1. Nursing Management of Pain During Labor and Birth
Chapter 7
Nursing Management of Pain
During Labor and Birth
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2. 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.
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3. 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.
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4. 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.
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5. 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.
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6. 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?
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7. 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
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8. 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
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9. 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
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10. 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.
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11. 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?
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12. 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.
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13. 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
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14. 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.
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15. 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
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16. 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
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17. 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
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18. 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
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19. 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.
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20. 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.
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21. 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?
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22. 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.
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23. 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.
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24. Difference Between Analgesic and Anesthetic (p. 167)
Analgesic blocks pain
Anesthetic blocks both pain and motor responses
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25. 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.
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26. Epidural and Spinal Anesthesia (p. 167)
Most common side effects are maternal hypotension and urinary retention.
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27. 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.
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28. 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
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29. 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.
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30. 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.
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