Maternity: McKinney: Chapter 18: Pain Management for Childbirth

Childbirth preparation can be considered successful if the outcome is described as follows:

a. Labor and delivery were pain-free.

b. The woman's partner participated eagerly.

c. The woman rehearsed labor and practiced skills to master pain.

d. Only nonpharmacologic methods for pain control were used.

c. The woman rehearsed labor and practiced skills to master pain.

Preparation allows the woman to rehearse for labor and to learn new skills to cope with the pain of labor and the expected behavioral changes. Childbirth preparation does not guarantee a pain-free labor. A woman should be prepared for pain and anesthesia/analgesia realistically. The partner's role and participation level should be established by the couple. Women will not always achieve their desired level of pain control by using nonpharmacologic methods alone. p. 356

In order to help patients manage discomfort and pain during labor, nurses should be aware that

a. the predominant pain of the first stage of labor is the visceral pain located in the lower portion of the abdomen.

b. somatic pain is the extreme discomfort between contractions.

c. the somatic pain of the second stage of labor is more generalized and related to fatigue.

d. pain during the third stage is a somewhat milder version of the second stage.

a. the predominant pain of the first stage of labor is the visceral pain located in the lower portion of the abdomen.

This pain comes from cervical changes, distention of the lower uterine segment, and uterine ischemia. Somatic pain is a faster, sharp pain. Somatic pain is most prominent during late first-stage labor and during second-stage labor as the descending fetus puts direct pressure on maternal tissues. Second-stage labor pain is intense, sharp, burning, and localized. Third-stage labor pain is similar to that of the first stage. p. 355

The nurse caring for women in labor understands that childbirth pain is different from other types of pain in that it is

a. more responsive to pharmacologic management.

b. associated with a physiologic process.

c. designed to make one withdraw from the stimulus.

d. less intense.

b. associated with a physiologic process.

Childbirth pain is part of a normal process, whereas other types of pain usually signify an injury or illness. Childbirth pain is not more or less responsive to medication. The pain with childbirth is a normal process; it is not caused by the type of injury when withdrawal from the stimuli is seen. Childbirth pain is not less intense than other types of pain. p. 354

Excessive anxiety in labor heightens the woman's sensitivity to pain by increasing

a. muscle tension.

b. blood flow to the uterus.

c. the pain threshold.

d. rest time between contractions.

a. muscle tension.

Anxiety and fear increase muscle tension, diverting oxygenated blood to the woman's brain and skeletal muscles. Prolonged tension results in general fatigue, increased pain perception, and reduced ability to use coping skills. It can also decrease blood flow to the uterus, the pain threshold, and the amount of rest the mother gets between contractions. p. 356

When providing labor support, the nurse knows that which fetal position might cause the laboring woman more back discomfort?

a. Right occiput anterior

b. Left occiput anterior

c. Right occiput transverse

d. Left occiput posterior

d. Left occiput posterior

In the left occiput posterior position, each contraction pushes the fetal head against the mother's sacrum, which results in intense back discomfort. The other fetal positions do not cause more back discomfort. p. 358

The nurse working with a pregnant woman explains that a major advantage of nonpharmacologic pain management is that

a. more complete pain relief is possible.

b. no side effects or risks to the fetus are involved.

c. the woman remains fully alert at all times.

d. a more rapid labor is likely.

b. no side effects or risks to the fetus are involved.

Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. There is less pain relief with nonpharmacologic pain management during childbirth. The woman's alertness is not altered by medication, but the increase in pain will decrease alertness. Pain management may or may not alter the length of labor. At times when pain is decreased, the mother relaxes and labor progresses at a quicker pace. p. 356

The best time to teach nonpharmacologic pain control methods to an unprepared laboring woman is during which phase?

a. Latent phase

b. Active phase

c. Transition phase

d. Second stage

a. Latent phase

The latent phase of labor is the best time for intrapartum teaching, because the woman is usually anxious enough to be attentive, yet comfortable enough to understand the teaching. During the active phase, the woman is focused internally and unable to concentrate on teaching. During transition, the woman is focused on keeping control; she is unable to focus on anyone else or learn at this time. During the second stage, the woman is focused on pushing. She normally handles the pain better at this point because she is active in doing something to hasten the delivery. p. 357

The nurse providing newborn stabilization must be aware that the primary side effect of maternal narcotic analgesia in the newborn is

a. respiratory depression.

b. bradycardia.

c. acrocyanosis.

d. tachypnea.

a. respiratory depression.

