Management of discomfort. Nursing care during labour and birth
Prepared by Assistant professor N.Petrenko, MD, PhD
KEY TERMS AND DEFINITIONS
analgesia Absence of pain without loss of consciousness
anesthesia Partial or complete absence of sensation with or without loss of consciousness
ataractics Medications capable of promoting tranquility; tranquilizers
Bradley method Husband-coached childbirth preparation method using labor breathing techniques and environmental modification
counterpressure Pressure applied to the sacral area of the back during uterine contractions
Dick-Read method A prepared childbirth approach based on the premise that fear of pain produces muscular tension, producing pain, and greater fear; includes teaching physiologic processes of labor, exercise to improve muscle tone, and techniques to assist in relaxation and prevent the fear-tension-pain mechanism
effleurage Gentle stroking used in massage
epidural block Type of regional anesthesia produced by injection of a local anesthetic alone or in combination with a narcotic analgesic into the epidural (peridural) space
epidural blood patch A patch formed by a few milliliters of the mother's blood occluding a tear in the dura mater around the spinal cord that occurs during induction of spinal block; its purpose is to prevent headache associated with leakage of spinal fluid
gate-control theory of pain Pain theory used to explain the neurophysiologic mechanism underlying the perception of pain: the capacity of nerve pathways to transmit pain is reduced or completely blocked by using distraction techniques
Lamaze (psychoprophylaxis) method Childbirth preparation method developed in the 1950s by a French obstetrician, Fernand Lamaze, that gained popularity in the United States in the 1960s; requires practice at home and coaching during labor and birth; goals are to minimize fear and the perception of pain and to promote positive family relationships by using both mental and physical preparation, including breathing and relaxation techniques, effleurage, and focusing
local infiltration anesthesia Process by which a substance such as a local anesthetic medication is deposited within the tissue to anesthetize a limited region of the body
neonatal narcosis Central nervous system depression in the newborn caused by an opioid (narcotic); may be exhibited by respiratory depression, hypotonia, lethargy, and delay in temperature regulation
opioid (narcotic) agonist analgesics Medications that relieve pain by activating opioid receptors
opioid (narcotic) agonist-antagonist analgesics Medications that combine agonist activity (activates or stimulates a receptor to perform a function) and antagonist activity (blocks a receptor or medication designed to activate a receptor) to relieve pain without causing significant maternal or fetal/newborn respiratory depression
opioid (narcotic) antagonists Medications used to reverse the effects of an opioid (e.g., naloxone reverses the effects of meperidine)
pudendal block Injection of a local anesthetic at the pudendal nerve root to produce numbness of the genital and perianal region
spinal block Regional anesthesia induced by injection of a local anesthetic agent into the subarachnoid space at the level of the third, fourth, or fifth lumbar interspace
systemic analgesia Pain relief induced when an analgesic is administered parenterally (e.g., subcutaneous, intramuscular, or intravenous route) and crosses the blood-brain barrier to provide central analgesic effects
active phase Phase in the first stage of labor when the cervix dilates from 4 to 7 cm
amniotomy Artificial rupture of the fetal membranes (AROM), using a plastic Amnihook or surgical clamp
bloody or pink show Blood-tinged mucoid vaginal discharge that originates in the cervix and indicates passage of the mucous plug (operculum) as the cervix ripens before labor and dilates during labor; it increases as labor progresses crowning Phase in the descent of the fetus when the top of the head can be seen at the vaginal orifice as the widest part of the head (biparietal diameter) distends the vulva just before birth
doula Experienced female assistant hired to give the woman support during labor and birth
episiotomy Surgical incision of the perineum at the end of the second stage of labor to facilitate birth and to avoid laceration of the perineum
fern test The appearance of a fernlike pattern found on microscopic examination of certain fluids such as amniotic fluid
first stage of labor Stage of labor from the onset of regular uterine contractions to full effacement and dilation of the cervix
latent phase Phase in the first stage of labor when the cervix dilates from 0 to 3 cm
Leopold's maneuvers Four maneuvers for diagnosing the fetal position by external palpation of the mother's abdomen
lithotomy position Position in which the woman lies on her back with her knees flexed and with abducted thighs drawn up toward her chest; stirrups attached to an examination table can be used to facilitate assumption of this position
nitrazine test Evaluation of body fluids using a test strip to determine the fluid's pH; urine will exhibit an acidic result and amniotic fluid will exhibit an alkaline result
nuchal cord Encircling of fetal neck by one or more loops of umbilical cord
Ritgen maneuver Technique used to control the birth of the head; upward pressure from the coccygeal region to extend the head during the actual birth
rupture of membranes (ROM) Integrity of the amniotic membranes is broken either spontaneously or artificially (amniotomy)
second stage of labor Stage of labor from full dilation of the cervix to the birth of the baby
spontaneous rupture of membranes (SROM, SRM) Rupture of membranes by natural means, most often during labor
third stage of labor Stage of labor from the birth of the baby to the separation and expulsion of the placenta
transition phase Phase in the first stage of labor when the cervix dilates from 8 to 1 0 cm
uterine contractions Primary powers of labor that act involuntarily to dilate and efface the cervix, expel the fetus, facilitate separation of the placenta, and prevent hemorrhage
Pregnant women commonly worry about the pain they will experience during labor and birth and how they will react to and deal with that pain. A variety of childbirth preparation methods can help the woman or couple cope with the discomfort of labor. The interventions selected depend on the situation and the preference of both the woman and her health care provider. The discomforts experienced during labor are discussed in this chapter, as are the nonpharmacologic and pharmacologic interventions to relieve the discomforts possible during the different stages of labor. This information provides the basis for understanding the nurse's role in the management of maternal discomfort during labor.
DISCOMFORT DURING LABOR AND BIRTH
The discomfort experienced during labor has two origins (Lowe, 1996). During the first stage of labor, uterine contractions cause cervical dilation and effacement, and uterine ischemia (decreased blood flow and therefore local oxygen deficit) results from compression of the arteries supplying the myometrium. Pain impulses during the first stage of labor are transmitted via the T i l and T12 spinal nerve segment and accessory lower thoracic and upper lumbar sympathetic nerves. These nerves originate in the uterine body and cervix.
The discomfort from the cervical changes and uterine ischemia is visceral pain. It is located over the lower portion of the abdomen and radiates to the lumbar area of the back and down the thighs. The woman usually experiences discomfort only during contractions and is free of pain between contractions.
During the second stage of labor, the stage of expulsion of the baby, the woman experiences perineal or somatic pain. Perineal discomfort results from stretching of perineal tissues to allow passage of the fetus and from traction on the peritoneum and uterocervical supports during contractions. Discomfort also can be produced by expulsive forces or by pressure exerted by the presenting part on the bladder, bowel, or other sensitive pelvic structures. Pain impulses during the second stage of labor are transmitted via the SI to S4 spinal nerve segments and the parasympathetic system.
Pain experienced during the third stage of labor and the afterpains of the early postpartum period are uterine, similar to the pain experienced early in the first stage of labor. Areas of discomfort during labor are shown in Fig. 1.
Fig. 1 Discomfort during labor. A, Distribution of labor pain during first stage. B, Distribution of labor pain during transition and early phase of second stage. C, Distribution of pain during late second stage and actual birth. (Gray areas indicate mild discomfort; light-colored areas indicate moderate discomfort; dark-colored areas indicate intense discomfort.)
Pain may be local, with cramping and a tearing or bursting sensation caused by distention and laceration of the cervix, vagina, or perineal tissues. This discomfort is commonly perceived as an intense burning sensation as the tissue stretches. Pain also may be referred (referred pain), in which discomfort originating in the abdominal viscera is felt in the back, flanks, or thighs.
FACTORS INFLUENCING PAIN RESPONSE
A woman's pain during childbirth is unique to each woman and is influenced by a variety of factors. These factors include culture, anxiety and fear, previous birth experience, childbirth preparation, and support.
The obstetric population reflects the increasingly multicultural nature of U.S. society. As nurses care for women and families from a variety of cultural backgrounds, they must have knowledge and understanding of how culture mediates pain (Lee & Essoka, 1998; Weber, 1996). An understanding of the beliefs, values, and practices of various cultures helps the nurse provide appropriate culturally sensitive care.
Anxiety and fear
Anxiety and fear are commonly associated with increased pain during labor. Mild anxiety is considered normal for a woman during labor and birth. However, excessive anxiety and fear causes more catecholamine secretion, which increases the stimuli to the brain from the pelvis because of decreased blood flow and increased muscle tension; this in turn magnifies pain (Lowe, 1996). Thus, as fear and anxiety heighten, muscle tension increases, the effectiveness of the uterine contractions decreases, the experience of discomfort increases, and a cycle of increased fear and anxiety begins.
For women who have had a difficult and painful previous birth experience, anxiety and fear from this past experience may lead to increased pain. Conversely, a woman who has experienced a labor and birth where pain coping skills were successful may experience increased anxiety when those previous coping skills are ineffective during a more difficult labor and birth.
Women with a history of substance abuse experience as much pain during labor as other women. Although it is usually unnecessary to withhold pain medications, close monitoring for complications associated with each substance is part of the nursing assessment.
Pain is a personal response in each individual. As pain is experienced, people develop various coping mechanisms to deal with it. Emotional tension from anxiety and fear may increase pain and perception of pain during labor (see discussion of the Dick-Read method later in this chapter). Pain, or the possibility of pain, can induce fear in which anxiety borders on panic. Fatigue and sleep deprivation magnify pain. Parity may affect perception of labor pain because nulliparous women have longer labors and thus greater fatigue, causing a vicious cycle of increased pain and a more likely use of pharmacologic support.
Even pain stimuli that are particularly intense can, at times, be ignored. This is possible because certain nerve cell groupings within the spinal cord, brainstem, and cerebral cortex have the ability to modulate the pain impulse through a blocking mechanism. The gate-control theory of pain helps explain the way hypnosis and pain relief techniques taught in childbirth preparation classes work to relieve the pain of labor. According to this theory, pain sensations travel along sensory nerve pathways to the brain, but only a limited number of sensations, or messages, can travel through these nerve pathways at one time. Using distraction techniques such as massage or stroking, music, and imagery reduces or completely blocks the capacity of nerve pathways to transmit pain. These distractions are thought to work by closing down a hypothetic gate in the spinal cord, thus preventing pain signals from reaching the brain. Perception of pain is thereby diminished.
In addition, when the laboring woman engages in neuromuscular and motor activity, activity within the spinal cord itself further modifies the transmission of pain. Cognitive work involving concentration on breathing and relaxation requires selective and directed cortical activity that activates and closes the gating mechanism as well. The gate-control theory therefore underscores the need for a supportive birth setting that allows the laboring woman to relax and use various higher mental activities.
Although the predominant medical approach to labor is that it is painful and the pain must be removed, an alternative view is that labor is a natural process and women can experience comfort and transcend the discomfort or pain (Schuiling & Sampselle, 1999). Having needs and desires met engenders a feeling of comfort. Comfort may be viewed as strengthening; this represents a paradigm shift in the interpretation of pain in labor (Schuiling & Sampselle, 1999). The most helpful interventions in enhancing comfort are a caring nursing approach and a supportive presence.
The pain occurring during childbirth and the management of this pain belong to the woman experiencing the pain; the nurse must engage in a cooperative effort to provide whatever external tools the woman requires to manage her pain experience (Lowe, 1996). These tools include both nonpharmacologic and pharmacologic interventions. The presence of a person (e.g., doula, family member, friend) who provides physical, emotional, and psychologic support to the woman in labor is a beneficial form of care that significantly decreases intervention and complication rates associated with labor (Enkin et al., 2001; Righard, 2001).
Endorphins are endogenous opioids secreted by the pituitary gland that act on the central and peripheral nervous systems to reduce pain. Beta-endorphin is the most potent of the endorphins. The physiologic role of endorphins is not completely understood. It is thought that endorphin levels increase during pregnancy and birth in humans and may increase the ability of women in labor to tolerate acute pain and may reduce their irritability and anxiety. Levels of beta-endorphins are higher when a woman experiences a spontaneous, natural childbirth (Righard, 2001).
NONPHARMACOLOGIC MANAGEMENT OF DISCOMFORT
The alleviation of pain is important. Commonly, it is 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." The observant nurse looks for clues to the woman's desired level of control in the management of pain and its relief.
The woman who chooses to deal with childbirth pain using nonpharmacologic or a combination of nonpharmacologic and pharmacologic methods needs care and support from nurses and other care providers who are skilled in pain management. Nonpharmacologic methods for relief of discomfort are taught in many different types of prenatal preparation classes. Regardless of whether a woman or couple has attended these classes or read various books and magazines on the subject in advance, the nurse can teach the woman techniques to relieve discomfort while labor is in progress.
CHILDBIRTH PREPARATION METHODS
Most health care providers recommend or offer childbirth preparation classes to expectant parents. The major methods taught in the United States are the Dick-Read method, or natural childbirth method; the Lamaze method, or psychoprophylactic method; and the Bradley method, or husband-coached childbirth.
How childbirth education influences a woman's response to pain is not completely understood. Some data indicate that women who attend childbirth classes report less pain throughout labor and birth than do women who are unprepared, but other investigations have not supported this finding (Lowe, 1996). However, combined results of a number of studies suggest that not only is confidence greater after childbirth preparation but that this confidence is related to decreased pain perception and decreased analgesia during labor (Lowe, 1996).
To replace fear of the unknown with understanding and confidence, the Dick-Read method (Dick-Read, 1987) provides information on labor and birth, as well as nutrition, hygiene, and exercise. Classes include practice in three techniques: physical exercise to prepare the body for labor, conscious relaxation, and breathing patterns.
Conscious relaxation involves progressive relaxation of muscle groups in the entire body. With practice, many women can relax on command, both during and between contractions. Some woman actually sleep between contractions.
Breathing patterns include deep abdominal respirations for most of labor, shallow breathing toward the end of the first stage, and, until recently, breath holding for the second stage of labor.
Teachers of the Dick-Read method also contend that the weight of the abdominal musculature of the contracting uterus increases pain. The woman is taught to force her abdominal muscles to rise as the uterus rises forward during a contraction, thus lifting the abdominal muscles off the contracting uterus.
The Lamaze (psychoprophylaxis) method grew out of Pavlov's work on classical conditioning. According to Lamaze, pain is a conditioned response. Therefore women can also be conditioned not to experience pain in labor. The Lamaze method does this by conditioning women to respond to mock uterine contractions with controlled muscular relaxation and breathing patterns instead of crying out and losing control (Lamaze, 1972). Coping strategies also include concentrating on a focal point, such as a favorite picture or pattern, to keep nerve pathways occupied so that they cannot respond to painful stimuli.
Fig. 2 Expectant parents learning relaxation techniques. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
The woman is taught to relax uninvolved muscle groups while she contracts a specific muscle group (Fig. 2). She applies this during labor by relaxing uninvolved muscles while her uterus contracts. The perception of maintaining control has also been found to be closely associated with satisfaction with the birth experience.
Lamaze teachers believe that chest breathing lifts the diaphragm off the contracting uterus, thus giving it more room to expand. The chest-breathing patterns are varied according to the intensity of the contractions and the progress of labor. Teachers also seek to eliminate fear by increasing the woman's understanding of her body functions and the neurophysiology of pain. Support in labor is provided by the woman's partner or other support person or by a specially trained labor attendant termed a monitrice.
The Bradley method, also called husband-coached childbirth, was devised based on observations of animal behavior during birth. It emphasizes working in harmony with the body, using breath control and abdominal breathing, and promoting general body relaxation (Bradley, 1981).
The husband or partner takes an active role in assisting the woman to relax and use correct breathing techniques. This method also stresses environmental factors such as darkness, solitude, and quiet to make childbirth a more natural experience.
Comparison of childbirth methods
Most proponents of prepared childbirth agree that the major causes of pain in labor are fear and tension. All childbirth methods attempt to reduce fear, tension, and pain by increasing the woman's knowledge of the labor and birth process, enhancing her self-confidence and sense of control, preparing a support person, and training the woman in physical conditioning and relaxation breathing. Women or couples should not expect a pain-free childbirth but rather a childbirth in which pain is controlled using a variety of methods including prepared childbirth techniques.
