Nonpharmacological Pain Management: Sherpath

Question 1

What the two components of pain?

Answer 1

Physiologic

Psychologic

Question 2

Physiologic Component

Answer 2

includes reception by sensory nerves and transmission to the central nervous system

Question 3

Psychologic Component

Answer 3

involves recognizing the sensation, interpreting it as painful, and reacting to the interpretation

Question 4

Physiological: Adverse Effects

Answer 4

Labor increases a woman’s metabolic rate and her demand for oxygen. Pain and anxiety escalate her already high metabolic rate by increasing production of catecholamines, including epinephrine and norepinephrine, cortisol, and glucagon. The patient may hyperventilate in response to pain and increase sympathetic hormones to obtain more oxygen, exhaling too much carbon dioxide in the process and having less oxygen to share with the fetus. High catecholamine levels and excess of stress hormones reduce blood flow to the uterus and placenta.

Question 5

Psychological: Adverse Effects

Answer 5

Poorly relieved pain lessens the pleasure of this extraordinary life event for both partners. The mother may find it difficult to interact with her infant because she is depleted from a painful, exhausting labor. Unpleasant memories of the birth may affect her response to sexual activity or another labor. Her partner may feel inadequate as a support person during birth.

Question 6

Tissue Ischemia

Answer 6

The blood supply to the uterus decreases during contractions leading to tissue hypoxia. Ischemic uterine pain has been likened to ischemic heart pain.

Question 7

Cervical Dilation

Answer 7

Dilation and stretching of the cervix and lower uterus are a major source of pain. Pain stimuli from cervical dilation travel through the hypogastric plexus entering the spinal cord at the T10, T11, T12, and L1 levels.

Question 8

Pressure and pulling on pelvic structures

Answer 8

Some pain results from pressure and pulling on pelvic structures such as ligaments, pelvic bone, fallopian tubes, ovaries, bladder, and peritoneum. The pain is a visceral pain; a woman may feel it as referred pain in her back and legs.

Question 9

Distention of the vagina and perineum

Answer 9

Marked distention of the vagina and perineum occurs with fetal descent, especially during the second stage. The woman may describe a sensation of burning, tearing, or splitting. Pain from vaginal and perineal distention and pressure and pulling on adjacent structures enters the spinal cord at the S2, S3, and S4 levels.

Question 10

What are the sources of labor pain

Answer 10

Tissue Ischemia
Cervical Dilation
Pressure and pulling on pelvic structures
Distention of vagina and perineum

Question 11

Which examples demonstrate how labor pain is different from other types of pain?

Answer 11

Labor pain is intermittent.

A woman may experience little discomfort with contractions, and she may be relatively comfortable during the short rest periods between contractions. This makes labor different from other types of pain.

Labor pain has a foreseeable end.

A woman can expect her labor to end within hours, rather than days, weeks, or months, whereas other types of pain may not have a foreseeable end.

Childbirth pain is part of a normal process.

Childbirth pain is part of a normal process, whereas other types of pain usually indicate an injury or illness.

Woman can acquire skills to help manage labor pain.

Different from other types of pain, pain associated with the birth process can be addressed, in part, by realistic preparation and knowledge about the birth process.

Question 12

Which is a physiological effect resulting from labor pain?

Answer 12

Increased production of catecholamines

The production of “fight-or-flight” hormones increase as a result of labor pain and anxiety. These include the catecholamines epinephrine and norepinephrine.

Question 13

Match the type of labor pain with its cause.

Answer 13

Pain caused by decreased blood flow to the uterus
**Tissue ischemia
Pain caused by the stretching of the lower uterus
**Cervical dilation
Pain caused by strain on ligaments and the peritoneum
**Pressure and pulling on pelvic structures
Pain described as burning, tearing, or splitting of the vagina
**Distention of the vagina and perineum

Question 14

Promoting a relaxing environment for mom

Answer 14

Promotion of uterine blood flow, thus improving fetal oxygenation
Promotion of efficient uterine contractions
Reduction of tension that increases pain perception and increases pain tolerance
Reduction of tension that can inhibit fetal descent

Question 15

Cutaneous Stimulation

Answer 15

Cutaneous stimulation involves stimulation of nerves via skin contact in an effort to reduce pain impulses to the brain. Examples used during labor include massage, thermal simulation, and acupressure. Cutaneous stimulation techniques are often combined with each other or with other techniques.

