Chapter 8: Pain Management (only) Flashcards
non-pharmacological ways to manage (pain) discomfort
- childbirth preparation
- relaxation and breathing techniques
- effleurage
- thermal stimulation
- mental stimulation
- support person
pain management: complementary therapy
- aromatherapy- essential oils
- massage
- birthing ball
- hydrotherapy
- self-hypnosis
- music therapy
- acupuncture
- sterile water injections
pharmacological management of labor pain
- analgesia
- nitrous oxide
principles of using analgesia
- labor should be established
- medication should provide relief to mother with minimal risk to baby
- neonatal depression may occur if medication is given within an hour of delivery
- women with hx of drug abuse may have lessened effect from pain meds and may need higher doses
epidural anethesia
placement of a very small catheter and injection of local anesthesia and/or analgesia between 3rd and 5th vertebrae into the epidural space
what is the most common form of pain relief during labor in the US?
epidural anesthesia
nursing responsibilities for patients receiving regional anesthesia
- verify informed consent has been obtained by the anesthesia provider
- assess fetal status and maternal baseline, including pain level, BP, pulse, RR, temperature, O2 status, labor progress
- admin an IV bolus as ordered by the provider
- conduct a time-out before regional anesthesia admin
- provide patient education on the selected pain control method
anesthesia during labor
- regional anesthesia
-epidural
nursing care of the woman during regional anesthesia placement
- assist the woman to an appropriate position, either sitting, lateral, or pendant position
- assist with maintaining the position and with breathing and relaxation
- monitor for adverse maternal reactions during and immediately after test dose
- monitor for adverse fetal reactions during initiation medication
epidural placement
in the epidural space between the 3rd and 5th vertebrae in the lumbar region
which analgesics are used during labor?
- morphine sulfate (or opioid)
- butorphanol (or mixed opioid agonist or antagonist)
- sublimaze
- fentanyl (or opioid)
- nalbuphine (or mixed opioid agonist or antagonist)
physiologic birth is also called
normal birth
physiologic birth definition
birth that is powered by the innate human capacity of the woman and fetus
physiologic birth includes
spontaneous vaginal birth at term, with minimal technologic and pharmacologic interventions
physiologic birth is followed by
skin-to-skin contact and immediate breastfeeding
benefits to physiologic birth
- decreased interference with the birth process
- decreased length of labor
- decreased use of analgesia and anesthesia
- decreased operative birth
- decreased newborn complications associated with elective inductions of labor and operative births
- increased effectiveness of pushing
- increased maternal satisfaction and empowerment
- enhanced bonding
- enhanced breastfeeding
perinatal nurse role
- assess maternal/fetal well-being
- administer procedures and monitor for effectiveness
- interventions to assist with a laboring mom’s physical, emotional, and spiritual needs
- rendering care related to the birth process
- initiate newborn care
- providing care during early PP period
- advocating
- teaching/education
- communicating with other health care providers
- documentation
HypnoBirthing
- helps mom align with their own innate capacity to be able to give birth gently, comfortably, powerfully and joyfully
- no promises of a sensation free birth
- respects the rights and wishes of couple to birth the way that they want rather than by anyone else’s standards or timeline
what is the intention of HypnoBirthing
give power back to laboring mothers and fathers that has been taken away from them
HypnoBirthing was established by
Marie Mongan
why is fear during childbirth bad for the mother?
- she cannot relax
- tension in muscles throughout body
- intense tension causes pain in the uterine muscles which make the uterus work inefficiently, doesn’t allow uterus to open properly, causes lots of pain
why is removing fear important
no fear = no tension = no pain
what are some ways to remove fear from laboring mothers? (hint: exercises)
- lemon exercise
- pen drop exercise
what do endorphins do for laboring moms?
they act as the body’s natural relaxant
- slow down the firing rate of neurons which decreased pain sensations
in the absence of fear, how strong are endorphins compared to narcotics?
the body’s endorphins are 200x stronger than narcotics when allowed to be released from the pituitary in the absence of fear
uterine muscles are designed to
carry an infant to term and assist the infant to be born
how many layers of the uterus are there
3, but we are only concerned with 2: the outer layer and inner circular muscles
outer layer of the uterine muscles
-vertically aligned with the baby
- thickest and strongest on top, tighten and draw up the relaxed circular muscles at the neck of the uterus to nudge the baby down
inner circular muscles of the uterine muscles
- horizontally circular around the baby (cervix)
- thickest just above the neck of the uterus
- relax and thin out to allow the baby to emerge
when do the outer layer and inner circular muscle layer of the uterine muscles work well together?