There are a few fine differences in approach. For example, in the Bradley method, women are discouraged from using medication and encouraged to focus inwardly and to take direction from their own body. In the Lamaze method, external focusing and distraction are stressed. In reality, few instructors adhere strictly to one particular method, but instead incorporate a variety of strategies aimed at increasing the woman's ability to cope with labor and minimize her need for medication.
RELAXING AND BREATHING TECHNIQUES
Focusing and feedback relaxation
Attention focusing and distraction techniques are forms of care likely to be beneficial in relieving labor pain (Enkin et al., 2001). Some women bring a favorite object, such as a photograph, to the labor room and focus their attention on this object during contractions. Others choose to fix their attention on some object in the labor room. In either event, as the contraction begins, they focus on the object to reduce their perception of pain. With imagery, the nurse encourages the woman to focus on a pleasant scene, a place where she feels relaxed, or an activity she enjoys. She can imagine a walk through a restful garden or breathing in light, energy, and healing color and breathing out worries and tension (Hoffart & Pross-Keene, 1998). These techniques, coupled with feedback relaxation, help the woman work with her contractions rather than against them. The support person monitors this process, telling the woman when to begin the breathing techniques (Fig. 3).
Fig. 3 Laboring woman using focusing and breathing techniques during a uterine contraction with coaching from her partner. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
In a common feedback mechanism, the woman and her coach say the word "relax" at the onset of each contraction and throughout it as needed. The nurse can assist the woman by providing a quiet environment and offering cues as needed.
Music, taped or live, cues rhythmic breathing and enhances relaxation during labor, thereby reducing stress, anxiety, and pain. Women should be encouraged to bring their musical preferences and tape or compact disc players to the hospital or birthing center. Use of a headset or earphones may increase the effectiveness of the music because other sounds will be shut out. A study of Lamazetrained women suggested that women who listened to ocean waves and Baroque and New Age music demonstrated an improvement in relaxation responses when compared with women who used only progressive relax ation techniques (Wiand, 1997). Nurses can be advocates for implementation of this complementary therapy by developing protocols for the use of music, assessing a woman's desire to use music during labor, and mobilizing the musical talents of the woman, her family, and even health care providers (Olsen, 1998).
Different approaches to childbirth preparation stress the use of varying breathing techniques to provide distraction, thereby helping the woman maintain control through contractions. In the first stage of labor, such breathing techniques can promote relaxation of the abdominal muscles and thereby increase the size of the abdominal cavity. This lessens the discomfort generated by friction between the uterus and abdominal wall during contractions. Because the muscles of the genital area also become more relaxed, they do not interfere with descent. In the second stage, breathing is used to increase abdominal pressure and thereby assist in expelling the fetus. It can also be used to relax the pudendal muscles to prevent precipitate expulsion of the fetal head.
For couples who have prepared for labor by practicing such relaxing and breathing techniques, occasional reminders may be all that is necessary to help them along. For those who have had no preparation, instruction in simple breathing and relaxation can be given early in labor and often is surprisingly successful. Motivation is high, and readiness to learn is enhanced by the reality of labor.
There are various breathing techniques for controlling pain during contractions. The nurse needs to ascertain what, if any, techniques the laboring couple knows before giving them instruction. Simple patterns are more easily learned. Paced breathing is the technique most associated with prepared childbirth. The Lamaze method uses slowpaced, modified, and patterned breathing techniques with the understanding that each labor is different and that coupies need to adapt breathing techniques to their individual birth experience.
All patterns begin with the routine cleansing breath and end with a deep breath exhaled to "blow the contraction away." In general, slow abdominal breathing, approximately half the woman's normal breathing rate, is initiated when the woman can no longer walk or talk through contractions (Box-1). As contractions increase in frequency and intensity, the woman often needs to change to a more complex, chest breathing pattern, which is more shallow and approximately twice her normal rate of breathing. This pattern would require more concentration and therefore block more painful stimuli than a simple breathing pattern.
BOX 1 Breathing Techniques
Relaxed breath in through nose and out mouth. Used at the beginning and end of each contraction.
SLOW-PACED BREATHING (APPROXIMATELY 6 TO 8 BREATHS PER MINUTE)
Not less than half normal breathing rate (no. breaths/min divided by 2)
MODIFIED-PACED BREATHING (APPROXIMATELY 32 TO 40 BREATHS PER MINUTE)
Not more than twice normal breathing rate (no. breaths/min times 2)
For more flexibility and variety, the woman may combine the slow and modified breathing by using the slow breathing for beginnings and ends of contractions and modified breathing for more intense peaks. This technique conserves energy, lessens fatigue, and reduces risk for hyperventilation.
PATTERNED-PACED BREATHING (SAME RATE AS MODIFIED)
a. 3:1 Patterned breathing
IN-OUT/IN-OUT/IN-OUT/IN-BLOW (repeat through contraction)
b. 4:1 Patterned breathing
IN-OUT/IN-OUT/IN-OUT/IN-OUT/IN-BLOW (repeat through contraction)
You may do any pattern desired, although ratios of 5:1 or higher tend to be very tiring. Some people like to do patterned breathing to a tune ("Yankee Doodle," "Old McDonald"), to a repeated phrase ("I think I can, I think I can"), or in a pyramid pattern such as 1:1, 2:1, 3:1, 4:1, 5:1-5:1, 4:1, 3:1, 2:1, 1:1.
c. Coach call: May be used when the woman needs more distraction and concentration (e.g., during transition). The woman's coach signals the breathing ratio with his or her fingers or by verbal cues, changing the ratio after each "IN-BLOW." Example:
From Shapiro, H. et al. (1997). The Lamaze ready reference guide for labor and birth (2nd ed.). Washington, DC: Chapter ASPO/Lamaze.
The most difficult time to maintain control during contractions comes when the cervix dilates to 8 to 10 cm. This phase is the transition phase of the first stage of labor. Even for the woman who has prepared for labor, concentration on breathing techniques is difficult to maintain. The type of technique used during this phase may be the 4:1 pattern: breath, breath, breath, breath, blow (as though blowing out a candle). This ratio may be increased to 6:1 or 8:1. An undesirable side effect of this type of breathing may be hyperventilation. The woman and her support person must be aware of and watch for symptoms of the resultant respiratory alkalosis: light-headedness, dizziness, tingling of the fingers, or circumoral numbness. Respiratory alkalosis may be eliminated by having the woman breathe into a paper bag held tightly around the mouth and nose. This enables her to rebreathe carbon dioxide and replace the bicarbonate ion. She can also breathe into her cupped hands if no bag is available. Maintaining a breathing rate that is no more than twice the normal rate will lessen chances of hyperventilation. The partner can help the mother maintain her breathing rate using visual, tactile, or auditory means.
As the fetal head reaches the pelvic floor, the woman may experience the urge to push and may automatically begin to exert downward pressure by contracting her abdominal muscles. Nurses guide couples in the application of breathing and relaxation methods during labor, adapting methods to their particular needs, and using pushing techniques for birth that avoid a Valsalva response (Sampselle, 1999). Such techniques often involve moaning or other noise as women push without holding their breath.
The woman can control the urge to push by taking panting breaths or by slowly exhaling through pursed lips. This is good practice for the type of breathing to be used as the fetal head is slowly born.
Effleurage and counterpressure
Effleurage (light massage) and counterpressure are two methods that have brought relief to many women during the first stage of labor. The gate-control theory may supply the reason for the effectiveness of these measures. Effleurage is a light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used to distract the woman from contraction pain. Often the presence of monitor belts makes it difficult to perform effleurage on the abdomen; thus a thigh or the chest may be used. As labor progresses, hyperesthesia may make effleurage uncomfortable and thus less effective.
Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand, which may help the woman cope with the sensations of internal pressure and pain in the lower back. It is especially helpful when back pain is caused by pressure of the occiput against spinal nerves when the fetal head is in a posterior position. Counterpressure lifts the occiput off these nerves, thereby providing some pain relief. Although not scientifically evaluated, pressure may also be applied bilaterally to the hips or knees to reduce low back pain (Simkin & Ancheta, 2000). The support person will need to be relieved occasionally because application of counterpressure is hard work.
Bathing, showering, and jet hydrotherapy (whirlpool baths) using warm water are other nonpharmacologic measures that can be used to promote comfort and relaxation during labor (Fig. 4). Many new birthing units have baths with air jets. With or without air jets, however, the buoyancy of the warm water supports and soothes tense muscles.
Fig. 4 Water therapy during labor. A, Use of shower during labor. B, Woman experiencing back labor relaxes as partner sprays warm water on her back. C, Laboring woman relaxes in Jacuzzi. Note that fetal monitoring can continue during time in the Jacuzzi. (A and B courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA; C courtesy Spacelabs Medical, Redmond, WA.)
Water therapy has several immediate benefits. General body relaxation and relief from discomfort reduce the woman's anxiety, which in turn decreases adrenaline production. This triggers an increase in the levels of oxytocin (to stimulate uterine contractions) and endorphins (to reduce pain perception). In addition, the bubbles and gentle lapping of the water stimulate the nipples, which increases oxytocin production; this has not been observed to cause uterine hyperstimulation. The cervix has often been observed to dilate 2 to 3 cm in 30 minutes of whirlpool therapy. In addition, it promotes diuresis and a decrease in blood pressure (Simkin, 1995). Whirlpool baths during labor have also been found to have positive effects on analgesia requirements, instrumentation rates, condition of the perineum, and personal satisfaction with labor (Rush et al., 1996).
If the woman is experiencing "back labor" secondary to an occiput posterior or transverse position, she is encouraged to assume the hands-and-knees or the side-lying position in the tub. Because this position decreases pain and increases relaxation and production of oxytocin, the fetus can rotate spontaneously to the occiput anterior position.
In some settings, jet hydrotherapy may need to be approved by the woman's physician or nurse-midwife. The woman's vital signs must be within normal limits, and she should be in the active phase of the first stage of labor. If she is in the latent phase, her contractions slow down (Odent, 1997). Fetal well-being must also be documented.
Fetal heart rate (FHR) monitoring is done by Doppler device, fetoscope, or wireless external monitor device (see Fig. 4, Q. Internal fetal monitoring is contraindicated during use of jet hydrotherapy. The woman's membranes may be intact or ruptured. If ruptured, the fluid must be clear or only lightly stained with meconium (Simkin, 1995).
There is no limit to the time women can stay in the bath, and often women are encouraged to stay in it as long as desired. However, most women use jet hydrotherapy for 30-60 minutes (Schorn, McAllister&Blanco, 1993). After approximately 2 hours the effectiveness of hydrotherapy seems to diminish as uterine contractions become more intense (Eriksson et al, 1997; Odent, 1997).
During the bath, if the woman's temperature and the FHR increase, the water is cooled or she is asked to step out of the bath to cool down. The bath water is kept between 36.7° and 37.8° C (Simkin, 1995). The mother's temperature may remain slightly elevated for a short time after the bath. Fluids and ice chips and a cool face cloth are offered during the bath.
The tub must be kept meticulously clean. The cleansing solutions used vary with the institution; however, household bleach (Clorox) is commonly used.
Transcutaneous Blectrical nerve stimulation
Fig. 5 Placement of TENS electrodes on back for relief of labor pain.
Transcutaneous electrical nerve stimulation (TENS) involves placing of two pairs of electrodes on either side of the woman's thoracic and sacral spine (Fig. 5). These electrodes provide continuous mild electrical currents from a battery-operated device. During a contraction the woman increases the stimulation by turning control knobs on the device. Women describe the resulting sensation as a tingling or buzzing and the pain relief as good or very good. The use of TENS poses no risk to the mother or fetus, and it is credited with reducing or eliminating the need for analgesia and with increasing the woman's perception of control over the experience. It may be effective because of the placebo effect; that is, confidence in the effectiveness of TENS may stimulate the release of endogenous opiates in the woman's body and thus alleviate the discomfort (Scott et al., 1999). At present, TENS is considered a form of care with insufficient quality data to recommend its use (Enkin et al., 2001).
The nurse assists the mother in using TENS by explaining the device and its use, by carefully placing and securing the electrodes, and by closely evaluating its effectiveness.
Other nonpharrnacologic methods
There are various other nonpharmacologic methods for control of the discomfort of labor (Box 2). Many of these are taught in childbirth preparation classes. Most need practice for best results, although the nurse may use some of them successfully without the woman having prior knowledge.
BOX 2 Nonpharmacologic Strategies to Encourage Relaxation and Relieve Pain
CUTANEOUS STIMULATION STRATEGIES
Effleurage (light massage)*
Touch and massage*
Application of heat or cold*
Transcutaneous electrical nerve stimulation
SENSORY STIMULATION STRATEGIES
Use of focal points*
*Forms of care likely to be beneficial.
From Enkin, M. et al. (2001). Effective care in pregnancy and childbirth: A synopsis. Birth, 28[\), 41-51.
Acupressure. Acupressure techniques can be used in pregnancy, labor, and postpartum to relieve pain and other discomforts. Pressure, heat, or cold is applied to acupuncture points called tsubos. These points have an increased density of neuroreceptors and increased electrical conductivity. The effectiveness of acupressure has been attributed to the gate-control theory and an increase in endorphin levels (Tiran & Mack, 2000). Acupressure is best applied over the skin without using lubricants. Pressure is usually applied with the pads of the thumbs and fingers (Fig. 6). Synchronized breathing by the caregiver and the woman is suggested for greater effectiveness. Acupressure points include shoulders, low back, hips, ankles, nails on the small toes, soles of the feet, and sacral points
Fig. 6 Ho-Ku acupressure point (back of hand where thumb and index finger come together) used to enhance uterine contractions without increasing pain. (From Dickason, E., Silverman, B., & Kaplan, J. . Maternal-infant nursing care [3rd ed.]. St. Louis: Mosby.)
Application of heat and cold. Warmed blankets, warm compresses, a warm bath or shower, or use of a moist heating pad can enhance relaxation and reduce pain during labor. Heat acts to relieve muscle ischemia and increase blood flow to the area of discomfort. Heat application is effective for back pain caused by a posterior presentation or general backache from fatigue (Simkin, 1995).
Cold application such as cool cloths or ice packs may be effective in increasing comfort when the woman feels warm and may be applied to areas of pain. Cooling relieves pain by lowering the muscle temperature and relieving muscle spasms (Simkin, 1995).
Heat and cold may be used alternately for a greater effect. Neither heat nor cold should be applied over ischemic or anesthetized areas because tissues can be damaged.
Touch. Touch and massage are forms of care likely to be beneficial in relieving labor pain (Enkin et al., 2001). Therapeutic touch (TT) uses the concept of energy fields within the body called prana. Prana are thought to be deficient in some people who are in pain. Therapeutic touch uses laying on of hands by a specially trained person to redirect energy fields associated with pain (Mackey, 1995). Little is known about the use or effectiveness of therapeutic touch for relieving labor pain.
Healing touch (HT) is another energy-based touch healing modality. Whereas TT emphasizes a single sequence of energy modulation, HT combines a variety of techniques from a series of disciplines. This gives the practitioner an array of "tools" to use with patients. Practitioners are taught energetic diagnosis and treatment forms and the means for documenting the patient's response and progress. These techniques are said to align and balance the human energy field, thereby enhancing the body's ability to heal itself. HT has been used in labor management, but at present, no studies have been published about its effectiveness (HoverKramer et al, 1996) (Fig. 7).
Fig. 7 Healing touch used for labor care. (Courtesy Wendy Wetzel, Flagstaff, AZ.)
Hypnosis. Hypnosis, although not commonly used for pain management in the United States, is associated with shorter labors and less analgesia (Tiran & Mack, 2000). Hypnosis techniques used for labor and birth place an emphasis on relaxation. The woman may be given direct suggestions about pain relief or indirect suggestions that she is experiencing diminished sensations. The woman receives posthypnotic suggestions, such as, "You will be able to push the baby out easily," to increase her confidence.
