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Florida National University Epidural Anesthesia Brochure

Florida National University Epidural Anesthesia Brochure

The Nursing Role in Providing Comfort During Labor and Birth For additional ancillary materials related to this chapter, please visit thePoint. Jonny Baranca is a primipara in early labor whom you admit to a birthing unit. Her cervix is 3 cm dilated. She tells you her sister had epidural anesthesia that completely obliterated her pain in labor for the birth of her baby 3 months ago. Based on her sister’s experience, Jonny expected to be given epidural anesthesia as soon as she arrived at the hospital as she “is in early labor.” Her physician, however, asked her to wait until she is 4 cm dilated. When you enter her room, you find her lying on her back in a birthing bed, crying. Her husband shouts his “wife deserves better care than this.” The previous chapter discussed the process of labor and birth and nursing care responsibilities. This chapter adds information to your knowledge base about how to promote comfort during labor. Effective pain management in labor can change labor from an experience so negative it can result in a posttraumatic stress syndrome to a positive, forward-moving experience. Was the information Jonny received from her sister realistic? What are some immediate interventions you could do to help Jonny better cope with her pain? KEY TERMS analgesia anesthesia doula endorphins epidural anesthesia pain pressure anesthesia pudendal nerve block reflexology OBJECTIVES After mastering the contents of this chapter, you should be able to: 1. Describe the physiologic basis of contractions during labor and how nonpharmacologic therapies, as well as analgesia and anesthesia, can be used to promote a woman’s comfort during labor and birth. 2. Identify 2020 National Health Goals related to comfort and drug-free pain management measures effective in childbirth that nurses can help the nation achieve. 3. Assess the degree and type of discomfort a woman is experiencing during labor and birth, including her ability to cope with pain effectively and the maternal and fetal impact of pain management, including side effects and safety. 4. Formulate nursing diagnoses related to the effect of pain or pain management during labor and birth. 5. Establish expected outcomes to meet the needs of a woman experiencing discomfort during labor and birth and manage seamless transitions across differing healthcare settings. 6. Using the nursing process, plan nursing care that includes the six competencies of Quality & Safety Education for Nurses (QSEN): Patient-Centered Care, Teamwork & Collaboration, Evidence-Based Practice (EBP), Quality Improvement (QI), Safety, and Informatics. 7. Implement common complementary and pharmacologic measures for pain management during labor and birth. 8. Evaluate expected outcomes for effectiveness and achievement of care. 9. Integrate knowledge of pain management during labor and birth with the interplay of nursing process, the six competencies of QSEN, and Family Nursing to promote quality maternal and child health nursing care. Concerns about the discomfort and pain that accompany labor and birth can dominate a pregnant woman’s or couple’s thoughts during pregnancy; these can become particularly strong as the baby’s due date approaches. As discussed in Chapter 14, prepared childbirth classes provide couples with an opportunity to learn and practice a variety of pain management techniques, such as breathing patterns, to help reduce pain in labor. Often, however, the labor experience is so intense it becomes overwhelming, so administration of an analgesic or a regional anesthetic may be necessary to reduce discomfort sufficiently to allow a woman to regain control over herself and use breathing patterns. If the use of regional anesthesia makes labor a satisfying, positive experience, the intervention can ultimately promote the entire family’s health. Some women, however, may feel they have let down themselves, a partner, or childbirth educator by asking for anesthesia; if this happens, asking for pain medication can make labor a negative experience. Much has been written in nursing literature about using the neutral term contraction or other alternative reference instead of labor pain to keep from reminding a woman contractions are painful. The theory is a sound one, not only because a woman is experiencing a contracting sensation but also because calling it pain could magnify fear and tension; tension, in turn, magnifies pain. Remember, however, renaming it will not change its basic nature. Discomfort accompanies labor regardless of what term is used for it. Fortunately, many nursing interventions can help reduce pain, so labor is as fulfilling and rewarding an experience as a woman hoped it would be. Making labor and birth a memorable experience for families is so important that 2020 National Health Goals have been established to address this topic. These are shown in Box 16.1. BOX 16.1 Nursing Care Planning Based on 2020 National Health Goals Because administration of either analgesia or anesthesia during labor can prolong labor and can possibly increase the number of instruments used or risk for cesarean birth, several 2020 National Health Goals are related to the types of pain relief used in labor. Examples include: • Reduce the maternal mortality rate to no more than 11.4 deaths per 100,000 live births from a baseline of 12.7 per 100,000. • Reduce the fetal/newborn death rate during the perinatal period (28 weeks of gestation to 7 days after birth) to no more than 5.9 per 1,000 live births from a baseline of 6.6 per 1,000 live births (U.S. Department of Health and Human Services, 2010; see Nurses can help the nation achieve these goals by educating women about the advantages of preparing for childbirth, helping them to use breathing patterns or other complementary and alternative therapies and techniques during labor so they need a minimum of analgesia and anesthesia, and conscientiously monitoring women who receive analgesics and anesthesia. Nursing Process Overview FOR PAIN RELIEF DURING LABOR AND CHILDBIRTH ASSESSMENT Pain, the sensation of discomfort, is a subjective, personal symptom; it is what the experiencing person says it is and present when the experiencing person says it is present (McCaffery, 1972). It is unique to each individual, so a woman is the only person who can describe or know the extent of her pain. To assess the amount of discomfort a woman is having in labor, listen carefully to not only what she says but also how she rates her discomfort level on a pain assessment scale. Also look for subtle signs such as facial tenseness, flushing or paleness, hands clenched in fists, rapid breathing, or rapid pulse rate. NURSING DIAGNOSIS Although pain related to labor contractions is the most obvious nursing diagnosis applicable to labor, it is not the only relevant one because pain can create other problems for the laboring woman that can negatively affect the childbirth experience. If not resolved, these problems can intensify pain. Some women, for example, may become more concerned with their reaction to the pain than to the pain itself. Because of this, applicable nursing diagnoses might include: Pain related to labor contractions Powerlessness related to the duration and intensity of labor Anxiety related to lack of knowledge about “normal” labor process Risk for situational low self-esteem related to ineffectiveness of prepared childbirth breathing exercises Decisional conflict related to use of analgesia or anesthesia during labor OUTCOME IDENTIFICATION AND PLANNING When developing realistic outcomes and planning interventions to manage discomfort during labor, consider the woman’s perceptions about childbirth, her past childbirth experiences (if any), and the amount and type of childbirth preparation she and her partner have made. For example, if a woman is using breathing exercises well, expecting she will need medication late in labor is probably not realistic. However, if a woman has not made any preparation as to how she will manage labor contractions, expecting that no medication will be used might be inappropriate. Be aware that pharmacologic agents used during labor and birth may pose risks for both the woman, such as hypotension, as well as the fetus or neonate, such as bradycardia or respiratory issues at birth. Therefore, when considering use of pharmacologic intervention, the benefit to the woman and the fetus must outweigh the risks of medication use. In addition, a decision to use analgesia or anesthesia may also affect family functioning if the method chosen limits the partner’s participation in the birth. Contrarily, the use of a pharmacologic agent may be what a woman could most benefit from, particularly if she has a history of sexual trauma (Nerum, Halvorsen, Straume, et al., 2013). IMPLEMENTATION Keeping a woman and her support person informed about their options and how they differ as labor progresses is important. For instance, simply knowing that birth is getting closer can make the next few contractions easier to withstand. Supporting and encouraging a woman to use methods of complementary and alternative therapies for pain management, such as a birthing ball, ambulation, relaxation, and breathing techniques, also are helpful. Offering analgesia or assisting with anesthesia administration during labor or birth requires nursing judgment and a caring presence to help one woman accept analgesia when she needs it and to encourage another to experience childbirth without pharmacologic intervention when that is what she desires. OUTCOME EVALUATION Evaluations are ongoing and typically must occur within a short time frame. Examples of short-term expected outcomes that would indicate successful achievement during labor are: Patient states pain during labor is within a tolerable level for her. Couple reports they feel control throughout the labor process. Patient and fetus remain physiologically stable with use of pharmacologic interventions. Patient verbalizes satisfaction with current pain control measures. A long-term evaluation should reveal a woman found labor and birth to be an experience not only endurable but also that it allowed her to grow in self-esteem and the family to grow through a shared experience. Asking a woman to describe her labor experience afterward in relation to pain not only aids an evaluation of whether pain management was adequate but also helps her work through this emotional period of life and integrate it into her previous experiences as well. Experience of Pain During Childbirth Pain accompanies labor contractions for several different reasons and manifests itself in different ways for each woman (Box 16.2). BOX 16.2 Nursing Care Planning Using Assessment ASSESSING A WOMAN FOR SYMPTOMS OF PAIN DURING LABOR AND CHILDBIRTH ETIOLOGY OF PAIN DURING LABOR AND BIRTH Normally, contractions of involuntary muscles, such as the heart, stomach, and intestine, do not cause pain. This concept makes uterine contractions unique because they do cause pain. Several explanations exist for why this happens. During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. As labor progresses and contractions become longer and more intense, the ischemia to cells increases, the anoxia increases, and the pain intensifies. Pain also probably results from stretching of the cervix and perineum. This phenomenon is the same as the intestinal pain that results when accumulating gas stretches the intestines. At the end of the transitional phase in labor, when stretching of the cervix is complete and the woman feels she has to push, pain from the contractions often disappears as long as the woman is pushing, until the fetal presenting part causes a final stretching of the perineum. Additional discomfort in labor may stem from the pressure of the fetal presenting part on tissues, including pressure on surrounding organs, such as the bladder, the urethra, and the lower colon. In addition to these factors, cultural expectations effect how pain is perceived (Box 16.3). All these factors make nursing support, in addition to a doula or a partner, important as it can have a positive influence on pain relief in all situations of labor. BOX 16.3 Nursing Care