Chapter 18:Maximizing comfort during labour and birth

Question 1

1. A primiparous patient, is admitted to the labour and birth unit with moderate contractions every 5 minutes that last 40 seconds. The patient states, “My contractions are so strong that I don’t know what to do.” What should the nurse do?
   a. Assess for fetal well-being.
   b. Encourage the patient to lie on their side.
   c. Disturb the patient as little as possible.
   d. Recognize that pain is personalized for each individual.

Answer 1

ANS: D
Each person’s pain during childbirth is unique and is influenced by a variety of physiological, psychosocial, and environmental factors. A critical issue for the nurse is how support can make a difference in the pain of the patient during labour and birth. Assessing for fetal well-being includes no information that would indicate fetal distress or a logical reason to be overly concerned about the well-being of the fetus. The left lateral position is used to alleviate fetal distress, not maternal stress. The nurse has an obligation to provide physical, emotional, and psychosocial care and support to the labouring patient. This patient clearly needs support.

Question 2

2. Nursing care measures are commonly offered to patients in labour. Which nursing measure reflects application of the gate-control theory?
   a. Massaging the patient’s back
   b. Changing the patient’s position
   c. Giving the prescribed medication
   d. Encouraging the patient to relax

Answer 2

ANS: A
According to the gate-control theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Distraction techniques such as massage or stroking, music, focal points, and imagery reduce or completely block the capacity of nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetical gate in the spinal cord, thus preventing pain signals from reaching the brain. The perception of pain is thereby diminished. Changing the patient’s position, giving prescribed medication, and encouraging relaxation do not reduce or block the capacity of nerve pathways to transmit pain, according to the gate-control theory.

Question 3

3. With regard to breathing techniques during labour, perinatal nurses should understand that
   a. breathing techniques in the first stage of labour are designed to increase the size
   of the abdominal cavity to reduce friction.
   b. by the time labour has begun, it is too late for instruction in breathing and
   relaxation.
   c. controlled breathing techniques are most difficult near the end of the second stage
   of labour.
   d. the patterned-paced breathing technique can help prevent hyperventilation.

Answer 3

ANS: A
First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Instruction in simple breathing and relaxation techniques early in labour is possible and effective. Controlled breathing techniques are most difficult in the late active phase at the end of the first stage of labour. Patterned-paced breathing sometimes can lead to hyperventilation.

Question 4

4. A labouring patient received fentanyl citrate (Sublimaze) intravenously 90 minutes before they gave birth. Which medication should be available to reduce the postnatal effects of Sublimaze on the newborn?
   a. Meperidine (Demerol)
   b. Promethazine (Phenergan)
   c. Naloxone (Narcan)
   d. Nalbuphine (Nubain)

Answer 4

ANS: C
An opioid antagonist can be given to the newborn as one part of the treatment for neonatal narcosis, which is a state of central nervous system (CNS) depression in the newborn produced by an opioid. Opioid antagonists such as naloxone (Narcan) can promptly reverse the CNS depressant effects, especially respiratory depression. Demerol is no longer recommended for use in Canada. Promethazine and nalbuphine do not act as opioid antagonists to reduce the postnatal effects of Sublimaze on the newborn.

Question 5

5. A patient in labour has just received an epidural block. What is the priority nursing intervention?
   a. Limit parenteral fluids.
   b. Monitor the fetus.
   c. Monitor the maternal blood pressure for signs of hypotension.
   d. Monitor the maternal pulse

Answer 5

ANS: C
The most important nursing intervention for a patient who has received an epidural block is to monitor the maternal blood pressure frequently for signs of hypotension. Intravenous fluids are increased for a patient receiving an epidural to prevent hypotension. The nurse observes for signs of fetal bradycardia and monitors the maternal pulse but the priority is to monitor for hypotension.

Question 6

6. A nurse should be aware that a plan to achieve adequate pain relief without maternal risk is most effective if which occurs?
   a. The mother gives birth without any analgesic or anaesthetic.
   b. The mother and family’s priorities and preferences are incorporated into the plan.
   c. The primary health care provider determines the best pain relief for the mother
   and family.
   d. The nurse informs the family of all alternative methods of pain relief available in
   the hospital setting.