Biofeedback. Biofeedback is another relaxation technique that can be used for labor. Biofeedback is based on the theory that if a person can recognize physical signals, certain internal physiologic events can be changed (i.e., whatever signs the woman has that are associated with her pain). A woman must be educated to become aware of her body and its responses and how to relax for biofeedback to be effective (Alexander & Steeful, 1995). Informational biofeedback helps couples develop awareness of their bodies and learn strategies to change their responses to stress. If the woman responds to pain during a contraction with tightening muscles, frowning, moaning, and breath holding, her partner uses verbal and touch feedback to help her relax (Alexander & Steeful, 1995). Formal biofeedback, which uses machines to detect skin temperature, blood flow, or muscle tension, can also prepare women to intensify their relaxation response.
Aromatherapy. Aromatherapy uses oils distilled from plants, flowers, herbs, and trees to promote health and wellbeing and to treat illnesses. The use of herbal teas and vapors is reported to have good effects in pregnancy and labor for some women (Tiran & Mack, 2000). Lavender, clary sage, and bergamot promote relaxation and can be used by adding a few drops to a warm bath, to warm water used for soaking compresses that can be applied to the body, to an aromatherapy lamp to vaporize a room, or to oil for a back massage (Tiran, 1996).
NURSE ALERT Caution: Never apply the oils used for aromatherapy full strength directly to the skin.
PHARMACOLOGIC MANAGEMENT OF DISCOMFORT
Pharmacologic measures for pain management should be implemented before pain becomes so severe that catecholamines increase and labor is prolonged. Pharmacologic and nonpharmacologic measures, when used together, increase the level of pain relief and create a more positive labor experience for the woman and her family. Often, less pharmacologic intervention is required because nonpharmacologic measures enhance or potentiate the analgesic effect (Faucher & Brucker, 2000).
Sedatives such as barbiturates relieve anxiety and induce sleep only in prodromal or early latent labor and in the absence of pain. If the woman is experiencing pain, sedatives given without an analgesic may increase apprehension and cause the mother to become hyperactive and disoriented. Undesirable side effects include respiratory and vasomotor depression of both the mother and newborn. These effects are increased if a barbiturate is administered with another central nervous system (CNS) depressant such as an opioid analgesic. Because of these disadvantages, barbiturates are seldom used (Faucher & Brucker, 2000; Scott et al., 1999).
ANALGESIA AND ANESTHESIA
Nursing management of obstetric analgesia and anesthesia combines the nurse's expertise in maternity care with a knowledge and understanding of anatomy and physiology and of medications and their desired and undesired side effects and methods of administration.
Anesthesia encompasses analgesia, amnesia, relaxation, and reflex activity. Anesthesia abolishes pain perception by interrupting the nerve impulses going to the brain. The loss of sensation may be partial or complete, sometimes with the loss of consciousness.
The term analgesia is best reserved to describe the alleviation of the sensation of pain or the raising of the threshold for pain perception but without loss of consciousness. The type of analgesic or anesthetic chosen is determined in part by the stage of labor the woman is in and by the method of birth planned (Box 3).
BOX 3 Pharmacologic Control of Discomfort by Stage of Labor and Method of Birth
Narcotic analgesic compounds
Mixed narcotic agonist-antagonist compounds, analgesic potentiators
Nerve block analgesia/anesthesia
Lumbar epidural analgesia
Nerve block analgesia/anesthesia
Local infiltration anesthesia
Subarachnoid (spinal) anesthesia
Epidural and spinal narcotics
Lumbar epidural block
Saddle block (low spinal)
Lumbar epidural block
Systemic analgesia remains the major method of analgesia for the woman in labor when personnel trained in regional analgesia are not available (Scott et a l , 1999). Systemic analgesics cross the blood-brain barrier to provide central analgesic effects. They also cross the placental barrier. Effects on the fetus depend on the maternal dosage, the pharmacokinetics of the specific medication, and the route and timing of administration. Intravenous (TV) administration is often preferred over intramuscular (IM) administration because the onset of the medication's effect is faster and more reliable; as a result a higher level of pain relief usually occurs. Classes of analgesics used to relieve the pain of childbirth include opioid (narcotic) agonists and opioid (narcotic) agonist-antagonists. Tranquilizers, such as ataractics, can be used to potentiate the analgesic effect of the opioid analgesics.
Opioid (narcotic) agonist analgesics. Opioid (narcotic) agonist analgesics such as meperidine (Demerol) and fentanyl (Sublimaze) are especially effective for the relief of severe, persistent, or recurrent pain. They have no amnesic effect (see Medication Guides).
Meperidine is the most commonly used opioid agonist analgesic for women in labor (Faucher & Brucker, 2000; Scott et al., 1999). It overcomes inhibitory factors in labor and may even relax the cervix. After IV injection, the onset of its effect is rapid (30 to 60 seconds); the maximum effect is reached in 5 to 7 minutes and lasts for approximately 2 to 4 hours. The peak effect after an IM injection of meperidine is reached in 30 to 50 minutes. Ideally, birth should occur less than 1 hour or more than 4 hours after an IM injection so that neonatal CNS depression resulting from meperidine is minimized. Because tachycardia is a possible side effect, meperidine is used cautiously in women with cardiac disease (Faucher & Brucker, 2000; Lehne, 2001) (see Medication Guide).
Fentanyl is a potent, short-acting opioid agonist analgesic (see Medication Guide). Onset of the medication effect after IV injection occurs within 2 minutes and lasts approximately 30 to 60 minutes. Onset of the medication effect occurs within 7 to 8 minutes after IM injection, reaches its peak effect in 20 to 30 minutes, and lasts for 1 to 2 hours. Additive CNS and respiratory depression occurs if fentanyl is given with alcohol, antihistamines, antidepressants, or other sedative-hypnotics. Fentanyl is commonly used alone or in combination with a local anesthetic agent for induction of an epidural block (Faucher & Brucker, 2000).
Medication Guide Fentanyl (Sublimaze) and Sufentanil (Sufenta)
Opioid analgesics, rapid action with short duration (1-2 hr)
For epidural or intrathecal analgesia, usually in combination with a local anesthetic
DOSAGE AND ROUTE
Fentanyl —IM 50 to 100 /j,g; IV 25 to 50 /xg
Epidural—fentanyl, 1 to 2 g with 0.125% bupivacaine at rate of 8 to 10 ml/hr; sufentanil, 1 g with 0.125% bupivacaine at rate of 10 ml/hr
Dizziness, drowsiness, allergic reactions, rash, pruritus, respiratory depression, nausea and vomiting, urinary retention
Assess for respiratory depression; naloxone should be available as antidote
Opioid (narcotic) agonist-antagonist analgesics. An agonist is an agent that activates or stimulates a receptor to act; an antagonist is an agent that blocks a receptor or a medication designed to activate a receptor. Opioid (narcotic) agonist-antagonist analgesics such as butorphanol (Stadol) and nalbuphine (Nubain), in the doses used during labor, provide analgesia without causing significant respiratory depression in the mother or neonate. Both IM and IV routes are used. Butorphanol and nalbuphine may be given during the first stage of labor. Neither of these analgesics is suitable for women with an opioid dependency, as a result of the antagonist activity (see Medication Guide).
Analgesic potentiators (ataractics). Phenothiazines, so-called tranquilizers, have the property of augmenting most of the desirable but few of the undesirable effects of analgesics or general anesthetics. These ataractics do not relieve pain but decrease anxiety and apprehension, as well as potentiate the opioid effects. This potentiation effect causes the two drugs to work together more effectively, so the opioid dose can be reduced. Analgesic potentiators include medications such as promethazine (Phenergan), propiomazine (Largon), hydroxyzine (Vistaril), and promazine (Sparine).
In addition to potentiating the effects of the analgesic, the ataractic (tranquilizer) also acts as an antinauseant and antiemetic. The combination of agents can be administered safely until the end of the first stage of labor. Because hydroxyzine is given only by IM injection in a large muscle, the onset of effect is slower and less predictable. Fetal or neonatal problems rarely develop when the mothers are given recommended doses.
Opioid (narcotic) antagonists. Opioids such as meperidine and fentanyl can cause excessive CNS depression in the mother, newborn, or both. Opioid (narcotic) antagonists, such as naloxone (Narcan), can promptly reverse the depressant effects. The mother must be told, however, that the pain she had been experiencing will return with the administration of the antagonist. In addition, the antagonist also counters the effect of the stress-induced levels of endorphins. An opioid antagonist is especially valuable if labor is more rapid than expected and birth is anticipated when the opioid is at its peak effect (i.e., the 1- to 4-hour window after administration). The antagonist may be given through the woman's IV line, or it can be administered intramuscularly (see Medication Guide).
Medication Guide Naloxone (Narcan)
Reverses opioid-induced respiratory depression in woman or newborn
DOSAGE AND ROUTE
Adult, 0.4 to 2 mg IV/IM/SC, repeat at 2- to 3-min intervals until desired effect occurs; newborn, 0.1 mg/kg IV (umbilical vein); repeat as for adult, may also be given IM orSC
Maternal hypotension/hypertension, tachycardia, nausea and vomiting, drowsiness, nervousness
Woman should delay breastfeeding until medication is out of system; do not give if woman is opioid dependent—may cause abrupt withdrawal; if given to woman for reversal of respiratory depression due to opioid analgesic, pain will return
NURSE ALERT An opioid antagonist must be administered cautiously to an opioid-dependent woman because it can precipitate abstinence syndrome (withdrawal symptoms) (see Signs of Potential Complications box).
SIGN OF POTENTIAL COMPLICATIONS
Maternal Opioid Abstinence Syndrome (OpioId/IMarcotic Withdrawal)
Yawning, rhinorrhea (runny nose), sweating, lacrimation (tearing), mydriasis (dilation of pupils)
Irritability, restlessness, generalized anxiety
Chills and hot flashes
Weakness, fatigue, and drowsiness
Nausea and vomiting
Diarrhea, abdominal cramps
Bone and muscle pain, muscle spasm, kicking movements
An opioid antagonist can be given to the newborn to treat neonatal narcosis, which is a state of CNS depression in the newborn produced by an opioid. Affected infants may exhibit respiratory depression, hypotonia, lethargy, and a delay in temperature regulation. Alterations in neurologic and behavioral responses may be evident in the newborn for 72 hours after birth. Meperidine may be present in the neonate's urine for up to 3 weeks. Some depression of attention and social responsiveness can be evident for up to 6 weeks after birth.
Nerve block analgesia and anesthesia
A variety of compounds are used in obstetrics to produce regional analgesia (some pain relief and motor block) and anesthesia (pain relief and motor block). Most of these drugs are related chemically to cocaine and end with the suffix -caine. This helps identify a local anesthetic.
The principal pharmacologic effect of local anesthetics is the temporary interruption of the conduction of nerve impulses, notably pain. Examples of common agents given in 0.25% to 1% solutions are lidocaine (Xylocaine), bupivacaine (Marcaine), chloroprocaine (Nesacaine), tetracaine (Pontocaine), and mepivacaine (Carbocaine).
Rarely, people are sensitive (allergic) to one or more local anesthetics. Such a reaction may include respiratory depression, hypotension, and other serious adverse effects. Atropine, antihistamines, oxygen, and supportive measures should reverse these effects. Sensitivity may be identified by administering minute amounts of the drug to be used to test for an allergic reaction.
Local infiltration anesthesia. Local infiltration anesthesia of perineal tissues is commonly used when an episiotomy is to be done and when time or the fetal head position does not permit a pudendal block to be administered (Scott et al., 1999). Rapid anesthesia is produced by injecting 1% lidocaine or 2% chloroprocaine into the skin and then subcutaneously into the region to be anesthetized. Epinephrine often is added to the solution to intensify the anesthesia in a limited region and to prevent excessive bleeding and systemic effects by constricting local blood vessels (Lehne, 2001). Repeated injection will prolong the anesthesia as long as needed.
Pudendal block. Pudendal block is useful for the second stage of labor, for episiotomy, and for birth. Although it does not relieve the pain from uterine contractions, it does relieve pain in the lower vagina, vulva, and perineum (Fig. 8, A). A pudendal nerve block must be administered 10 to 20 minutes before perineal anesthesia is needed.
Fig. 8 Pain pathways and sites of pharmacologic nerve blocks. A, Pudendal block: suitable during second and third stages of labor and for repair of episiotomy or lacerations. B, Epidural block: suitable for all stages of labor and for repair of episiotomy and lacerations.
The pudendal nerve traverses the sacrosciatic notch just medial to the tip of the ischial spine on each side. Injection of an anesthetic solution at or near these points anes thetizes the pudendal nerves peripherally (Fig. 9). The transvaginal approach is generally used because it is less painful for the woman, has a higher success rate, and tends to cause fewer fetal complications (Chestnut, 1999). Pudendal block does not change maternal hemodynamic or respiratory functions, vital signs, or the FHR. However, the bearing-down reflex is lessened or lost completely.
Fig. 9 Pudendal block. Use of needle guide (Iowa trumpet) and Luer-Lok syringe to inject medication.
If all branches of the pudendal nerve are anesthetized, analgesia is sufficient for a spontaneous vaginal birth, for outlet (low) forceps-assisted birth, or for vacuum-assisted birth. A pudendal block does not provide analgesia for uterine exploration or manual removal of the placenta (Scott et al., 1999).
Spinal anesthesia. In spinal block, local anesthetic is injected through the third, fourth, or fifth lumbar interspace into the subarachnoid space (Fig. 10), where the medication mixes with cerebrospinal fluid (CSF). This technique is commonly used for cesarean births. A low spinal block may be used for vaginal birth, but it is not suitable for labor. The spinal block given for cesarean birth provides anesthesia from the nipple (T6) to the feet. If used for vaginal birth, the anesthesia level is from the hips (T10) to the feet (Fig. 10, C).
Fig. 10 A, Membranes and spaces of spinal cord and levels of sacral, lumbar, and thoracic nerves. B, Cross section of vertebra and spinal cord. C, Level of anesthesia necessary for cesarean birth and for vaginal births.
For spinal block, the woman is positioned to widen the intervertebral space for ease of inserting the spinal needle and to allow the heavy anesthetic solution to flow downward (Fig. 12-11, A and B). The nurse supports the woman because she must remain still during the placement of the spinal needle. The insertion is made between contractions.
After the anesthetic has been injected, the woman may be positioned in an upright position to get the level of anesthesia for a vaginal birth or positioned supine if the level desired is for cesarean birth. The anesthetic effect usually begins 1 to 2 minutes after the anesthetic is injected and lasts 1 to 3 hours, depending on the type of agent used (Chestnut, 1999).
Fig 11 Position for spinal and epidural blocks. A, Lateral position. B, Upright position. C, Catheter for epidural taped to woman’s back with port segment with post segment located near shoulder (B and C courtesy Michael S. Clement, MD, Mesa AZ)
Marked hypotension, decreased cardiac output and placental perfusion, and respiratory inadequacy may occur during any spinal anesthesia. Therefore the woman receives hydration with IV fluids before injection of an anesthetic to decrease the potential for hypotension caused by sympathetic blockade. After injection, maternal blood pressure, pulse, respirations, and FHR must be checked and recorded every 5 to 10 minutes. If signs of serious maternal hypotension or fetal distress develop, emergency care must be given (see Emergency box).
Maternal Hypotension with Decreased Placental Perfusion
Maternal hypotension (20% drop from preblock level or less than 100 mm Hg systolic)
Decreased beat-to-beat FHR variability
Turn woman to lateral position or place pillow or wedqe under hip (see Fig. 14-4) to deflect uterus
Maintain IV infusion at rate specified, or increase prn per hospital protocol.
Administer oxygen by face mask at 10-12 L/min or per protocol.
Elevate the woman's legs.
Notify the Physician/midwife/anesthesiologist/nurse anesthetist.
Administer IV vasopressor (e.g., ephedrine) per protocol
Remain with woman; continue to monitor maternal blood pressure and FHR every 5 minutes until her condition is stable or per primary health care provider's order.
Because the mother is not able to sense her contractions, she must be instructed when to bear down during a vaginal birth. If the birth occurs in a delivery room (rather than a labor-delivery-recovery room), the mother will need assistance in the transfer to a recovery bed after delivery of the placenta.