Planning to Respect Cultural Diversity Some women believe their expected role during labor is to be stoic and nonverbal even in the face of intense pain. Others believe expressing their discomfort by screaming or verbalizing their discomfort is what is expected. If a woman is not proficient in English, it may be particularly difficult for her to describe her level of discomfort and that she needs some assistance. Assess each woman individually to determine not only what level of comfort she feels is right for her during labor but also the manner in which she feels most able to express discomfort. Assessing individuals in this way rather than relying on a list of “typical” ways Hispanic women, Asian women, and so forth, react to pain achieves better individual care. Because of Americanization, a woman’s surname or her appearance may be not be indicative at all of how she wants to manage pain. The amount of analgesia women desire or will accept is dependent both on the situation and her culture. In a culture in which birth is seen as a “natural” process or if a woman has attended a class to prepare for birth, the less analgesia is generally desired. Any woman who has an effective support person with her generally needs less pharmacologic pain relief than one who does not. PHYSIOLOGY OF PAIN Pain is a basic protective mechanism that alerts a person that something threatening is happening somewhere in the body. The Melzack–Wall gate control theory of pain (Melzack & Wall, 1965), the most widely accepted theory of pain response, proposes pain can be halted at three points: • The peripheral end terminals • The synapse points in the dorsal horn of the spinal cord • The point at which the impulse is interpreted as pain in the brain cortex Pain in peripheral terminals is automatically reduced by the production of endorphins and encephalins, naturally occurring opiates that limit transmission of pain from the end terminals. Pain can be reduced further at these end points by mechanically irritating nerve fibers through an action such as rubbing the skin, which blocks nerve transmission. A major way to block spinal cord neurotransmitters (i.e., never allowing the pain impulse to cross to a spinal nerve) is by the administration of pain medications. In addition, the brain cortex can be distracted from sensing impulses as pain by such techniques as imagery, thought stopping, and perhaps aromatherapy or yoga. Sensory impulses of pain from the uterus and cervix synapse at the spinal column at the level of T10 through L1, whereas motor impulses register higher in the cord at T5 through T10. Anesthetic pain relief measures for the first stage of labor, therefore, are designed to stop pain by blocking the lower sensory sites, but not the upper motor sites, so strong contractions can continue. Sensory impulses from the perineum, which is involved in the second stage of labor, are carried by the pudendal nerve to join the spinal column at S2, S3, and S4. When the perineum is initiating the pain, anesthetic pain relief must block these lower receptor sites. This is an important point to remember when talking to a woman in labor about pain relief. Some interventions relieve pain for both the first and second stages of labor, whereas others work for one stage but not both. PERCEPTION OF PAIN The amount of discomfort a woman experiences during contractions differs according to her expectations of and preparation for labor; the length of her labor; the position of her fetus; the presence of fear, anxiety, worry, body image, and self-efficacy; and the availability of meaningful people around her to offer support (Fig. 16.1). As a rule, women who believe they can control their situation (have self-efficacy) are more apt to report a satisfactory birth experience than those who do not feel in control (Howarth, Swain, & Treharne, 2011). Figure 16.1 The discomfort a woman experiences during childbirth is related to the amount of support she receives from her family and healthcare providers. Here, the woman’s support person uses the palm of his hand to apply counter pressure to her lower back, helping to ease back pain. Fetal position is a physical variable that influences the degree of pain a woman experiences. If the fetus is in an occiput posterior position, the woman often reports intense or nagging back pain, even between contractions, much more than if a fetus is in an occipitoanterior position (Impey & Child, 2012). Pain is perceived differently by different individuals because of psychosocial, physiologic, and cultural responses. The body’s ability to produce and maintain endorphins may influence a person’s overall pain threshold and the amount of pain a person perceives at any given time. Women who come into the labor experience believing the pain will be horrible are usually surprised afterward to realize the agony they expected never materialized. However, women who thought pain would be minimal can be overwhelmed by its intensity. Unrealistic expectations of labor pain can make a woman so tense during labor her pain feels worse than it would have if she had been relaxed. A woman cannot relax simply because she is instructed to do so by another person, however. Some additional interventions must be used. Comfort and Nonpharmacologic Pain Relief Measures The pattern of interventions to promote comfort and manage pain in labor has swung from a philosophy of no intervention (none given because pain in labor was expected), to a philosophy that drug intervention was always required (excessive amounts were given), to the modern approach of empowering women and their partners with information so they can choose how to best relieve pain during labor within the limits of medical safety. Nurses play a key role in educating women and their support persons about the numerous comfort and pain relief strategies available and making sure certain couples understand the choices available to them along with the benefits and risks (L. Jones, Othman, Dowswell, et al., 2012). Throughout their decision-making process, couples need support for their choices so they can feel confident in the method they choose. SUPPORT FROM A DOULA OR COACH Although, historically, women have always attended other women in childbirth, in the past 45 years or so, the father or partner of a woman’s child has traditionally served as her chief support person in labor. Some partners or fathers, however, find it difficult to serve as effective coaches because they are so emotionally involved in the birth. Some women prefer to ask a sister, mother, or friend to serve as a coach. A doula is a woman who is experienced in childbirth and postpartum support. These support persons (who may hold certificates as birth or postpartum doulas) provide physical, emotional, and informational support prenatally, during labor and birth, and even at home in the postnatal period. Having an effective doula can increase a woman’s selfesteem, speed the labor process, and improve breastfeeding success as well as decrease rates of oxytocin augmentation, epidural anesthesia, cesarean birth, and postpartum complications (Hodnett, Gates, Hormeyr, et al., 2013). QSEN Checkpoint Question 16.1 PATIENT-CENTERED CARE Jonny Baranca is having a painful labor. She asks the nurse if she should have hired a doula. The nurse identifies which answer as best? a. “Definitely. Doulas time contractions and perform many tasks, taking the burden off you.” b. “Maybe. Doulas are good at telling you if you are doing everything correctly.” c. “That’s an individual choice, but a doula can serve as an important support person.” d. “No. A second person giving advice is apt to cause conflict.” Look in Appendix A for the best answer and rationale. COMPLEMENTARY AND ALTERNATIVE THERAPIES Complementary and alternative therapies for pain relief involve nonpharmacologic measures that may be used either as a woman’s total pain management program or to complement pharmacologic interventions. Most of these interventions are based on the gate control theory concept that distraction can be effective at preventing the brain from processing pain sensations coming into the cortex. Many of the same techniques may help the descent of a fetus. These may include the use of acupressure, position changes, imagery, and other relaxation techniques. Relaxation The technique of relaxation, as discussed in Chapter 14, is taught in most preparation for childbirth classes but can be taught in early labor as well. Relaxation keeps the abdominal wall from becoming tense, allowing the uterus to rise with contractions without pressing against the hard abdominal wall. It also serves as a distraction technique because, while concentrating on relaxing, a woman cannot concentrate on pain. Asking a woman to bring favorite music or aromatherapy with her to enjoy in the birthing room, although not evidence based, can help with relaxation. Remember, no aromatic candles should be used because of nearby oxygen outlets. Focusing and Imagery Concentrating intently on an object is another method of distraction, or another method of keeping sensory input from reaching the cortex of the brain (Smith, Levett, Collins, et al., 2011). For this technique, a woman uses a photograph of someone important to her or some setting she finds appealing such as a beautiful sunset. She concentrates on the photo during contractions (focusing). A woman can also concentrate on a mental image, such as waves rolling onto a beach (imagery), or chant a word or phrase such as the new baby’s name during contractions, all of which help prevent her from concentrating on the pain of contractions. If a woman has never used these techniques before, she may question how effective they are. Urge her to try one of them at least for a few contractions before she dismisses them entirely, as evidence supports their efficacy (Hodnett et al., 2013). Do not ask questions or talk while a woman is using focusing, imagery, or chanting because that is apt to break her concentration and let the sensation of pain break through. QSEN Checkpoint Question 16.2 EVIDENCE-BASED PRACTICE To investigate if listening to music can help women feel less pain and anxiety in labor, researchers assigned 30 primiparas expected to have normal spontaneous births to either an experimental group that received routine labor care or a control group that received routine care plus music therapy. Both women and their nurses assessed the degree of pain experienced during labor. Results of the study revealed women who listened to music had significantly lower pain during the latent phase of labor (Simavli, Gumus, Kaygusuz, et al., 2014). Based on this study, which statement by Jonny represents the best way to use music therapy in labor? a. “I’ve brought techno music to play during the second stage so I can push to a rhythm.” b. “I’ll need distraction most just before I have to push. I’ll save my music until then.” c. “I know music probably won’t make a difference but I’ll enjoy listening to it anyway.” d. “I brought some romantic music to play during early labor to help me relax.” Look in Appendix A for the best answer and rationale. Spirituality For many women, prayer may be the first measure they use to relieve a stress they are facing (Abbaspoor, Moghaddam-Banaem, Ahmadi, et al., 2014). Provide uninterrupted time as needed. Women may bring helpful worship objects such as a Bible or Qur’an into their birthing setting to use during prayer. Remember, these are sacred objects; be careful when changing sheets that you do not accidentally throw such important objects away or let them fall to the floor. Breathing Techniques Breathing patterns are taught in most preparation for childbirth classes and are well documented to decrease pain in labor (Dick-Read & Gaskin, 2013). They are largely distraction techniques because a woman concentrating on slow-paced breathing cannot concentrate on pain. Breathing strategies can be taught to a woman in labor if she is not familiar with their advantages before labor (see Chapter 14). Stay with her until she appreciates how useful slow-paced breathing can be and feels comfortable using this technique independently. Herbal Preparations Several herbal preparations have traditionally been used to reduce pain with dysmenorrhea or labor, although there is little evidence-based support