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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 partner of a woman’s child has traditionally served as her chief support person in labor. Some partners or fathers, however, find it difficult to serve as effective coaches because they are so emotionally involved in the birth. Some women prefer to ask a sister, mother, or friend to serve as a coach. A doula is a woman who is experienced in childbirth and postpartum support. These support persons (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 woman’s selfesteem, speed the labor process, and improve breastfeeding success as well as decrease rates of oxytocin augmentation, epidural anesthesia, cesarean birth, and postpartum complications (Hodnett, Gates, Hormeyr, et al., 2013). QSEN Checkpoint Question 16.1 PATIENT-CENTERED CARE Jonny Baranca is having a painful labor. She asks the nurse if she should have hired a doula. The nurse identifies which answer as best? a. “Definitely. Doulas time contractions and perform many tasks, taking the burden off you.” b. “Maybe. Doulas are good at telling you if you are doing everything correctly.” c. “That’s an individual choice, but a doula can serve as an important support person.” d. “No. A second person giving advice is apt to cause conflict.” Look in Appendix A for the best answer and rationale. COMPLEMENTARY AND ALTERNATIVE THERAPIES Complementary and alternative therapies for pain relief involve nonpharmacologic measures that may be used either as a woman’s total pain management program or to complement pharmacologic interventions. 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, position changes, imagery, and other relaxation techniques. Relaxation The technique of relaxation, as discussed in Chapter 14, is taught in most preparation for childbirth classes but can be taught in early labor as well. 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, a woman cannot concentrate on pain. Asking a woman to bring favorite music or aromatherapy with her to enjoy in the birthing room, although not evidence based, can help with relaxation. Remember, no aromatic candles should be used because of nearby oxygen outlets. 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 (Smith, Levett, Collins, et al., 2011). For this technique, a woman uses a photograph of someone important to her or some setting she finds appealing such as a beautiful sunset. She concentrates on the photo during contractions (focusing). A woman 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 contractions, all of which help prevent her from concentrating on the pain of contractions. If a woman has never used these techniques before, she may question how effective they are. Urge her to try one of them at least for a few contractions before she dismisses them entirely, as evidence supports their efficacy (Hodnett et al., 2013). Do not ask questions or talk while a woman is using focusing, imagery, or chanting because that is apt to break her concentration and let the sensation of pain break through. QSEN Checkpoint Question 16.2 EVIDENCE-BASED PRACTICE To investigate if listening to music can help women feel less pain and anxiety in labor, researchers assigned 30 primiparas expected to have normal spontaneous births to either an experimental group that received routine labor care or a control group that received routine care plus music therapy. Both women and their nurses assessed the degree of pain experienced during labor. Results of the study revealed women who listened to music had significantly lower pain during the latent phase of labor (Simavli, Gumus, Kaygusuz, et al., 2014). Based on this study, which statement by Jonny represents the best way to use music therapy in labor? a. “I’ve brought techno music to play during the second stage so I can push to a rhythm.” b. “I’ll need distraction most just before I have to push. I’ll save my music until then.” c. “I know music probably won’t make a difference but I’ll enjoy listening to it anyway.” d. “I brought some romantic music to play during early labor to help me relax.” Look in Appendix A for the best answer and rationale. Spirituality For many women, prayer may be the first measure they use to relieve a stress they are facing (Abbaspoor, Moghaddam-Banaem, Ahmadi, et al., 2014). Provide uninterrupted time as needed. Women may bring helpful worship objects such as a Bible or Qur’an into their birthing setting to use during prayer. Remember, these are sacred objects; be careful when changing sheets that you do not accidentally throw such important objects away or let them fall to the floor. Breathing Techniques Breathing patterns are taught in most preparation for childbirth classes and are well documented to decrease pain in labor (Dick-Read & Gaskin, 2013). They are largely distraction techniques because a woman concentrating on slow-paced breathing cannot concentrate on pain. Breathing strategies can be taught to a woman in labor if she is not familiar with their advantages before labor (see Chapter 14). Stay with her until she appreciates how useful slow-paced breathing can be and feels 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 (women freeze it 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 (squawroot), an herb that induces uterine contractions, is not recommended because of the risk of acute toxic effects such as cerebrovascular accident to the mother or fetus (Ulbricht & Windsor, 2015). Aromatherapy and Essential Oils Aromatherapy is the use of aromatic oils to complement emotional and physical well-being. Their use is based on the principle that the sense of smell plays a significant role in overall health. 