1. Chapter 17 Maximizing Comfort for the Laboring Woman Copyright © 2016 by Elsevier Inc. All rights reserved.

2. 2 Learning Objectives  Identify nonpharmacologic strategies, including breathing and relaxation techniques, used to enhance relaxation and promote comfort during labor and birth.  Compare pharmacologic methods used to relieve discomfort in different stages of labor and for vaginal or cesarean birth.  Discuss the effects of medication management for the mother and for the newborn both during and after birth.

3. 3 Copyright © 2016 by Elsevier Inc. All rights reserved. Learning Objectives (Cont.)  Construct an evidence-based plan to manage the discomfort that a woman experiences during childbirth.  Explain the nurse’s role and responsibilities while providing care for a woman receiving analgesia or anesthesia during labor.  Describe the nurse’s role in promoting comfort and safety throughout the labor and birth process.

4. 4 Copyright © 2016 by Elsevier Inc. All rights reserved. Pain During Labor and Birth  Neurologic origins  Visceral  Referred  Somatic  Perception of pain  Expression of pain

5. 5 Copyright © 2016 by Elsevier Inc. All rights reserved. Factors Influencing Pain Response  Physiologic factors  Culture  Anxiety  Previous experience  Gate-control theory of pain  Comfort  Support  Environment

6. 6 Copyright © 2016 by Elsevier Inc. All rights reserved. Nonpharmacologic Pain Management  Childbirth preparation methods  Relaxing and breathing techniques  Focusing and relaxation  Breathing techniques  Effleurage and counterpressure  Touch and massage  Therapeutic touch  Application of heat and cold

7. 7 Copyright © 2016 by Elsevier Inc. All rights reserved. Nonpharmacologic Pain Management (Cont.)  Acupressure and acupuncture  Transcutaneous electrical nerve stimulation  Water therapy (hydrotherapy)  Intradermal water block  Aromatherapy  Music  Hypnosis  Biofeedback

8. 8 Copyright © 2016 by Elsevier Inc. All rights reserved.

9. 9 Pharmacologic Pain Management  Sedatives: relieve anxiety and induce sleep; typically used for women in a prolonged latent phase of labor when there is a need to lessen the intensity of the contractions, decrease anxiety, or promote sleep  Barbiturates  Phenothiazines  Benzodiazepines

10. 10 Copyright © 2016 by Elsevier Inc. All rights reserved. Pharmacologic Pain Management (Cont.)  Anesthesia encompasses analgesia, amnesia, relaxation, and reflex activity.  Analgesia: the alleviation of the sensation of pain or the raising of the threshold for pain perception without loss of consciousness  The type of analgesic or anesthetic chosen is determined in part by the stage of labor of the woman and by the method of birth planned.

11. 11 Copyright © 2016 by Elsevier Inc. All rights reserved. Pharmacologic Pain Management (Cont.)  Systemic analgesia Opioid (narcotic) agonist analgesics Opioid (narcotic) agonist–antagonist analgesics Opioid (narcotic) antagonists

12. 12 Copyright © 2016 by Elsevier Inc. All rights reserved. Pharmacologic Pain Management (Cont.)  Nerve block analgesia and anesthesia  Local perineal infiltration anesthesia  Pudendal nerve block  Spinal anesthesia (block) Post–dural puncture headaches Epidural blood patch

13. 13 Copyright © 2016 by Elsevier Inc. All rights reserved. Pharmacologic Pain Management (Cont.)  Nerve block analgesia and anesthesia (Cont.)  Epidural anesthesia or analgesia (block): currently the most effective pharmacologic pain relief method for labor  Combined spinal-epidural (CSE) analgesia: sometimes referred to as a “walking epidural,” although women often choose not to walk because of sedation and fatigue, abnormal sensations in and weakness of the legs, and a feeling of insecurity  Epidural and intrathecal (spinal) opioids

14. 14 Copyright © 2016 by Elsevier Inc. All rights reserved.

