THE

NURSING
ROLE IN
PROVIDI
NG
COMFOR
T
DURING
LABOR
GROUP 1
Experienc
e Of Pain
During
 Pain accompanies
labor contractions
for several different
reasons and
manifests itself in
different ways for
each woman.
 Etiology of pain
during labor and
birth
Normally, contractions of involuntary muscles, such
as the heart, stomach and intestine, do not cause
pain. This concept makes uterine contractions
unique because they do cause pain. Several
explanations exits for why this happens. During
contractions, blood vessels constrict. Reducing the
blood supply to uterine and cervical cells, resulting
in anoxia to muscle fibers. This anoxia can cause
pain in the same way blockage of the cardiac
arteries causes the pain of a heart attack. As labor
progresses and contractions become longer and
more intense, the ischemia to cells increases, and
the pain intensifies.
Pain also probably results from stretching of the
cervix and perineum. This phenomenon is the
same as the intestinal pain that results when
accumulating gas stretches the intestines. 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 stretching of the perineum.
Additional discomfort in
labor may stem from the
pressure of the fetal
presenting part on tissues,
including pressure on
surrounding organs, such as
the bladder, the urethra, and
the lower colon. In addition
to these factors, cultural
expectations effect how pain
is perceived.
 PHYSIOLOG
Y OF PAIN
Pain is basic protective mechanism that alerts a person that something threatening is
happening somewhere in the body.

In order to explain why our mental states impact pain perceptions, researchers Ronald
Melzack and Patrick Wall proposed what is known as gate control theory during the
early 1960s specifically in 1965. This theory suggests that the spinal cord contains a
neurological "gate" that either blocks pain signals or allows them to continue on to the
brain.
The Melzack-Wall gate control theory of pain (Melzack & Wall, 1965), it is the most
widely accepted theory of pain response, it proposes pain can be halted at three points:
o The peripheral end terminals
o The synapse points in the dorsal horn of the spinal cord
o The point at which the impulse is interpreted as pain in the brain cortex

Researchers have long observed that factors such as thoughts, emotions, and
expectations can influence our perceptions of pain. If you expect something to hurt, it
probably will hurt worse. If you are upset or frightened, pain may seem more intense
than it would if you were calm.
 How Gate
Control Works
Following an injury, pain signals are transmitted to the spinal cord and then up
to the brain. Melzack and Wall suggest that before the information is transmitted to the
brain, the pain messages encounter "nerve gates" that control whether these signals are
allowed to pass through to the brain.
This gating mechanism takes place in the dorsal horn of the body's spinal cord.
Both small nerve fibers (pain fibers) and large nerve fibers (normal fibers for touch,
pressure, and other skin senses) both carry information to two areas of the dorsal horn.
Large fiber activity excites the inhibitory neurons, which diminishes the
transmission of pain information. When there is more large fiber activity in
comparison to small fiber activity, people tend to experience less pain.
Small fibers impede the inhibitory interneurons, allowing pain information to
travel up to the brain. When there is more small fiber activity, it inactivates the
inhibitory neurons so that pain signals can be sent to the brain in order for pain
perception (also known as nociception) to take place.
The interplay among these connections determines
when painful stimuli go to the brain:
 PHYSIOLOG
Y OF PAIN
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.
A major way to block spinal cord neurotransmitters (I.e.,
nerve allowing the pain impulse to cross to a spinal nerve) is
by the administration of pain medications.
 PHYSIOLOG
Y OF PAIN
Sensory impulses of pain from
the uterus and cervix synapse
at the spinal column at the level
of T10 through L1, whereas
motor impulses register higher
in the cord at T5 through T10.

Sensory impulses from the

perineum, which is involved
in the second stage of labor,
are carried by the pudendal
nerve to join the spinal
column at S2, S3, and S4.
 PERCEPTIO
o
N OF PAIN
Differs according to:

Expectations and preparation for labor

o Length of labor
o Presence of fear
o Anxiety
o Worry
o Body image
o Self-efficacy
o Position of the fetus
 PERCEPTIO
•
N OF PAIN
Fetal position is physical variable that influences the degree of pain a woman
experiences

• If the fetus is in a occiput posterior position, the woman often reports intense
or nagging back pain, even between contractions , much more than if a fetus is
in an occipitoanterior position.

• Most babies navigate best through the pelvis if they are head down, with their
face toward your spine which is called the anterior position. Previous
observations have shown that OP position can lead to an increase of
complications, such as an abnormally long labour, maternal and fetal
exhaustion, instrumental delivery, severe perineal tears, and emergency
caesarean section
PERCEPTIO
N OF PAIN
 PERCEPTIO
•
N OF PAIN
Pain is perceived differently by different
individual because of psychosocial,
physiologic, and cultural responses.