Advantages of spinal anesthesia include ease of administration and absence of fetal hypoxia with maintenance of normotension. Maternal consciousness is maintained, excellent muscular relaxation is achieved, and blood loss is not excessive.
Disadvantages of spinal anesthesia include drug reactions (e.g., allergy), hypotension, and respiratory paralysis; cardiopulmonary resuscitation may be needed. When a spinal anesthetic is given, the need for operative delivery (i.e., episiotomy, low forceps extraction) tends to increase because the voluntary expulsive efforts are eliminated. After birth the incidence of bladder and uterine atony, as well as postspinal headache, is higher.
Leakage of CSF from the site of puncture of the meninges (membranous coverings of the spinal cord) is thought to be the major causative factor in postlumbar puncture (postspinal) headache. Presumably, postural changes cause the diminished volume of CSF to exert traction on pain-sensitive CNS structures. The resulting headache and auditory and visual problems may persist for days or weeks.
The likelihood of headache after lumbar puncture can be reduced, however, if the anesthesiologist uses a smallgauge spinal needle and avoids making multiple punctures or the meninges. Positioning the woman flat in bed (with only a small, flat pillow for her head) for at least 8 hours after spinal anesthesia has also been recommended to prevent headache, but there is no definitive evidence showing this measure is effective. Positioning the woman on her abdomen is thought to decrease the loss of CSF through the puncture site. Hydration has been claimed to be of value in preventing and treating headache, but there is no compelling evidence to support its use (Cunningham et al 2001) Initial treatment for post-lumbar puncture headache usually includes analgesics, bed rest, caffeine and increased fluid intake (e.g., 150 ml/hr intravenously) (American College of Obstetricians and Gynecologists 1996).
An autologous epidural blood patch is often beneficial; such treatment may be considered if the headache does not resolve spontaneously (Scott et al., 1999). To form a patch, a few milliliters of the woman's blood without anticoagulant is injected epidurally at the site of the dura puncture (Fig. 12), which then forms a clot that covers the hole and prevents further fluid loss.
Fig. 12 Blood patch therapy for spinal headache.
Epidural block. Relief from the pain of uterine contractions and birth (vaginal and abdominal) can be accomplished by injecting a suitable local anesthetic alone or combined with an opioid agonist (e.g., fentanyl) into the epidural (peridural) space (see Figs. 8, B, and 10, A).
Complete lumbar epidural block for relieving the discomfort of labor and vaginal birth requires a block from T10 to S5. For cesarean birth, a block from at least T6 to SI is essential. The diffusion of epidural anesthesia depends on the location of the catheter tip, the dose and volume of the anesthetic agent used, and the woman's position (e.g., horizontal or head-up position) (Cunningham et al., 2001).
For induction of lumbar epidural anesthesia, the woman is positioned as for a spinal injection (i.e., sitting) or in a modified Sims position (see Fig. 11). For the modified lateral Sims position, the woman is placed on her side with her shoulders parallel, legs slightly flexed, and back arched.
After the epidural has been started, the woman is preferably positioned on her side so that the uterus does not compress the ascending vena cava and descending aorta, which can impair venous return and decrease placental perfusion. Her position should be alternated from side to side every 30 to 60 minutes. Oxygen should be available to treat hypotension should it occur despite maintenance of hydration with IV fluid and displacement of the uterus to the side. Ephedrine (a vasopressor used to increase maternal blood pressure) and increased IV fluid infusion may be needed (see Emergency box). The FHR and progress in labor must be monitored carefully because the woman in labor may not be aware of changes in the strength of the uterine contractions or the descent of the presenting part.
A single injection or continuous infusion (via pump) through an indwelling plastic catheter results in excellent epidural analgesia-anesthesia. The advantages of an epidural block are numerous: the mother experiences excellent pain relief and remains alert and cooperative, good relaxation is achieved, airway reflexes remain intact, only partial motor paralysis develops, gastric emptying is not delayed, and blood loss is not excessive (see Research box). Fetal distress is rare but may occur in the event of rapid absorption or marked maternal hypotension. The dose, volume, and type of anesthetic can be modified to allow the mother to push, to produce perineal anesthesia, and to permit forceps or even cesarean birth if required (Cunningham et al, 2001).
RESEARCH Fathers' Experiences with Epidurals
Researchers have documented the psychosocial response to pain in the laboring woman. Although keenly aware and socially responsive in early labor, women become increasingly introspective as labor progresses.They are no longer as responsive to partner or environment, detaching so as to focus inward. This can cause their partners discouragement and frustration. Epidural analgesia is increasingly becoming common pain management for labor, and women often respond to the pain relief by becoming more responsive to their partners and interacting in a positive manner during the labor experience.
To examine expectant fathers' responses to their experiences of labor before and after their partners received epidural anesthesia, a nurse researcher asked 17 men to describe their recent birth experiences. The fathers identified two stages, "losing her," or detachment/lack of responsiveness before the epidural placement, and "she's back," or the relief from pain and return to interaction after the epidural placement. The fathers felt that they were poorly prepared for the severity of their partners' pain.The fathers were frustrated and fearful when their attempts to relieve it were ineffective, even rebuffed. They used the word helpless repeatedly. When their partners received epidurals, the fathers expressed profound relief at the woman's pain relief and her ability to interact with them again.
IMPLICATIONS FOR PRACTICE
Childbirth classes must present a realistic picture of labor. Couples need information about the normal introversion women experience as labor progresses and their partners' possible feelings of anxiety, frustration, and helplessness. Partners need to know how to adapt to the laboring women's changing responses. Labor nurses can reinforce what couples learned in childbirth classes and educate those couples who had no prenatal education. Nurses can also be proactive in pain management, and, if an epidural is the choice of the woman, they can reinforce information about epidural analgesia so that the woman and her partner know what to expect.
Source: Chapman, L (2000). Expectant fathers and labor epidurals. MCNAm J Matern Child Nurs, 25(3), 133-138.
The disadvantages of an epidural block for the woman include the need for an IV line, occasional dizziness, weakness of the legs, difficulty emptying the bladder, and shivering (Buggy & Bardiner, 1995; Youngstrom et al., 1996). Because a considerable amount of the drug must be used, adverse reactions or the rapid absorption of the anesthetic agent may result in maternal hypotension, convulsions, or paresthesia.
Data from retrospective studies and clinical trials indicate that epidural analgesia provides a higher level of pain relief than nonepidural pain relief measures. A relationship between epidural analgesia and longer first- and second-stage labor and increased incidence of fetal malposition, use of oxytocin, and forceps- or vacuum-assisted birth has been documented. Women who receive an epidural have a higher rate of fever, especially when labor lasts longer that 12 hours; the temperature elevation most likely is related to thermoregulatory changes, although infection cannot be ruled out. Current research findings have been unable to demonstrate a significant increase in cesarean birth associated with epidural analgesia (Howell, 2001; Lieberman, 1999; Thorpe & Breedlove, 1996). Occasionally, accidental high-spinal anesthesia (and later, postspinal headache) may follow inadvertent perforation of the dural membrane during the administration of lumbar epidural anesthesia.
For some women the epidural block is not effective, and a second form of analgesia is required to establish effective pain relief. When women progress rapidly in labor, pain relief may not be obtained before birth occurs.
Epidural and intrathecal opioids (narcotics). There is a high concentration of opioid receptors along the pain pathway in the spinal cord, in the brainstem, and in the thalamus. Because these receptors are highly sensitive to opioids, a small quantity of an opioid agonist produces marked analgesia that lasts for several hours. Medication (injected through a catheter placed in the epidural or subarachnoid space) reacts with these opioid receptors, and pain transmission is blocked without compromising motor ability. This so-called walking epidural restores the woman's confidence in her ability to master labor no longer dominated by pain (Youngstrom et al., 1996).
The use of epidural or intrathecal opioids during labor has several advantages. These agents do not cause maternal hypotension or affect vital signs. The woman feels contractions but not pain. Her ability to bear down during the second stage of labor is preserved because the pushing reflex is not lost and her motor power remains intact.
Fentanyl, sufentanil, or preservative-free morphine may be used. Fentanyl and sufentanil produce short-acting analgesia (i.e., 1.5 to 3.5 hours), and morphine may provide pain relief for 4 to 7 hours. Morphine may be combined with fentanyl or sufentanil. The short-acting opioids are often used with multiparous women, and morphine may be used with nulliparous women or women with a history of long labors (Manning, 1996). For most women, intrathecal opioids do not provide adequate analgesia for second-stage labor pain, episiotomy, or birth (Cunningham et al., 2001). Pudendal blocks or local anesthetics may be necessary.
A more common indication for the administration of epidural or intrathecal opioids is the relief of postoperative pain. For example, women who give birth by cesarean receive fentanyl or morphine through the catheter. The catheter may then be removed, and the women are usually free of pain for 24 hours. Occasionally, the catheter is left in place in case another dose is needed.
Women who receive epidurally administered morphine after the cesarean birth are up soon after surgery with surprising ease and are able to care for their babies. The early ambulation and freedom from pain also facilitate bladder emptying. To those women who have had a previous cesarean birth and have experienced the usual postoperative pain, the effects of this approach seem miraculous. However, the mother may not understand why she may experience pain after the opioid effect wears off.
Side effects of opioids administered by the epidural and intrathecal route include nausea, vomiting, pruritus (itching), urinary retention, and delayed respiratory depression. These side effects are more common when morphine is administered. Antiemetics, antipruritics, and opioid antagonists are used to relieve these symptoms. For example, naloxone (Narcan), nalbuphine hydrochloride (Nubain), promethazine (Phenergan), or metoclopramide (Reglan) may be administered. Hospital protocols should provide specific instructions for the treatment of these side effects. Use of epidural opioids is not without risks. Respiratory depression is a serious concern; for this reason the woman's respiratory rate should be assessed and documented every hour for 24 hours, or per the timing designated by hospital protocol. Naloxone should be readily available for use if the respiratory rate decreases below 10 breaths per minute or if the oxygen saturation rate drops below 89%. Administration of oxygen by face mask may also be initiated, and the anesthesiologist/anesthetist should be notified.
Contraindications to subarachnoid and epidural blocks. Some contraindications to epidural analgesia apply equally to caudal and subarachnoid blocks (Scott et al., 1999):
• Antepartum hemorrhage. Acute hypovolemia leads to increased sympathetic tone to maintain the blood pressure. Any anesthetic technique that blocks the sympathetic fibers can produce significant hypotension that can endanger the mother and baby.
• Anticoagulant therapy or bleeding disorder. If a woman is receiving anticoagulant therapy or has a bleeding disorder, injury to a blood vessel may cause the formation of a hematoma that may compress the cauda equina or the spinal cord and lead to serious CNS sequelae.
• Infection at the injection site. Infection can be spread through the peridural or subarachnoid spaces if the needle traverses an infected area.
• Allergy to the anesthetic drug.
Drug effects on neonate. Debate persists concerning the effects of epidural anesthesia on the newborn's neurobehavioral responses. Findings from studies that examine associations between neurobehavioral outcome and epidural anesthesia are far from consistent. For example, studies comparing the neonatal neurobehavioral scores for infants born to mothers who did and mothers who did not receive epidural analgesia have shown either little or no difference in the scores (Hamza, 1994; Scherer & Holzgreve, 1995) or have shown that infants of mothers who received epidural anesthesia did not score as well on neurobehavioral tests (Sepkoski et al., 1992).
General anesthesia rarely is used for uncomplicated vaginal birth and is infrequently used for cesarean birth. It may be necessary if there is a contraindication to nerve block analgesia or anesthesia or if indications necessitate rapid birth (vaginal or cesarean).
If general anesthesia is being considered, the nurse gives the woman nothing by mouth and sees that an IV infusion is established. If time allows, the nurse premedicates the woman with a nonparticulate oral antacid such as sodium citrate (30 ml) to neutralize the acidic contents of the stomach. If there is sufficient time, some anesthesiologists/anesthetists and physicians also order the administration of a histamine blocker such as cimetidine to decrease the production of gastric acid and metoclopramide to increase gastric emptying (Scott et al., 1999). Before the anesthesia is given, a wedge should be placed under the woman's right hip to displace the uterus to the left. Uterine displacement prevents aortocaval compression, which interferes with placental perfusion. Sometimes the nurse is asked to assist with applying cricoid pressure before intubation (Fig. 13)
Fig. 13 Technique for applying pressure on cricoid cartilage to occlude esophagus to prevent pulmonary aspiration of gastric contents during induction of general anesthesia.
Priorities for recovery room care are to maintain an open airway, maintain cardiopulmonary functions, and prevent postpartum hemorrhage. Routine postpartum care is organized to facilitate parent-infant attachment as soon as possible and to answer the mother's questions. Whenever appropriate, the nurse assesses the mother's readiness to see the baby, as well as her response to the anesthesia and to the event that necessitated general anesthesia (e.g., cesarean birth when vaginal birth was anticipated).
Inhalation analgesia and anesthesia
Nitrous oxide is the only inhalation agent used for obstetrics in the United States. It is rarely used for labor in the United States but may be used for this purpose in other countries.
Nitrous oxide is commonly used for cesarean births when inhalation anesthesia is needed. It is usually combined with oxygen in a 50:50 mixture. Thiopental, a shortacting barbiturate, combined with succinylcholine, a muscle relaxant, is given intravenously before tracheal intubation.
Other inhalation agents include halothane, enflurane or isoflurane, and methoxyflurane. These agents relax the uterus quickly and facilitate intrauterine manipulation, version, and extraction. However, these agents cross the placenta readily and can produce narcosis in the fetus. They are rarely used today in the United States.
Assessment and Nursing Diagnoses
The assessment of the woman, her fetus, and her labor is a joint effort of the nurse and the physician or nursemidwife, who consult with the woman regarding their findings and recommendations. The needs of each woman are different, and many factors must be considered before deciding whether nonpharmacologic, a combination of nonpharmacologic and pharmacologic, or pharmacologic methods of pain management are used. A self-assessment tool, such as an analog scale, allows the woman to indicate on a line how severe she perceives her pain experience to be. Self-assessment is recommended to ensure that pain management is based on the subjective nature of the woman's pain rather than on just the nurse's judgment (Olden et al., 1995).
The woman's prenatal record is read and relevant information identified. This includes the woman's parity, estimated date of birth, and complications and medications during pregnancy. If the woman has a history of allergies, this is noted and a warning displayed in a prominent place. A history of smoking and neurologic and spinal disorders is also noted.
Interview data consist of the time of the woman's last meal and the type of food consumed; the nature of any existing respiratory condition (cold, allergy); and unusual reactions to medications (e.g., allergy), cleansing agents, or tape. The woman is asked whether she attended childbirth preparation classes, and the extent of her preparation and preferences for management of discomfort are noted. Her knowledge of the options for the management of discomfort is also assessed. Information on the woman's perception of discomfort and about her expressed need for medication are added to the database. Relevant events that have occurred since the woman's last contact with the physician or nursemidwife are also reviewed (e.g., infections, diarrhea, change in fetal behavior). If verbal and physical signs indicate the existence of substance abuse, the nurse should ask the woman to identify the type of drug used, the last time the drug was taken, and the method of administration.
The character and status of the labor and fetal response are assessed during a physical examination. The nurse evaluates the woman's hydration status by assessing intake and output measurements, the moistness of the mucous membranes, and skin turgor. Bladder distention is noted. Any evidence of skin infection near sites of possible needle insertion is recorded and reported. Signs of apprehension such as fist clenching and restlessness are also noted.
If the woman is in labor, the status of maternal vital signs and FHR, uterine contractions, cervical effacement, and dilation; the station; and the anticipated time until birth are all considered. The length of labor and degree of fatigue are other important considerations. If pharmacologic methods are to be used, the type of analgesia or anesthesia chosen varies depending on the phase and stage of labor (see Box 3).
The results of laboratory tests are reviewed to determine whether the woman is suffering from anemia (hemoglobin and hematocrit), coagulopathy or bleeding disorder (prothrombin time and platelet count), or infection (white blood cell count and differential).
