Pain Management, Labor Theories, Signs, & Stages PDF

PAIN MANAGEMENT DURING LABOR Prepared by Rosalind S. Navarro MAN, RN  Methods For Pain Management (During Labor)  Most of the methods advocated are based on three premises:  Discomfort during labor can be minimized if a woman comes into labor informed a...

PAIN MANAGEMENT DURING LABOR Prepared by Rosalind S. Navarro MAN, RN  Methods For Pain Management (During Labor)  Most of the methods advocated are based on three premises:  Discomfort during labor can be minimized if a woman comes into labor informed about what is happening and prepared with breathing exercises to use during contractions. Discomfort during labor can be minimized if a woman’s abdomen is relaxed and the uterus is allowed to rise freely against the abdominal wall with contractions. Pain perception can be altered by distraction techniques or by the gating control theory of pain perception. A. The Bradley (Partner-Coached) Method Originated by Robert Bradley Based on the premise that childbirth is a joyful natural process and stresses the important role of a woman’s partner during pregnancy, labor, and the early newborn period. The Bradley Method emphasizes that birth is a natural process: mothers are encouraged to trust their body and focus on diet and exercise throughout pregnancy; it teaches couples to manage labor through deep breathing and the support of a partner or labor coach.[ ▪What is The Bradley Method®? The Bradley Method® teaches natural childbirth and views birth as a natural process. ▪The Bradley Method® is a system of natural labor techniques in which a woman and her coach play an active part. ▪It is a simple method of increasing self-awareness, teaching a woman how to deal with the stress of labor by tuning in to her own body. ▪The Bradley Method® encourages mothers to trust their bodies using natural breathing, relaxation, nutrition, exercise, and education. B. The Psychosexual Method Was developed by Sheila Kitzinger in England during the 1950s. It stresses that pregnancy, labor, and birth, and the early newborn period are important points in a woman’s life cycle. In includes a program of conscious relaxation and levels of progressive breathing that encourages a woman to “flow with” rather than struggle against contractions. Conscious relaxation Deliberately relaxing 1 set of muscles, then another, until her body is completely relaxed.  Cleansing breath To begin all breathing exercises and to end each exercise. Woman breathes in deeply and exhales deeply. It limits possibility of hyper- and hypoventilation If Respiratory alkalosis develops: Breath into a paper bag causes rebreathing of CO2  Consciously controlled breathing Level 1 Slow, chest breathing of comfortable but full respirations. 6 – 12 breaths/min. Used for early contractions Level 2 Lighter and more rapid than Level 1 Up to 40 breaths/min. For contractions with 4 – 6 cm cervical dilation.  Consciously controlled breathing Level 3 More shallow and more rapid breathing Rate is 50 – 70 breaths/min. Exhalation must be a little stronger than inhalation to prevent hypoventilation Keep the tip of tongue against the roof of her mouth to prevent oral mucosa from drying. Use for transition contractions (8 – 10 cm cervical dilation).  Consciously controlled breathing Level 4 A “pant – blow” pattern 3 or 4 quick breaths, then a forceful exhalation (breath – breath – breath – huff) Level 5 Quiet, continuous, very shallow panting. About 60breaths/min. Used during strong contractions, or 2nd stage of labor to prevent woman from pushing before full dilatation. C. The Dick-Read Method Is based on the approach proposed by Grantly Dick-Read, an English physician. The premise is that, fear leads to tension, which leads to pain. FEAR TENSION PAIN A woman achieves relaxation and reduced pain by focusing on abdominal breathing during contractions. D. The Lamaze Method One of the most often taught in the U.S. Based on the theory that through stimulus- response conditioning, women can learn to use controlled breathing to reduce pain during labor Was originally termed psychoprophylactic method. Focuses on preventing labor pains by use of the mind. Lamaze Method ▪Lamaze is a method of childbirth developed by French obstetrician Ferdinand Lamaze. ▪The core of Lamaze is focused on the utilization of controlled breathing to cope with pain. ▪Lamaze International states that their goal is to, "increase women's confidence in their ability to give birth". 