Experience of Pain During Childbirth Pain accompanies labor contractions for a number of different reasons.

Etiology of Pain During Labor and Birth Normally, contractions of involuntary muscles, such as the heart, stomach, and intestine, do not cause pain. This concept makes uterine contractions unique because they do cause it. Several explanations exist for why this happens. Durin contractions, blood vessels constrict, reducin the blood supply to uterine and cervical cells, resultin in anoxia to muscle fibers. This anoxia can cause pain in the same way that blocka e of the cardiac arteries causes the pain of a heart attack. !s labor pro resses and contractions become lon er and harder, the ischemia to cells increases, the anoxia increases, and the pain intensifies. Pain also probably results from stretchin of the cervix and perineum. This phenomenon is the same as that causin intestinal pain when accumulatin as stretches the intestines. !t the end of the transitional phase in labor, when stretchin of the cervix is complete and the woman feels she has to push, pain from the contractions often disappears as lon as the woman is pushin , until the fetal presentin part causes the final stretchin of the perineum. !dditional discomfort in labor may stem from the pressure of the fetal presentin part on tissues, includin pressure on surroundin or ans, such as the bladder, the urethra, and the lower colon. Pain at birth lar ely results from stretchin of the perineal tissue. Physiology of Pain Pain is a basic protective mechanism that alerts a person that somethin harmful is happenin somewhere in the body. Pain sensation be ins in nociceptors, the end points of afferent nerves, when they are activated by mechanical, chemical, or thermal stimuli. Nociceptors are located predominantly in the skin, bone periosteum, "oint surfaces, and arterial walls. #hen end terminals are stimulated, chemical mediators such as prosta landins, histamine, bradykinin, and serotonin are synthesi$ed and sensiti$e the nociceptors. The pain impulse is transmitted alon small, unmyelinated % fibers and lar e, myelinated !&delta fibers to the spinal cord. The more numerous % fibers conduct slowly and apparently carry dull, low&

level pain' the fewer !&delta fibers apparently carry sharp, well&locali$ed pain such as labor contractions. (n the dorsal horn of the spinal cord, somatostatin, cholecystokinin, and substance P serve as neurotransmitters or assist the pain impulse across the synapse between the peripheral nerve and the spinal nerve. The pain impulse then ascends the spinal cord to the brain cortex, where it is interpreted as pain. The )el$ack&#all ate control theory of pain control, the most widely accepted theory of pain response today, proposes that pain can be halted at three points* the peripheral end terminals, the synapse points in the dorsal horn, or the point at which the impulse is interpreted as pain in the brain cortex. Pain in peripheral terminals is automatically reduced by the production of endorphins and enkephalins, naturally occurrin opiates that limit transmission of pain from the end terminals. Pain can be reduced further by mechanically irritatin nerve fibers by an action such as rubbin the skin. This technique blocks nerve transmission. ! ma"or action of pain medications is to block spinal cord neurotransmitters, never allowin the pain impulse to cross to a spinal nerve. The brain cortex can be distracted from sensin impulses as pain by such techniques as ima ery, thou ht stoppin , aromatherapy, or yo a. Sensory impulses from the uterus and cervix synapse at the spinal column at the level of T+, throu h T+- and .+. Pain relief measures for the first sta e of labor, therefore, must block these upper synapse sites. /or the elimination of pain durin cesarean birth, receptors at the level of T0 throu h T1 must be blocked, so that both the upper and lower uterus are blocked. Sensory impulses from the perineum are carried by the pudendal nerve to "oin the spinal column at S-, S2, and S3. #hen the perineum is initiatin the pain, pain relief must block these lower receptor sites. This is an important point to remember when talkin to a woman in labor about pain relief. Some