An infant delivered within 5 hours of maternal analgesic administration (timing depends on drug used) is at risk for respiratory depression from the sedative effects of the opioid. Bradycardia, acrocyanosis, and tachypnea are not anticipated side effects of maternal analgesics. p. 365- Table 18.1

A woman received 50 mcg of fentanyl intravenously 1 hour before delivery. What drug should the nurse have readily available?

a. Promethazine (Phenergan)

b. Nalbuphine (Nubain)

c. Butorphanol (Stadol)

d. Naloxone (Narcan)

d. Naloxone (Narcan)

Naloxone reverses narcotic-induced respiratory depression, which may occur with administration of narcotic analgesia. Phenergan is normally given for nausea. Nubain and Stadol are analgesics that can be given to women in labor. p. 372-Table 18.2

The nerve block used in labor that provides anesthesia to the lower vagina and perineum is called a(n)

a. epidural.

b. pudendal.

c. local.

d. spinal block.

b. pudendal.

A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps if needed. An epidural provides anesthesia for the uterus, perineum, and legs. A local provides anesthesia for the perineum at the site of the episiotomy. A spinal block provides anesthesia for the uterus, perineum, and down the legs. p. 372- Table 18.2

A laboring woman has been given an injection of epidural anesthesia. Which assessment by the nurse takes priority?

a. Urinary output

b. Contraction pattern

c. Maternal blood pressure

d. Intravenous infusion rate

c. Maternal blood pressure

Epidural anesthesia may produce maternal hypotension due to vasodilation so the priority assessment by the nurse is maternal blood pressure. The other assessments are important for this woman but are not directly related to the anesthetic injection. p. 372-Table 18.2

Which statement is true about the physiologic effects of pain in labor?

a. It usually results in a more rapid labor.

b. It is considered to be a normal occurrence.

c. It may result in decreased placental perfusion.

d. It has no effect on the outcome of labor.

c. It may result in decreased placental perfusion.

When experiencing excessive pain, the woman may react with a stress response that diverts blood flow from the uterus and the fetus. Excessive pain may prolong the labor due to increased anxiety in the woman. Pain is considered normal for labor, however; this statement does not explain the physiologic effects. Pain may affect the outcome of the labor depending on the cause and the effect on the woman. p. 354

Which woman will most likely have increased anxiety and tension during her labor?

a. Gravida 1 who did not attend prepared childbirth classes

b. Gravida 2 who refused any medication

c. Gravida 2 who delivered a stillborn baby last year

d. Gravida 3 who has two children younger than 3 years

c. Gravida 2 who delivered a stillborn baby last year

If a previous pregnancy had a poor outcome, the woman will probably be more anxious during labor and delivery. The woman is not prepared for labor and will have increased anxiety during labor. However, the woman with a poor previous outcome is more likely to experience more anxiety, and good teaching by the nurse will diminish some of the anxiety. A gravida 2 has previous experience and can anticipate what to expect. By refusing any medication, she is taking control over her situation and will have less anxiety. This gravida 3 has previous experience and is aware of what to expect. p. 356

Which method of pain management does the nurse plan for a gravida 3 para 2 admitted at 8-cm cervical dilation?

a. Epidural anesthesia

b. Narcotics

c. Spinal block

d. Breathing and relaxation techniques

d. Breathing and relaxation techniques

Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. There is probably not enough remaining time to administer epidural anesthesia or spinal anesthesia. A narcotic given at this time may reach its peak about the time of birth and result in respiratory depression in the newborn. p. 357

The laboring woman who imagines her body opening to let the baby out is using a mental technique called

a. dissociation.

b. effleurage.

c. imagery.

d. distraction.

c. imagery.

Imagery is a technique of visualizing images that will assist the woman in coping with labor. Dissociation helps the woman learn to relax all muscles except those that are working. Effleurage is self-massage. Distraction can be used in the early latent phase by having the woman involved in another activity. p. 359

The registered nurse explains to the student that when giving a narcotic to a laboring woman, the nurse should inject the medication at the beginning of a contraction so that

a. full benefit of the medication is received during that contraction.

b. less medication will be transferred to the fetus.

c. the medication will be rapidly circulated.

d. the maternal vital signs will not be adversely affected.

b. less medication will be transferred to the fetus.