Question 16

Massage

Answer 16

Self-Massage
The woman may rub her abdomen, legs, or back in a self-massage called effleurage to counteract discomfort.

Massage by Others
The partner or the nurse can rub the woman’s back, shoulders, legs, or any area where she finds massage helpful. Nonclinical touch by the nurse is a powerful tool if the woman does not object to it. Holding her hand, stroking her hair, or similar actions convey caring, comfort, affirmation, and reassurance at this vulnerable time.

Question 17

thermal stimulation

Answer 17

Many women like to have warmth applied to their back, abdomen, or perineum during labor. A warm shower, tub bath, or whirlpool bath is relaxing and provides thermal stimulation. Cool, damp washcloths may be comforting, especially if a woman is hot. She may put them on her head, throat, abdomen, or any place she wants. She also may want to put them in or over her mouth to relieve dryness.

Question 18

Acupressure

Answer 18

Acupressure is a directed form of massage in which the support person applies pressure to specific pressure points using hands, rollers, balls, or other equipment.

Question 19

Hydrotherapy

Answer 19

The buoyancy afforded by immersion supports the body, equalizes pressure and aids muscle relaxation. In addition, fluid shifts from the extravascular space to the intravascular space, reducing edema as the excess fluid is excreted by the kidneys. Contraindications and/or precautions for hydrotherapy include thick meconium in the amniotic fluid, bleeding and oxytocin induction or augmentation, which requires continuous fetal monitoring. If fetal monitoring is available via waterproof telemetry monitors, which most large and modern facilities now have, hydrotherapy remains an option for these patients as well.

Question 20

Imagery

Answer 20

If the woman has not practiced a specific imagery technique, the nurse can help her create a relaxing mental scene. Most women find images of warmth, softness, security, and total relaxation most comforting. Imagery can help the woman dissociate herself from the painful aspects of labor.

Question 21

Focal Point

Answer 21

When using nonpharmacologic techniques, a woman may prefer to close her eyes or may want to concentrate on an external focal point. Keeping her eyes on a focal point may help the woman concentrate on something outside her body and thus away from the pain caused by contractions. She may bring a picture of a relaxing scene or an object to use as a focal point and to aid in the use of imagery. She can use any point in the room as a focal point.

Question 22

Types of breathing techniques

Answer 22

First-Stage Breathing
Cleansing Breath
Slow-Paced Breathing
Modified-Paced Breathing
Pattern-Paced Breathing

Question 23

First stage breathing

Answer 23

Breathing in the first stage of labor consists of a cleansing breath and various breathing techniques known as paced breathing. The method begins with a very simple technique that is used as long as possible.

Question 24

Cleansing Breath

Answer 24

Each contraction in first and second stages begins and ends with a deep inspiration and expiration known as the cleansing breath. Like a sigh, a cleansing breath helps the woman release tension. It provides oxygen to help prevent myometrial hypoxia, which is one cause of pain in labor. The woman may inhale through the nose and exhale through the mouth or take her cleansing breath in any way comfortable for her.

Question 25

Slow paced breathing

Answer 25

The first breathing is slow-paced breathing, a slow, deep breathing that increases relaxation. The woman should concentrate on relaxing her body rather than on regulating the rate of her breathing. Relaxation naturally brings about slower breathing, similar to that which occurs during sleep. She can use nose, mouth, or combination breathing, depending on which is most comfortable.

Question 26

Modified paced breathing

Answer 26

When the woman finds that slow-paced breathing is no longer effective, she begins modified-paced breathing. Although modified-paced breathing is more shallow than slow-paced breathing, the faster rate allows oxygen intake to remain about the same. As with slow-paced breathing, the focus is on release of tension rather than on the actual number of breaths taken.

