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Copyright 2008 by Saunders, an imprint of Elsevier Inc. 1

Chapter 8

Management of Pain

During Labor

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Chapter 8

Lesson 8.1

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Objectives

1. Define key terms listed.

2. Describe the factors that influence awomans comfort during labor.

3. Explain the physical causes of painduring labor.

4. Explain the role of endorphins in thebody.

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Nursing Responsibilities

Designing a care plan that meets the needsof 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

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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

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Factors That InfluenceLabor Pain

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Pain Threshold

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

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 thatthe 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

Dilation and stretching of cervix

Uterine contractions

Pressure and pulling of pelvic structures

Distention and stretching of the vagina andperineum

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Additional Contributing Factors

Cervical readiness

Interventions of caregivers

Psychosocial factors

Culture

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Chemical Factors

Neuromodulators, aka endorphins orendogenous 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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Chapter 8

Lesson 8.2

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Nonpharmacologic

Pain Control Strategies

General support

Imagery or visualization

Distraction

Changes in temperature Touch

Comfort measures

Baths

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Cutaneous Stimulation

Touch

Rubbing

Massaging

Counterpressure Rhythmic stroking

Effleurage

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Thermal Stimulation

Warm bath or shower during early phase oflabor

Cool damp cloth to the forehead later in labor

Hot or cold towels applied to the back

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Relaxation

Most effective teaching time, once labor hasbegun

Between contractions and during the first stage of

labor

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Hypnosis

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 Relationshipto Analgesia and Anesthesia

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Analgesics During Labor

May reduce hormonal and stress response topain of labor

May be especially advantageous to obese or

hypertensive woman

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Examples of Analgesics

Meperidine (Demerol)most common

Sublimaze (Fentanyl)rapid onset

Butorphanol (Stadol) and nalbuphine

(Nubain)combination opioid agonist-antagonist

Naloxone (Narcan)reverses effects of

opioids, can cause withdrawal symptoms in

drug-addicted mother or infant

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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

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Regional Anesthesia

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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Anesthesia for Cesarean

A spinal subarachnoid block is used for cesareanbirths

Levels of anesthesia for epidural and subarachnoid blocks.

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Epidural and Intrathecal Opioids

Without anesthetic agent

Allows woman to sense contractions without

feeling pain

Retains ability to voluntarily bear down during2nd stage of labor

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Side Effects of Regional Anesthesia and

the Nursing Role

Informed consent required Womans bladder is emptied before insertion

procedure

Assist with positioning woman

Monitor for hypotension; if it occurs,administer Ringers 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 theinjection?

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

Rare occurrence Symptoms include

Disorientation

Tinnitus Twitching

Seizures

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Side Effects from Spinal Blocks

Headache Caused by leakage of spinal

fluid

Bed rest, in a flat andsupine position, can relieveheadaches that may occur

in the postpartum period Blood patch often provides

relief

Avoid coughing or strainingfor bowel movements for a

few daysBlood patch for relief of spinal headache.

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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 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 notcontract

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The Nurses Role

in Pharmacologic Techniques

Question woman about last food intake and whethershe has any food and drug allergies, including dental

anesthetics and latex

Helps to identify pain relief measures that may not be

advisable

Ask about the womans 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

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

Assessment and documentation of oral intake Administration of medications

Providing key information to woman, such asshe will be asleep before the initial incision is

made Postoperative: vital signs, fundal massage,

assess for signs of hemorrhage, urinaryoutput

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Postoperative Assessment

Respiratory rate, especially if given narcotics Includes assessing mother and newborn for

Late-appearing respiratory depression

Excessive sedation, if epidural narcotics given aftercesarean 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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Question for Review

What are two priority assessments for awoman who has received epidural analgesia

during labor?

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