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 are used in a mister so they are inhaled and then carried throughout the body. The oils may be able to penetrate cell walls and transport nutrients or oxygen to the inside of cells. The effects of aromatherapy can range from reducing postcesarean incisional pain to reducing anxiety in the first stage of labor (Fakari, Tabatabaeichehr, Kamali, et al., 2015; Metawie, Amasha, Abdraboo, et al., 2015; Roozbahani, Attarha, Akbari Torkestani, et al., 2015). The evidence regarding the efficacy of aromatherapy continues to be studied with mixed results. QSEN Checkpoint Question 16.3 INFORMATICS The nurse offers to teach Jonny controlled breathing to help with pain management until she can receive her epidural. Which instruction by the nurse would be best? a. “Lie on your back and breathe in slowly while repeating, ‘I can do this.’” b. “Hold your breath as long as you possibly can before exhaling.” c. “Breathe in as slowly as you can and then breathe out just as slowly.” d. “Pant rapidly as this best lifts your abdominal wall off your expanding uterus.” Look in Appendix A for the best answer and rationale. Heat or Cold Application The application of heat and cold has always been used for pain relief after injuries such as minor burns or strained muscles. It is only lately that their use has been investigated as effective ways to help relieve the pain of labor. Women 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 (Aasheim, Nilsen, Lukasse, et al., 2011). Caution women 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. Women 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. Cultural differences exist with preference to heat and cold. This may be evident in dietary choices or compress application (Goyal, 2016). It is imperative that nurses to provide care that is culturally competent and respectful of the practices of their patients. 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 (Fig. 16.2) (Harper, 2014). The temperature of water used should be 37°C to prevent hyperthermia of the woman and also the newborn at birth. Figure 16.2 A woman in labor enjoys the soothing effects of a warm water bath. Remind women that plastic or porcelain tubs are slippery, so they should ask for help stepping into and out of them. Do not leave women unsupervised in a tub as they could slip and have difficulty getting their head above water. A support person can join the woman in a tub or shower if she wishes and can continue with back massage or other measures she finds soothing. Timing of contractions, auscultation of fetal heart rate, and vaginal examinations can all be done without the woman needing to leave the water. The birth environment, including the use of hydrotherapy in labor, can help support physiologic birth (Stark, Remynse, & Zwelling, 2016). 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. Effleurage, the technique of gentle abdominal massage often taught with Lamaze in preparation for childbirth classes is a classic example of therapeutic touch (see Chapter 14, Fig. 14.8). Reiki can also promote healing. The term Reiki consists of two Japanese words: rei, which means “God’s wisdom or the higher power,” and ki, which means “life force energy.” So Reiki is actually “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 (Rakestraw, 2010). 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. 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 women find massage, especially of the lower back or feet, helpful in the first and second stages of labor (L. Jones et al., 2012; Smith et al., 2012). QSEN Checkpoint Question 16.4 SAFETY Jonny asks the nurse if she could safely use warm water tub bathing during labor. Which answer by the nurse would be best? a. “No. The chilling that sometimes results can lead to hypothermia.” b. “Yes, as long as your membranes are not ruptured.” c. “No. This technique will separate you from your partner.” d. “Yes, as long as you know warm water has no significant effect.” Look in Appendix A for the best answer and rationale. 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 through the release of endorphins. Mothers who engage in yoga prenatally have been shown to have a greater sense of self-efficacy and may experience fewer episodes of antenatal depression (Battle, Uebelacker, Magee, et al., 2015; Schwartz, Toohill, Creedy, et al., 2015). Meditation is a self-directed practice for relaxing the body and calming the mind. Mindfulness-based stress reduction (MBSR), an 8-week intervention program developed by Dr. John Kabat Zinn for patients dealing with issues of chronic pain, is based on the cultivation of intentional awareness of experiences in the present moment. Transcendental meditation (TM) 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 (Chan, 2016). Women can meditate in any position. Do not interrupt a woman using meditation as a pain relief technique if at all possible in order to not break her concentration. Reflexology Reflexology is the practice of stimulating the hands, feet, and ears as a form of therapy (Smith, Levett, Collins, et al., 2012). Professional reflexologists apply pressure to specific areas of the hands, feet, and ears to alleviate common ailments such as headache, back pain, sinus colds, and stress. 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 Hypnosis is yet another method that can be used for pain relief in labor. A woman who wants to use this modality needs to meet with her hypnotherapist during pregnancy. At these visits, she is evaluated for and conditioned for susceptibility to hypnotic suggestion. Close to her last weeks of pregnancy, she is given a posthypnotic suggestion that she will experience a reduction in or absence of pain during labor. Fully awake and able to participate in labor, the woman who is susceptible to hypnotic suggestion may find this may provide a very satisfactory and drug-free method of pain relief (Streibert, Reinhard, Yuan, et al., 2015). A woman who wants to use this system but began labor before the posthypnotic suggestion was given may be very disappointed to find herself in labor without the help she envisioned. Some hypnotists may visit during labor or supply