Answer 6

ANS: B
The assessment of the patient, their fetus, and their labour is a joint effort of the nurse and the primary health care providers, who consult with the laboring patient about their findings and recommendations. The needs of each patient are different, and many factors must be considered before a decision is made whether pharmacological methods, nonpharmacological methods, or a combination of the two will be used to manage labour pain

Question 7

7. A patient in the active phase of the first stage of labour is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. They state that they are feeling lightheaded and dizzy and that their fingers are tingling. What should the nurse do?
   a. Notify the patient’s primary health care provider.
   b. Teach the patient to slow the pace of their breathing.
   c. Administer oxygen via a mask or nasal cannula.
   d. Help them breathe into a paper bag.

Answer 7

ANS: D
This patient is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, or circumoral numbness. Having the patient breathe into a paper bag held tightly around their mouth and nose may eliminate respiratory alkalosis. This enables them to rebreathe carbon dioxide and replace the bicarbonate ion.

Question 8

8. A patient is experiencing intense labour pain in their lower back. Which would be an effective relief measure for this patient?
   a. Counterpressure against the sacrum
   b. Pant-blow (breaths and puffs) breathing techniques
   c. Effleurage
   d. Conscious relaxation or guided imagery

Answer 8

ANS: A
Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the patient cope with the sensations of internal pressure and pain in the lower back. The pain management techniques of pant-blow and conscious relaxation or guided imagery are usually helpful for contraction per the gate-control theory. Effleurage is helpful as a method of distraction.

Question 9

9. What should the labouring patient be taught if they are receiving an opioid antagonist?
   a. Their pain will decrease.
   b. Their pain will return.
   c. They will feel less anxious.
   d. They will no longer feel the urge to push.

Answer 9

ANS: B
The patient should be told that the pain that was relieved by the opioid analgesic will return with administration of the opioid antagonist. Opioid antagonists, such as Narcan, promptly reverse the central nervous system (CNS) depressant effects of opioids. In addition, the antagonist counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if labour is more rapid than expected and birth is anticipated when the opioid is at its peak effect.

Question 10

10. A patient who receives an epidural during labour at increased risk of experiencing what?
    a. Hypertension
    b. Hypotension
    c. Decreased oxytocin requirements
    d. Decreased oxygen requirements

Answer 10

ANS: B
The patient receiving an epidural is at risk of hypotension. The patient is not at risk for hypertension. There is an increased oxytocin requirement with an epidural. There is an increased oxygen requirement with an epidural.

Question 11

11. Which reflects the role of the nurse with regard to informed consent?
    a. Inform the patient about the procedure and have them sign the consent form.
    b. Act as a patient advocate and provide clarification.
    c. Call the physician to see the patient.
    d. Witness the signing of the consent form

Answer 11

ANS: B
Nurses play a part in the informed consent process by clarifying and describing procedures or by acting as the patient’s advocate and asking the primary health care provider for further explanations. The physician is responsible for informing the patient of their options, explaining the procedure, and advising the patient about potential risk factors. The physician must be present to explain the procedure to the patient. The nurse’s responsibilities go further than simply asking the physician to see the patient.

Question 12

12. A first-time mother is concerned about the type of medications they will receive during labour. They are in a fair amount of pain and are nauseous. In addition, they appear to be very anxious. A nurse explains that opioid analgesics often are used with sedatives for which reason?
    a. The two together work best for the mother and baby.
    b. Sedatives help the opioid work better and will help relax the mother and relieve nausea.
    c. The two work better together so the patient can sleep until the baby is born.
    d. These medication are what the health care provider has ordered.

Answer 12

ANS: B
Sedatives can be used to reduce the nausea and vomiting that often accompany opioid use. In addition, some ataractics reduce anxiety and apprehension and potentiate the opioid analgesic affects. A potentiator may cause the two medications to work together more effectively, but it does not ensure maternal or fetal complications. Sedation may be a related effect of some ataractics, but it is not the goal. Furthermore, a patient is unlikely to be able to sleep through active labour. “This is what the health care provider has ordered for you” may be true, but it is not an acceptable comment for the nurse to make.

