Chapter 13: Promoting Patient Comfort During Labor and Birth Flashcards
What is Pain
whatever the person who is experiencing it says it is
-an unpleasant sensory and emotional experience arising from actual or potential tissue damage
-pain includes the perception of an uncomfortable stimulus and also the response to that perception
>perception of pain is influenced by psychosocial and cultural factors
Physiological and psychological changes that are indicative of maternal pain
- increased pulse rate and blood pressure
- changes in mood
- increased anxiety and stress
- marked agitation
- confusion
- decreased urine output
- decreased intestinal motility
- guarding of the target area of discomfort
These factors can intensify pain
-fear, anxiety, and fatigue
When Caring for a laboring woman, the nurse must recognize that unlike other sources of pain, childbirth pain:
- is part of a normal process (not associated with illness or injury)
- can be anticipated and thus prepared for (through childbirth education and the practice of distraction techniques and comfort measures)
- has an end point (the babies birth brings relief on a physical and emotional level)
Pain Neurology
pain associated with birth has visceral and somatic properties
-uterine contractions during the first stage of labor bring about cervical dilation and effacement; during each contraction, arteries that supply the myometrium are compressed, causing uterine ischemia (oxygen deficit that results from decreased blood flow)
>during first stage of labor, pain impulses are transmitted via the T11 and T12 spinal nerve segments and accessory lower thoracic and upper lumbar sympathetic nerves; these nerves originate in the uterus
Visceral Pain
slow, deep, poorly localized pain that occurs over the lower abdomen; dull aching pain
- describes the predominant discomfort experienced during the first stage of labor
- r/t changes in the cervix (i.e. dilation and effacement), distention of the lower uterine segment, and uterine ischemia
Referred Pain
describes pain that originates in the uterus and then radiates to the abdominal wall, the lumbosacral area of the back, the iliac crests, the gluteus maximus, and down the thighs
- usually discomfort felt only during contractions
- a period of pain relief can occur between contractions
Somatic Pain
faster, well-localized intense, sharp, burning, prickling pain
- occurs during second stage of labor
- associated with stretching and distention of the perineal body to allow for birth
- r/t distention and traction placed on the peritoneum and uterocervical supportive tissue during contractions and can result from soft tissue lacerations that occur in the cervix, vagina, or perineum
- may also occur from maternal expulsive forces during the second, or “pushing” stage of labor or by fetal pressure on the bladder, bowel, or other pelvic structures
Recognizing Cultural Influences on the experience of Pain
nurses must recognize that culture strongly influences how one perceives and copes with pain
-woman from certain cultures seek pain relief through prayer; others rely on herbal remedies, the application of cold or warmth, acupuncture, the “laying on of hands”, and therapeutic massage
>Assessment of cultural beliefs and practices, questions to identify specific needs and encouragement, and support to use safe interventions is key in providing culturally sensitive care that empowers the patient to maintain her sense of control over her labor and childbirth experience
Sympathetic Nervous System Response to Pain
during labor and childbirth, the sympathetic nervous system responds to pain with increased levels of catecholamines (e.g. epinephrine and norepinephrine–biologically active substances that produce a marked effect on the nervous and cardiovascular systems, metabolic rate, temperature, and smooth muscle)
-rise in blood pressure and heart rate
-increased maternal oxygen consumption results in an altered respiratory pattern that may produce hyperventilation and respiratory alkalosis
-woman may be diaphoretic, and nausea and vomiting are common during the active phase of labor
>throughout this process, decreased placental perfusion and uterine activity can prolong labor and adversely affect fetal well-being
Assessment of Pain During Labor
throughout the process of labor and birth, the nurse continuously assesses the patient and addresses her needs for comfort measures
- conducting an initial and ongoing pain assessment lays the foundation for intrapartal nursing care
- once the beginning assessment has been completed, the nurses uses the information to develop an individualized plan of care that includes pain relief interventions acceptable to the patient
- may be modified or adapted as needed
Benefits of comfort and support on pain perception