The following nursing diagnoses are relevant in the management of discomfort during labor and birth:
• Risk for ineffective tissue perfusion related to
-effects of analgesia or anesthesia
• Hypothermia related to
-effects of analgesia or anesthesia
• Anxiety related to lack of knowledge concerning
-procedure for nerve block analgesia
-expected sensation during nerve block analgesia
-mother's role during nerve block analgesia
-options for effective pain relief during labor
• Risk for injury to fetus related to
-maternal position (aortocaval compression)
Expected Outcomes of Care
The expected outcomes for nursing care in the management of discomfort of labor and birth include the following:
• The woman will experience adequate pain relief without adding to maternal risk (e.g., through the use of appropriate nonpharmacologic methods and appropriate medication, including the appropriate dose, timing, and route of administration).
• The fetus will maintain well-being, and the neonate will adjust to extrauterine life.
• The woman, her partner, and her family will verbalize understanding of their needs in relation to the use of nonpharmacologic methods, analgesia, or anesthesia.
Plan of Care and Interventions
A plan of care is developed for each woman and should address her particular clinical and nursing problems. The nurse collaborates with the primary health care provider relevant to the woman and her family.
The nurse supports and assists the woman as she uses nonpharmacologic interventions for pain relief and relaxation. During labor, the nurse should ask the woman how she feels in order to evaluate the effectiveness of the specific pain management techniques used. Appropriate interventions can then be planned or continued for effective care, such as trying other nonpharmacologic methods or combining nonpharmacologic methods with medications (see Plan of Care).
PLAN OF CARE Nonpharmacologic Management of Discomfort
NURSING DIAGNOSIS Acute pain related to physiologic response to labor
Expected Outcome Woman will express decrease in intensity of discomfort and experience satisfaction with her labor and birth performance.
Assess whether woman and significant other have attended childbirth classes, her knowledge of labor process, and her current level of anxiety to plan supportive strategies.
Encourage support person to remain with woman in labor to provide support and increase probability of response to comfort measures.
Teach or review nonpharmacologic techniques available to decrease anxiety and pain during labor (e.g., focusing and feedback, breathing techniques, effleurage, and sacral pressure) to enhance chances of success in using techniques.
Explore other techniques that the woman or significant other may have learned in childbirth classes (e.g., hypnosis, yoga, acupressure, biofeedback, therapeutic touch, aromatherapy, imaging, music) to provide largest repertoire of coping strategies.
Explore use of jet hydrotherapy if ordered by physician or nurse-midwife and if woman meets use criteria (i.e., vital signs within normal limits [WNL], cervix 4 to 5 cm dilated, active phase of first stage labor) to aid relaxation and stimulate production of natural oxytocin.
Explore use of transcutaneous nerve stimulation per physician or nurse-midwife order to provide an increased perception of control over pain and an increase in release of endogenous opiates.
Assist woman to change positions and to use pillows to reduce stiffness, aid circulation, and promote comfort.
Assess bladder for distention and encourage voiding often to avoid bladder distention, subsequent discomfort, and inhibition of labor.
Encourage rest between contractions to minimize fatigue.
Keep woman and significant other informed about progress to allay anxiety.
Guide couple through the labor stages and phases, helping them use and modify comfort techniques that are appropriate to each phase, to ensure greatest effectiveness of techniques employed.
Support couple if pharmacologic measures are required to increase pain relief, explaining effectiveness and safety to reduce anxiety and maintain self-esteem and sense of control over labor process.
The woman's perception of her behavior during labor is of utmost importance. If she planned a nonmedicated birth but then needs and accepts medication, her self-esteem may falter. Verbal and nonverbal acceptance of her behavior is given as necessary by the nurse and reinforced by discussion and reassurance after birth when possible. Explanations about fetal response to maternal discomfort, the effects of maternal fatigue on the progress of labor, and the medication itself are supportive measures. The woman may also be experiencing anxiety and stress related to the anticipated or actual pain. Stress can cause increased maternal catecholamine production. Raised levels of catecholamines have been linked to dysfunctional labor and fetal and neonatal distress and illness. Nurses must be able to implement strategies aimed at reducing this stress.
The physician or nurse-midwife and anesthesia care provider are responsible for informing women of the alternative methods of pharmacologic pain relief available in the hospital setting. A description of the various anesthetic techniques and what they entail is essential to informed consent, even if the woman has received information about analgesia and anesthesia earlier in her pregnancy. The discussion of pain management options should take place just before or early in labor so the woman has time to consider alternatives. Nurses play a part in the informed consent by clarifying and describing procedures or by acting as a patient's advocate and asking the physician or nurse-midwife for further explanations. The procedure and its advantages and disadvantages must be thoroughly explained.
LEGAL TIP Informed Consent for Anesthesia
The woman receives (in an understandable manner) the following:
• Explanation of alternative methods of anesthesia and analgesia available
• Description of anesthetic and procedure for administration
• Description of the benefits, discomfort, risks, and consequences of the selected anesthetic for the mother and the fetus
• Explanation of how complications can be treated
• Information that the anesthetic is not always effective Indication that the woman may withdraw consent at any time
• Opportunity to have any questions answered
• Opportunity to explain in her own words components of the consent The consent form will
• Be written in the woman's primary language
• Have the woman's signature
• Have the date of consent
• Carry the signature of anesthesia caregiver, certifying that the woman has received and appears to understand the explanation
Timing of administration
It is often the nurse who notifies the physician or nursemidwife that the woman is in need of pharmacologic measures to relieve her discomfort. Orders often are written for the administration of pain medication as needed based on the nurse's clinical judgment. Generally, pharmacologic measures for pain relief are avoided until labor has advanced to the active phase of the first stage of labor and the cervix has dilated to approximately 4 to 5 cm. See Box 3 for the pharmacologic measures used to manage the discomfort of labor, summarized by the stage of labor and method of birth.
Preparation for procedures
The nurse reviews the methods of pain relief available to the woman (or validates her choices) and clarifies information as necessary. The procedure and what will be asked of the woman (e.g., to maintain flexed position during insertion of epidural needle) must be explained. The woman can also benefit from knowing the way that the medication is to be given, the degree of discomfort to expect from administration of the medication, the sensations she can expect, the time required for administration, the interval before the medication takes effect, and the expected effect of the medication in terms of pain relief. The nurse explains the need for emptying the bladder before analgesic or anesthetic is given and explains the reason for keeping the bladder empty. When an indwelling epidural catheter is to be threaded, the woman should be told that she may experience a momentary twinge down her leg, hip, or back and that this feeling is not a sign of injury.
A long needle is used for pudendal blocks (see Fig. 9). The sight of this needle may be frightening, and the woman should be reassured that only the tip of the needle will be inserted.
Administration of medications
Accurate monitoring of the progress of labor forms the basis for the nurse's judgment that a woman needs pharmacologic control of discomfort. Knowledge of the medications that are used during childbirth is essential. The most effective route of administration is selected for each woman; then the medication is prepared and administered correctly.
Intravenous route. The preferred route of administration of medications such as meperidine or fentanyl is through IV tubing, administered into the port nearest the woman while the infusion of IV solution is stopped. The medication is given slowly in small doses at the beginning of a contraction and over three to five consecutive contractions. Because uterine blood vessels are constricted during contractions, the medication stays within the maternal vascular system for several seconds before the uterine blood vessels reopen. The IV infusion is then restarted slowly to prevent a bolus of medication from forming. Using this method of injection, the amount of drug crossing the placenta to the fetus is minimized. With decreased placental transfer, the mother's degree of pain relief is maximized.
The IV route is associated with the following advantages:
• The onset of pain relief is more predictable.
• Pain relief is obtained with small doses of the drug.
• The duration of effect is more predictable.
Intramuscular route. IM injections of analgesics, although still used, are not the preferred route of administration for women in labor. Identified disadvantages of the IM route include the following:
• The onset of pain relief is delayed.
• Higher dosages of medication are required.
• Medication from the muscle tissue is released at an unpredictable rate and is available for transfer across the placenta to the fetus.
IM injections are given in the upper portion of the arm (deltoid site) if regional anesthesia is planned later in labor. This is the preferred site because the autonomic blockade from the regional (e.g., epidural) anesthesia increases blood flow to the gluteal region and accelerates absorption of the drug. The maternal plasma level of the drug necessary to bring pain relief usually is reached 45 minutes after IM injection, followed by a decline in plasma levels. The maternal drug levels (after IM injections) are unequal because of uneven distribution (maternal uptake) and metabolism. The advantage of using the IM route is quick administration.
Nerve blocks. An IV line is established before the induction of nerve blocks such as epidural, spinal, and general anesthesia. Anesthesia protocols usually include the administration of a bolus of IV fluid before giving the anesthesia to expand the blood volume to prevent maternal hypotension.
Lactated Ringer's or Plasma-Lyte A and normal saline solutions are the preferred infusion solutions. Infusion solutions without dextrose are preferred, especially when the solution must be infused rapidly (e.g., to treat severe dehydration or to maintain blood pressure) because solutions containing dextrose rapidly raise the maternal blood glucose levels. The fetus responds to high blood glucose levels by increasing insulin production; fetal or neonatal hypoglycemia may result. In addition, dextrose changes osmotic pressure, so fluid is excreted from the kidneys more rapidly.
The woman needs assistance in assuming and maintaining the correct position for epidural and spinal anesthesia (see Fig. 11).
Signs of potential problems
Any medication can cause an allergic reaction that may be minor or as severe as anaphylaxis. Minor reactions can consist of a rash, rhinitis, fever, asthma, or pruritus. Management of the less acute allergic response is not an emergency. As part of the assessment for such allergic reactions, the nurse should monitor the woman's vital signs, respiratory status, cardiovascular status, platelet count, and white blood cell count. The woman is observed for side effects of medications, especially drowsiness (Lehne, 2001).
Severe reactions may occur suddenly and lead to shock. The most dramatic form of anaphylaxis is sudden severe bronchospasm, vasospasm, severe hypotension, and death. Signs of anaphylaxis are largely caused by contraction of smooth muscles and may begin with irritability, extreme weakness, nausea, and vomiting. This may lead to dyspnea, cyanosis, convulsions, and cardiac arrest. The acute allergic reaction (anaphylaxis) must be diagnosed and treated immediately. Treatment usually consists of 1:1000 epinephrine injected subcutaneously or intramuscularly, followed by parenteral administration of antihistamines. Supportive care is given to alleviate symptoms; the type of care is determined by the rapidly assessed cardiovascular and respiratory response of the woman to primary interventions. Cardiopulmonary resuscitation may be necessary. The nurse must also be alert to fetal well-being; any nonreassuring changes in FHR and FHR pattern should be noted and reported to the physician or nurse-midwife.
Safety and general care
After administration of a nerve block, the woman is protected from injury by raising the side rails and by placing a call bell within easy reach for times when the nurse is not in attendance. Oxygen and suction should be readily available at the bedside. The nurse must make sure there is no prolonged pressure on an anesthetized part (e.g., no lying on one side with weight on one leg; no tight linen on feet). If stirrups are used for birth, the nurse should pad them, adjust both stirrups at the same level and angle, place both of the woman's legs into them simultaneously while avoiding putting pressure against the popliteal angle, and apply restraints without restricting circulation.
The nurse monitors and records the woman's response to nonpharmacologic pain relief methods and to medication. This includes the level of pain relief, the level of apprehension, the return of sensations and perception of pain, and allergic or untoward reactions (e.g., hypotension, respiratory depression, hypothermia). The nurse continues to monitor maternal vital signs, blood pressure, strength and frequency of uterine contractions, changes in the cervix and station of the presenting part, presence and quality of the bearing-down reflex, bladder filling, and state of hydration. Determining the fetal response after administration of analgesia or anesthesia is vital. The woman is asked if she (or the family) has any questions. The nurse also assesses the woman's and her family's understanding of the need for ensuring her safety (e.g., keeping side rails up, calling for assistance as needed).
The time that elapses between the administration of a narcotic and the baby's birth is noted. Medication given to the newborn to reverse narcotic effects is recorded. Postpartum, the woman who has had spinal, epidural, or general anesthesia is assessed for return of sensory and motor sensation in addition to the usual postpartum assessments.
Evaluation of the effectiveness of care of the woman needing management of discomfort during labor and birth is based on the previously stated outcomes (see Plan of Care).
Nursing Care During Labor and Birth
For most women, labor begins with the first uterine contraction, continues with hours of hard work during cervical dilation and birth, and ends as the woman and her family begin the attachment process with the infant. Nursing care management focuses on assessment and support of the woman and her family throughout childbirth with the goal of ensuring the best possible outcome for all involved.
FIRST STAGE OF LABOR
The first stage of labor begins with the onset of regular uterine contractions and ends with complete cervical effacement and dilation. Labor care begins when the woman reports one or more of the following:
• Onset of progressive, regular uterine contractions that increase in frequency, strength, and duration
• Blood-tinged vaginal discharge (bloody or pink show) indicating that the mucous plug (operculum) has passed
• Fluid discharge from the vagina representing the spontaneous rupture of membranes (SROM, SRM)
The first stage of labor consists of three phases: the latent phase (0 to 3 cm of dilation), the active phase (4 to 7 cm of dilation), and the transition phase (8 to 10 cm of dilation). Most nulliparous women seek admission to the hospital in the latent phase because they have not experienced labor before and are unsure of the "right" time to come in. Multiparous women usually do not come to the hospital until they are in the active phase.
Nurses should involve the laboring woman as a partner in formulating an individualized plan of care that preserves the woman's sense of control, facilitates her participation in her own childbirth experience, and enhances her selfesteem and level of satisfaction (Proctor, 1998). Women often have lingering impressions of their childbirth experience. Caregivers who are supportive, respectful, encouraging, kind, patient, professional, and comforting help these women to remember their childbirth experience in positive terms (Fowles, 1998; Tumblin & Simkin, 2001).
ASSESSMENT AND NURSING DIAGNOSES
Assessment begins at the first contact with the woman, whether by telephone or in person. Many women call the hospital or birthing center first to receive validation that it is all right for them to come in for evaluation or admission. The manner in which the nurse communicates with the woman during this first contact can set the tone for a positive birth experience. A caring attitude by the nurse encourages the woman to verbalize her questions and concerns. If possible, the nurse should have the woman's prenatal record in hand when speaking to her or admitting her for evaluation of labor. Copies of records are often filed on the perinatal unit at some time during a woman's third trimester. Certain factors are assessed initially to determine whether the woman is in true labor and should come to the hospital for further assessment or admission (Varney, 1997) (see Teaching Guidelines box). When a woman calls and there is a question about whether she is in labor (or in labor advanced enough to be admitted), the nurse should suggest that she either call her physician or nurse-midwife or come to the hospital. This may occur when the woman is in false labor or early in the latent phase of the first stage of labor. She may feel discouraged on learning that the contractions that feel so strong and regular are not causing cervical dilation or are still not strong or frequent enough for admission.
How to Distinguish True Labor from False Labor
Occur regularly, becoming stronger, lasting longer, and occurring closer together.
Become more intense with walking.
Usually felt in lower back, radiating to lower portion of abdomen.
Continue despite use of comfort measures.
Cervix (by vaginal examination)
Shows progressive change (softening, effacement, and dilation signaled by the appearance of bloody show).
Moves to an increasingly anterior position.
Presenting part usually becomes engaged in the pelvis. This results in increased ease of breathing; at the same time, the presenting part presses downward and compresses the bladder, resulting in urinary frequency.
Occur irregularly or become regular only temporarily.
Often stop with walking or position change.
Can be felt in the back or abdomen above the navel.
Often can be stopped through the use of comfort measures.
Cervix (by vaginal examination)
May be soft but there is no significant change in effacement or dilation or evidence of bloody show.
Is often in a posterior position.
Presenting part is usually not engaged in the pelvis.
If the woman lives near the hospital, she may be asked to stay home or return home to allow labor to progress (i.e., until the contractions are more frequent and intense). The ideal setting for the low risk woman in early labor is the familiar environment of her home. The nurse can use a telephone interview to assess the woman's status and to give instructions regarding the optimum timing for admission and to reinforce teaching of the signs that require immediate notification of the physician or nurse-midwife (Box 1). Measures the woman and her family can use to enhance the progress of labor, reduce anxiety, and maintain comfort should be described. The woman is encouraged to ambulate and asked to adjust her oral intake according to the preferences of her primary health care provider.
