Chapter 15: Pain Management During Childbirth Flashcards
Pain involves 2 components
Physiological and psychological
Physiological component of pain
Includes reception by sensory nerves and transmission to the CNS
Psychological component of pain
Involves recognizing the sensation, interpreting it as painful and reacting to the interpretation.
How can excessive pain affect labor?
Can cause maternal fear and anxiety -> which stimulates SNS activity -> secretion of catecholamines (NE and epinephrine) -> can alter uterine blood flow and effectiveness of contractions.
Stimulation of alpha receptors by NE and Epinephrine causes
- Uterine and generalized vasoconstriction in the uterine muscle tone.
- Reduced uterine blood flow as they raise the maternal blood pressure.
Stimulation of the beta receptors by epinephrine causes
- Relaxation of the uterine muscle and causes vasodilation.
- Uterine vessels are already dilated in pregnancy, so dilation of other maternal vessels allows the woman’s blood to pool in them -> reduces the amount of blood available to perfuse to the placenta
The combined effects of excessive catecholamine secretion are:
- Reduced blood flow to and from the placenta, restricting fetal oxygen supply and waste removal **
- Reduced effectiveness of uterine contractions, slowing labor progress**
Labor increases maternal metabolic rate and O2 demand:
These changes alter placental exchange significantly if they are persistent.
NE and Epinephrine stimulate what receptors?
Epinephrine: Alpha and Beta receptors
Norepinephrine: Alpha receptors
How can increased maternal metabolic rate and O2 demand in labor affect the fetus?
- Fetus may have less O2 available for uptake and have less ability to unload carbon dioxide to the mother.
- This can cause the fetus to shift to anaerobic metabolism, with build up of hydrogen ions (acidosis)
What are the two types of pain?
- Somatic
2. Visceral
Somatic Pain Characteristics
- Quick, sharp, localized pain
- Occurs during the 1st & 2nd sage of labor
What causes somatic pain during labor?
It is due to descending fetus putting pressure on maternal tissues
Visceral Pain Characteristics
o Slow, deep, poorly localized pain
o “dull or achy”
o Common in 1st stage
What can cause visceral pain during labor?
It can be due to uterine contraction and cervical dilation.
What are the four sources of labor pain?
- Ischemia
- Dilation
- Pressure and pulling on pelvic structures
- Distention of the vagina and perineum
How does ischemia cause pain during labor?
Blood supply to the uterus decreases during contractions -> tissue hypoxia and anaerobic metabolism.
How does dilation and stretching of the cervix cause pain during labor?
Pain stimuli from cervical dilation travel through the hypogastric plexus and enters the spinal cord at the T10, T11, T12, and L1 levels**
How does pressure and pulling on pelvic structures cause pain during labor?
- Causes a visceral pain.**
- Woman may feel it as referred pain in her back and legs.
Pressure and pulling on pelvic structures during labor cause pain. What structures are they referring to?
Pressure and pulling occur on the ligaments, fallopian tubes, ovaries, bladder, and peritoneum
When does distention of the vagina and perineum occur?
Occurs with fetal descent, especially during the second stage.
How does distention of the vagina and perineum cause pain during labor?
-Causes women to feel a described sensation of burning, tearing or splitting. (Somatic pain)**
Pain from vaginal and perineal distention and pressure and pulling on adjacent structures enters the spinal cords at what levels?
S2, S3 and S4 levels**
What are factors that influence perception or tolerance of pain during labor?
- Labor intensity
- Cervical readiness
- Fetal position
- Pelvic readiness
- Fatigue and hunger
- Caregiver interventions
- Psychosocial factors
How does labor intensity influence perception or tolerance of pain?
- A short, intense labor may complain of severe pain (each contraction does so much work)
- A rapid labor may limit her options for adequate pain relief.
How does cervical readiness influence perception or tolerance of pain?
- If prelabor cervical changes are incomplete, cervix won’t open as easily.
- More contractions are needed resulting in a longer labor and greater fatigue.
How does fetal position influence perception or tolerance of pain during labor?
- It is longer and more painful if baby is in an unfavorable position.
- Common variant is occiput posterior position.
How can occiput posterior position affect pain during labor?
- Each contraction pushes the fetal occiput against the woman’s sacrum
- Causes intense back discomfort (back labor) that persists between contraction.
