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

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 page 157.
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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
Woman has several months to prepare for pain management
Is self-limiting and rapidly declines after birth
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- pain perception- least amt of sensation
Pain tolerance- pain one is able to perceive
Sources of pain during labor- dilatation stretching, reduction in uterine blood supply during contraction, pressure of fetus on pelvis structure, stretching of vagina and perineum
Central nervous system factors
Gate control theory- small diameter nerve fibers (stroke)
Endorphins –natural body substances similar to morphine
Maternal conditions
Cervical readiness
Pelvis
Labor intensity
Fatigue
Fetal presentation and position
Identify sources of pain during labor.
What maternal factors can contribute to a painful labor and delivery experience?
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8. 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
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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9. Methods of Childbirth Preparation
Dick-Read method- fear- tension- pain cycle
Bradley method- husband-coached childbirth
Lamaze method-responds to contraction with relaxation rather than tension
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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10. Selected Nonpharmacological Pain Relief Measures
Relaxation techniques- showers, decrease muscle tension
Skin stimulation- variations of massage
Effleurage- stimulates lg diameter nerve fibers- stroke abd in circular motion
Sacral pressure- firm pressure against lower back to relieve back pain during labor
Thermal stimulation
Positioning
Diversion and distraction
Breathing
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 seen in the clinical setting.
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
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11. Skin Stimulation
Skin stimulation evokes nerve fiber responses that are able to reduce or inhibit painful sensations.
Why should a patient be instructed to alternate methods of skin stimulation? Skin stimulation, if repeated in the same site over time, will become less effective.
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12. Breathing
First stage
Slow-paced- cleansing breath ending with contraction (6-9 breaths/min)
Modified-paced- more rapidly and shallow. Begins and ends with cleansing breath
Patterned-paced- focus on pattern of breathing
Constant pattern- pant-pant-pant blow
Stairstep pattern- pant-blow, pant-pant blow, pant-pant-pant blow, pant-pant-pant-pant-blow
Second stage
Used when pushing- cleansing breath, then take another breath and pushes down while exhaling to count of 10. blows out, takes a deep breath and pushes again while exhaling
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. Breathing Patterns
As a class, review the patterns listed on the slide.
Include the timing and use of each of the techniques.
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14. 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
Audience Response Question #2
A laboring woman reports that she is “dizzy” and experiencing “tingling” in her hands and around her mouth and nose. You recognize that these symptoms are most likely related to:
1. hyperventilation.
2. stroke.
3. anxiety.
4. medication side effect.
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15. Nursing Tip
If a woman is successfully using a safe, nonpharmacological pain control technique, do not interfere
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16. Pharmacological Pain Management
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17. 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.
1. The pregnant woman has an increased risk for hypoxia.
2. Reduced GI activity can promote nausea and vomiting.
3. There is an increased incidence of hypotension and the onset of shock.
Review the underlying physiological factors which are responsible for these physiological changes.
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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 participate in her care.
Review misconceptions that exist concerning the use of medications in labor.
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19. Pharmacological Methods (cont.)
Limitations
Any medication used must be considered for its potential impact on the condition of the fetus.
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
Narcotic antagonist- Narcan to reduce respiratory distress
Adjunctive drugs- enhance pain-relieving of analgesics and reduce nausea. Hydroxyzine IM using Z-track
Narcotics are used most frequently.
What are two commonly used narcotics?
Narcotic antagonists are used to reverse the respiratory depression associated with opioid use.
Name a narcotic antagonist.
Adjunctive drugs enhance the actions of analgesics and reduce nausea.
Name an adjunctive medication used for the laboring patient.
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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. Types of Anesthesia for Childbirth
Anesthetic method- blocks pain and motor responses
Local infiltration- episiotomy
Pudendal block- blocking pudendal nerves on each side of pelvis. Goes to vagina and to perineum (S.E. hematoma)
Epidural block- epidural space while in sitting position
Subarachnoid (spinal) block- similar to epidural block. One time injection
General anesthesia- emergency C section with no time for epidural block or C section who refuses epidural block
Review nursing implications for the various types of anesthesia.
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24. Epidural and Spinal Anesthesia
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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. Epidural Block Limitations Adverse Reactions Abnormal blood clotting
Infection in area of injection or systemic infection
Hypovolemia
Adverse Reactions
Maternal hypotension- LR rapidly before block begins
Urinary retention- insert catheter
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27. General Anesthesia Adverse effects in the mother
Regurgitation 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
Discuss additional interventions the nurse should undertake when a laboring woman has received anesthesia or analgesics.
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