Chapter 15: Pain Management During Childbirth

Which factors contribute to pain during labor and birth? (Select all that apply). a. Tissue ischemia b. Cutting of the nerves with dilatation c. Cervical dilation d. Distention of the vagina and perineum

A, C, D

Firm sacral pressure is likely to be most helpful in which situation? a. Rapid labor and birth b. Fetal occiput posterior position c. Oxytocin induction of labor d. If analgesics should be avoided

A posterior position of the vertex will cause pressure against the sacrum. This pressure increases back pain during and between contractions. Firm sacral pressure may help relieve some of the pressure.

Why is a cleansing breath at the beginning and end of contractions important? (Select all that apply). a. Helps the woman release tension b. Provides oxygen to reduce myometrial hypoxia c. Provides a diversional activity for the woman d. Helps the fetus to release tension

A, B

Relaxation of the mother during labor is important for several reasons. Listed below are the reasons that promoting relaxation is important. (Select all that apply). a. Promotes uterine blood flow b. Improves fetal oxygenation c. Promotes efficient uterine contractions d. Reduces tension that increases pain e. Inhibits rapid fetal descent

A, B, C, D

How does childbirth pain differs from other types of pain? (Select all that apply). a. It is a normal process. b. There is preparation time. c. It is stronger than most other types of pain. d. It is self-limiting. e. It is intermittent. f. It is always a dull, achy type of pain.

A, B, D, E

Excessive anxiety during labor heightens the client's sensitivity to pain by increasing: a. muscle tension. b. the pain threshold. c. blood flow to the uterus. d. rest time between contractions.

ANS: A Anxiety and fear increase muscle tension, diverting oxygenated blood to the woman's brain and skeletal muscles. Prolonged tension results in general fatigue, increased pain perception, and reduced ability to use coping skills. Anxiety will decrease the pain threshold. Anxiety can decrease blood flow to the uterus. Anxiety will decrease the amount of rest the mother gets between contractions.

A laboring client who imagines her body opening to let the baby out is using a mental technique called: a. imagery. b. effleurage. c. distraction. d. dissociation.

ANS: A Imagery is a technique of visualizing images that will assist the woman in coping with labor. Effleurage is self-massage. Distraction can be used in the early latent phase by having the woman involved in another activity. Dissociation helps the woman learn to relax all muscles except those that are working.

A client received 25 mg of meperidine (Demerol) intravenously 1 hour before birth. Which drug should the nurse have readily available? a. Naloxone (Narcan) b. Butorphanol (Stadol) c. Nalbuphine (Nubain) d. Promethazine (Phenergan)

ANS: A Naloxone (Narcan) reverses narcotic-induced respiratory depression, which may occur with the administration of narcotic analgesia. Phenergan is normally given for nausea. Nubain and Stadol are analgesics given to women in labor

A client is admitted to the labor and birth room in active labor; contractions are 4 to 5 minutes apart and last for 30 seconds. The nurse needs to perform a detailed assessment. When is the best time to ask questions or do procedures? a. After the contraction is over b. When it is all right with the coach c. During increment of next contraction d. After administration of analgesic-anesthetic

ANS: A Reduce intrusions as much as possible. Longer assessments may span several contractions. The coach is the support person. The woman needs to feel confident in her ability to go through labor and birth, and she should be encouraged to express her own needs and concerns. The increment is the beginning of the next contraction. It is best to stop with questions and procedures during each contraction. An analgesic or anesthetic may cause adverse reactions in the woman, preventing her from answering questions correctly.

The best time to teach nonpharmacologic pain control methods to an unprepared laboring client is during which stage? a. Latent phase b. Active phase c. Second stage d. Transition phase

ANS: A The latent phase of labor is the best time for intrapartum teaching because the woman is usually anxious enough to be attentive yet comfortable enough to understand the teaching. During the active phase, the woman is focused internally and unable to concentrate on teaching. During the second stage, the woman is focused on pushing. She normally handles the pain better at this point because she is active in doing something to hasten the birth. During transition, the woman is focused on keeping control; she is unable to focus on anyone else or learn at this time.

The nurse is providing care to a patient in the active phase of the first stage of labor. The patient is crying out loudly with each contraction. What is the nurse's priority action for this patient? a. Ask the patient's labor coach if this is a usual expression of pain for her. b. Refer to the patient's chart to determine any orders for pain medication. c. Tell the patient that she is disturbing the other laboring patients on the unit. d. Encourage the patient to try to suppress her noisiness during contractions.

