Ch 18 Pain mangamegment for childbirth


Pain Management for Childbirth Chapter 18
The two components of pain during birth include 1. A physiological component and a psychological
component. The psychological component deals with how
the women reacts to the pain she is experiencing. Childbirth pain differs than normal pain in
various ways including the pain is not constant. The women has time to prepare for the pain
during pregnancy and the end of the pain has the birth of a child. Physical pain that is felt during labor is
due to tissue ischemia that occurs with the loss of blood flow to the uterus during contractions. It also occurs from the cervical dilation
and pulling and pressure on the pelvic structures. The last physical component is due to distention
of the vagina and perineum. The characteristic of the pain can determine
how the women handles it. Fatigue can make the pain seem worse. The fetal position can make the pain worse
as well. Are we doing an interventions to help with
the pain? For example, changing positions can sometimes
lessen the pain. There are also a variety of psychosocial factors
that will affect pain as well. Culture can play a part in this. In many cultures women are stoic and not ask
for pain meds. Or the man will make the decision if she needs
something. Anxiety and fear can cause the pain to become
intense as well. It doesn’t allow her to relax. Previous experience with pain can also make
it hard to deal with the pain. Childbirth education classes can sometimes
help with the pain as they teach non-pharmacological measures to deal with the pain. Also having a good support system can also
help a women deal with the pain. Some women choose to use nonpharmacologic
pain management throughout their labor. Or some women will use it during the early
stage of labor. There are advantages which include they don’t
have side effects and there is no risk to mom or the fetus. Sometimes they will use these measures along
with pharmacologic measures. The limitations include they may not be effective
for the pain. It is ideal to prepare for these measures
before labor starts. Practicing during pregnancy can help them
be prepared during labor. If they did not prepare then it is ideal to
prepare during the latent phase of labor before the pain becomes too intense. General comfort measures can include keeping
the room dimly lit, quiet environment, maintaining a comfortable position are a few ways. Reducing anxiety and fear can be done many
times just by keeping the women updated on the plan of care. Keeping her informed can help her relax. Relaxation can be obtained by using music,
lowlights, massage, soft touch. Mind-body stimulation can be effleurage which
is self massage on the abdomen, legs or wherever it helps the women relax. Warm packs on their back can help or acupuncture
is preferred for some women. Hydrotherapy involves using a tub or shower
to provide relief and relaxation. Mental Stimulation can use guided imagery
where a woman closes her eyes and imagines she is at her favorite place. She can see the sights, smell the smells and
feel the environment. They can use a focal point to focus on with
each contraction and think about that item each time she is having a contraction instead
of the pain she is experiencing. Breathing exercises can be very effective
for some women. They may use them during early labor or through
out the whole labor process. There is no wrong way to do the exercises
so I am going to be very brief on these. During what they call the first stage of breathing
exercises the women will take a big cleansing breath where she fills her lungs with extra
oxygen and exhales. Then she focuses on paced breathing .When
the pain is not as bad it is typically a slow paced breathing. As the pain intensifies it becomes more a
modified paced breathing. Her pace picks up but she is still remaining
in control and trying to follow a pattern. Common problems with the breathing is she
can hyperventilate if she is breathing too fast. She would start to feel dizzy and some numbness
or tingling in her extremities. Having her slow down her breathing and breath
into a paper bag or her cupped hands can help the situation. Second stage breathing helps her with the
pushing process. It used to be they would have you hold your
breath and count to ten while pushing. This can cause vasoconstriction and decrease
in blood pressure so now they encourage open glottis pushing. She doesn’t have to scream with each push
but grunting or groaning can help. Effects on the fetus from pharmacologic pain
management includes direct effect and non direct effect. The direct effect is when the medication crosses
the placenta and enters into the fetus’s blood stream and can cause decrease in FHR or variability. An indirect effect is when the medication
effects mom and those effects are carried over to the fetus. For example, if mom gets an epidural, one
of the side effects is maternal hypotension. When mom experiences hypotension, there is
a decrease blood flow to the placenta which can then cause a decrease in FHR. Some medications can slow labor so it should
be determined she is in a good labor pattern before administering. Epidurals can make it hard for a women to
push effectively at the time of birth so many times the epidural is turned down so she can
assist in the pushing efforts. Pain medications can interact with medications
or herbal products or street drugs. Getting a good history is crucial so the correct
pain management can be followed. Local infiltration anesthesia is used prior
to an episiotomy is performed or if repair of a laceration is needed. This type of anesthesia will not decrease
uterine contraction pain. It just numbs the local area where it is injected. There rarely any side effects from this type
of anesthesia. An epidural is the popular choice for many
laboring women. It can instantly take the pain away for most
women. It allows the women to be pain free and relax
during the birth process. It is safe for most women. A few instances where it is not recommended
would be if the women has any coagulation defects and she has hypovolemia. If she has a severe infection then this option
is also not the right choice. The biggest adverse effect is the maternal
hypotension we just talked about. Vasodilation can occur and this causes decreased
blood flow to the placenta which in turn can cause a decrease in FHR which can cause fetal
hypoxia or acidosis. Providing mom with a bolus of lactated ringers
or normal saline prior to the epidural can sometimes offset the hypotension by providing
the extra fluid volume. Bladder distention is also a possible adverse
effect. This is due to those rapid fluids they gave
and her decrease sensation to feel the fullness of the bladder. Intermittent or continuous catheterization
is standard of care. It can cause an increase in that second stage
of labor as she has the decrease urge to push and may not push effectively. Turning down the dose can help with this problem. A maternal fever may also occur and the baby
can also have a fever after delivery. There is not known cause for this. Effects of the actual opioid medication can
include nausea and vomiting, pruritus and respiratory depression. Nursing care includes being sure the consent
form is signed, providing that fluid bolus prior to administration and good assessment
and monitoring after the procedure to help reduce the adverse effects to mom and baby. The combined analgesics is also known as an
intrathecal. It injects an opioid analgesic into the intrathecal
space. Many times an epidural catheter is placed
as well so if later the woman needs more pain relief, an epidural can be administered. With the intrathecal, many women do not lose
sensation like they would for an epidural so many women can still get out of bed. It does not take away as much of the pain
as an epidural but offers good pain control. The adverse effects are the same for the opioid
side effects for an epidural and include nausea and vomiting, itching and delayed respiratory
depression can occur. Nursing care includes monitoring vials and
FHR and managing any side effects that may occur. The spinal block is used for cesarean sections
if the women doesn’t already have an epidural in place. The medication is given in the subarachnoid
space and the women has no sensation anywhere below that spot. She is numb and will not feel the cut for
the incision but she may feel some tugging as they are getting baby out. Contraindications and precautions are the
same as with the epidurals. Adverse effects include hypotension, bladder
distention and the risk for a spinal headache. If a spinal headache occurs, it is from leaking
of spinal fluid from the injection site. Bed rest and IV fluids is the treatment measure
they will first try. If this is not effective, then a blood patch
may be needed. 10-20 mL is obtained from the women and then
injected into the spinal site. Typically immediate relief of the headache
is noted.

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