for their effectiveness. Examples include chamomile tea for its relaxing properties; raspberry leaf tea (women freeze it into ice cubes to suck on), which is thought to strengthen uterine contractions; skullcap; and catnip, which are thought to help with pain. Black cohosh (squawroot), an herb that induces uterine contractions, is not recommended because of the risk of acute toxic effects such as cerebrovascular accident to the mother or fetus (Ulbricht & Windsor, 2015). Aromatherapy and Essential Oils Aromatherapy is the use of aromatic oils to complement emotional and physical well-being. Their use is based on the principle that the sense of smell plays a significant role in overall health. When an essential oil is inhaled, its molecules are transported via the olfactory system to the limbic system in the brain. The brain then responds to particular aromas with emotional responses such as relaxation. These oils should not be applied directly to the skin to avoid irritation but are used in a mister so they are inhaled and then carried throughout the body. The oils may be able to penetrate cell walls and transport nutrients or oxygen to the inside of cells. The effects of aromatherapy can range from reducing postcesarean incisional pain to reducing anxiety in the first stage of labor (Fakari, Tabatabaeichehr, Kamali, et al., 2015; Metawie, Amasha, Abdraboo, et al., 2015; Roozbahani, Attarha, Akbari Torkestani, et al., 2015). The evidence regarding the efficacy of aromatherapy continues to be studied with mixed results. QSEN Checkpoint Question 16.3 INFORMATICS The nurse offers to teach Jonny controlled breathing to help with pain management until she can receive her epidural. Which instruction by the nurse would be best? a. “Lie on your back and breathe in slowly while repeating, ‘I can do this.’” b. “Hold your breath as long as you possibly can before exhaling.” c. “Breathe in as slowly as you can and then breathe out just as slowly.” d. “Pant rapidly as this best lifts your abdominal wall off your expanding uterus.” Look in Appendix A for the best answer and rationale. Heat or Cold Application The application of heat and cold has always been used for pain relief after injuries such as minor burns or strained muscles. It is only lately that their use has been investigated as effective ways to help relieve the pain of labor. Women who are having back pain may find the application of heat to the lower back by a heating pad, instant hot pack, or warm moist compress extremely comforting. Heat applied to the perineum is proven to provide the dual benefits of soothing and softening the perineum and decreasing the risk of perineal tears (Aasheim, Nilsen, Lukasse, et al., 2011). Caution women if they are going to heat pads in a microwave to test the temperature of the pad on the forearm before applying it to their perineum. Pressure anesthesia (pressure to an area of the body that interferes with pain receptors) can dull sensation and, with an overheated pack, patients could sustain a perineal burn without realizing it. Women who become warm from the exertion of labor find a cool washcloth to the forehead, chest, or back of the neck comforting. Sucking on ice chips to relieve mouth dryness is also refreshing. Immediately following birth, an ice pack applied to the perineum feels soothing, and it helps reduce edema and swelling. Cultural differences exist with preference to heat and cold. This may be evident in dietary choices or compress application (Goyal, 2016). It is imperative that nurses to provide care that is culturally competent and respectful of the practices of their patients. Bathing or Hydrotherapy Standing under a warm shower or soaking in a tub of warm water, jet hydrotherapy tub, or whirlpool is another way to apply heat to help reduce the pain of labor (Fig. 16.2) (Harper, 2014). The temperature of water used should be 37°C to prevent hyperthermia of the woman and also the newborn at birth. Figure 16.2 A woman in labor enjoys the soothing effects of a warm water bath. Remind women that plastic or porcelain tubs are slippery, so they should ask for help stepping into and out of them. Do not leave women unsupervised in a tub as they could slip and have difficulty getting their head above water. A support person can join the woman in a tub or shower if she wishes and can continue with back massage or other measures she finds soothing. Timing of contractions, auscultation of fetal heart rate, and vaginal examinations can all be done without the woman needing to leave the water. The birth environment, including the use of hydrotherapy in labor, can help support physiologic birth (Stark, Remynse, & Zwelling, 2016). Therapeutic Touch and Massage In a classic work, Krieger (1990) defined therapeutic touch as the laying on of hands to redirect energy fields that lead to pain. It is based on the concept that everyone’s body contains energy fields that, when plentiful, lead to health or, when in low supply, result in illness. Effleurage, the technique of gentle abdominal massage often taught with Lamaze in preparation for childbirth classes is a classic example of therapeutic touch (see Chapter 14, Fig. 14.8). Reiki can also promote healing. The term Reiki consists of two Japanese words: rei, which means “God’s wisdom or the higher power,” and ki, which means “life force energy.” So Reiki is actually “spiritually guided life force energy.” The technique includes “laying on of hands” and is based on the theory that an unseen “life force energy” flows through us and is what causes us to be alive (Rakestraw, 2010). If one’s life force energy is low, then a person is more likely to get sick or feel stress. If it is high, a person is more capable of being happy and healthy. Although the effectiveness of therapeutic touch is not well documented, both touch and massage probably work to relieve pain by increasing the release of endorphins. Both techniques may also work because they serve as forms of distraction. Many women find massage, especially of the lower back or feet, helpful in the first and second stages of labor (L. Jones et al., 2012; Smith et al., 2012). QSEN Checkpoint Question 16.4 SAFETY Jonny asks the nurse if she could safely use warm water tub bathing during labor. Which answer by the nurse would be best? a. “No. The chilling that sometimes results can lead to hypothermia.” b. “Yes, as long as your membranes are not ruptured.” c. “No. This technique will separate you from your partner.” d. “Yes, as long as you know warm water has no significant effect.” Look in Appendix A for the best answer and rationale. Yoga and Meditation Yoga, a term derived from the Sanskrit word for “union,” describes a series of exercises that were originally designed to bring people closer to a divine power. It offers a significant variety of proven health benefits, including increasing the efficiency of the heart, slowing the respiratory rate, improving fitness, lowering blood pressure, promoting relaxation, reducing stress, and allaying anxiety. Exercises consist of deep breathing exercises, body postures to stretch and strengthen muscles, and meditation to focus the mind and relax the body. It may be helpful in reducing the pain of labor through its ability to relax the body and possibly through the release of endorphins. Mothers who engage in yoga prenatally have been shown to have a greater sense of self-efficacy and may experience fewer episodes of antenatal depression (Battle, Uebelacker, Magee, et al., 2015; Schwartz, Toohill, Creedy, et al., 2015). Meditation is a self-directed practice for relaxing the body and calming the mind. Mindfulness-based stress reduction (MBSR), an 8-week intervention program developed by Dr. John Kabat Zinn for patients dealing with issues of chronic pain, is based on the cultivation of intentional awareness of experiences in the present moment. Transcendental meditation (TM) is a simple, natural, and effortless activity done while resting comfortably with the eyes closed. Using one of these techniques, an individual experiences a state of deep rest that can change physical and emotional responses to stress (Chan, 2016). Women can meditate in any position. Do not interrupt a woman using meditation as a pain relief technique if at all possible in order to not break her concentration. Reflexology Reflexology is the practice of stimulating the hands, feet, and ears as a form of therapy (Smith, Levett, Collins, et al., 2012). Professional reflexologists apply pressure to specific areas of the hands, feet, and ears to alleviate common ailments such as headache, back pain, sinus colds, and stress. The theory behind reflexology holds that the body is divided into 10 zones that run in longitudinal lines from the top of the head to the tips of the toes. Each of the body’s organs and glands is linked to corresponding areas of the hands and feet. Application of pressure to a specific area aims to restore energy to the body and improve the overall condition. The point that corresponds to the uterus is located on the inside ankle about halfway between the ankle bone (malleolus) and the heel. Massaging this area is believed to begin labor or hurry labor, thus creating less pain. Hypnosis Hypnosis is yet another method that can be used for pain relief in labor. A woman who wants to use this modality needs to meet with her hypnotherapist during pregnancy. At these visits, she is evaluated for and conditioned for susceptibility to hypnotic suggestion. Close to her last weeks of pregnancy, she is given a posthypnotic suggestion that she will experience a reduction in or absence of pain during labor. Fully awake and able to participate in labor, the woman who is susceptible to hypnotic suggestion may find this may provide a very satisfactory and drug-free method of pain relief (Streibert, Reinhard, Yuan, et al., 2015). A woman who wants to use this system but began labor before the posthypnotic suggestion was given may be very disappointed to find herself in labor without the help she envisioned. Some hypnotists may visit during labor or supply the suggestion over the telephone so a woman can still use the method. Further research is needed to determine the effectiveness of the effects of hypnosis on pain relief in labor (Madden, Middleton, Cyna, et al., 2016). Biofeedback Biofeedback is based on the belief that people have control and can regulate internal events such as heart rate and pain responses. Women who are interested in using biofeedback for pain relief in labor must attend several sessions during pregnancy to condition themselves to regulate their pain response. During these sessions, a biofeedback apparatus is used to measure muscle tone or the woman’s ability to relax. Evidence is continuing to emerge that shows biofeedback is an effective method for reducing the pain of labor (Janula & Mahipal, 2015). Transcutaneous Electrical Nerve Stimulation Transcutaneous electrical nerve stimulation (TENS) works to relieve pain by applying counterirritation to nociceptors (Santana, Gallo, Ferreira, et al., 2016). When two pairs of electrodes are attached to a woman’s back to coincide with the T10 through L1 nerve pathways, low-intensity electrical stimulation is given continuously or is applied by the woman herself as a contraction begins. This stimulation blocks the afferent fibers, preventing pain from traveling to the spinal cord synapses from the uterus. As labor and descent progress, the electrodes are moved to stimulate the S2 through S4 level. High-intensity stimulation is generally needed to control the pain at this stage. TENS can be as effective as epidural anesthesia for pain relief in labor, although some women object to being “tied down” to the equipment. Women with extreme back pain may benefit most from a TENS unit because this type of pain is difficult to relieve with controlled breathing exercises (Santana et al., 2016). This method may not only reduce the need for epidural anesthesia but also postpone the use of pharmacologic agents (Santana et al., 2016). TENS is further discussed in Chapter 24 as it applies to postoperative pain of a cesarean birth. Intracutaneous Nerve Stimulation Intracutaneous nerve stimulation (INS) is a technique of counterirritation involving the intradermal injection of sterile water or saline along the borders of the sacrum to relieve low back pain during labor (Derry, Straube, Moore, et al., 2012). Although some women find the technique helpful, there is little evidence as to its effectiveness; other women prefer to bear back pain or relieve it by massage rather than submit to injections. Acupuncture and Acupressure Acupuncture is based on the concept that illness results from an imbalance of energy. To correct the imbalance, needles are inserted into the skin at designated susceptible body points (tsubos) located along meridians that course throughout the body to supply the organs of the body with energy. Activation of these points (which are not necessarily near the affected organ) results in a release of endorphins, which makes this system helpful, especially in the first stage of labor (Ozgoli, Mobarakabadi, Heshmat, et al., 2016). Acupuncture may also decrease the duration of labor (Asadi, Maharlouei, Khalili, et al., 2015). Acupressure is the application of pressure or massage at these same points. It seems to be most effective for low back pain. A common point used for women in labor is Co4 (Hoku or Hegu point), which is located between the first finger and thumb on the back of the hand. Women may report their contractions feel lighter when a support person holds and squeezes their hand because the support person is accidentally triggering this point. Acupressure can reduce maternal anxiety as well as the length of labor when specific pressure points are used (Akbarzadeh, Masoudi, Zare, et al., 2015). What If . . . 