interventions relieve pain for both the first and second sta es of labor, whereas others work for one sta e but not both. Perception of Pain The amount of discomfort a woman experiences durin contractions differs accordin to her expectations of and preparation for labor, the len th of her labor, the position of her fetus, and the availability of support people around her. The discomfort she experiences can become compounded when fear and anxiety are also present. Pain is perceived differently by different individuals because of psychosocial, physiolo ic, and cultural response. The body4s ability to produce and maintain endorphins 5naturally occurrin opiate&like substances6 may influence a person4s overall pain threshold and the amount of pain a person perceives at any iven time. #omen who come into labor believin the pain will be horrible are usually surprised afterward to reali$e that the a ony they expected never materiali$ed. 7n the other hand, expectations of pain may make a woman so tense durin labor that her pain is worse than it would have been if she had been relaxed. ! woman cannot relax simply because she is instructed to do so by another person, however. Some additional interventions must be used. Factors Influencing Pain Perception /etal position is a physical variable that can influence the de ree of pain a woman experiences. (f the fetus is in an occiput posterior position, for example, the woman often reports intense or na in back pain, even between contractions. Psycholo ical factors that can influence pain include fear, anxiety, worry, expectation of pain, body ima e, and self&efficacy. #omen who believe that they can control their situation 5have self&efficacy6 are more apt to report a satisfactory birth experience than those who do not feel in control

8esponses to pain are, in part, culturally determined. 9ased on this, some women believe that bein stoic and nonverbal is what is expected of them. 7thers believe that expressin their discomfort by screamin or verbali$in their feelin s will best reduce pain. !ssess each woman

individually to determine not only what level of comfort she feels is ri ht for her durin labor but also the manner in which she feels most able to express discomfort. Depend on facial expression, body posture, and tension, as well as voiced expressions, to determine a client4s level of comfort.

The amount of anal esia that women desire or will accept is both situationally and culturally determined. (n a culture in which birth is seen as a :natural; process, less anal esia is enerally desired. #omen who have an effective support person with them may need less pharmacolo ic pain relief than those who do not. Providin nursin support can have a positive influence on pain relief in labor.

Comfort and Pain Relief Measures Nurses play a key role in educatin women and their support persons about the numerous comfort and pain relief strate ies available and makin sure couples understand the choices available to them alon with the benefits and risks. Throu hout their decision&makin process, couples need support for their choices so that they can feel confidence in the method chosen. upport from a Doula or Coach ! woman4s husband or the father of her child has traditionally served as the chief support person in labor. <owever, some husbands or fathers find it difficult to provide effective coachin or support in labor because of their own emotional involvement in the birth. #omen who are aware that they may not have effective one&to&one support in labor from their baby4s father should be encoura ed to identify an additional person who could come with them and provide this support. ! doula is a woman who is experienced in childbirth, but without professional credentials, who uides and assists women in labor. <avin a doula can increase a woman4s self&esteem as well as decrease rates of oxytocin au mentation, epidural anesthesia, and cesarean birth. Complementary and !lternati"e #herapies for Pain Relief %omplementary and alternative therapies for pain relief involve nonpharmacolo ic measures that may be used either as a woman4s total pain mana ement pro ram or to complement pharmacolo ic interventions. )ost

of these interventions are based on the ate control theory concept that distraction can be effective in preventin the brain from processin pain sensations comin into the cortex. Relaxation 8elaxation keeps the abdominal wall from becomin tense, allowin the uterus to rise with contractions without pressin a ainst the hard abdominal wall. (t also serves as a distraction technique because, while concentratin on relaxin , a woman cannot concentrate on pain. (n addition to conscious relaxation, havin a woman shift position or find the position in labor that is most comfortable for her can be helpful. !skin a woman to brin favorite music tapes or aromatherapy with her to en"oy in the birthin room is a ood way to aid relaxation. Focusing and Imagery %oncentratin intently on an ob"ect is another method of distraction, or another method of keepin sensory input from reachin the cortex of the brain. /or this technique, a woman uses a photo raph of someone important to her or some ima e she finds appealin . She concentrates on it durin contractions 5focusin 6. 7ther women concentrate on a mental ima e, such as waves rollin onto a beach 5ima ery6. Do not ask questions or talk to a woman while she is usin ima ery or focusin , because it breaks her concentration. Breathing #echni$ues 9reathin patterns are also tau ht in most preparation for childbirth classes. They are advanta eous because they help to relax a woman4s abdomen. They are lar ely distraction techniques, because a woman concentratin on slow& paced breathin cannot concentrate on pain. 9reathin strate ies can be tau ht to a woman in labor if she is not familiar with their advanta es before labor. %erbal Preparations Several herbal preparations have traditionally been used to reduce pain with dysmenorrhea or labor, althou h there is little factual support for their effectiveness. =xamples include raspberry leaves, fennel, and life root. 9lue cohosh 5squaw root6, used to induce uterine contractions, is not

