Maximizing comfort in the laboring Women: Chapter 14 Flashcards
laboring women experience a significant amount of discomfort and pain as well as a variety of other challenging Sensations
although labor and birth are considered to be natural processes
So neurologic origins of pain during labor and childbirth there are three types of pain experienced by women during the first stage of Labor
Visceral pain:
Referred pain:
Somatic pain:
Pain management: neurologic origins
from cervical changes, distention of lower uterine segment, and uterine ischemia (First and third stages of labor)
contractions cause cervical dilation and effacement
uterine ischemia results from compression of the arteries supplying the myometrium during uterine contractions the pain from distention of the lower uterine segment stretching of cervical tissue as it efaces and dilates pressure and traction on adjacent nerves and structures and uterine ischemia during the first stage of Labor is visceral pain
Visceral pain:
originates in uterus, radiates to abdominal wall, lumbosacral area of back, iliac crests, gluteal area, and down thighs
Is located over the lower portion of the abdomen
originates when the pain that originates in the uterus radiates and that’s what referred pain is it
doesn’t women who or anybody really who’s actually had their abdomen opened up during surgery and closed and stitched back up people will complain of severe shoulder pain after an abdominal surgery there’s nothing wrong with her shoulder they have trapped air that is causing referred pain to the shoulders so that’s what referred pain is a woman in labor will have referred pain during most of the first stage of Labor the woman usually has discomfort only during contractions and is free from pain between the contractions during the second stage of Labor the woman has so much pain which is often described as intense sharp burning and very well localized as you can see down here and be well actually no skip down to see there’s seat this pain results from the following distention and traction on the peritoneum and uteruservical supports during contraction pressure against the bladder and rectum stretching and distention of the perineal tissues and laceration of the soft tissues of the cervix vagina and perineum so most of this pain they said they stop they feel the contractions but what they’re complaining of most is right here this red area
Referred pain:
pain described as intense, sharp, burning, and 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
Second stage
Is right here this red area which would make sense they’re about to give birth to a baby pain experience or the third stage of Labor or when the placenta is delivered and the after Pains of that early postpartum period or uterine similar to the pain experienced early in the first stage of Labor so that would be more visceral pain
Somatic pain:
Physiologic Factors
Culture
Anxiety
Previous experience
Gate-Control Theory of Pain
Comfort
Environment
Factors influencing pain
can affect the intensity of childbirth pain and we know pain is tough because it is very subjective you’ll see one woman react one way and another woman react to completely different way in the same phase of Labor fatigue can decrease or if she just worked at 12 hour shift at night and then gets home and then her labor starts she’s already tired it’s going to be harder for her to cope
Physiologic Factors
culture imposes certain behavioral expectations regarding acceptable and unacceptable behavior when experiencing pain recognize that although a woman’s behavior and response to pain may very according to her cultural background it may not actually reflect the intensity of the pain she is experiencing it is the nurses role to assess the woman for the physiologic effects of pain increases
Culture
anxiety is commonly associated with increased pain during labor mild anxiety is considered normal for a woman excessive anxiety and fear however cause more catecholamines secretion which will increase stimuli to the brain and increase that pain perception this is anxiety and fear heightened muscle tension increases in the effectiveness of uterine contractions decrease we often call this the bear tension pain cycle as the fear elevates detention the body tightening up and using a lot of energy will increase which will make you sore and worn out and will increase the pain which will also increase the anxiety which will increase the tension so if I can never ending cycle challenge
Anxiety
Childbirth for a healthy young woman maybe her first experience was significant pain and as a result she may not have developed effective pain coping strategies this is what we talk about when we’re referring to previous experience women who’ve had three and four kids know exactly what to expect their neighbors are shorter typically is each with each child and they know what to expect so they’re a little less afraid of the painful experiencing experiences in her life may have a really hard time coping if she’s not prepared adequately
Previous experience
helps explain the way hypnosis and the pain relief techniques taught in childbirth preparation classes work to relieve the pain of Labor according to this 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 so using distraction techniques you can they work by closing down a hypothetic gate in the spinal cord that’s preventing the pain signal from reaching the brain and the perception of pain is there by diminished so obstetric pain management techniques that utilize distraction include massage a back massage or effleurage of the abdomen aromatherapy hypnosis music guided imagery there’s there’s quite a few different ways that we can distract the pain signal from reaching the brain and thus decrease the perception the main impetus behind the gate control theory as it relates to pain to a positive stimulus by using all of the five senses to accept the more positive stimulus and pay less attention to the negative
Gate-Control Theory of Pain