• The body’s ability to produce and maintain

endorphins may influence a person’s
overall pain threshold and the amount of
pain a person perceives at any given time.

• A woman cannot relax simply because she

is instructed to do so by another person,
however, some additional interventions
must be used.
Nursing care
plan
Assessment Nursing Diagnosis Goals and Objective Nursing interventions Rationale Assessment
  Acute pain related to After 2 hours of >Provide Comfort >To alleviate pain by  
Subjective: surgical incision due Nursing Interventions Measures such as promoting non- Subjective:
N/A to cesarean birth as the patient’s pain repositioning or quiet pharmacological pain N/A
  evidenced by facial scale will decrease environment management  
  grimace with a pain        
Objective: scale   >Instruct the patient >To distract attention Objective:
>Facial Grimace with     to use relaxation and reduce tension >Facial Grimace with
pain scale     techniques and   pain scale
>Protective Gesture     encourage diversional   >Protective Gesture
to avoid pain in     activity such as   to avoid pain in
incision site     listening to music,   incision site
>Expressive Behavior     watching television   >Expressive Behavior
such as sighing     and socialization with   such as sighing
>Limited movement     others   >Limited movement
           
      >Instruct patient to    
      us supportive    
      materials such as >To reduce pain  
      binder especially when  
        moving  
           
      >Encourage patient  
      to do Deep Breathing >it is an effective  
      Exercise by comfort strategy  
      demonstrating how during childbirth and  
      to do it(every 4 hour this not only help  
      daily with 5-10 sharpen your focus but  
      breaths during also provide oxygen  
      exercise for the baby also the  
      mother’s muscle and  
      uterus  
       
       
       
   
   
   
   
Assessment Nursing Diagnosis Goals and Nursing Rationale Evaluation
Objective interventions
  Acute pain related After 8 hours of >Evaluate pain >understand the After 8 hours of
Subjective: to disruption of nursing regularly nothing cause of the pain nursing
N/A skin, tissue, and intervention the characteristic to help determine intervention the
  muscle integrity patient pain will be   the best treatment patient was
for the mother in
Objective: secondary to relieved and   pain
relieved or
>Facial Mask of Cesarean section controlled.   controlled.
pain Decreased intensity     Goal was met
>Guarding of pain >Provide additional >Promotes patient verbalized
behavior comfort relaxati on, pain decrease
> Narrowed focus   refocuses att enti on  
  >measures like and may enhance  (-) facial
V/S taken as back rub coping abiliti es . grimace
follows      (-) guarding
BP     behavior
PR   >Once the mother  
RR >recommended have recovered from Frequent
  planned or your C-section and small talks
  progressive no longer have any with
  exercise pain, it is usually significant
    safe to start low- others.
    impact exercises,
    such as swimming,
    pilates, yoga, gentle
    jogging and low
    resistance gym work
     
      
   
   
   
    
   
 
 
 
 
Assessment Nursing Diagnosis Goals and Nursing Rationale Evaluation
Objective interventions
  
    >having a woman
    shift positi on or
  >reposition as fi nd the positi on
indicated that is most
  comfortable for
   
  her can be
    helpful.
     
     
    > because a woman
  >encourage patient concentrating on
  technique like deep slow-paced
  breathing and breathing cannot
coughing concentrate on pain
   
  Exercise
   
   
   
   
 
>dress wound as  
indicated >Promote dress
wound left in place
for 24 to 48
hours following
cesarean secti on
to allow ample
ti me for healing
and re-
epithelializati on.
Assessment Nursing Goals and Nursing Rationale Evaluation
Diagnosis Objective interventions
Subjective: Acute pain After 30 Assess pain, >Provides >After 30
N/A related to minutes of noting location, information to minutes
  physical nursing intensity (scale aid in of nursing
Objective: agents such interventions, of determining interventions,
 Facial grimace as laboring the 0 – 10), choice or the
 Uncomfortable patient’s pain Duration. Effectiveness of patient’s pain
 Irritability will be   interventions. was
 restlesness relieved or     relieved and
 Vital Signs: controlled Provide >Promotes Controlled.
BP comfort relaxation,
Pain Scale measure like refocuses
  back rub, Attention, and
  Helping may enhance
  position of coping abilities.
  comfort.  
  Suggest
  use of
  relaxation
  technique and
  deep breathing
  Exercises.
   
 
 
COMFORT
AND
NONPHAR
MACOLOGI
C PAIN
 The pattern of intervention to promote
comfort and manage pain in labor has swung
from a philosophy of no intervention (none given
because pain in labor was expected), to a
philosophy that drug intervention was always
required (excessive amounts were given), to the
modern approach of empowering woman and
their partners with information so they can
choose how to best relieve pain during labor
within the limits of medical safety.
SUPPORT FROM A
DOULA OR COACH

A doula is a woman who is

experienced in childbirth and
postpartum support. These supports
persons (who may hold certificates as
birth or postpartum doulas) provide
physical, emotional, and
informational support prenatally,
during labor and birth, and even at
home in the postnatal period.
Complementar
y and
Alternative
Therapies
Relaxat
ion
 Relaxation keeps the abdominal wall
from becoming tense, allowing the uterus
to rise with contractions without pressing
against the hard abdominal wall.

