Management of Pain During Labor

Name: Management of Pain During Labor
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Description: Management of Pain During Labor

Management of Pain During Labor
Chapter 8 Management of Pain During Labor Review chapter objectives. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Managing the Pain of Labor
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
Objectives Define key terms listed. Describe the factors that influence a woman’s comfort during labor. Explain the physical causes of pain during labor. Explain the role of endorphins in the body. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Pain Management Designing a care plan that meets the needs of a woman in labor includes Knowledge of the characteristics of pain in various stages of labor Interventions for pain relief Comfort methods Cultural responses to labor This knowledge assists in the development of a nursing plan of care Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Standards of Pain Management
The Joint Commission standards for patients and pain management include: The right to pain management Staff must competently assess and manage pain Policies should support prescription pain medication Education about pain management should be provided Exists past discharge Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

The Unique Pain of Labor
Part of a normal process Source of pain is known Woman has time to prepare for it Known to be self-limiting Ends with the birth of the baby The sensation should be referred to as a contraction rather than pain. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Factors That Influence Labor Pain

Pain Threshold Pain perception Least amount of sensation that a person perceives as painful Fairly constant Varies little under different conditions Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Pain Tolerance Amount of pain one is willing to endure Tolerance can change under different conditions Primary nursing responsibility Modify as many factors as possible so woman can safely tolerate the labor and delivery process Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Sources of Pain During Labor

Sources of Pain During Labor
Dilation and stretching of cervix Uterine contractions Pressure and pulling of pelvic structures Distention and stretching of the vagina and perineum Intensity of contractions Length of time for cervical changes to occur Size/position of fetus Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Additional Contributing Factors
Woman’s fatigue and pain tolerance Fear and anxiety Cervical readiness Interventions of caregivers Psychosocial factors Culture Refer back to Table 7-1 regarding cultural issues (pp ). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Gate Control Theory Gating mechanism occurs in spinal cord Pain sensations are transmitted from periphery of body along nerve pathways to the brain Only a limited number of sensations can travel at a time Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Distraction Distraction or focused activity can replace travel of pain sensation Gate closes and impulses are less likely to be transmitted to brain when activity fills the path When gate opens, pain impulses ascend to the brain Cutaneous stimulation such as effleurage may have a direct effect on closing the gate. The gate control theory, by using descending and ascending neural pathways, helps to explain the effectiveness of various types of focusing strategies taught in childbirth preparation classes. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Examples of Distraction
Breathing Listening to music Verbal coaching Effleurage Acupuncture External analgesics Back massage These help close the “gate” to discomfort. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Chemical Factors Neuromodulators, also called endorphins or endogenous opiates Protein chemicals found in the brain Known to relieve pain Endorphins are similar to morphinelike substances Believed to play a role in biologic response to pain How are chemical factors released in the body to aid in controlling or minimizing the sensation of pain? Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Endorphins May be produced by stress and increase the pain threshold May make the woman drowsy and sleepy What leads to more natural protection against pain? Answer: a positive attitude. How does this work? Answer: the body is able to produce its own endorphin analgesia. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Audience Response System Question 1
What type of stimulation during the labor process uses focal points to distract the woman from the pain of the contraction? Thermal Breathing Cognitive Hypnosis Answer: C. The woman’s ability to imagine something pleasant can serve as a distraction from the painful stimuli she may be experiencing. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Methods to Control Pain

Objectives Discuss three nonpharmacologic pain control strategies. Review the potential effect of sedatives and narcotics on the newborn. Explain the advantages and limitations of pharmacologic methods of pain management. Outline the nursing responsibilities related to pharmacologic and nonpharmacologic pain management during labor. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Nonpharmacologic Pain Control Strategies
General support Imagery or visualization Distraction Changes in temperature Touch Comfort measures Baths See Box 8-1 (p. 149). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Comfort Measures and Stimuli
Eliminate sources of noxious (offensive) stimuli Relieve thirst, sweating, and heat through comfort measures Repositioning Adjusting monitoring belts See Box 8-1 (p. 149). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Cognitive Stimulation
Mental stimulation Imagery Focal point Require active participation by the woman in labor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Cutaneous Stimulation
Touch Rubbing Massaging Counterpressure Rhythmic stroking of the abdomen (effleurage) Refer to Chapter 21 for CAM therapies. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Thermal Stimulation Warm bath or shower during early phase of labor Cool damp cloth to the forehead later in labor Hot or cold towels applied to the back Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Recognizing and Correcting 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 in exhalation Breathe into cupped hands Place a moist washcloth over the mouth and nose while breathing Hold breath for a few seconds before exhaling Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Hypnosis Appears to be safe, without known side effects Positive physical and psychological outcomes Woman in labor is usually trained in self-hypnosis Nurse may need to help trigger it by using specific suggestions or playing specific audiotapes Careful observation and documentation concerning labor progress are essential Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Pharmacologic Pain Control Strategies

