Chapter 16

Management of Discomfort

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Discomfort During Labor and Birth

Pain and discomfort experienced during labor have two neurologic origins: visceral and somatic Neurologic origins

Visceral pain: from cervical changes, distention of lower uterine segment, and uterine ischemia Located over lower portion of abdomen Referred pain: originates in uterus, radiates to abdominal
wall, lumbosacral area of back, iliac crests, gluteal area, and down thighs

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Discomfort During Labor and Birthcontd

Neurologic origins

Somatic pain: pain described as intense, sharp, burning, and well localized Stretching and distention of perineal tissues and pelvic
floor to allow passage of fetus from distention and traction on peritoneum and uterocervical supports during contractions and lacerations of soft tissue

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Discomfort During Labor and Birthcontd

Perception of pain

Threshold remarkably similar in all, regardless of gender, social, ethnic, or cultural differences Differences play definite role in persons perception of and behavioral responses to pain

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Discomfort During Labor and Birthcontd

Expression of pain

Pain results in physiologic effects and sensory and emotional (affective) responses Emotional expressions of suffering often seen Increasing anxiety Writhing, crying, groaning, gesturing (hand clenching and
wringing), and excessive muscular excitability Cultural expression of pain varies

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Discomfort During Labor and Birthcontd

Factors influencing pain response

Physiologic factors Culture Anxiety and fear Previous experience Gate-control theory of pain Comfort and support Environment

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Fig. 16-1. Discomfort during labor. A, Distribution of labor pain during first stage. B, Distribution of labor pain during later phase of first stage and early phase of second stage. C, Distribution of labor pain during later phase of second stage and during birth. (Gray shading indicates areas of mild discomfort; light-colored shading indicates areas of moderate discomfort; dark-colored shading indicates areas of intense discomfort.)
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Nonpharmacologic Management of Discomfort

Nonpharmacologic measures often simple, safe, and inexpensive Provide sense of control over childbirth and measures best for woman Methods require practice for best results Try variety of methods and seek alternatives, including pharmacologic methods, if measure used is not effective

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Nonpharmacologic Management of Discomfortcontd

Childbirth preparation methods

Dick-Read method Lamaze method Bradley method HypnoBirthing Birthing from within Childbirth and Postpartum Professional Association

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Nonpharmacologic Management of Discomfortcontd

Relaxing and breathing techniques

Relaxation Imagery and visualization Music Touch and massage Conscious breathing Energy work Effleurage and counterpressure Water therapy (hydrotherapy)
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Nonpharmacologic Management of Discomfortcontd

Relaxing and breathing techniques

Transcutaneous electrical nerve stimulation Acupressure and acupuncture Applications of heat and cold Hypnosis Biofeedback Aromatherapy Intradermal water block

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Fig. 16-7. Intradermal injections of 0.1 ml of sterile water in the treatment of women with back pain during labor. Sterile water is injected into four locations on the lower back, two over each posterior superior iliac spine (PSIS) and two 3 cm below and 1 cm medial to the PSIS. The injections should raise a bleb on the skin. Simultaneous injections administered by two clinicians decreases the pain of the injections.

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The Coalition to Improve Maternity Services

Adopted Lamaze Institute for Normal Birth principles

Labor to begin on its own Freedom of movement throughout labor Continuous labor support No routine interventions Nonsupine No separation of mother and baby

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Pharmacologic Management of Discomfort

Sedatives Analgesia and anesthesia

Anesthesia Systemic analgesia Opioid (narcotic) agonist analgesics Opioid (narcotic) agonistantagonist analgesics Opioid (narcotic) antagonists

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Pharmacologic Management of Discomfortcontd

Nerve block analgesia and anesthesia

Local perineal infiltration anesthesia Pudendal nerve block Spinal anesthesia (block) Disadvantages

Marked hypotension Impaired placental perfusion Ineffective breathing patterns Autologous epidural blood patch

Headache

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Fig. 16-8. Pain pathways and sites of pharmacologic nerve blocks. A, Pudendal block; suitable during second and third stages of labor and for repair of episiotomy. B, Epidural block; suitable during all stages of labor and for repair of episiotomy.
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Fig. 16-9. Pudendal block. Use of needle guide (Iowa trumpet) and Luer-Lok syringe to inject medication.
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Pharmacologic Management of Discomfortcontd

Nerve block analgesia and anesthesia

Epidural anesthesia/analgesia Lumbar epidural anesthesia/analgesia Caudal epidural block Walking epidural analgesia Epidural and intrathecal opioids

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Pharmacologic Management of Discomfortcontd

Nerve block analgesia and anesthesia

Epidural anesthesia/analgesia Contraindications to epidural blocks

Maternal refusal or inability to cooperate Maternal cardiac conditions Antepartum hemorrhage Anticoagulant therapy or bleeding disorder Infection at injection site Allergy to anesthetic drug

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Pharmacologic Management of Discomfortcontd

Nerve block analgesia and anesthesia

Epidural anesthesia/analgesia Effects of epidural block on neonate Paracervical (uterosacral) nerve block Nitrous oxide for analgesia

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Fig. 16-10. A, Membranes and spaces of spinal cord and levels of sacral, lumbar, and thoracic nerves. B, Cross section of vertebra and spinal cord.
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Fig. 16-10. C, Levels of anesthesia necessary for cesarean and vaginal births.

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Pharmacologic Management of Discomfortcontd

General anesthesia

Used rarely for vaginal births Infrequently for elective cesarean section May be necessary if indications necessitate a rapid birth

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Fig. 16-13. Technique of applying pressure on cricoid cartilage to occlude esophagus to prevent pulmonary aspiration of gastric contents during induction of general anesthesia.
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Nursing Care Management

Plan of care and implementation

Nonpharmacologic interventions Informed consent Timing of administration Preparation for procedures

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Nursing Care Managementcontd

Plan of care and implementation

Administration of medication Intravenous route Intramuscular route Spinal nerve block Signs of potential problems Safety and general care Anesthesia in obese woman

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Nursing Care Managementcontd

Plan of care and implementation

Maternal hypothermia after analgesia and anesthesia Defined as core body temperature of less than 35 C Caused by effects of analgesia and anesthesia May result in cardiovascular, pulmonary, circulatory,
hematologic, neurologic, or renal complications

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Key Points

Expected outcome of preparation for childbirth and parenting is education for choice Nonpharmacologic pain and stress management strategies are valuable for managing labor discomfort alone or in combination with pharmacologic methods

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Key Pointscontd

Gate-control theory of pain and stress response are bases for many of the nonpharmacologic methods of pain relief Type of analgesic or anesthetic used is determined in part by stage of labor and method of birth Sedatives may be appropriate for women in early labor

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Key Pointscontd

Phenothiazines or benzodiazepines can be used during labor to decrease anxiety and apprehension Naloxone (Narcan) is an opioid antagonist that can reverse opioid effects, especially respiratory depression Pharmacologic control of discomfort during labor requires collaboration of care providers and laboring woman
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Key Pointscontd

Nurse must understand medications, expected effects, potential adverse reactions, and methods of administration Maternal fluid balance is essential during spinal and epidural nerve blocks Maternal analgesia or anesthesia potentially affects neonatal neurobehavioral response

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Key Pointscontd

Use of opioid agonist-antagonist analgesics in women with preexisting opioid dependence may cause symptoms of abstinence syndrome (opioid withdrawal) General anesthesia rarely used for vaginal birth

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