Florida National University Epidural Anesthesia Brochure
Florida National University Epidural Anesthesia Brochure
The Nursing Role in Providing Comfort During Labor and Birth For additional ancillary materials related to this chapter, please visit thePoint. Jonny Baranca is a primipara in early labor whom you admit to a birthing unit. Her cervix is 3 cm dilated. She tells you her sister had epidural anesthesia that completely obliterated her pain in labor for the birth of her baby 3 months ago. Based on her sister’s experience, Jonny expected to be given epidural anesthesia as soon as she arrived at the hospital as she “is in early labor.” Her physician, however, asked her to wait until she is 4 cm dilated. When you enter her room, you find her lying on her back in a birthing bed, crying. Her husband shouts his “wife deserves better care than this.” The previous chapter discussed the process of labor and birth and nursing care responsibilities. This chapter adds information to your knowledge base about how to promote comfort during labor. Effective pain management in labor can change labor from an experience so negative it can result in a posttraumatic stress syndrome to a positive, forward-moving experience. Was the information Jonny received from her sister realistic? What are some immediate interventions you could do to help Jonny better cope with her pain? KEY TERMS analgesia anesthesia doula endorphins epidural anesthesia pain pressure anesthesia pudendal nerve block reflexology OBJECTIVES After mastering the contents of this chapter, you should be able to: 1. Describe the physiologic basis of contractions during labor and how nonpharmacologic therapies, as well as analgesia and anesthesia, can be used to promote a woman’s comfort during labor and birth. 2. Identify 2020 National Health Goals related to comfort and drug-free pain management measures effective in childbirth that nurses can help the nation achieve. 3. Assess the degree and type of discomfort a woman is experiencing during labor and birth, including her ability to cope with pain effectively and the maternal and fetal impact of pain management, including side effects and safety. 4. Formulate nursing diagnoses related to the effect of pain or pain management during labor and birth. 5. Establish expected outcomes to meet the needs of a woman experiencing discomfort during labor and birth and manage seamless transitions across differing healthcare settings. 6. Using the nursing process, plan nursing care that includes the six competencies of Quality & Safety Education for Nurses (QSEN): Patient-Centered Care, Teamwork & Collaboration, Evidence-Based Practice (EBP), Quality Improvement (QI), Safety, and Informatics. 7. Implement common complementary and pharmacologic measures for pain management during labor and birth. 8. Evaluate expected outcomes for effectiveness and achievement of care. 9. Integrate knowledge of pain management during labor and birth with the interplay of nursing process, the six competencies of QSEN, and Family Nursing to promote quality maternal and child health nursing care. Concerns about the discomfort and pain that accompany labor and birth can dominate a pregnant woman’s or couple’s thoughts during pregnancy; these can become particularly strong as the baby’s due date approaches. As discussed in Chapter 14, prepared childbirth classes provide couples with an opportunity to learn and practice a variety of pain management techniques, such as breathing patterns, to help reduce pain in labor. Often, however, the labor experience is so intense it becomes overwhelming, so administration of an analgesic or a regional anesthetic may be necessary to reduce discomfort sufficiently to allow a woman to regain control over herself and use breathing patterns. If the use of regional anesthesia makes labor a satisfying, positive experience, the intervention can ultimately promote the entire family’s health. Some women, however, may feel they have let down themselves, a partner, or childbirth educator by asking for anesthesia; if this happens, asking for pain medication can make labor a negative experience. Much has been written in nursing literature about using the neutral term contraction or other alternative reference instead of labor pain to keep from reminding a woman contractions are painful. The theory is a sound one, not only because a woman is experiencing a contracting sensation but also because calling it pain could magnify fear and tension; tension, in turn, magnifies pain. Remember, however, renaming it will not change its basic nature. Discomfort accompanies labor regardless of what term is used for it. Fortunately, many nursing interventions can help reduce pain, so labor is as fulfilling and rewarding an experience as a woman hoped it would be. Making labor and birth a memorable experience for families is so important that 2020 National Health Goals have been established to address this topic. These are shown in Box 16.1. BOX 16.1 Nursing Care Planning Based on 2020 National Health Goals Because administration of either analgesia or anesthesia during labor can prolong labor and can possibly increase the number of instruments used or risk for cesarean birth, several 2020 National Health Goals are related to the types of pain relief used in labor. Examples include: • Reduce the maternal mortality rate to no more than 11.4 deaths per 100,000 live births from a baseline of 12.7 per 100,000. • Reduce the fetal/newborn death rate during the perinatal period (28 weeks of gestation to 7 days after birth) to no