Chapter 18: Comfort Measures During Labour and Birth

Lithotomy. Going against gravity

Worst positioning for birth

1. endorphins

2. culture

3. anxiety and fear

4. past experiences

5. suportive care

6. environment

Factors influencing pain/discomfort in labour: (6)

endorphins

Natural endogenous opioids. High levels during labour and birth, lower if they have been medicated

Beta-endorphins

endogenous opioids secreted by the pituitary gland that act on the central nervous system to reduce pain/

Produces catecholamines, increases stimuli to the brain from the pelvis because of decreased blood flow and muscle tension. Muscle tension increases, effectiveness of uterine contractions decreases, and discomfort continues.

How do fear and anxiety slow the progression of labour?

1. Nulliparous: greater pain during early latent labout because reproductive tract is less supple. Less pain during active phase and second stage because baby is descending slower. Labour is longer and may experience more fatigue (magnifying pain_

2. Multiparous: less pain during early stages, more pain during later because baby is descending faster.

How does parity influence labour pain?

• Provide companionship and reassurance.

• Offer positive reinforcement and praise.

• Encourage participation in distracting activities and nonpharmacological measures for comfort.

• Encourage fluid intake.

• Provide nourishment if possible.

• Assist with personal hygiene.

• Offer information and advice.

• Ensure the patient is the primary decision maker regarding their care.

• Interpret the patient’s wishes to other health care providers and to their support group.

• Create a relaxing environment.

• Use a calm and confident approach.

• Support and encourage the patient’s family members by role modelling labour support measures and providing time for breaks.

Suggested measures for supporting a patient in labour [12]

Dick-Read method

Method for child-birth preparation that focuses on the idea that pain in childbirth is socially conditioned and caused by a fear-tension-pain syndrome.

Hypnobirthing

Childbirth preparation method where pregnant patients (couples) learn how the birthing muscles work when the patient is in a state of relaxation. The aim is for the patient to be in a state of relaxation

The Bradley Method

Childbirth preparation method that uses partner-coached childbirth, breath control, abdominal breathing, and general body relaation. Working in harmony with the body is empasized. Emphasizes darkness, solitude, and quiet to make it a natural experience.

Birthing from within

Childbirth preparation method where mentors (Teachers) believe that childbirth is not a medical event but a rite of passage. Parents are taught the power of birthing-in-awareness. Birth is taught from four perspectives: mother, partner, baby, culture

Childbirth and Postpartum Professional Associatio (CAPPA)

Nonprofit international organization that provides professional membership and training to antepartum doulas, postpartum doulas, and lactation educators. They are proponents of evidence-informed practice in childbirth education

Lamaze Method

Childbirth preparation method that has core values that include: care for normal pregnancy and birth should be removed from total control of doctors, be based on the use of approrpriate technlogy (as opposed to overuse) and be evidence-informed, regionalized, multidisciplinary, holistic, family-centered, and culturally appropriate

relaxation

Reduces body tension, can help couples with the stresses of pregnancy, childbirth, and adjustment to parenting. Combined often with walking, slow dancing, rocking, and position changes to help baby rotate through the pelvis.

stimulates mechanoreceptors in the brain which decreases pain perception.

How does rhythmic motion help with pain management?

imagery and visualization

Techniques used to purposely direct thoughts to relieve stress and provide a sense of relief. Can produce a sense of well-being, assist with cervical dilation, and decrease pain and tension during labour. Imagine walking though a relaxing place, visualizing baby coming down the birth canal..

Music

Can provide a distraction, enhance relaxation, lift spirits, and reduce patient’s level of stress and anxiety and perception of pain. Creates a more relaxed atmosphere. Can facilitate guided imagery and release of endorphins.

Therapeutic touch

Based on the concept of energy fields within the body called prana, thought to be deficient in some people who are in pain.

head, hand, back, shoulder, and foot massage. Can be relaxing in advanced labour when hyperesthesia limits a patient’s tolerance for touch

What kinds of massage may be effective in reducing tension and enhancing comfort in labour?

