Exam 9: OB Discomfort
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| Childbirth Pain | -Differs from other types of pain
-Four Sources of Pain in most labors
-Excessive pain can heighten fear and anxiety
-Poorly relieved pain lessens the pleasure
-Many factors influence perception and tolerance
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| Delivery Presentation | The position of the presenting part of the fetus (head, feet, etc.) as it comes out of the birth canal.
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| When does the end of labor pain occur? | With the birth of the baby.
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| How does childbirth pain differ from other types of pain? | There is a great result at the end of pain. It is not usually associated with illness or injury.
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| Non-Pharmacological Pain Management | Can help with uncontrolled pain.
Hydrotherapy.
Mental Stimulation.
Breathing Techniques.
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| Non-Pharmacological Pain Management: Application Techniques | Relaxation
Environmental
Cutaneous
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| What application of non-pharmacologic techniques can be applied during labor? | Relaxation/Stimulation
Environmental Comfort
Cutaneous Stimulation
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| What is the goal of second stage breathing? | assist the mother to respond to her urge to push rather than pushing once her cervix is completely dilated without the urge.
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| Nursing Interventions in Nonpharmacological Management | Work with what patient knows
Promote relaxation
Minimize outside sources of discomfort
Provide accurate information
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| Guide mothers through techniques: | Massage
Mental stimulation
Breathing
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| Pharmacological Pain Management | Medicating a pregnant woman involves several areas that must be considered
Given when labor is well established
Limit choices
Interactions
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| Pharmacological Pain Management: Includes | Systemic drugs
Regional pain management
General anesthesia
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| Regional Pain Management: Types | Epidural Block
Intrathecal Opioids Analgesics
Subarachnoid (spinal) Block (SAB)
Systemic Drugs
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| Epidural Block | regional anesthesia by injection into the epidural space, either between the vertebral spines, in the cervical, thoracic, or lumbar region, or into the sacral hiatus, which is also called caudal block
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| General Anesthesia | Produces loss of sensation & consciousness
Not recommended for uncomplicated vaginal birth
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| General Anesthesia: Adverse Effects | Maternal aspiration
Respiratory depression in both mother and fetus
Possible hemorrhage since general anesthesia yields uterine smooth muscle relaxation
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| General Anesthesia: Reduce risk of maternal aspiration | Reduce/restrict intake
Pre-op Meds:
Citric acid (Bicitra)
Ranitidine (Zantac)
Glycophyrrolate (Robinul)
Metoclopramide (Reglan)
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| When can pharmacologic techniques begin? | Pain is subjective. it is dependant on the patient.
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| If an epidural or subarachnoid block is given, what should the nurse observe for? | Vital Signs.
Fetal Heart Rate.
Any S/S of side effects.
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| Four sources of labor pain in most labors: | -Dilation & stretching of the cervix.
-Tissue Ischemia (Blood supply to uterus decreases during contractions, leads to tissue hypoxia & anerobic metabolism).
-Pressure and pulling from pelvis.
-Stretching of vagina and perineum.
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| The Effects of excessive catecholamines are: | 1. Reduce blood flow to and from the placenta which restricts fetal oxygen supply and waste removal.
2. Reduced effectiveness of uterine contractions, slowing labor progression.
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| Factors that influence the perception and tolerance of pain: | -Cervical readiness.
-Pelvis (size & shape)
-Labor intensity
-Fatigue
-Fetal Position
-Interventions of care givers
-Psychological factors
-Previous Experience
-Childbirth education
-Anxious partner.
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| Pain: Cervical Readiness | the cervix normally undergoes changes that facilitate effacement and dilation prior to the beginning of labor. If this does not happen or is incomplete, more contractions are needed to achieve dilation and effacement.
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| Pain: Pelvis | the size and shape significantly influence how readily the fetus can descend through it which influences the course and length of labor.
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| Pain: Labor Intensity | short, intense labor often causes more pain than labor that is more gradual because each contraction does so much work (effacement, dilation and fetal descent).
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| Pain: Fatigue | reduces pain tolerance and ability to use coping skills. An extremely fatigued woman may have an exaggerated response to contractions or she may be unable to respond to the urge to push.
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| Pain: Fetal Position | labor is more likely to be longer and more uncomfortable if the fetus is in an unfavorable position for delivery.
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| Pain: Intervention of Care Givers | also cause a certain amount of discomfort to a laboring woman, even though they may be intended to promote maternal and fetal safety.
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| Interventions of Care Givers | Inserting IV lines.
Continuous fetal monitoring.
Induction of labor b/c contractions peak intensely quickly.
Vaginal examinations.
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| Pain: Psychological Factors | Culture with influences on women and pregnancy.
Anxiety and fear can inhibit learning coping methods.
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| Pain: Previous Labor Experience | -Pain experiences other than Labor may have provided positive coping skills that could increase ability to cope with pain of labor.
-Previous births, a woman who had a long and difficult labor may be more apprehensive during her present labor.
