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Labor Support & Non-Pharmacologic Pain Management
Linda Robinson, MSN, RNC
Clinical Nurse Specialist, Northwest Hospital
Fall 2016
History of
where we
have been
2
To annul pain by anesthesia is “a questionable attempt to abrogate one of the general conditions of man”. Dr. Meigs, as taken from
The British Record of Obstetric Medicine & Surgery for 1848-1849.
Merriman opposed anesthesia on the grounds of “the great superiority of allowing nature to conduct the whole process of the birth”.
3
Labor results in severe pain for many
women. There is no other
circumstance where it is considered
acceptable for a person to experience
untreated severe pain, amenable to
safe intervention, while under a
physician’s care. In the absence of a
medical contraindication, maternal
request is a sufficient medical
indication for pain relief during labor.
ACOG Committee Opinion, 2004,
Reaffirmed in 2015
Why no one uses Mid Husbands
5
Objectives Discuss the uniqueness of labor pain and
factors of pain response
Discuss the roles of nursing, doulas and
family in labor support
Discuss positions and movements for comfort
Identify methods of non-pharmacologic pain
management
Nature of Labor Pain
Pain from Pathology stems
from injury or disease
Pain in childbirth has a biological
basis
What is our best response?
#1
Safety for
mother
and baby
Emotionally Satisfying
Physiologic
approach
Vaginal birth
Empowering
Experience
The Source and Origin of Childbirth Pain
The International Association for the Study
of Pain (IASP) has defined pain as:
“an unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage”.
vs.
Suffering
It has been said that women the origin of their pain
and view the labor and delivery process as positive
and non-threatening may undergo pain without
suffering.
Some women who requested and received an
epidural for labor described a sense of deprivation
from having missed the natural labor expereince in
its entirety.
Can we predict who will
have pain?
Level of Fear is related to her level of
preparation
Degree of fatigue
Anxiety
Her ability to distraction
Tension Pain More preparation showed a decreased pain
perception and less use of analgesia but an
increase in her level of confidence~
Lowe, 2002
Fear
What does this mean for you?
Labor Support Practices
Be Present
Reduce Anxiety
Consider Environment
http://birthtools.org
Major push across America to reduce the C/S
rate
Intermittent monitoring
Intermittent auscultation
Standard definitions of labor dystocia
DEFINITIONS
Non-Pharmacologic Labor Support--includes
physical and emotional nursing interventions
that support a woman who is in labor to enhance her
physical comfort, confidence in her
ability to give birth, and sense of being cared for and
being safe. A registered nurse or other
members of the care team with licenses must
supervise non-licensed individuals performing
labor support interventions, e.g., a doula. Individuals
must have evidence-based knowledge
concerning how to perform and customize non-
pharmacologic labor support interventions.
Non-pharmacologic labor support nursing
interventions include the following:
•
• Be in the room with the woman continuously;
• Encourage the woman to labor in positions of her choice, e.g., walk
or use balance ball;
• Use guided imagery and therapeutic breathing;
• Use touch therapy, such as a back rub, leg massage, or counter
pressure;
• Use hydrotherapy in a tub or shower;
• Apply warm or cool compresses to various parts of the woman’s
body;
• Use aromatherapy;
• Provide emotional support: verbally encourage, reassure, and
praise the woman and provide easy to understand information
about how labor is progressing and how she and her baby are
doing;
• Support the woman’s nutritional needs; and
• Advocate for the woman by helping her to articulate her wishes to
others
(Hodnett et al., pg. 7, 2011; Sleutel, 2002; Sleutel, 2003)
Relaxation is contagious
Be Present Spending time with the patient allows you to see
her needs and emotions as they change over time
In the active phase, she may become dependent
on others and express wavering self confidence.