6 major concepts are stressed: 1. Labor should begin on its own, not be artificially induced. 2. Women should be able to move freely throughout labor, not be confined to bed. 3. Women should receive continuous support during labor. 4. No routine interventions such as IV fluids are needed. 5. Women should be allowed to assume a non-supine (upright or side-lying) position for birth. 6. Mother and baby should be housed together following birth, with unlimited opportunity for breast-feeding. Effleurage Light abdominal massage Additional technique to encourage relaxation and displace pain in the Lamaze Method. A woman traces a pattern on her abdomen with her fingertips. Serves as a distraction technique Focusing or imagery Focusing intently on an object (sensate focus) Example: Photograph of her partner or children A graphic design The woman concentrates on the object during contractions Imagery Imagining to be in a calm place, such as on a beach THEORIES OF LABOR ONSET & SIGNS OF LABOR PREPARED BY ROSALIND S. NAVARRO MAN, RN  THEORIES OF LABOR ONSET It is believed that labor is influenced by a combination of factors originating from the mother and the fetus. These factors include the following: 1. Uterine muscle stretching, which results in release of prostaglandins (Uterine Stretch Theory) ▪ Prostaglandins promote cervical ripening, uterine contractions ▪ In late pregnancy, a woman starts to have a larger number of certain types of prostaglandins in her uterine tissue. These include PGE2 and PGE2a. Doctors believe these types are responsible for creating uterine contractions. 2. Pressure on the cervix, which stimulates the release of oxytocin from the posterior pituitary (Oxytocin Theory) 3. Oxytocin stimulation, which works together with prostaglandins to initiate contractions. 4. Change in the ratio of estrogen to progesterone (Progesterone deprivation theory) ▪ increasing estrogen in relation to progesterone stimulates uterine contractions 5. Placental age, which triggers contractions at a set point 6. Rising fetal cortisol levels, which reduce progesterone formation and increase prostaglandin formation. 7. Prostaglandin theory  In the latter part of pregnancy, fetal membranes and uterine decidua increase prostaglandin levels.  This hormone is secreted from the lower area of the fetal membrane (forebag).  A decrease in progesterone amount also elevates the prostaglandin level.  Synthesis of prostaglandin, in return, causes uterine contraction thus, labor is initiated.  Signs of Labor Preliminary Signs of Labor  All pregnant women should be taught these signs so that they can recognize when labor is beginning. 1. Lightening  descent of the fetal presenting part into the pelvis  in primiparas, it occurs approximately 10 to 14 days before labor begins  As the fetus sinks lower in the pelvis, the mother may experience shooting leg pains from the increased pressure on the sciatic nerve, increased amounts of vaginal discharge, and urinary from pressure on the bladder  this changes a woman’s abdominal contour as the uterus becomes lower and more anterior.  gives a woman relief from the diaphragmatic pressure and shortness of breath.  In multiparas, it usually occurs on the day of labor or even after labor has begun 2. Increase in Level of Activity  a woman may awaken on the morning of labor full of energy  this is related to an increase in epinephrine release that is initiated by a decrease in progesterone produced by the placenta  additional epinephrine prepares a woman’s body for the work of labor ahead 3. Braxton Hicks Contractions  In the last week or days before labor begins, a woman usually notices extremely strong Braxton Hicks contractions which she may interpret as true labor contractions  Remind her that if false contractions have become strong enough to be mistaken for true labor, true labor must not be far away 4. Ripening of the Cervix  is an integral sign seen only on pelvic examination  throughout pregnancy, the cervix feels softer than normal, similar to the consistency of an earlobe (Goodell’s sign)  at term, the cervix becomes still softer (described as “butter-soft”)  Ripening is an integral announcement that labor is very