Hyperesthesia.

In advanced labor, limits a patient’s tolerance for touch. means baby is coming soon.

using varying breathing techniques to provide distraction, thereby reducing the perception of pain and helping the patient maintain control throughout contractions.

In first stage, breathing promotes relaxaion of the abdominal muscles and icnreases size of the abdominal cavity.

Relaxed genital area helps with fetal descent

Second stage, increases abdominal pressure and assist with expelling the detus

How can breathing decrease pain and help with labour? [4]

Paced breathing

Breathing most associated with prepared childbirth and includes slow-paced, modified-paced, and patterned-pace (pant-blow) breathing techniques.

1. cleansing breath

2. Slow-paced breathing (8-10 bpm)

3. modified-paced (32-40 bpm)

4. patterned-paced breathing /pant-blow (enhances concentration through contractions)

Conscious breathing techniques: [4]

effleurage

Light stroking, usually of the abdomen, often in rhythmic with breathing during contractions. It is used to distract patient from the pain.

Counterpressure

A steady pressure by support person to the sacral area with a firm object of the heel of the hand. Pressure can also be applied with both hips or to the knees. Helps cope with sensations of internal pressure or pain in lower back. Lifts the occiput off nerves, providingpain relief

Water immersion

Specific form of hydrotherapy that involves immersion of the labouring patient in water deep enough to completely cover the abdomen. Increases buoyancy and provides weightlessness and preedom of movement

Transcutaneous electrical Nerve stimulation (TENS)

Involves placement of two pairs of flat electrodes on either side of the labouring patient’s sacral spine. Provides continuous low-voltage electrical impulses or stimuli from a handheld device. increasing stimulation from low to high during contractions to facilitate release of endorphins.

Hypnosis

a form of deep relaxation, similar to daydreamng or meditaion. The subconscious mind can be mroe easily accessed. Places an emphasis on enhancing relaxation and diinishing fear, anxiety, and perception of pain.

Aromatherapy

Highly concentrated essential oils used to promote health and to treat and balance the mind, body, and spirit. Can evoke pleasant memories or feelings of love and security.

Intradermal sterile water block

Injection of sterile water with a fine needle into four locations on the lower back to relieve low back pain. Can relieve pain for up to two hours.

Ho-Ku acupressure poin

Point on back of hand where thumb and index finger come together used to enhance uterine contractions without increasing pain

Sedatives

Medications used to relieve anxiety and induce sleep. Given to a patient experiencing prolonged latent phase, or when there is a need to decrease anxiety o promote sleep

Benzodiazapemes

Sedative that, when given with opioid analgesic, seems to enhance pain relief and reduce nausea and vomiting

Disrupts thermoregulation in newborns

Major disdvantage of benodiazapemes for newborns:

Analgesia

refers to the alleviation of the sensation of pain or raising the threshold for pain perception without loss of consciousness

Provide adequate pain relief without increasing risk to either patient or fetus, or affecting the process of labour

Ideal obstetrical analgesic or anaethetic should:

Anaesthesia

Encompasses analgesia, amnesia, relaxation, and reflex activity. Abolishes pain perception by interupting the nerve impulses in the brain. Loss of sensation may be partial or complete, sometimes with loss of consciousness.

Delayed gastric emptying of solids. Opioid analgesics can further delay.

Why shouldn’t patients eat solid foods once they are in established labour?

1. systemic analgesia

   1. opioid agonist analgesics

   2. opioid antagonist analgesics

2. epidural (block) analgesia

3. combined spinal-epidural analgesia

4. nitrous oxide

Medications used in first stage of labour: [4]

1. Nerve block analgesia/anaesthesia

   1. Local infiltration anaesthesia

   2. Pudendal block

   3. Epidural (block) analgesia and anaesthesia

   4. Spinal (block) anaesthesia

   5. CSE analgesia and anaesthesia

2. nitrous oxide

Medications used for second stage of labour [7]

Patient Controlled Analgesia (PCA)

Patient self-administers small doses of opioid analgesic intravenously by using a pump programmed for dose and frequency. Overall, a lower amount of analgesic is used

Opioids provide sedation and euphoria, but their analgesic effect is limited. The pain relief is incomplete, temporary, and more effective in early labour.

how do opioids affect labour?