the suggestion over the telephone so a woman can still use the method. Further research is needed to determine the effectiveness of the effects of hypnosis on pain relief in labor (Madden, Middleton, Cyna, et al., 2016). Biofeedback Biofeedback is based on the belief that people have control and can regulate internal events such as heart rate and pain responses. Women 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 woman’s ability to relax. Evidence is continuing to emerge that shows biofeedback is an effective method for reducing the pain of labor (Janula & Mahipal, 2015). Transcutaneous Electrical Nerve Stimulation Transcutaneous electrical nerve stimulation (TENS) works to relieve pain by applying counterirritation to nociceptors (Santana, Gallo, Ferreira, et al., 2016). When two pairs of electrodes are attached to a woman’s back to coincide with the T10 through L1 nerve pathways, low-intensity electrical stimulation is given continuously or is applied by the woman herself 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. TENS can be as effective as epidural anesthesia for pain relief in labor, although some women object to being “tied down” to the equipment. Women with extreme back pain may benefit most from a TENS unit because this type of pain is difficult to relieve with controlled breathing exercises (Santana et al., 2016). This method may not only reduce the need for epidural anesthesia but also postpone the use of pharmacologic agents (Santana et al., 2016). TENS is further discussed in Chapter 24 as it applies to postoperative pain of a cesarean birth. 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 (Derry, Straube, Moore, et al., 2012). Although some women find the technique helpful, there is little evidence as to its effectiveness; other women 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 (Ozgoli, Mobarakabadi, Heshmat, et al., 2016). Acupuncture may also decrease the duration of labor (Asadi, Maharlouei, Khalili, et al., 2015). 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 women in labor is Co4 (Hoku or Hegu point), which is located between the first finger and thumb on the back of the hand. Women may report 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 maternal anxiety as well as the length of labor when specific pressure points are used (Akbarzadeh, Masoudi, Zare, et al., 2015). What If . . . 16.1 The nurse had met Jonny during pregnancy and discovered she did not attend any preparation for childbirth classes because she planned to rely totally on epidural anesthesia for pain relief. Would the nurse have supported her plan? Now that she is in early labor, what are some complementary and alternative therapies the nurse could teach her to use while she waits for anesthesia? 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 for the woman during labor and birth. Women, afterward, had difficulty believing the birth was over and that the infant was their child. This led to an era (late 1960s to the 1980s) in which women refused pharmacologic pain relief in labor and depended entirely on prepared childbirth measures such as breathing patterns. Since the advent of epidural anesthesia, women now have more options regarding how much or what kind of pain relief they want in labor (Anim-Somuah, Smyth, & Jones, 2011). 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 pain sensation. For the best results, be certain women are included in the selection of these methods and understand any fetal effects or maternal side effects that might occur. 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 maternal and fetal responses to the administration of systemic medication. However, labor should not test a woman to the limit of her endurance because both analgesia and anesthesia are available. Be sure to caution women not to take acetylsalicylic acid (aspirin) for pain in labor as aspirin interferes with blood coagulation, increasing the risk for bleeding in the newborn or herself. In addition, the manufacturers of pain relief patches such as Salonpas, Absorbine Jr., and Icy Hot caution women not to use these in labor because of the potentially teratogenic effect of the menthol ingredient. The best approach to pain management for women in labor is to always aid any pharmacologic intervention with a complementary or alternative therapy measure. For example, an intramuscular analgesic can be linked with breathing exercises to make both more effective. Goals of Pharmacologic Pain Management During Labor The ideal or goal of medications used during labor is to relax a woman and relieve her discomfort and yet have minimal systemic effects on uterine contractions, her pushing effort, or the fetus (Box 16.4). 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. BOX 16.4 Nursing Care Planning Based on Family Teaching Q. Jonny asks you, “Can I choose what medicine I want to use in labor for pain or do I have to do whatever my doctor says?” A. A number of helpful rules about pain in labor are: • You have the right to choose how much pharmacologic pain relief you want to use. • It’s best if analgesia and anesthesia are begun after labor is well established, although this should be balanced against the need for pain relief. • Any drug used should provide maximum relief for you and have minimal effect on your fetus. • Constant fetal and maternal monitoring should be available, although periodic monitoring is acceptable. • Any medicine given should not interfere with the ability of your uterus to contract during labor or interfere with contraction after labor to prevent uterine hemorrhage. If a drug causes a systemic response, such as hypotension in a woman, 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 woman may be unable to work effectively with contractions, thus prolonging labor and increasing discomfort for her. 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, a woman

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