ANS: A Women should be encouraged to express themselves in any way they find comforting, and the diversity of their expressions must be respected. Loud and vigorous expression may be a woman's personal pain coping mechanism, whereas a quiet woman may need medication relief but feels the need to remain stoic. Accepting a woman's individual response to labor and pain promotes a therapeutic relationship. Restraint is difficult because noisy women are challenging to work with and may disturb others.

The priority intervention for a client with epidural anesthesia whose blood pressure is 80/50 mm Hg is: a. reposition to supine position. b. administer ephedrine, 5 mg IV push. c. maintain IV infusion rate at 150 mL/hr. d. Notify anesthesia about maternal hypotension.

ANS: B A significant blood pressure decrease is a drop to 100 mm Hg or lower systolic. If hypotension is significant, ephedrine is ordered to increase the blood pressure to normal values. The supine position will further decrease maternal blood pressure by compressing the major vessels. Maintaining the IV infusion rate will not return blood pressure to normal values as quickly as needed; immediate action needs to be taken, and notifying anesthesia would be time-consuming.

A client in labor is approaching the transition stage and already has an epidural in place. An additional dose of medication has been prescribed and administered to the client. Which priority intervention should be done by the nurse to help evaluate clinical response to treatment? a. Obtain a pain scale response from the client based on a 0 to 10 scale. b. Document maternal blood pressure and fetal heart rates following medication administration and observe for any variations. c. Document intake and output on the electronic health record (EHR). d. Increase the flow rate of prescribed parenteral fluid to maintain hydration.

ANS: B Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) evidence-based practice guidelines note that maternal blood pressure and fetal heart tones should be assessed following any bolus of additional medication via the epidural route. Obtaining a pain scale response is not typically used for the laboring client but used for postoperative and/or chronic pain clients. Intake and output should be documented as part of the clinical record but is not the priority intervention based on this client's situation. Increasing the flow rate of parenteral fluids requires a physician's order, and there is no clinical evidence that this is needed. Giving parenteral fluids in excess can lead to fluid retention and fluid volume excess.

A labor client, gravida 2, para 1, at term has received meperidine (Demerol) for pain control during labor. Her most recent dose was 15 minutes ago and birth is now imminent. Maternal vital signs have been stable and the EFM tracing has not shown any baseline changes. Which medication does the nurse anticipate would be required in the birth room for administration? a. Oxytocin (Pitocin) b. Naloxone (Narcan) c. Bromocriptine (Parlodel) d. Oxygen

ANS: B Because birth is imminent, and considering that the client has had a recent dose of narcotics, the nurse anticipates that naloxone (Narcan) will be administered to the newborn to combat the effects of the opioid. Although Pitocin will be given following birth of the placenta, the newborn will be delivered prior to that and will receive priority intervention. Parlodel is not typically given in the labor and birth area any more. It was previously used to suppress lactation. At present, there is no need for the administration of oxygen because there is no evidence that the mother is showing any signs of respiratory depression.

Childbirth pain is different from other types of pain in that it is: a. less intense. b. associated with a physiologic process. c. more responsive to pharmacologic management. d. designed to make one withdraw from the stimulus.

ANS: B Childbirth pain is part of a normal process, whereas other types of pain usually signify an injury or illness. Childbirth pain is not less intense than other types of pain. Pain management during labor may affect the course and length of labor. The pain with childbirth is a normal process; it is not caused by the type of injury as when withdrawal from the stimulus occurs.

Which client will most likely have increased anxiety and tension during labor? a. Gravida 2 who refused any medication b. Gravida 2 who delivered a stillborn baby last year c. Gravida 1 who did not attend prepared childbirth classes d. Gravida 3 who has two children younger than 3 years

ANS: B If a previous pregnancy had a poor outcome, the client will probably be more anxious during labor and birth. The client without childbirth education classes is not prepared for labor and will have increased anxiety during labor. However, the client with a poor previous outcome is more likely to experience more anxiety. A gravida 2 has previous experience and can anticipate what to expect. By refusing any medication, she is taking control over her situation and will have less anxiety. This gravida 3 has previous experience and is aware of what to expect.

Which fetal position may cause the laboring client more back discomfort? a. Left occiput anterior b. Left occiput posterior c. Right occiput anterior d. Right occiput transverse

ANS: B In the left occiput posterior position, each contraction pushes the fetal head against the mother's sacrum, which results in intense back discomfort. Back labor is seen mostly when the fetus is in the posterior position.

When giving a narcotic to a laboring client, which statement explains why the nurse should inject the medication at the beginning of a contraction? a. The medication will be rapidly circulated. b.Less medication will be transferred to the fetus. c. The maternal vital signs will not be adversely affected. d. Full benefit of the medication is received during that contraction.

