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
Ideally, educational preparation for childbirth begins prior to conception
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3. 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.
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4. Variations of Basic Childbirth Preparation Classes
Refresher
Cesarean birth
Vaginal birth after cesarean
Adolescent
Review Health Promotion, Types of Prenatal Classes on p. 158.
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5. 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.
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6. 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.
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7. 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?

8. 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?

9. 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.
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10. 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?
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11. 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.

12. 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.
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13. 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

14. Nursing Tip
If a woman is successfully using a safe, nonpharmacological pain control technique, do not interfere
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15. 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
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16. 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
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17. 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.
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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 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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19. 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?
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20. 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.
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21. 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.
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22. Difference Between Analgesic and Anesthetic
Analgesic blocks pain
Anesthetic blocks both pain and motor responses
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23. 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.

24. Epidural and Spinal Anesthesia
Most common side effects are maternal hypotension and urinary retention.
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25. 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.
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26. 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
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27. 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.
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28. 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.
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