Emotional support----use of voice, words, touch;
be aware of how your body language, tone of
voice, choice of words are making an
impression upon your patient and family
Environment
Allow for privacy
Fluids and Nutrition
Reduce noise; use music
Proper lighting, Proper temperature
Discomforts associated with the
technology of birth. 19
Continuous Support in Labor
reduces the risk of:
medication use
longer labors
operative vaginal birth
C-Section
5 minute Apgar less than 7
(Hodnett, 2003, 2004)
Doula - “in service of”
Shorter labors
Less need for oxytocin to speed up
labor
Reduced use of forceps
Less post-partum depression
Mother more satisfied with birth
Women request less pain meds and epidurals
Informational Support
Anticipatory guidance and information
Breathing
Relaxation
Imagery
Focal point
Breathing
Cleansing and Ending Breath
Slow Deep Chest Breathing
Accelerated Breathing
Patterned Breathing
Relaxation
Guided Relaxation
Soft, gentle voice
Touch the location you would like her to relax
Give positive feedback as she relaxes
“You have total control”
Relaxation travels, help it by guiding it
25
Imagery
Finding an image that works
Needs to be individualized
Should bring her a sense of calm and control
Ex: seaweed, mirror, flower opening, floating on a river
Past experience of success or empowerment of the woman
Focal Point
Something to look at: partner, pictures, holes in a tile
Something to feel: soft & silky, arm, stuffed animal, tub water
Something to hear: music, voice, counting, encouragement
Something to do: walking, rocking, pacing, dancing, taking care of others
Rhythm
Care of the partner
Nutrition
Rest
Instruction
Encouragement
Non-pharmacologic
Pain Relief
Position
Hypnosis
TENS unit
Sterile Water Blocks
Acupuncture
Application of Heat or Cold
Hydrotherapy
POSITIONS
FOR
LABOR
Peanut Ball
Moms who had received an
epidural and used a peanut
ball:
Women were half as likely to
need a c-section
Optimal fetal positioning
Increased pelvic diamter
Significantly shorter time in
labor
Peanut Ball
https://www.youtube.com/
watch?v=hSn_BWjL1nw
32
33
36
SIM’S POSITION FOR COMFORT
37
Hypnosis
Is a state of attentive and focused concentration
During trance-like state, therapeutic suggestions can be given
Possible Benefits of
Hypnosis Shorter labor
Less opioid use
More spontaneous vaginal deliveries
Higher APGAR scores
Reduced perception & awareness of pain
Few side effects and risks
Possible Benefits of Hypnosis
More satisfying birth experience
Less tension and anxiety
Less Analgesia & Epidural use
Can empower the woman
She may become very self-sufficient
Limits of Hypnosis
Needs antepartum training
Most beneficial results to “good”
subjects (about 25% of population)
Variable skill and experience of the
hypnotherapist
5-31% may experience mild
dizziness, nausea & headache, r/t
failure to dehypnotize properly
TENS - Transcutaneous
Electrical Nerve
Stimulation
Low voltage electrical impulses are administered through flat electrodes applied to the skin.
Most useful early in labor
Most useful for back pain
TENS - benefits Easy to use, easy to discontinue
May provide some beneficial pain
relief in early labor
Non-invasive
No harmful effects on fetus
If fails, can use other methods
TENS – Drawbacks
Can interfere with fetal monitor
Requires education of patient
and staff
Finding institutional support for
use of TENS can be a hurdle
Sterile Water
Blocks 2 intracutaneous injections are made on each
side of back about 2 cm below and 1 cm
medically to superior iliac spines.
Does not need to be precise placement
A fine needle used to inject 0.1 ml of sterile
water at each point.
A small white papule surrounded by a red zone
should be produced. 46
Sterile Water
Injections - Benefits Instant and complete relief of low
back pain in many women.
Pain relief lasted as long as 3 hours
No harmful effects on mom or fetus
Less pain than TENS users
May help women attain a goal of birth
without an epidural
Sterile Water
Injections - Drawbacks
Stinging pain can last 30 seconds
Short Acting
Warn her and help her focus during administration.
