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Chapter 16

NUR1 233 Chapter Notes - Chapter 16: Meconium, Uterine Atony, Subarachnoid Space


Department
Nursing
Course Code
NUR1 233
Professor
Sonia Elizabeth Semenic
Chapter
16

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Chapter 16: Management of Discomfort
Discomfort during labor and birth
Neurological origins
o visceral and somatic origins of pain and discomfort during labor
o 1st stage of labor: uteirne contractions cause cervical dilation and effacement
Uterine ischemia (decreased blood flow and local O2 deficit) results from compression of arteries
supplying myometrium during uterine contractions
Pain impulses: transmitted through T10 and T12 spinal nerve segment and accessory lower thoracic
and upper lumbar sympathetic nerves nerves originate in uterine body and cervix
Visceral pain: pain from cervical changes, distention of lower uterine segment and uterine ischemia
located over lower portion of abdomen
Referred pain: occurs when pain originated in uterus and radiated to abdominal wall, lumbosacral
area of back, iliac crests, gluteal area, and down thighs
Pain during contractions and not between contractions some have continuous
o 2nd stage of labor: stage of expulsion of baby
Somatic pain: intesnse, sharp, burning and well localized
Results from: stretching and distention of perineal tissues and pelvic floor to allow passage of fetus,
from distention and traction on the peritoneum and uterocervical supports during contractions, and
from lacerations of soft tissue
Discomfort: expulsive forces or pressure exerted by presenting part on bladder, bowel, or other
sensitive pelvic structures
Pain impulses: transmitted from perineal tissues via S2-S4 and parasympatic system
o 3rd stage of labor and afterpains: similar to that experienced udring 1st stage lower back, vagina, abdomen
Perception of pain: ethnic, social, and cultural differences
Expression of pain:
o Sympathetic activity: stimulated in response to pain, resulting in increase atecholamine level
o BP and HR: increase
o Respiraion: increased O2 needs hyperventilation resp. alkalosis
o Pallor and diaphoresis
o Gastric acidity: increases
o Nausea and vomitting are common in active phase of labor
o Placetal perfusion: may decrease and uterine activity may diminish potentially prolonging labor and
affecting fetal well-being
o Sensory quality of visceral and somatic pain: prickling, stabbing, burning, bursting, aching, heavy, pulling,
throbbing, sharp, shooting, stinging, cramping
o Emotional quality of visceral and somatic pain: tiring, exhausting, annoying, sickening, and nauseating
Factors influencing pain response
o History of dysmenorrhea: may experience increased pain as result of increased prostaglandin levels
o Back pain with mentruation: increase contraction-related lower back pain
o Upright position: decreased pain and increased comfort compared to supine position
o Endorphins and endogenous opiods: secreted by pituitary gland act on central an dperipheral nervous
systems to reduce pain
B-Endorphin: most potent of endorphins higher levels for spontaneous, natural birth
higher endorphin levels increase ability of women in labor to tolerate acute pain and may reduce
irritabilty and anxiety
o Anxiety and fear
Excessive anxiety: increase in catecholamine secretion more pelvic pain stimuli reaching brain
magifies pain perception
Anxiety heightens muscle tension increases effectiveness of uterine contractions decreases
discomfort intensifies
o Previous experience
Nulliparous: sensory pain greater during early labor than for multiparous women because
reproductive tract structures are less supple

