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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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