 It also serves as a distraction technique

because, while concentration on relaxing,
a woman cannot concentrate on pain.
 Focusing and Imagery
 Concentrating intently on an object is another
method of distraction

 For this technique, a woman uses a photograph

of someone important to her or some setting she
finds appealing such as beautiful sunset.

 A woman can also concentrate on a mental

image, such as waves rolling onto a beach
(imagery) or chant a word or phrase such as
baby’s name during contraction.
 Spirituality
 For many women, prayer may be the
first measure they use to relieve a stress
they are facing.

 Women may bring helpful worship

object such as Bible or Qur’an into
their birthing setting to use during
prayer.
Breathing Techniques
 They are largely distraction techniques because a
woman concentrating on slow-paced breathing
cannot concentrate on pain.

 Breathing strategies can be taught to a woman

in labor if she is not familiar with their
advantages before labor.

 Stay with her until she appreciates how useful

slow-paced breathing can be and feels
comfortable using this technique independently.
Herbal Preparations
 Several herbal preparations have
traditionally been used to reduce pain with
dysmenorrhea or labor, although there is
little evidence-based support for their
effectiveness.
 Examples include chamomile tea for its
relaxing properties; raspberry leaf tea
(women freeze it into ice cubes to suck on),
which is thought to strengthen uterine
contractions; skullcap; and catnip, which
are thought to help with pain.
Aromatherapy and
Essential Oils
 Aromatherapy is the use of aromatic oils to complement
emotional and physical wellbeing. Their use is based on
the principle that the sense of smell plays a significant role
in overall health.

 When an essential oil is inhaled, its molecules are

transported via the olfactory system to the limbic system in
the brain. The brain then responds to particular aromas
with emotional responses such as relaxation.

 The effects of aromatherapy can range from reducing post

cesarean incisional pain to reducing anxiety in the first
stage of labor.
Heat or Cold
Application
 The application of heat and cold has always been used for pain relief after injuries
such as minor burns or strained muscles.

 Women who are having back pain may find the application of heat to the lower
back by a heating pad, instant hot pack, or warm moist compress extremely
comforting.

 Heat applied to the perineum is proven to provide the dual benefits of soothing and
softening the perineum and decreasing the risk of perineal tears.

 Women who become warm from the exertion of labor find a cool washcloth to the
forehead, chest, or back of the neck comforting. Sucking on ice chips to relieve
mouth dryness is also refreshing. Immediately following birth, an ice pack applied
to the perineum feels soothing, and it helps reduce edema and swelling.
Bathing or
Hydrotherapy
 Standing under a warm shower or soaking in a tub of
warm water, jet hydrotherapy tub, or whirlpool is another
way to apply heat to help reduce the pain of labor.

 The temperature of water used should be 37°C to prevent

hyperthermia of the woman and also the newborn at birth.

 Timing of contractions, auscultation of fetal heart rate,

and vaginal examinations can all be done without the
woman needing to leave the water. The birth environment,
including the use of hydrotherapy in labor, can help
support physiologic birth.
 Therapeutic Touch and
Massage
 In a classic work, Krieger (1990) defined therapeutic touch as the
laying on of hands to redirect energy fields that lead to pain.

 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. The technique includes “laying on of

hands” and is based on the theory that an unseen “life force energy”
flows through us and is what causes us to be alive.

 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.
 Yoga and Meditation
 Yoga, a term derived from the Sanskrit word for “union,”
describes a series of exercises that were originally designed to
bring people closer to a divine power.

 Mothers who engage in yoga prenatally have been shown to

have a greater sense of self-efficacy and may experience fewer
episodes of antenatal depression.

 Meditation is a self-directed practice for relaxing the body and

calming the mind. Mindfulness-based stress reduction (MBSR),
an 8-week intervention program for patients dealing with issues
of chronic pain, is based on the cultivation of intentional
awareness of experiences in the present moment.
 Transcendental meditation (TM) is a simple, natural, and
effortless activity done while resting comfortably with the eyes
closed.

 Using one of these techniques, an individual experiences a

state of deep rest that can change physical and emotional
responses to stress.
Reflexology
 Reflexology is the practice of stimulating
the hands, feet, and ears as a form of
therapy.

 Professional reflexologists apply pressure

to specific areas of the hands, feet, and
ears to alleviate common ailments such as
headache, back pain, sinus colds, and
stress.
 Hypnosis

 Hypnosis is yet another method that can be used for pain relief in
labor. A woman who wants to use this modality needs to meet with
her hypnotherapist during pregnancy.

