Chapter 08 LO

Chapter 8
Management of Pain During Labor
Copyright 2008 by Saunders, an imprint of Elsevier Inc.
Chapter 8
Lesson 8.1
Objectives
1. 2.
3.
4.
Define key terms listed. Describe the factors that influence a womans comfort during labor. Explain the physical causes of pain during labor. Explain the role of endorphins in the body.
Nursing Responsibilities
Designing a care plan that meets the needs of a woman in labor includes

Knowledge of the characteristics of pain in various stages of labor Interventions for pain relief Comfort methods Cultural responses to labor
The Unique Pain of Labor

Part of a normal process Source of pain is known Woman has time to prepare for it Known to be self-limiting Ends with the birth of the baby
Factors That Influence Labor Pain
Pain Threshold

Pain perception Least amount of sensation that a person perceives as painful Fairly constant Varies little under different conditions
Pain Tolerance

Amount of pain one is willing to endure Tolerance can change under different conditions
Pain and Nursing Responsibility
Modify as many factors as possible so that the woman can safely tolerate the pain of labor and delivery
Sources of Pain During Labor
10
Sources of Pain During Labor

Dilation and stretching of cervix Uterine contractions Pressure and pulling of pelvic structures Distention and stretching of the vagina and perineum
11
Additional Contributing Factors

Cervical readiness Interventions of caregivers Psychosocial factors
Culture
12
Gate Control Theory

Gating mechanism occurs in spinal cord Pain sensations are transmitted from periphery of body along nerve pathways to the brain Only a limited number of sensations can travel at a time
13
Distraction
Distraction or focused activity can replace travel of pain sensation Gate closes and impulses are less likely to be transmitted to brain when activity fills the path When gate opens, pain impulses ascend to the brain
14
Examples of Distraction

Breathing Listening to music Verbal coaching Effleurage Acupuncture External analgesics Back massage
15
Chemical Factors
Neuromodulators, aka endorphins or endogenous opiates Protein chemicals found in the brain Known to relieve pain Endorphins are similar to morphinelike substances Believed to play role in biologic response to pain
16
Endorphins
May be produced by stress and increase the pain threshold May make the woman drowsy and sleepy
17
Chapter 8
Lesson 8.2
18
Objectives
5.
6.
7.
8.
Identify three nonpharmacologic pain control strategies. Review the potential effect of sedatives and narcotics on the newborn. Explain the advantages and limitations of pharmacologic methods of pain management. Describe the nursing responsibilities related to pharmacologic and nonpharmacologic pain management during labor.
19
Nonpharmacologic Pain Control Strategies

General support Imagery or visualization Distraction Changes in temperature Touch Comfort measures Baths
20
Comfort Measures and Stimuli
Eliminate sources of noxious (offensive) stimuli Relieve thirst, sweating, and heat through comfort measures Repositioning Adjusting monitoring belts
21
Cognitive Stimulation

Mental stimulation Imagery Focal point Require active participation by the woman in labor
22
Cutaneous Stimulation

Touch Rubbing Massaging Counterpressure Rhythmic stroking Effleurage
23
Thermal Stimulation
Warm bath or shower during early phase of labor Cool damp cloth to the forehead later in labor Hot or cold towels applied to the back
24
Breathing Techniques

Change the focus during the contraction Can be taught to the unprepared woman while in labor
25
Recognizing and Correcting 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 in exhalation Breathe into cupped hands Place a moist washcloth over the mouth and nose while breathing Hold breath for a few seconds before exhaling
26
Relaxation
Most effective teaching time, once labor has begun
Between contractions and during the first stage of labor
27
Hypnosis

Appears to be safe, without known side effects Positive physical and psychologic outcomes Woman in labor is usually trained in self-hypnosis
Nurse may need to help trigger it by using specific suggestions or playing specific audiotapes
Careful observation and documentation concerning labor progress are essential
28
Pharmacologic Pain Control Strategies
29
Physiology of Pregnancy and Its Relationship to Analgesia and Anesthesia
30
Factors Affecting Womans Response
Higher risk for hypoxia caused by pressure of enlarging uterus on diaphragm Sluggish GI tract of woman can result in increased risk for vomiting and aspiration Aortocaval compression increases risk of hypotension and development of shock Effect on fetus must also be considered
31
Advantages of Pharmacologic Methods
Help woman relax and work with contractions; otherwise

Labor pain may cause stress response Results in increased autonomic activity Release of catecholamines Decrease in platelet formation Can cause maternal hyperventilation Respiratory alkalosis, then compensating metabolic
acidosis Results in fetal acidosis
32
Limitations of Pharmacologic Methods

2 persons are affected: mother and fetus Drug effects can be prolonged in the newborn long after delivery May slow labors progress if used early in labor Decision to prescribe and administer drugs must be carefully weighed due to fetal effects
Fetus cannot metabolize drugs as quickly as mother
33
Before Administration of Drugs

Baseline assessment of woman and fetus Labor should be well established, with cervical dilation of at least 4 cm, before woman receives pain medication
34
Analgesics During Labor
May reduce hormonal and stress response to pain of labor May be especially advantageous to obese or hypertensive woman
35
Analgesia

Can reduce gastric emptying Increasing risk of aspiration if food or fluids are in stomach Careful monitoring of vital signs and fetal heart rate is essential
36
Examples of Analgesics