16.1 The nurse had met Jonny during pregnancy and discovered she did not attend any preparation for childbirth classes because she planned to rely totally on epidural anesthesia for pain relief. Would the nurse have supported her plan? Now that she is in early labor, what are some complementary and alternative therapies the nurse could teach her to use while she waits for anesthesia? PHARMACOLOGIC MEASURES FOR PAIN RELIEF DURING LABOR The discovery of ether and chloroform in the 1800s led to the determination that childbirth could be managed relatively pain free. Unfortunately, this goal was achieved by means of complete anesthesia or unconsciousness for the woman during labor and birth. Women, afterward, had difficulty believing the birth was over and that the infant was their child. This led to an era (late 1960s to the 1980s) in which women refused pharmacologic pain relief in labor and depended entirely on prepared childbirth measures such as breathing patterns. Since the advent of epidural anesthesia, women now have more options regarding how much or what kind of pain relief they want in labor (Anim-Somuah, Smyth, & Jones, 2011). Pharmacologic management of pain during labor and birth includes analgesia, which reduces or decreases awareness of pain, and anesthesia, which causes partial or complete loss of pain sensation. For the best results, be certain women are included in the selection of these methods and understand any fetal effects or maternal side effects that might occur. Virtually all medications given during labor cross the placenta and have some effect on the fetus, which makes it important to do regular assessments of maternal and fetal responses to the administration of systemic medication. However, labor should not test a woman to the limit of her endurance because both analgesia and anesthesia are available. Be sure to caution women not to take acetylsalicylic acid (aspirin) for pain in labor as aspirin interferes with blood coagulation, increasing the risk for bleeding in the newborn or herself. In addition, the manufacturers of pain relief patches such as Salonpas, Absorbine Jr., and Icy Hot caution women not to use these in labor because of the potentially teratogenic effect of the menthol ingredient. The best approach to pain management for women in labor is to always aid any pharmacologic intervention with a complementary or alternative therapy measure. For example, an intramuscular analgesic can be linked with breathing exercises to make both more effective. Goals of Pharmacologic Pain Management During Labor The ideal or goal of medications used during labor is to relax a woman and relieve her discomfort and yet have minimal systemic effects on uterine contractions, her pushing effort, or the fetus (Box 16.4). Whether a drug affects a fetus depends on its ability to cross the placenta and that depends on its molecular weight. Drugs with a molecular weight of less than 600 Da cross very readily; drugs with a molecular weight of more than 1,000 Da cross poorly. Drugs with highly charged molecules or molecules strongly bound to protein also tend to cross more slowly than others. Fat-soluble drugs cross the easiest. BOX 16.4 Nursing Care Planning Based on Family Teaching Q. Jonny asks you, “Can I choose what medicine I want to use in labor for pain or do I have to do whatever my doctor says?” A. A number of helpful rules about pain in labor are: • You have the right to choose how much pharmacologic pain relief you want to use. • It’s best if analgesia and anesthesia are begun after labor is well established, although this should be balanced against the need for pain relief. • Any drug used should provide maximum relief for you and have minimal effect on your fetus. • Constant fetal and maternal monitoring should be available, although periodic monitoring is acceptable. • Any medicine given should not interfere with the ability of your uterus to contract during labor or interfere with contraction after labor to prevent uterine hemorrhage. If a drug causes a systemic response, such as hypotension in a woman, it can result in a decreased oxygen (PO2) gradient across the placenta, causing the indirect result of fetal hypoxia. If a drug causes confusion or disorientation, a woman may be unable to work effectively with contractions, thus prolonging labor and increasing discomfort for her. A preterm fetus, which has an immature liver and is unable to metabolize or inactivate drugs, is generally more affected by drugs than a term fetus. If a medication causes changes in a fetus, such as a decreased heart rate or central nervous system (CNS) depression, it may be difficult for the newborn infant to initiate respirations at birth, severely compromising the infant in the important first minutes of life. In addition, if a drug reduces or eliminates the bearing down reflex, a woman may have difficulty pushing effectively, which may prolong the second stage and increase the risk for a cesarean birth. Lastly, because pain is a subjective sensation, some women are most aware of pain early in labor, whereas some report the second stage of labor as the most difficult. The point at which pain medication is needed, therefore, differs from one individual to another and should be given at whatever point an individual woman feels she needs it. When labor is in the active phase of the first stage, medication to relieve discomfort tends to speed labor progress because, with the pain gone, a woman can relax and work with, not against, her contractions. In contrast, at the second stage, epidural anesthesia or a drug that disorients a woman can slow progress and may result in more instrumentation or cesarean births. For all these reasons, no perfect analgesic agent exists for labor or birth that has no effect on labor, the mother, or the fetus. Preparation for Medication Administration The type of medication used during labor varies among different healthcare providers and also changes based on new research as the effectiveness and safety of new drugs for use during labor are tested. To be safe, follow The Joint Commission’s 2016 National Patient Safety Goals (The Joint Commission, 2016) and remember the criteria a drug must fulfill to be used in pregnancy at any point. Never give a drug to a pregnant woman unless you know the benefit outweighs the risk for both of your patients: the mother and the fetus. Be certain to ask about allergies to all medications before administering them during labor as women in distress from pain can be too distracted to mention this unless directly asked. Prepare a woman for the type of agent prescribed, how it will be administered with an explanation such as “You’ll need to lie on your side” as well as what she can expect to happen after administration (“I’ll be taking your blood pressure frequently”). Women in labor are under a lot of stress. That can make experiencing surprising body sensations from a drug without preparation about the effects that may occur so frightening it can defeat their individual coping ability and any relaxation potential associated with it. Opioid (Narcotic) Analgesics Narcotics may be given during labor because of their potent effect, but all drugs in this category cause maternal respiratory depression as well as fetal CNS depression to some extent and so should be used cautiously (Brimdyr, Cadwell, Widström, et al., 2015). Timing the administration of narcotics during labor is especially important as, if given too early (before 3 cm cervical dilatation), they tend to slow labor. If given close to birth, because the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered in the fetus for 2 to 3 hours after birth. For this reason, narcotics are preferably given when the mother is more than 3 hours away from birth. This allows the peak action of the drug in the fetus to have passed by the time of birth so the newborn breathes easily. It can be puzzling to see a sleepy baby born to a woman who was given butorphanol tartrate 2 hours before birth, for example, and an alert baby delivered to a woman who had the same drug within 1 hour of birth. In the second instance, the peak action or peak effect has not yet occurred in the infant. This newborn needs careful assessment for the next 4 hours until the drug does reach its peak. Common opioid analgesics used in labor traditionally include butorphanol tartrate (Stadol), morphine sulfate, nalbuphine (Nubain), meperidine (Demerol), and fentanyl (Sublimaze). None of these drugs completely eliminate the pain of contractions, but they do reduce pain sensation to a level where other nonpharmacologic methods of pain relief can begin to be effective. They all begin to work 15 to 30 minutes after intramuscular administration or about 5 minutes after intravenous (IV) administration. A drawback to all these opioids is they may cause nausea and vomiting in some women. These effects appear to be doserelated (Armstrong & Fernando, 2016). They also produce a feeling of euphoria, so women often report they feel as if they are “floating”; because of this sensation, they may feel they have lost control or are unable to breathe effectively with contractions. Routes of administration and common side effects are shown in Table 16.1. TABLE 16.1 ANALGESICS AND ANESTHETICS COMMONLY USED IN LABOR AND BIRTH Typ Drug Method of e Administration Effect on Mother Effect on Labor Progress Effect on Fetus or Newb orn Narc otic anal gesic Butor Intramuscular or phano intravenous l tartrat e (Stad ol) Effective analgesic; withdrawal symptoms if woman is opiate dependent Possible slowing of labor if given early Result s in some respira tory depres sion Nalbu Intramuscular or phine intravenous (Nub ain) Effective analgesic; slowing of respiratory rate Mild maternal sedation Result s in some respira tory depres sion Morp Intrathecal prior to hine epidural anesthesia sulfat e Pruritus; effective analgesia Possible slowing of labor contraction s Some respira tory depres sion Fenta Intravenous nyl (Subli maze) Lum Local Injected by bar anest anesthesiologist or epid hetic nurse anesthetist at ural L3–L4 for first stage bloc of labor; with k continuous block, anesthesia will last through birth; fentanyl or morphine possibly added to cerebral spinal fluid first Bupiv acain e (Marc aine) Ropiv acain e (Naro pin) Hypotension; Slowing of May respiratory labor if result depression given early in respira tory depres sion Rapid onset in minutes lasting 60–90 min; loss of pain perception for labor contractions and birth; possible maternal hypotension Slowing of labor if given too early; pushing feeling is obliterated, resulting in possible prolonged second stage May be some differe nces in respon se in first few days of life Pude Local Administered just ndal anest before birth for bloc hetic perineal anesthesia; k injected through vagina Rapid None anesthesia of apparent perineum None appare nt Anesthesia of None perineum apparent almost immediately None appare nt Lidoc aine (Xylo caine) Loca Local Injected just before l anest episiotomy incision infilt hetic ratio n of perin eum Lidoc aine (Xylo caine) Gene ral anest hetic Thiop Intravenous by ental anesthesiologist or sodiu nurse-anesthetist m Rapid anesthesia; also rapid recovery Forceps required because abdominal pushing is no longer possible Result s in infant being born with central nervou s system depres sion Source: Karch, A. M. (2013). 