BOX 1 Telephone Interview with Woman in Latent Phase of Labor
The perinatal nurse performs the following steps of the nursing process:
• Gathers data regarding the woman's status, including signs and symptoms indicative of true or false labor.
• Discusses instructions given by the woman's primary health care provider regarding when to come for admission.
PLANNING AND IMPLEMENTATION
• Decides whether the woman will come for labor assessment and admission or be encouraged to stay at home until contractions increase in duration, frequency, and intensity.
• Assures the woman that she is welcome to call the perinatal unit at any time to discuss her labor status.
• Answers questions the woman and her family may have regarding labor or provides instruction as needed (e.g., which entrance of the hospital to enter).
• Suggests a variety of positions she can assume to maximally enhance uteroplacental and renal blood flow (i.e., side-lying position) and enhance the progress of labor (i.e., upright positions and ambulation).
• Suggests diversional activities, such as walking, reading, watching television, talking to friends.
• Suggests measures to maintain comfort, such as a warm bath or shower, back or foot massage.
• Discusses the oral intake of foods and fluids appropriate for early labor (light foods or fluids or clear liquids depending on the preference of her primary health care provider).
• Instructs the woman to come in immediately if membranes rupture, bleeding occurs, or fetal movements change.
• Evaluates whether instructions and information have been understood by the woman by asking her to verbalize her understanding.
A warm shower can be relaxing for the woman in early labor. However, warm baths should be avoided until the cervix is approximately 5 cm dilated, because water immersion in early labor could prolong the labor process and increase the use of oxytocin to stimulate uterine contractions and epidural analgesia for pain reduction (Eriksson, Mattsson, & Ladfors, 1997; Odent, 1997). Soothing back, foot, and hand massage or a warm drink of preferred liquids such as tea or milk can help the woman to rest and even to sleep, especially if false or early labor is occurring at night. Diversional activities such as walking, reading, watching television, doing needlework, or talking with friends can reduce the perception of early discomfort, help the time pass, and reduce anxiety (Austin & Calderon, 1999; Varney, 1997).
The woman who lives at a considerable distance from the hospital may be admitted in early labor. The same measures used by the woman at home should be offered to the hospitalized woman in early labor.
Admission to labor unit
Fig. 1 Woman being admitted. (Courtesy Marjorie Pyle, RNC, Lifecircle, Costa Mesa, CA.)
When the woman arrives at the perinatal unit, assessment is the top priority (Fig. 1). The nurse first performs a screening assessment, using the techniques of interview and physical assessment, and reviews laboratory findings to determine the health status of the woman and her fetus and the progress of her labor. The physician or nurse-midwife is notified, and if the woman is admitted, a detailed systems assessment is done.
Because first impressions are important, the woman and her family are welcomed by name and introduced to the staff members who will be involved in their care. If the woman wishes, her partner is included in the assessment and admission process.
As part of the admission process, the nurse orients the woman and her family to the layout and operation of the unit and the features of their room (e.g., call light, telephone system, personal storage areas, lighting). The nurse may assist in obtaining the required consents for the care the woman and her newborn are to receive (e.g., anesthesia consent). The nurse can minimize the woman's anxiety by explaining terms commonly used during labor. The woman's interest and response guide the depth and breadth of these explanations.
Fig. 2 Obstetric admitting record. (Permission to use and/or reproduce this copyrighted material has been granted by the owner, Hollister Incorporated, Libertyville , IL.)
Admission forms such as the one in Fig. 2 can provide guidelines for the acquisition of important assessment information when a woman in labor is being evaluated or admitted. Additional sources of data include (1) the prenatal record, (2) the initial interview, (3) physical examination to determine baseline physiologic parameters, (4) laboratory and diagnostic test results, (5) expressed psychosocial and cultural factors, and (6) the clinical evaluation of labor status.
Prenatal data. The nurse reviews the prenatal record to identify the woman's individual needs and risks. Incomplete information regarding a woman's prenatal health status could adversely affect the quality and safety of the care provided to her and her fetus/newborn during labor and birth and in the postpartum period. Use of standardized worksheets and flow sheets developed by health care providers and computer access to antepartal health records are strategies that can facilitate the gathering of information relevant to the safe and effective management of care during labor (Hill, Lowery, & Chez, 1998).
If the woman has not had any prenatal care, certain baseline information must be obtained. If the woman is experiencing discomfort, the nurse asks questions between contractions when the woman can concentrate more fully on her responses.
It is important to know the woman's age so that the plan of care can be tailored to the needs of her age-group. For example, a 14-year-old and a 40-year-old have different but specific needs, and their ages place them at risk for different problems. Height and weight relationships are important to determine because a weight gain greater than that recommended may place the woman at a higher risk for cephalopelvic disproportion and cesarean birth. Other factors to consider are general health, current medical conditions or allergies she may have, her respiratory status, and surgical procedures she has undergone.
Her past and present pregnancy history are carefully noted. These include gravidity and parity and problems such as history of vaginal bleeding, pregnancy-induced hypertension (PIH), anemia, gestational diabetes, infections (e.g., bacterial or sexually transmitted), and immunodeficiency.
If this is not the woman's first labor and birth experience, it is important to note the characteristics of her previous experiences. This information includes the duration of previous labors, the type of anesthesia used, and the kind of birth (e.g., spontaneous vaginal, forceps-assisted, vacuum-assisted, or cesarean birth) and the condition of the baby. The woman's perception of her previous labor and birth experiences may influence her attitude toward her current experience. The memory of labor and birth events can affect a woman's postpartum emotional adjustment, self-esteem, and ability to parent effectively (Simkin, 1996).
It is important to confirm that the expected date of birth (EDB) is as accurate as possible. Other data in the prenatal record include patterns of maternal weight gain; physiologic measurements, such as maternal vital signs (blood pressure, temperature, pulse, respiration); fundal height; baseline fetal heart rate (FHR); and laboratory and diagnostic test results. Laboratory tests include the woman's blood type and Rh factor, a complete or partial blood cell count (CBC or hemoglobin and hematocrit), the 50 g blood glucose test, determination of the rubella titer, serologic tests (Venereal Disease Research Laboratories [VDRL] or rapid plasma reagin [RPR]) for syphilis, hepatitis B surface antigen (HBsAg), culture for group B streptococci, and urinalysis. Additional tests may include a tuberculosis screen with purified protein derivative (PPD), screening for the human immunodeficiency virus (HIV), and screening for the sickle cell trait or other genetic disorders (e.g., maternal serum alpha-fetoprotein). Diagnostic tests can include amniocentesis, nonstress test, contraction stress test, biophysical profile, and ultrasound examination.
Interview. The woman's primary complaint or reason for coming to the hospital is determined first in the interview. Her primary complaint may be that her bag of waters (amniotic membranes) ruptured, with or without contractions. The woman may have come in for an obstetric check, which is a period of observation reserved for women who are unsure about the onset of their labor. This allows time on the unit for the diagnosis of labor without official admission and minimizes or avoids cost to the patient when used by the hospital and approved by the woman's health insurance plan.
Even the experienced mother may have difficulty determining the onset of labor. The woman is asked to recall the events of the previous days and to describe the following:
• Time and onset of regular contractions
• Frequency and duration of contractions
• Location and character of discomfort from contractions (e.g., back pain, suprapubic discomfort)
• Persistence of contractions despite changes in maternal position and activity (e.g., walking or lying down)
• Presence and character of vaginal discharge or show
• The status of amniotic membranes, such as a gush or seepage of fluid (rupture of membranes [ROM])
If there has been a discharge that may be amniotic fluid, she is asked the date and time the fluid was first noted and the fluid's characteristics (e.g., amount, color, unusual odor). In many instances a sterile speculum examination and a Nitrazine test or fern test can confirm that the membranes are ruptured (see Procedure box).
These descriptions help the nurse assess the degree of progress in the process of labor. Bloody show is distinguished from bleeding by the fact that it is pink in color and feels sticky because of its mucoid nature. It is scant to begin with and increases with effacement and dilation of the cervix. A woman may report a scant brownish discharge that may be attributed to cervical trauma resulting from vaginal examination or coitus within the last 48 hours.
In case general anesthesia is required in an emergency, it is important to assess the woman's respiratory status. The nurse determines this by asking the woman if she has a cold or related symptoms, stuffy nose, sore throat, or cough. The status of allergies is rechecked, including allergies to medications routinely used in obstetrics, such as meperidine (Demerol) and lidocaine (Xylocaine). Some allergic responses cause swelling of the mucous membranes breathing and the administration of inhalation anesthesia.
Because vomiting and subsequent aspiration into the respiratory tract can complicate an otherwise normal labor, the nurse records the time and type of the woman's last solid food and liquid intake.
Any information not found in the prenatal record is obtained during the admission assessment. Pertinent data include the birth plan, the choice of infant feeding method, the type of pain management, and the name of the pediatrician.
The nurse uses the information in the birth plan to individualize the care given the woman during labor. The nurse prepares the woman for the possibility that changes may be needed in her plan as labor progresses and assures her that information will be provided so that she can make informed decisions. If no written plan has been prepared, the nurse helps the woman formulate a birth plan when she arrives at the hospital. The nurse describes options available and finds out the woman's wishes and preferences.
The nurse should discuss with the woman and her family their plans for preserving childbirth memories using photography and videotaping. Health care agencies and insurance companies have voiced concern that this type of recording of childbirth events could be used in court should the couple sue the health care agency or health care providers. The nurse can promote the appropriate use of cameras during labor and birth, including who and what will be recorded, the method that will be used, and the person who will perform this task. Protection of privacy and safety and infection control are major concerns. Policies should be in place that address such issues as use of flash photography in the presence of combustible gases and where the person who is recording the labor and birth should stand. The record should reflect that the childbirth was recorded (Cesario, 1998).
Psychosocial factors. The woman's general appearance and behavior (and that of her family) provide valuable clues to the type of supportive care she will need (Table 1).
NURSE/SUPPORT PERSON'S ACTIONS*
DILATION OF CERVIX 0-3 CM (LATENT) (contractions 10-30 sec long, 5-30 min apart, mild to moderate)
Mood: alert, happy, excited, mild anxiety
Settles into labor room; selects focal point
Rests or sleeps, if possible
Uses breathing techniques
Uses effleurage, focusing, and relaxation
Provides encouragement, feedback for relaxation, companionship
Assists woman to cope with contractions
Encourages use of focusing techniques
Helps to concentrate on breathing techniques
Uses comfort measures
Assists woman into comfortable position
Informs woman of progress; explains procedures and routines
Offer fluids, ice chips as ordered
DILATION OF CERVIX 4-7 CM (ACTIVE) (contractions 30-45 sec long, 3-5 min apart, moderate to strong)
Mood: seriously labor oriented, concentration and energy needed for contractions, alert, more demanding
Continues relaxation, focusing techniques
Uses breathing techniques
Acts as buffer; limits assessment techniques to between contractions
Assists with contractions
Encourages woman as needed to help her maintain breathing techniques
Uses comfort measures
Assists with frequent position changes, emphasizing side-lying and upright positions
Encourages voluntary relaxation of muscles of back, buttocks, thighs, and perineum; effleurage
Applies counterpressure to sacrococcygeal area
Encourages and praises
Keeps woman aware of progress
Offers analgesics as ordered
Checks bladder; encourages her to void
Gives oral care; offers fluids, ice chips as ordered
DILATION OF CERVIX 8-10 CM (TRANSITION) (contractions 45-90 sec long, 2-3 min apart, strong)
Mood: irritable, intense concentration,
symptoms of transition (e.g., nausea, vomiting)
Continues relaxation, needs greater concentration to do this
Uses breathing techniques
Uses 4:1 breathing pattern if using psychoprophylactic techniques
Uses panting to overcome response to urge to push
Stays with woman; provides constant support
Assists with contractions
Reminds, reassures, and encourages woman to reestablish breathing pattern and concentration as needed
Alerts woman to begin breathing pattern before contraction becomes too intense if she is sedated or drowsy
Prompts panting respirations if woman begins to push prematurely
Uses comfort measures
Accepts woman's inability to comply with instructions
Accepts irritable response to helping, such as counterpressure
Supports woman who has nausea and vomiting; gives oral care as needed; gives reassurance regarding signs of end of first stage
Uses relaxation techniques (effleurage and voluntary relaxation)
Keeps woman aware of progress
However, the nurse should keep in mind that general appearance and behavior may vary depending on the stage and phase of labor. Psychosocial factors to assess include the following:
Verbal interactions. Does the woman ask questions? Can she ask for what she needs? Does she talk to her support person)?
Does she talk freely with the nurse or respond only to questions?
Body language. Is she relaxed or tense? What is her anxiety level? How does she react to being touched by the nurse or support person? Does she change positions or lie rigidly still? Does she avoid eye contact? Does she look tired? How much rest has she had during the past day?
Perceptual ability. Does she understand what the nurse says? Is there a language barrier? Are repeated explanations necessary because her anxiety level interferes with her ability to comprehend? Can she repeat what she has been told or demonstrate her understanding?
Discomfort level. To what degree does the woman describe what she is experiencing? How does she react to a contraction? Are any nonverbal pain messages seen? Does she complain to the nurse or her partner? Can she ask for comfort measures?
Women with a history of sexual abuse. Memories of sexual abuse can be triggered during labor by intrusive procedures such as vaginal examinations; loss of control; being confined to bed and "restrained" by monitors, intravenous (IV) lines, and epidurals; being watched by students; and experiencing intense sensations in the uterus and genital area, especially at the time when she must push the baby out. Women who are abuse survivors may fight the labor process by reacting in panic or anger toward care providers, may take control of everyone and everything related to their childbirth, may surrender by being submissive and dependent, or may retreat by mentally dissociating themselves from the sensations of labor and birth (Rhodes & Hutchinson, 1994).
The nurse can help these women to associate the sensations they are experiencing with the process of childbirth and not their past abuse. The woman's sense of control should be maintained by explaining all procedures and why they are needed, validating her needs and paying close attention to her requests, proceeding at the woman's pace by waiting for her to give permission to touch her, accepting her often extreme reactions to labor, and protecting her privacy by limiting the amount of exposure of her body and the number of persons involved in her care. It is recommended that all laboring women be cared for in this manner because it is not unusual for a woman to choose not to reveal a history of sexual abuse. These care measures can help a woman to perceive her childbirth experience in positive terms and to effectively parent her new baby (Heritage, 1998; Waymire, 1997).
Stress in labor. The way in which women and their families approach labor is related to the manner in which they have been socialized to the childbearing process. Their reactions reflect their life experiences regarding childbirth—physical, social, cultural, and religious.
Usually women in labor have a variety of concerns that they will voice if asked but rarely volunteer. To correct misinformation, it is important for the nurse to ask the woman what she expects or to suggest that the woman ask her primary health care provider about an issue. The following are common concerns that women in labor have: Will my baby be all right? Will I be able to stand labor? Will my labor be long? How will I act? Will I need medication? Will it work for me? Will my partner or someone be there to support me? Do I have to have an IV? The nurse's responsibility to the woman in labor with regard to these concerns is to answer her questions or find out the answers, to provide support for her and her family, to take care of her in partnership with those persons the woman wants as her support team, and to serve as their advocate. Women feel empowered when they are given information they can understand and that shows support for their efforts. This feeling of empowerment gives women the sense that they have the freedom to participate fully in their labor and birth and fosters a positive perception of the experience. In contrast, a woman's level of anxiety and fear may rise when she does not understand what is being said. The woman who is unfamiliar with expressions such as "bloody show," "the membranes ruptured," "scalp electrode," and "baby's lying on the cord" could panic. Many such expressions sound violent and could conjure up thoughts of injury or pain.
The nurse communicates to the woman that she is not expected to act in any particular way and that the process will end in the birth of her baby, which is the only expectation she should have. Women need to be able to behave in a manner that is natural for them and be able to "let go" (Waldenstrom et al, 1996).
