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Chapter 16

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NUR1 233
Sonia Elizabeth Semenic

Chapter 16: Management of Discomfort Discomfort during labor and birth Neurological origins o visceral and somatic origins of pain and discomfort during labor o 1 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 nd Pain during contractions and not between contractions some have continuous o 2 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 3 stage of labor and afterpains: similar to that experienced udring 1 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 Transition phsae of 1 stage and 2 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 2 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 Womans 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 1 stage contractions, shallow breathing for later 1 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 Coalition to improve maternity services o Birth is normal, natural and healthy o Expeience of birth profoundly affects owmen and thier families o Womens inner wisdom guides them through birth o Womens 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 relaxat
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