Nursing Role in Providing Comfort During Labor and Birth PDF

THE NURSING ROLE IN PROVIDING COMFORT DURING LABOR AND BIRTH NCM 107 CHAPTER 16 Experience of Pain During Childbirth Pain accompanies labor contractions for several different reasons and manifests in different ways for each person  ETIOLOGY OF PAIN DURING LABOR AND BIRT...

THE NURSING ROLE IN PROVIDING COMFORT DURING LABOR AND BIRTH NCM 107 CHAPTER 16 Experience of Pain During Childbirth Pain accompanies labor contractions for several different reasons and manifests in different ways for each person  ETIOLOGY OF PAIN DURING LABOR AND BIRTH 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.  ETIOLOGY OF PAIN DURING LABOR AND BIRTH Pain also results from stretching of the cervix and perineum. This phenomenon is similar to 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 laboring person feels the urge to push, pain from the contractions often disappears as long as they are actively pushing, until the fetal presenting part causes a final stretching of the perineum.  ETIOLOGY OF PAIN DURING LABOR AND BIRTH Additional discomfort in labor may stem from the pressure of the fetal presenting part on tissues, including pressure of surrounding organs, such as the bladder, the urethra, and the lower colon 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, 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 PHYSIOLOGY OF PAIN 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. PHYSIOLOGY OF PAIN 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. PHYSIOLOGY OF PAIN 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 about pain relief in labor. 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 experienced during contractions differs according to a person’s expectations of and preparation for labor; the length of labor; the position of the fetus; the presence of fear, anxiety, worry, body image, and self-efficacy; and the availability of meaningful people to offer support. As a rule, those who believe they can control their situation (have self-efficacy) are more apt to report a satisfactory birth experience that those who do not feel in control PERCEPTION OF PAIN Fetal position is a physical variable that influences the degree of pain experienced. If the fetus is in an occiput posterior position, intense or nagging back pain is often present, even between contractions, much more than if a fetus is in an occipitoanterior position 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 patients with information so that they can choose how to best relieve pain during labor within the limits of medical safety. Comfort and Nonpharmacologic Pain Relief Measures Nurses play a key role in educating patients about the numerous comfort and pain relief strategies available and making sure they understand the choices available to them along with the benefits and risks. Throughout their decision-making process, patients need support for their choices so that they can feel confident in the method they choose.  SUPPORT FROM A DOULA OR COACH A doula is a person who is experienced in childbirth and postpartum support. These support people (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 person’s self-esteem, speed the labor process, and improve breastfeeding success as well as decrease rates of oxytocin augmentation, epidural anesthesia, cesarean birth, and postpartum COMPLEMENTARY AND ALTERNATIVE THERAPIES 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, acupuncture, massage, position changes, imagery, and other relaxation techniques. Relaxation 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, an individual cannot concentrate on pain. Asking a patient to bring favorite music or aromatherapy with them to enjoy in the birthing room can help with relaxation 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 For this technique, a person uses a photograph of someone important to them or some setting they find appealing such as a beautiful sunset. They concentrate on the photo during contractions (focusing). A laboring person 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 contraction all of which help prevent them from concentrating on the pain of contractions. Do not ask questions or talk while a person is using focusing, imagery, or chanting because that is apt to break the concentration and let the sensation of pain intrude. Breathing Techniques Breathing patterns are taught in most preparation for childbirth classes and are well documented to decrease pain in labor. They are largely distraction techniques because a person concentrating on slow-paced breathing cannot concentrate on pain. Stay with the patient until they incorporate the slow-paced breathing and feel 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 (frozen 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, an herb that induces uterine contractions, is not recommended because Black of the risk of acute toxic effects such as cohosh cerebrovascular accident to the laboring  Aromatherapy and Essential Oils Aromatherapy is the use of aromatic oils to complement emotional and physical well-being. 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 may be used in a mister so that they are inhaled and then carried throughout the body. The effects of aromatherapy can range Heat or Cold Application Laboring people 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. Caution patients 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. Heat or Cold Application Individuals 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. 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. The temperature of water used should be 98.6°F (37°C) to prevent hyperthermia of the patient and also the newborn at birth. Bathing or Hydrotherapy Remind laboring patients that plastic or porcelain tubs are slippery, so they should ask for help stepping into and out of them. Do not leave individuals unsupervised in a tub as they could slip and have difficulty getting their head above water. A support person can join the laboring person in a tub or shower if they wish and can continue with back massage or other measures that are soothing. Timing of contractions, auscultation of fetal heart rate (FHR), and vaginal examinations can all be done without the patient needing to leave the water. 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. Therapeutic Touch and Massage Effleurage, the technique of gentle abdominal massage often taught with Lamaze in preparation for childbirth classes, is a classic example of therapeutic touch Reiki is another practice many believe can promote healing. The term Reiki consists of two Japanese words, rei and ki, which together can be translated to mean “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. 