ANS: B Injecting at the beginning of a contraction, when blood flow to the placenta is normally reduced, limits transfer to the fetus. It will not increase the circulation of the medication. It will not alter the vital signs any more than giving it at another time. The full benefit will be received by the woman, but it will decrease the amount reaching the fetus.

You are preparing a client for epidural placement by a nurse anesthetist in the LDR. Which interventions should be included in the plan of care? (Select all that apply.) a. Administer a bolus of 500 to 1000 mL of D5 normal saline prior to catheter placement. b. Have ephedrine available at bedside during catheter placement. c. Monitor blood pressure of client frequently during catheter insertion and for the first 15 minutes of epidural administration. d. Insert a Foley catheter prior to epidural catheter placement. e. Monitor the client for hypertension in response to epidural insertion.

ANS: B, C A bolus of nondextrose fluid is recommended prior to epidural administration to prevent maternal hypotension. Ephedrine should be available at the bedside in case maternal hypotension is exhibited. Blood pressure should be monitored frequently during insertion and for the first 15 minutes of therapy. It is not necessary to insert a Foley catheter prior to epidural catheter placement. Hypertension is not a common clinical response to this treatment but hypotension is.

The nerve block used in labor that provides anesthesia to the lower vagina and perineum is a(n): a. local. b. epidural. c. pudendal. d. spinal block.

ANS: C A pudendal block anesthetizes the lower vagina and perineum to provide anesthesia for an episiotomy and use of low forceps, if needed. A local provides anesthesia for the perineum at the site of the episiotomy. An epidural provides anesthesia for the uterus, perineum, and legs. A spinal block provides anesthesia for the uterus, perineum, and down the legs.

A client presents to the labor and birth area for emergent birth. Vaginal exam reveals that the client is fully dilated, vertex, +2 station, with ruptured membranes. The client is extremely apprehensive because this is her first childbirth experience and asks for an epidural to be administered now. What is the priority nursing response based on this client assessment? a. Use contact anesthesia for an epidural and prepare the client per protocol. b. Tell the client that she will not need any pain medication because the birth will be over in a matter of minutes and the pain will stop. c. Assist the client with nonpharmacologic methods of pain distraction during this time as you prepare for vaginal birth. d. Call the physician for admitting orders.

ANS: C By assisting the client with nonpharmacologic methods of pain distraction, the nurse is focusing on the client's needs while still preparing for vaginal birth. The client presents in an emergent situation with birth being imminent. Thus, there is not enough time to administer an epidural. Telling the client that she will not need any pain medication because the birth will be over soon does not address the client's concerns of apprehension and therefore is not therapeutic. Because this is an emergency birth situation, the nurse should be attending to the client. If needed, another nurse and/or supervisor can contact the physician.

Which clinical effect can occur in the presence of increased maternal pain perception during labor? a. Increase in uterine contractions in response to catecholamine secretion b. Decrease in blood pressure in response to alpha receptors c. Decreased perfusion to the placenta in response to catecholamine secretion d. Increased uterine blood flow, causing increase in maternal blood pressure

ANS: C Decreased perfusion to and from the placenta occurs as result of catecholamine secretion. A decrease in uterine contractions is seen in response to catecholamine secretion. Maternal blood pressure is increased in response to alpha receptors. Decreased uterine blood flow causes an increase in maternal blood pressure.

The method of anesthesia in labor that is considered the safest for the fetus is: a. epidural block. b. pudendal block. c. local infiltration. d. spinal (subarachnoid) block.

ANS: C Local infiltration of the perineum rarely has any adverse effects on the mother or the fetus. With an epidural, pudendal, or spinal block the fetus can be affected by maternal side effects and maternal hypotension.

Which client will be most receptive to teaching about nonpharmacologic pain control methods? a. Gravida 1, para 0, in transition b. Gravida 2, para 1, admitted at 8 cm c. Gravida 1, para 0, dilated 2 cm, 80% effaced d. Gravida 3, para 2, complaining of intense perineal pressure

ANS: C The latent phase of labor is the best time for intrapartum teaching; the latent phase of labor is the first centimeter of cervical dilation. Clients in the transition phase (8 to 10 cm) are experiencing intense pain and are not receptive to teaching. A multigravida complaining of intense perineal pressure indicates a client whose birth is imminent.

Which statement is true with regard to the type of pain associated with childbirth experience? a. Pain is constant throughout the labor experience. b. Labor pain during childbirth is considered to be an abnormal response. c. Pain associated with childbirth is self-limiting. d. Pain associated with childbirth does not allow for adequate preparation.