more than 5.9 per 1,000 live births from a baseline of 6.6 per 1,000 live births (U.S. Department of Health and Human Services, 2010; see www.healthypeople.gov). Nurses can help the nation achieve these goals by educating women about the advantages of preparing for childbirth, helping them to use breathing patterns or other complementary and alternative therapies and techniques during labor so they need a minimum of analgesia and anesthesia, and conscientiously monitoring women who receive analgesics and anesthesia. Nursing Process Overview FOR PAIN RELIEF DURING LABOR AND CHILDBIRTH ASSESSMENT Pain, the sensation of discomfort, is a subjective, personal symptom; it is what the experiencing person says it is and present when the experiencing person says it is present (McCaffery, 1972). It is unique to each individual, so a woman is the only person who can describe or know the extent of her pain. To assess the amount of discomfort a woman is having in labor, listen carefully to not only what she says but also how she rates her discomfort level on a pain assessment scale. Also look for subtle signs such as facial tenseness, flushing or paleness, hands clenched in fists, rapid breathing, or rapid pulse rate. NURSING DIAGNOSIS Although pain related to labor contractions is the most obvious nursing diagnosis applicable to labor, it is not the only relevant one because pain can create other problems for the laboring woman that can negatively affect the childbirth experience. If not resolved, these problems can intensify pain. Some women, for example, may become more concerned with their reaction to the pain than to the pain itself. Because of this, applicable nursing diagnoses might include: Pain related to labor contractions Powerlessness related to the duration and intensity of labor Anxiety related to lack of knowledge about “normal” labor process Risk for situational low self-esteem related to ineffectiveness of prepared childbirth breathing exercises Decisional conflict related to use of analgesia or anesthesia during labor OUTCOME IDENTIFICATION AND PLANNING When developing realistic outcomes and planning interventions to manage discomfort during labor, consider the woman’s perceptions about childbirth, her past childbirth experiences (if any), and the amount and type of childbirth preparation she and her partner have made. For example, if a woman is using breathing exercises well, expecting she will need medication late in labor is probably not realistic. However, if a woman has not made any preparation as to how she will manage labor contractions, expecting that no medication will be used might be inappropriate. Be aware that pharmacologic agents used during labor and birth may pose risks for both the woman, such as hypotension, as well as the fetus or neonate, such as bradycardia or respiratory issues at birth. Therefore, when considering use of pharmacologic intervention, the benefit to the woman and the fetus must outweigh the risks of medication use. In addition, a decision to use analgesia or anesthesia may also affect family functioning if the method chosen limits the partner’s participation in the birth. Contrarily, the use of a pharmacologic agent may be what a woman could most benefit from, particularly if she has a history of sexual trauma (Nerum, Halvorsen, Straume, et al., 2013). IMPLEMENTATION Keeping a woman and her support person informed about their options and how they differ as labor progresses is important. For instance, simply knowing that birth is getting closer can make the next few contractions easier to withstand. Supporting and encouraging a woman to use methods of complementary and alternative therapies for pain management, such as a birthing ball, ambulation, relaxation, and breathing techniques, also are helpful. Offering analgesia or assisting with anesthesia administration during labor or birth requires nursing judgment and a caring presence to help one woman accept analgesia when she needs it and to encourage another to experience childbirth without pharmacologic intervention when that is what she desires. OUTCOME EVALUATION Evaluations are ongoing and typically must occur within a short time frame. Examples of short-term expected outcomes that would indicate successful achievement during labor are: Patient states pain during labor is within a tolerable level for her. Couple reports they feel control throughout the labor process. Patient and fetus remain physiologically stable with use of pharmacologic interventions. Patient verbalizes satisfaction with current pain control measures. A long-term evaluation should reveal a woman found labor and birth to be an experience not only endurable but also that it allowed her to grow in self-esteem and the family to grow through a shared experience. Asking a woman to describe her labor experience afterward in relation to pain not only aids an evaluation of whether pain management was adequate but also helps her work through this emotional period of life and integrate it into her previous experiences as well. Experience of Pain During Childbirth Pain accompanies labor contractions for several different reasons and manifests itself in different ways for each woman (Box 16.2). BOX 16.2 Nursing Care Planning Using Assessment ASSESSING A WOMAN FOR SYMPTOMS OF PAIN DURING LABOR AND CHILDBIRTH ETIOLOGY OF PAIN DURING LABOR AND BIRTH Normally, contractions of involuntary muscles, such as the heart, stomach, and intestine, do not cause pain. This concept makes uterine contractions unique because they do cause pain. Several explanations exist for why this happens. 