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. Therapeutic Touch and Massage 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 find massage, especially of the lower back or feet, helpful in the first and second stages of labor  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 10/2/2024 through the release of endorphins. Yoga and Meditation Meditation is a self-directed practice for relaxing the body and calming the mind. Transcendental meditation ™ 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. Individuals can meditate in any position. Do not interrupt a laboring patient using meditation as a pain relief technique to avoid breaking their concentration.  Reflexology Reflexology is the practice of stimulating the hands, feet, and ears as a form of therapy. 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 A person who wants to use this modality needs to meet with a hypnotherapist during pregnancy. At these visits, the patient is evaluated for and conditioned to susceptibility to hypnotic suggestion. Close to the last weeks of pregnancy, they are given a posthypnotic suggestion that they will experience a reduction in or absence of pain during labor. Fully awake and able to participate in labor, the person who is susceptible to hypnotic suggestion may find that this may provide a very satisfactory and drug-free method of pain relief. If labor starts before the posthypnotic suggestion was given, a person using this method may be very disappointed to find themselves in labor without the help they envisioned Biofeedback Biofeedback is based on the belief that people have control over and can regulate internal events such as heart rate and pain responses. Those 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 ability to relax. Evidence that shows biofeedback is an effective method for reducing the pain of labor is continuing to emerge Transcutaneous Electrical Nerve Stimulation Transcutaneous electrical nerve stimulation (TENS) works to relieve pain by applying counterirritation to nociceptors. When two pairs of electrodes are attached to a person’s back to coincide with the T10 through L1 nerve pathways, low-intensity electrical stimulation is given continuously or is applied by the individual themselves 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.  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 Although some people find the technique helpful, there is little evidence as to its effectiveness; others 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  Acupuncture and Acupressure 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 labor is Co4 (Hoku or Hegu point), which is located between the first finger and thumb on the back of the hand. Individuals in labor may report that 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 anxiety as well as the length of labor when specific pressure points are used 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 during labor and birth. After giving birth, birthing parents had difficulty believing the birth was over and that the infant was their child. PHARMACOLOGIC MEASURES FOR PAIN RELIEF DURING LABOR 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 the pain sensation. For the best results, be certain that patients are included in the selection of these methods and understand any fetal effects or side effects that might occur. PHARMACOLOGIC MEASURES FOR PAIN RELIEF DURING LABOR 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 both the patient’s and fetal responses to the administration of systemic medication. Be sure to caution patients not to take acetylsalicylic acid (aspirin) for pain in labor as aspirin interferes with blood coagulation, increasing the risk of bleeding in the newborn or themselves. In addition, the manufacturers of pain relief patches such as Salonpas, Absorbine Jr., and Icy Hot caution against use in labor because of the potentially teratogenic effect of the menthol ingredient. Goals of Pharmacologic Pain Management During Labor The goal of medications used during labor is to encourage relaxation and relieve discomfort while having minimal systemic effects on uterine contractions, pushing effort, or the fetus. 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. Goals of Pharmacologic Pain Management During Labor If a drug causes a systemic response, such as hypotension, 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 person may be unable to work effectively with contractions, thus prolonging labor and increasing discomfort. Goals of Pharmacologic Pain Management During Labor 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, it may be difficult to push effectively, which may prolong the second stage and increase the risk of a cesarean birth. Goals of Pharmacologic Pain Management During Labor Lastly, because pain is a subjective sensation, some individuals 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 person to another and should be given at whatever point an individual feels they need it. Goals of Pharmacologic Pain Management During Labor 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 person can relax and work with, not against, the contractions. In contrast, at the second stage, epidural anesthesia or a drug that causes disorientation 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 patient, 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 (2016) and remember the criteria a drug must fulfill to be used in pregnancy at any point. Never give a drug to a pregnant person unless you know the benefit outweighs the risk for both of your patients: the laboring individual and the fetus. Be certain to ask about allergies to all medications before administering them during labor as those in distress from pain can be too distracted to mention this unless directly asked. Preparation for Medication Administration Prepare a patient 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 is to be expected after administration (“I’ll be taking your blood pressure frequently”). Those in labor are under a lot of stress. That can make the experience of new and surprising body sensations caused by a drug so frightening that 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 respiratory depression as well as fetal CNS depression to some extent and so they should be used cautiously Opioid (Narcotic) Analgesics Timing the administration of narcotics during labor is especially important; 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 laboring patient 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 and so the newborn breathes easily. Opioid (Narcotic) Analgesics It can be puzzling to see a sleepy baby who is lethargic due to butorphanol tartrate given 2 hours before birth, for example, and an alert baby who had exposure to 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 it peak. Opioid (Narcotic) Analgesics 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. Opioid (Narcotic) Analgesics A drawback to all these opioids is that they may cause nausea and vomiting for some. These effects appear to be dose related. They also produce a feeling of euphoria, so patients 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. Opioid (Narcotic) Analgesics 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. 