Labor pains exist for a short time only. However, within that short time, the discomfort progresses from a slightly unpleasant experience to intense sensations. To the woman in labor, discomfort or pain may seem endless, and she may wonder whether she can tolerate it. To the nurse, the process of labor is a challenge. Armed with knowledge of the characteristics of pain in the various stages of labor, interventions for pain relief, comfort methods, and cultural responses to labor pain, the nurse is able to design a care plan to meet the specific needs of the woman in labor. Working with the woman, family, and other health professionals, the nurse can meet the challenges of making each labor and birth a safe and satisfying experience.

Standards of Pain Management

The Joint Commission (TJC) recognizes the importance of pain control in all health care settings for all patients. Standards include:

• Patients have the right to pain management.

• Staff must competently assess and manage pain.

• Policies should be in place to support prescription of pain medication.

• Patients should be educated about pain management.

• Pain management extends past discharge.

The Unique Pain of Labor

Pain is universal. How it is experienced is both personal and subjective. Childbirth pain differs from pain experienced in other conditions in the following ways:

• Labor pain is part of the normal process, whereas pain at other times usually indicates illness or injury.

• The sources of pain are known. The purpose of the muscle contraction helps in the birthing process.

• The woman has time for preparation. Knowledge and skills can be developed to manage the pain. The sensation is referred to as a contraction rather than a pain.

• The pain is known to be self-limiting. It is anticipated to last only hours, not days or weeks. Each contraction pain has a beginning, peak (or acme), and ending that can be anticipated to help the woman cope during the labor process.

• The pain ends with the birth of a baby.

Pain control during labor can be managed by nonpharmacologic (non-drug) or pharmacologic (drug) methods. General nonpharmacologic comfort measures during labor, such as adjustment of the environment, breathing techniques, or maternal positioning, are discussed in Chapter 5.

Factors that Influence Labor Pain

Several factors cause pain during labor and influence the amount of pain a woman experiences. Other factors influence a woman’s response to and ability to tolerate or cope with labor pain.

Pain Threshold and Pain Tolerance

Two terms are often used interchangeably to describe pain, although they have different meanings. Pain threshold, also called pain perception, is the least amount of sensation that a person perceives as painful. Pain threshold is fairly constant, and it varies little under different conditions. Pain tolerance is the amount of pain one is willing to endure. Unlike the pain threshold, one’s pain tolerance can change under different conditions. A primary nursing responsibility is to modify as many factors as possible so that the woman can safely tolerate the pain of labor and delivery.

Sources of Pain During Labor

Physical sources are the main contributors to pain during labor:

• Dilation and stretching of the cervix (stimulates nerve ganglia)

• Uterine contractions (decrease in blood supply to uterus causes ischemic uterine pain similar to ischemic heart pain)

• Pressure and pulling of pelvic structures (ligaments, fallopian tubes, and peritoneum)

• Distention and stretching of the vagina and perineum (splitting and tearing sensation)

• The intensity of labor contractions

• The length of time for cervical changes to occur

• The size and position of the fetus, which add to the length of labor

Other factors that contribute to the pain of labor include:

• The mother’s fatigue and pain tolerance

• Fear and anxiety: These result in muscle tension, which exaggerates the pain sensation of the labor contraction.

• Cervical readiness: The mother’s cervix normally undergoes changes that facilitate effacement and dilation in labor. If the cervix has not made these changes (ripening), more contractions are needed to cause effacement and dilation.

• Interventions of caregivers: Although they are intended to promote maternal and fetal safety, common interventions such as intravenous lines, fetal monitoring, amniotomy, or vaginal examinations can be a source of discomfort or pain in the laboring woman.

• Psychosocial factors: Culture influences how a woman reacts to pain during childbirth (see Table 7-1).

Gate Control Theory

The gate control theory of pain has application to labor and childbirth. According to the gate control theory, a gating mechanism occurs in the spinal cord. Pain sensations are transmitted from the periphery of the body along nerve pathways to the brain. Only a limited number of sensations can travel these pathways at one time. Distractions or focused activity can replace travel of pain sensation. When the activity fills the path, the gate is closed, and impulses are less likely to be transmitted to the brain. When the gate is open, pain impulses ascend to the brain. Similar gating mechanisms exist in the descending nerve fibers from the hypothalamus and cerebral cortex. These areas of the brain regulate a person’s thoughts and emotions and can influence whether pain impulses reach the level of conscious awareness. Effleurage, cutaneous stimulation by a patterned massage of the abdomen, may have a direct effect on closing the gate. The gate control theory, by using descending and ascending neural pathways, helps explain the effectiveness of various types of focusing strategies taught in childbirth preparation classes, such as breathing, listening to music, verbal coaching, and effleurage. Acupuncture, external analgesics, and back massage provide relief because they help close the “gate” to the discomfort.

