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

2. Classes Offered Adjust to pregnancy Cope with labor
Prepare for life with an infant

3. Types of Prenatal Classes
Vary by area – may include pregnancy, labor, infant care, breastfeeding, sibling & grandparent classes, etc.
Content: Exercises, pain control methods, relaxation, nutrition, facility tour, videos, etc.
Gestational Diabetes Mellitus
Monitoring blood glucose levels, diet modifications, prenatal visits, infection/complication prevention

4. Pain Control Methods
Variety of techniques that may be used during labor:
Skin stimulation, effleurage
Diversion and distraction
Breathing Techniques

5. Childbirth and Pain Unpleasant and Distressing Personal and Subjective
How childbirth pain differs from other pain
Pain is part of a normal birth process
Woman has several months to prepare for pain management
Is self-limiting and rapidly declines after delivery
Culture influences effect how a woman feels about pregnancy & pain during childbirth
See table 6-1 p. 117

6. Factors that Influence Labor Pain
Pain threshold and pain tolerance
Threshold/Perception: least amount of sensation that the person perceives as painful. Fairly consistent, varies little under different conditions
Tolerance: amount of pain willing to endure. Can change under different conditions.
Nursing Responsibility is to modify as many factors as possible so that the woman can tolerate the pain of labor.
Sources of pain during labor or Physical Factors
Dilation and stretching of the cervix
Reduced uterine blood supply during contractions (ischemia)
Pressure of the fetus on pelvic structures
Stretching of the vagina and perineum

7. Factors that Influence Labor Pain
Central nervous system factors
Gate control theory
Explains how pain impulses reach the brain for interpretation.
Supports several non-pharmacological methods of pain control.
Massage, Palm and Fingertip pressure, heat and cold applications
Endorphins
Natural body substances similar to morphine.
Levels increase during pregnancy and peak during labor.
Laboring women often tolerate more pain than usual during labor because they have high levels of endorphins and concerned about infant’s well-being.

8. Factors that Influence Pain
Maternal conditions
Cervical readiness
Cervix undergoes prelabor changes that facilitate effacement and dilation in labor
If cervix does not make these changes (ripening), more contractions are needed to cause effacement and dilation.
Pelvis
Size and Shape significantly influence how readily the fetus can descend
Pelvic abnormalities result in longer labor and maternal fatigue
Interferes with normal mechanisms of labor
Labor intensity
Short, intense – more pain compared to women whose birth process was gradual
Cervix, vagina, and perineum stretch more abruptly than during a gentler labor
Fatigue
Reduces pain tolerance and a women’s ability to use coping skills.
Fetal presentation and position
Presenting part acts as a wedge to efface and dilate the cervix as each contraction pushes it downward.

9. Pharmacological vs. Non Pain Management
cannot be used until labor is well-established bc they slow the progression of labor.
Most medications do not alleviate pain
Nonpharmacological
Help the women cope with labor before it has advanced far enough for her to be given medications
Only realistic option during advanced labor

10. 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

11. Selected Nonpharmacological Pain Relief Measures
Relaxation techniques
Skin stimulation
Effleurage
Sacral pressure
Thermal stimulation
Positioning
Diversion and distraction
Breathing Techniques
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

12. Skin Stimulation
Effleurage: stroking abdomen in large circles during contractions
Sacral pressure: firm pressure against lower back helps relieve back labor
Thermal stimulation
Be careful for burns

13. Breathing Techniques
Should not use tech. until needed, when cannot walk or talk through contraction. Tiring if used too early.
Each breathing pattern begins and ends with a cleansing breath – Helps relaxation & focusing
Advantage: Do not interfere with normal laboring process
First-stage breathing
Slow-paced breathing
Starts with a cleansing breath, then breaths slowly, as during sleep.
Cleansing breath ends the contraction.
6-9 breaths per minute is average
Half of usual rate to ensure adequate fetal oxygenation and prevent hyperventilation

14. Breathing Techniques Modified-paced breathing
Begins and ends with a cleansing breath
Breathes more rapidly and shallowly
No more than 2x usual
Hyperventilation is sometimes a problem with rapid breathing
Patterned-paced breathing
More difficult bc requires focus on pattern of breathing
Begins with cleansing breath – rapid breaths – and slight blows
“pant/blow” or “hee/hoo”
Second-stage breathing
At pushing time
Begins with cleansing breath
Deep breath
Push down during exhalation and count to 10

15. 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

16. Breathing Patterns

17. Relationship of Pregnancy to Analgesia and Anesthesia
Pregnant woman at higher risk for hypoxia
Caused by pressure of the enlarged uterus on the diaphragm
Sluggish GI tract can result in increased risk of vomiting and aspiration
Aortocaval compression (pressure on the abd aorta by heavy uterus when supine)
increases risk of hypotension and shock
Effect on fetus must be considered
Lethargic at birth

18. 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.
Limitations
Two people are being medicated
Any drug given can affect fetus, and effect may be prolonged after birth
Slow labor progression if used in early labor

19. Analgesics and Adjunctive Drugs
Narcotic (opioid) analgesics
Most common means of labor analgesia in US
Small doses to avoid fetal resp. depression
Do not provide complete pain relief
Used to help cope with labor at tolerable level
Avoid if birth anticipated within 1 hour
Narcotic antagonist
Narcan – reverses respiratory depression
Adjunctive drugs
Enhance the pain-relieving action of analgesics and reduce nausea
Hydralizine

20. Types of Anesthesia for Childbirth
Local infiltration
Injection at perineal area – episiotomy, laceration repair
Short delay between injection and loss of pain
No risks if woman is not allergic to medication
Pudendal block
Less common
Injects the pudendal nerve on each side of mothers pelvis
Used during forcep assisted births
Does not block pain of contractions
Epidural block
Done by physician or nurse anesthetist
PN can assist in positioning women: sitting or side-lying
Numbness or loss of movement after small test – dura mater was punctured and med was injected into the subarachnoid space
Numbness around mouth, tinnitus, visual disturbances, jitteriness – injection in vein

21. Types of Anesthesia for Childbirth
Subarachnoid (spinal) block
Spinal fluid confirm placement
Anethesia occurs quickly and more profound than epidural
Women loses all movement and sensation below the block
“one shot” – no placement of catheter
General anesthesia
Rarely used
Emergency cesarean births, refusal or contraindication of epidural/block

22. 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
Subarachnoid block
Pia mater

23. Epidural and Spinal Anesthesia

24. Adverse Effects of Pharmacological Methods
Systemic opioid
Fetal respiratory depression
Pudendal block
Vaginal hematoma or abscess may develop, not common
Epidural and subarachnoid block (spinal block)
Maternal hypotension and urinary retention
Spinal headache with subarachnoid block (Pt. should remain flat for several hours to reduce chance of postspinal HA.)
Blood patch (seal) used to provide relief from postspinal headache
General anesthesia
Maternal: aspiration of stomach contents
Fetus: respiratory depression

25. Pharmacological Techniques
The nurse’s role
Begins at admission
Assess Allergies: drug, anesthetics, latex
Woman’s preference for pain relief
Keep side rails up if women takes pain relief drugs
Side Effects of Narcotics
Reinforce education regarding procedures and expected effects of pain management method
Observe for hypotension if epidural or subarachnoid block is given

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