Nursing Management of Pain During Labor and Birth Chapter 7 Nursing Management of Pain During Labor and Birth Elsevier items and derived items © 2015, 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 © 2015, 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 © 2015, 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 p. 158. Elsevier items and derived items © 2015, 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 © 2015, 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 Pain is different for each individual and need to assess if patient is in pain look for things like facial grimacing Woman has several months to prepare for pain management When does not have any preparation or prenatal classes chances are they will have a problem with pain related to uterine contractions Is self-limiting and rapidly declines after birth Position changes can help with pain and descent of fetus ***Remember that culture can influence how a woman will individualize her pain.*** 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 © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Factors that Influence Labor Pain Pain threshold-is the least amount of sensation that one perceives as pain Pain tolerance-is the amount of pain one is willing to endure Sources of pain during labor-remember that the “coach” can help with labor pains by having patient pant with contractions Central nervous system factors Gate control theory-stimulating large diameter nerve fibers-massage is excellent example of how to use the large nerve fibers; use of hot and cold applications Endorphins-natural body substances that are similar to morphine Identify sources of pain during labor. What maternal factors can contribute to a painful labor and delivery experience?

Factors that Influence Labor Pain Maternal conditions Cervical readiness-could end up with cervical laceration Pelvis-size and shape so fetus can descend Labor intensity-short, intense brings more pain; contractions can come too fast Fatigue-reduces the pain tolerance and affects her coping skills Fetal presentation and position-remember that occipital presentation will put pressure on sacral area Identify sources of pain during labor. What maternal factors can contribute to a painful labor and delivery experience?

Nonpharmacological Pain Management Advantages Nonpharmacological methods do not harm the mother or fetus They do not interfere with the excitement of the birthing process They do not slow labor if they provide adequate pain control They carry no risk for allergy or adverse drug effects They do not have to be delayed until labor is established 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 © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Methods of Childbirth Preparation Dick-Read method-the use of relaxation techniques to reduce the discomforts of labor Bradley method-emphasizes slow abdominal breathing and relaxation techniques; first to include father as part of the labor Lamaze method-uses mental techniques that condition the woman to respond to contractions with relaxation rather than tension-respirations no lower than ½ of normal rate 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 © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Nonpharmacological Pain Relief Measures Relaxation techniques-techniques require concentration, thus occupying the mind while reducing muscle tension Skin stimulation-variations of massage Effleurage- a technique that stimulates the large-diameter nerve fibers; done by stroking abdomen in circular motions during contractions Sacral pressure-apply pressure firmly to lower back Thermal stimulation-hot and cold applications Positioning- relieves muscle fatigue and strain and promotes normal mechanisms of labor Diversion and distraction-stimulate the woman’s brain, thus limiting her ability to perceive sensations as painful Breathing-should not use them until she needs them 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.

Breathing First stage/Abdominal breathing Second stage Slow-paced-begins and ends with a cleansing breath with slow breathing between Modified-paced-begins and ends with a cleansing breath with rapid breathing between Patterned-paced Constant pattern-Pant-pant-pant-blow, pant-pant-pant-blow, and so on. Stairstep pattern-Pant-blow, pant-pant-blow, pant-pant-pant-blow, pant-pant-pant-pant-blow Second stage Used when pushing-takes a cleansing breath, then deep breath, and then pushes down while counting to 10 then blows out 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 © 2015, 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

Nursing Tip If a woman is successfully using a safe, nonpharmacological pain control technique, do not interfere Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

The Nurse’s Role In Nonpharmacological Techniques 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Pharmacological Pain Management Analgesics Systemic Adjunctive drugs to improve effectiveness or counteract side effects Anesthetics Regional: loss of sensation General: loss of consciousness and sensation Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Physiology of 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. 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. Elsevier items and derived items © 2015, 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 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. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Pharmacological Methods 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? Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Analgesics and Adjunctive Drugs Narcotic (opioid) analgesics Avoid if birth anticipated within 1 hour-because can cause respiratory depression in the fetus Meperidine (Demerol) Fentanyl (Sublimaze)-rapid onset, short duration; can cause respiratory depression Narcotic antagonist: reverses respiratory depression-naloxone (Narcan)-caused by opiods Adjunctive drugs: relieves nausea/vomiting 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. Elsevier items and derived items © 2015, 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 © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Difference Between Analgesic and Anesthetic Analgesic blocks pain Anesthetic blocks both pain and motor responses Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

Types of Anesthesia for Childbirth Anesthetic method Local infiltration-of perineal area for episiotomy Pudendal block-blocks pain in perineal area does not have effect on pain from contractions; vaginal hematoma or possible abscess Epidural block-most common side effects is maternal hypotension & urinary retention; What are some limitations in using and epidural block? Subarachnoid (spinal) block-most common hypotension and urinary retention; care of patient after block –postspinal headache-blood patch General anesthesia-used for C-sections either in emergency or woman who refuses or has contraindication to epidural or subarachnoid; major risk-regurgitation with aspiration ***Always be sure to assess the ability of moving legs and the sensation prior to ambulation takes place. Also assess for signs of impending birth*** 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.

Epidural and Spinal Anesthesia Most common side effects are maternal hypotension and urinary retention. Elsevier items and derived items © 2015, 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 © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

General Anesthesia 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 Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

General Anesthesia Adverse effects in the mother Regurgitation or vomit 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 © 2015, 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 and respiratory depression Document interventions and assessments Discuss additional interventions the nurse should undertake when a laboring woman has received anesthesia or analgesics. Elsevier items and derived items © 2015, 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.