Question 13

13. Which should a nurse be aware of when helping patients manage discomfort and pain during labour?
    a. The predominant pain of the first stage of labour is the visceral pain located in the
    lower portion of the abdomen.
    b. Referred pain is the extreme discomfort between contractions.
    c. The somatic pain of the second stage of labour is more generalized and related to
    fatigue.
    d. Pain during the third stage is similar to pain in the second sta

Answer 13

ANS: A
This pain comes from cervical changes, distension of the lower uterine segment, and uterine ischemia. Referred pain occurs when the pain that originates in the uterus radiates to the abdominal wall, lumbosacral area of the back, iliac crests, and gluteal area. Second-stage labour pain is intense, sharp, burning, and localized. Third-stage labour pain is similar to that of the first stage.

Question 14

14. A nurse is aware that which statement correctly describes the effects of various pain factors?
    a. Higher prostaglandin levels arising from dysmenorrhea can blunt the pain of
    childbirth.
    b. Upright positions in labour increase the pain factor because they cause greater
    fatigue.
    c. Patients who move around trying different positions are experiencing more pain.
    d. Levels of pain-mitigating beta-endorphins are higher during a spontaneous,
    natural childbirth.

Answer 14

ANS: D
Higher endorphin levels help patients tolerate pain and reduce anxiety and irritability. Higher prostaglandin levels correspond to more severe labour pains. Upright positions in labour usually result in improved comfort and less pain. Moving freely to find a more comfortable position is important for reducing pain and muscle tension.

Question 15

15. Patients who have participated in childbirth education classes often bring a “birth bag” or “Lamaze bag” with them to the hospital. Which is a common item that a patient might bring with them for their labour and birth?
    a. Candles
    b. Tennis balls
    c. Bubble bath solution
    d. Burning incense for aromatherapy

Answer 15

ANS: B
Tennis balls are used to provide counterpressure, especially if the patient is experiencing back labour. Although many patients find the presence of candles conducive to creating calm and relaxing surroundings, these are not suitable for a hospital birthing room environment. Oxygen may be in use, resulting in a fire hazard. Bubble bath solution is not recommended for a labouring patient with ruptured membranes. Burning incense for aromatherapy would not be appropriate as it is a fire hazard. Nonburning incense would not violate the fire and safety regulations of a hospital.

Question 16

16. What should a nurse be aware of with regard to a pregnant patient’s anxiety and pain experience?
    a. Even mild anxiety must be acknowledged and treated.
    b. Excessive anxiety increases tension, which increases pain and fear.
    c. Anxiety increases the perception of pain, but it does not affect the mechanism of
    labour.
    d. Patients who have had a painful labour will have less anxiety the second time
    because of increased familiarity.

Answer 16

ANS: B
Anxiety and pain reinforce each other in a cyclical manner. Mild anxiety is normal for a patient in labour and likely needs no special treatment other than the standard reassurances. Anxiety increases muscle tension and ultimately can build sufficiently to slow the progress of labour. Unfortunately, an anxious, painful first labour is likely to carry over, through expectations and memories, into an anxious and painful experience in the second pregnancy.

Question 17

17. Nurses should be aware of which difference that experience can make in relation to labour pain?
    a. Sensory pain for nulliparous patients often is greater than for multiparous patients
    during early labour.
    b. Affective pain for nulliparous patients usually is less than that for multiparous
    patients throughout the first stage of labour.
    c. Patients with a history of substance use experience more pain during labour.
    d. Multiparous patients have more fatigue from labour and thus experience more
    pain.

Answer 17

ANS: A
Sensory pain is greater for nulliparous patients because their reproductive tract structures are less supple. Affective pain is greater for nulliparous patients during the first stage but decreases for both nulliparous and multiparous patients during the second stage. Patients with a history of substance use experience the same amount of pain as those without such a history. Nulliparous patients have longer labours and thus experience more fatigue.

Question 18

18. A patient is experiencing back labour and states they have intense pain in their lower back. An effective relief measure would be to use
    a. counterpressure against the sacrum.
    b. pant-blow (breaths and puffs) breathing techniques.
    c. effleurage.
    d. conscious relaxation or guided imagery.