 A woman who wants to use this system but began labor before the
posthypnotic suggestion was given may be very disappointed to
find herself in labor without the help she envisioned.

 Some hypnotists may visit during labor or supply the suggestion

over the telephone so a woman can still use the method.
Biofeedback
 Biofeedback is based on the belief that people have control and
can regulate internal events such as heart rate and pain responses.

 Women who are interested in using biofeedback for pain relief in

labor must attend several sessions during pregnancy to condition
themselves to regulate their pain response.

 During these sessions, a biofeedback apparatus is used to measure

muscle tone or the woman’s ability to relax.
 Transcutaneous Electrical
Nerve Stimulation
 Transcutaneous electrical nerve stimulation (TENS)
works to relieve pain by applying counter-irritation to
nociceptors.

 TENS can be as effective as epidural anesthesia for pain

relief in labor, although some women object to being “tied
down” to the equipment.

 This method may not only reduce the need for epidural
anesthesia but also postpone the use of pharmacologic
agents
 Intracutaneous Nerve
Stimulation
 Intracutaneous nerve stimulation (INS) is a technique
of counter-irritation involving the intradermal injection of
sterile water or saline along the borders of the sacrum to
relieve low back pain during labor.

 Although some women find the technique helpful, there is

little evidence as to its effectiveness; other women prefer
to bear back pain or relieve it by massage rather than
submit to injections.
 Acupuncture and
Acupressure
 Acupuncture is based on the concept that illness results
from an imbalance of energy. To correct the imbalance,
needles are inserted into the skin at designated
susceptible body points (tsubos) located along meridians
that course throughout the body to supply the organs of
the body with energy.

 Acupressure is the application of pressure or massage at

these same points. It seems to be most effective for low
back pain. A common point used for women in labor is
Co4 (Hoku or Hegu point), which is located between the
first finger and thumb on the back of the hand
 PHARMACOLOGIC
MEASURES FOR PAIN
RELIEF DURING LABOR
The discovery of either and chloroform in 1800s led to the
determination that childbirth could be managed relatively pain
free. Unfortunately, this goal was achieved by means of
complete anesthesia or unconscious for the woman during labor
and birth. Women, afterward, had difficulty believing the birth
was over and that the infant was their child.
Pharmacologic management of pain during
labor and birth includes analgesia, which
reduces or decreases awareness of pain, and
anesthesia, which causes partial or complete
loss of pain sensation. For the best results, be
certain women are included in the selection
of these methods and understand any fetal
effects or maternal side effects that might
occur.
Virtually all medications given during labor
cross the placenta and have some effect on the
fetus, which makes it important to do regular
assessments of maternal and fetal responses to
the administration of systemic medication.
However, labor should not test women not to
take acetylsalicylic acid (aspirin) for pain in
labor as aspirin interferes with blood
coagulation, increasing the risk for bleeding in
the newborn or herself.
 GOALS OF
PHARMACOLOGIC PAIN
MANAGEMENT
The ideal DURING
or goal of medications used during labor is to relax a woman and
relieve her discomfort and yet have minimal systemic effects on uterine
LABOR
contractions, her pushing effort, or the fetus. Whether a drug affects a fetus.
Whether a drug affects a fetus depends on its ability to cross the placenta
and that depends on its molecular weight. Drugs with a molecular weight of
less than 600 Da cross very readily: drugs with a molecular weight of more
than 1,000 Da cross poorly. Drugs with highly charged molecules or
molecules strongly bound to protein also tend to cross more slowly than
others. Fat-soluble drugs cross the easiest.
If a drug causes a systemic response, such as
hypotension in a woman, it can result in a decreased
oxygen gradient across the placenta, causing the
indirect result of fetal hypoxia. If a drug causes
confusion or disorientation, a woman may be unable to
work effectively with contractions, thus prolonging
labor and increasing discomfort for her. A preterm
fetus, which has an immature liver and is unable to
metabolize or inactive drugs, is generally more affected
by drugs than a term fetus.
• Lastly, because pain is a subjective sensation, some women
are most aware of pain early in labor, whereas some report the
second stage of labor as the most aware of pain early in labor,
whereas some report the second stage of labor as the most
difficult. The point at which pain medication is needed,
therefore, differs from one individual woman feels she needs
it.

● In contrast, at the second stage, epidural anesthesia or a drug

that disorients a woman can slow progress and may result in
more instrumentation or cesarean births. For all these reasons,
no perfect analgesic agent exists for labor or birth that has no
effect on labor, the mother or the fetus.
PREPARATION FOR
MEDICATION
The type of medication used during labor varies among different
healthcare providers and also changes based on new research as the
ADMINISTRATION
effectiveness and safety of new drugs for use during labor are tested. To
be safe, follow The Joint Commission’s 2016 National Patient Safety
Goals (The Joint Commission, 2016) and remember the criteria a drug
must fulfill to be used in pregnancy at any point.