Question 27

Pattern paced breathing

Answer 27

Pattern-paced breathing (sometimes called “pant blow,” “hee hoo,” or “hee blow” breathing) involves focusing on a rhythmic pattern of breathing. It is similar to modified-paced breathing. It differs in that after a certain number of breaths, the woman exhales with a slight emphasis or blow and then begins the modified-paced breathing again. The addition of a blow causes her to focus more on her breathing and reduces habituation.

Question 28

Which statement, if made by the nurse, can reduce a woman’s anxiety during labor?

Answer 28

“Susan, you can select the relaxation method you wish to use first.”

Addressing the patient by name and offering her choices reduces a woman’s anxiety during labor.

Question 29

A laboring patient places a cool, dark compress over her forehead during labor. This is an example of which relaxation technique?

Answer 29

Thermal stimulation

The laboring woman may place it on her head, throat, or abdomen, particularly if she feels overheated. Another example of thermal stimulation is a relaxing warm shower or bath.

Question 30

A woman is experiencing intense pain with each contraction during labor. Her partner asks her to describe in detail her favorite beach. Which relaxation technique is her husband utilizing?

Answer 30

Imagery

Describing in vivid detail the location of a pleasant destination is an example the use of imagery and an example of mental stimulation. Imagery can help a laboring woman dissociate herself from the painful aspects of labor.

Question 31

The nurse cares for a woman experiencing a difficult labor. Due the psychological effects of the long and painful labor and delivery, the nurse knows that the patient may experience which consequence?

Answer 31

Difficulty bonding with infant
As a result of a difficult labor and delivery, a new mother may find it difficult to interact with her infant because she may feel physically and emotionally depleted.

Question 32

The nurse is caring for a patient in the second stage of labor. The patient reports burning pain across her perineum. The nurse understands that this is likely related to which cause?

Answer 32

Fetal descent
Burning pain across the perineum in the second stage of labor is likely due to fetal descent. This occurs along with marked distension of the vagina and perineum. The patient may report a sensation of burning, tearing, or splitting.

Question 33

A laboring patient reports lower back pain with each contraction and asks why it hurts there. The nurse explains to the patient that which sources contribute to back pain during labor?

Answer 33

Pressure on the bladder
Lower back pain during contractions is likely related to increased pressure on the bladder and the pulling of pelvic structures. This pain is visceral and often refers to the back and legs.

Pulling on the peritoneum
Lower back pain with contractions is likely related to pressure and pulling of the pelvic structures, including the peritoneum. This pain is visceral and often refers to the back and legs.
Correct

Pulling of ligaments of the pelvis
Lower back pain with contractions is likely related to pressure and pulling of the pelvic structures including the ligaments of the pelvis. This pain is visceral and often refers to the back and legs.

Question 34

A woman is brought into labor and delivery in the early stages of labor. Place the following breathing techniques in the order in which they should be implemented during the labor process.

Answer 34

Cleansing breath
Slow-paced breathing
Modified-pace breathing
Pattern-paced breathing

Question 35

A laboring patient reports moderate back pain. Her partner rubs her lower back and reminds her to look at the teddy bear they bought for the newborn. This is an example of which relaxation technique(s)?

Answer 35

Massage
Massage is a form of cutaneous stimulation that involves rubbing areas of pain to reduce discomfort. This relaxation technique can help with lower back pain during labor.
Correct

Focal point
The use of a teddy bear to look at during labor is an example of a focal point. By using a focal point, the woman focuses on an external focal point usually on object with positive associations) as opposed to the internal sensation of pain

Question 36

When teaching a childbirth class for first-time parents, the nurse includes which benefits of breathing techniques used during labor?

Answer 36

Decreased sensation of pain
The sensation of pain is decreased with breathing techniques.
Provides a different focus during contractions
Breathing techniques provide laboring women with a different focus during contractions, reducing the perception of pain. This is a benefit of using breathing techniques in labor.
Can be used with other nonpharmacologic techniques
Breathing techniques can be used to supplement other relaxation techniques during labor, such as mental stimulation and cutaneous stimulation.