when mom is relaxed
fear triggers what system
the ANS (autonomic nervous system)
what is the job of the ANS
- to interpret messages that it receives and then relay that to the rest of the body systems
- responses are involuntary
what are the two parts of the ANS
- sympathetic: panic room
- parasympathetic: healing room
sympathetic nervous system
- triggered by fear, stress, startled
- fight, flight or freeze response
sympathetic nervous system response (signs/symptoms)
- pupils dilate
- HR increases
- RR increases
- digestive processes are suspended (vomiting)
- closes arteries to organs not needed for defense, ie uterus
- halts labor as it preps body to deal with emergency
does the body know the difference between a real danger and a perceived danger
no, it acts the same way for both
what is referred to as the body’s “emergency system”
sympathetic nervous system
parasympathetic nervous system
keeps the body in a state of balance and harmony
parasympathetic nervous system response
- slows HR
- slows breathing
- reduces stimulation
- slows the firing or harmful neuropeptides
*happy mom = happy baby
if mom approaches birth with unresolved fear and stress, what stressor hormone is released?
catecholomine
where can negative messages about birth and the birth experience come from?
- family
- movie and tv images
- scary birthing scenes
- baby shower horror stories
- labor nurses
what does the body do when there is fear surrounding birth?
it can’t fight or flight so it freezes
what causes the “freeze” response during labor
the blood flow to the uterus is decreased
- causes uterine muscles to constrict and tighten
- cervical muscles stop opening
- the vertical muscles try to draw up and back but there is tension and constriction between the two muscle groups, which causes the pain that laboring women feel
(FTP) failure to progress is equivalent to
(FTP) fear tension pain
hypnosis
a natural state that you drift in and out of every day
- in a hypnotic state, you are hyperaware of yourself
how many conscious thoughts can we hold at a time? what do we do as a result of this?
- can only hold one conscious thought at a time
- train our brains to go into autopilot so we can think of other things, (i.e. drive a car, grooming, eating)
hypnosis: conditioned responses
responses to certain situations that we have worked up in our mind and our body responds accordingly
ie being pulled over by the police, sex, going on an amusement ride
what is the most important aspect of hypnosis regarding our body’s response to birthing?
- for every suggestion, thought, or emotion there is a corresponding physiological response within the body
- whatever mom chooses to accept as real or “perceives” as real, the body will act accordingly
law of motivation
when the mind is highly motivated, the body will respond accordingly
HypnoBirthing Techniques
- breathing
- relaxation
- visualization
- deepening
breathing: types
- sleep breathing
- slow breathing
- birth breathing
sleep breathing
- type of breathing you use to slip into a deep state of relaxation or sleep
- the breathing done in-between the surges and while at rest
- Eyes gently closed, breathe in through mouth to a count of 4 and feel the breath go to the back of the throat and then out to a count of 8 through the nose
slow breathing
- VERY important because it is the breathing that we do with the surges
- Goal is to make the breath as long in as it is out.
- With eyes closed, the entire body relaxed focusing on breathing in slowly as the uterus draws up to the top of the abdomen and then breathing it back down slowly and controlled. In to the count of 20 out to the count of 20.
birth breathing
- also called “slanted J” breathing as this is the “shape” it should take
- assists with the natural expulsion reflex of the body to move baby down gently to crowning and birth It is not pushing, that is counter productive and slows birth
- a short quick breath in, move the air to the back of the throat and then down the body to the vaginal outlet
what type of breathing is also referred to as (slanted) J breathing?
birth breathing
calming behaviors to promote mom’s relaxation
- letting her choose clothes to birth in
- soft music or nature sounds
- soft voice
- dim lighting
- essential oils diffused or applied topically
progressive relaxation
- deep inhalation, picturing numbers counting down and moving relaxation throughout the body systems
(relaxation) anchors
- creating a lasting imprint with an association of a gesture, sound, image or touch
light touch massage
- most beneficial if someone has had limited training in natural birth techniques
- great for fathers or partners to perform
- can do this on multiple different areas with the patient in different position
- a light touch, over a three-square-foot area of sensitive skin area is a massive stimulation, contraction the central nervous system and the peripheral nervous system
light touch massage: objective
- To stimulate and reprogram the internal mechanism in the brain without drugs.