Comfort the most helpful interventions enhancing Comfort are caring nursing approach in a supportive presence which leads you to support evidence indicates that a woman satisfaction with her labor and birth experience is determined by how well her personal expectations of childbirth and the quality of support and interaction she receives from her caregivers women who have continuous support beginning early and labor or less likely to use pain medications or epidural analgesia or anesthesia and are more likely to experience a spontaneous vaginal birth and express satisfaction with their childbirth experience
Comfort
important because if they’re very stressed out if there’s a lot of lighting if there’s a lot of people in the room it’s a lot of noise in the room that’s what you may think is being more of a distraction technique actually has the opposite effect where it’s more like a living room environment or a home environment or have home births because it’s the most comfortable place that you know to help with that nonpharm management
Environment
many non-pharmacologic measures is comparable to or even Superior to that of opioids that are administered parentally
In the past few years attendance a child with education classes has declined increasing numbers of women are utilizing online childbirth education rather than attending traditional classes
Encourage nonpharm first - need know how cope with pain
Nonpharmacologic measures often simple, safe, few adverse reactions, and inexpensive
Provide sense of control over childbirth
Methods require practice for best results
Try variety of methods and seek alternatives, including pharmacologic methods, if measure used is not effective
Non-pharmacologic pain management
choose them first before going to pharmacologic measures many of the non-pharmacologic methods for relief of discomfort are taught in different types of prenatal preparation classes or the women or couple may have searched the internet or reads various books and articles on the subjects in advance
however any of these methods require practice for best results because of the increased use of epidural analgesia or anesthesia nurses may be less likely to encourage women to use non-pharmacologic measures in part because these methods may be viewed as more complex and time consuming
Lamaze, Bradley, breathing techniques, touch, hydrotherapy, hypnosis, music
Lamaze and Bradley are several childbirth prepared methods women can take classes with their Partners however in the past few years attendance
some other techniques would be distraction techniques to attention focusing techniques like breathing paste breathing imagery Pace breathing
effleurage which is that light stroking usually of the woman’s abdomen counter pressure so back lower back pain is very effectively comforted with some steady pressure applied to Mom’s hips Touch Massage the feet the the shoulders the back application of heat or cold acupressure some countries use something called a transcutaneous electrical nerves stimulation or TENS unit during labor and especially in the postpartum
increase in aromatherapy though especially with the invention of Doterra and Young Living
hypnosis
music
Nonpharmacologic measures often simple, safe, few adverse reactions, and inexpensive
should be implemented before pain becomes so severe that catecholamines increase and labor is prolonged
it is unacceptable for women in labor to endure severe pain when safe and effective relief measures are available unless she wants to be in that pain but then even then we need to attempt the non pharmacologic pain management
pharmacologic and non-pharmacologic measures when used together increase the level of pain relief and create a more positive labor experience for the woman and her family
Sedatives
Analgesia and Anesthesia
Pharmacologic pain management
sedatives relieve anxiety and induce sleep they may also be given to augment analgesics and reduce nausea when an opioid is being used don’t typically use them very metally Phenergan not using those very very much anymore but they can be used together so you’ve got Valium Ativan Phenergan seek and all just to help Mom relax not necessarily to take all the pain away however because of the potential for neonatal central nervous system depression barbiturate should be avoided if birth is anticipated within 12 to 24 hours so anything that’s going to barbiturates as in the secanal I’ve not seen seeking all used very much at all it’s been a long time since I’ve seen that used anything that’s going to pass the blood-brain barrier of the fetus is going to impact how they respond to the extra uterine environment
Sedatives
so keep this in mind as we go through this analgesia and anesthesia anesthesia encompasses analgesia Amnesia relaxation and reflex activity anesthesia abolishes pain perception by interrupting the nerve impulses to the brain the loss of sensation
Refers to the alleviation of the sensation of pain or the raising of a threshold for pain perception without loss of consciousness so here are some systemic analgesia
Opioids
Opioid Agonist
Opioid Agonist-Antagonist
Opioid Antagonists
Analgesia and Anesthesia
provide sedation and Euphoria but they’re analgesic effect in labor is fairly Limited we often go straight for the short acting analges because of because they actually readily cross that placenta effects on the fetus and newborn can be profound including absent or minimal fetal heart rate variability which we’ll talk about in the next chapter and significant neonatal respiratory depression requiring treatment right after birth the opioid the opioids commonly used currently In Obstetrics are my parading fentanyl Fentanyl and now beeping which is new Bang a parenting Fentanyl
Opioids
Fentanyl are opioid agonists because opioids can inhibit uterine contractions they should not be administered until Labor as well established unless they are being used to enhance therapeutic rest during prolonged early phase if you remember from lecture early phase is the longest of the three phases of the first stage of Labor in fact it’s not it’s as long as both second and third are as long as active in transition put together it’s the longest now some women have a prolonged early phase labor giving them a little bit of an opioid Agonist or even an opioid with a sedative however neonatal effects can persist for the first two to three days of life with my parity so my parenting which is your Demerol we don’t typically use because of that effect but you can
Opioid Agonist