Prepare a woman for the type of agent prescribed, how it will be

administered with an explanation such as “You’ll need lie on your side”
as well as what she can expect to happen after administration (“I’ll be
taking your blood pressure frequently”).
 OPIOID (NARCOTIC)
ANALGESICS
● Narcotics may be given during labor because of their potent effect, but all
drugs in this category cause maternal respiratory depression as well as
fetal CNS depression to some extent and so should be used cautiously.
● Timing the administration of narcotics during labor is especially
important as, if given too early (before 3 cm cervical dilatation), they tend
to slow labor. If given close to birth, because the fetal liver takes 2 to 3
hours to activate a drug, the effect will not be registered in the fetus for 2
to 3 hours after birth.
● For this reason, narcotics are preferably given when the mother is 3 more
hours away from birth. This allows the peak action of the drug in the fetus
to have passed by the time of birth so the newborn breathes easily.
● Common opioid analgesics used in labor traditionally include
butorphanol tartrate (Stadol), morphine sulfate, nalbuphine (Nubain),
meperidine (Demerol), and fentanyl (Sublimaze).
● They all begin to work 15 to 30 minutes after intramuscular
administration or about 5 minutes after intravenous (IV)
administration. A drawback to all these opioids is they may cause
nausea and vomiting in some women. These effects appear to be
dose-related. They also produce a feeling of euphoria, so women
often report they feel as if they are “floating”; because of this
sensation, they may feel they have lost control or are unable to
breathe effectively with contractions.
Because of the fetal effects, whenever a
narcotic is given during labor, whenever a
narcotic is given labor, narcotic antagonist
such as naloxone hydrochloride (Narcan)
should be available for administration to the
infant at birth if needed.
Additional
drugs
 Definition
● Known as “Tranquilizers”
● Reduces anxiety or potentiate
the action of a narcotic.
● Example: hydroxyzine
hydrochloride (Vistaril)
● DO NOT RELIEVE PAIN,
woman in labor needs pain
management measures in
addition to these drugs.
Nitrou
s oxide
Definition
● Nitrous oxide inhalation, has been widely
used in Europe for effective pain relief in
labor.
● Adverse neonatal outcomes such as brain
cell apoptosis leading to developmental
impairment.
● Rooks (2011) has shown that in
appropriate doses (</= 50% blend with
oxygen) and with proper and now
standard delivery system, nitrous oxide
can be safe for mothers, fetus, neonate
and caregivers.
● It does not affect the pattern or intensity
of contractions and does not interfere with
normal labor.
 Regional
(local)
anesthesia
 Definition
● Is the injection of a local anesthetic such as
”chloroprocaine” (Nescaine) or bupivacaine
(Marcaine) to block specific nerve pathways.
● Any woman with a bleeding defect, such as
those that may occur with preeclampsia, need to
be assessed carefully before regional anesthesia
is administered to prevent bleeding at the
injection site.
● Have the potential to result in fetal bacycardia.
● Is able to completely eliminate pain yet allow a
woman to be completely awake and aware of
what is happening during birth.
 Epidural
anesthesia
 Definition
● The nerves in the spinal cord is protected by
several tissue layers.
1. Pia Mater – is the membrane adhering to the
nerve fibers.
2. Cerebrospinal fluid (CSF) – surrounding the
Pia Meter
3. Arachnoid membrane comes next; outside that
is Dura mater.
4. Outside the dura mater is a vacant space (the
epidural space).
5. Beyond it is the ligamentum flavum, yet
another protective shield for the vulnerable
spinal cord.
 Definition
● An aesthetic agent is introduced into the CSF in the subarachnoid
space is spinal injection or spinal anesthesia.
● Anesthetic agent placed just inside the ligamentum flavum in the
epidural space is called epidural anesthesia.
● Anesthetic agents placed in the epidural apace 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; these
blocks can provide pain relief both labor or birth.
● DISADVANTAGE- is that the bearing down reflex may be
reduced or absent, making it difficult for a woman to push
effectively.
 Epidural Blocks
● Is suitable for almost all women, especially
with heart & pulmonary disease, diabetes and
sometimes severe gestational hypertension
because they make labor pain free.
● Epidural blocks are acceptable for use in
preterm labor because the drug has scant
effect on a fetus and allows for a controlled
and gentle birth with lessened trauma to an
immature fetal skull.
● CHIEF CONCERN- tendency to cause
hypotension because of its blocking effect on
the sympathetic nerve fibers in the epidural
space.
Technique for
administratio
n
 Definition
● Epidural blocks are usually delayed until woman's cervix is dilated 3 to 5 cm as
earlier administration may slow the first stage of labor. Be certain an infusion of
Ringer's lactate solution is began preprocedure and that equipment for blood
pressure monitoring is in place and functioning. Help position the woman on her
side on her birthing bed. If she curves her back outward, this increases the
intravertebral spaces and allows easier access to the injection site.
● An epidural block may consist of only an anesthetic injection into the epidural space
or a combined method where a low-dose anesthetic is injected into the epidural
space and a small dose of an analgesic such as fentanyl is also injected into the CSF
space. This combination of drugs and technique is advantageous because it results in