close at hand SIGNS OF TRUE LABOR  Signs of true labor involve uterine and cervical changes 1. Uterine Contractions The surest signs that labor has begun is productive uterine contractions Because contractions are involuntary and come without warning, their intensity can be frightening in early labor Helping a woman appreciate that she can predict can control the degree of discomfort she feels by using breathing exercises offers her a sense of control 2. Show As the cervix softens and ripens, the mucus plug that filled the cervical canal during pregnancy(operculum) is expelled The exposed cervical capillaries seep blood as a result of pressure exerted by the fetus The blood mixed with mucus, takes on a pink tinge and is referred to as “show” or “bloody show” Women need to be aware of this event so that they do not think they are bleeding abnormally 3. Rupture of Membranes Labor may begin with rupture of the membranes, experienced either as a sudden gush or as scanty, slow seeping of clear fluid from the vagina Two risks associated with ruptured membranes are: 1. intrauterine infection 2. prolapse of the cord which can cut off the oxygen supply to the fetus In most instances, if labor has not spontaneously occurred by 24 hours after membrane rupture and the pregnancy is at term, labor is induced to help reduce these risks Differentiation Between True and False Labor Contractions False Contractions True Contractions  Begin and remain irregular  Begin irregularly but become regular and predictable  Felt first abdominally and remain  Felt first in lower back and sweep confined to the abdomen and around to the abdomen in a wave groin  Often disappear with ambulation  Continue no matter what the and sleep woman’s level of activity.  Do not increase in duration,  Increase in duration, frequency, frequency or intensity and intensity  Do not achieve cervical  Achieve cervical dilatation dilatation  Prepared by Rosalind S. Navarro MAN, RN Learning Objectives: 1. Describe the components of labor. 2. Demonstrate skill in identifying abnormal patterns in fetal heart tone in relation to the uterine contraction; 3. Monitor frequency, interval and duration of uterine contractions; 4. Identify maternal danger signs of labor; 5. Distinguish early deceleration from late and from variable decelerations; and Learning Objectives: 6. Assess a family in labor and birth and identify the woman’s readiness, stage, and progression. 7. Formulate nursing diagnoses related to the physiologic and psychological aspects of labor and birth. 8. Develop expected outcomes to meet the needs of a family throughout the labor process. 9. Devise a nursing care plan using identified nursing diagnoses. 10. Implement nursing care for a family during labor such as teaching about the stages of labor. Learning Objectives: 11. Evaluate expected outcomes for achievement and effectiveness of care. 12. Integrate knowledge of labor and birth with the interplay of nursing process to promote quality maternal and child health nursing care. COMPONENTS OF LABOR ❑a successful labor depends on four integrated concepts: 1. The PASSAGE (the woman’s pelvis) 2. The PASSENGER (the fetus) 3. The POWERS (uterine factors) 4. The PSYCHE (the woman’s view) 1. PASSAGE ▪ Refers to the route a fetus must travel from the uterus through the cervix and vagina to the external perineum. ▪ Because the cervix and vagina are contained inside the pelvis, a fetus must pass through the bony pelvic ring. ▪ The pelvis must be of adequate size. ▪ 2 pelvic measurements are important to determine the adequacy of the pelvic size: a. the diagonal conjugate (the anterio- posterior diameter of the inlet) b. the transverse diameter of the outlet  The Pelvic Inlet At the pelvic inlet, the anteroposterior diameter is the narrowest diameter (12.5 cm)  The Pelvic Outlet At the outlet, the transverse diameter is the narrowest (11 cm)  If a disproportion between the fetus and pelvis occurs, the pelvis is the structure at fault. When an infant cannot be born vaginally, emphasize that it is the pelvis that is too small, not that the head is too big. 2. PASSENGER ▪ The passenger is the fetus ▪ The body part of the fetus that has the widest diameter is the HEAD, so this is the part least likely to be able to pass through the pelvic ring. ▪ Whether a fetal skull can pass or not depends