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| Pain: Preparation for Childbirth | childbirth education should prepare a woman realistically for pain and for reasonable expectations about analgesia and anesthesia.
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| Pain: Anxious Partner | less able to provide the support and reassurance that a woman needs during labor.
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| Non-Pharmacological Pain Management: Relaxation/Stimulation | it promotes blood flow to the uterus improving fetal oxygenation, efficient uterine contractions, reduces tension that increases pain perception and decreases tension
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| Non-Pharmacological Pain Management: Environmental Comfort Measure | Reduce irritants
Music and imagery
Promote general comfort
Reduce anxiety and fear (normality of childbirth)
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| Non-Pharmacological Pain Management: Cutaneous stimulation Combination | Self Massage
Massage by others
Counterpressure
Touch (holding hands)
Thermal Stimulation
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| Non-Pharmacological Pain Management: Hydrotherapy | thermal stimulation via a shower, tub bath or whirlpool
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| Non-Pharmacological Pain Management: Mental Stimulation | the woman’s mind and competes with pain stimuli.
-Imagery
-Focal Point
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| Non-Pharmacological Pain Management: Breathing Techniques | patterns and progress to more complex ones as the labor progresses
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| Breathing Techniques: First Stage Breathing | all patterns start and end with a cleansing breath, which is a deep inspiration and expiration
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| First Stage Breathing: Types | Slow-Paced Breathing
Modified-Paced Breathing
Combined Slow-paced & Modified-Paced
Patterened-Paced Breathing
Breathing to Prevent Pushing
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| Slow-Paced Breathing | starts with cleansing breath then breathes slowly, about half her unusual rate, ending with a second cleansing breath at the end of the contraction. The woman should focus on relaxing her body versus the breathing rate.
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| Modified-Paced Breathing | cleansing breath then breathes rapidly and shallowly, no faster than twice her usual respiratory rate, during the peak of the contraction, ends with a cleansing breath. The focus continues to be on releasing tension
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| Combined Slow-Paced & Modified-Paced | cleansing breath then begins with slow paced breathing at the first of the contraction, switching to faster breathing during its peak, ends with a cleansing breath. During labor, women naturally do this breathing pattern.
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| Patterned-Paced Breathing | cleansing breath then during the contraction, the woman takes rapid breaths punctuated with an intermittent slight blow, often called pant-blow, or "hee hoo" breathing.
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| Breathing to Prevent Pushing | technique used whereby the woman blows repeatedly, using short puffs when the urge to push is strong. This helps to prevent the woman from pushing before the cervix is completely dilated.
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| Breathing Techniques: Second Stage Breathing (Goal) | assist the mother to respond to her urge to push rather than pushing once her cervix is completely dilated without the urge.
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| Breathing Techniques: Second Stage Breathing (Lengthy Pushing) | results in maternal fatigue, more births by caesarean section and nonreassuring fetal heart rate patterns.
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| Breathing Techniques: Second Stage Breathing (Prolonged Breath holding) | (greater than 8 seconds) causes recurrent increases in intrathoracic pressure with a resulting fall in cardiac output and blood pressure. This causes less blood flow to the placenta which results in fetal hypoxia.
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| Breathing Techniques: Second Stage Breathing (Open-glottis Pushing or Limited Breath) | holding to under 8 seconds promotes the best fetal oxygenation.
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| OB Discomfort Nursing Interventions | Massage
Mental Stimulation
Breathing
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| OB Discomfort: Pharmacological Pain Management (definintion) | administration of systemic drugs, regional pain management techniques and general anesthesia.
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| OB Discomfort: Pharmacological Pain Management (Maternal Physiological Alterations) | Cardiovascular Changes.
Respiratory Changes.
Gastrointestinal Changes.
Nervous System Changes.
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| Epidural Block | a popular block that provides analgesia and anesthesia for labor and birth without sedation of the woman and fetus.
(a) A local anesthetic agent usually combined with an opioid is injected into the epidural
space.
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| Epidural Block Contraindications | 1)Coagulation defects.
2)Uncorrected hypovolemia.
3)Infection in the area of insertion.
4)Severe systemic infection.
5)Allergy.
6)Fetal condition that demands immediate birth.
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| Intrathecal Opioids Analgesics | provide another option for pain management without
sedation.
(a) The drug is injected into the subarachnoid space where it binds to opiate receptors
and provides pain relief.
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| Subarachnoid (spinal) Block (SAB) | local anesthetic is injected into the subarachnoid
space in a single dose. Appearance of CSF at needle hub assures correct placement.
The woman loses both sensory and motor function below the level of the block
with relief of pain from contractions.
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| Parenteral Analgesia | opioids analgesics are the most common parental medications.
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| Parenteral Analgesia (Commonly used Drugs) | Meperidine (Demerol).
Fentanyl (Sublimaze).
Butorphanol (Stadol).
Nalbuphine (Nubain).
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| OB Discomfort: General anesthesia | produces loss of sensation and loss of consciousness. It is seldom indicated for uncomplicated vaginal births, but it still has a place in cesarean births. Emergency Situations.
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