- support during labor has a major impact
- support includes both pharmacological and non-pharmacological measures
- nurse’s attitude, expressions of caring, and supportive actions play a role
- patients who feel they have control over their situation (self efficacy) and who are actively engaged in decision-making process concerning interventions and pain relief measures during labor and birth report a greater sense of satisfaction with their birth experience
- spend as much time as you can at patients bedside (e.g. charting in the room and assessing the woman’s comfort level and satisfaction with birth plan) is an important nursing strategy
- offering verbal support, touch, and eye contact ca help keep the woman centered and in control
Non-Pharmacological Pain Relief Measures
- maternal position and movement
- breathing techniques
- music
- relaxation
- other attention-focusing strategies
- massage and touch
- hydrotherapy
- hypnotherapy
- aromatherapy
- application of heat and cold
- biofeedback
- transcutaneous electrical nerve stimulation
- intradermal water block
- acupressure and acupuncture
Maternal Position and Movement
find a position of comfort; as patient changes positions, gravity assists the fetus’s decent down the birth canal
- slow dancing during labor; can be comforting and relaxing; the woman can lean on her coach (this helps support her) and they can sway and dance together through the contractions
- use a “squatting bar” or assume a squatting position at the edge of the bed; helps open the pelvic outlet, which facilitates the fetus’s downward movement
- “hands and knees” position is comforting for woman who have back labor or whose fetus is in a posterior position; decreases the patient’s back pressure and helps the fetus rotate in to an anterior position
- use of a “birth ball”; with help, the patient carefully sits on the birth ball and rhythmically rocks back and forth or moves the ball around in a circular motion; assuming a sitting position on the birth ball facilitates a supported squatting position that opens the pelvis to allow fetal descent in preparation for birth; warm compresses applied to the back and perineum while balancing on the ball enhance relaxation and promote comfort; the birth ball should be large enough to allow the woman to sit comfortably on it with her knees bent to a 90 degree angle with her feet flat on the floor approximately 2 feet apart; may also place birth ball against the wall behind the small of her back and gently lunge from side to side to open the pelvis; when needed, assuming a kneeling position while leaning forward on the ball may encourage rotation of the fetus from posterior to an anterior position
Birth Ball
- use of a “birth ball”; with help, the patient carefully sits on the birth ball and rhythmically rocks back and forth or moves the ball around in a circular motion; assuming a sitting position on the birth ball facilitates a supported squatting position that opens the pelvis to allow fetal descent in preparation for birth
- warm compresses applied to the back and perineum while balancing on the ball enhance relaxation and promote comfort
- the birth ball should be large enough to allow the woman to sit comfortably on it with her knees bent to a 90 degree angle with her feet flat on the floor approximately 2 feet apart
- may also place birth ball against the wall behind the small of her back and gently lunge from side to side to open the pelvis
- when needed, assuming a kneeling position while leaning forward on the ball may encourage rotation of the fetus from posterior to an anterior position
Breathing Techniques
the woman is instructed to take slow, deep cleansing breath in through the nose and out through the mouth at the beginning of every contraction
- slow-paced breathing
- modified-paced breathing
- pattern-paced breathing
Breathing Techniques: Slow-paced breathing
used during early labor, when the woman is no longer able to walk or talk through contractions
>following a cleansing breath, the woman begins to slowly breathe in and out through her mouth while her coach slowly counts out loud
>the breathing rate is half the woman’s normal breathing rate— 6 to 8 breaths per minute
>she is prompted to slowly breathe in while the coach counts “one, two, three, four”, and then slowly breathe out to the same rhythm as the couch counts “one, two, three, four”
Breathing Technique: Modified-paced
uses this as the labor progresses and the contractions increase in frequency and intensity
- shallower an twice the woman’s normal rate of breathing—32 to 40 breaths per minute
- after a deep cleansing breath, the woman inhales slowly, but exhales at a faster pace
- ex: the coach instructs her to take a cleansing breath, then breathe in a count of one, two, three, four and breathe out to a count of one, two , three