Injecting at the beginning of a contraction, when blood flow to the placenta is normally reduced, limits transfer to the fetus. The full benefit will be received by the woman; however, it will decrease the amount reaching the fetus. It will not increase the circulation of the medication. It will not alter the vital signs any more than giving it at another time. p. 367

The method of anesthesia in labor considered the safest for the fetus is the

a. pudendal block.

b. epidural block.

c. spinal (subarachnoid) block.

d. local infiltration.

d. local infiltration.

Local infiltration of the perineum rarely has any adverse effects on either the mother or the fetus. The fetus can be affected by maternal side effects of the other types of anesthesia. p. 362

A woman received an epidural anesthetic and now her blood pressure is 88/64 mm Hg. What action by the nurse takes priority?

a. Turn the woman to the left side.

b. Place a wedge under the woman's right hip.

c. Call the provider or nurse-anesthetist immediately.

d. Decrease the intravenous infusion rate.

b. Place a wedge under the woman's right hip.

If hypotension occurs after administration of an epidural, turn the patient to the left lateral side-lying position, and infuse intravenous crystalloids. These actions will improve placental blood flow. Oxygen administration is also recommended, but placing the patient on the left side takes priority. The providers should be notified after corrective actions have occurred. p. 373-Table 18.2

The priority nursing intervention for the patient who has received an epidural narcotic is

a. monitoring respiratory rate hourly.

b. administering analgesics as needed.

c. monitoring blood pressure every 4 hours.

d. assessing the level of anesthesia.

a. monitoring respiratory rate hourly.

The possibility of respiratory depression exists for up to 24 hours after administration of an epidural narcotic. The nurse should monitor the woman's respiratory rate hourly during this time frame. Epidural narcotic should be enough pain relief that further medication is not necessary. Administering any other narcotic may cause an overdose. The patient's blood pressure needs to be monitored. However, that is not the major concern with this medication. The epidural narcotic should provide pain relief but not anesthesia. p. 367

One of the greatest risks to the mother during administration of general anesthesia is

a. respiratory depression.

b. uterine relaxation.

c. inadequate muscle relaxation.

d. aspiration of stomach contents.

d. aspiration of stomach contents.

Aspiration of acidic gastric contents and possible airway obstruction is a potentially fatal complication of general anesthesia. Respirations can be altered during general anesthesia, and the anesthesiologist will take precautions to maintain proper oxygenation. Uterine relaxation can occur with some anesthesia, but this can be monitored and prevented. Inadequate muscle relaxation can be altered. This is not the greatest risk for the mother. p. 367

The student nurse is working with a laboring woman. What action by the student requires the registered nurse to intervene?

a. Placing the woman in a supine position

b. Assisting the woman to a sitting position

c. Turning the woman to a side-lying position

d. Providing safety while the woman labors while standing

a. Placing the woman in a supine position

The supine position allows the heavy uterus to compress the inferior vena cava and can reduce placental blood flow, compromising fetal oxygen supply. The nurse should intervene to position the woman in any of the other positions, which are all appropriate for labor if no contraindications exist. p. 363

A woman had spinal anesthesia for delivery. Now she complains of a pounding headache rated 7/10. What action by the nurse is most appropriate?

a. Prepare to assist with a blood patch procedure.

b. Give the woman IV opioid pain medications.

c. Increase the rate of her nonadditive IV fluids.

d. Place a cool cloth on her forehead and dim the room lights.

a. Prepare to assist with a blood patch procedure.

The subarachnoid block may cause a postspinal headache due to loss of cerebrospinal fluid from the puncture in the dura. When blood is injected into the epidural space in the area of the dural puncture ("blood patch"), it forms a seal over the hole to stop leaking of cerebrospinal fluid. The spinal anesthesia makes further narcotic administration inadvisable at this time. Increasing IV fluid rate is not needed for headache. A cool cloth and dim lights may be very comforting but will not eliminate this severe headache.

p. 373 -Table 18.2

The nurse teaching a childbirth preparation class teaches the participants that the first type of breathing technique used in labor is called

a. slow-paced.

b. modified-paced.

c. patterned-paced.

d. pant-blow.

a. slow-paced.