- To release endorphins needed to stifle pain, reduce stress and eliminate back strain
light touch massage: how
- a light touch is administered to the skin over the neck, spine and upper arms.
- produces a massive sensation, stimulating the nerves in that area.
light touch massage: method
- a repetitive light stroke, applied simultaneously on both sides of the entire spine
- using light, kinesthetic, vertical “V” and horizontal “8” strokes to the upper part of the torso (neck, back and arms).
what is the Reticular Formation responsible for?
- filtering the impulses entering the system and regulating the body’s level of arousal, from a state of deep sleep at one extreme to a state of intense mental activity at the other
when is light touch massage very effectively administered?
when laboring mom wants to change into a kneeling position
the light touch V
- The birth companion places his/her hands on the small of the back to become centered, then with the backside of the fingers meeting at the base of the spine, lightly using fingernails draw up, out and across creating a shallow pattern of vertical V
the “8”
- Starting at the base of the spine, criss-cross hands at the center of the back to create horizontal figure “8” pattern
- Light touch should be administered with the back of the thumbnails, leading all the way to the skull. The hands are brought around the neck and sides of ears
what makes light touch special for labor
- touching breasts and ears is allowed
what are the most common practices of essential oils
- aromatic diffusion
- topical application
- dietary consumption
popular essential oils for spiritual focus
- sacred frankincense
- white angelica
- live your passion
- inspiration
essential oils to rediscover peace, balance, joy
joy
- lavender
- orange
peace and calming
- peppermint
- jasmine
essential oils that offer natural support for wellness
- lavender
- peppermint
- thieves essential oil blend
- frankincense
- R.C.
- PanAway
what are some other names for guided imagery
- guided meditation
- visualization
- mental rehearsal
- guided self-hypnosis
guided imagery is
a gentle but powerful technique that focuses the imagination in proactive, positive ways
- involves all the senses, not just vision
what are the 3 principles of Guided Imagery
- the mind-body connection
- the altered state
- locus of control
imagery tips
- works best in a permissive, unforced atmosphere
- engage all senses
- music can increase the effects of imagery
- don’t have to be a “believer” to make it work
- touch is a powerful accompaniment
- aches and pains are often gone after imagery meditation
interferences with physiologic birth
- IOL for no medical indication
- oxytocin or AROM to “speed it up”
- unnecessary IV fluids and boluses
- epidurals
- hospital culture that is not supportive to normal labor
- nurses having limited knowledge of labor support techniques
medically managed labor includes
- AROM
- oxytocin IOL or augmentation in absence of medical indication
- cytotec
- cervidil
- balloon induction
- manual removal of placenta in the absence of an indication
cesarean section rates
as of 2011, 1/3 women delivered via c/s
factors contributing to the increase in cesarean section rates
- rise in maternal age
- obesity
- cultural considerations
Low risk women are safer and have a lower mortality rate when delivering their infants _____
vaginally compared to a c/s
modifiable hospital culture
- Communication practices between nurse, patient and providers
- Nurses being powerful advocates for birth choice of patients
- Hospital Education available to support birth choice
- Hospital support for natural early labor techniques with portable monitors, ambulation, partner support, birth balls and hydrotherapy options
underused interventions
- Midwives and Family Physicians
- Continuous Labor Support
- Measures to Relieve Pain, Bring Comfort, and/or Promote Progress during Labor
- Delayed and Spontaneous Pushing
- Non-supine Positions for Giving Birth
- Delayed Cord Clamping in Full-Term and Preterm Newborns
- Early Skin-to-Skin Contact
- Breastfeeding and Interventions to Promote Its Initiation and Duration
what are some factors working against physiologic birth?