- May not be able to deliver until it rotates to the occiput anterior position; makes labor longer.
How does pelvic readiness influence the perception or tolerance of pain during labor?
Size and shape of woman’s pelvis influences the course and length of her labor.
How does fatigue and hunger influence perception or tolerance of pain during labor?
- Oral intake is often limited, so her energy reserves are also likely to be depleted in a long labor
- Sleep is difficult during the last weeks of pregnancy due to SOB, frequent urination, and fetal activity are at their peaks.
How can caregiver interventions influence perception or tolerance of pain during labor?
- IV site can cause pain
- Fetal monitoring equipment is uncomfortable.
- Induced or augmented labors are often more painful.
- Vaginal manipulation often stimulates contraction.
Ferguson’s reflex**
….
What psychosocial factors can influence perception or tolerance of pain during labor?
- Culture
- Anxiety and fear
- Previous experiences with pain
How can culture influence perception or tolerance of pain during labor?
o A woman’s sociocultural roots influence how she perceives, interprets, and responds to pain during birth
o Some encourage loud & vigorous expression of pain whereas others value self-control
o Should be encouraged to express themselves in any way they find comforting whether it is being loud or quiet
How does anxiety and fear influence perception or tolerance of pain during labor?
High anxiety and fear can magnify sensitivity to pain & impair toleration to it
In what ways can anxiety and fear magnify sensitivity to pain and impair toleration of it?
- Increases muscle tension, diverting oxygenated blood to brain & skeletal muscles.
- Tension in pelvic muscles counters the expulsive forces of uterine contractions and laboring woman’s pushing.
How ones prolonged tension affect pain perception during labor?
Prolonged tension results in general fatigue, increases pain perception or threshold (lowest stimulus level perceived as pain), and reduces ability to use skills to cope.
How does previous experiences with pain influence perception or tolerance of pain during labor?
-A woman who has given birth previously can have a different perspective because she knows labor sensations and is less likely to associate them with injury or abnormality.
o Woman with previously long and difficult labor can be anxious. They can find late first stage and second stage to be more painful b/c fetus descends faster.
Preparation for childbirth
- Does not ensure pain-free labor
- Woman should be prepared for pain realistically, including reasonable expectations about analgesia and anesthesia (loss of sensation)
What are the benefits for preparation for childbirth?
Reduces anxiety and fear of unknown and allows mother to rehearse for labor and learn variety of skills to master pain as labor progresses.
Why is it important to control anxiety in the mother’s support partner?
- Anxious partner is less able to provide support & reassurance that woman needs during labor
- Anxiety in others can be contagious and therefore anxious partners can increase woman’s anxiety.
What are advantages of nonpharmacological pain measures given to women during labor?
- Does not slow labor and has no side effects or risk of allergy.
- May be only realistic option for woman who enters hospital in advanced, rapid labor.
- Woman who receives analgesia may not eliminate labor pain & needs other techniques to control pain.
What are limitations to nonpharmacological measures used during labor?
- Women do not always achieve their desired level of pain control using these methods alone.
- B/c of many variables in labor, a well-prepared, highly-motivated woman may need analgesia or anesthesia.
Gate-control theory
Transmission of nerve impulses is controlled by neural mechanism in dorsal horn of spinal cord that acts like a gate to control impulses transmitted to the brain
Pain transmitted through small-diameter sensory nerve fibers
▪Stimulation of large-diameter fibers in the skin blocks conduction of pain through small-diameter fibers -> “closes gate” & decreases amount of pain felt
▪Impulses from brain can have similar ability to impede transmission through dorsal horn using visual & auditory stimulation -> use of focal point or breathing techniques
Ideal time to prepare for nonpharmacological pain control is
Before labor.
A nurse can teach an unprepared woman and support person nonpharmacological techniques during which point in labor?
Latent phase of labor is best time for teaching.
Benefits of Relaxation
▫ Promotes uterine blood flow, which improves fetal oxygenation
▫ Promotes efficient uterine contractions
▫ Reduces tension that increases pain perception and decreases pain tolerance (maximum pain one is willing to endure)
▫ Reduces tension that can inhibit fetal descent
How can you enhance environmental comfort?