Chemical Factors

Neuromodulators, also called endorphins or endogenous opiates, are protein chemicals found in the brain. They are produced by the anterior pituitary gland and the hypothalamus. They are natural opiate-like substances known to relieve pain. Endorphins (and enkephalins) are similar to morphine-like substances. They are believed to play a major role in the biologic response to pain. They may be produced by stress and increase the pain threshold, thus helping the woman tolerate the pain of labor and birth. Endorphins are believed to make the woman drowsy and sleepy. Studies have shown that the endorphin blood level in a woman during the birthing process is much higher than that of a nonpregnant woman. Women who have a positive attitude during labor and birth have more natural protection because of their body’s ability to produce its own endorphin analgesia.

Nonpharmacologic Pain Control Strategies

The United States is a multicultural society, and the nurse must understand the cultural traditions concerning expression of pain to provide culturally sensitive care and support. Fear, anxiety, and muscle tension increase catecholamine secretion and increase pain perception. All laboring women benefit from nursing interventions that can relieve fear, tension, and anxiety. The nurse must empower the mother to use her own method of dealing with pain.

Various nonpharmacologic measures for control of labor pain are practiced (Box 8-1). Many of these techniques are learned in childbirth education classes. These include general support, imagery or visualization, distraction, changes in temperature, touch, comfort measures, and baths (whirlpool if available). The nurse’s role is to assist the woman in using the techniques she has learned during childbirth classes and to encourage support and participation of the partner or coach (Figure 8-1).

Box 8-1

Nonpharmacologic Pain Relief Measures

Progressive Relaxation

• The woman contracts and then consciously releases different muscle groups.

• Technique helps the woman to distinguish tense muscles from relaxed ones.

• The woman can assess and then release muscle tension throughout her body.

• Technique is most effective if practiced before labor.

Neuromuscular Dissociation (Differential Relaxation)

• The woman strongly contracts one group of muscles and consciously relaxes all others.

• The coach checks for unrecognized tension in muscle groups other than the one contracted.

• This prepares the woman to relax the rest of her body while the uterus is contracting.

• Technique is most effective if practiced before labor.

Touch Relaxation

• The woman contracts a muscle group and then relaxes it when her partner strokes or massages it.

• The woman learns to respond to touch with relaxation.

• Technique is most effective if practiced before labor.

Relaxation Against Pain

• The woman’s partner exerts pressure against a tendon or large muscle of the arm or leg, gradually increasing the pressure and gradually decreasing pressure to simulate the gradual increase, peak, and decrease in contraction strength.

• The woman consciously relaxes despite this deliberate discomfort.

• This gives the woman practice in relaxation against pain.

• Technique is most effective if practiced before labor.

Effleurage

• The abdomen or other areas are massaged during contractions.

• Massage interferes with transmission of pain impulses, but prolonged continuous use reduces effectiveness (habituation). The pattern or area massaged should be changed when it becomes less effective.

• Massaging in a specific pattern (such as circles or a figure eight) also provides distraction.

Other Massage

• Massage of the feet, hands, or shoulders often helps relaxation.

• Habituation may occur in any type of massage. Change the area massaged if it occurs.

Sacral Pressure

• Technique helps reduce the pain of back labor (see Figure 8-2).

• Obtain the woman’s input about the best position. Moving the pressure point a fraction of an inch or changing the amount of pressure may significantly improve effectiveness.

• Pressure may also be applied by tennis balls in a sock, a warmed plastic container of intravenous solution, or other means.

Thermal Stimulation

• Technique stimulates temperature receptors that interfere with pain transmission.

• Either heat or cold applications may be beneficial. Examples are cool cloths to the face and ice in a glove to the lower back.

Positioning

• Any position except the supine position is acceptable if there is no need for a specific position.

• Upright positions favor fetal descent.