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. Pain also probably results from stretching of the cervix and perineum. This phenomenon is the same as 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 woman feels she has to push, pain from the contractions often disappears as long as the woman is pushing, until the fetal presenting part causes a final stretching of the perineum. Additional discomfort in labor may stem from the pressure of the fetal presenting part on tissues, including pressure on surrounding organs, such as the bladder, the urethra, and the lower colon. In addition to these factors, cultural expectations effect how pain is perceived (Box 16.3). All these factors make nursing support, in addition to a doula or a partner, important as it can have a positive influence on pain relief in all situations of labor. BOX 16.3 Nursing Care Planning to Respect Cultural Diversity Some women believe their expected role during labor is to be stoic and nonverbal even in the face of intense pain. Others believe expressing their discomfort by screaming or verbalizing their discomfort is what is expected. If a woman is not proficient in English, it may be particularly difficult for her to describe her level of discomfort and that she needs some assistance. Assess each woman individually to determine not only what level of comfort she feels is right for her during labor but also the manner in which she feels most able to express discomfort. Assessing individuals in this way rather than relying on a list of “typical” ways Hispanic women, Asian women, and so forth, react to pain achieves better individual care. Because of Americanization, a woman’s surname or her appearance may be not be indicative at all of how she wants to manage pain. The amount of analgesia women desire or will accept is dependent both on the situation and her culture. In a culture in which birth is seen as a “natural” process or if a woman has attended a class to prepare for birth, the less analgesia is generally desired. Any woman who has an effective support person with her generally needs less pharmacologic pain relief than one who does not. 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 (Melzack & Wall, 1965), 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 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. A major way to block spinal cord neurotransmitters (i.e., never allowing the pain impulse to cross to a spinal nerve) is by the administration of pain medications. In addition, the brain cortex can be distracted from sensing impulses as pain by such techniques as imagery, thought stopping, and perhaps aromatherapy or yoga. 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. 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 to a woman in labor about pain relief. 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 a woman experiences during contractions differs according to her expectations of and preparation for labor; the length of her labor; the position of her fetus; the presence of fear, anxiety, worry, body image, and self-efficacy; and the availability of meaningful people around her to offer support (Fig. 16.1). As a rule, women who believe they can control their situation (have self-efficacy) are more apt to report a satisfactory birth experience than those who do not feel in control (Howarth, Swain, & Treharne, 2011). Figure 16.1 The discomfort a woman experiences during childbirth is related to the amount of support she receives from her family and healthcare providers. Here, the woman’s support person uses the palm of his hand to apply counter pressure to her lower back, helping to ease back pain. Fetal position is a physical variable that influences the degree of pain a woman experiences. If the fetus is in an occiput posterior position, the woman often reports intense or nagging back pain, even between contractions, much more than if a fetus is in an occipitoanterior position (Impey & Child, 2012). Pain is perceived differently by different individuals because of psychosocial, physiologic, and cultural responses. The body’s ability to produce and maintain endorphins may influence a person’s overall pain threshold and the amount of pain a person perceives at any given time. Women who come into the labor experience believing the pain will be horrible are usually surprised afterward to realize the agony they expected never materialized. However, women who thought pain would be minimal can be overwhelmed by its intensity. Unrealistic expectations of labor pain can make a woman so tense during labor her pain feels worse than it would have if she had been relaxed. A woman cannot relax simply because she is instructed to do so by another person, however. Some additional interventions must be used. 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 women and their partners with information so they can choose how to best relieve pain during labor within the limits of medical safety. Nurses play a key role in educating women and their support persons about the numerous comfort and pain relief strategies available and making sure certain couples understand the choices available to them along with the benefits and risks (L. Jones, Othman, Dowswell, et al., 2012). Throughout their decision-making process, couples need support for their choices so they can feel confident in the method they choose. SUPPORT FROM A DOULA OR COACH Although, historically, women have always attended other women in childbirth, in the past 45 years or so, the father or pa