recommended because of the risk of acute toxic effects 5e. ., cerebrovascular accident6 to the mother or fetus. !romatherapy and Essential &ils !romatherapy is the use of aromatic oils to complement emotional and physical well&bein . Their use is based on the principle that the sense of smell plays a si nificant role in overall health. #hen an essential oil is inhaled, its molecules are transported via the olfactory system to the limbic system in the brain. The brain responds to particular aromas with emotional responses. #hen applied externally, they are absorbed by the skin and then carried throu hout the body. The oils used may be able to penetrate cell walls and transport nutrients or oxy en to the inside of cells. >asmine and lavender are oils thou ht to be responsible for an easier labor. #hen a drop of oil, such as lavender, is placed on the skin, a woman is able to taste it within +? seconds. %eat or Cold !pplication <eat and cold have always been used for pain relief after in"uries such as minor burns or strained muscles. (t is only lately that they have been investi ated as effective ways to help relieve the pain of labor contractions. #omen who are havin back pain may find application of heat to the lower back by a heatin pad or a moist compress very comfortin . #omen who become warm from the exertion of labor find a cool washcloth to the forehead comfortin . (ce chips to suck on to relieve mouth dryness are also refreshin . Bathing or %ydrotherapy Standin under a warm shower or soakin in a tub of warm water, "et hydrotherapy tub, or whirlpool is another way to apply heat to help reduce the pain of labor. The temperature of water used should be between @?A/ and +,,A/ 52?.,A% and 2B.1A%6 to prevent hyperthermia. This type of pain relief measure usually is not recommended for women whose membranes have ruptured because of the risk of infection. #herapeutic #ouch and Massage Therapeutic touch is the use of touch to comfort and relieve pain. (t is based on the concept that the body contains ener y fields that, when plentiful, lead

to health and, when in less supply, result in ill health. Therapeutic touch is defined as the layin on of hands to redirect the ener y fields that lead to pain. !lthou h the action is not well documented, touch and massa e probably work to relieve pain by increasin the release of endorphins. (t also is a form of distraction. =ffleura e, the technique of entle abdominal massa e often tau ht with .ama$e preparation for childbirth classes, is a form of therapeutic touch 'oga Co a, a term derived from the Sanskrit word for union, denotes a series of exercises that were ori inally desi ned to brin people who practice it closer to their Dod. (t offers a si nificant variety of proven health benefits, includin increasin the efficiency of the heart, slowin the respiratory rate, improvin fitness, lowerin blood pressure, promotin relaxation, reducin stress, and allayin anxiety. =xercises consist of deep breathin exercises, body postures to stretch and stren then muscles, and meditation to focus the mind and relax the body. (t may be helpful in reducin the pain of labor throu h its ability to relax the body and possibly throu h the release of endorphins that may occur. Reflexology 8eflexolo y is the practice of stimulatin the hands, feet, and ears as a form of therapy. Professional reflexolo ists apply pressure to specific areas of the hands, feet, and ears to alleviate common ailments such as headaches, back pain, sinus colds, and stress. The theory behind reflexolo y is that each of the body4s or ans and lands are linked to correspondin areas of the hands and feet. The body is divided into +, $ones that run in lon itudinal lines from the top of the head to the tips of the toes. !pplication of pressure to the specific area aims to restore ener y to the body and improve the overall condition. Crystal or (emstone #herapy Some emstones or crystals are thou ht to have healin powers, and women may brin these into a birthin room to use durin labor. ! woman who uses crystals or emstones may believe that their healin power is ma nified when they are positioned around her body. 9e especially careful when chan in beddin or rearran in equipment in a birthin room to respect the position