on both its structure (bones, fontanelles, and suture lines) and its alignment with the pelvis. Structure of the Fetal Skull ▪ The cranium, the uppermost portion of the skull, comprises eight bones (important in childbirth): - 4 superior bones > the frontal (two fused bones) > two parietal > the occipital - the other four bones of the skull lie at the base of the cranium - they are of little significance in childbirth because they are never presenting parts > sphenoid > ethmoid > two temporal bones - The bones of the skull meet at suture lines - The suture lines are important in birth because, as membranous interspaces, they allow the cranial bones to move and overlap, molding or diminishing the size of the skull so that it can pass through the birth canal more readily. Fontanelles - membrane-covered spaces found at the junction of the main suture lines 1. Anterior fontanelle (bregma) * lies at the junction of the coronal and sagittal sutures * fusion of 2 frontal bones and 2 parietal bones making the anterior fontanelle diamond-shaped 2. Posterior fontanelle - lies at the junction of the lambdoidal and sagittal sutures - because the two parietal bones and the occipital bone are involved at this junction, the posterior fontanelle is triangular - smaller than the anterior fontanelle - fontanelle spaces compress during birth to aid in molding the fetal head - their presence can be assessed manually through the cervix after it has dilatated during labor - this helps establish the position of the fetal head and whether it is in a favorable position for birth - the space between the two fontanelles is referred to as the vertex - the area over the frontal bone is referred to as the sinciput; occipital bone is occiput Molding - is the change in the shape of the fetal skull produced by the force of uterine contractions pressing the vertex of the head against the not-yet-dilated cervix causing the bones of the fetal skull to overlap and cause the head to become narrower and longer. - only lasts a day or two Fetal Presentation and Position - two other factors play a part in whether a fetus is lined up in the best position to be born 1. Attitude - describes the degree of flexion a fetus assumes during labor or the relation of the fetal parts to each other a. Good attitude - is in complete flexion - the spinal column is bowed forward - the head is flexed forward so much that the chin touches the sternum - the arms are flexed and folded on the chest - the thighs are flexed onto the abdomen - and the calves are pressed against the posterior aspect of the thighs b. Moderate flexion - if the chin is not touching the chest but is in an alert or “military position” c. Partial extension - presents the “brow” of the head to the birth canal d. Poor flexion - the back is arched, the neck is extended, and a fetus is in complete extension presenting the occipitomental diameter of the head 2. Engagement - refers to the settling of the presenting part of a fetus far enough into the pelvis to be at the level of the ischial spines, a midpoint of the pelvis. - the degree of engagement is assessed by vaginal and cervical examination. - a presenting part that is not engaged is said to be “floating” - a presenting part that is descending but has not yet reached the ischial spines is called “dipping” Engagement 3. Station - refers to the relationship of the presenting part of a fetus to the level of the ischial spines. - when the presenting part is at the level of the ischial spines, it is at 0 station (synonymous with engagement) - if the presenting part is above the spines, the distance is measured and described as minus stations, which range from -1 to -4 cm. - if the presenting part is below the ischial spines, the distance is stated as plus stations (+1 to +4 cm) - at a +3 or +4 station, the presenting part is at the perineum and can be seen if the vulva is separated (crowning) 4. Fetal lie - is the relationship between the long (cephalocaudal) axis of the fetal body and the long (cephalocaudal) axis of a woman’s body - horizontal (transverse) or vertical (longitudinal) - approximately 99% of fetuses assume a longitudinal lie  Types of Fetal Presentation 1. Cephalic Presentation Most frequent type of presentation (95%) The fetal head is the body part that will first contact the cervix  Types of Cephalic