Breathing Technique: Pattern-paced
during the transition phase of labor, when contractions are most intense, patients usually find it difficult to concentrate on breathing techniques
- this technique requires increased concentration
- following a cleansing breath, the woman begins with a 3:1 pattern; breathe in, breathe out, breathe in, breathe out, breathe in, then blow (as if blowing out a candle)
- as needed, ratio may be increased to 4:1
- as with the other breathing patterns, a cleansing breathe is taken at the end of each contraction
Recognizing Hyperventilation
the pattern-paced breathing may result in maternal hyperventilation
-nurse should alert the patient and support person to symptoms of respiratory alkalosis: light-headedness, dizziness, tingling of the fingers, or circumoral numbness
>strategies to eliminate respiratory alkalosis focus on replacement of the bicarbonate ion by rebreathing carbon dioxide; breathe into paper bag held tightly around mouth and nose, or, if no bag is available, breathe into her cupped hands
Use of Music
help to create a relaxing environment and boosts spirits
- provides comfort and decreases maternal anxiety by stimulating release of endorphins
- encouraged to supply music of their choice
- promotes maternal relaxation thereby increasing oxygen intake
Promote Relaxation
diminish the level of anxiety also reduces stress and tension
-when tension is reduced, the woman breathes more deeply, resulting in improved maternal and fetal oxygenation
-when experiencing increased anxiety, stress levels and tension build and trigger a cascade of events that heighten the sensation of pain; pain impeded ability to relax
>nurses ongoing assessment of maternal pain should be conducted throughout labor and birth; use of a visual analog scale for assessment of pain
Other Attention-focusing strategies: Guided Imagery
state of intense, focused concentration that one uses to create persuasive mental images
-distracts the laboring woman and transports her to a place that is special to her
>nurse or labor support person asks the laboring woman to focus on a place where she likes to be; next, the nurse or labor support person verbalizes sights and sounds of that unique place in an attempt to relax and distract the patient
Other Attention-Focusing strategies: Focal Points
may be a picture, photograph, stuffed animal, or piece of needlework
- concentrates or “focuses” on the object while breathing during the contractions
- “internal” focal point= thought or visual image— closes her eyes and focuses on the mental image
Use of Massage and Touch
reduces pain and improve woman’s emotional experience of labor
- effleurage
- counterpressure
- therapeutic touch
- healing touch
Massage and Touch: Effleurage
(to touch lightly)
-gentle stroking technique performed in rhythm with contractions
-massages abdomen using light circular motions
>massage of the hands, feet, and back may be effective in diminishing tension and in enhancing comfort
Massage and Touch: Counterpressure
enhances woman’s ability to cope with discomfort from internal pressure and lower back pain
- involves use of labor support person’s fist or heel of hand to apply steady pressure to the sacral area
- helpful when maternal back pain results from pressure of the occiput against spinal nerves when the fetal head is in a posterior position
- counterpressure lifts the occiput off of the spinal nerves
Massage and Touch: Therapeutic Touch
use of “prana”, the body’s energy fields
-specially trained persons use laying-on of hands to provide therapeutic touch to redirect the energy fields thought to be associated with the pain
Massage and Touch: Healing Touch
-based on use of body’s energy fields
-combination of techniques from multiple disciplines
-persons trained in healing touch are taught energetic diagnosis and treatment forms and how to document the patient’s response and progress
>the various techniques align and balance the human energy field, enhancing the body’s ability to heal itself
Hydrotherapy
(water therapy)
-use of warm water to promote comfort and relaxation
>may involve showering or soaking in a regular tub or whirl pool bath
-fetal heart rate monitoring may be intermittent or continuous; conducted via doppler technique, fetoscope, or use of wireless external monitor device; internal electrode placement may not be used with whirlpool baths
Hydrotherapy: If showering as a selected method
-patient stands in a warm shower and allows the water to gently glide over the abdomen
-may wish to sit in a shower chair
-the labor coach or nurse may use a handheld sprayer to direct a steady stream of water over the abdomen or back
-the support person provides reassurance and encouragement, assists with breathing techniques during contractions, and offers touch and massage