• Hands-and-knees position helps reduce the pain of back labor.

• Change positions about every 30 to 60 minutes to relieve pressure and muscle fatigue.

Diversion and Distraction

• Technique increases mental concentration on something besides the pain. It may take many forms:

• Focal point: concentrating on a specific object or other point

• Imagery: creating an imaginary mental picture of a pleasant environment or visualizing the cervix opening and the infant descending

• Music: serves as a distraction or provides “white noise” to obscure environmental sounds

Hydrotherapy

• Water delivered by shower, tub, or whirlpool relieves tired muscles and relaxes the woman.

• Nipple stimulation by shower can increase contraction because it stimulates the pituitary to release oxytocin.

General Comfort Measures

General comfort can reduce stress and thus reduce pain. Also, comfort measures can encourage relaxation. It is important to eliminate sources of noxious (offensive) stimuli whenever possible. The nurse can try to relieve thirst, sweating, and heat through comfort measures. Providing ice chips and lollipops and repositioning the woman or adjusting the monitoring belts may provide relief.

Cognitive Stimulation

Several cognitive stimulation methods (mental stimulation) of pain control may be tried. Imagery (imagining a pleasant experience) can help the woman by serving as a distraction from the painful stimuli. Using a focal point or focusing on breathing patterns or a spot on the wall may help the woman block out painful sensations. This behavior requires her active participation.

Cutaneous Stimulation

Cutaneous stimulation, involving touching, rubbing, or massaging (back or shoulders), often decreases discomfort. Counter-pressure—a variation with the palm, closed fist, or firm object pressed at the point of back pain (sacral pressure)—is often helpful (Figure 8-2). Rhythmic stroking and massage of the abdomen (effleurage) during a contraction can also lessen discomfort (see Figure 5-13 and Chapter 21). Note that some women do not like to be touched.

Figure 8-2 Sacral pressure applied by the partner during early labor.

Thermal Stimulation

During early labor, women may find a warm bath or shower relaxing. A cool, damp cloth applied to the forehead is especially comforting to some women in the later phases of labor. Hot or cold towels applied to the back may be effective, or the use of a shower or a disposable bottle filled with warm water can be used to provide warmth and mild pressure to the back.

Breathing Techniques

Breathing techniques change the focus during the contraction. There is no right or wrong breathing pattern, but rather the woman should use what she feels comfortable with (see Chapter 5). Breathing techniques can be taught to the unprepared woman while she is in labor (ideally during early labor). The nurse evaluates the breathing techniques used by the laboring woman.

Relaxation

Even if the woman has attended prenatal classes, she will need continued support in achieving relaxation of her voluntary muscles. The most effective teaching time, once labor has begun, is between contractions and during the first stage of labor.

Hypnosis

Hypnosis can be a powerful labor intervention that appears to be safe, is without known side effects, and has positive physical and psychological outcomes. With hypnosis, the woman retains a feeling of control. The nurse can optimize the woman’s hypnosis experience by understanding how his or her role in the labor room may be modified. Hypnosis is a technique that the mother may select during pregnancy; she is usually trained in self-hypnosis that can be used during labor. In the labor room, the nurse may help trigger self-hypnosis by using specific suggestions or playing specific audiotapes provided by the woman. The labor nurse must not interrupt the woman during a contraction when the woman is using self-hypnosis techniques. Characteristic signs of progression in labor may not be evident in a patient under hypnosis; therefore, careful observation and documentation concerning the progress of labor are essential.

Pharmacologic Pain Control Strategies

Physiology of Pregnancy and Its Relationship to Analgesia and Anesthesia

Specific factors in the physiology of pregnancy affect the pregnant woman’s response to analgesia and anesthesia:

• The pregnant woman is at increased risk for hypoxia caused by the pressure of the enlarging uterus on the diaphragm.

• The sluggish gastrointestinal tract of the pregnant woman can result in increased risk for vomiting and aspiration.

• Aortocaval compression, also known as vena cava syndrome (pressure on the abdominal aorta by the heavy uterus when the woman is in a supine position), increases the risk of hypotension and the development of shock.

• The effect on the fetus must be considered.

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Tags: Maternity Nursing An Introductory Text

Nov 26, 2016 | Posted by admin in NURSING | Comments Off

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8. Management of Pain During Labor

Management of Pain During Labor

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