Presentations TYPE LIE ATTITUDE DESCRIPTION VERTEX LONGITUDINAL GOOD The head is sharply flexed, making the parietal bones or the (FULL space between the fontanelles (the vertex) the presenting part. FLEXION) This is the most common presentation BROW LONGITUDINAL MODERATE Because the head is only moderately flexed, the brow or sinciput becomes the presenting part. FACE LONGITUDINAL POOR The fetus has extended the head to make the face the presenting part. From this position extreme edema and distortion of the face may occur. The presenting diameter is so wide that birth may be impossible. MENTUM LONGITUDINAL VERY The fetus has completely hyperextended the head to present the POOR chin. The widest diameter (occipitomental) is presenting. As a rule, the fetus cannot enter the pelvis in this presentation. 2. Breech Presentation means that either the buttocks or the feet are the first body parts that will contact the cervix. Breech presentations occur in approximately 3% of births and are affected by fetal attitude. Breech presentations can be difficult births, with the presenting point influencing the degree of difficulty It can be complete, frank, and footling. Types of Fetal Position- refers to the relationship of the presenting part to a specific quadrant of a woman’s pelvis.  Position is indicated by an abbreviation of three letters: 1. Middle letter denotes the fetal landmark 2. First letter defines whether the landmark is pointing to the mother’s right (R) or Left (L). 3. Last letter defines whether the landmark points anteriorly (A), posteriorly, (P), or transversely (T).  Mechanisms of Labor (EDFIRE ERE)  Engagement  Descent  Flexion  Internal rotation  Extension  External Rotation 3. POWERS OF LABOR  Supplied by the fundus, are implemented by the uterine contractions, a process that causes cervical dilatation and then expulsion of the fetus from the uterus A  Phases of Contraction: a. Increment b. Acme c. Decrement I D  Uterine Contraction A I D interval  Cervical Changes  Effacement- shortening and thinning of the cervical canal from a structure 1 or 2 cm in length to one in which no canal at all exists, except a circular orifice with almost paper-thin edges  Dilatation- enlargement of the cervical os from an orifice a few millimeters in size to an aperture large enough to permit the passage of a fetus (diameter about 10cm) 4. PSYCHE-  The 4th “P” or Psyche, refers to the psychological state that a woman brings into labor.  For many women, this is a feeling of apprehension or fright.  For almost everyone, it includes a sense of excitement or awe.  Prepared by Rosalind S. Navarro MAN, RN Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 76  FIRST STAGE OF LABOR ❖ASSESSMENT 1. LATENT PHASE Begins at the onset of regular uterine contractions and ends when rapid cervical dilatation begins. Contractions lasting 20- 40 sec. Frequency: 15-30 min. Cervix dilates 0-3 cm Intensity: mild, 25 – 40 mmHg Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 77  Latent phase contractions cause minimal discomfort. A woman can continue to walk about and make preparations for birth. This phase lasts 6 hrs. in nulliparas; 4.5 hrs. in multiparas Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 78 ❖IMPLEMENTATION: (Latent Phase) 1. Encourage mother & partner to participate in care. 2. Assist with comfort measures, changes of position, and ambulation 3. Keep mother and partner informed of progress 4. Offer fluids & ice chips 5. Encourage voiding every 1- 2 hrs. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 79 2. Active Phase Labor ❖ASSESSMENT Cervical dilatation occurs more rapidly At least 4-7 cm dilated Regular, frequent, usually painful contractions, lasting 40-60 sec. Frequency: every 3-5 min. Are not comfortable with talking or laughing during their contractions Contractions grow so strong, last longer This phase lasts 3 hours in nullipara; and 2 hours in multipara. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 80  vaginal secretions (show) Spontaneous rupture of membranes may occur. Active stage of labor in a Friedman Graph can be subdivided into the following periods: 1) Acceleration (4-5 cm) 2) Maximum slope (5-9 cm) ▪ Very rapid cervical dilatation ▪ 3.5 cm/hr (nulliparas) ▪ 5-9 cm/hr (multiparas) Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 81 ❖IMPLEMENTATION (Active Phase) 1. Encourage maintenance of effective breathing patterns 2. Provide a quiet environment 3. Keep mother & partner informed of progress 4. Promote comfort with backrubs, sacral pressure, pillow support, and position changes 5. Instruct partner in effleurage 6. offer fluids & ice chips, and ointments for dry lips 7. Encourage voiding every 1 – 2 hrs. