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15
0
,2

LABOR AND BIRTH PART II

TSG 2015

OBJECTIVES
Mechanisms of labor
How does pain in labor differ from other pain
Describe the physiological sources of pain in labor and birth.
Discuss principles of pain relief in labor
Discuss non-pharmacologic nursing care strategies and to enhance
relaxation and pain relief in labor and birth.
Differentiate between analgesia and anesthesia
Anesthetic means loss of feeling.Analgesic means loss of pain
Describe the role of the nurse and the application of the nursing process
to pharmacological pain management during labor and birth.
Discuss nursing implications in the use of regional and epidural
anesthesia.
Explain major complications associated with epidural and spinal
anesthesia
Shared decision making

TSG 2015

W
E
I PP
V
E LA

T
S
LA

C
IS

N
O
I
S
S
U

N
O
I
T
CA
I
L

R LINICA
C

TSG 2015

MEET JULIA

TSG 2015

CLINICAL APPLICATION
Julia L. is a G3 P1102 at 38.2 weeks gestation.
She has been in labor for 10 hours. And in the hospital for 1
hour.
Her cervix is 4 cm /80% effaced /-1. station
The baby is LOA.
Her membranes are intact.
Her contractions are q 4-5 min x 50 sec, moderate to palpation.
FHR is 140s, with a reassuring tracing.
Shes here with her boyfriend and her sister.
She was walking and took a warm shower for labor pain relief,
but now she wants an epidural.

TSG 2015

SORTING THROUGH THE DATA

Explain G3 P1102.
Is she term or preterm?
Why does it matter?
What stage of labor is she in?
Is the fetus engaged?
Which of the following is the fetal position?

TSG 2015

JULIA CONT.
Julias provider explains the possible side
effects of receiving an epidural at her
current dilitation and station and
encourages her to continue alternative
methods of coping for another hour.
Julia agrees.
What are some considerations if Julia has
not progressed in an hour?

TSG 2015

JULIA CONT.
An hour later Julia is 5 cm and the fetal station is 0. Fetal
status is reassuring.. She receives her epidural.
Knowing the 5 Ps, if Julias labor progress slows down or stops,
what factors would you evaluate?

TSG 2015

S
M
S
I
N
A
H
EC OR
M B
LA

F
O

RM
O
N

L
A

TSG 2015

MECHANISMS OF
LABOR

Movements of fetus
in labor:
Engagement
Descent
Flexion
Internal Rotation
Extension
External Rotation
Expulsion

TSG 2015

1
0

FORCES GUIDING MECHANISMS OF

LABOR

Engagement-Occurs prior to labor

Descent: Occurs because of four forces: pressure of amniotic fluid, direct
pressure of uterine fundus on infants bottom, contraction of
abdominal muscles, extension and straightening of fetal body
Flexion: Occurs as fetal head descends and meets resistance from the soft
tissues of the pelvis, the muscles of the pelvic floor, and the cervix
Internal Rotation: Fetal head must rotate to fit the diameter of the pelvic
cavity (widest in the anteroposterior position)
Extension: Resistance of the pelvic floor and the mechanical movement
of the vulva opening anteriorly assist with extension of fetal head as it
passes under the symphysis pubis
External Rotation: Shoulders Rotate to the anteroposterior position in
the pelvis and the heads turns farther to one side
Expulsion: Anterior shoulder before the posterior shoulder and rest of
body follows quickly.

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11

G
A
N

E
EM

T
N

IN

A
M
N R
I
PA BO
LA

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12

Pain is usually
associated with
injury but guides
labor
Greater intensity
associated with
greater progress
in labor
Labor pain occurs
in a predictable
pattern
How does pain in labor differ?
TSG 2015

13

PAIN ASSESSMENT
Verbal report (0-10).

Visual analog :-)

to : '(

Behavior (crying, moaning, screaming, writhing, withdrawal, inability to

follow instructions).

Increased BP, HR, respirations.

Length, frequency & intensity of contractions, description & location of

pain (uterine, sacral, vaginal).
Cultural beliefs & behaviors of how a woman should experience labor &
act.
TSG 2015

14

P
pu res
lli su
st pe ng re,
r u lv o
ct i c n
ur
es

stretching
of cervix,

Hypoxia from
frequent uterine
contractions

1st Stage of
labor

Fa
An tig
x i ue
et ,
y

SOURCES OF
PAIN

stretching
of uterine
ligaments

TSG 2015

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SOURCES OF PAIN

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Factors Affecting Maternal Response to labor

TSG 2015

17

PRINCIPLES OF PAIN RELIEF

Women are more satisfied when they
participate in the decision regarding pain
relief
Providers commonly under rate the pain of
women who do not vocalize
Women who prepare psychologically and
physically usually report greater
satisfaction with pain relief choices
Pain does not necessarily = Distress

TSG 2015

18

GATE THEORY
Limited strong impulses can travel the nerve
pathway to the cerebral cortex at a time
Cutaneous stimuli: back rubs, massage, effleurage,
sacral pressure, heat or cold, water,
acupressure,
TENS, intradermal
water block
Sensory stimulation: breathing and relaxation,
aromatherapy music, imagery
can close the gate.
Morphine like substances called endorphins
produced by the body in response
to pain and distress. Induce a sleeplike
state.