>flow of warm water enhances feelings of relaxation, reducing muscle tension
>reduced discomfort empowers the woman to have more control over her labor
Hydrotherapy: If immersion in a tub of warm water filled up to shoulder level is selected method
promotes comfort and relaxation
-production of catecholamines is decreased, prompting an increase in the release of oxytocin (stimulates uterine contractions) and endorphins (reduced perception of pain)
>if the woman is experiencing “back labor” from a fetal occiput posterior or transverse position, she may be assisted to a side-lying or hands-and-knees position in the tub; enhance comfort and help to facilitate fetal rotation into a occiput anterior position
>patients may stay in tub as long as desired; mostly 40 to 60 minutes; if maternal temperature or FHR increase, if the labor slows or becomes too intense, or if comforting effects of the water diminish, patients may come out and return at a later time
>avoid overheating= water temp kept at 96.8 to 100.4 degrees F
Hydrotherapy: Whirl pool (“jet hydrotherapy”)
pulsating flow of warm water from the whirlpool jet is soothing and delivers continuous massage to the legs, abdomen, and back
-provides a soothing sound that aids in relaxation
-some institutes require approval for use from primary care provider
>in some settings, women with ruptured membranes are allowed to use jet hydrotherapy, provided that the amniotic fluid is clear
Hypnotherpay
enables the patient to achieve a state of heightened awareness and focused concentration that can be used to alter the perception of pain
-emphasis is placed on promoting maternal relaxation while decreasing fear, anxiety, and the perception of pain
>the woman may be given direct suggestions about pain relief or indirect suggestions that she is experiencing decreased discomfort
Aromatherapy
use of essential oils, derived from plants, flowers, herbs, and trees, whose aroma is thought to have a therapeutic effect in treating illnesses and promoting health and well-being
-rose, lavender, frankincense, and bergamot oils are believed to promote comfort and relaxation and decrease pain
-adding a few drops to a warm tub bath, add to body compresses and massage lotions, or to an aroma therapy lamp
-drops of lavender and other essential oils may also be massaged into the woman’s temples or forehead or placed on a pillow to induce relaxation
>never apply to the skin in full-strength form; must be diluted, usually in vegetable oil base, before application
>not all are safe; some oils when inhaled cause side effects such as nausea and vomiting
Application of Heat and Cold
promote comfort and help decrease pain
-may be used alternately
>Heat:
-relieves muscle ischemia and increasing blood flow to the area of discomfort; applied to the perineum help to relieve the discomfort associated with stretching and may help prevent tearing during second stage of labor;
-socks or bags that are sewn from cloth can be filled with uncooked rice and heated in a microwave oven; once warmed, can be placed on neck, lower back, or where discomfort is felt; when desired, lavender oil may be added before heating
>Cold:
-placed on forehead, chest, or face, may be comforting to laboring women who feel warm
-may also be applied to areas of pain where they exert a therapeutic effect by reducing muscle temperature and relieving muscle spasms
-during contractions, ice massage to the acupuncture point on the hand (Hoku point) may help reduce pain
What you should know when using heat and cold therapy
- avoid over body areas that have been anesthetized because of the risk for tissue damage
- be used only after one to two layers o cloth have been placed between the pack and the patient’s skin
Biofeedback
based on the concept that the mind controls the body
-during the prenatal period, the woman is taught body awareness, how to recognize responses to stimuli, and various relaxation techniques; practices using strategies such as concentration, focal points, and breathing to control her response to uncomfortable stimuli
-labor partner learns to recognize cues (e.g. grimacing, tensing, frowning, moaning, and breath holding) indicative of pain and uses verbal feedback and touch to help the woman to achieve relaxation
>formal biofeedback involves the use of a recording device to measure physiological responses, requires special training by a biofeedback therapist
Transcutaneous Electrical Nerve Stimulation (TENS)
involves the delivery of an electrical current through electrodes that are applied to the skin over the panful region of a peripheral nerve
-relieves pain by producing counterirritation on the nociceptors
-two pairs of flat electrodes are placed on the patients thoracic and sacral spine
>high-intensity levels maintained for at least 1 minutes to release endorphins