2013 Lippincott’s nursing drug guide. Philadelphia, PA: Lippincott Williams & Wilkins. Because of the fetal effects, whenever a narcotic is given during labor, a narcotic antagonist such as naloxone hydrochloride (Narcan) should be available for administration to the infant at birth if needed (Box 16.5). Carefully observe any infant who received naloxone hydrochloride in the immediate postpartum period because the infant’s respirations may become severely depressed again when the drug’s effect wears off (Karch, 2013). If severe infant respiratory depression is anticipated, naloxone hydrochloride can be given to a woman just before birth. It readily crosses the placenta and, because it interferes with or competes for narcotic binding sites, may increase the chance for spontaneous respiratory activity in the newborn. BOX 16.5 Nursing Care Planning Based on Responsibility for Pharmacology NALOXONE HYDROCHLORIDE (NARCAN) Action: Naloxone hydrochloride is a narcotic antagonist that counteracts the effect of narcotic analgesics (Karch, 2013). It is used to counteract respiratory depression in newborns when a woman has received a narcotic analgesic during labor. Pregnancy Risk Category: B Dosage: 0.01 mg/kg, administered either intravenously via umbilical vein, subcutaneously, or intramuscularly; repeated at 2- to 3-minute intervals until a response is obtained Possible Adverse Effects: Hypotension, hypertension, tachycardia, diaphoresis, tremulousness Nursing Implications • Anticipate the need for newborn resuscitative measures including the use of naloxone hydrochloride; have resuscitative equipment and emergency drugs readily available. • If no intravenous access is available, prepare for possible administration via endotracheal tube. • If no response is seen after two or three doses, question whether the respiratory depression is caused by maternal narcotic administration. • Continuously monitor all vital signs for changes. • Remember that the pain-relieving effect of a narcotic will be reversed as the narcotic is cleared from the baby’s system; assess for pain in the neonate if a narcotic was given for pain relief. What If . . . 16.2 Jonny receives no narcotics during labor, yet her newborn is born very sleepy. Would the nurse administer naloxone hydrochloride? Would asking Jonny if she uses recreational drugs be warranted in order to discover the cause of newborn respiratory depression? Additional Drugs Additional drugs, such as tranquilizers, may be administered during labor to reduce anxiety or potentiate the action of a narcotic. An example of such a drug is hydroxyzine hydrochloride (Vistaril). These drugs do not relieve pain, so the woman in labor needs pain management measures in addition to these drugs. Nitrous Oxide Nitrous oxide inhalation has been widely used in Europe for effective pain relief in labor. In the United States, it is beginning to be used more prevalently. In the past, this method had resulted in adverse neonatal outcomes such as brain cell apoptosis leading to developmental impairment. There was also concern about caregiver and maternal exposure. Over the past decade, nitrous oxide has made a comeback in the United States. Research by Rooks (2011) has shown that in appropriate doses (≤50% blend with oxygen) and with a proper and now standard delivery system, nitrous oxide can be safe for mother, fetus, neonate, and caregivers. It does not affect the pattern or intensity of contractions and does not interfere with normal labor. Apgar scores in neonates whose mothers used nitrous oxide do not significantly differ from those who used other forms of pharmacologic pain relief, or no analgesia (Likis, Andrews, Collins, et al., 2014). Regional (Local) Anesthesia Regional anesthesia is the injection of a local anesthetic such as chloroprocaine (Nesacaine) or bupivacaine (Marcaine) to block specific nerve pathways (Anim-Somuah et al., 2011). This achieves pain relief by blocking sodium and potassium transport in the nerve membrane, thereby stabilizing the nerve in a polarized resting state so the nerve is unable to conduct sensations. Various regional anesthetic injection sites are shown in Figure 16.3. Any woman with a bleeding defect, such as those that may occur with preeclampsia, need to be assessed carefully before regional anesthesia is administered to prevent bleeding at the injection site. Figure 16.3 Anatomy of the spinal canal and sites of injection for regional anesthesia. Regional anesthetics have the potential to result in fetal bradycardia. This is not due to the transmission of the drug from maternal to fetal circulation but rather secondary to the effects of maternal hypotension following administration of the medication. This may resolve spontaneously, with position change or with the administration of additional medication (Mohta, Aggarwal, Sethi, et al., 2016). The effects of epidurals on breastfeeding show mixed and contradictory results in the literature (French, Cong, & Chung, 2016). Most importantly, regional anesthesia is able to completely eliminate pain yet allow a woman to be completely awake and aware of what is happening during birth. It can make pushing with second stage labor more difficult, but it does not depress uterine tone, so the uterus remains capable of optimal contraction after birth, thereby helping to prevent postpartal hemorrhage. In the rare event an infant is born with symptoms of toxicity from a regional anesthetic, an exchange transfusion at birth will remove the anesthetic from the infant’s bloodstream. Gastric lavage also will remove a great deal of anesthetic because anesthetics have a strong affinity for acid media, such as stomach acid. Epidural Anesthesia The nerves in the spinal cord are protected by several tissue layers. • The pia mater is the membrane adhering to the nerve fibers. • Surrounding this is the cerebrospinal fluid (CSF). • Next comes the arachnoid membrane and, outside that, the dura mater. • Outside the dura mater is a vacant space (the epidural space). • Beyond it is the ligamentum flavum, yet another protective shield for the vulnerable spinal cord (see Fig. 16.3). An anesthetic agent introduced into the CSF in the subarachnoid space is spinal injection or spinal anesthesia. An anesthetic agent placed just inside the ligamentum flavum in the epidural space is called epidural anesthesia. Anesthetic agents placed in the epidural space at the L4–L5, L3–L4, or L2–L3 interspace block not only spinal nerve roots in the space but also the sympathetic nerve fibers that travel with them. Therefore, these blocks can provide pain relief during both labor and birth. Because a woman no longer experiences pain, the release of catecholamines (epinephrine) with a β-blocking effect from a pain response is decreased, making this a very effective pain relief measure for labor (Impey & Child, 2012). Epidural blocks are suitable for almost all women. They are advantageous for women with heart disease, pulmonary disease, diabetes, and sometimes severe gestational hypertension because they make labor virtually pain free and thereby reduce stress from the discomfort of labor. Because the woman does not feel contractions, her physical energy is preserved. Epidural blocks are acceptable for use in preterm labor because the drug has scant effect on a fetus and allows for a controlled and gentle birth with lessened trauma to an immature fetal skull. Because the woman receives no systemic medication, the infant responds more quickly after birth than if systemic narcotic analgesics were used. The chief concern with epidural anesthesia is its tendency to cause hypotension because of its blocking effect on the sympathetic nerve fibers in the epidural space. This blocking leads to decreased peripheral resistance in the woman’s circulatory system. Decreased peripheral resistance causes blood to flow freely into peripheral vessels, and a pseudohypovolemia develops, which registers as hypotension. This risk can be reduced by being certain a woman is well hydrated with 500 to 1,000 ml of IV fluid, such as Ringer’s lactate, before the anesthetic is administered. Ringer’s lactate is preferable to a glucose solution because too much maternal glucose can cause hyperglycemia with rebound hypoglycemia in the newborn. Be certain a woman does not lie supine after an epidural block but remains on her side to help prevent supine hypotension syndrome. If hypotension should occur, raising the woman’s legs and administering oxygen and additional IV fluid along with an antihypotensive agent such as ephedrine to elevate blood pressure may be necessary to stabilize cardiovascular status. This is an emergency because if the woman is severely hypotensive, blood is shunted away from the uterus and leads to poor perfusion of the placenta, eventually causing fetal distress. A disadvantage of epidural anesthesia is that the bearing down reflex may be reduced or absent, making it difficult for a woman to push effectively. This may delay fetal descent, thus prolonging the second stage of labor and leading to an increased number of instrument-assisted births (Schrock & Harraway-Smith, 2012). A second stage delay this way occurs primarily when the fetus is in an occipitoposterior position. Changing the woman’s position (e.g., to all fours) to help fetal rotation can be helpful to aid descent. For both of these situations, allowing an epidural to wear off by the second stage of labor so that a woman can push with contractions is another option. If this is unsuccessful, an oxytocin IV to help strengthen contractions can be administered. Many women are understandably overwhelmed and disappointed if the epidural is allowed to wear off; the excellent pain control they had may make the return of contraction pain seem extreme. Encouragement and use of nonpharmacologic methods will be critical nursing interventions at this time. In rare instances, the anesthetic enters the woman’s blood circulation instead of settling into the epidural space. Drowsiness, a metallic taste on the tongue, slurred speech, blurred vision, unconsciousness, and seizure, which may lead to cardiac arrest, are alerts this has happened and, again, is an emergency situation. The woman needs oxygen and an anticonvulsant, such as diazepam (Valium) or thiopental sodium (Pentothal) IV, followed by the prompt birth of the fetus to protect the health of the woman and the fetus. Technique for Administration Epidural blocks are usually delayed until a woman’s cervix is dilated 3 to 5 cm as earlier administration may slow the first stage of labor. Be certain an infusion of Ringer’s lactate solution is begun preprocedure and that equipment for blood pressure monitoring is in place and functioning. Help position the woman on her side on her birthing bed. If she curves her back outward, this increases the intravertebral spaces and allows easier access to the injection site. An epidural block may consist of only an anesthetic injection into the epidural space or a combined method where a low-dose anesthetic is injected into the epidural space and a small dose of an analgesic such as fentanyl is also injected into the CSF space. This combination of drugs and technique is advantageous because it results in a “walking” or “mobile” block, which produces anesthesia up to the level of the umbilicus in 10 to 15 minutes that will last for approximately 40 minutes to 2 hours (Schrock & Harraway-Smith, 2012). Its second advantage is that it allows a woman to move about and walk while anesthesia is in effect. A catheter is left in place attached to a syringe to allow for repeated injections without further injection pain (Fig. 16.4). Figure 16.4 Epidural anesthesia. (A) A needle is inserted into the epidural space. (B) A catheter is threaded