of these crystals. ! woman may feel that they do not work their healin powers in an altered position. %ypnosis <ypnosis is yet another method of pain relief for labor. ! woman who wants to use this modality needs to meet with her hypnotherapist durin pre nancy. !t these visits, she is evaluated for and further conditioned for susceptibility to hypnotic su estion. !t the last prenatal visit, she is iven the posthypnotic su estion that she will experience reduced pain or absence of pain durin labor. /or a woman who is susceptible to hypnotic su estion, the method can provide a very satisfactory dru &free method of pain relief. Biofeedbac) 9iofeedback is based on the belief that people have control and can re ulate internal events such as heart rate and pain response. #omen who are interested in usin biofeedback for pain relief in labor must attend several sessions durin pre nancy to condition themselves to re ulate their pain response. Durin these sessions, a biofeedback apparatus is used to measure muscle tone or the woman4s ability to relax. #ranscutaneous Electrical *er"e timulation Transcutaneous electrical nerve stimulation 5T=NS6 relieves pain by counterirritation on nociceptors. #ith two pairs of electrodes attached to a woman4s back to coincide with the T+,E.+ nerve pathways, low&intensity electrical stimulation is iven continuously or is applied by the woman herself as a contraction be ins. This stimulation blocks the afferent fibers, preventin pain from travelin to the spinal cord synapses from the uterus. !s labor pro resses and the pelvic division be ins, the electrodes are moved to stimulate the S-E3 level. <i h&intensity stimulation is enerally needed to control the pain at this sta e. T=NS can be as effective as epidural anesthesia for pain relief in labor, but some women may ob"ect to bein :tied down; to the equipment. #omen with extreme back pain durin labor may benefit the most from a T=NS unit, because this type of pain is difficult to relieve with controlled breathin exercises. T=NS is also discussed in %hapter -, as it applies to the postoperative pain of a cesarean birth.

!cupressure and !cupuncture !cupuncture is based on the concept that illness results from an imbalance of ener y. To correct the imbalance, needles are inserted into the skin at desi nated susceptible body points 5tsubos6 located alon meridians that course throu hout the body to supply the or ans of the body with ener y. These points are not necessarily near the affected or an. !ctivation of these points apparently results in release of endorphins, so the system can be helpful, especially in the first sta e of labor. !cupressure, in contrast, is the application of pressure or massa e at these points. ! common point used for a woman in labor is %o3 5<oku or <e u point6 located between the first and second metacarpal bones on the back of the hand. #hen a support person holds and squee$es a woman4s hand in labor, he or she may be accidentally tri erin this point. Pharmacologic Pain Relief During Labor Pharmacolo ic mana ement of pain durin labor and birth includes anal esia, which reduces or decreases awareness of pain, and anesthesia, which causes partial or compete loss of sensation. )any choices are available today. /or the best results, be sure women are included in a selection that is ri ht for them. Firtually all medication iven durin labor crosses the placenta and has some effect on the fetus, which makes it important for a woman to receive as little systemic medication as possible. 7n the other hand, labor should not test a woman to the limit of her endurance, especially since local anesthesia is available. 9e sure to caution women not to take acetylsalicylic acid 5aspirin6 for pain in labor. !spirin interferes with blood coa ulation, increasin the risk for bleedin in the newborn or mother. (oals of Pharmacologic Management of Pain During Labor )edication effectively used durin labor must relax a woman and relieve her discomfort, yet have minimal systemic effects on her uterine contractions, her pushin effort, or her fetus. #hether a dru affects a fetus depends on its ability to cross the placenta. Dru s with a molecular wei ht of more than +,,,, cross poorly, whereas those with a molecular wei ht of less than 0,, cross very readily. Dru s with hi hly char ed molecules or molecules stron ly bound to protein cross more slowly than others. /at&soluble dru s