opioid Agonist antagonist analgesic would be your newbane it’s commonly used in the labor and delivery setting the opioid Agonist antagonists are Agonist at the Kappa opioid receptors you don’t need to know all the ins and outs of these this is not pharmacology so you don’t need to worry about the method of action the onset and the peak I’m not asking for any of that okay what I want you to take away from these systemic and analgia or anesthesia is that it does cross the placenta it does affect the fetus this is very important opioids can also cause excessive CNS depression in the mother or both of them
Opioid Agonist-Antagonist
we also have Narcan on hand for Mom and for baby so if the excessive CNS depression in the mom we give Mama some Narcan if baby is born we give a that’s why they’re short acting again and we give Mom an injection of State all or newbain or fentanyl and the baby is born soon after that Administration the baby is still experiencing effects so they don’t want to breathe it’s the first time taking a big deep breath and they’re going to not want to do that so we always make sure that we pass on to the nursery nurse the last time that that system that they can be prepared in case they need to administer the Narcan to the newborn let’s see here what else can we tell you about this so yeah as far as like your medication guide on pages like 346 and 347 you don’t need to worry about all those details I’m not going to ask you what the dosages for newbane for the first time you have Minister not important just understand the big picture idea systemic it’s going to affect the baby and what happens when the baby is seeing us depressed they don’t want to breathe they don’t want to suck they don’t want to do anything but be a blob so we have to reverse him sometimes with Narcan
Opioid Antagonists
Several different methods referred to as neuraxial analgesic and anesthetic techniques are used and obstetrics to produce sensory blockade in various degrees of motor blockade over a specific region of the body a variety of local anesthetic agents are used in these techniques to reduce Regional anesthesia the principal pharmacologic effect of local anesthetics is the temporary Interruption of the conduction of nerve impulses notably pain these are usually your cane drugs that were using to produce the sensation
Leaving the discomfortable labor and vaginal birth a block from the 10 to S5 is required for cesarean birth of block from T8 to S1 is essential so same way with a spinal we got to get her to curve her back and assume the Sims position or sit on the edge and really really roll her shoulders over to open up that integral space to allow for them to put the needle in insert the epidural catheter they take the needle out they tape up the epidural catheter in the right space and that is a joint effort the nurse and the CRNA or anesthesia provider where she’s checking mom’s pulse she’s got a pulse oxide and then make sure there’s not a significant increase in Mom’s heart rate and Mom doesn’t experience side effects of having that lidocaine opioid are there legs automatically fall asleep the CRNA will kind of go over what to expect during that initiation the testos was good to go they go ahead and hook her up to the pump and get her get her comfortable woman is positioned preferably on her side but not completely on our sides this is kind of done with the wedge we want to get the uterus off of that ascending being a Cava and the descending a order and we’re taking blood pressures about every 3 minutes to assess for hypotension I didn’t need to make sure oxygen is on standby and ephedrine which will be given by the CRNA and if need be you open up your IV fluids to give her a little bolus beat a heart rate pattern and contraction pattern is all also evaluated closely if Mom has a drop in her heart rate baby will have a reflexive reaction to that as well with a drop in their heart rate the most common message of epidural block is the continuous block so it’s hooked to a pump they’re not coming in and giving additional additional injections so the advantages of epidural blocker there’s quite there’s quite a few they’re awake they’re comfortable they good relaxation Airway reflexes remain intact but the disadvantages are fairly numerous the women’s ability to move freely into maintain control of her labor is limited she’s not getting out of the bed CNS effects can occur if a solution containing a local anesthetic agent is accidentally injected that’s why we do that testos hypotension hypotension happens this is 10 to 30% of women I’m betting it’s higher anecdotally would be higher hypertension you typically are going to see at some degree I can result in significant decrease in utero placental perfusion and auction delivery to the fetus urinary retention so we got to put a Foley in and they’ll tend to itch women who what’s making them itch is the fentanyl it’s not a reaction it’s not it’s just a side effect of the fentanyl they’ll be a little itchy so that’s our epidural so some contraindications people who can’t get a spinal or epidural these would be somebody who has an active maternal hemorrhage maternal hypertension we’re having a hard time maintaining her blood pressure coagulopathy so if a woman’s receiving anticoagulant therapy she has to have been off of it for over 12 hours if she’s a bleeding disorder and that’s just because we don’t want to introduce that needle into her back and bleed into her spine she has an increased ICP due to mass if she’s allergic to any of it if she refuses or is it able to cooperate and then there are some maternal cardiac conditions were that she she can not have an epidural or spinal
Local perineal infiltration anesthesia
Pudendal nerve block
Spinal anesthesia (block)
Epidural anesthesia/analgesia
Pharmacologic pain management: nerve blocks
that would be just a local block right there on the perineum either before the head is delivered or after or in that fourth fourth stage of Labor when we’re doing the episiotomy repair lacerations that need to be sutured to do a repair nerve block does not relieve the pain from the contraction it does absolutely relieve the pain in the lower vagina the vulva and the perineum
Local perineal infiltration anesthesia
