OB LECTURE
CHAPTER 16 – COMFORT MEASURES DURING LABOR AND BIRTH
ETIOLOGY OF LABOR PAINS
• Anoxia in uterine muscle as the supply of
oxygenated blood is cut off
o During contractions, the uterine muscles are
unoxygenated, the lack of oxygen causes
pain.
o Pain felt during labor is similar to MI
o Chemicals released from the contracting
muscles of the uterus which make pain
receptors more susceptible to feel pain
• Stretching of the perineum and cervix
o At the end of the transitional phase in labor,
when stretching of the cervix is complete and
the woman feels she has to push, pain from
the contractions often disappears as long as
the woman is pushing, until the fetal
presenting part causes a final stretching of
the perineum.
• Pressure of the presenting parts to the organs
PHYSIOLOGY OF PAIN
• Pain is a protective mechanism – it is a way of the
body to alert itself when there is something
abnormal or unusual happening
- In labor, pain alerts the uterus to contract to
expel the baby and return to pre- pregnant
state
- Pain in peripheral terminals is automatically
reduced by the production of endorphins
and encephalins, naturally occurring opiates
that limit transmission of pain from the end
terminals.
- Pain can be reduced further at these end
points by mechanically transmission.
- A major way to block spinal cord
neurotransmitters (i.e., never allowing the
pain impulse to cross to a spinal nerve) is by
the administration of pain medications.
- In addition, the brain cortex can be distracted
from sensing impulses as pain by such
techniques as imagery, thought stopping,
and perhaps aromatherapy or yoga.
Pain Gate Control Theory
- Perception of pain is affected by various factors
including psychological and emotional ones
- Subtantia Gelatinosa on the dorsal horns of the
spinal cord regulates the input and output of
impulses similar to a function of a gate
- -
TOQUILAR
- These fibers respond to non-painful stimulus, like
non-painful tactile and cutaneous stimuli. Once
activated, could close the pain gate inhibiting the
transmission of the pain stimuli.
- There are fibers which recognizes both painful
and non-painful stimulus, but can only process
one at a time. When both painful and non-painful
stimuli is given at the same time, perception of
the painful stimulus is lessened.
PHARMACOLOGIC MEASURES
Ø Analgesia – decreases awareness of pain but
there is still pain
Ø Anesthesia – partial or complete loss of
sensation; blocks pain sensation
¬ Can cross the placenta
¬ Be aware of the timing of administration
and the condition of the fetus
» Preterms are prone to respiratory
depression because of immature
lungs
Ø Not given: Aspirin, pain relief patches
o Aspirin given to mother in labor can cause further
bleeding tendencies to the newborn (cant
produce vitamin K yet)
o Pain relief patches – teratogen causing respiratory
problems
NONPHARMACOLOGIC PAIN RELIEF MEASURES
• Support system
- It is promoted in unang yakap to have a
companion during labor and delivery
• Breathing techniques
- Distracts the patient
• Bathing
- Hydrotherapy – submerged in water up
to the abdomen; effective because
another stimulus is picked up aside from
pain
- The temperature of water used should be
37°C to prevent hyperthermia of the
woman and also the newborn at birth.
• Massage
- Touch therapy – distracts the patient
- Effleurage, the technique of gentle
abdominal massage often taught with
Lamaze in preparation for childbirth
classes is a classic example of therapeutic
touch
Reiki can also promote healing.
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» The term Reiki consists of two
Japanese words: rei, which means
“God’s wisdom or the higher power,”
and ki, which means “life force
energy.”
» So Reiki is actually “spiritually guided
life force energy.”
» If one’s life force energy is low, then a
person is more likely to get sick or
feel stress. If it is high, a person is
more capable of being happy and
healthy.
OPIOIDS (NARCOTIC)
- Causes respiratory depression
» Assess RR
» Ask pt to report signs of respiratory
depression
» SIGNS OF DYSPNEA: slowed, heavy
breathing (bradypnea) and awareness of own
breathing
- Most commonly given to pt in labor
- TIME OF ADMINISTRATION: give approx. 3 hrs
from birth (active phase of the 1st stage of labor –
3 to 4 cm)
§ If given too early in labor, slows down
labor (uterine contractions and cervical
dilatations are affected)
§ If given close to 2nd stage of labor,
affects infant few hours after birth
- EFFECT: reduces pain sensation but does not
eliminate pain
- SIDE EFFECT: N/V, euphoria, floating
- NARCOTIC ANTAGONIST: Naloxone
Hydrochloride (Narcan) for respiratory distress
Special Precaution:
• Nalbuphine (Nubain) – given IV or IM; causes
Sedation
- Given more frequently than Fentany
- Ensure safety: raise side rails and
endorse to relatives to look after the pt
• Morphine sulfate – administered intrathecal
(directly at the spinal spaces) prior to epidural
anesthesia; causes pruritus (itching)
- Causes bronchoconstriction
- Causes the most respiratory depression
- Give antihistamine or benadril
• Fentanyl – given IV
- Causes drowsiness
- Fentanyl is a controlled medication; it is
not normally prescribed and needs a
TOQUILAR
yellow form before administration to
make sure it will not be used illegally.