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Transition phsae of 1st stage and 2nd stage: multiparous women experience greater sensory pain
than nulliparous women because their more supple tissue increases speed of fetal descent and
intensifies pain
Nulliparous: firmer tissue more slow and gradual descent
Affective pain: greater for nulliparous women throughout first stage of labor but decreases for both
nulliparous and multiparous women during 2nd stage of labor
Fatigue and sleep deprivation: magnify pain
o Gate-control theory of pain
Certain nerve cell groupings within spinal cord, brainstem, and cerebral cortex have the ability to
modulate the pain impulse through a blocking mechanism
Helps explain the way hypnosis and the pain relief techniques taught in childbirth classes work to
relive the pain of labor
Pain sensations travel along sensory nerve pathways to the brain but only a limited number of
sensations can travel through these nerve pathways at one time
Distraction: massage, music, focal points, imageery the capacity of nerve pathways to transmit
pain is reduced or blocked distractions close down a hypothetic gate in the spinal cord and prevent
signals from reaching the brain
Cognitive work involving concentration on breathing and relaxation requires selective and directed
cortical activity that activates and closes the gating mechanism as well
Gate-control theory underscores need for supportive birth setting that allows the laboring woman to
relax and use various higher mental activities
o Support
Woman’s satisfaction with her childbirth experience is primarily influenced by the attitudes and
behaviors of her caregivers and ability to communicate and be helpful and supportive
o Environment
Persons present and physical space in which labor occurs
Should be safe and private allowing woman to feel free to be herself as she tries out different comfort
measures
Nonpharmacological Management of Discomfort
Not the amount of pain the woman experiences but whether she meets her goals for herself in coping with the pain
that influences her perception of the birth experience as good or bad
Hypnosis, relaxation, massage and touch, slow-paced breathing, aromatherapy, childbirth education, imagery, music,
walking, rocking, acupressure, intradermal water block, effleurage (light massage)
The analgesic effec of many nonpharmalogical measures is comparable to or even superior to opiods that are
administered parentally
None more effective than methods of epidural analgesia
Little scientific evidence regarding effectiveness of nonpharmacological measures in relieving the pain of childbirth
Early Methods of Childbirth Education
Dick-read method
o Pain in childbirth is socially conditioned and caused by a fear-tension-pain syndrome
o Recommended: deep abdominal breathing during 1st stage contractions, shallow breathing for later 1st stage
and sustained pushing iwth breath holding
o Taught to: relax different muscle groups through entire body, consciously, and progressively until a high
degree of skill at relaxation achieved relax completely between contractions and keep all muscles except
uterus relaxed during contractions
Lamaze method
o Emphasized control using the mind
o Controlled muscular relaxation and breathing techniques
o Contract specific muscle groups while relaxing the remainder of body
o Conditioned to respond with relaxation and breathing patterns to uteirne contractions
Bradley method
o Natural childbirth: no anesthesia or analgesia and with a husband-coach and breathing techinuqes for labor
o Used breath control, abdominal breathing and general body relaxation
o Working in harmony with body emphasized
o Environmental variables: darkness, solitude, and quiet to make childbirth more natural experience
Newer Methods of Childbirth Education
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Coalition to improve maternity services
o Birth is normal, natural and healthy
o Expeience of birth profoundly affects owmen and thier families
o Women’s inner wisdom guides them through birth
o Women’s confidence and ability to give birth is either enhanced or diminished by the care provider and place
o Women have right to give birth free from routine medical interventions
o Birth can safely take place in birth centers and homes and hospitals
o Childbirth education empowers women to make informed choices in health care, to assume responsibility for
their health and to trust thier inner wisdom
Hypnobirthing
o Fear and tension leads to pain
o Pregnant women learn how birthing muscles work when woman in state of relaxation
Birthing from within
o Childbirth not a medical event but profound rite of pasage
o Parents taught power of birthing-in awareness
o Birth taught from 4 perspectives: mother, father, baby, culture
o Fathers: provide most help as long partners and birth guardians and not coaches
Childbirth and postpartum professional association
o Provides professinonal membership and training to antepartum doulas, childbirth educators, labor doulas,,
postpartum doulas, and lactation educators
o Generally recommend deep abdominal breathing relaxation, vocalization, position changes, walking,
frequent urination, and hydrotherapy
Relaxation and breathing techniques
Relaxation
o Relaxation skill is the most effective nonpharmacologic strategy for coping with stress of labor
o Ideally combined with activity such as walking, slow dancing, rocking, and position changes wihch help baby
rotate thorugh pelvis
o Rythmic motion stimulates mechanoreceptors in the brain, which decreases pain perception
Imagery and visualization
o Useful in preparation for birth
o Used to produce a sense of well-being during pregnancy, assist with cervical dilation, and decrease experience
of pain and tension
Music: enhances relaxation, reduces stress and perception of pain
Touch and massage
o Holding hand, stroking body and embracing
o Hand, head, back and food massage very effective in reducing tension and enhancing comfort
o Hand and food massage: especially relaxing in advanced labor when hyperesthesia limits woman’s tolerance
for touch on other parts of body
Energy work
o Therapeutic touch or healing touch involves manipulation of energy fields around body and can decrease
anxiety and pain and increase relaxation
Conscious breathing
o Alkalosis: breathe into paper bag held tightly around mouth rebreathe CO2 and replace bicarbonate ion
Effleurage and counterpressure
o Bring relief in 1st stage
o Effleurage: light stroking, usually of abdomen, in rhythm with breathing during contractions
o Used to distract woman from contraction pain
o Counterpressure: steady pressure in sacral area with fist or heel of hand, which may help woman cope with
sensation of internal pressure and pain in the lower back
Water therapy (hydrotherapy)
o Showers in early labor provide relaxation and comfort
o Sitting in tub of water up to shoulders for 1-2 hours has several immediate benefits
o Buoyancy in water: gneeral body relaxation and temporary relief from discomfort and pain
o Catecholamine production decreases increase in oxytocon and endorphins
o Back labor: as a result of occiput posterior or transverse position encouraged to assume hands-and-knees
position or side-lying position in tub decreases pain and increases relaxation and production of oxytocin
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