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 82 3.Transition Phase ❖ASSESSMENT Contractions reach their peak of intensity Frequency: every 2-3 min. Duration: 60 – 90 sec. Maximum dilatation: 8 – 10 cm. By the end of this phase, both FULL DILATATION and COMPLETE CERVICAL EFFACEMENT have occurred. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 83  Woman experience: 1) Intense discomfort 2) Nausea & vomiting 3) Feeling of loss of control 4) Anxiety, panic, or irritability 5) She may resist being touched 6) Irresistible urge to push as woman reaches full cervical dilatation (10 cm.) Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 84 ❖IMPLEMENTATION (Transition Phase) 1. Encourage rest between contractions. 2. Wake mother at beginning of contractions so she can begin breathing pattern 3. Keep mother & partner informed of progress 4. Provide privacy 5. Offer fluids & ice chips, and ointments for dry lips 6. Encourage voiding every 1 – 2 hrs. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 85  General Nursing Care Intrapartal Period A. ASSESSMENT (On Admission) 1. Age, weight, height 2. Parity, gravidity, obstetric history 3. Allergies 4. Urine specimen 5. Time & type of last meal 6. Frequency, duration, intensity of contractions 7. Time of onset of contractions 8. Presence of bloody show Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 86  9. Status of amniotic membrane 10.Dilatation and effacement 11.Position of fetus (Leopold’s Maneuver) 12.FHR & pattern 13.V/S and Bp of mother 14.Emotional response to labor 15.Presence of support persons B. ANALYSIS/NURSING Dx 1. Mother 1) Altered cardiopulmonary tissue perfusion associated with hypovolemia r/t uterine relaxation following birth. Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 87 2. Ineffective individual coping r/t exhaustion 3. Fear r/t lack of knowledge and unfamiliarity with labor process 4. Impaired gas exchange r/t hyperventilation 5. Risk for injury r/t lack of control especially during transition phase, position during birth 6. Pain r/t labor process and episiotomy 7. Impaired physical mobility related to need for fetal monitoring, bed rest, or positioning 8. Altered urinary elimination r/t pressure of enlarged uterus, analgesia or anesthesia, and trauma of labor and birth Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 88 2. Infant 1) Ineffective thermoregulation r/t immature heat regulation, inability to shiver 2) Risk for injury r/t trauma of birth or maternal infection 3) Ineffective airway clearance r/t excessive mucus, aspiration of meconium, or inability to clear airway Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 89 C. PLANNING/ IMPLEMENTATION: 1. FIRST STAGE 1. Admit Mother and Labor Coach a) Orient to unit b) Obtain history 1. Parity & gravidity 2. EDB 3. Onset of contractions 4. Status of membranes 5. Time & contents of last meal 6. Allergies 7. Intent to breast feed or bottlefeed 8. Prenatal care Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 90 c) Obtain V/S d) Perform Leopold’s maneuver e) Time & assess contractions f) Assist with vaginal exam g) Test urine for protein, glucose & ketones h) Collect blood for CBC and cross match i) Give emotional support to mother & labor coach Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 91 2. Maintain asepsis; use universal precaution 3. Monitor frequency, duration and strength of contractions a) Palpate fundus b) Interpret data on maternal uterine monitor c) Prolonged contractions of 90 sec. or more may occur with administration of oxytocin; discontinue drug 4. Monitor FHR a) Fetoscope or Doppler b) Internal or external fetal monitor Operational Obstetrics & Gynecology · Bureau of Medicine and Surgery · 2000 Slide 92 Monitor the Fetal Heart During early labor, for low risk patients, note the fetal heart rate every 1-2 hours. During active labor, evaluate the fetal heart every 30 minutes Normal FHR is 120-160 BPM Persistent tachycardia (>160) or bradycardia (