• Demerol
REGIONAL (LOCAL) ANESTHESIA FOR LABOR AND
BIRTH
- Blocking nerve pathways with the use of local
anesthetics (Chloroporocaine or Bupivacaine)
- Completely eliminate pain but still with
contractions
- Woman stays completely awake
- Does not depress uterine tone but may make
pushing during 2nd stage of labor difficult
- SIDE EFFECT: may cause maternal hypotension -
Monitor BP
- TIME OF ADMINISTRATION: active phase of
labor
Ø Epidural Anesthesia – anesthesia placed on
vacant space outside dura mater at spaces L4-L5,
L3-L4, or L2-L3
¬ Blocks pain during labor and birth
¬ Pushing will be difficult because of the
absence of pain.
¬ Pushing effort is better with pain,
decreased when with epidural
anesthesia.
EPIDURAL ANESTHESIA
- An anesthetic agent introduced into the CSF in
the subarachnoid space is spinal injection or
spinal anesthesia.
- An anesthetic agent placed just inside the
ligamentum flavum in the epidural space is called
epidural anesthesia. Anesthetic agents placed in
the epidural space at the L4–L5, L3–L4, or L2–L3
interspace block not only spinal nerve roots in the
space but also the sympathetic nerve fibers that
travel with them.
- Therefore, these blocks can provide pain relief
during both labor and birth.
• TIME OF ADMINISTRATION: at least 3 to 5 cm cervix
(active phase of labor)
- Pt is hydrated before administration, usually with
1000mL fast drip PLRS/PNSS
§ Do not use D5 (dextrose) containing
fluids to avoid increase in maternal
blood sugar which would increase
the baby’s insulin and cause rebound
hypoglycaemia
§ D5 is okay if not in fast drip
• Combined Method:
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- ANALGESIC + SMALL AMOUNT OF EPIDURAL PUDENDAL BLOCK
BLOCK
Ø Analgesic – nubain, morphine, fentanyl (choose
only 1)
Ø Epidural block – chloroporocaine, bupivacaine
- If pure anesthesia only, there will be no sedation etc.,
only hypotension. Other effects will depend on the
analgesic mixed.
- Up to level of umbilicus
- INDICATION: heart disease, pulmonary disease,
gestational hypertension, preterm labor
- SIDE EFFECTS: hypotension
¬ Assess side effects of the opioids mixed if
combined method is used EMERGENCY ANESTHESIA
- PREVENTION: hydration of 1000mL IV PLRS prior to SPINAL ANESTHSIA
induction of anesthesia
¬ PLRS/PNSS > D5-containing to avoid
rebound fetal hypoglycaemia
POST EPIDURAL ANESTHESIA CARE
¬ Assess for pruritus
¬ Assess for urinary retention/sensation to void
¬ Assess for postpartal dural headache (spinal
headache)
o d/t sudden drop of CSF level
Touhy Needle is inserted most ideally at the level
of L4 to L5 (end of spinal cord – best location). Epidural
space is reached once there is vacuum pressure at the
needle. Touhy needle is just a guide and will be pulled
out, but the catheter of the epidural anesthesia will remain
inside the epidural space and taped at the pt’s back.
¬ Be careful in moving the pt as the epidural
anesthesia can easily be removed from the back. GENERAL ANESTHESIA
Leg raise test – effective once if the client cannot lift the
leg: The goal is to block pain sensation, not to completely
stop control on the leg, so that when this test is done, the
pt can still lift the leg above the table, but only low.
PAIN RELIEF DURING BIRTH
INFILTRATION OF LOCAL ANESTHETIC
- Inject the Lidocaine solution into the vaginal
mucosa, beneath the skin of the perineum and
into the perineal muscle
- Wait 2 minutes then pinch the incision site with
forceps.
- If the woman feels the pinch, wait 2 more minutes
then retest.
» Only numbs the area
» Lidocaine – local infiltration (at the
cut only) using ordinary needle, wait
for anesthetic agent to effect
TOQUILAR
- The doctor looks for the pudendal nerve with
the ischial spine as guide.
- Anesthetic is introduced at the sacrospinous
ligament.
- Ordinary syringe is used, but special needle
(trumpet needle) is needed since the doctor’s
finger will be the guide and it has to be
protected.
- Uses Marcaine or Lidocaine to anesthetize
pudendal nerve
- Painless episiotomy and repair
- Administration is much simpler. Spinal needle is
used to inject anesthesia at the spinal column.