Factors Affecting Woman’s Response
Higher risk for hypoxia Increased risk for vomiting and aspiration Increased risk of hypotension and development of shock Have class state the causes of each of these factors. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Advantages of Pharmacologic Methods
Help woman relax and work with contractions; otherwise Labor pain may cause “stress response” Results in increased autonomic activity Release of catecholamines Decrease in platelet formation Can cause maternal hyperventilation Respiratory alkalosis, then compensating metabolic acidosis Results in fetal acidosis See Box 8-2 (p. 151). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Limitations of Pharmacologic Methods
Two people are affected: mother and fetus Drug effects can be prolonged in the newborn long after delivery May slow labor’s progress if used early in labor Decision to prescribe and administer drugs must be carefully weighed due to fetal effects Fetus cannot metabolize drugs as quickly as mother Review Box 8-3 (p. 152) with the class. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Before Administration of Drugs
Baseline assessment of woman and fetus Labor should be well-established, with cervical dilation of at least 4 cm, before woman receives pain medication Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Analgesics During Labor
May reduce hormonal and stress response to pain of labor May be especially advantageous to obese or hypertensive woman Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Analgesia Can reduce gastric emptying Increasing risk of aspiration if food or fluids are in stomach Careful monitoring of vital signs and fetal heart rate is essential Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Examples of Analgesics
Meperidine (Demerol)—most common Sublimaze (Fentanyl)—rapid onset Butorphanol (Stadol) and nalbuphine (Nubain)—combination opioid agonist-antagonist Naloxone (Narcan)—reverses effects of opioids, can cause withdrawal symptoms in drug-addicted mother or infant Review with the class what each of these drugs is used for. Include what the nursing responsibilities would be with each one. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Sedatives Do not produce relief of pain May relieve anxiety and nausea Do cross placenta No reversing agents May inhibit mother’s ability to cope with pain of labor Not usually given during active labor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Adjunctive Drugs Phenothiazine medication Promethazine (Phenergan) Hydroxyzine (Vistaril) Can control nausea and anxiety Reduce narcotic requirements during labor Do not relieve pain Used in conjunction with opioids Review additional drugs in this area (e.g., valium, flumazenil, benadryl). Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Regional Anesthesia Woman is able to participate in the birth Retains her protective airway reflexes Informed consent is required prior to administration of any regional anesthesia Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Regional Anesthesia Locations
Pudendal block provides local anesthesia adequate for an episiotomy and use of low forceps Injection sites of regional anesthetics Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Epidural Blocks Anesthetic is injected into epidural space Inside the vertebral column surrounding dural sac in lumbar region of spine Given during first or second stage of labor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Anesthesia for Cesarean
A spinal subarachnoid block is used for cesarean births Levels of anesthesia for epidural and subarachnoid blocks. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Epidural and Intrathecal Opioids
Without anesthetic agent Allows woman to sense contractions without feeling pain Retains ability to voluntarily bear down during second stage of labor Review what a “walking epidural” is. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Contraindications to Epidural and Subarachnoid Blocks
Hypovolemia Anticoagulant therapy Blood-clotting disorder Allergy Infection at injection site Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Side Effects of Regional Anesthesia and the Nursing Role
Woman’s bladder is emptied before insertion procedure Assist with positioning woman Monitor for hypotension; if it occurs, administer Ringer’s lactate or normal saline Monitor fetal heart rate Assist woman with position changes If woman becomes hypotensive, what can happen? Answer: can cause decreased uteroplacental blood perfusion. Why aren’t glucose-containing fluids administered during labor? Answer: they can cause the fetus to increase insulin production, which can result in hypoglycemia after delivery and can increase urine production in the woman. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Intramuscular Medication
Why is the deltoid the preferred site of the injection? It has a predictable absorption rate when compared to the rest of the possible injection sites on the body. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Side Effects from Spinal Blocks
Headache Caused by leakage of spinal fluid Bed rest, in a flat and supine position, can relieve headaches that may occur in the postpartum period Blood patch often provides relief Avoid coughing or straining for bowel movements for a few days NOTE: headaches do not occur with epidural blocks because the dura mater of the spinal canal has not been penetrated and there is no leakage of spinal fluid. Therefore lying flat after birth is not necessary when an epidural has been used. Blood patch for relief of spinal headache Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

General Anesthesia Rarely given for vaginal births Sometimes used in emergency cesarean births when the woman is not a good candidate for spinal block Relieves pain through loss of consciousness Woman is at risk for regurgitation and aspiration of gastric contents Crosses placental barrier Fetus will be under its effects at birth Causes uterus to relax postpartum Newborn may need resuscitation, and establishment of initial respirations may be a challenge. Because uterus will not be contracting as with a normal vaginal delivery, woman is at greater risk for clot formation, hemorrhage, etc. Therefore careful postpartum assessment, including fundal massage, is essential. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

The Nurse’s Role in Pharmacologic Techniques
Question woman about last food intake and whether she has any food or drug allergies, including dental anesthetics and latex Helps to identify pain relief measures that may not be advisable Ask about the woman’s preference for pain relief Once medications have been given, side rails on the bed should be kept up Refer to Nursing Care Plan 8-1 (p. 156). Narcotics can cause drowsiness or dizziness. Regional anesthetics reduce sensation and movement to varying degrees, and woman may have less control over her body. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Monitor Laboring Woman
Vital signs Observe fetal monitor for signs associated with fetal compromise Observe for signs of imminent birth (e.g., increased bloody show, perineal bulging) Nurse will help coach woman on when to start and stop pushing with each contraction Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Nursing Responsibilities and General Anesthesia
Assessment and documentation of oral intake Administration of medications Providing key information to woman, such as she will be asleep before the initial incision is made Postoperative: vital signs, fundal massage, assess for signs of hemorrhage, urinary output Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Postoperative Assessment
Respiratory rate, especially if given narcotics Includes assessing mother and newborn for Late-appearing respiratory depression Excessive sedation, if epidural narcotics given after cesarean birth May last for up to 24 hours Assess level of sensation If woman complains of numbness in chest or higher, this is an emergency and should be reported immediately Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

Audience Response System Question 2
Normal saline or lactated Ringer’s solution is administered to a laboring woman to treat dehydration. Glucose is not given because it can: Decrease kidney excretion of urine Cause decreased insulin production in the woman Cause hypoglycemia in the infant Decrease uteroplacental blood flow Answer: C. Glucose given to the laboring woman can cause increased insulation production in the fetus which can then lead to hypoglycemia a short time after the birth of the infant. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.

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