Breathing for the first stage of labor consists of a cleansing breath and various breathing techniques known as paced breathing. The first type used in labor is the slow-paced. Modified-paced breathing is used when the slow-paced breathing is no longer effective Patterned-paced breathing is used later in the labor and has the woman focusing on a pattern of breathing. Pant-blow breathing can be used to prevent pushing before the cervix is completely dilated. p. 359

When instructing the woman in early labor, the nurse teaches her that an important aspect of proper breathing technique is

a. breathing no more than three times the normal rate.

b. beginning and ending with a cleansing breath.

c. holding the breath no longer than 10 seconds.

d. adhering exactly to the techniques as they were taught.

b. beginning and ending with a cleansing breath.

The cleansing breath helps the woman clear her mind to focus on relaxing and signals the coach that the contraction is beginning or ending. It is important to prevent hyperventilation; however, the cleansing breaths are the most important aspect of the breathing techniques. The woman should hold her breath for no more than 6 to 8 seconds. The woman needs to be flexible and change her breathing techniques as needed to keep her comfortable. p. 359

Which patient is most likely to experience pain during labor?

a. Gravida 2 who has not attended childbirth preparation classes

b. Gravida 2 who is anxious because her last labor was difficult

c. Gravida 1 whose fetus is in a breech presentation

d. Gravida 3 who is using Lamaze breathing techniques

b. Gravida 2 who is anxious because her last labor was difficult

Anxiety affects a woman's perception of pain. Tension during labor causes tightening of abdominal muscles, impeding contractions and increasing pain by stimulation of nerve endings. The gravida 2 has previous experience, and this will decrease anxiety. This woman will have more pain than if the infant is in vertex. Also, there is an increased likelihood that she will have a cesarean section and not go through labor. The gravida 3 has previous experience and has prepared herself for the labor. p. 356

Which type of cutaneous stimulation involves massage of the abdomen?

a. Thermal stimulation

b. Imagery

c. Mental stimulation

d. Effleurage

d. Effleurage

Effleurage is massage usually performed on the abdomen during contractions. Thermal stimulation is the use of warmth to provide comfort, such as showers and baths. Imagery involves the woman creating a relaxing mental scene and dissociating herself from the painful aspects of labor. Mental stimulation occupies the woman's mind and competes with pain stimuli. p. 357

A woman is experiencing most of her labor pain in her back. What action by the nurse is best?

a. Positioning the woman lying supine with head slightly elevated

b. Showing the support person how to apply firm pressure to the sacrum

c. Assisting the woman to sit upright with the legs straight

d. Massaging her upper back during a contraction

b. Showing the support person how to apply firm pressure to the sacrum

Firm pressure against the sacrum may be helpful in relieving the discomfort associated with back labor. The nurse can provide this action, but including the support person (if desired) is beneficial. The woman should not lie on her back. Sitting up with legs straight would put more pressure onto the lower back area. The massage should be in the lower back where the pain is located. p. 358

Which technique could the support person use when the laboring woman appears to be losing control?

a. Have the nurse take over the role of support.

b. Tell the woman that she is causing stress to her baby and herself.

c. Wait for the contraction to end and discuss the problem with her.

d. Make eye contact with the woman and breathe along with her.

d. Make eye contact with the woman and breathe along with her.

Making eye contact and breathing along with the laboring woman to help pace her breathing will assist her in remaining calm. The woman already has a trusting relationship with the support person so they should stay in that position if possible. Telling the woman she is stressing herself and the baby is very uncaring and will not be helpful. A woman who has lost control will not be able to engage in a productive discussion. p. 371

A nurse admits a woman to the labor and delivery unit who has a history of IV drug abuse. In planning care for this patient, the nurse explains to the student that which pain control plan is contraindicated for this woman?

a. Epidural anesthesia

b. Bolus administration of butorphanol (Stadol)

c. Promethazine (Phenergan) for opioid-induced nausea

d. Naloxone (Narcan) if needed for respiratory depression

b. Bolus administration of butorphanol (Stadol)

Women who are opiate-dependent should not receive analgesics having mixed agonist and antagonist actions (butorphanol and nalbuphine). Epidural anesthesia not using these drugs is appropriate as are promethazine and naloxone if needed. Table 18.2

A woman has received an epidural block. What action by the nurse takes priority?

a. Instruct her to call for help when getting out of bed.

b. Assess the woman for a post-procedure headache.

c. Determine type and time of last oral intake.

d. Administer metoclopramide within the first hour.

a. Instruct her to call for help when getting out of bed.