a “walking” or “mobile” block, which produces anesthesia up to the level of the
umbilicus in 10 to 15 minutes that will last for approximately 40 minutes to 2 hours.
A catheter is left in place attached to a syringe to allow for repeated injections
without further injection pain.
 Definition
● Assess a woman’s pulse and blood pressure following the injection. Observe
for toxic symptoms of hypotension, slurred speech, and rapid pulse, which
would occur if the anesthetic was accidentally placed into a blood vessel and
not the hollow epidural space. Be certain to review agency policy regarding
catheter care before caring for a person with a catheter in place to prevent
infection at the site. Proper gowning is encouraged prior to administration for
colonization reduction.
● An epidural block provides anesthesia for uterine contractions but not perineal
relaxation. Close to birth, if the woman sits up and an additional dose of
anesthesia is added to the catheter, perineal anesthesia will result as well.
Leaving the lower anesthesia for late in labor this way is thought to allow for
better internal rotation of the fetal head because the perineal muscle is not lax,
creating a lessened need for forceps for rotation.
 Aftercare for the
Woman With an
Epidural Anesthesia
 Definition
● Following anesthetic administration, be certain a woman lies on her side, or if on
her back, she should place a firm towel under her left hip to avoid hypotension
from poor blood return to the heart. To keep her free from discomfort during the
duration of labor, anesthetic can be continually infused by an infussion pump, or
other doses of anesthetic, termed "top-ups”, can be added at intervals.
● Each time, before an additional top-up dose is administered, ask the woman to say
out loud a phrase such as “I can do it” three times. If she is unable to do this,
question the dose, lack of fine motor coordination and slurred speech can indicate
a slowly occurring toxic reaction.
● Another technique used to maintain epidural anesthesia is self-administration or
patient-controlled epidural analgesia (PCEA). With this technique, following a
lockout period when no more anesthetic can be administered to avoid overdosing,
an analgesic mixture is delivered whenever the patient presses a button on a PCEA
pump.
● When recording vital signs, be aware epidural anesthesia can cause a temporary
elevation in temperature, which is not serious unless it rises above 101 F.
 Definition
● To detect if hypotension is occurring, continuously monitor blood
pressure for the first 20 minutes after each new injection of
anesthetic. Be certain the woman’s systolic pressure does not fall
to less than 100 mmHg or decrease by 20 mmHg or more in a
hypertensive woman.
● After an epidural block, a woman loses sensation of blader filling.
Remind her to void every 2 hours, monitor intake and output, and
observe and palpate for bladder distention to avoid overfilling,
especially if labor is prolonged. Be aware of the standards and
policies of the healthcare agency related to who may add
additional anesthesia or remove the catheter.
 Spinal
(Subarachnoid)
Anesthesia
 Definition
● Spinal anesthesia is not used frequently in preference to epidural blocks, but it may be
used in an emergency or for a cesarean birth. Before spinal anesthesia, as a guard
against hypotension, an IV fluid such as Ringer’s lactate solution is usually begun to
ensure good hydration. Be certain the fluid is infusing well before the anesthesia is
administered.
● For spinal anesthesia, a local anesthetic agent such as bupivacaine (Marcaine) is
injected using lumbar puncture technique into the subarachnoid space into the CSF at
the L3 and L4 interspace. A narcotic agonist such as morphine or fentanyl may be
added for additional pain relief.
● After injection, the anesthetic normally rises to the level of T10. Anesthesia up to the
umbilicus and including both legs will be achieved. Spinal anesthetic agents may be
“loaded” or “weighted” with glucose to make them heavier than CSF. This helps them
from rising too high in the spinal canal and interfering with the motor control of the
uterus or with respiratory muscles.
● Following the anesthetic injection, if the woman was sitting, the anesthesiologist will
ask the woman to lie down. Lying with a pillow under the head is another method to
help ensure the anesthesia will be confined to the lower spinal canal.
 Definition
● If hypotension occurs, placental blood perfusion can be compromised. Tum
woman to her left side to reduce vena cava compression. Expect the
anesthesiologist to quickly increase the rate Of IV fluid administration to
increase blood volume; ephedrine to increase blood pressure and oxygen also
may be administered. Never place a woman in a Trendelenburg position to help
restore blood pressure after spinal anesthesia. A late complication Of spinal
anesthesia is a PDPH or “spinal headache. This occurs because of CSF leakage
from the needle insertion site and also possibly from irritation of a small amount
of air that entered at the injection site.
● A spinal headache can be relieved by the administration of hydrocortisone to
reduce inflammation. Having the woman lie flat and administering an analgesic
also helps. If a headache is incapacitating, it can be treated with a blood patch
technique. For this, 10 to 20 ml of blood is withdrawn from an accessible vein
and injected into the epidural space over the spinal injection site. The injected
blood clots and seals off any further leakage of CSF.
 MEDICATION FOR PAIN
RELIEF
LOCAL ANESTHETICSDURING BIRTH
local anesthesia reduces the ability of local nerve fibers to conduct pain.
 