into the space; the needle is then removed. The catheter allows medication to be administered intermittently or continuously to relieve pain during labor and childbirth. Assess a woman’s pulse and blood pressure following the injection. Observe for toxic symptoms of hypotension, slurred speech, and rapid pulse, which would occur if the anesthetic was accidentally placed into a blood vessel and not the hollow epidural space. Be certain to review agency policy regarding catheter care before caring for a person with a catheter in place to prevent infection at the site. Proper gowning is encouraged prior to administration for colonization reduction (Siddiqui, Davies, McGeer, et al., 2014). An epidural block provides anesthesia for uterine contractions but not perineal relaxation. Close to birth, if the woman sits up and an additional dose of anesthesia is added to the catheter, perineal anesthesia will result as well. Leaving the lower anesthesia for late in labor this way is thought to allow for better internal rotation of the fetal head because the perineal muscle is not lax, creating a lessened need for forceps for rotation. Aftercare for the Woman With an Epidural Anesthesia Following anesthetic administration, be certain a woman lies on her side, or if on her back, she should place a firm towel under her left hip to avoid hypotension from poor blood return to the heart. To keep her free from discomfort during the duration of labor, anesthetic can be continually infused by an infusion pump, or other doses of anesthetic, termed “top-ups,” can be added at intervals. Both techniques are equal in their effect on length of labor, although continuous administration may result in more cesarean births because of difficulty pushing and fetal descent (Siddiqui et al., 2014). Each time, before an additional top-up dose is administered, ask the woman to say out loud a phrase such as “I can do it” three times. If she is unable to do this, question the dose; lack of fine motor coordination and slurred speech can indicate a slowly occurring toxic reaction. Yet another technique used to maintain epidural anesthesia is selfadministration or patient-controlled epidural analgesia (PCEA). With this technique, following a lockout period when no more anesthetic can be administered to avoid overdosing, an analgesic mixture is delivered whenever the patient presses a button on a PCEA pump (Jokinen, Weibel, Afshari, et al., 2015). This method of administration is advantageous because less anesthetic is required compared with continuous epidural infusion (CEI) and can give the woman a feeling of empowerment as she controls her own pain management. A nurse should be in continuous attendance as long as epidural anesthesia is being used. When recording vital signs, be aware epidural anesthesia can cause a temporary elevation in temperature, which is not serious unless it rises above 101°F (Sultan, David, Fernando, et al., 2016). Possible complications that can occur from epidural blocks include hypotension, pruritus (especially if morphine was used), urinary retention, nausea and vomiting, and, rarely, a postpartal dural puncture headache (PDPH) (because the subarachnoid space was entered for the analgesic injection). To detect if hypotension is occurring, continuously monitor blood pressure for the first 20 minutes after each new injection of anesthetic. Continue to periodically monitor blood pressure throughout the time the anesthetic is in effect to be certain the woman’s systolic pressure does not fall to less than 100 mmHg or decrease by 20 mmHg or more in a hypertensive woman. A drop greater than this could be life-threatening to a fetus unless prompt and effective corrective measures are taken, such as repositioning and administering an antihypotensive agent (e.g., ephedrine) to ensure the fetal outcome will not be compromised. After an epidural block, a woman loses sensation of bladder filling. Remind her to void every 2 hours, monitor intake and output, and observe and palpate for bladder distention to avoid overfilling, especially if labor is prolonged. Be aware of the standards and policies of the healthcare agency related to who may add additional anesthesia or remove the catheter. To assess after birth whether the anesthesia is wearing off, touch a woman’s leg and ask if she can feel your touch. Ask her to raise her knees and observe whether she can do this easily. Even after feeling in her legs returns, walking may be difficult for her. Be certain to stay with the woman the first time she is out of bed following regional block anesthesia to prevent her from falling. Spinal (Subarachnoid) Anesthesia Spinal anesthesia is not used frequently in preference to epidural blocks, but it may be used in an emergency or for a cesarean birth because the administration technique is simpler than that of an epidural and can be accomplished more rapidly. Before spinal anesthesia, as a guard against hypotension, an IV fluid such as Ringer’s lactate solution is usually begun to ensure good hydration. Be certain the fluid is infusing well before the anesthesia is administered. For spinal anesthesia, a local anesthetic agent such as bupivacaine (Marcaine) is injected using lumbar puncture technique into the subarachnoid space (into the CSF) at the L3 and L4 interspace. A narcotic agonist such as morphine or fentanyl may be added for additional pain relief. For administration, the woman is usually asked to sit on the side of the bed with legs dangling and head bent. Ask her to bend her head forward so her back curves and the intravertebral spaces open. Be sure either you or her support person steadies her in this sitting position because she is very “front heavy” as a result of her pregnancy and could easily fall forward if not well supported. After injection, the anesthetic normally rises to the level of T10. Anesthesia up to the umbilicus and including both legs will be achieved. Spinal anesthetic agents may be “loaded” or “weighted” with glucose to make them heavier than CSF. This helps prevent them from rising too high in the spinal canal and interfering with the motor control of the uterus or with respiratory muscles (Drasner & Larson, 2011). Following the anesthetic injection, if the woman was sitting, the anesthesiologist will ask the woman to lie down. It’s important a woman lies down at this time because if she continues to sit upright, the anesthetic will not rise high enough in the canal to achieve pain relief. She must not lie down before this time, however, or the anesthetic could rise too high in the canal. Lying with a pillow under the head is another method to help ensure the anesthesia will be confined to the lower spinal canal. As mentioned, hypotension from sympathetic blockage in the lower extremities may occur immediately after spinal anesthetic administration. This leads to vasodilation and a decrease in central blood pressure. If hypotension occurs, placental blood perfusion can be compromised. Turn the woman to her left side to reduce vena cava compression. Expect the anesthesiologist to quickly increase the rate of IV fluid administration to increase blood volume; ephedrine to increase blood pressure and oxygen also may be administered. Never place a woman in a Trendelenburg position (head lower than her body) to help restore blood pressure after spinal anesthesia. This could make the anesthetic rise high in her spinal column, causing uterine or respiratory function to cease. A late complication of spinal anesthesia is a PDPH or “spinal headache.” This occurs because of CSF leakage from the needle insertion site and also possibly from the irritation of a small amount of air that entered at the injection site. It has been demonstrated that the type of needle used may be a significant factor in whether or not a woman will have a spinal headache (Genç, Sahin, Maral, et al., 2016). The shift in pressure of the CSF causes strain on the cerebral meninges, initiating the pain. The incidence of such headaches is reduced if a woman is well hydrated before injection. If a headache occurs, the postpartum woman can be encouraged to drink a large quantity of fluid because a high fluid intake rapidly provides replacement of spinal fluid. A spinal headache can be relieved by the administration of hydrocortisone to reduce inflammation (Hanling, Lagrew, Colmenar, et al., 2016). Having the woman lie flat and administering an analgesic also helps. Some women find a cold cloth applied to their forehead helpful. If a headache is incapacitating, it can be treated with a blood patch technique. For this, 10 to 20 ml of blood is withdrawn from an accessible vein and then immediately injected into the epidural space over the spinal injection site. The injected blood clots and seals off any further leakage of CSF (Hanling et al., 2016). QSEN Checkpoint Question 16.5 TEAMWORK & COLLABORATION Jonny has chosen to have epidural anesthesia, and the nurse has consequently informed the anesthesiologist. What are two risks that are potentially associated with this form of anesthesia? a. Hypotension and a prolonged second stage of labor can occur. b. Severe headache and peripheral cyanosis can occur. c. Women have increased back pain and abrupt transitions between stages of labor. d. Maternal hypertension and a reduced red blood cell count can occur. Look in Appendix A for the best answer and rationale. MEDICATION FOR PAIN RELIEF DURING BIRTH Stretching of the perineum causes pain that occurs during the birth. The simplest form of relief for this type of pain is the natural pressure anesthesia that results from the fetal head pressing against the stretched perineum. This natural anesthesia is often adequate to allow the fetal head to be born with only momentary pain, which, although intense and hot, occurs suddenly and is over quickly. Often, after the hours of hard contractions a woman has come through, this flash of pain seems insignificant. For some women, however, additional medication is needed to reduce the pain of birth. Local Anesthetics Local anesthesia reduces the ability of local nerve fibers to conduct pain. Local Infiltration Local infiltration is the injection of an anesthetic such as lidocaine (Xylocaine) into the superficial nerves of the perineum along the vulva. The effect lasts for approximately 1 hour, allowing for a less painful birth and suturing of an episiotomy (a cut to enlarge the vagina opening; discussed in Chapter 24). Pudendal Nerve Block A pudendal nerve block is the injection of a local anesthetic such as bupivacaine (Marcaine) through the vagina to anesthetize the pudendal nerve. It is used for a woman who has not had an epidural to provide a pain-free birth and, if the woman should have an episiotomy, painless surgical suturing and repair. Although a pudendal nerve block is local, assess the fetal heart rate and the mother’s blood pressure immediately after the injection to be certain maternal hypotension does not occur. General Anesthesia General anesthesia is never preferred for childbirth because it carries the dangers of hypoxia and possible inhalation of vomitus during administration. Because it is used so rarely, you probably will not see this used; if it is used, there are special precautions you need to be aware of. Pregnant women are particularly prone to gastric reflux and aspiration because of increased stomach pressure from the weight of the full uterus beneath it. The gastroesophageal valve at the top of the stomach also may be displaced and possibly functioning improperly. Despite these risks, general anesthesia may be necessary in emergency situations, such as if the placenta loosens before the fetus is born (placental abruption), spinal anesthesia is contraindicated, or an immediate cesarean birth is required. For complete and rapid anesthesia during childbirth, thiopental sodium (Pentothal), a short-acting barbiturate, is usually the drug of choice. It causes rapid induction of anesthesia and, because it has a short half-life, allows for good uterine contraction afterward and so prevents postpartal hemorrhage. All women who receive a general anesthetic, however, must be observed closely in the postpartal period for uterine relaxation and the risk of uterine atony and postpartal hemorrhage. For the procedure, after induction with thiopental sodium, the woman is intubated, and