Chapter 8 Management of Pain During Labor Copyright © 2012, 2008 by Saunders, an imprint of...

Chapter 8

Management of Pain

During Labor

Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1

Managing the Pain of Labor


Objectives

Define key terms listed. Describe the factors that influence a woman’s

comfort during labor. Explain the physical causes of pain during

labor. Explain the role of endorphins in the body.


Pain Management

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 This knowledge assists in the development of a

nursing plan of care


Standards of Pain Management

The Joint Commission standards for patients and pain management include: The right to pain management Staff must competently assess and manage pain Policies should support prescription pain

medication Education about pain management should be

provided Exists past discharge


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 Primary nursing responsibility

Modify as many factors as possible so woman can safely tolerate the labor and delivery process


Sources of Pain During Labor


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 Intensity of contractions Length of time for cervical changes to occur Size/position of fetus


Additional Contributing Factors

Woman’s fatigue and pain tolerance Fear and anxiety Cervical readiness Interventions of caregivers Psychosocial factors

Culture


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


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


Examples of Distraction

Breathing Listening to music Verbal coaching Effleurage Acupuncture External analgesics Back massage


Chemical Factors

Neuromodulators, also called endorphins or endogenous opiates

Protein chemicals found in the brain Known to relieve pain Endorphins are similar to morphinelike

substances Believed to play a role in biologic response to

pain


Endorphins

May be produced by stress and increase the pain threshold

May make the woman drowsy and sleepy


Audience Response SystemQuestion 1

What type of stimulation during the labor process uses focal points to distract the woman from the pain of the contraction?A. Thermal

B. Breathing

C. Cognitive

D. Hypnosis


Methods to Control Pain


Objectives

Discuss 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.

Outline the nursing responsibilities related to pharmacologic and nonpharmacologic pain management during labor.


Nonpharmacologic Pain Control Strategies

General support Imagery or visualization Distraction Changes in temperature Touch Comfort measures Baths


Comfort Measures and Stimuli

Eliminate sources of noxious (offensive) stimuli

Relieve thirst, sweating, and heat through comfort measures

Repositioning Adjusting monitoring belts


Cognitive Stimulation

Mental stimulation Imagery Focal point Require active participation by the woman in

labor


Cutaneous Stimulation

Touch Rubbing Massaging Counterpressure Rhythmic stroking of the abdomen

(effleurage)


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


Breathing Techniques

Change the focus during the contraction Can be taught to the unprepared woman

while in labor


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


Relaxation

Most effective teaching time, once labor has begun Between contractions and during the first stage of

labor


Hypnosis

Appears to be safe, without known side effects

Positive physical and psychological 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


Pharmacologic Pain Control Strategies


Physiology of Pregnancy and Its Relationship

to Analgesia and Anesthesia


Factors Affecting Woman’s Response

Higher risk for hypoxia Increased risk for vomiting and aspiration Increased risk of hypotension and

development of shock


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


Limitations of Pharmacologic Methods

Two people are affected: mother and fetus Drug effects can be prolonged in the newborn

long after delivery May slow labor’s 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


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


Analgesics During Labor

May reduce hormonal and stress response to pain of labor

May be especially advantageous to obese or hypertensive woman


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


Examples of Analgesics

Meperidine (Demerol)—most common Sublimaze (Fentanyl)—rapid onset Butorphanol (Stadol) and nalbuphine

(Nubain)—combination opioid agonist-antagonist

Naloxone (Narcan)—reverses effects of opioids, can cause withdrawal symptoms in drug-addicted mother or infant


Sedatives

Do not produce relief of pain May relieve anxiety and nausea Do cross placenta No reversing agents May inhibit mother’s ability to cope with pain

of labor Not usually given during active labor


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


Anesthesia

Regional blocks General anesthesia


Regional Anesthesia

Woman is able to participate in the birth Retains her protective airway reflexes Informed consent is required prior to

administration of any regional anesthesia


Regional Anesthesia Locations


Injection sites of regional anesthetics

Pudendal block provides local anesthesia adequate for an episiotomy and use of low forceps

Epidural Blocks

Anesthetic is injected into epidural space Inside the vertebral column surrounding dural

sac in lumbar region of spine Given during first or second stage of labor


Anesthesia for Cesarean

A spinal subarachnoid block is used for cesarean births


Levels of anesthesia for epidural and subarachnoid blocks.

Epidural and Intrathecal Opioids

Without anesthetic agent Allows woman to sense contractions without

feeling pain Retains ability to voluntarily bear down during

second stage of labor


Contraindications to Epiduraland Subarachnoid Blocks

Hypovolemia Anticoagulant therapy Blood-clotting disorder Allergy Infection at injection site


Side Effects of Regional Anesthesia and the Nursing Role

Woman’s bladder is emptied before insertion procedure

Assist with positioning woman Monitor for hypotension; if it occurs,

administer Ringer’s lactate or normal saline Monitor fetal heart rate Assist woman with position changes


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.


Signs of Toxicity to Local Anesthetics

Rare occurrence Symptoms include

Disorientation Tinnitus Twitching Seizures


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

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 is at risk for regurgitation and

aspiration of gastric contents Crosses placental barrier Fetus will be under its effects at birth Causes uterus to relax postpartum


The Nurse’s Rolein Pharmacologic Techniques

Question woman about last food intake and whether she has any food or drug allergies, including dental anesthetics and latex Helps to identify pain relief measures that may not

be advisable Ask about the woman’s preference for pain

relief Once medications have been given, side rails

on the bed should be kept up


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


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


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


Audience Response SystemQuestion 2

Normal saline or lactated Ringer’s solution is administered to a laboring woman to treat dehydration. Glucose is not given because it can:A. Decrease kidney excretion of urine

B. Cause decreased insulin production in the woman

C. Cause hypoglycemia in the infant

D. Decrease uteroplacental blood flow


Review Key Points


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