Meperidine (Demerol)most common Sublimaze (Fentanyl)rapid onset Butorphanol (Stadol) and nalbuphine (Nubain)combination opioid agonistantagonist Naloxone (Narcan)reverses effects of opioids, can cause withdrawal symptoms in drug-addicted mother or infant
37
Sedatives

Do not produce relief of pain May relieve anxiety and nausea Do cross placenta No reversing agents May inhibit mothers ability to cope with pain of labor Not usually given during active labor
38
Adjunctive Drugs
Phenothiazine medication

Promethazine (Phenergan) Hydroxyzine (Vistaril)
Can control nausea and anxiety Reduce narcotic requirements during labor Do not relieve pain Used in conjunction with opioids
39
Anesthesia

Regional blocks General anesthesia
40
Regional Anesthesia

Woman is able to participate in the birth Retains her protective airway reflexes
41
Regional Anesthesia Locations
Injection sites of regional anesthetics.
Pudendal block provides local anesthesia adequate for an episiotomy and use of low forceps.
42
Epidural Blocks

Anesthetic is injected into epidural space Inside the vertebral column surrounding dural sac in lumbar region of spine Given during 1st or 2nd stage of labor
43
Anesthesia for Cesarean
A spinal subarachnoid block is used for cesarean births
Levels of anesthesia for epidural and subarachnoid blocks.
44
Epidural and Intrathecal Opioids

Without anesthetic agent Allows woman to sense contractions without feeling pain Retains ability to voluntarily bear down during 2nd stage of labor
45
Contraindications to Epidural and Subarachnoid Blocks

Hypovolemia Anticoagulant therapy Blood-clotting disorder Allergy Infection at injection site
46
Side Effects of Regional Anesthesia and the Nursing Role

Informed consent required Womans bladder is emptied before insertion procedure Assist with positioning woman Monitor for hypotension; if it occurs, administer Ringers lactate or normal saline Monitor fetal heart rate Assist woman with position changes
47
Intramuscular Medication
Why is the deltoid the preferred site of the injection?
It has a predictable absorption rate when compared to the rest of the possible injection sites on the body
48
Signs of Toxicity to Local Anesthetics

Rare occurrence Symptoms include

Disorientation Tinnitus Twitching Seizures
49
Side Effects from Spinal Blocks

Headache Caused by leakage of spinal fluid
Bed rest, in a flat and supine position, can relieve headaches that may occur in the postpartum period
Blood patch often provides relief Avoid coughing or straining for bowel movements for a few days
Blood patch for relief of spinal headache.
50
General Anesthesia

Rarely given for vaginal births Sometimes used in emergency cesarean births when the woman is not a good candidate for spinal block Relieves pain through loss of consciousness Woman at risk for regurgitation and aspiration of gastric contents Crosses placental barrier Fetus will be under its effects at birth In postpartum period, causes uterus to relax and not contract
51
The Nurses Role in Pharmacologic Techniques
Question woman about last food intake and whether she has any food and drug allergies, including dental anesthetics and latex
Helps to identify pain relief measures that may not be advisable
Ask about the womans preference for pain relief Once medications have been given, side rails on the bed should be kept up
52
Monitor Laboring Woman

Vital signs Observe fetal monitor for signs associated with fetal compromise Observe for signs of imminent birth (e.g., increased bloody show, perineal bulging) Nurse will help coach woman on when to start and stop pushing with each contraction
53
Nursing Responsibilities and General Anesthesia

Assessment and documentation of oral intake Administration of medications Providing key information to woman, such as she will be asleep before the initial incision is made Postoperative: vital signs, fundal massage, assess for signs of hemorrhage, urinary output
54
Postoperative Assessment

Respiratory rate, especially if given narcotics Includes assessing mother and newborn for

Late-appearing respiratory depression Excessive sedation, if epidural narcotics given after cesarean birth May last for up to 24 hours
Assess level of sensation If woman complains of numbness in chest or higher, this is an emergency and should be reported immediately
55
Question for Review
What are two priority assessments for a woman who has received epidural analgesia during labor?
56
Review Key Concepts of the Chapter
57

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Chapter 8

Management of Pain During Labor

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

The Unique Pain of Labor

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Factors That Influence Labor Pain

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Pain and Nursing Responsibility

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Sources of Pain During Labor

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Sources of Pain During Labor

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Additional Contributing Factors

Cervical readiness Interventions of caregivers Psychosocial factors

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Gate Control Theory

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Nonpharmacologic Pain Control Strategies

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Comfort Measures and Stimuli

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Touch Rubbing Massaging Counterpressure Rhythmic stroking Effleurage

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Recognizing and Correcting Hyperventilation

Signs and symptoms

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Most effective teaching time, once labor has begun

Between contractions and during the first stage of labor

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Careful observation and documentation concerning labor progress are essential

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Pharmacologic Pain Control Strategies

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Physiology of Pregnancy and Its Relationship to Analgesia and Anesthesia

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Factors Affecting Womans Response

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Advantages of Pharmacologic Methods

Help woman relax and work with contractions; otherwise

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Limitations of Pharmacologic Methods

Fetus cannot metabolize drugs as quickly as mother

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Before Administration of Drugs

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Analgesics During Labor

Copyright 2008 by Saunders, an imprint of Elsevier Inc.

Copyright 2008 by Saunders, an imprint of Elsevier Inc.