 Local Infiltration
● is the injection of an anesthetic such as lidocaine (Xylocaine) intro the
superficial nerves of the perinuem along the vulva.

 Pudendal Nerve Block

● is the injection of a local anesthetic such as bupivacaine (Marcaine)
through the vagina to anesthetize the pudendal nerve.
 GENERAL ANESTHESIA
is never preferred for childbirth because it carries the dangers of hypoxia and possible
inhalation of vomitus during administration.

For complete and rapid anesthesia during childbirth, thiopental sodium (Pentothal), a
short-acting barbiturate, is usually the drug of choice. All women who receive a general
anesthetic, however, must be observed closely in the postpartal period for uterine
relaxation and the risk of uterine atony and postpartal hemorrhage.
 
Preparation for the Safe Administration of General Anesthesia
→ Ephedrine to use in the event blood pressure falls
→ Atrophine sulfate to dry oral and respiratory secretions to prevent aspiration
→ Thiopental sodium for rapid induction
→ Succinylcholine to achieve laryngeal relaxation for intubation
→ Diazepam to control seizures, a possible reaction to anesthetics
→ Isoproterenol to reduce bronchospasm, should aspiration occur

 Aspiration of Vomitus
There is danger of vomiting with general anesthetic, this can be fatal if a woman’s
airway becomes occluded by foreign matter.
Nursing care
plan
 NCP for Pain Relief during Labor and Childbirth
Assessment Nursing Diagnosis Outcome Implementation Rationale Outcome
Identification & Evaluation
planning
Subjective: Pain related to Delivers Supporting and Provides pain Patient states pain
  labor interventions to encouraging the relief during during labor is
Patient verbalizes pain, contractions. manage woman to use labor. within a tolerable
sensation of discomfort.   discomfort during methods of   lever for her.
  labor. complementary and
Objective:   alternative therapies
  for pain management.
Assess vital signs.  
  Powerlessness Delivers Keeping the patient Can make next Couple reports
Assess pain using pain related to the interventions to and her support contractions they feel control
assessment scale. duration and manage duration person informed easier to throughout the
  intensity of labor. and intensity of about the labor withstand. labor process.
Observe for:   labor. progress.    
Facial tenseness,      
Flushing or paleness, Anxiety related to  The nurse Keep the patient and Alleviates Couple reports
Hands clenched in fists, lack of knowledge Consider the her support person anxiety related they feel control
Rapid breathing, about “normal” woman’s informed about their to lack of throughout the
  labor process. perception about options and how they knowledge labor process.
  childbirth, her differ as labor about labor  
past childbirth progress. process. .
experience (if any)    
and the amount     
and type of  
childbirth
preparation she
and her partner
have made.
 NCP for Pain Relief during Labor and Childbirth
Assessment Nursing Diagnosis Outcome Implementation Rationale Outcome
Identification & Evaluation
planning
           
Risk for situational The nurse A nurse must have  To boost self- Patient and fetus
low self-esteem prepares the a caring presence esteem of the remain
related to need of to help the patient woman in physiologically
ineffectiveness of medication later accept analgesia labor. stable with use of
prepared childbirth in labor. when she needs it pharmacologic
breathing exercises.   and to encourage interventions.
the patient to
experience
childbirth without
pharmacologic
intervention when
that is what she  
  desires.  
Decisional conflict      
related to use of In considering To have a good To prevent risk Patient verbalizes
analgesia or pharmacologic nursing judgement complications satisfaction with
anesthesia during intervention, the in offering in labor. current pain
labor. nurse identifies analgesia or control measures.
the benefits of assisting with
the mother and anesthesia
the fetus must administration
outweigh the risk during labor or
of medication both.
use.  
   