The father, coach, or significant other also experiences stress during labor. The nurse can assist and support these individuals by identifying their needs and expectations and by helping make sure these are met. The nurse can ascertain what role the support person intends to fulfill and whether he or she is prepared for that role by making observations and asking such questions as, Has the couple attended childbirth classes? What role does this person expect to play? Does he or she do all the talking? Is he or she nervous, anxious, aggressive, or hostile? Does he or she look hungry, tired, worried, or confused? Does he or she watch television, sleep, or stay out of the room instead of paying attention to the woman? Where does he or she sit? Does he or she touch the woman? What is the character of the touch? The nurse should be sensitive to the needs of support persons and provide teaching and support as appropriate. Often the support this person is able to give the laboring woman is in direct proportion to the support he or she receives from the nurses and other health care providers (Nichols, 1993).
Cultural factors. It is important to note the woman's ethnic or cultural and religious background to anticipate nursing interventions that may need to be added or eliminated from the individualized plan of care (Fig. 3). The woman should be encouraged to request specific caregiving behaviors and practices that are important to her. If a special request contradicts usual practices in that setting, the woman or the nurse can ask the woman's physician or nurse-midwife to write an order to accommodate the special request. For example, in many cultures it is unacceptable to have a male caregiver examine a pregnant woman. In some cultures it is traditional to take the placenta home; in others the woman is given only certain nourishments during labor. Some women believe that cutting her body, as with an episiotomy, allows her spirit to leave her body and that rupturing the membranes prolongs, not shortens, labor. It is important that the rationale for required care measures be carefully explained (Mattson, 2000) (see Cultural Considerations box).
Fig. 3 Birthing room specific to a Native American population. Note the arrow pointing east, the rug on the wall, and the cord hanging from the ceiling. (Courtesy Patricia Hess, San Francisco, CA; Chinle Comprehensive Health Care Center, Chinle, AZ.)
Birth Practices in Different Cultures
South Korea —Stoic response to labor pain; father usually not present.
Japan —Natural childbirth methods practiced; may labor silently; may eat during labor; father may be present.
China —Stoic response to pain; father not present; sidelying position preferred for labor and birth because this position is thought to reduce infant trauma.
India —Natural childbirth methods preferred; father usually not present; female relatives usually present.
Iran —Father not present; prefers female support and female caregivers.
Mexico —May be stoic about discomfort until second stage, then may request pain relief; father and female relatives may be present.
Laos—May use squatting position for birth; father may or may not be present; prefers female attendants.
Modified from Geissler, E. (1999). Pocket guide to cultural assessment (2nd ed.). St Louis: Mosby.
Cultural beliefs and values can influence a woman's reliance on her physician or nurse-midwife during labor, as well as her desire to participate in making decisions about the care she receives (Callister, Vehvilainen-Julkunen, & Lauri, 1996). When assessing a woman's cultural and religious preferences, Callister (1995) suggests that the nurse ask questions regarding the following:
• Value and meaning placed on the childbirth experience
• View of childbirth as a wellness or illness experience and as a private or social event
• Practices regarding diet, medications, activity, and emotional and physical support
• Appropriate maternal and paternal behaviors
• Birth companions—who they should be and what they should do
• Views regarding the newborn and the newborn's care immediately after birth
Within cultures women may have the "right" way to behave in labor instilled in them and learn to react to the pain experienced in that way. These behaviors can range from total silence to moaning or screaming, but they are not in and of themselves a reflection of the degree of pain. A woman who moans with contractions may not be in as much physical pain as a woman who is silent but winces during contractions (Table 2). Some women feel it is shameful to scream or cry out in pain if a man is present. If the woman's support person is her mother, she may perceive the need to "behave" more strongly than if her support person is the father of the baby. She will perceive herself as failing or succeeding on the basis of her ability to adhere to these "standards" of behavior. Conversely, a woman's behavior in response to pain may influence the support received from significant others. In some cultures women who lose control and cry out in pain may be scolded, whereas in other cultures support persons will become more helpful (Choudhry, 1997; Weber, 1996).
TABLE 2 Sociocultural Basis of Pain Experience
WOMAN IN LABOR
PERCEPTION OF MEANING
Origin: Cultural concept of and personal experience with pain; for example:
Pain in childbirth is inevitable, something to be borne.
Pain in childbirth can be avoided completely.
Pain in childbirth is punishment for sin.
Pain in childbirth can be controlled.
Origin: Cultural concept of and personal experience with pain; in addition, nurse becomes accustomed to wrking with certain "expected" pain trajectories. For example, in obstetrics, pain is expected to increase as labor progresses, be intermittent, and have end point; relief can be derived from medications once labor is well established and fetus or newborn can cope with amount and elimination of medications; relief can also come from woman's knowledge, attitude, and support from family or friends.
Woman may exhibit the following behaviors:
Be traditionally vocal or nonvocal; crying out or groaning, or both, may be part of her ritual response to pain.
Use counter stimulation to minimize pain (e.g., rubbing, applying heat, or applying counterpressure).
Use relaxation, distraction, or autosuggestion as paincountering techniques.
Resist any use of "needles" as modes of administering pain relief agents.
Nurse may respond by:
Using self effectively (e.g., using tone of voice, closeness in space, and touch as media for conveying message of interest and caring).
Using avoidance, belittling, or other distracting actions as protective device for self.
Using pharmacologic resources at hand judiciously.
Using comfort measures.
Assuming accountability for control and management of pain.
EXPECTATIONS OF OTHERS
Nurse may be seen as someone who will accept woman's statement of pain and act as her advocate.
Medical personnel may be expected to relieve woman of all pain sensations.
Nurse may be expected to be interested, gentle, kind, and accepting of behavior exhibited.
Only certain verbal or nonverbal responses to pain may be accepted as appropriate responses.
Couple that is prepared for childbirth may be expected to refuse medication and to wish to "do everything on their own."
Woman's definition of pain may not be accepted; that is, woman may wish to experience and participate in controlling pain or may not be able to accept any pain as reasonable.
In Western societies the father is being increasingly viewed as the ideal birth companion (Chalmers & Meyer, 1994). For European-American couples, attending childbirth classes together has become a traditional, expected activity— a rite of passage (Finn, 1994). Laotian (Hmong) husbands actively participate in the labor process, often by supporting their wife's position, catching the baby as it emerges, cutting the cord, and burying the placenta. A Mormon woman expects her husband to be present during her labor and to lay his hands on her head, in a blessing that imparts strength, comfort, and well-being for safe passage through childbirth (Callister, 1992, 1995). In some cultures the father may be available, but his presence in the labor room with the mother may not be considered appropriate or he may be present but resist active involvement in her care. Such behavior could be misconstrued by the nursing staff to represent a lack of concern, caring, or interest. Latina women expect their male partner to be present at their bedside during labor, to talk to them, keep them calm, and tell them everything is going to be okay and not to worry. The men are expected to show love and affection by telling the women they love them, by hugging them, and by holding their hand. However, Latino men do not become actively involved in giving their partners care during labor by performing such activities as back rubs and helping with pushing (Khazoyan & Anderson, 1994). Lantican and Corona (1992) identified the importance of the affectional bond Mexican-American and Filipina women have with their female relatives when it comes to home-related activities such as childbearing. This is also true for the women of many other cultural groups. The presence of another woman or women is highly desired at such occasions. Women who come from some of these cultures and who give birth in the hospital like to have at least one woman present for assistance. Vietnamese, Chinese, and Indian women prefer a female companion during childbirth and are very concerned about their modesty (Choudhry, 1997). Islamic women are also very modest and would not accept the presence of a man during childbirth, not even the father (Woods, 1991). The religious beliefs of some Orthodox Jews forbid the father from touching his wife during labor or being present at the birth. Instead, while he prays, the female members of the laboring woman's family act as supportive childbirth companions (Callister, 1995; De Sevo, 1997). In India, women are attended by other women and in rural areas by a local untrained midwife or dai. Men usually are not present and in some cases may not be allowed to see the face of their child until certain prayers are said or an astrologically appropriate time is reached (Choudhry, 1997).
The non-English-speaking woman in labor. A woman's level of anxiety in labor rises when she does not understand what is happening to her or what is being said (McKay & Smith, 1993). Some misunderstanding may occur with English-speaking women and cause some stress, but the effect of misunderstanding on non-English-speaking women is much more dramatic. These women often feel a complete loss of control over their situation if there is no health care provider present who speaks their language. They can panic and withdraw or become physically abusive when someone tries to do something they perceive might harm them or their babies. Sometimes a support person is able to serve as a translator. However, this must be done with caution because the translator may not be able to convey exactly what the nurse or others are saying or what the woman is saying and may raise the woman's stress level even more.
Ideally, a bilingual nurse will care for the woman. Alternatively, an employee or volunteer translator may be contacted for assistance. Preferably, the translator is from the woman's culture. If no one in the hospital is able to translate, a translation service can be called so that a translation can take place over the telephone. For some women, a female translator may be more acceptable. If no translator is available, the labor and birth unit staff can prepare a set of cards with graphic depictions that illustrate common situations. These cards then can be used to communicate with non-English-speaking women. Even when the nurse has limited ability to communicate orally with the woman, in most instances the nurse's efforts to communicate are meaningful and appreciated by the woman. Speaking slowly and avoiding complex words and medical terms can help a woman to understand (Mattson, 2000).
The initial physical examination includes a general systems assessment; performance of Leopold's maneuvers to determine fetal presentation and position and the point of maximum intensity (PMI) for auscultating the FHR; assessment of fetal status; assessment of uterine contractions; and vaginal examination to assess the status of cervical effacement and dilation, fetal descent, and amniotic membranes and fluid. The most vital aspect of the assessment is the determination of fetal status. The findings serve as a baseline for assessing the woman's progress from that point.
It is important to obtain as many related pieces of information as possible before planning and implementing care. Women often focus on the nature of their contractions as the clearest indicator of how far advanced their labor is. However, the findings from the vaginal examination are more valid indicators of the phase of labor, especially for nulliparous women.
The information yielded by a complete and accurate assessment during the initial examination serves as the basis for determining whether the woman should be admitted and what her ongoing care should be. Expected maternal progress and minimum assessment guidelines during the first stage of labor are presented in Table 3 and the Care Path.
TABLE 3 Expected Maternal Progress in First Stage of Labour
The assessment procedures described in the following paragraphs can be used as a basis for teaching women and their families. The equipment needed, the nursing actions involved, and the rationale for each procedure can be shared with the woman. The nurse should thoroughly wash her hands before performing any of these procedures. Handwashing is also important after the examinations are completed. Standard Precautions should be used for all assessment and care measures (Box 2). The assessment findings are explained to the woman whenever possible. Throughout labor, accurate documentation following agency policy and professional standards of care is done as soon as possible after a procedure has been performed.
BOX 2 Standard Precautions During Childbirth
Birth is a time when nurses and other health care providers are exposed to a great deal of maternal and newborn blood and body fluids. Observation of Standard Precautions is necessary to prevent the transmission of infection. Perinatal infections most often are transmitted through contact with body fluids. The Standard Precautions applicable to childbirth include:
• Wash hands before and after putting on gloves and performing procedures.
• Wear gloves (clean or sterile, as appropriate) when performing procedures that require contact with the woman's genitalia and body fluids, including bloody show (e.g., during vaginal examination, amniotomy, hygienic care of the perineum, insertion of an internal scalp electrode and intrauterine pressure monitor, and catheterization).
• Wear cap, a mask that has a shield or protective eyewear, shoe covers, and cover gown during the birth. Gowns worn by the primary health care provider who is attending the birth should have a waterproof front and sleeves and should be sterile.
• Drape the woman with sterile towels and sheets as appropriate. Explain to the woman what can and cannot be touched.
• Help the woman's partner put on appropriate coverings for the birth, such as cap, mask, gown, and shoe covers. Show the partner where to stand and what can and cannot be touched.
• Wear gloves and gown when handling the newborn immediately after birth.
• Use an appropriate method to suction the newborn's airway, such as a bulb syringe, mechanical wall suction, or DeLee oral suction device that prevents the newborn's mucus from getting into the user's mouth.
General systems assessment. A brief systems assessment is performed. This includes an assessment of the heart, lungs, and skin; an examination to determine the presence and extent of edema of the legs, face, hands, or sacrum; and testing of deep tendon reflexes and clonus.
Vital signs. Temperature, pulse, respirations, and blood pressure are assessed on admission, and initial values are used for comparison with subsequent values. If the blood pressure is elevated, it should be reassessed 30 minutes later, between contractions, using a correct-size blood pressure cuff to obtain a reading after the woman has relaxed. To prevent supine hypotension and fetal distress, the woman should be encouraged to lie on her side and not supine (Fig. 4). Her temperature is monitored so that signs of infection or a fluid deficit (e.g., dehydration associated with inadequate intake of fluids) can be identified.
Fig. 4 Supine hypotension. Note relationship of pregnant uterus to ascending vena cava in standing position (A) and in supine position (B). C, Compression of aorta and inferior vena cava with woman in supine position. D, Compression of these vessels is relieved by placement of a wedge pillow under the woman's right side.
Leopold's maneuvers (abdominal palpation). Leopold's maneuvers are performed with the woman briefly lying on her back (Fig. 5; see Procedure box). These maneuvers help identify (1) number of fetuses; (2) presenting part, fetal lie, and fetal attitude; (3) degree of the presenting part's descent into the pelvis; and (4) expected location of the PMI of the fetal heart tones (FHTs) on the woman's abdomen.
Fig. 5 Leopold's maneuvers.
Procedur Leopold’s Maneuver and Determination of the points of Maximum Intensity of the Fetal heart Tone (FHT)
Ask woman to empty bladder.
Position woman supine with one pillow under her head and with her knees slightly flexed.
Place small rolled towel under woman's right or left hip to displace uterus off major blood vessels (prevents supine
hypotensive syndrome; see Fig. 4).
If right-handed, stand on woman's right, facing her:
1. Identify fetal part that occupies the fundus. The head feels round, firm, freely movable, and palpable by ballottement; the breech feels less regular and softer. This maneuver identifies fetal lie (longitudinal or transverse) and presentation (cephalic or breech) (Fig. 5, A).
2. Using palmar surface of one hand, locate and palpate the smooth convex contour of the fetal back and the irregularities that identify the small parts (feet, hands, elbows). This maneuver helps identify fetal presentation (Fig. 5, B).
3. With right hand, determine which fetal part is presenting over the inlet to the true pelvis. Gently grasp the lower pole of the uterus between the thumb and fingers, pressing in slightly (Fig. 5, C). If the head is presenting and not engaged, determine the attitude of the head (flexed or extended).
4. Turn to face the woman's feet. Using both hands, outline the fetal head (Fig. 5, D) with the palmar surface of the fingertips. When the presenting part has descended deeply, only a small portion of it may be outlined. Palpation of the cephalic prominence helps identify the attitude of the head. If the cephalic prominence is found on the same side as the small parts, this means that the head must be flexed and the vertex is presenting (Fig. 5, D). If the cephalic prominence is on the same side as the back, this indicates that the presenting head is extended and the face is presenting (Fig. 5, D) ocument fetal presentation, position, and lie and whether presenting part is flexed or extended, engaged, or free floating. Use hospital's protocol for documentation (e.g., "Vtx, LOA, floating").
DETERMINATION OF PMI OF FHT
Perform Leopold's maneuvers.
Auscultate FHT based on fetal presentation identified with Leopold's maneuvers. The PMI is the location where the FHT is heard the loudest, usually over the fetal back (see Fig. 6).