anesthesia is then maintained by administration of nitrous oxide and oxygen. Thiopental sodium crosses the placenta rapidly, so an infant born to a woman anesthetized by this method may be slow to respond at birth and may need resuscitation. Some women comment that their throat feels raw or sore after general anesthesia administration; this is from the insertion and maintenance of an endotracheal tube. Using an anesthetic throat spray or gargle, sipping cold liquids, or sucking on ice chips (as soon as this is safe after general anesthesia) can help to relieve the discomfort. Preparation for the Safe Administration of General Anesthesia To ensure safe general anesthesia administration, an anesthesiologist or nurse anesthetist needs a minimum of six drugs readily available: • Ephedrine to use in the event blood pressure falls • Atropine sulfate to dry oral and respiratory secretions to prevent aspiration • Thiopental sodium (Pentothal) for rapid induction • Succinylcholine (Anectine) to achieve laryngeal relaxation for intubation • Diazepam (Valium) to control seizures, a possible reaction to anesthetics • Isoproterenol (Isuprel) to reduce bronchospasm, should aspiration occur In addition to these medications, an adult laryngoscope, an endotracheal tube, a breathing bag with a source of 100% oxygen, and a suction catheter and suction source should be at hand. Aspiration of Vomitus There is a danger of vomiting with a general anesthetic; this can be fatal if a woman’s airway becomes occluded by foreign matter. In addition, stomach contents have an acid pH that can cause chemical pneumonitis and secondary infection of the respiratory tract. Some anesthesiologists may prescribe IV ranitidine (Zantac) or an oral antacid such as sodium citrate to be given before general anesthesia is administered to reduce the level of acid in stomach contents should aspiration occur. Metoclopramide (Reglan) increases gastric emptying and may also be prescribed. For general anesthesia administration, the woman is asked to lie on her back with a wedge under her left hip to displace the uterus from the vena cava. To reduce the occurrence of hypotension and to establish a line for emergency medications, IV fluid administration is begun. The woman is then given a rapid-induction IV agent, followed by intubation with a cuffed endotracheal tube. The moments of induction of general anesthesia before the endotracheal tube is safely in place are critical ones for the anesthesiologist. Respect his or her need to concentrate by not talking until the task is achieved. If aspiration of vomitus should occur following administration, prompt attention is essential. The anesthesiologist suctions the woman’s trachea to remove as much foreign material as possible. The woman is intubated, if she was not previously, and given 100% oxygen. IV isoproterenol to reduce bronchospasm and a corticosteroid to reduce inflammation may be given. Positive-pressure ventilation may be initiated. Blood gas analysis and a chest X-ray usually are obtained to determine how much aeration the woman is still capable of achieving. The woman may receive mechanical ventilation until her overall clinical condition improves, as shown by X-ray films and blood gas concentrations. She may be critically ill at the time of aspiration and, after the cesarean birth, often will be transferred to an intensive care unit for the special care she needs to survive this emergency. QSEN Checkpoint Question 16.6 QUALITY IMPROVEMENT There is no reason to think Jonny will need a general anesthetic. But if she did, what type of drug would the nurse want to ensure is readily available on a birthing unit to help minimize the risk of aspiration of vomitus? a. An anticonvulsant such as diazepam (Valium) b. A nerve relaxant such as phenobarbital c. Metoclopramide (Reglan) to speed gastric emptying d. Oxytocin to increase the effectiveness of labor Look in Appendix A for the best answer and rationale. Nursing Diagnoses and Related Interventions Nursing Diagnosis: Anxiety related to more pain than expected from labor contractions Outcome Evaluation: Patient identifies beginning and end of contractions, expresses confidence rather than confusion about ongoing process, states she feels less anxious, and is able to concentrate on controlled breathing. In addition to causing local discomfort, pain can evoke a general stress response (fight-or-flight syndrome). This releases epinephrine, which causes peripheral and uterine vasoconstriction. This can increase the degree of pain experienced because of the resulting increase in tissue anoxia. Reducing anxiety through relaxation techniques such as spaced breathing exercises or through administration of medication to reduce anxiety can reduce vasoconstriction and help reduce pain. Reduce Anxiety With Explanations of the Labor Process. Planning with women their options for pain relief during labor should begin prenatally (Box 16.6). BOX 16.6 Nursing Care Planning to Empower a Family PAIN RELIEF DURING LABOR Q. Jonny tells you, “I know my friends have told me pain during labor would be horrible, but what can I do so I won’t hurt so much?” A. Here are some common suggestions to help with pain relief: • Ask your primary healthcare provider early in pregnancy about pain management options for labor. The options your care provider suggests may actually influence your decision as to whether this is the optimal care provider for you. • Attend childbirth preparation classes during pregnancy and conscientiously practice breathing or other relaxation exercises. These measures can be adequate all by themselves; if not, they may complement pharmacologic methods of pain relief. • Make a birth plan detailing what position you choose for labor and other options you want to use. This helps give you a greater sense of control in the face of pain. • Be certain a support person will be with you during labor. Name a second person or investigate using a doula if you are uncertain whether your usual support person will be available or can fill this role. • Late in pregnancy, if you are still concerned, let your primary healthcare provider know. In addition to medication for pain relief during labor, medication to reduce anxiety is also available. • On admission to the hospital, let the medical and nursing staff know you are concerned so they can work with you to find satisfactory pain management. • The most commonly used options today are oral, intramuscular, or intravenous administration of narcotics or injection of regional anesthesia by epidural block. Ask questions about any method suggested if necessary so you’re aware of action and side effects. • Be aware the choice of receiving analgesia or anesthesia is yours. However, if a complication occurs, be ready to compromise in the interest of safety for yourself and your child. During labor, use a standard method of pain assessment, such as asking a woman to rate her pain level on a scale of 1 to 10 or show her a paper with a line marked 1 to 10 if she’s more visually oriented, so she can rate her pain. Based on her response, evaluate whether pain relief is adequate and effective. Introduce natural methods based on the gate control theory of pain relief such as massage or imagery. Be sure to offer careful explanations of what is happening or what will happen during labor because this can help alleviate anxiety and thereby reduce some discomfort. Be certain to explain the characteristics of contractions (e.g., labor contractions are rhythmic and come and go repeatedly) and reinstruct as necessary. Do not assume a woman is aware of this simply because she is experiencing the contractions. Her pain may be so intense and the intensity so unexpected that she is unaware of any relief between contractions (Box 16.7). BOX 16.7 Nursing Care Planning Tips for Effective Communication Jonny stated early in labor that she didn’t want to use any medication for pain relief. As soon as her contractions became 30 seconds in length, however, she requested some analgesia. Her physician prescribed intramuscular butorphanol tartrate (Stadol). Her contractions are now 40 seconds in duration and only moderately strong. She looks increasingly uncomfortable with each contraction. Tip: Ask the patient to rate her pain on a scale of 1 to 10 rather than just asking how she feels. Assess whether she has a clear understanding of the nature of labor contractions to make it easier for her to manage them. Because women in labor are under stress, they may not hear instructions when they are given. Nurse: How are you feeling, Jonny? Is there anything I can do for you? Jonny: I need something stronger for pain. Nurse: On a scale of 1 to 10, with 1 being little pain and 10 being the worst pain ever, how would you rate the pain you’re having? Jonny: Two, but I know it’ll be 10 in another half hour when my contractions get so strong that they’re constant. Nurse: I can assist you with relaxation techniques to lessen your discomfort. Contractions aren’t constant and resting in-between contractions is helpful. This on/off effect of labor contractions differentiates the pain from that of a toothache or headache, which is continuous. Sometimes, just knowing this can help a woman tolerate the pain even as it increases in intensity. Do not assume a woman knows such things like when membranes rupture it is painless, that a pink-stained show is normal, or that contractions change in character during labor. A woman having her first child may not know these things. A woman having her second child may not remember what her labor was like the last time, or she may find this time so different (even if it is well within usual limits) she is frightened by it. Be certain to give explanations to a woman’s partner or support person as well because it’s hard to support someone when you need support yourself. Unless the support person’s anxiety and fear are relieved, he or she may start to convey anxiety back to the woman in labor rather than help her relax. Nursing Diagnosis: Ineffective coping related to combination of uterine contractions and anxiety Outcome Evaluation Patient demonstrates effective coping by expressing confidence in her ability to maintain active participation during labor, using continued breathing techniques, expressing the need to change position, and verbalizing confidence in healthcare providers. Help the Woman Identify Coping Strategies. Because pain is not a new phenomenon for a woman of childbearing age, it can be helpful to ask her to recall methods she usually uses to combat pain or anxiety, such as meditation or applying a cool cloth. Associating labor pain with usual circumstances can go a long way toward helping her collect her resources and decide on a workable pain relief strategy. Box 16.8 shows an interprofessional care map illustrating both nursing and team planning for helping reduce anxiety to manage discomfort during labor. BOX 16.8 Nursing Care Planning AN INTERPROFESSIONAL CARE MAP FOR A WOMAN REQUIRING COMFORT MEASURES DURING LABOR AND BIRTH Jonny Baranca is a primipara in early labor whom you admit to a birthing unit. Her contractions are 7 minutes apart, and her cervix is 3 cm dilated. She tells you her sister had epidural anesthesia that completely obliterated her pain in labor for the birth of her baby 3 months ago. Based on her sister’s experience, Jonny expected to be given epidural anesthesia as soon as she arrived at the hospital. As she is in early labor, her physician asked her to wait until she is 4 cm dilated. When you enter her room, you find her lying on her back in a birthing bed, crying from pain. Her husband shouts at you that his “wife deserves better care than this.” Family Assessment: Gravida 1, para 0; accompanied by husband who will act as support person and coach. Patient works as clerk in clothing store; husband is physical education major at local university. Patient Assessment: Contractions are of moderate intensity, every 6 to 7 minutes, with a duration of 35 seconds. Cervix dilated 3 cm, 80% effaced, −1 station. Membranes intact. Fetal heart rate (FHR), 148 beats/min; fetus in right occiput anterior (ROA) position. Attended childbirth education classes but did not practice breathing exercises. Last meal: 3 hours ago; last voided, 2 hours ago. Nursing Diagnosis: Pain related to effects