- ADMINISTRATION: Bupivacaine is injected using
lumbar puncture into the subarachnoid space
into the CSF
- EFFECT: no sensation and control from umbilicus
to the legs
• Immediately after administration, pt
cannot move feet completely until the
anesthetics wear off
• NEVER place a woman in Trendelenburg
because it will cause anesthesia to rise
high in spinal column causing
uterine/respiratory effect
- SIDE EFFECT: hypotension
- PREVENTION: hydration of 1000mL IV PLRS prior
to induction of anesthesia
- Rarely used for delivery
- Indicated if delivery of the baby must be done
quickly and operatively
- Pentothal:
§ Rapid induction but short- acting, allows
uterine contractions
§ Crosses the placenta quickly, fetus often
needs resuscitation
- ROUTE: endotracheal administration (combined
with O2)
§ Mother is intubated
§ Via inhalation (others in the DR may inhale it
too)
- SIDE EFFECT: severe respiratory depression in
fetus
§ Emergency drugs for GA (p. 387) must be
available
- Teratogenic – if you are pregnant, try to excuse
yourself
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OB LECTURE
CHAPTER 6 – REPRODUCTIVE LIFE PLANNING
- Part of care for the client
- Given as early as prenatal care, but sometimes
given PP
TOQUILAR
- Because it is difficult for many couples to adhere
to abstinence, the method has a high failure rate
- Most effective way to prevent STIs

Reproductive Life Planning is all about: 2. LACTATION AMENORRHEA METHOD

• Decisions - 1-5% failure rate
o From mother AND father When a woman is breastfeeding, there is a
• Knowing consequences natural suppression of both ovulation and
o Physiologic – risks and dangers on the
- menses
body of the mother
- Effective on the first 6 months postpartum
o Quality of life of the children
- Effective if infant is frequently and exclusively
o Gaps – their focus on each children
breastfed (q4 during the day, q6 during the night)
- Effective if no return of menses yet
Considerations for Contraception
» Values – eg. Catholic
3. COITUS INTERRUPTUS (WITHDRAWAL METHOD)
» Ability – can they understand the method, will
- (+) coitus but only until moment of ejaculation
they
- Spermatozoa are emitted outside the vagina
» follow religiously, is it doable
- About 12% failure rate due to:
» Sexual enjoyment – discomforts caused
a) Possibility of ejaculation before complete
» Financial factor
withdrawal from vagina
» Relationship – monogamous or polygamous
b) Pre-ejaculation fluid may contain sperm
» Prior experience – effectivity of previously used
» contraception
4. POSTCOITAL DOUCHING
» Future plans
- Douching following intercourse, no matter what
solution is used, is ineffective as a contraceptive
NATURAL FAMILY PLANNING
measure as sperm may be present in cervical
- methods that involve no introduction of chemical
mucus as quickly as 90 seconds after ejaculation,
or foreign material into the body
long before douching could be accomplished.
- Others simply believe a “natural” way of planning
pregnancies is best for them, one that will involve
5. FERTILITY AWARENESS
no expense, does not introduce a foreign
Ø CALENDAR (RHYTHM) METHOD
substance into their body, and has no risk to a
- requires a couple to abstain from coitus on the
fetus should they become pregnant.
days of a menstrual cycle when the woman is
- The effectiveness of these methods varies greatly
most likely to conceive.
from a 2% ideal failure rate to about a 25% failure
- To plan for this, the woman keeps a diary of about
rate, depending mainly on the couple’s ability to
six menstrual cycles.
refrain from having sexual relations on fertile days
- Periodic abstinence – be aware of fertility days
or days in which a woman is most likely to
and abstain on those fertility days
become pregnant
- Failure is due to irregular menstrual cycle
A. Observe menstrual cycle for 6 months
1. ABSTINENCE
first to know shortest and longest
- Abstaining from sexual relation
B. Subtract 18 from the shortest cycle then
- 0% failure rate
subtract 11 from the longest cycle
- Failure is only due to in adherence
- Due to the natural human sexual drive, patients
Ø BASAL BODY TEMPERATURE
may find it difficult to adhere to abstinence
because they may deny the possibility of sexual - BBT falls 0.5°F before ovulation then rises 1°F
activity and fail to plan for pregnancy and STI during ovulation
prevention. - Temperature taking (oral or tympanic) before any
- activity

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- Slight dip then increase means ovulation = refrain
from coitus
- Higher failure rate because
a) Many factors can affect temperature
b) Sperm can survive for 72 hours after
Ø BILLING’S METHOD
- Changes in cervical mucus
- Fertile on days when mucus is copious and 4 days
- after
- Abstain 4 days before mucus becomes copious
- then 4 days after
- Difficult to approximate
• Spinnbarkeit test
o Not ovulating: cervical mucus is thick and
does not stretch
o Just before ovulation: mucus secretion
increases
o Ovulation: copious, thin, transparent, and
watery
BARRIER METHODS
- Chemical or latex barrier between cervix and
advancing sperm so sperm cannot reach and
fertilize an ovum
1. SPERMICIDE
- acidifies vagina and causes death of sperms
- No protection from STIs
- Gel, creams, foam, and suppository
- Side Effects: Vaginally inserted spermicidal
products are contraindicated in women with
acute cervicitis because they might further irritate
the cervix. Some women find the vaginal leakage
after use of these products bothersome. Vaginal
suppositories, because of the cocoa butter or
glycerin base, are the most bothersome in this
regard.