Answer 18

ANS: A
Counterpressure is a steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the patient cope with the sensations of internal pressure and pain in the lower back. The pain-management techniques of pant-blow, effleurage, and conscious relaxation or guided imagery are usually helpful for contractions per the gate-control theory.

Question 19

19. When is effleurage most effective?
    a. First stage of labour
    b. Prelabour
    c. Second stage of labour
    d. Placental delivery

Answer 19

ANS: A
Effleurage is most effective during the first stage of labour. As labour progresses, hyperesthesia (hypersensitivity to touch) may make effleurage uncomfortable and thus less effective.

Question 20

20. Which should perinatal nurses be aware of when answering questions about the many ways people have tried to make the birthing experience more comfortable?
    a. Music supplied by the support person has to be discouraged because it could
    disturb others or upset the hospital routine.
    b. Patients in labour can benefit from sitting in a bathtub, but they must limit
    immersion to no longer than 15 minutes at a time.
    c. Counterpressure is almost always counterproductive.
    d. Electrodes attached to either side of the spine to provide high-intensity electrical
    impulses facilitate the release of endorphins.

Answer 20

ANS: D
Transcutaneous electrical nerve stimulation does help. Music may be very helpful for reducing tension and certainly can be accommodated by the hospital. Patients can stay in a bath as long as they want, although repeated baths with breaks might be more effective than a long soak. Counterpressure can help the patient cope with lower back pain.

Question 21

21. What should nurses be aware of with regard to systemic analgesics administered during labour?
    a. Systemic analgesics cross the maternal blood–brain barrier as easily as they do
    the fetal blood–brain barrier.
    b. Effects on the fetus include absent or minimal fetal heart rate (FHR) variability.
    c. Intramuscular (IM) administration is preferred over intravenous (IV)
    administration.
    d. IV patient-controlled analgesia (PCA) results in increased use of an analgesic.

Answer 21

ANS: B
Opioids readily cross the placenta. Effects on the fetus and the newborn can be profound, including absent or minimal FHR variability during labour and significant newborn respiratory depression requiring treatment after birth. Systemic analgesics cross the fetal blood–brain barrier more readily than the maternal blood–brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCA results in decreased use of an analgesic.

Question 22

22. What should nurses be aware of with regard to nerve block analgesia and anaesthesia?
    a. Most local agents are chemically related to cocaine and end in the suffix -caine.
    b. Local perineal infiltration anaesthesia is effective when epinephrine is added, but
    it can be injected only once.
    c. A pudendal nerve block is designed to relieve the pain from uterine contractions.
    d. A pudendal nerve block, if done correctly, does not significantly lessen the
    bearing-down reflex.

Answer 22

ANS: A
Most local agents are chemically related to cocaine and end in the suffix -caine, such as lidocaine and chloroprocaine. Injections can be repeated to prolong the anaesthesia. A pudendal nerve block relieves pain in the vagina, vulva, and perineum but not the pain from uterine contractions, and it lessens or shuts down the bearing-down reflex.

Question 23

23. What should the nurse be cognizant of with regard to spinal and epidural anaesthesia?
    a. It is commonly used for Caesarean births but is not suitable for vaginal births.
    b. A higher incidence of after-birth headache is seen with spinal blocks.
    c. Epidural blocks allow the patient to move freely.
    d. Spinal and epidural blocks are never used together.

Answer 23

ANS: B
Headaches may be prevented or mitigated to some degree by a number of methods. Spinal blocks may be used for vaginal births, but the patient must be assisted through labour. Epidural blocks limit the patient’s ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular.

Question 24

24. A patient in labour is breathing into a mouthpiece just before the start of her regular contractions. As she inhales, a valve opens, and gas is released. She continues to inhale the gas slowly and deeply until the contraction starts to subside. When the inhalation stops, the valve closes. Which statement is accurate in relation to this scenario?
    a. This method is not used much anymore.
    b. This method is likely to be used only in the second stage of labour.
    c. This describes an application of nitrous oxide.
    d. This describes a preparation for Caesarean birth.

Answer 24

ANS: C
This is an application of nitrous oxide, which could be used in either the first or second stage of labour (or both) as part of the preparation for a vaginal birth.