- Reduce irritants like bright lights and uncomfortable temperature
- Change soiled underpads
- Music can distract pain perception
How can you reduce anxiety and fear in a woman in labor?
Provide accurate information and focus on normality of labor.
Specific relaxation techniques work best when?
works best if mother practices before labor
Relaxation Techniques: Progressive relaxation
Woman contracts and then releases specific muscle groups until all muscles are relaxed.
Relaxation Techniques: Neuromuscular dissociation
Helps woman learn to relax all muscles except those that are working (uterus or abdominal muscles when pushing)
Relaxation Techniques: Touch relaxation
Response to partner’s touch
Relaxation Techniques: Relaxation against pain
Partner deliberately causes mild pain and woman learns to relax despite pain.
Cutaneous stimulation used in pain relief during labor include
- Self-massage
- Massage by others
- Counterpressure
- Touch
- Thermal stimulation
- Acupressure
Cutaneous Stimulation: Self-massage
- rub abdomen, legs or back during labor (effleurage) to counteract discomfort
- some benefit from firm palm or sole stimulation during labor
Cutaneous Stimulation: Massage by others
- Increases circulation and reduces muscle tension
- Can rub back, shoulders, legs or any area where she finds massage helpful.
Cutaneous Stimulation: Counterpressure
sacral pressure can help when having back pain -> can be applied using palm of hand, fist or fists, or firm object like 2 tennis balls in sock
Cutaneous Stimulation: Touch
holding hand, stroking hair, or similar actions conveying caring, comfort, affirmation and reassurance can be helpful to some women
Cutaneous Stimulation: Thermal Stimulation
warmth applied to back abdomen or perineum during labor increases local blood flow, relaxes muscles and raises pain threshold.
Methods for thermal stimulation include
▫ Warm shower, tub bath or whirlpool
▫ Cool damp washcloths provide comforting coolness if woman feels hot
Benefits of Hydrotherapy
▪ Buoyancy afforded by immersion supports the body, equalizes pressure on the body & aids muscle relaxation
▪ Fluid shifts from extravascular space to intravascular space reduces edema as the excess fluid is excreted by the kidneys.
Methods for hydrotherapy include
Shower
Tub
Bath
Whirlpool
What is a concern about hydrotherapy?
Newborn and postpartum maternal infections caused by microorganisms in the water.
Breathing Techniques are beneficial because
▪ Gives woman different focus during contractions, interfering with pain sensory transmission
For the best result for breathing techniques, what should the woman do?
Woman and partner should practice frequently -> if patterns are to complicated or woman has not practiced, they may not be helpful
First stage breathing includes what breathing techniques?
- Cleansing Breath
- Slow-Paced Breathing
- Modified-Paced Breathing
- Patterned-Paced Breathing
- Breathing to prevent pushing
Cleansing Breath
Each contraction begins and ends with deep inspiration and expiration -> helps release tension.
What are benefits of the cleansing breath technique?
· Provides oxygen to help reduce myometrial hypoxia
· Helps clear mind to focus on relaxing and signals her labor partner that contraction is beginning and ending
Slow-Paced Breathing
Slow, deep breathing that increases relaxation.
Benefits of slow-paced breathing include?
➢ Concentrate on relaxing body rather than on regulating rate of breathing
➢ Use as long as possible during labor b/c promotes relaxation & oxygenation
Modified-Paced Breathing
Chest breathing at faster rate matches natural tendency to use more rapid breathing during stress or physical work like labor.
Benefits of modified-paced breathing include
➢ Allows oxygen intake to remain about the same although breaths are shallower
Patterned-Paced Breathing
Focusing on pattern breathing.
Relaxation of entire body is the goal.
Patterned-Pace Breathing Instructions
➢ After certain number of breaths, woman exhales with slight emphasis or blow and then begins modified paced breathing again
➢ Mouth should remain relaxed and woman should try not to make specific sounds that would tighten vocal cords
➢ Set patterns include: “3-1, 5-1, 3-1” or “6-1, 5-1, 4-1, 3-1” (stair step pattern)
Breathing to Prevent Pushing
Blows repeatedly using short puffs when urge to push is strong.
Benefits to breathing to prevent pushing
Blowing prevents closure of glottis and breath-holding, helping to overcome urge to push strenuously.