Use helper and inject two at a time
Acupuncture
Based on principles of trying to achieve or
restore balance between Yin & Yang
How it works is unknown - changing
neurotransmitters, hypnosis, or alternations in
electromagnetic fields
May be given by needles, heat, pressure,
friction, suction of impulses of electromagnetic
energy
Acupuncture -
Benefits
Less use of epidural and opioids for pain
relief
Shorter labors
Less oxytocin augmentation
No adverse maternal or fetal effects
identified
Acupuncture -
Drawbacks
Requires skilled practitioner in labor
Long time to do full placement of needles
Limited movement of mother
Needles may be troublesome for some
women
Accupressure
Accupressure
Accupressure
Accupressure
Application of Heat or Cold Increased or decreased local blood flow
Increased or decreased local skin and muscle temperature
Decreased muscle spasm
Relaxation of tiny muscles in the skin
Elevated pain threshold
No rigorous scientific studies
No harm to mother or fetus (provided proper temperature used)
Hydrotherapy
Helps relaxation
Decreases pain
Decreases anxiety
No risk to mother or
fetus **
Be careful!
Weakness
Dizziness
Nausea
Maternal or fetal tachycardia
Maternal hypotension
To Prepare
Childbirth Classes
Hypnosis
AcupunctureAccupressure
TENS unit
Self-education
How could you empower her to
enhance her ability to cope with
labor?
Positive attitude re childbirth.
Faith in her
Emphasize Fundamental strategies for which
she has control.
Let her know she has control by choosing to
focus on coping strategies versus the pain.
59
Scene: Woman in early labor,
breathing at peak of contractions,
appears relaxed. What does she need?
Praise, Praise, Praise, Praise, Praise
Reassurance, Reassurance
Express Confidence in her ability
Mom is well, baby is well and process is going well.
Scene: Woman in early labor,
her back is hurting.
Positions
Back Massage
Hip Press
TENS unit
Sterile Water Injections
Scene: First time mother in early labor.
Strategies to encourage labor. Fluids, Oral with calories
Position change
Upright positions
Walking, Showering, Rocking, Dancing
Reassurance and Praise
Focus her on coping.
Active Labor Signs
Intense contractions, requiring her
full attention from beginning to end.
Facial flushing
Frequent q 2-4 minute contractions
Decreased ability to talk/chat
Decreased ability to self analyze and
objectively plan strategies to cope.
Active Labor Help Recognize it, let her know her progress
Reassure her about labor progress
Reassure her that these sensations are normal
Consider all or part of Take Charge Routine
Guide partner in coaching strategies
When to consider
another method?
Her birth-plan states epidural, so when
eligible
At her request, when eligible, if desire
for pain medications was wait-and-see,
or neutral.
Long hard labor and a delivery is not
expected within 1-2 hours, and patient
requests.
When to try longer?
Normal progress, delivery expected within 1-2
hours
In early labor, she is just beginning to
experience active labor. She wanted natural
childbirth, but has not started to utilize a coping
strategy. Teach and support, then reevaluate.
The Take Charge Routine
Routine from Penny Simkin, The Birth Partner.
She hits an emotional low
Despair, crying
Wants to give up
Very tense and cannot relax
The Take Charge Routine from Penny Simkin, The Birth Partner.
Remain calm (touch and voice)
Stay close
Anchor her. Hold her shoulders or her head in your hands - gently, confidently , firmly - or hold tightly in your arms
Make eye contact - “open your eyes and look at me”
68
The Take Charge Routine from Penny Simkin, The Birth Partner.
Change the ritual she has been using
during contractions: - position, breathing.
Help pace her breathing
Encourage her every breath. “Breathe
with me, that’s the way, just like that.
Good, stay with it, breathe with me, look
at me, just like that, it’s going away. Good.
Good. Now a deep breath and let it go.
Good work.” 69
The Take Charge Routine from Penny Simkin, The Birth Partner.
Talk to her between contractions -
“what is helping? Let me help you
more. Take a deep breath and look at
me with the beginning of the next
contraction.”
Repeat yourself.
As a labor nurse, it
is your honor to be
present in this most
precious of events
Both the family and you will be blessed!
But, by contrast, unrelieved severe labor pain can
have psychological and physical consequences,
including depression and negative thoughts about
sexual relationships.
Psychological harm can be experienced through the
provision or withholding of labor analgesia,
underscoring the tremendous variability in the
meaning of labor pain in different women
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