- Lack of a National Standardized Set of Maternity Performance Measures
- A Payment System That Incurs Perverse Incentives
- Malpractice Concerns
- Specialist Orientation Care Typical for Healthy, Low-Risk Mothers and Babies
- Current Maternity Practice Guidelines Excessively Reliant on Opinion
- Lack/Loss of Professional Core Knowledge/Skills for Optimal Childbirth
- Harms and Iatrogenesis Often Not Adequately Understood/Considered
- Knowledge Transfer and Application Challenging
- Pressure from Industry
- Increased Harm/Expense and More Entrenched Problems to Result If Policy Intervention Delayed
- Media Depiction of the Childbirth Experience Often Limited
- Informed Consent Processes Often Inadequate
promoting best practices
- Implement hard stop policies to prevent elective induction of labor prior to 39 weeks gestation. Hard stop policies require compliance with the guidelines by all providers.
- Only Induce labor before 41 0/7 weeks for evidence-based maternal or fetal indications and ideally with nulliparous women with Bishop score > 8 or multiparous women with Bishop score > 6.2
- Use cervical ripening methods of labor induction for a woman with an unfavorable cervix.
- Provide prenatal education to women to increase awareness of the possible benefits and harms and evidence-based indications for induced labor.
- Offer external cephalic version to women with a breech or transverse fetus at term.
birth satisfaction increases with
physiologic birth
- also increased when the choice made is mom’s
PTSD is more likely when a patient is
pressured into a choice that she did not come to on her own: IOL, c/s, epidural
- PTSD symptoms decrease when mom’s physiologic birth is supported
what three things are known to improve patient satisfaction with a mom who just delivered a child?
- amount of support from their caregivers
- quality of relationship with her caregivers
- level of involvement in her labor process
which fibers: small or large diameter, feel acute pain v. sensation?
- large diameter fibers: sensations
- small diameter fiber: acute pain
women who attend childbirth prep classes report ____
greater birth experiences
what is the difference between a spinal and regional epidural anesthesia?
- spinal is for c/s (higher up)
- regional is for vaginal delivery (just hips down)
adverse affects of epidural
- hyperthermia
- systemic toxicity
- urinary retention
- pruritus
nursing care after regional anesthesia placement
- assess fetal response frequently to regional anesthesia. assist with maternal positioning and avoid the supine position
- assess uterine activity every 5 minutes for the first 15 minutes
- assess for urinary retention and bladder distention q4h and assist with bladder emptying on bedpan
- assess maternal BP after initiation or re-bolus of a regional block, including PCEA
- monitor the woman for signs of sedation and respiratory depression
- perform intermittent urinary catheterization using a straight cath if she is unable to void spontaneously
- BP should be assessed at least q5 min for the first 15 min, then repeated at 30 min, and 1 hour after procedure
- assess level of motor blockade hourly throughout the period of analgesia or anesthesia
- if frequent bladder catheterizations are indicated, consider the use of indwelling urinary catheter
- resolve maternal hypotension, according to provider orders and facility protocol, such as lateral positioning, and administer additional crystalloid fluid boluses or vasopressors
- monitor maternal temp q2-4h after anesthesia
- assess for sedation level, N/V, pruritus
popular types of childbirth education classes
- lamaze
- the Bradley method
- the international childbirth education association (ICEA)
- hypnobirthing
- birthing from within
- hospital-based birthing classes
childbirth education classes: Lamaze
- offers childbirth education classes grounded in the idea that women have an innate ability to give birth
- letting labor begin on its own, freedom of movement in labor, labor support, no routine interventions, spontaneous pushing in non-supine positions, and keeping mother and baby together
childbirth education classes: the ICEA
- classes sponsored by the ICEA do not emphasize any one approach to childbirth but offer general information about the process of labor and birth
- they discuss natural childbirth, teach various methods of dealing with the pain of labor and birth, and present the options available for pain birthing
childbirth education classes: birthing from within
- a holistic approach to childbirth, Birthing from Within offers patients a general informative teaching experience
- activities and processes teach parents specific skills to holistically inform and prepare them for birth
childbirth education classes: hospital-based birthing classes
- many hospitals offer birthing classes for parents planning to give birth at their facility
- these classes may follow a specific method or a combination of methods, with the goal of preparing the mother and birth partner for labor and postpartum
childbirth education classes: the Bradley method
- emphasizes natural childbirth with the birth partner as the coach
- this method encourages concentrated awareness that works through pain rather than blocking it
- parents are taught deep abdominal breathing, massage, and an understanding of the labor and delivery process
which essential oil helps with nausea during labor?
peppermint oil