Due to variable leg strength and sensation with an epidural block, the woman who is able to get out of bed needs to call for assistance for safety. Post-procedure headaches are associated with subarachnoid blocks. Oral intake and pro-motility agents are important for the woman having general anesthesia. Table 18.2

What statement by the woman after a childbirth education class demonstrates that she needs more information?

a. "I'm having a pudendal block so control my labor pain."

b. "I may get a headache after a subarachnoid block."

c. "I don't want IV opioids as they may cause breathing problems."

d. "Some anesthetic agents may cause itching but it can be treated."

a. "I'm having a pudendal block so control my labor pain."

A pudendal block numbs the lower vagina and perineum for vaginal birth. There is no relief of labor pain because it is done just before birth. This woman needs further education. The other statements are all accurate. Table 18.2

A woman had an epidural place an hour ago and is now complaining of severe itching. What action by the nurse is most appropriate?

a. Discontinue the epidural infusion at once.

b. Notify the anesthesia provider.

c. Prepare to administer diphenhydramine (Benedryl).

d. Prepare to administer promethazine (Phenergan).

c. Prepare to administer diphenhydramine (Benedryl).

Pruritis (itching) is a common side effect of epidural medications. The nurse should be prepared to administer diphenhydramine. There is no need to discontinue the epidural infusion or notify the anesthesia provider. Promethazine is used for nausea. Table 18.1

While developing an intrapartum care plan for the patient in early labor, it is important that the nurse recognize that psychosocial factors may influence a woman's experience of pain. These include (Select all that apply.) FOUR answers

a. culture.

b. anxiety and fear.

c. previous experiences with pain.

d. intervention of caregivers.

e. support systems.

a. culture.

b. anxiety and fear.

c. previous experiences with pain.

e. support systems.

Culture: a woman's sociocultural roots influence how she perceives, interprets, and responds to pain during childbirth. Some cultures encourage loud and vigorous expressions of pain, whereas others value self-control. The nurse should avoid praising some behaviors (stoicism) while belittling others (noisy expression). Anxiety and fear: extreme anxiety and fear magnify sensitivity to pain and impair a woman's ability to tolerate it. Anxiety and fear increase muscle tension in the pelvic area, which counters the expulsive forces of uterine contractions and pushing efforts. Previous experiences with pain: fear and withdrawal are a natural response to pain during labor. Learning about these normal sensations ahead of time helps a woman suppress her natural reactions of fear regarding the impending birth. If a woman previously had a long and difficult labor, she is likely to be anxious. She may also have learned ways to cope and may use these skills to adapt to the present labor experience. Support systems: an anxious partner is less able to provide help and support to a woman during labor. A woman's family and friends can be an important source of support if they convey realistic and positive information about labor and delivery. Although this may be necessary for the well-being of the woman and her fetus, some interventions add discomfort to the natural pain of labor (i.e., fetal monitor straps). p. 356

The nurse is caring for a laboring patient who develops a fever after she has had her epidural initiated. What actions by the nurse are appropriate? (Select all that apply.) TWO answers

a. Palpate the woman's bladder distention.

b. Assess the woman's blood pressure.

c. Observe the woman for shivering.

d. Check the skin for color and warmth.

e. Prepare to assist with a blood patch.

c. Observe the woman for shivering.

d. Check the skin for color and warmth.

Heat dissipation is reduced as a result of decreased hyperventilation, sweating, and activity after the onset of pain relief. Vasodilation redistributes heat from the core to the periphery of the body, where it is lost to the environment. Assessing the skin will demonstrate findings consistent with vasodilation. Shivering often occurs with sympathetic blockade accompanied by a dissociation between warm and cold sensations. In essence, the body believes that the temperature is lower than it actually is and turns up the "thermostat." Bladder distention is an anticipated effect of having an epidural. A woman's bladder fills quickly because of the large quantity of IV solution, yet her sensation to void is reduced. Maternal hypotension is an expected side effect of epidural initiation. The nurse should assess the bladder and blood pressure, but these actions are not related to the fever. A blood patch procedure is not warranted for this patient. p. 364

A newborn infant weighing 8 lb needs naloxone (Narcan). This infant should receive approximately _____ mg.

0.36

The dose of naloxone is 0.1 mg/kg. This baby weighs 3.6 kg, so 0.1 ´ 3.6 = 0.36 mg. Table 18.1