Physiology of labor pain Examine how physical and psychological forces interact in the laboring woman's pain experience

Theories of labor pain Describe use of Pharmacologic pain relief methods. Describe use of Non Pharmacologic pain management techniques in labor Explain the nursing management of woman in labor pain

Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.

Showing pain sensors in the skin Otherwise called NOCICEPTOR

Event stimulates pain receptors Stimulus is transferred via specialized nerves to the spinal cord From there up to the brain- processed in the brain Brain sends an impulse down the spinal cord, via descending nerves Command the body to react eg withdraw the hand from a very hot object.

 There

are 3 types of sensory nerve fibres that interpret sensations in our bodies. A - d (delta) fibres, which are medium nerve fibres that sense brief, sharp, jabbing or 'pricking' type pain. C fibres, which are small nerve fibres that sense longer lasting, burning or aching sensations. A - b (beta) fibres, which are large skin nerve fibres that can sense light touch, heat, cold and massage.

From the pain receptors, the pain stimulus is transmitted through peripheral nerves to the spinal cord and from there to the brain. This happens through two different types of nerves fibers: A-delta "fast pain and C-fibers slow pain nerve fibers.

Pain in labor is transmitted along the A - d (delta) and C nerve fibres that are designed to sense sharp, burning or aching pain. These nerves sense the contractions of the uterus, the dilation of the cervix and the Pressure and stretching of the vagina, pelvic floor and perineum. The A - b (beta) skin nerve fibres come into play in the final stages of the birth, as the skin of the perineum and anus stretch.

Gate Control Theory

Dorsal horn cell acts as a gate to control impulses transmitted to the brain. When the gate is open the person feels pain and pain impulses stop when the gate is closed Opening the gate is influenced by small- diameter sensory nerve fibers Closing the gate is by large- diameter fibers

Visceral Pain Occurs during 1st stage of labor Diffuse abdominal cramping and uterine contractions Caused by uterine distention and stretching of the cervix These stimuli are transmitted to the spinal cord at the level of the tenth thoracic to the first lumbar root

Somatic Pain Occurs in 2nd stage of labor Sharper, stinging, more continuous type of pain Usually in the vagina, rectum, and perineum Due to stretching of the structures of the lower birth canal Caused by the descent of the fetus These stimuli are transmitted via the pudendal nerve to the second to fourth sacral nerves

 Increase

in anxiety & fear causing release of epinephrine & nor- epinephrine which causes vasoconstriction & reduced blood flow to & from the placenta as well as decreased effectiveness of uterine contractions Labor also increases the metabolic rate & demand for oxygen so she breaths fast to get more oxygen & exhales too much CO2 this alter placental exchange which may result in fetal metabolic acidosis

PSYCHOLOGICAL EFFECT OF PAIN Poorly relived pain lessens the pleasure of labor experience Bonding may be affected Woman may feel helpless & frustrated May affect sexual activity & future labors

The discomfort experienced during labor has 4 sources : 1.Bood supply to uterus decreases during contractions causing tissue ischemia 2.Dilatation & stretching of cervix & lower uterus are a major source of pain 3.Some pain results from pressure & pulling on pelvic structures 4.Distention of the vagina & perineum during 2nd stage may cause burning, tearing, or splitting sensation

Psychosocial variables influence a woman's experience of pain Culture Anxiety and Fear Previous experiences with pain Preparation For Child Birth

Intensity of labor Cervical readiness Fetal position Maternal pelvis Fatigue Hunger Interventions of caregivers

Less pain
Small baby Multiparty Short labor Mature mum Birthing classes

More pain
Big baby First baby Long labor Oxytocin Immaturity Little education

 Regional

pain management techniques Systemic Drugs General Anesthesia

 it is a popular regional block that provides analgesia & anesthesia for labor & birth without sedation An epidural block is done by injecting local anesthetic, usually combined with opiod drugs, in the epidural space May be continuous or intermittent Side effects may include spinal headache
Epidural

Adverse effects may include: Hypotension Bladder distention Prolonged 2nd stage Catheter migration Maternal fever Nausea, vomiting Pruritis Delayed respiratory suppression

PCEA, more commonly called a "patient controlled epidural analgesia," or simply an "epidural", is one of many options for pain control (analgesia) during labor. It is achieved by injecting pain medicine directly into the epidural space of the lower back via a small plastic tube.

This epidural catheter is typically left in place so that additional medication can be administered for as long as women are in labor. Once woman have delivered, it is removed. PCEA is generally considered one of the most effective methods for patients wishing for pain relief but wanting to

be awake and able to participate in the birth. Patient controlled means that you help decide what level of pain relief you require.