2. MALE AND FEMALE CONDOMS
- Protection from STI
- Made of latex
- Female condoms must adhere to the cervical area
- Male and female condoms should not be used
together or there is an increased chance of
tearing one or the other.
- The ideal failure and usual failure rate of female
condoms equals those of male condoms, 5% and
15%
TOQUILAR
3. DIAPHRAGM
- May be left in place for 24 hours (at least 6 hours
post coitus)
- High risk of UTI and other infections
4. CERVICAL CAPS
- soft rubber shaped like a thimble, which fits
snugly over the uterine cervix
- Easily dislodged
- May be left in place for 48 hours
- The failure rate is estimated to be as high as 23%
(ideal) to 35% (typical use) because caps tend to
dislodge more readily than diaphragms during
Coitus
5. ORAL CONTRACEPTIVES
- Composed of estrogen with small amount of
progesterone
o Estrogen suppresses FSH and LH therefore
suppressing ovulation
o Progesterone decreases mucus permeability
therefore restricts motility
- SIDE EFFECTS: nausea, weight gain, headache,
breast tenderness, spotting in between menses,
vaginal infection, depression
o Myocardial/Thromboembolic Symptoms:
chest pain, DOB, severe headache, severe
leg pain, blurred vision
- Not routinely prescribed for women with hx of
CVA, TE disease, diabetes – it worsens these
diseases
o Hormones have steroids which increases
glucose
DRUG INTERACTION
1. Reduces the effects of:
» Acetaminophen
» Anticoagulants
» Anticonvulsants
2. Decreased effectiveness with the following:
» Barbiturates, isoniazid, penicillin, tetracyclin
» If the pt will undergo an antibiotic therapy, to
secure protection from pregnancy, the pt and
partner must use secondary means of
contraception
Combination Oral Contraceptives
- All of these contain both estrogen and progestin,
they all just vary in the amount of progestin,
frequency of intake, and at which part of the cycle
they will be taken
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1. Monophasic pills, which contain fixed doses of
both estrogen and progestin throughout a 21-day
cycle
2. Biphasic, or preparations that deliver a constant
amount of estrogen throughout the cycle but
varying amounts of progestin
3. Triphasic and tetraphasic preparations, which
vary in both estrogen and progestine throughout
the cycle
Progestin Only (mini pills)
- No estrogen
- Oral contraceptives containing only progestins
are popularly called mini-pills and, like
combination types, must be taken conscientiously
every day.
- Without estrogen content, ovulation may occur,
but because the progestins have not allowed the
endometrium to develop fully or sperm to freely
access the cervix, fertilization and implantation
will not take place.
TOQUILAR
SURGICAL METHODS
VASECTOMY
• Vas deferens on each side is cut and tied
• Can be done in an ambulatory clinic
• Under local anesthetics
• Does not cause impotence, only prevents sperm
from passing through
TUBAL LIGATION
• Fallopian tubes are cut, tied, or blocked
• Minor surgery, laparoscopic
• May be under General Anesthesia
• Scheduled after a menstrual flow, before
ovulation
• Causes abdominal discomfort post-procedure

Hormonal Contraception
- Oral contraceptives
- Can be taken 2 weeks after birth of PP mother
- 28 pill dispenser, 21 active, 7 placebo
- Not effective initial 7 days
- Start 2nd dispenser 1 day after finishing the 1st
dispenser
o if you finished your first dispenser on a
Monday, on Tuesday, you won’t take
anything and on Wednesday, you’ll start
with your 2nd dispenser.

INTRAUTERINE DEVICE
- Suggested not to be placed immediately PP as it
may be displaced during uterine involution, but
since IE is done before discharge, we can check if
the IUD is still in place.
- Can be hormonal or not
- Effective for 10 years
- Causes sterile inflammation reaction prevents
implantation
o If there is inflammation, implantation will
be impossible.
- Copper prevents sperm from crossing
- Woman must not be pregnant upon insertion
o May cause abortion when pulled out
- String protrudes to the vagina after attachment

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