of uterine contractions and pressure on pelvic structures Outcome Criteria: Patient confirms discomfort is controlled (pain is a 3 or less on a 1 to 10 pain scale) with either nonpharmacologic or pharmacologic methods; responds to questions and instructions; identifies need for additional pain relief measures if required. Team Member Responsible Assessment Intervention Rationale Activities of Daily Living, Including Safety Expected Outcome Nurse Assess what birth plan the woman wants to follow. Inspect her suprapubic area and palpate for bladder distention. Remind patient she does not need to remain in bed. Encourage her to void every 2 hours. Ambulation can increase comfort and progress. A full bladder contributes to discomfort and may impede fetal descent, possibly prolonging labor. Patient ambulates in early labor. Has no signs of bladder distention; voids every 2 hours during labor. Respecting patient’s wishes is a prime method of encouraging self-efficacy. Pain management team supports patient’s wish for pharmacolog ic intervention; encourages nonpharmaco logic measures until epidural anesthetic is appropriate. Teamwork and Collaboration Nurse/primar Locate the y healthcare on-call provider healthcare provider to provide anesthetic pain relief when patient reaches 4 cm dilation. Notify nurseanesthetist concerning patient’s wish to receive an epidural block as soon as possible. Procedures/Medications for Quality Improvement Nurse Assess how patient’s husband views his role in labor. Assess if patient will try controlled breathing exercises learned in preparation for labor class. Refresh controlled breathing and imagery with support of husband. Allow husband occasional breaks. Stay with the patient during this time to provide support. A support person increases satisfaction with labor; controlled breathing and imagery can be learned during labor. Support person helps patient with imagery and controlled breathing. Patient allows healthcare providers to substitute for husband so husband can take occasional breaks. Determine what patient would like to eat or drink while in labor. Provide patient with a beverage at least every hour; food as desired. Fluid maintains hydration; ice chips or hard candy can relieve mouth dryness from breathing exercises. Patient states she has no mouth discomfort from breathing; drinks fluid every hour. Nutrition Nurse Patient-Centered Care Nurse/nurse anesthetist Assess if patient still desires epidural anesthesia for pain management. Provide information on epidural anesthesia as needed; update the couple on labor progress. Frequent updates on progress help alleviate anxiety and fears that may exacerbate pain. Couple confirms they are certain epidural anesthesia is their method of choice; receive frequent updates on labor progress. Praise can instill a sense of control and motivation to continue to use alternative methods of pain control. Patient rates her level of pain from labor contractions not above 3 on a 1 to 10 scale. Psychosocial/Spiritual/Emotional Needs Nurse Assess level of patient’s pain by verbal, pain scale, and nonverbal indicators. Use 1 to 10 scale and evaluate response to techniques used. Support patient in her ability to manage pain until her epidural can be given. Nurse Assess what nonpharmaco logic measures (such as music, touch, environment al calm) patient thinks would help complement epidural block and aid comfort. Provide a comfortable environment: clean sheets, cool washcloth to forehead, closed room door. Refrain from intervening with patient during a contraction. A comfortable environment aids in relaxation, promoting effective coping. Interrupting the patient’s breathing can make the technique ineffective as a pain relief measure. Patient reports she feels environment is comfortable and complements other pain relief measures. Informatics for Seamless Healthcare Planning Nurse Ask patient and husband to evaluate their labor experience. Review with patient pain relief measures used and determine which were most effective. Reviewing a possibly traumatic experience helps to put it into perspective among life events. Patient and support person state labor and birth were, at worst, a tolerable experience and, at best, a highlight of their lives. Provide Comfort Measures. Usually, anyone can tolerate a little discomfort from a backache, being thirsty, having dry lips, or having a leg cramp. However, few people can tolerate having all of these discomforts simultaneously or feeling even one of them while experiencing a labor contraction. Assist the woman’s support person to provide the usual comfort measures that are helpful for anyone with pain, such as reassurance, massage, or a change in position. For dry lips, ice chips to suck on, moistening the lips with a wet cloth, or using a moisturizing jelly or balm can be helpful. A cool cloth to wipe perspiration from the forehead, neck, and chest can keep a woman from feeling overheated. A woman’s sheets and clothing may wrinkle rapidly and stick to her skin if she is perspiring. The waterproof pad under her buttocks will become soiled with vaginal secretions and will begin to feel hot and sticky. Never apply sanitary pads in labor because, although they absorb vaginal secretions well, they also tend to slip out of place, possibly carrying pathogens from the rectal area forward to the vaginal opening. Instead, change waterproof pads frequently. At least halfway through the first stage of labor, or more frequently as indicated by the woman’s condition, change her sheets, offer her a clean gown, and ask if she’d like to bathe or take a shower. These measures can help her feel clean and refreshed, with a ready-to-go-again feeling. Think of comfort measures for the woman’s support person as well. Is the chair by the side of the bed comfortable? Does he or she need to stretch or take a beverage or bathroom break? Could you serve as the coach while the support person makes some phone calls? Breaks such as these allow a partner to come back rested and ready to give support again. Nursing Diagnosis: Pain related to labor contractions Outcome Evaluation: Patient states pain is reduced to a tolerable level with techniques used so she is able to handle or “work with” contractions and demonstrates ability to listen and respond to questions and instructions. Assist the Woman With Prepared Childbirth Method. Depending on the type of childbirth preparation a woman and her support person have had, the method used may include breathing exercises, distraction by focusing on an external object, acupressure, therapeutic touch, music therapy, guided imagery, self-hypnosis, or a combination of these methods. The use of biofeedback is not well documented in labor but may also be effective. Even though a woman conscientiously practiced breathing or focusing in a relaxed, fun setting of an antepartal class, the discomfort and stress of labor may make it easy for her to forget what she learned. As necessary, review previously learned breathing techniques with her. Urge her to begin using these early in labor, before contractions become strong, so she gains confidence that they can be effective at diminishing pain. If a woman has had no prior training in breathing exercises, sit with her and teach her a simple breathing pattern, so she can begin to utilize this to relieve some of her pain. Massage is another pain relief method that can be taught to a woman and her support person during labor. This may be especially useful if a woman is experiencing back pain because rubbing or massaging the sacral area often alleviates that. Firm massage on her shoulders can provide a relaxing distraction from the sensation of internal pressure and pain. Encourage Comfortable Positioning. An upright position, sitting, walking, or swaying with a partner may be most comfortable for a woman in early labor and aids contractions and descent through gravity (see Chapter 15). If a woman wants to walk and has no support person, walk with her as she may need support during a contraction. Leaning forward against a birthing ball or pelvic rocking between contractions may relieve tense back muscles. If a woman must remain in bed because of a situation such as her membranes have ruptured and the fetal head is not engaged, urge her to keep active within the limits of bed rest and especially not to lie on her back to avoid supine hypotension syndrome. Move bedclothes or monitor leads, if any are attached, as needed to allow her to be able to turn and remain active. Position changes during the second stage of labor help fetal descent and may shorten labor. Urge a woman to sit, stand, kneel on hands and knees, lie in a lateral recumbent position, squat, or use whatever position she prefers (see Chapter 15). Keep in mind that maintaining these positions often requires assistance from one or two support people to keep an unbalanced woman from falling. Provide Pharmacologic Pain Relief. Helping a woman decide if and when medication for pain relief should be used requires an in-depth understanding of the available drugs, their effects on the mother and the fetus, and their mechanism and duration of action. It also requires sympathetic listening and counseling skills. Many women come into labor wishing to avoid drugs entirely. Once in labor, they may change their minds but hesitate to say so, especially if their partners also believe a birth without the use of drugs is ideal. Other women come into labor asking to receive something immediately to avoid experiencing any pain. In both instances, provide information about the use of drugs and their ultimate effects. Maintain a supportive presence to help a woman make the best decision for herself and her baby. Some women require analgesia or anesthesia because of a complication. Helping these women and their support persons understand why the medication is necessary calls for equal care and skill. As a rule, record a baseline fetal heart rate and maternal blood pressure and pulse before administering medication; reassess 15 minutes later for fetal and maternal safety. What If . . . 16.3 Jonny, who is still in early labor, tells the nurse if she can’t have an epidural immediately, she wants a general anesthesia. If she can’t have that, she will leave the hospital. Her physician has said she cannot justify a general anesthesia for uncomplicated labor. The nurse finds Jonny crying because her doctor won’t give her anything for pain. How would the nurse handle this situation? The Woman With Unique Needs THE MORBIDLY OBESE WOMAN Morbidly obese women may have more difficulty using some nonpharmacologic measures for pain relief than other women. For example, be certain a portable birthing tub (looks like a child’s plastic pool) will be sturdy enough to support her weight as she leans against the side. Check to be certain the labor room shower is wide enough if she wishes to use warm water sprays for pain management. Remember, birthing beds are not very wide; be cautious when you ask her to turn that she has adequate space to do that. Straddling a chair and leaning against the back may be unsafe if the chair is not strong enough to support her weight. Analgesic administration may also pose a problem as a usual dose may not be as effective in extremely obese women. Question doses for women who might need a larger amount so they can achieve pain relief. Anesthetic administration may also cause concern as it may be more difficult for an anesthetist to identify the L3–L4 intravertebral space for injection. Although women who are classified as obese do have higher risk of labor complications, they are also at greater risk for procedures such as induction of labor, resulting in cesarean birth (Kerrigan, Kingdon, & Cheyne, 2015). THE WOMAN WITH CULTURAL CONCERNS Because of cultural traditions, some women are very opposed to the use of analgesia or anesthesia in labor. Be certain to respect this concern by aiding women in any way possible to use the methods they have chosen for pain control and to not interrupt distraction techniques such as controlled breathing, meditation, or chanting. Mark a nursing care plan as to the woman’s preference so other team members don’t suggest analgesia. Caution other team members as well to remain quiet while the baby is …

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