Nursing Management of Pain During Labor and Birth Chapter 7 Nursing Management of Pain During Labor and Birth

Objectives List the common types of classes offered to childbearing families. Describe factors that influence a woman’s comfort during labor. Describe the methods of childbirth preparation. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Objectives (cont.) Discuss the advantages and limitations of nonpharmacological methods of pain management during labor. Explain nonpharmacological methods of pain management for labor, including the nursing role for each. Discuss the advantages and limitations of pharmacological methods of pain management. Explain each type of pharmacological pain management including the nursing role for each. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Education for Childbearing Ideally, educational preparation for childbirth begins prior to conception Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Types of Classes Available Gestational diabetes mellitus Early pregnancy Exercise for pregnant women Infant care Breastfeeding Sibling Grandparent Adolescent childbirth 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 © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Variations of Basic Childbirth Preparation Classes Refresher Cesarean birth Vaginal birth after cesarean Adolescent Review Health Promotion, Types of Prenatal Classes on page 157. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Content of Childbirth Preparation Classes 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 © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Childbirth and Pain 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 © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Factors that Influence Labor Pain Pain threshold Sources of pain during labor Central nervous system factors Gate control theory Endorphins Maternal conditions Cervical readiness Pelvis Labor intensity Fatigue Fetal presentation and position Identify sources of pain during labor. What maternal factors can contribute to a painful labor and delivery experience? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nonpharmacological Pain Management 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 © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Methods of Childbirth Preparation Dick-Read method Bradley method Lamaze method 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 © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Selected Nonpharmacological Pain Relief Measures 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 seen in the clinical setting. Audience Response Question #1 A woman is in the first stage of labor. She reports that her she is experiencing moderate back discomfort with every contraction. The best nonpharmacological intervention you can encourage is: 1. Diversion 2. Sacral pressure 3. Effleurage 4. Thermal stimulation Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Skin Stimulation Skin stimulation evokes nerve fiber responses that are able to reduce or inhibit painful sensations. Why should a patient be instructed to alternate methods of skin stimulation? Skin stimulation, if repeated in the same site over time, will become less effective. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Breathing First stage Second stage Slow-paced Modified-paced Patterned-paced Constant pattern Stairstep pattern Second stage Used when pushing 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 © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Breathing Patterns As a class, review the patterns listed on the slide. Include the timing and use of each of the techniques. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

How to Recognize and Correct Hyperventilation 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 Audience Response 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: 1. hyperventilation. 2. stroke. 3. anxiety. 4. medication side effect. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nursing Tip If a woman is successfully using a safe, nonpharmacological pain control technique, do not interfere Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Pharmacological Pain Management Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Relationship of Pregnancy to Analgesia and Anesthesia 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. 1. The pregnant woman has an increased risk for hypoxia. 2. Reduced GI activity can promote nausea and vomiting. 3. There is an increased incidence of hypotension and the onset of shock. Review the underlying physiological factors which are responsible for these physiological changes. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Pharmacological Methods Advantages Using medications during labor allows the mother to be more comfortable and relaxed. Increased relaxation will aid in her ability to participate in her care. Review misconceptions that exist concerning the use of medications in labor. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Pharmacological Methods (cont.) Limitations Any medication used must be considered for its potential impact on the condition of the fetus. What is the relationship of timing of medication administration to the stage of the woman’s labor? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Analgesics and Adjunctive Drugs Narcotic (opioid) analgesics Avoid if birth anticipated within 1 hour Narcotic antagonist Adjunctive drugs Narcotics are used most frequently. What are two commonly used narcotics? Narcotic antagonists are used to reverse the respiratory depression associated with opioid use. Name a narcotic antagonist. Adjunctive drugs enhance the actions of analgesics and reduce nausea. Name an adjunctive medication used for the laboring patient. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Regional Analgesics and Anesthetics 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 © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Types of Anesthesia for Childbirth Anesthetic method Local infiltration Pudendal block Epidural block Subarachnoid (spinal) block General anesthesia Review nursing implications for the various types of anesthesia. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Epidural and Spinal Anesthesia Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Epidural Blood Patch 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 © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

General Anesthesia 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 © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Pharmacological Techniques 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 Discuss additional interventions the nurse should undertake when a laboring woman has received anesthesia or analgesics. Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Question for Review What is the most important nursing responsibility after an epidural or spinal block analgesia during labor and delivery? Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Review Objectives Key Terms Key Points Online Resources Critical Thinking Questions Review Questions Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.