ANS: C The pain associated with childbirth is self-limiting in that it typically stops once the child is delivered. Pain is intermittent during the labor experience. Labor pain is considered to be a normal response during childbirth. Pregnant woman can prepare for the expected pain of childbirth by taking prepared childbirth classes and using relaxation techniques during the course of labor.

The nurse detects hypotension in a laboring client after an epidural. Which actions should the nurse plan to implement? (Select all that apply.) a. Encourage the client to drink fluids. b. Place the client in a Trendelenburg position. c. Administer a normal saline bolus as prescribed. d. Administer oxygen at 8 to 10 L/min per face mask. e. Administer IV ephedrine in 5- to 10-mg increments as prescribed.

ANS: C, D, E If hypotension occurs after an epidural has been placed, techniques such as a rapid nondextrose IV fluid bolus, maternal repositioning, and oxygen administration are implemented. If those interventions are ineffective, IV ephedrine in 5- to 10-mg increments can be prescribed to promote vasoconstriction to raise the blood pressure. The client in active labor should not be encouraged to drink fluids. In a Trendelenburg position, the body is flat, with the feet elevated. This would not be a position to use for a pregnant client.

The primary side effect of maternal narcotic analgesia in the newborn is: a. tachypnea. b. bradycardia. c. acrocyanosis. d. respiratory depression.

ANS: D An infant delivered within 1 to 4 hours of maternal analgesic administration is at risk for respiratory depression from the sedative effects of the narcotic. The infant who is having a side effect to maternal analgesics normally would have a decrease in respirations, not an increase. Bradycardia is not the anticipated side effect of maternal analgesics. Acrocyanosis is an expected finding in a newborn and is not related to maternal analgesics.

A major advantage of nonpharmacologic pain management is that: a. a more rapid labor is likely. b. more complete pain relief is possible. c. the woman remains fully alert at all times. d. there are no side effects or risks to the fetus.

ANS: D Because nonpharmacologic pain management does not include analgesics, adjunct drugs, or anesthesia, it is harmless to the mother and the fetus. There is less pain relief with nonpharmacologic pain management during childbirth. Pain management may or may not alter the length of labor. At times, when pain is decreased, the mother relaxes and labor progresses at a quicker pace. The woman's alertness is not altered by medication, but the increase in pain will decrease alertness.

Which method of pain management would be safest for a gravida 3, para 2, admitted at 8 cm cervical dilation? a. Narcotics b. Spinal block c. Epidural anesthesia d. Breathing and relaxation techniques

ANS: D Nonpharmacologic methods of pain management may be the best option for a woman in advanced labor. At 8 cm cervical dilation there probably not enough time remaining to administer spinal anesthesia or epidural anesthesia. A narcotic given at this time may reach its peak at about the time of birth and result in respiratory depression in the newborn.

Childbirth preparation can be considered successful if the outcome is described as which of the following? a. Labor was pain-free. b. The birth experiences of friends and families were ignored. c. Only nonpharmacologic methods for pain control were used. d. The client rehearsed labor and practiced skills to master pain.

ANS: D Preparation allows the woman to rehearse for labor and to learn new skills to cope with the pain of labor and the expected behavioral changes. Childbirth preparation does not guarantee a pain-free labor. A woman should be prepared for pain and anesthesia-analgesia realistically. Friends and families can be an important source of support if they convey realistic information about labor pain. Women will not always achieve their desired level of pain control by using nonpharmacologic methods alone.

A patient in active labor requests an epidural for pain management. What is the nurse's priority action for this patient? a. Assess the fetal heart rate pattern over the next 30 minutes. b. Take the patient's blood pressure every 5 minutes for 15 minutes. c. Determine the patient's contraction pattern for the next 30 minutes. d. Initiate an IV infusion of lactated Ringer's solution at 2000 mL/hr over 30 minutes.

ANS: D Rapid infusion of a nondextrose IV solution, often warmed, such as lactated Ringer's or normal saline, before initiation of the block fills the vascular system to offset vasodilation. Preload IV quantities are at least 500 to 1000 mL infused rapidly. Vasodilation with corresponding hypotension can reduce placental perfusion and is most likely to occur within the first 15 minutes after the initiation of the epidural. Determining the fetal heart rate every 30 minutes is the standard of care. The patient is in active labor, which indicates a contraction pattern resulting in cervical dilation.

To improve placental blood flow immediately after the injection of an epidural anesthetic, the nurse should: a. give the woman oxygen. b. turn the woman to the right side. c. decrease the intravenous infusion rate. d. place a wedge under the woman's right hip.