Chart PMI of FHT using a two-line figure to indicate the four quadrants of the maternal abdomen, as follows: right upper quadrant (RUQ), left upper quadrant (LUQ), left lower quadrant (LLQ), and right lower quadrant (RLQ):
The umbilicus is the reference point for the quadrants (point where the lines cross). The PMI for the fetus in vertex presentation, in general flexion with the back on the mother's right side, commonly is found in the mother's right lower quadrant and is recorded with an "X" or with the FHT, as follows:
Fig. 6 Areas of maximum intensity of fetal heart rate for differing positions. RSA, Right sacrum anterior; ROP, right occipitoposterior; RMA, right mentum anterior; ROA, right occipitoanterior; LSA, left sacrum anterior; LOP, left occipitoposterior; LMA, left mentum anterior; LOA, left occipitoanterior. A, Presentation is breech if fetal heart rate is heard above umbilicus. B, Presentation is vertex if fetal heart rate is heard below umbilicus
Assessment of fetal heart rate and pattern. It is important or the nurse to understand the relationship between the location of the PMI of the FHT and fetal presentation, lie, and position. A high risk for childbirth complications may be revealed by variations in these findings. The PMI of the FHT is the location on the maternal abdomen where the FHT is heard the loudest. It is usually directly over the fetal back. The PMI is also an aid in determining the fetal presentation and position. In a vertex presentation, the FHT is heard below the mother's umbilicus in either the right or left lower quadrant of the abdomen; in a breech presentation, the FHT is heard above the mother's umbilicus (Fig. 6). As the fetus descends and rotates internally, the FHT is heard lower and closer to the midline of the maternal abdomen. The assessment recommended for determining fetal status in the low risk woman during the first stage of labor is summarized in the Care Path. The FHR and pattern are assessed (1) immediately after ROM, because this is the most common time for the umbilical cord to prolapse; (2) after any change in the contraction pattern or maternal status; and (3) before and after medicating the woman or performing a procedure.
Assessment of uterine contractions. A general characteristic of effective labor is regular uterine activity, but uterine activity is not directly related to labor progress. Uterine contractions are the primary powers that act involuntarily to expel the fetus and the placenta from the uterus. Several methods are used to evaluate uterine contractions. These include the woman's subjective description, palpation and timing of the contraction by a health care provider, and electronic monitoring.
Each contraction exhibits a wavelike pattern. It begins with a slow increment (the "building up" of a contraction from its onset), gradually reaches an acme (the peak with intrauterine pressure of 50 to 75 mm Hg), and then diminishes rapidly (decrement, the "letting down" of the contraction). An interval of rest follows (intrauterine pressure 5 to 15 mm Hg) that ends when the next contraction begins. The outward appearance of the woman's abdomen during and between contractions and the pattern of a typical uterine contraction are shown in Fig. 7.
Fig. 7 Assessment of uterine contractions. A, Abdominal contour before and during uterine contraction. B# Wavelike pattern of contractile activity.
The following characteristics are used to describe uterine contractions:
• Frequency of uterine contractions: How often uterine contractions occur; the time that elapses from the beginning of one contraction to the beginning of the next or from the peak of one contraction to the peak of the next (if using electronic monitoring)
• Intensity of uterine contractions: The strength of a contraction at its peak
• Duration of uterine contractions: The time that elapses between the onset and the end of a contraction
• Resting tone of uterine contractions: The tension in the uterine muscle between contractions
Uterine contractions are assessed by palpation or by an external or internal electronic monitor. Frequency and duration can be measured by all three methods of uterine activity monitoring. The accuracy of determining intensity varies by the method used. Palpation is more subjective and is a less precise way of determining the intensity of uterine contractions (Arrabal & Naegy, 1996). The following terms are used to describe what is felt on palpation:
• Mild: Slightly tense fundus that is easy to indent with fingertips (feels like touching finger to tip of nose)
• Moderate: Firm fundus that is difficult to indent with fingertips (feels like touching finger to chin)
• Strong: Rigid, boardlike fundus that is almost impossible to indent with fingertips (feels like touching finger to forehead)
Women in labor tend to describe the pain of contractions in terms of the sensations they are experiencing in the lower abdomen or back, which may be unrelated to the firmness of the uterine fundus. Thus their assessment of the strength of their contractions can be less valid than that of an experienced health care provider, although the amount of discomfort reported is valid.
External electronic monitoring provides information about the relative strength of the uterine contractions. Internal electronic monitoring using an intrauterine pressure catheter is the most reliable way of assessing the intensity of uterine contractions.
On admission, a 20- to 30-minute baseline monitoring of uterine contractions and the FHR usually is done (Scott et al, 1999). The minimum assessment times and the findings expected during each phase of the first stage of labor are summarized in Table 3 and the Care Path.
The nurse's responsibility in the monitoring of uterine contractions is to ascertain whether they are powerful and frequent enough to accomplish the work of expelling the fetus and the placenta.
NURSE ALERT If the characteristics of contractions are found to be abnormal, either exceeding or falling below what is considered acceptable in terms of the standard characteristics, the nurse should report this to the primary health care provider.
Vaginal examination. The vaginal examination reveals whether the woman is in true labor and enables the examiner to determine whether the membranes have ruptured (Fig. 8). Because this examination is often stressful and uncomfortable for the woman, it should be performed only when indicated by the status of the woman and her fetus. For example, a vaginal examination should be performed on admission, when significant change has occurred in uterine activity, on maternal perception of perineal pressure or the urge to bear down, when membranes rupture, or when variable decelerations of the FHR are noted. A full explanation of the examination and support of the woman are important factors in reducing the stress and discomfort associated with the examination (Bergstrom et al., 1992). Chapter 4 describes a typical vaginal examination. Variations in the examination of the woman in labor include the following:
1. Use a sterile glove and antiseptic solution or soluble gel; use water for lubrication during the initial examination if rupture of membranes is suspected and a Nitrazine test is required.
2. Position the woman to prevent supine hypotension (see Fig. 4). Cleanse perineum and vulva if needed.
3. Ask the woman for permission to touch her before proceeding (Waymire, 1997) and explain that she will feel the insertion of the nurse's index and middle fingers into the vagina. Perform the examination gently, with concern for the woman's comfort. Acknowledge the woman's expressions of pain or discomfort and anxiety.
4. Assess the status of the cervix, presenting part, amniotic membranes, and bloody show (see Fig. 8).
5. Discuss the findings of the examination with the woman or couple.
6. Document the findings and report them to the physician or nurse-midwife.
Fig. 8 Vaginal examination. A, Undilated, uneffaced cervix; membranes intact. B, Palpation of sagittal suture line. Cervix effaced and partially dilated.
Cervical dilation, effacement, and station. Uterine activity must be considered in the context of its effect on cervical effacement and dilation and on the degree of descent of the presenting part. The effect on the fetus also must be considered. The progress of labor can be effectively verified by the use of graphic charts (partograms) on which cervical dilation and station (descent) are plotted. This type of graphic charting assists in early identification of deviations from expected labor patterns. Fig. 9 provides examples of partograms illustrating the expected pattern of cervical dilation and fetal descent for both nulliparous and multiparous women. Hospitals and birthing centers may develop their own graphs for recording assessments.Such graphs may include not only data on dilation
and descent but also on maternal vital signs, FHR,
and uterine activity.
NURSE ALERT) It is important for the nurse to recognize that active labor can actually last longer than the expected labor patterns. This finding should not be a cause for concern unless the maternal-fetal unit exhibits signs of distress (e.g., nonreassuring FHR pattern, maternal fever).
Fig. 9 Partogram for assessment of patterns of cervical dilation and descent. Individual woman's labor patterns (colored) are superimposed on prepared labor graph (black) for comparison. A, Labor of a nulliparous woman. B, Labor of a multiparous woman. The rate of cervical dilation is plotted with the circled plot points. A line drawn through these symbols depicts the slope of the curve. Station is plotted with Xs. A line drawn through the Xs reveals the pattern of descent.
Laboratory and diagnostic tests
Analysis of urine specimen. A clean-catch urine specimen may be obtained to gather data about the pregnant woman's health. It is a convenient and simple procedure that can provide information about her hydration status (e.g., specific gravity, color, amount), nutritional status (e.g., ketones), infection (e.g., leukocytes), or the status of possible complications such as PIH, shown by finding protein in the urine. The results can be obtained quickly and help the nurse determine appropriate interventions to implement.
Blood tests. The blood tests performed vary with the hospital protocol and the woman's health status. An example of a minimum assessment is a hematocrit determination, in which the specimen is centrifuged in the perinatal unit. Blood can be obtained by a finger stick or from the hub of a catheter used to start an IV line. More comprehensive blood assessments such as white blood cell count, red blood cell count, hemoglobin level, hematocrit, and platelet values are included in the CBC. A CBC may be ordered for women with a history of infection, anemia, PIH, or other disorders.
If the woman's blood type has not been verified, blood is drawn to determine the type and Rh factor. If blood typing has already been done, the primary health care provider may choose not to repeat the test. If obvious signs of immunocompromise or substance abuse are present, other diagnostic blood tests may be ordered.
Assessment of amniotic membranes and fluid. Labor is initiated at term by spontaneous rupture of membranes (SROM, SRM) in approximately 25% of pregnant women. A lag period, rarely exceeding 24 hours, may precede the onset of labor. Membranes (the bag of waters) can also rupture spontaneously any time during labor, most likely during the transition phase of the first stage. Amniotomy, or artificial rupture of membranes (AROM, ARM), may be done to augment or induce labor or to facilitate placement of internal monitors when fetal status indicates the need for some form of direct assessment (e.g., insertion of a fetal scalp electrode or an intrauterine pressure catheter). The tests used to assess amniotic fluid are discussed in the Procedure box, and characteristics of the fluid are described in Table 4
Assessment of Amniotic Fluid Characteristics
CHARACTERISTIC OF FLUID
DEVIATION FROM NORMAL FINDING
CAUSE OF DEVIATION FROM NORMAL
Pale, straw colored; may contain white flecks of vernix caseosa
Greenish brown color
Yellow-stained fluid Port wine-colored
Hypoxic episode in fetus; meconium in fluid May be normal finding in breech presentation
Fetal hypoxia a36 hrs before ROM; fetal hemolytic disease; intrauterine infection Bleeding associated with abruption placentae
Viscosity and odor
Watery; no strong odor
Thick, cloudy, foul-smelling
Intrauterine infection Large amount of meconium can make fluid thick
500 to 1200 ml
Hydramnios; associated with congenital anomalies of the fetus when fetus cannot drink fluid
Oligohydramnios; associated with incomplete or absent kidney; obstruction of urethra; infant cannot secrete or excrete urine
NURSE ALERT The umbilical cord may prolapse when the membranes rupture. It is the nurse's responsibility to monitor the FHR and pattern for several minutes immediately after rupture of membranes to ascertain fetal well-being and then to document the findings.
Infection. When membranes rupture, microorganisms from the vagina can then ascend into the amniotic sac, causing chorioamnionitis and placentitis to develop. For this reason, maternal temperature and vaginal discharge are assessed frequently (every 1 to 2 hours) so that an infection developing after ROM can be identified early. Even when membranes are intact, however, microorganisms may ascend and cause premature ROM. There is controversy regarding whether prophylactic antibiotic therapy can protect against infection (chorioamnionitis), which involves both the maternal and fetal sides of the membrane.
The nurse is responsible for reporting findings promptly to the physician and nurse-midwife and documenting findings according to agency policy. If abnormal findings are noted, continuous electronic monitoring is usually used and maintained for the duration of labor. The presence of meconium-stained amniotic fluid alerts the nurse to the necessity of observing fetal status more closely. After birth, the newborn may be at high risk for alteration in respiratory status if meconium is aspirated into the lungs with the first breath.
Assessment findings serve as a baseline for evaluating the woman's subsequent progress during labor. Although some problems of labor are anticipated, others may appear unexpectedly during the clinical course of labor (see Signs of Potential Complications box).
SIGNS of POTENTIAL COMPLICATIONS
• Intrauterine pressure of more than 75 mm Hg (determined by intrauterine pressure catheter monitoring) or resting tone of more than 15 mm Hg
• Contractions consistently lasting 90 seconds or more
• Contractions consistently occurring 2 minutes or less apart
• Fetal bradycardia, tachycardia, or persistently decreased variability
• Irregular FHR; suspected fetal dysrhythmias
• Appearance of meconium-stained or bloody fluid from the vagina
• Arrest in progress of cervical dilation or effacement or descent of the fetus
• Maternal temperature of 38° C or more
• Foul-smelling vaginal discharge
• Persistent bright or dark red vaginal bleeding
Nursing diagnoses appropriate for the woman in first stage labor include the following:
Anxiety related to
-negative experience with previous childbirth
• Impaired urinary elimination related to
-reduced intake of oral fluids
-diminished sensation of bladder fullness associated with epidural anesthesia/analgesia
• Impaired fetal gas exchange related to
-compression of the umbilical cord
• Situational low self-esteem (maternal) related to
-inability to meet self-expectations regarding performance during childbirth
-loss of control during labor
Nursing diagnoses that represent potential areas for concern during the second stage of labor include the following:
• Risk for injury to mother and fetus related to
-persistent use of Valsalva maneuver
• Situational low self-esteem related to
-deficient knowledge of normal, beneficial effects of vocalization during bearing-down efforts
-inability to carry out plan for birth without medication
• Ineffective coping related to
-coaching that contradicts woman's physiologic urge to push
• Anxiety related to
-inability to control defecation with bearing-down efforts
-deficient knowledge regarding perineal sensations associated with the urge to bear down
Examples of nursing diagnoses relevant to the third stage of labor include the following:
• Risk for deficient fluid volume related to
-blood loss occurring after placental separation and expulsion
-inadequate contraction of the uterus
• Anxiety related to
-lack of knowledge regarding separation and expulsion of the placenta
-occurrence of perineal trauma and the need for repair
• Fatigue related to
-energy expenditure associated with childbirth and the bearing-down efforts of the second stage
Expected Outcomes of Care
Planning with the woman is essential to ensure the implementation of expected outcomes and maintain her sense of control over her own childbirth experience. Expected outcomes for the woman in labor are that the woman will accomplish the following:
• Continue normal progression of labor while the FHR and pattern remain within the expected range and without signs of distress.
• Maintain adequate hydration status through oral or IV intake.
• Actively participate in the labor process.
• Verbalize discomfort and indicate the need for measures that help reduce discomfort and promote relaxation.
• Accept comfort and support measures from significant others and health care providers as needed.
• Sustain no injury to herself or the fetus during labor and birth.
• Initiate, along with the partner and family, the processes of bonding and attachment with the newborn.
• Express satisfaction with her performance during labor and birth.
Plan of Care and Interventions
Standards of care
Standards of care guide the nurse in preparing for and implementing procedures with the expectant mother. Protocols for care based on standards include the following:
• Check the primary health care provider's orders.
• Assess the orders for appropriateness and correctness (e.g., analgesic to be administered to relieve discomfort).
• Check labels on IV solutions, medications, and other materials used for nursing care.
• Check the expiration date on any packs of supplies used for procedures.
• Ensure that information on the woman's identification band is accurate (e.g., band is the appropriate color for allergies).
• Employ an empathic approach when giving care:
-Use words the woman can understand when explaining procedures.
-Respect the woman's individual needs and behaviors.
-Establish rapport with the woman and her support persons/family.
-Be kind, caring, and competent when performing necessary procedures.
-Be aware that pain and discomfort are as the woman describes them.
-Repeat instructions as necessary and ensure that they are understood by the woman.
-Carry out appropriate comfort measures, such as mouth care and back care, and ensure that the support person is coping.
-Recognize that a woman's current childbirth experience and the actions of nurses and other health care providers can have a positive or negative effect on the woman's future childbirth experiences.
• Use Standard Precautions, including precautions for invasive procedures.
• Document care according to hospital guidelines, and promptly communicate information to the physician or nurse-midwife.
Physical nursing care during labor
The physical nursing care of the woman in labor is an essential component of her care. The current emphasis on evidence-based practice has led to the following labeling of care measures used during labor and birth:
• Demonstrably beneficial (useful) or likely to be beneficial
• A trade-off between beneficial and having a potentially adverse effect or of unknown effectiveness with insufficient evidence to support use
• Unlikely to be beneficial or likely to be harmful or ineffective
Managing care using this approach will enhance the safety, effectiveness, and acceptability of the physical care measures chosen to support the woman during labor and birth (Enkin et al., 2001; Technical Working Group, World Health Organization, 1997). The various physical needs, the requisite nursing actions, and the rationale for care are presented in the Care Path, Table 5, and the Plan of Care.
Table 5 Physical Nursing Care During Labor