Chap 8

Report
Chapter 8
Management of Pain
During Labor
Copyright © 2012, 2008 by Saunders, an imprint of Elsevier Inc.
1
Managing the Pain of Labor
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2
Objectives
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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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3
Pain Management
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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
This knowledge assists in the development of a
nursing plan of care
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4
Standards of Pain Management
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The Joint Commission standards for patients
and pain management include:
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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
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5
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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6
Factors That Influence
Labor Pain
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7
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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8
Pain Tolerance
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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
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9
Sources of Pain During Labor
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10
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
Intensity of contractions
Length of time for cervical changes to occur
Size/position of fetus
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11
Additional Contributing Factors
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Woman’s fatigue and pain tolerance
Fear and anxiety
Cervical readiness
Interventions of caregivers
Psychosocial factors

Culture
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12
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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13
Distraction
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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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14
Examples of Distraction
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Breathing
Listening to music
Verbal coaching
Effleurage
Acupuncture
External analgesics
Back massage
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15
Chemical Factors
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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
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16
Endorphins
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May be produced by stress and increase the
pain threshold
May make the woman drowsy and sleepy
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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
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18
Methods to Control Pain
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19
Objectives
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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.
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20
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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21
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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22
Cognitive Stimulation
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Mental stimulation
Imagery
Focal point
Require active participation by the woman in
labor
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23
Cutaneous Stimulation
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Touch
Rubbing
Massaging
Counterpressure
Rhythmic stroking of the abdomen
(effleurage)
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24
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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25
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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26
Recognizing and Correcting
Hyperventilation
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Signs and
symptoms
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Corrective measures
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Dizziness
Tingling of hands
and feet
Cramps and muscle
spasms of hands
Numbness around
nose and mouth
Blurring of vision
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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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27
Relaxation
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Most effective teaching time, once labor has
begun
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Between contractions and during the first stage of
labor
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28
Hypnosis
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Appears to be safe, without known side
effects
Positive physical and psychological outcomes
Woman in labor is usually trained in selfhypnosis
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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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29
Pharmacologic
Pain Control Strategies
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30
Physiology of Pregnancy
and Its Relationship
to Analgesia and Anesthesia
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31
Factors Affecting Woman’s
Response
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Higher risk for hypoxia
Increased risk for vomiting and aspiration
Increased risk of hypotension and
development of shock
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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
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33
Limitations of Pharmacologic
Methods
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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
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34
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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35
Analgesics During Labor
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May reduce hormonal and stress response to
pain of labor
May be especially advantageous to obese or
hypertensive woman
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36
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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37
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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38
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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39
Adjunctive Drugs
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Phenothiazine medication
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Promethazine (Phenergan)
Hydroxyzine (Vistaril)
Can control nausea and anxiety
Reduce narcotic requirements during labor
Do not relieve pain
Used in conjunction with opioids
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40
Anesthesia
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Regional blocks
General anesthesia
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41
Regional Anesthesia
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Woman is able to participate in the birth
Retains her protective airway reflexes
Informed consent is required prior to
administration of any regional anesthesia
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42
Regional Anesthesia Locations
Pudendal block provides local
anesthesia adequate for an
episiotomy and use of low
forceps
Injection sites of regional
anesthetics
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43
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 first or second stage of labor
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44
Anesthesia for Cesarean
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A spinal subarachnoid block is used for
cesarean births
Levels of anesthesia for epidural and subarachnoid blocks.
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45
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
second stage of labor
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46
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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47
Side Effects of Regional
Anesthesia and the Nursing Role
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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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48
Intramuscular Medication
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Why is the deltoid the preferred site of the
injection?
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It has a predictable absorption rate when
compared to the rest of the possible injection sites
on the body.
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49
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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50
Side Effects from Spinal Blocks
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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
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51
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 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
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52
The Nurse’s Role
in Pharmacologic Techniques
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Question woman about last food intake and
whether she has any food or drug allergies,
including dental anesthetics and latex
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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
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53
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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54
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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55
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
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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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
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57
Review Key Points
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58

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