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. If severe infant respiratory depression is anticipated, naloxone hydrochloride can be given to a laboring patient just before birth. It readily crosses the placenta and, because it interferes with or competes for narcotic binding sites, may increase the chance of spontaneous respiratory activity in the newborn. NALOXONE HYDROCHLORIDE (NARCAN) Action: Naloxone hydrochloride is a narcotic antagonist that counteracts the effect of narcotic analgesics (Karch, 2019). It is used to counteract respiratory depression in newborns when a laboring patient has received a narcotic analgesic during labor. PREGNANCY RISK CATEGORY: B Dosage: 0.01 mg/kg, administered either IV 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 IV 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 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. 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 pain needs to be managed with other 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. Research by Rooks (2011) has shown that in appropriate doses (50% or less blend with oxygen) and with a proper and now standard delivery system, nitrous oxide can be safe for all involved at the birth: laboring patient, fetus, and caregiver. It does not affect the pattern or intensity of contractions and does not interfere with normal labor. Apgar scores in neonates whose laboring parent used nitrous oxide do not significantly differ from those who used other forms of pharmacologic pain relief, or no analgesia Regional (Local) Anesthesia Regional anesthesia is the injection of a local anesthetic such as chloroprocaine (Nesacaine) orbupivacaine (Marcaine) to block specific nerve pathways. This achieves pain relief by blocking sodium and potassium transport in the nerve membrane, thereby stabilizing the nerve in a polarized resting state so that the nerve is unable to conduct sensations. Anyone 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. Regional (Local) Anesthesia Regional anesthetics have the potential to result in fetal bradycardia. This is not due to the transmission of the drug to the fetal circulation but rather secondary to the effects of hypotension that can occur for the laboring patient following administration of the medication. This may resolve spontaneously, with position change or with the administration of additional medication. Regional (Local) Anesthesia Most importantly, regional anesthesia is able to completely eliminate pain, yet allow for a patient 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. Regional (Local) Anesthesia 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 Epidural Anesthesia 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 person no longer experiences pain, the release of catecholamines (epinephrine) with a beta-blocking effect from a pain response is decreased, making this a very effective pain relief measure for labor. Epidural Anesthesia Epidural blocks are suitable for almost all patients. They are advantageous for those 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 laboring patient does not feel contractions, their 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 patient receives no systemic medication, the infant responds more quickly after birth than if systemic narcotic analgesics were used. Epidural Anesthesia 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 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 that a person 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 parenteral (IV fluid) glucose can cause hyperglycemia with rebound hypoglycemia in the newborn. Be certain that a patient does not lie supine after an epidural block but Epidural Anesthesia If hypotension should occur, raising the patient’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 they are severely hypotensive, blood is shunted away from the uterus and leads to poor perfusion of the placenta, eventually causing fetal distress. Epidural Anesthesia A disadvantage of epidural anesthesia is that the bearing down reflex may be reduced or absent, making it difficult 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 A second-stage delay this way occurs primarily when the fetus is in an occipitoposterior position Epidural Anesthesia Changing the patient’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 to help with the urge to push with contractions is another option. If this is unsuccessful, an oxytocin IV to help strengthen contractions can be administered. Epidural Anesthesia In rare instances, the anesthetic enters the patient’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 patient 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 patient and the fetus. Technique for Administration Epidural blocks are usually delayed until a patient’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 patient on their side on the birthing bed or sitting up and leaning over a bedside table. If their back curves outward, this increases the intravertebral spaces and allows easier access to the injection site.  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 Technique for Administration 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 for movement and, possibly, walking while the anesthesia is in effect. A catheter is left in place attached to a syringe to allow for repeated injections without further injection pain  Technique for Administration Assess a patient’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 Technique for Administration An epidural block provides anesthesia for uterine contractions but not perineal relaxation. Close to birth, if the patient 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 Patient With an Epidural Anesthesia Following anesthetic administration, be certain that a patient lies on their side, or if on their back, place a firm towel under their left hip to avoid hypotension from poor blood return to the heart. To keep the patient 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 Aftercare for the Patient With an Epidural Anesthesia Each time, before an additional top-up dose is administered, ask the patient to say out loud a phrase such as “I can do it” three times. If they are unable to do this, question the dose; lack of fine motor coordination and slurred speech can indicate a