 
Nursing
care to a
woman
during
 Labor is the series of events by which uterine contractions and
abdominal pressure expel a fetus and placenta from a woman’s
body. Regular contractions cause progressive dilata tion
(enlargement or widening of the cervical canal) and create
sufficient muscular force to allow a baby to be pushed from the
birth canal (or vagina). It is a time of change, both an ending and
a beginning, for a woman, a fetus, and her family. Labor and birth
require a woman to use all the psycholog ical and physical coping
methods she has available. Regardless of the amount of childbirth
preparation or the number of times she has been through the
experience before, family-fo cused nursing care is needed to
support the family as they mark the beginning of a new family
structure.
Assess
ment
Assessment of a woman in labor must be done quickly yet thoroughly and
gently. A woman is keenly aware of words spoken around her and the
manner with which procedures are carried out. Because of this sensitivity,
she may have difficulty relaxing for a vaginal examination if she fears that
pressure on the fetal head will cause her pain.

Remember that pain is a subjective symptom. Only the woman can evaluate
how much she is experiencing or how much she wants to endure. Assess how
much discomfort a woman in labor is having, not only by what she scores on
a pain scale but also by subtle signs of pain such as facial tenseness, flushing
or paleness of the face, hands clenched in a fist, rapid breathing, or rapid
pulse rate. Knowing the extent of a woman’s discomfort helps guide.
 Nursing
diagnosis
Common nursing diagnoses pertinent to labor include:

• Pain related to labor contractions

• Anxiety related to process of labor and birth
• Health-seeking behaviors related to management of
discomfort of labor
• Situational low self-esteem related to inability to use
prepared childbirth method

Although the discomfort of labor is commonly referred

to as “contractions” rather than “pain,” do not omit the
word “pain” from a nursing diagnosis, because the term
strengthens an understanding of the problem.
outcome identification and
planning
When establishing expected outcomes for a woman in labor and her partner, be
certain they are realistic. Because labor usually takes place over a relatively
short timeframe, outcomes must be met within this period. It is unlikely that all
the fear or anxiety experienced during a woman’s labor can be
alleviated. Often, because it is such an unusual and significant experience, an
average couple may need assistance with using additional coping measures.
Although a couple may have learned this information during pregnancy, the
reality of labor may seem much different from what they imagined. Planning
also must be flexible, changing with the progress of labor, and
individualized, allowing a woman to experience the significance of the event
for herself.
Comfort promotion is a vital part of care.
implementation
The person a woman chooses to stay with her during childbirth can be
a husband, the father of the child, a sister or parent, or a close
friend. Which of these persons a woman chooses is somewhat
culturally determined. If the woman is not proficient in English, make
arrangements to locate an interpreter. Remember that whether a
woman enjoys being touched or not during labor is in part culturally
determined.

Assess early in a woman’s labor whether she might benefit from such
caring measures as having her hand held or her back rubbed.
Outcome evaluation
After birth, evaluation helps to determine a woman’s
opinion of her experience with labor and birth.
Ideally, the experience should be not only one that
she was able to endure but one that allowed her self-
esteem to grow and the family to grow through a
shared experience.
Assessment Nursing Diagnosis Nursing outcomes Implementation Rationale Evaluation

Subjective: Pain related to Patient will As much as possible, To limit the Patient states pain
  labor contraction. appreciate the pain interventions during discomfort of the during labor was
The patient vocalizes   and magnitude of labor should always contractions. tolerable because of
pain because of labor   labor. be carried out   her advance
contraction.     between   preparation.
      contractions so the    
Objective:     woman can use a    
      prepared childbirth    
Get the mother and     technique.    
the fetus Vital signs.          
         
Vaginal examination.      
  Anxiety related to If not all, at least To have a good This lessens the Patient states
Assess pain using: process of labor most of the fear or coordination of care woman’s anxiety anxiety during labor
Pain scale, and birth. anxiety experienced among health care related to process of was alleviated
Facial tenseness,   during the patient’s providers and the labor and birth. because of her
Flushing or paleness   labor will be patient and her   advance
of the face,   alleviated. support person.   preparation.
Hands clench in fist,          
Rapid breathing,       
Rapid pulse rate.      
         
           
         
         
       
   
Assessment Nursing Diagnosis Nursing outcomes Implementation Rationale Evaluation

  Situational low The couple will be To have a good To uplift self-esteem Patient and family
  self-esteem related guided to be able to coordination of care related to planned members state the
to inability to use employ additional among health care childbirth method. labor and birth
planned childbirth coping measures. providers and the experience was a
method. woman and her positive growth
support person. experience for them,
both individually
and as a family.

Patient verbalizes
Health seeking To incorporate a The person the The support person that her need for
behaviors related support person to patient chooses to the woman choose non-pharmacologic
to management of the patient during stay with her during will help her manage comfort measures
discomfort of labor so that the childbirth is often discomfort of labor. was met.
labor. experienced is a culturally determined
shared one. and varies from
being a husband, a
significant other or a
partner, the father of
the child, a sister, a
parent, or a close
friend.