cross most easily. ! preterm fetus, which has an immature liver and is unable to metaboli$e or inactivate dru s, is enerally more affected by dru s than a term fetus. (f a dru causes a systemic response, such as hypotension, in a woman, it can result in a decreased oxy en 5P7-6 radient across the placenta and fetal hypoxia. (f it causes confusion or disorientation, she may be unable to work effectively with contractions, prolon in labor. (f a medication causes chan es in a fetus, such as a decreased heart rate or central nervous system 5%NS6 depression, it may be difficult for the newborn infant to initiate respirations at birth, severely compromisin the infant in the important first minutes of life. 9ecause pain is a sub"ective sensation, women experience different levels of pain durin labor. Some women are most aware of pain early in labor, whereas some report the second sta e of labor as the most difficult. The point at which pain medication is needed, therefore, differs from one individual to another. Preparation for Medication !dministration The type of medication used durin labor varies amon different health care a encies and also chan es based on new research as the effectiveness and safety of new dru s for use durin labor are tested. To be safe, remember the criteria that a dru must fulfill to be used in pre nancy, or expand the rule of basic medication administration from :Never ive any dru unless you know it is safe for your individual client; to :Never ive a dru durin labor without knowin it is safe for both of your clients* the mother and the fetus.; )edicines frequently used in labor and birth are shown in T!9.= +@.+. Prepare the woman for the type of a ent to be iven, how it will be administered 5e. ., :Cou4ll need to lie on your side;6, and what she can expect to happen after administration 5e. ., :(4ll be takin your blood pressure frequently;6. #omen in labor are under stress. =xperiencin surprisin body sensations from a dru without preparation can be so fri htenin that it can defeat their individual copin abilities. #hen a person stru les a ainst medication administration because she does not understand the stran e feelin it is causin , the risk of inadvertent problems increases. *arcotic !nalgesics

Narcotics are often iven durin labor because of their potent anal esic effect. !ll dru s in this cate ory cause fetal %NS depression to some extent. 9e sure to question an order for a narcotic if a woman is in preterm labor. 9ecause of possible lun immaturity, a preterm infant may have extreme difficulty copin with the added insult of respiratory depression at birth. Narcotic anal esics commonly used include meperidine hydrochloride 5Demerol6, morphine sulfate, nalbuphine 5Nubain6, fentanyl 5Sublima$e6, and butorphanol tartrate 5Stadol6. )eperidine is advanta eous as an anal esic in labor because it has additional sedative and antispasmodic actions' these make it effective not only for relievin pain but also for helpin to relax the cervix and providin a feelin of euphoria and well&bein . (t may be iven either intramuscularly or intravenously. The dose is -? to +,, m , dependin on a woman4s wei ht and the route of administration. The dru be ins to act about 2, minutes after intramuscular 5()6 in"ection and about ? minutes after intravenous 5(F6 administration. (ts duration of action is - to 2 hours. Demerol also may be self&administered by a patient&controlled anal esic 5P%!6 pump for low&dose but frequent administration durin labor . (ntrathecal administration 5in"ection into the cerebral spinal fluid6 is used less frequently. 9ecause Demerol crosses the placenta, it can cause respiratory depression in a fetus. The dru crosses the placenta minutes after either (F or () administration to the mother. <owever, because the fetal liver takes - to 2 hours to activate the dru into the fetal system, the effect will not be re istered in the fetus for - to 2 hours after maternal administration. /or this reason, Demerol is iven when the mother is more than 2 hours away from birth. This allows the peak action of the dru in the fetus to have passed by the time of birth. #henever a narcotic is iven durin labor, a narcotic anta onist such as naloxone 5Narcan6 should be available for administration to the infant at birth. %arefully observe an infant who receives naloxone in the immediate postpartum period, because the infant4s respirations may become severely depressed a ain when the dru 4s effect wears off. (f severe infant respiratory depression is anticipated, Narcan can be iven to the mother "ust before birth.

(t readily crosses the placenta and, because it interferes with or competes for narcotic bindin sites, may increase the chance for spontaneous respiratory activity in the newborn.