>woman report a pleasant buzzing or tingling sensation that offsets the pain
>doctor or certified nurse midwife prescribes; usually applied by physical therapist; nurse explains use of device, assists with application, and evaluates effectiveness
Intradermal Water Block
technique that involves use of a small (e.g. 25-gauge) needle to inject small amounts (e.g. 0.05 to 0.1 mL) of sterile water into four locations (two over each posterior superior iliac spine and two 3 cm below and 1 cm medial to each of the first sites) on the patients lower back to relieve back pain
>two people perform injection simultaneously to decreased pain of injections
>may be used during early labor to delay initiation of pharmacological pain relief methods
-experience a brief, intense stinging sensation immediately after injections, but the back pain is generally relieved for 45 minutes to 2 hours
Acupressure
“Chinese massage”
-involves the application of pressure, or heat or cold to identified acupuncture points to decrease the sensation of pain
-pressure may be applied by the support persons hands, tennis balls, or by the application of pressure bands–cloth covered elastic bands that contain rigid plastic inserts– to provide pressure
>during labor, pressure is applied to various acupressure points, located on neck, shoulders, wrists, lower back, hips, area below kneecaps, ankles, toenails, and soles of feet; Co4 (Hoku or Hegu point), which is located between the first and second metacarpal bones on the back of the hand
-another is located between the inner anklebone and the Achilles’ tendon ; applying pressure for 1 minute on each ankle to relieve labor pain
Acupuncture
involves insertion of fine, sterile, stainless steel needles into specific points in the body (e.g. those associated with labor pain) to control the flow of “chi” or life energy
- activation of the insertion points is believed to trigger release of endorphins
- performed only by trained acupuncturist
- safe but invasive, = risk for infection
When should Pharmacological methods of pain be initiated?
before the pain intensifies to the point that catecholamines are released and labor is prolonged
-usually as labor progresses and contractions and discomfort intensify
Legal Alert: Ensure the patient is informed about available pharmacological methods of pain relief
- ensure the woman understands the alternative methods of pain relief that are available in the birth facility and, when indicated, by asking primary care provider for further detail or clarification
- obtaining an informed consent for interventions means that the procedure and its advantages and disadvantages are fully explained; the patient must agree with the plan of care as it is described to her, and patients consent must be given freely without coercion or manipulation from health-care provider
Sedatives
Sedatives are agents that relieve anxiety and induce sleep
-used during the early latent phase of labor, when the cervix is long, closed, and thick and rest has been prescribed for the patient
-sedatives may also be used to augment analgesics and reduce nausea after the administration of opioids
-induce sleep for a few hours; once woman awakens, either contractions have ceased (i.e. person experienced false labor) or regular, effective contractions that produce cervical change occur
>Sedatives should not be used during active labor because they can cause respiratory depression in the neonate
Legal Alert: Assess and Reassess during the intrapartal period
it is important to assess the laboring patient and her fetus following each intervention to promote comfort
- assess for risk factors: bleeding, infection, ruptured membranes, fetal presentation, prolapsed cord, precipitous labor, meconium-stained amniotic fluid, postmaturity, prematurity, or fetal heart rate irregularities
- assess maternal vital signs per facility protocol
- assess the patient’s anxiety level, coping mechanisms, and labor support
- assess the progress of labor
- assess the fetal heart rate, lie, and presentation
- assess the maternal and fetal response to each comfort measure
- carefully document all findings
Barbiturates
rarely used in labor
-most common: Secobarbital sodium (Seconal); fast-acting oral agent that produces mild sedation within 15 minutes after administration; effects last for 3 to 4 hours
>undesirable effects: maternal and neonatal respiratory and vasomotor depression; effects are intensified if barbiturate is administered with another CNS depressant
Benzodiazepines
agents primarily used to treat anxiety (e.g. diazepam (Valium) and lorazepam (Ativan))
>mechanism similar to barbiturates; when given with an opioid analgesic, benzodiazepines enhance pain relief and decrease nausea and vomiting
>Flumazenil to reverse the effects of benzodiazepine sedatives