Question 25

25. After a change-of-shift report a nurse assumes care of a multiparous patient in labour. The patient states they are having pain that radiates to their abdominal wall, lower back, and buttocks and down the thighs. Which type of pain is the patient experiencing? a. Visceral
    b. Referred
    c. Somatic d. Afterpain

Answer 25

ANS: B
As labour progresses, the patient often experiences referred pain. This occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and thighs. The patient usually has pain only during a contraction and is free from pain between contractions. Visceral pain is that which predominates during the first stage of labour. This pain originates from cervical changes, distension of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. This results from stretching of the perineal tissues and the pelvic floor. This occurs during the second stage of labour. Pain experienced during the third stage of labour or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labour.

Question 26

26. Maternal hypotension is a potential adverse effect of regional anaesthesia and analgesia. Which nursing intervention would the
    nurse use to raise the patient’s blood pressure?
    a. Place the patient in a supine position.
    b. Perform a vaginal examination.
    c. Increase intravenous (IV) fluids.
    d. Implement continuous electronic fetal heart monitoring.

Answer 26

ANS: C
Nursing interventions for maternal hypotension arising from analgesia or anaesthesia include turning the patient to a lateral position, increasing IV fluids, administering oxygen via face mask, elevating the patient’s legs, notifying the primary health care provider, administering an IV vasopressor, and monitoring the maternal and fetal status at least every 5 minutes until both are stable. Placing the patient in a supine position would cause venous compression, thereby limiting blood flow to and oxygenation of the placenta and fetus. A sterile vaginal examination has no bearing on maternal blood pressure. Electronic monitoring will not affect maternal hypotension.

Question 27

27. It is important for a nurse to work with the patient to develop a birth plan that meets the pregnant person’s wishes. The nurse can explain that the most important advantage of nonpharmacological pain management is
    a. greater and more complete pain relief is possible.
    b. no side effects or risks to the fetus are involved.
    c. the patient remains fully alert at all times.
    d. a more rapid labour is likely.

Answer 27

ANS: B
Because nonpharmacological pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. There is less pain relief with nonpharmacological pain management during childbirth. The patient’s alertness is not altered by medication; however, the increase in pain will decrease alertness. Pain management may or may not alter the length of labour. At times when pain is decreased, the mother relaxes and labour progresses at a quicker pace.

Question 28

28. A nurse providing newborn stabilization must be aware that the primary side effect of maternal opioid analgesia in the newborn is
    a. respiratory depression.
    b. bradycardia.
    c. acrocyanosis.
    d. tachypnea.

Answer 28

ANS: A
An infant who is born within 1 to 4 hours of maternal analgesic administration is at risk for respiratory depression from the sedative effects of the opioid. Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is an expected finding in a newborn and is not related to maternal analgesics. The infant who is having a side effect to maternal analgesics normally would have a decrease in respira

Question 29

29. The nerve block used in labour that provides anesthesia to the lower vagina and perineum is called
    a. an epidural.
    b. a pudendal.
    c. a local.
    d. a spinal block.

Answer 29

ANS: B
A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps if needed. An epidural provides anesthesia for the uterus, perineum, and legs. A local provides anesthesia for the perineum at the site of the episiotomy. A spinal block provides anesthesia for the uterus, perineum, and down the legs.

Question 30

30. Which method of pain management is safest for a G3T2P0A0L2 admitted at 8 cm cervical dilation?
    a. Epidural anesthesia
    b. Opioids
    c. Spinal block
    d. Breathing and relaxation techniques

Answer 30

ANS: D
Nonpharmacological methods of pain management may be the best option for a patient in advanced labour. It is unlikely that enough time remains to administer epidural or spinal anesthesia. An opioid given at this time may reach its peak about the time of birth and result in respiratory depression in the newborn.

Question 31

31. The labouring patient who imagines their body opening to let the baby out is using a mental technique called a. dissociation.
    b. effleurage. c. imagery.
    d. distraction.

Answer 31

ANS: C
Imagery is a technique of visualizing images that will assist the patient in coping with labour. Dissociation helps the patient learn to relax all muscles except those that are working. Effleurage is self-massage. Distraction can be used in the early latent phase by having the patient engage in another activity.