TSG 2015

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NURSING ROLE IN PAIN MANAGEMENT

Support and Comfort is one of the

primary activities of nursing:
Emotional, physical and informational
support for the woman, her partner and
her family
Advocacy
Benefits: Noninvasive, Promotes
womans sense of control
Trained Doulas

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PHARMACOLOGIC TREATMENT IN LABOR

1. Sedatives may be used in early or latent phase to relieve
anxiety and enable sleep.
Ambien, Restoril
2. Opioid analgesics used in active labor to decrease perception
of pain.
Stadol, Nubain
3. Phenothiazines may be used to decrease nausea & anxiety.
Phenergan (promethazine), Vistaril (hydroxyzine)
4. Epidural & spinal analgesia administers short-acting opioids
to epidural or intrathecal space for regional motor & nerve
block.
Fentanyl, Duramorph

TSG 2015

21

Narcotics can induce a temporary pseudosinusoidal EFM pattern

Narcotics used in labor

TSG 2015

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ADVANTAGES AND DISADVANTAGES

OPIODS
Allows continued
Pain not
mobility with
completely gone
support
Some women
Nurse
experience
Administered
unpleasant side
May be d/cd by
effects
woman if she
chooses

TSG 2015

23

NARCOTICS IN LABOR
Administer with caution in Opioid dependent
women and previously Opioid dependent
women
Stadol is agnoist-antagonist and may precipitate
withdrawal
Women with tolerance may require large doses
which may impact the newborn
Women with previous history of opioid addiction
may find an opioid a trigger and begin using
again postpartum

TSG 2015

24

NURSING RESPONSIBILITIES
Before administration:
Explain options, benefits, risks, side effects and likely degree
of pain relief to patient.
Have patient empty bladder.
Explain may cause drowsiness, request assistance with
ambulation.
Have Narcan available.

After administration:
BR with side rails up.
Monitor maternal VS and FHR.
Monitor efficacy and SE.
Provide antiemetic as ordered, prn.

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USAGE OF ANESTHETICS
Local- Perineal infiltration prior to birth or for
repair or as sterile water papules in lower
back for back pain in labor
Pudendal-local infiltration through vagina into
pudendal nerve. For late second stage and
deliver
Regional- Administered into epidural ,
intrathecal or spinal space for labor or delivery
General- Administered through mask when
regional unable

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Anesthetics for Labor + Birth

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EPIDURAL ADMINISTRATION

http://www.youtube.com/watch?v=1evFwMXnGiI

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EPIDURAL USE
Up to 95% in some hospitals
Benefits: most comprehensive pain relief,
generally safe
Risks/SE:Potential to interfere with normal physiologic birth
Growing evidence that support an increase in malposition of fetal head (OP
position) especially when administered early
Increase in maternal fever, hypotension and fetal distress and oxytocin use.
Linked with fewer spontaneous vaginal deliveries and more operative
deliveries
Itching it common. Windows provide incomplete relief and
Some women experience
postpartum headache and backache

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PUSHING WITH EPIDURALS

7 RCTs of initial period of passive descent
(laboring down) vs. immediate
pushing in primigravidas with epidurals
found that passive descent:
increased incidence of spontaneous birth
reduced risk of instrument-assisted delivery
decreased active pushing time
no change in cesarean section rate

Brancato 2008
Copyright 2010, American College of Nurse-Midwives Inc.
All Rights Reserved.

TSG 2015

30

Local

Pudendal

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31

CLINICAL APPLICATION
Your patient is a
G3 P2 at 8 cm
dilation. Shes
been in labor for 4
hours and wants
something for the
pain.
What do you
suggest?

TSG 2015

32

BACK TO JULIA
When she received her epidural how did you counsel her
about what should she expect in terms of pain relief?
Describe the possible side effects of the epidural?
As her nurse, what will you do before, during and after the
epidural is inserted?
How did you coach her in second stage?

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33

HAPPY ENDING

TSG 2015

34

Labor & Birth 2

Worksheet

What is fetal descent and how is it measured?

What are the 5 Ps that affect the speed, ease or difficulty, and ultimate success (or not) of any labor?
What is the definition of macrosomia?
What is fetal lie?

What is fetal presentation? Give examples.

What is fetal position?
What does fetal attitude mean and why does it matter for delivery?
Sometimes a womans labor stalls. If your client were stuck at 6 cm dilation for 2 hours, what assessment and intervention options could you consider?

List 5 different maternal positions a woman could adopt in labor.

Why do we discourage a woman from lying flat on her back in pregnancy or labor?
Your client has spontaneous rupture of membranes. Whats the first nursing action you should take and why?

TSG 2015

35

If a woman calls c/o spontaneous rupture of membranes, what questions should you ask her?
How do you assess a womans pain in labor?
Describe the gate-control theory of pain.
What are the opioid analgesics for labor, how are they given, and what are potential side effects?
What nursing care would you provide to a woman receiving an opioid analgesic in labor?
What are the risks and benefits of epidural anesthesia in labor?

What nursing care would you provide to a woman receiving an epidural?

Your patient is a G1 P0 at 6 cm dilation. She has coped well with early labor by walking and showering but now requests pain
medication. What do you suggest and why (may be more than 1 option)?
Your patient is a G3 P2 at 8 cm dilation. Shes been in labor for 4 hours and wants something for the pain. What do you suggest
and why?

Describe a 1st-4th perineal laceration.

TSG 2015

36