slowly occurring toxic reaction Aftercare for the Patient With an Epidural Anesthesia Yet another technique used to maintain epidural anesthesia is self-administration 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. This method of administration is advantageous because less anesthetic is required compared with continuous epidural infusion (CEI) and can give the patient a feeling of empowerment as they control their own pain management. Aftercare for the Patient With an Epidural Anesthesia A nurse should be in continuous attendance as long as epidural anesthesia is being used. When recording vital signs, be aware that epidural anesthesia can cause a temporary elevation in temperature, which is not serious unless it rises above 101°F (38°C) 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). Aftercare for the Patient With an Epidural Anesthesia 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 that the patient’s systolic blood pressure does not fall to less than 100 mm Hg or decrease by 20 mm Hg or more in a hypertensive patient. 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. Aftercare for the Patient With an Epidural Anesthesia After an epidural block, a patient loses sensation of bladder filling. Remind them to void every 2 hours, monitor intake and output, and observe and palpate for bladder distention to avoid overfilling, especially if labor is prolonged. To assess after birth whether the anesthesia is wearing off, touch a patient’s leg and ask if they can feel your touch. Ask them to raise their knees and observe whether they can do this easily. Even after feeling in their legs returns, walking may be difficult. Be certain to stay with the patient the first time they are out of bed following regional block anesthesia to prevent them 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. Spinal (Subarachnoid) Anesthesia 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 that the fluid is infusing well before the anesthesia is administered. Spinal (Subarachnoid) Anesthesia 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 patient is usually asked to sit on the side of the bed with legs dangling and head bent. Ask them to bend their head forward so the back curves and the intravertebral spaces open. Be sure either you or the support person steadies them in this sitting position because a pregnant patient is “front heavy” and could easily fall forward if not well supported Spinal (Subarachnoid) Anesthesia 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 Spinal (Subarachnoid) Anesthesia Following the anesthetic injection, if the patient was sitting, the anesthesiologist will ask them to lie down. It is important they lie down at this time because if they continue to sit upright, the anesthetic will not rise high enough in the canal to achieve pain relief. They 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. Spinal (Subarachnoid) Anesthesia As mentioned, hypotension from sympathetic blockage in the lower extremities may occur immediately after spinal anesthetic administration. This leads to vasodilatation and a decrease in central blood pressure. If hypotension occurs, placental blood perfusion can be compromised. Turning to the left reduces 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. Trendelenburg position (head lower than the body) should not be used to help restore blood pressure after spinal anesthesia. This could make the anesthetic rise high in the spinal column, causing uterine or respiratory function to cease. Spinal (Subarachnoid) Anesthesia 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. The shift in pressure of the CSF causes strain on the cerebral meninges, initiating the pain. The incidence of such headaches is reduced if the patient is well hydrated before the injection. If a headache occurs, the patient can be encouraged to drink a large quantity of fluid during the postpartum stay because a high fluid intake rapidly provides replacement of spinal fluid. Spinal (Subarachnoid) Anesthesia A spinal headache can be relieved by the administration of hydrocortisone to reduce inflammation. Having the patient lie flat and administering an analgesic also helps. Some 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 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 laboring patient has come through, this flash of pain seems insignificant. For some, 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. 1. 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) 2. 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 someone who has not had an epidural to provide a pain-free birth and, if an episiotomy is needed, painless surgical suturing and repair. Although a pudendal nerve block is local, assess the FHR and the patient’s blood pressure immediately after the injection to be certain hypotension does not occur. 3. 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 it used; if it is used, there are special precautions you need to be aware of. Pregnant individuals 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. 3. General Anesthesia 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 those 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 3. General Anesthesia For the procedure, after induction with thiopental sodium, the patient is intubated, and anesthesia is then maintained by administration of nitrous oxide and oxygen. Thiopental sodium crosses the placenta rapidly, so an infant born when a patient is anesthetized by this method may be slow to respond at birth and may need resuscitation. Some people comment that their throats feel raw or sore after general anesthesia 3. 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 Preparation for the Safe Administration of General Anesthesia 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 patient’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. Aspiration of Vomitus The moments of induction of general anesthesia before the endotracheal tube is safely in place are critical ones for the anesthesiologist. Respect their 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 patient’s trachea to remove as much foreign material as possible. The patient is intubated, if they were not previously, and given 100% oxygen. IV isoproterenol to reduce bronchospasm and a corticosteroid to reduce inflammation may be given. Aspiration of Vomitus Positive-pressure ventilation may be initiated. Blood gas analysis and a chest X-ray usually are obtained to determine how much aeration the patient is still capable of achieving. The patient may receive mechanical ventilation until their overall clinical condition improves, as shown by X-ray films and blood gas concentrations. They 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 they need to survive this emergency.