Pain Management of the Laboring Woman

Labor pain is...

Individual and subjective!

Types of pain

Visceral pain, referred pain, and somatic pain

Visceral pain description

Dull and aching

Visceral pain results from...

The activation of nociceptors of the thoracic, pelvic, or abdominal viscera (organs)

Visceral structures

Are highly sensitive to distention (stretch), ischemia, and inflammation

Description of somatic pain

Sharp, burning, prickling

Somatic pain AKA

Skin, tissue, or muscle pain

Nerves that detect somatic pain

Are in the skin and deep tissues

Pain during labor and birth

Shaped by past experiences

Assessing pain -- physiological & psychological indicators, patient responses, and may be intensified by fear, anxiety, fatigue

How is labor pain different from other types of pain?

It is not a symptom of injury or illness

It only lasts a certain amount of time

It is predictable

It intensifies gradually over time

Significance of difference of labor pain from other kinds of pain

Makes coping easier!

Labor pain is not a symptom of injury or illness -- nursing implications

We often associate pain with something being wrong, which can increase a laboring woman's anxiety

Must remind her that labor pain she is feeling is normal and is a sign that her body is working hard and well

Labor pain only lasts a certain amount of time -- nursing implications

Once active labor begins, the process rarely takes more than 24 hours

Labor pain is predictable -- nursing implications

Contractions last up to 90 secs and come in a regular pattern, followed by a few pain-free minutes in between them -- laboring woman can predict and prepare for each contraction and rest between them

Labor pain intensifies over time -- nursing implications

Contractions almost always start off mild and gradually grow longer, stronger, and closer together -- gives laboring woman time to adapt

Pain perception and expression

Highly personal and subjective

Affected by gender, culture, ethnicity, and past experiences

Physiological/affective expression

Physiological/affective expression of pain

Increased catecholamines

Increased BP, HR, and temp

Altered resp pattern

Factors affecting maternal pain response

Physical (PAIN)

Physiological

Psychological -- anxiety, fear, previous experience, ability to cope support systems, childbirth prep

Environmental

What does PAIN stand for?

Purposeful

Anticipated

Intermittent

Normal

Locations of pain for physical aspects

Lower abd pain during contractions

Low back pain, either w/ contractions, or less often, continuously

Pain throughout the belly, in the hips, buttocks or thighs, or in some combo of these locations

Pain that moves from front to back, back to front or down the thighs

Pain that is felt in several areas at or just in one specific place

Word women use to describe labor pain

Cramping, sharp, aching, throbbing, pressing, and shooting

Physiological aspects of pain

During labor, there is an increase in endorphins, acting as the body's natural pain relief

Research shows that massage may stimulate endorphin production in the brain

Gate-control theory

Gate-control theory proposes that there is a gating mechanism involved in transmission of pain impulses to the cerebral cortex (affects level of pain awareness)

Using massage, focal point, relaxation, and pattern breathing closes a gate to prevent other impulses from being interpreted as the primary message, allowing for a degree of pain relief

Environmental aspects of pain

Loud noises, on-going interruptions, bright lights, restricted movement, and limited privacy can intensify a woman's pain during labor

Impact of pain on processes in the body

Increased stress --> increased oxygen consumption, hyperventilation, increased autonomic activity, increased endorphin release, increased ACTH & cortisol release, increased ADH release

Impact of hyperventilation during pain

Respiratory alkalosis --> metabolic acidemia --> fetal acidosis

Hypocalcemia --> disorientation, paresthesia, tetany

Impact of increased autonomic activity during pain

Increased PVR, CO, BP

Impaired uterine contractions

Increased catecholamines --> impaired uterine contractions, increased gastrin release & increased gastric acidity, decreased placental perfusion & fetal acidosis

Pain pathways of birth

Gate-control theory suggests that spinal cord contains neurological gate that either blocks pain signals or allows them to continue to the brain

In times of anxiety or stress, descending messages from the brain may amplify the pain signal at the nerve gate as it moves up the spinal cord, intensifying pain

Non-pharm pain relief measures

Maternal position & movement

Vocalization

Breathing techniques

Biofeedback, TENS, intradermal water block

Application of heat and cold

Acupressure/acupuncture

Relaxation techniques

Breathing techniques for non-pharm pain relief

Rhythmic breathing develops body awareness and improved oxygenation

The relaxation and oxygenation help reduce pain perception

Relaxation techniques for non-pharm pain relief

Music, guided imagery

Massage and touch -- effleurage, counter pressure, therapeutic touch, healing touch

Hydrotherapy, hypnotherapy, aromatherapy

Pharm choices for pain relief

Nitrous oxide

Epidural

Spinal

Combined spinal/epidural

Pudendal

Local

General

IV analgesics

Nitrous oxide

Self-admin for labor analgesia

Onset takes about a min and lasts about a min

Not readily available at all facilities

IV analgesics

Opioid agonist -- morphine

Opioid agonist-antagonist -- Stadol and Nubain

Opioid antagonist

naloxone (Narcan) --> rescue med for IV opioids

Epidural block consists of

Fentanyl and bupivacaine -- provide pain relief from contractions/birth

Impact of epidural on fetal resp pattern

No fetal resp depression at delivery!

Complications/side effects of epidural block

Maternal hypotension & fetal bradycardia

Maternal postpartum back pain

Spinal HA

Limited mobility d/t sympathetic blockage

Positional effects (one-sided numbness)

Accidental injection into blood vessel

Urinary retention, bladder distention

Lab consideration w/ epidural block

Platelets MUST be above 100,000

Management of maternal hypotension w/ epidural block

Prevent by preloading w/ IVF

Requires constant nursing surveillance

IVF bolus to prevent maternal hypotension w/ epidural block

500-1000 mL bolus is given prior to epidural insertion

Nursing surveillance for maternal hypotension following epidural

Maternal BPs every min during admin of loading dose

On-going BP monitoring q15 min while in place

Spinal nerve block

Spinal anesthesia block, AKA a spinal -- used for C/section

Complications of a spinal

Maternal hypotension, decreased placental perfusion, ineffective breathing pattern

Duramorph

Given as part of nerve block before c/s or before epidural is removed after c/s

Duration of Duramorph

Lasts 12-18 hours

Considerations w/ other drugs when using Duramorph

Pt can have no other opioids but it is usually paired with ketorolac (Toradol) 30 mg IVP q6h x 3 doses

General anesthesia

Major risks for woman and fetus

Preop prep

Intubation required

PACU nursing care --> cardiac monitoring, continuous VS, PCA pump set up and admin

Pre-op prep for general anesthesia

Patient interview and consent

IV admin

Assessment of mouth/teeth and airway

Major risks of general anesthesia include

Maternal hyperoxia (too much O2 can be toxic to the CNS; seizures/coma)

Maternal hypercapnia which can lead to fetal acidosis (excessive CO2 in the bloodstream d/t inadequate respiration)

Maternal uterine vasoconstriction and reduce uterine blood flow, which could lead to decreased fetal perfusion

Nursing care r/t comfort measures

Ongoing and collaborative assessment

Individualized and patient-centered plan of care that is modified PRN ad uses a collaborative approach

Potential nursing diagnoses for the laboring woman

Anxiety

Ineffective coping

Acute pain

Disturbed sleep pattern