Question 32

32. A perinatal nurse is preparing the patient for an emergency Caesarean birth, with no time to administer spinal anesthesia. The nurse is aware and prepared for the greatest risk of administering general anesthesia to the patient. This risk is
    a. respiratory depression.
    b. uterine relaxation.
    c. inadequate muscle relaxation.
    d. aspiration of stomach contents.

Answer 32

ANS: D
Aspiration of acidic gastric contents with possible airway obstruction is a potentially fatal complication of general anesthesia. Respirations can be altered during general anesthesia, and the anesthesiologist will take precautions to maintain proper oxygenation. Uterine relaxation can occur with some anesthesia; however, this can be monitored and prevented. Inadequate muscle relaxation can be improved with medication.

Question 33

33. To assist the patient after the birth of their infant, a nurse knows that the blood patch is used after spinal anesthesia to relieve
    a. hypotension.
    b. headache.
    c. neonatal respiratory depression.
    d. loss of movement.

Answer 33

ANS: B
The subarachnoid block may cause a postspinal headache resulting from loss of cerebrospinal fluid from the puncture in the dura. When blood is injected into the epidural space in the area of the dural puncture, it forms a seal over the hole to stop leaking of cerebrospinal fluid. Hypotension is prevented by increasing fluid volume before the procedure. Neonatal respiratory depression is not an expected outcome with spinal anesthesia. Loss of movement is an expected outcome of spinal anesthesia.

Question 34

1. Which interventions are appropriate when caring for a patient with maternal hypotension who has a spinal anaesthesia? (Select all that apply.)
   a. High-Fowler’s position.
   b. Increase IV infusion rate.
   c. Increase the rate of the spinal anaesthesia as ordered.
   d. Administer IV vasopressor as ordered.
   e. Monitor fetal heart rate every 30 minutes

Answer 34

ANS: B, D
Interventions for maternal hypotension are turning the patient to a lateral position or placing a wedge under her hip; maintaining or increasing IV fluid; notifying the primary health care provider; administering IV vasopressor as ordered; and monitoring maternal blood pressure and fetal heart rate every 5 minutes.

Question 35

2. The class of medications known as opioid analgesics (butorphanol, nalbuphine) is not suitable for administration to patients with known opioid dependence. The antagonistic activity could precipitate withdrawal symptoms (abstinence syndrome) in both mothers and newborns. Signs of opioid/narcotic withdrawal in the mother would include (Select all that apply.)
   a. yawning, runny nose.
   b. increase in appetite.
   c. chills and hot flashes.
   d. constipation.
   e. irritability, restlessness.

Answer 35

ANS: A, C, E
The patient experiencing maternal opioid abstinence syndrome will exhibit yawning, runny nose, sneezing, anorexia, chills or hot flashes, vomiting, diarrhea, abdominal pain, irritability, restlessness, muscle spasms, weakness, and drowsiness. It is important for the nurse to assess both mother and baby and to plan care accordingly.

Question 36

3. While developing an intrapartum care plan for the patient in early labour, it is important that the nurse recognize that psychosocial factors may influence a patient’s experience of pain. These include (Select all that apply.)
   a. culture.
   b. anxiety and fear.
   c. previous experiences with pain.
   d. intervention of caregivers.
   e. support systems.

Answer 36

ANS: A, B, C, E
Culture: A patient’s sociocultural roots influence how they perceive, interpret, and respond to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviours (stoicism) while belittling others (noisy expression). Anxiety and fear: Extreme anxiety and fear magnify sensitivity to pain and impair a patient’s ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts. Previous experiences with pain: Fear and withdrawal are a natural response to pain during labour. Learning about these normal sensations ahead of time helps a patient suppress their natural reactions of fear regarding the impending birth. If a patient previously had a long and difficult labour, they are likely to be anxious. They may also have learned ways to cope and may use these skills to adapt to the present labour experience. Support systems: An anxious partner is less able to provide help and support to a patient during labor. A patient’s family and friends can be an important source of support if they convey realistic and positive information about labour and birth. Although the intervention of caregivers may be necessary for the well-being of the patient and their fetus, some interventions add discomfort to the natural pain of labour (i.e., fetal monitor straps, intravenous lines).