Chapter 17
MAXIMIZING COMFORT FOR
THE LABORING WOMAN
Copyright © 2016 by Elsevier Inc. All rights reserved.
Learning Objectives



Identify nonpharmacologic strategies, including
breathing and relaxation techniques, used to
enhance relaxation and promote comfort during
labor and birth.
Compare pharmacologic methods used to
relieve discomfort in different stages of labor and
for vaginal or cesarean birth.
Discuss the effects of medication management
for the mother and for the newborn both during
and after birth.
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Learning Objectives (Cont.)



Construct an evidence-based plan to manage
the discomfort that a woman experiences during
childbirth.
Explain the nurse’s role and responsibilities while
providing care for a woman receiving analgesia
or anesthesia during labor.
Describe the nurse’s role in promoting comfort
and safety throughout the labor and birth
process.
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3

Pain During Labor and Birth
Neurologic origins
 Visceral
 Referred
 Somatic

Perception of pain

Expression of pain
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Factors Influencing Pain
Response

Physiologic factors

Culture

Anxiety

Previous experience

Gate-control theory of pain

Comfort

Support

Environment
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Nonpharmacologic Pain
Management

Childbirth preparation methods

Relaxing and breathing techniques

Focusing and relaxation

Breathing techniques

Effleurage and counterpressure

Touch and massage


Therapeutic touch
Application of heat and cold
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6
Nonpharmacologic Pain
Management (Cont.)








Acupressure and
acupuncture
Transcutaneous
electrical nerve
stimulation
Water therapy
(hydrotherapy)
Intradermal water block
Aromatherapy
Music
Hypnosis
Biofeedback
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Pharmacologic Pain
Management

Sedatives: relieve anxiety and induce
sleep; typically used for women in a
prolonged latent phase of labor when
there is a need to lessen the intensity of
the contractions, decrease anxiety, or
promote sleep

Barbiturates

Phenothiazines

Benzodiazepines
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Pharmacologic Pain
Management (Cont.)

Anesthesia encompasses analgesia,
amnesia, relaxation, and reflex activity.

Analgesia: the alleviation of the
sensation of pain or the raising of the
threshold for pain perception without
loss of consciousness

The type of analgesic or anesthetic chosen
is determined in part by the stage of labor
of the woman and by the method of birth
planned.
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Pharmacologic Pain
Management (Cont.)

Systemic analgesia
 Opioid
(narcotic) agonist
analgesics
 Opioid
(narcotic) agonist–
antagonist analgesics
 Opioid
(narcotic) antagonists
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Pharmacologic Pain
Management (Cont.)

Nerve block analgesia and
anesthesia
 Local
perineal infiltration anesthesia
 Pudendal
 Spinal
nerve block
anesthesia (block)
 Post–dural
 Epidural
puncture headaches
blood patch
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11
Pharmacologic Pain
Management (Cont.)

Nerve block analgesia and anesthesia
(Cont.)



Epidural anesthesia or analgesia (block):
currently the most effective pharmacologic
pain relief method for labor
Combined spinal-epidural (CSE) analgesia:
sometimes referred to as a “walking
epidural,” although women often choose
not to walk because of sedation and
fatigue, abnormal sensations in and
weakness of the legs, and a feeling of
insecurity
Epidural and intrathecal (spinal) opioids
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Copyright © 2016 by Elsevier Inc. All rights reserved.
13
Pharmacologic Pain
Management (Cont.)

Contraindications to subarachnoid and epidural
blocks

Active or anticipated serious maternal hemorrhage

Maternal hypotension

Maternal coagulopathy

Infection at the injection site

Increased intracranial pressure

Allergy to the anesthetic drug

Maternal refusal or inability to cooperate

Some types of maternal cardiac conditions
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Pharmacologic Pain
Management (Cont.)
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Pharmacologic Pain
Management (Cont.)

Nitrous oxide for analgesia

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Nitrous oxide mixed with oxygen can be inhaled in a
low concentration (50% or less) to provide analgesia
during the first and second stages of labor.
General anesthesia



Rarely used for uncomplicated vaginal birth
The woman should be premedicated with (clear)
oral antacid to neutralize the acidic contents of the
stomach.
Because of this risk for neonatal narcosis, it is critical
that the baby be delivered as soon as possible after
induction of general anesthesia, to reduce the
degree of fetal exposure to the anesthetic agents
and the CNS depressants administered.
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Care Management for
Nonpharmacologic Interventions

Ask the woman how she feels to
evaluate the effectiveness of the
specific pain management
techniques used

Use a pain scale and/or coping
scale
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17
Care Management for
Pharmacologic Interventions

General informed consent

Informed consent for anesthesia

Timing of administration

Preparation for procedures

Administration of medication


Intravenous route

Intramuscular route

Regional (epidural or spinal) anesthesia
Safety and general care
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Key Points

Nonpharmacologic pain and stress management
strategies are valuable for managing labor
discomfort alone or in combination with
pharmacologic methods.

The gate-control theory of pain and the stress
response are the bases for many of the
nonpharmacologic methods of pain relief.

The type of analgesic or anesthetic to be used is
determined by maternal and health care provider
preference, the stage of labor, and the method of
birth.
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Key Points (Cont.)

Sedatives may be appropriate for women in
prolonged early labor when there is a need to
decrease anxiety or promote sleep or therapeutic
rest.

Naloxone (Narcan) is an opioid (narcotic)
antagonist that can reverse narcotic effects,
especially respiratory depression.

Pharmacologic control of pain during labor requires
collaboration among the health care providers and
the laboring woman.
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Key Points (Cont.)

The nurse must understand medications, their
expected effects, potential side effects, and
methods of administration.

Maintenance of maternal fluid balance is essential
during spinal and epidural nerve blocks.

Maternal analgesia or anesthesia potentially affects
neonatal neurobehavioral response.
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Key Points (Cont.)

The use of opioid agonist-antagonist analgesics in
women with preexisting opioid dependence may
cause symptoms of abstinence syndrome (opioid
withdrawal).

Epidural anesthesia and analgesia are the most
effective available pharmacologic pain relief
methods for labor. They are used by the majority of
women in the United States.

General anesthesia is rarely used for vaginal birth
but may be used for cesarean birth or whenever
rapid anesthesia is needed in an emergency
childbirth situation.
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Question
1.
A woman in labor has just received an epidural
block. The most important nursing intervention is to:
a. Limit parenteral fluids
b. Monitor the fetus for possible
tachycardia
c. Monitor the maternal blood
pressure for possible hypotension
d. Monitor the maternal pulse for
possible bradycardia
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