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Difference Between Analgesic and Anesthetic (p. 167) Analgesic blocks pain Anesthetic blocks both pain and motor responses Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Types of Anesthesia for Childbirth (p. 166) Anesthetic method Local infiltration – for episiotomy Pudendal block – see figure 7-6 Epidural block – catheter placed inject with local anesthetic agent Subarachnoid (spinal) block – quick action General anesthesia – Rare – may be used for an emergency Csection Review nursing implications for the various types of anesthesia. Pudendal block provides adequate anesthesia for an episiotomy and most low forceps births. It does not block pain from contractions. Could cause vaginal hematoma If woman has abnormal blood clotting, infection in the area of the injection site or hypovolemia, an epidural block cannot be administered. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Epidural and Spinal Anesthesia (p. 167) Most common side effects are maternal hypotension and urinary retention. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Epidural Blood Patch (p. 169) Postspinal headache from subarachnoid block… treatment When a spinal headache results, the anesthesiologist or CRNA can perform a blood patch. Review the technique used for the epidural blood patch. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

General Anesthesia (p. 169) May be necessary in the following circumstances: Emergency cesarean birth: not enough time to establish a block Cesarean birth in woman who refuses or has a contraindication to block Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

General Anesthesia (cont.) (p. 169) Adverse effects in the mother Regurgitation with aspiration of gastric contents Can result in chemical injury to lungs Adverse effects in the neonate Respiratory depression Aggressive resuscitation may be necessary General anesthesia is seldom used for vaginal deliveries or cesarean births. Discuss instances in which general anesthesia might be used. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Pharmacological Techniques (p. 169) The nurse’s role Begins at admission Woman’s preference for pain relief Keep side rails up Provide education regarding procedures and expected effects Observe for hypotension and respiratory depression Document interventions and assessments Discuss additional interventions the nurse should undertake when a laboring woman has received anesthesia or analgesics. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.