Record base line maternal vital signs, FHR Intravenous Fluids Electric shock sensation is felt as catheter is passed. Nurse should assist until the block is completed Observe for signs of subarachnoid puncture maternal BP and FHR every 5 minutes during first 15 minutes after initiation of epidural medication Bladder status to assess due large fluid load and reduced sensation to void

A spinal usually involves a single ,one time dose of anesthetic, which is injected beyond the epidural space in to the fluid filled spinal canal. A spinal takes effect almost immediately but is shorter acting.

Adverse Effects Of Intrathecal Opiods Nausea ,vomiting Pruritus Delayed maternal respiratory depression Nursing Care Vital signs and FHR To watch for side effects To watch for drug`s reduced effectiveness

Parental Analgesia Opioid analgesics is used as it reduces pain without loss of consciousness Drugs used are meperidine,fentanyl,butorphanol and nalbuphine Meperidine : 12.5-50 mg every 2-4 hr I.V may be given by PCA Side Effect : Respiratory depression in the neonate Fentanyl : 50-100 mg, every hr may be given by PCA Side Effect : Nausea ,vomiting and respiratory depression Epidural may cause pruritus

Butorphanol : 1 mg every 3-4 hr range 0.5-2mg; I.V may be given by PCA Nalbuphine : 10 mg every 3-6 hr I.V may be given by PCA Side Effect : Same as butorphanol Pruritus associated with epidural narcotics

Sedatives Small dose of short acting barbiturate given to promote rest to woman in prolonged latent phase not given routinely as it may prolong depressant effects Vaginal Birth Anesthesia Local infiltration of the perineum prior to episiotomy suturing a laceration Pudental Block Anesthetizes lower vagina and part of perineum Injecting pudental nerves near each ischial spine with local anesthetic Perineum is infiltrated with local anesthetic

Systemic pain control with loss of consciousness Used in cesarean births Adverse Effects Maternal Aspiration of gastric contents Respiratory Depression Uterine relaxation

Warm Water Baths Involves immersion in warm water deep enough to cover the womans abdomen Women who used water immersion during the first stage of labor reported statistically significantly less pain than those not laboring in water

 Intradermal Water Injections

Used to decrease low back pain in labor Intradermal injections of 0.05- 0.1mL sterile water
Maternal Movement and Positioning Most women prefer upright positions over sitting or supine

Touch and Massage Used during labor to enhance relaxation and reduce pain and suffering Touch relaxation : helps to loosen taut muscles when touched by her partner Transcutaneous Electrical Nerve Stimulation (TENS) Transmission of low-voltage electrical impulses from a handheld battery Causes a buzzing or prickling sensation that may reduce awareness of contraction pain

Acupressure Pressure is applied simultaneously to both sides of the spine in the lower back

Aromatherapy The science of using highly concentrated essential oils or essences distilled from plants in order to utilize their therapeutic properties Music and Audio analgesia The use of auditory stimulation, such as music or environmental sounds to decrease pain perception Childbirth Education Individual or group classes designed to inform pregnant women and their partners about labor and birth, early parenthood, and infant feeding

Breathing Techniques Cleansing Breath : Each contraction begins and ends with a deep inspiration and expiration Slow Paced Breathing : A slow deep breathing that increases relaxation Modified Paced Breathing : Chest breathing at a faster rate allows oxygen intake to remain about the same. Patterned- Paced Breathing : after certain breaths woman exhales with a blow and begins modified paced breathing Breathing to Prevent Pushing : Blowing prevents closure of glottis and breath holding, helping to overcome the urge to push strenuously

MENTAL STIMULATION
Occupy woman's mind and compete with pain stimuli. Imagery : create a mental scene pleasant relaxed mental image as a way to decrease the pain intensity Hypnosis A state of focused concentration in which suggestions may be made, focusing on diminishing awareness of pain, fear and anxiety

Nursing Diagnosis Pain related to effects of uterine contractions and pressure on pelvic structures Planning : Pain relief measures both Pharmacologic and non Pharmacologic methods Interventions : Promoting Relaxation Reducing Outside sources of Discomfort Reducing Anxiety and Fear Helping to use Non Pharmacologic Techniques Incorporating Pharmacologic methods Evaluation Pain rating scale

Sharon Smith and Emily Slone Foundations of Maternal Newborn Nursing ,4th edition ,Saunders publications Margaret .F. Myles Text book for Midwives14th edition, Churchill Livingstone