Chapter 8 Management of Pain During Labor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 1 Managing the Pain of Labor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 2 Objectives 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. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 3 Pain Management Designing a care plan that meets the needs of a woman in labor includes Knowledge of the characteristics of pain in various stages of labor Interventions for pain relief Comfort methods Cultural responses to labor This knowledge assists in the development of a nursing plan of care Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 4 Standards of Pain Management The Joint Commission standards for patients and pain management include: The right to pain management Staff must competently assess and manage pain Policies should support prescription pain medication Education about pain management should be provided Exists past discharge Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 5 The Unique Pain of Labor 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 6 Factors That Influence Labor Pain Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 7 Pain Threshold Pain perception Least amount of sensation that a person perceives as painful Fairly constant Varies little under different conditions Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 8 Pain Tolerance Amount of pain one is willing to endure Tolerance can change under different conditions Primary nursing responsibility Modify as many factors as possible so woman can safely tolerate the labor and delivery process Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 9 Sources of Pain During Labor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 10 Sources of Pain During Labor Dilation and stretching of cervix Uterine contractions Pressure and pulling of pelvic structures Distention and stretching of the vagina and perineum Intensity of contractions Length of time for cervical changes to occur Size/position of fetus Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 11 Additional Contributing Factors Woman’s fatigue and pain tolerance Fear and anxiety Cervical readiness Interventions of caregivers Psychosocial factors Culture Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 12 Gate Control Theory 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 13 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 14 Examples of Distraction Breathing Listening to music Verbal coaching Effleurage Acupuncture External analgesics Back massage Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 15 Chemical Factors Neuromodulators, also called endorphins or endogenous opiates Protein chemicals found in the brain Known to relieve pain Endorphins are similar to morphinelike substances Believed to play a role in biologic response to pain Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 16 Endorphins May be produced by stress and increase the pain threshold May make the woman drowsy and sleepy Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 17 Audience Response System Question 1 What type of stimulation during the labor process uses focal points to distract the woman from the pain of the contraction? A. B. C. D. Thermal Breathing Cognitive Hypnosis Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 18 Methods to Control Pain Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 19 Objectives Discuss 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. Outline the nursing responsibilities related to pharmacologic and nonpharmacologic pain management during labor. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 20 Nonpharmacologic Pain Control Strategies General support Imagery or visualization Distraction Changes in temperature Touch Comfort measures Baths Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 21 Comfort Measures and Stimuli Eliminate sources of noxious (offensive) stimuli Relieve thirst, sweating, and heat through comfort measures Repositioning Adjusting monitoring belts Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 22 Cognitive Stimulation Mental stimulation Imagery Focal point Require active participation by the woman in labor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 23 Cutaneous Stimulation Touch Rubbing Massaging Counterpressure Rhythmic stroking of the abdomen (effleurage) Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 24 Thermal Stimulation 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 25 Breathing Techniques Change the focus during the contraction Can be taught to the unprepared woman while in labor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 26 Recognizing and Correcting Hyperventilation Signs and symptoms Corrective measures Dizziness Tingling of hands and feet Cramps and muscle spasms of hands Numbness around nose and mouth Blurring of vision 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 27 Relaxation Most effective teaching time, once labor has begun Between contractions and during the first stage of labor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 28 Hypnosis Appears to be safe, without known side effects Positive physical and psychological outcomes Woman in labor is usually trained in selfhypnosis Nurse may need to help trigger it by using specific suggestions or playing specific audiotapes Careful observation and documentation concerning labor progress are essential Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 29 Pharmacologic Pain Control Strategies Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 30 Physiology of Pregnancy and Its Relationship to Analgesia and Anesthesia Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 31 Factors Affecting Woman’s Response Higher risk for hypoxia Increased risk for vomiting and aspiration Increased risk of hypotension and development of shock Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 32 Advantages of Pharmacologic Methods Help woman relax and work with contractions; otherwise 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 33 Limitations of Pharmacologic Methods Two people 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 34 Before Administration of Drugs Baseline assessment of woman and fetus Labor should be well-established, with cervical dilation of at least 4 cm, before woman receives pain medication Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 35 Analgesics During Labor May reduce hormonal and stress response to pain of labor May be especially advantageous to obese or hypertensive woman Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 36 Analgesia 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 37 Examples of Analgesics 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 38 Sedatives 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 39 Adjunctive Drugs Phenothiazine medication Promethazine (Phenergan) Hydroxyzine (Vistaril) Can control nausea and anxiety Reduce narcotic requirements during labor Do not relieve pain Used in conjunction with opioids Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 40 Anesthesia Regional blocks General anesthesia Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 41 Regional Anesthesia Woman is able to participate in the birth Retains her protective airway reflexes Informed consent is required prior to administration of any regional anesthesia Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 42 Regional Anesthesia Locations Pudendal block provides local anesthesia adequate for an episiotomy and use of low forceps Injection sites of regional anesthetics Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 43 Epidural Blocks Anesthetic is injected into epidural space Inside the vertebral column surrounding dural sac in lumbar region of spine Given during first or second stage of labor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 44 Anesthesia for Cesarean A spinal subarachnoid block is used for cesarean births Levels of anesthesia for epidural and subarachnoid blocks. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 45 Epidural and Intrathecal Opioids Without anesthetic agent Allows woman to sense contractions without feeling pain Retains ability to voluntarily bear down during second stage of labor Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 46 Contraindications to Epidural and Subarachnoid Blocks Hypovolemia Anticoagulant therapy Blood-clotting disorder Allergy Infection at injection site Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 47 Side Effects of Regional Anesthesia and the Nursing Role 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 48 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. Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 49 Signs of Toxicity to Local Anesthetics Rare occurrence Symptoms include Disorientation Tinnitus Twitching Seizures Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 50 Side Effects from Spinal Blocks Blood patch for relief of spinal headache 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 51 General Anesthesia 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 is at risk for regurgitation and aspiration of gastric contents Crosses placental barrier Fetus will be under its effects at birth Causes uterus to relax postpartum Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 52 The Nurse’s Role in Pharmacologic Techniques Question woman about last food intake and whether she has any food or drug allergies, including dental anesthetics and latex Helps to identify pain relief measures that may not be advisable Ask about the woman’s preference for pain relief Once medications have been given, side rails on the bed should be kept up Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 53 Monitor Laboring Woman 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 54 Nursing Responsibilities and General Anesthesia 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 Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 55 Postoperative Assessment Respiratory rate, especially if given narcotics Includes assessing mother and newborn for Late-appearing respiratory depression Excessive sedation, if epidural narcotics given after cesarean birth May last for up to 24 hours Assess level of sensation If woman complains of numbness in chest or higher, this is an emergency and should be reported immediately Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 56 Audience Response System Question 2 Normal saline or lactated Ringer’s solution is administered to a laboring woman to treat dehydration. Glucose is not given because it can: A. B. C. D. Decrease kidney excretion of urine Cause decreased insulin production in the woman Cause hypoglycemia in the infant Decrease uteroplacental blood flow Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 57 Review Key Points Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc. 58