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Chapter 8

Management of Pain During Labor

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Chapter 8
Lesson 8.1

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Objectives
1. 2.

3.

4.

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.

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Nursing Responsibilities

Designing a care plan that meets the needs of a woman in labor includes
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Knowledge of the characteristics of pain in various stages of labor Interventions for pain relief Comfort methods Cultural responses to labor

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The Unique Pain of Labor
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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

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Factors That Influence Labor Pain

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

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Pain Tolerance
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Amount of pain one is willing to endure Tolerance can change under different conditions

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Pain and Nursing Responsibility

Modify as many factors as possible so that the woman can safely tolerate the pain of labor and delivery

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Sources of Pain During Labor

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Sources of Pain During Labor
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Dilation and stretching of cervix Uterine contractions Pressure and pulling of pelvic structures Distention and stretching of the vagina and perineum

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Additional Contributing Factors
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Cervical readiness Interventions of caregivers Psychosocial factors

Culture

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Gate Control Theory
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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

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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

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

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Chemical Factors

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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

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Endorphins

May be produced by stress and increase the pain threshold May make the woman drowsy and sleepy

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Chapter 8
Lesson 8.2

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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.

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Nonpharmacologic Pain Control Strategies
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General support Imagery or visualization Distraction Changes in temperature Touch Comfort measures Baths

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Comfort Measures and Stimuli

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Eliminate sources of noxious (offensive) stimuli Relieve thirst, sweating, and heat through comfort measures Repositioning Adjusting monitoring belts

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

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Cutaneous Stimulation
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Touch Rubbing Massaging Counterpressure Rhythmic stroking Effleurage

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Thermal Stimulation

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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

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Breathing Techniques
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Change the focus during the contraction Can be taught to the unprepared woman while in labor

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Recognizing and Correcting Hyperventilation

Signs and symptoms
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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

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Relaxation

Most effective teaching time, once labor has begun

Between contractions and during the first stage of labor

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Hypnosis
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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

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Pharmacologic Pain Control Strategies

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Physiology of Pregnancy and Its Relationship to Analgesia and Anesthesia

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Factors Affecting Woman’s 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

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Advantages of Pharmacologic Methods

Help woman relax and work with contractions; otherwise
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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

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Limitations of Pharmacologic Methods
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2 persons 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

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Before Administration of Drugs
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Baseline assessment of woman and fetus Labor should be well established, with cervical dilation of at least 4 cm, before woman receives pain medication

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Analgesics During Labor

May reduce hormonal and stress response to pain of labor May be especially advantageous to obese or hypertensive woman

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Analgesia
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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

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Examples of Analgesics
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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

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Sedatives
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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

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Adjunctive Drugs

Phenothiazine medication
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Promethazine (Phenergan) Hydroxyzine (Vistaril)

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Can control nausea and anxiety Reduce narcotic requirements during labor Do not relieve pain Used in conjunction with opioids

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Anesthesia
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Regional blocks General anesthesia

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Regional Anesthesia
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Woman is able to participate in the birth Retains her protective airway reflexes

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Regional Anesthesia Locations

Injection sites of regional anesthetics.

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

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Epidural Blocks
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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

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Anesthesia for Cesarean

A spinal subarachnoid block is used for cesarean births

Levels of anesthesia for epidural and subarachnoid blocks.

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

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Contraindications to Epidural and Subarachnoid Blocks
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Hypovolemia Anticoagulant therapy Blood-clotting disorder Allergy Infection at injection site

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Side Effects of Regional Anesthesia and the Nursing Role
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Informed consent required 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

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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

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Signs of Toxicity to Local Anesthetics
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Rare occurrence Symptoms include
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Disorientation Tinnitus Twitching Seizures

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Side Effects from Spinal Blocks
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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.

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General Anesthesia
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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

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The Nurse’s 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

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Ask about the woman’s preference for pain relief Once medications have been given, side rails on the bed should be kept up

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Monitor Laboring Woman
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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

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Nursing Responsibilities and General Anesthesia
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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

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Postoperative Assessment
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Respiratory rate, especially if given narcotics Includes assessing mother and newborn for
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Late-appearing respiratory depression Excessive sedation, if epidural narcotics given after cesarean birth May last for up to 24 hours

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Assess level of sensation If woman complains of numbness in chest or higher, this is an emergency and should be reported immediately

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Question for Review

What are two priority assessments for a woman who has received epidural analgesia during labor?

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Review Key Concepts of the Chapter

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