Respiratory depression. Others include sedation, N+V, dizziness, altered mental status, decreased gastric motility and emptying, and urinary retention.

More serious opioid adverse effect:

1. absent or minimal FHR variability

2. significant newborn respiratory depression requiring treatment after birth

Effects of opioids on fetus/newborn (because opioids cross the placenta)

1. opioid agonists

2. opioid agonist-antagonists

Classifications of analgesic drugs used to relieve the pain of childbirth include : [2]

local perineal infiltration anesthesia

This may be used when an episiotomy is to be performed, or when lacerations must be sutured after birth in a patient with no regional anesthesia.

10 to 20mL of 1% lidcodain into the skin and the subcutaneously into the region to be anesthetized. Epinephrine is often added to intensify the anesthesia and prevent excessive bleeding

How is local infiltration anesthesia administered?

Pudenal nerve block

administered late in the second stage of labour, useful if an episiotomy is eing performed or if forceps or a vacuum extractor is to be used (in a patient without epidural). Relieves pain in lower vagina, vulva, and perineum

spinal block

anesthetic solution is injected into subarachnoid space where it mixes with CSF. Commonly used for c-sections.

large bore needle is inserted to the epidural space, between the fourth and fifth lumbar vertebrae to block from T10 to S5. A catherter is inserted and secured, and a small amount of medication is injected to ensure that the catheter has not been palced into the subarachnoid (spinal) space or a blood vessel

Where is epidural administered?

T8 to S1

A spinal block blocks from which vertebrae?

Sit with back curved or assume lateral recumbent position with shoulders parallel, legs flexed slightly, and back arched.

How do patients position to receive an epidural or spinal block?

so the uterus does not compress the ascending vena cava or aorta. Switch sides every hour (minimum)

why should patients lie on their side after receiving epidural?

• The patient remains alert and is more comfortable and remains able to participate in the birth.

• Good relaxation is achieved.

• Airway reflexes remain intact.

• Motor paralysis is mild.

• Gastric emptying is not delayed.

The advantages of an epidural block include the following: [5]

Hypotension

Local anaesthetic toxicity

Lightheadedness

Dizziness

Tinnitus (ringing in the ears)

Metallic taste

Numbness of the tongue and mouth

Bizarre behaviour

Slurred speech

Convulsions

Loss of consciousness

High or total spinal anaesthesia

Fever

Urinary retention

Pruritus (itching)

Limited movement

Longer second-stage labour

Increased use of oxytocin

Increased likelihood of forceps- or vacuum-assisted birth

Postdural puncture headache

Potential Adverse Effects of Epidural and Spinal Anaesthesia [21]

Postdural puncture headache, aka Spinal headache

Puncture of the dura mater during spinal incision and inadvertent puncture during epidural insertion may cause leakage of CSF from site. Causes this:

Nitrous oxide

Inhaled anesthetic gas. can be used during first and second stages of labour and can be used in combination with other pain relief methods. Can reduce the percepion of pain, causes feelings of euphoria and decreases anxiety

Explanation of the alternative methods of analgesia and anaesthesia available

• Description of anaesthetic, including its effects and procedure for its administration

• Description of the benefits, discomfort, risks, and consequences for the labouring patient and the fetus

• Explanation of how complications can be treated

• Information that the anaesthetic is not always effective

• Indication that the patient may withdraw consent at any time

• Opportunity to have any questions answered

• Opportunity to have components of the consent explained in the patient’s own words

all information to give when gaining informed consent: [8]