NURSING DIAGNOSIS:Pain [acute]May Be Related To:
Mechanical pressure of presenting part, tissue dilation/stretching,nerve compression, muscle hypoxia, intensified contractile pattern
Possibly Evidenced By:
Verbalizations, distraction behavior (e.g., restlessness), facial mask of pain, narrowed focus, autonomic responses
Verbalize reduction of pain.
Use appropriate techniques to maintain control.Rest between contractions.
Identify degree of discomfort and its sources.Clarifies needs; allows for appropriate intervention.Provide comfort measures, such as mouth care; Promotes psychological and physical comfort,perineal care/massage; clean, dry linen and allowing client to focus on labor, and may reduceunderpads; cool environment (68°F–72°F [20°C–22.1°C]), the need for analgesia or anesthesia.cool, moist cloths to face and neck; or hot compressesto perineum, abdomen, or back, as desired.Review information with client/couple about type Although client is under the stress of labor andof regional analgesia/anesthesia available at this discomfort levels may interfere with normalstage specific to the delivery setting (e.g., local, decision-making skills, she still needs to be inpudendal block, lumbar epidural reinforcement) control and make her own informed decisionsor use of transcutaneous electrical nerve stimulation regarding anesthesia. Note: The option of a nerve(TENS), acupressure/acupuncture. Review root block should be restricted to a hospital settingadvantages/disadvantages, as appropriate.where emergency equipment is available.Monitor and record uterine activity with Provides information/legal documentation abouteach contraction. continued progress; helps identify abnormalcontractile pattern, allowing prompt assessment and intervention.(Refer to CP:
DysfunctionalLabor/Dystocia.)Provide information and support related to Keeps couple informed of proximity of delivery;progress of labor.reinforces that efforts are worthwhile and the “end is in sight.”Encourage client/couple to manage efforts to Anesthetics may interfere with client’s ability tobear down with spontaneous, rather than sustained, feel sensations associated with contractions,pushing during contractions. Stress importance of resulting in ineffective bearing down.using abdominal muscles and relaxing pelvic floor.Spontaneous, rather than sustained, efforts to beardown avoid negative effects of Valsalva’s maneuverassociated with reduced maternal and fetal oxygenlevels. Relaxation of the pelvic floor reduces resistanceto pushing efforts, maximizing effort to expel the fetus.Observe for perineal and rectal bulging, openingAnal eversion and perineal bulging occur as theof vaginal introitus, and changes in fetal station.fetal vertex descends, indicating need to prepare fordelivery.