15. 15 Copyright © 2016 by Elsevier Inc. All rights reserved. Pharmacologic Pain Management (Cont.)  Contraindications to subarachnoid and epidural blocks  Active or anticipated serious maternal hemorrhage  Maternal hypotension  Maternal coagulopathy  Infection at the injection site  Increased intracranial pressure  Allergy to the anesthetic drug  Maternal refusal or inability to cooperate  Some types of maternal cardiac conditions

16. 16 Copyright © 2016 by Elsevier Inc. All rights reserved. Pharmacologic Pain Management (Cont.)

17. 17 Copyright © 2016 by Elsevier Inc. All rights reserved. Pharmacologic Pain Management (Cont.)  Nitrous oxide for analgesia  Nitrous oxide mixed with oxygen can be inhaled in a low concentration (50% or less) to provide analgesia during the first and second stages of labor.  General anesthesia  Rarely used for uncomplicated vaginal birth  The woman should be premedicated with (clear) oral antacid to neutralize the acidic contents of the stomach.  Because of this risk for neonatal narcosis, it is critical that the baby be delivered as soon as possible after induction of general anesthesia, to reduce the degree of fetal exposure to the anesthetic agents and the CNS depressants administered.

18. 18 Copyright © 2016 by Elsevier Inc. All rights reserved. Care Management for Nonpharmacologic Interventions  Ask the woman how she feels to evaluate the effectiveness of the specific pain management techniques used  Use a pain scale and/or coping scale

19. 19 Copyright © 2016 by Elsevier Inc. All rights reserved. Care Management for Pharmacologic Interventions  General informed consent  Informed consent for anesthesia  Timing of administration  Preparation for procedures  Administration of medication  Intravenous route  Intramuscular route  Regional (epidural or spinal) anesthesia  Safety and general care

20. 20 Copyright © 2016 by Elsevier Inc. All rights reserved. Key Points  Nonpharmacologic pain and stress management strategies are valuable for managing labor discomfort alone or in combination with pharmacologic methods.  The gate-control theory of pain and the stress response are the bases for many of the nonpharmacologic methods of pain relief.  The type of analgesic or anesthetic to be used is determined by maternal and health care provider preference, the stage of labor, and the method of birth.

21. 21 Copyright © 2016 by Elsevier Inc. All rights reserved. Key Points (Cont.)  Sedatives may be appropriate for women in prolonged early labor when there is a need to decrease anxiety or promote sleep or therapeutic rest.  Naloxone (Narcan) is an opioid (narcotic) antagonist that can reverse narcotic effects, especially respiratory depression.  Pharmacologic control of pain during labor requires collaboration among the health care providers and the laboring woman.

22. 22 Copyright © 2016 by Elsevier Inc. All rights reserved. Key Points (Cont.)  The nurse must understand medications, their expected effects, potential side effects, and methods of administration.  Maintenance of maternal fluid balance is essential during spinal and epidural nerve blocks.  Maternal analgesia or anesthesia potentially affects neonatal neurobehavioral response.

23. 23 Copyright © 2016 by Elsevier Inc. All rights reserved. Key Points (Cont.)  The use of opioid agonist-antagonist analgesics in women with preexisting opioid dependence may cause symptoms of abstinence syndrome (opioid withdrawal).  Epidural anesthesia and analgesia are the most effective available pharmacologic pain relief methods for labor. They are used by the majority of women in the United States.  General anesthesia is rarely used for vaginal birth but may be used for cesarean birth or whenever rapid anesthesia is needed in an emergency childbirth situation.

24. 24 Copyright © 2016 by Elsevier Inc. All rights reserved. Question 1.A woman in labor has just received an epidural block. The most important nursing intervention is to: a.Limit parenteral fluids b.Monitor the fetus for possible tachycardia c.Monitor the maternal blood pressure for possible hypotension d.Monitor the maternal pulse for possible bradycardia