ANS: D Tilting the woman's pelvis to the left side relieves compression of the vena cava and compensates for a lower blood pressure without interfering with dispersal of the epidural medication. Oxygen administration will not improve placental blood flow. The woman needs to maintain the supine position for proper dispersal of the medication. However, placing a wedge under the hip will relieve compression of the vena cava. The intravenous infusion rate needs to be increased to prevent hypotension.

A nurse is teaching a childbirth education class. Which information about excessive pain in labor should the nurse include in the session? a. It usually results in a more rapid labor. b. It has no effect on the outcome of labor. c. It is considered to be a normal occurrence. d. It may result in decreased placental perfusion.

ANS: D When experiencing excessive pain, the woman may react with a stress response that diverts blood flow from the uterus and the fetus. Excessive pain may prolong the labor because of increased anxiety in the woman. It may affect the outcome of the labor, depending on the cause and the effect on the woman. Pain is considered normal for labor. However, excessive pain may be an indication of other problems and must be assessed.

During the latent phase of labor, the nurse suggests that the woman play cards with her husband. The nurse is aware that this will help the woman deal with the pain of contractions. This technique is called: a. Cutaneous stimulation. b. Gate control theory. c. Thermal stimulation. d. Hydrotherapy.

B In the gate control theory of pain, the use of cognitive processes can affect the perception of stimuli as painful. Diversional activities in early labor and focal points or breathing techniques later in labor are examples of the gate control theory of pain. Cutaneous stimulation is using touch to relax the muscles. Thermal stimulation is the use of warmth to relax the muscles. Hydrotherapy is the use of water for relaxation.

Which of the following women can the nurse anticipate having difficulty dealing with labor pain? a. Primigravida who has attended childbirth preparation classes b. A woman having her second baby; the first child was in a posterior position and the labor lasted 18 hours. c. A woman having her sixth child and who has not attended any prenatal teaching classes d. Primigravida who has her mother as her birth support person. The mother is encouraging her with every contraction.

B Previous experiences with pain can alter a woman's perception of labor pain. The woman with a prolonged labor and posterior position with the last birth will come to this labor anxious about the outcome and amount of pain. Preparation for labor and previous positive experiences will help the woman tolerate the pain. A support person who has been through the process and is encouraging can also assist the woman in a positive way.

During the active stage of labor the woman is using a rapid "pant-blow" breathing pattern. She starts to complain of feeling dizzy and has some numbness in her fingers. The nurse's next action should be to: a. Notify the physician. b. Do a vaginal exam to check for the progression of labor. c. Have the woman breathe into a paper bag. d. Offer pain medication.

C Hyperventilation is common when breathing techniques are used. It results from rapid deep breathing that causes excessive loss of carbon dioxide and therefore respiratory alkalosis. Blowing into a paper bag or her own cupped hands will increase her carbon dioxide level by having the woman rebreathe her exhaled air.

All the following women in labor are requesting pain medication. To which one should the nurse administer an opioid analgesic first? a. Primigravida, 2 cm dilated, 50% effaced, grimacing slightly with each contraction b. Gravida 4, 9 cm dilated, 100% effaced, wants to push with each contraction c. Gravida 2, 6 cm dilated, 100% effaced, rocks back and forth in bed with each contraction d. Primigravida, 1 cm dilated, moans loudly with each contraction, has present history of heroin use

C The gravida 2 is well established into the labor and the medication will not slow the contractions. The primigravida who is 2 cm dilated is too early into the labor; the medication may slow or stop her contractions. The gravida 4 is too near birth and the medication may affect the newborn's respiratory effort. The primigravida who is 1 cm dilated has a history of heroin use; further opioid medication is not recommended.

A primigravida is admitted in early labor. The nurse notices on the prenatal record that the position of the fetus is left occiput posterior. Because of this information, the nurse can anticipate: a. A cesarean section. b. A short labor and birth process. c. Increased back pain with labor. d. A short labor with a prolonged birth process.

C When the fetus is in the posterior position, the labor may be longer and more uncomfortable. Back discomfort increases with contractions and will continue between contractions. The fetus may not be able to deliver until it rotates into the anterior position.

On admission to the labor suite, the woman begins to cry out loudly, "Lord help me, I am going to die." She repeats this phase loudly with each contraction. The nurse's best response would be to: a. Explain to the woman that she is disturbing other clients. b. Praise her between contractions when she is quiet. c. Understand that this may be a cultural mannerism and accept her individual response to labor. d. Understand that this may be a cultural mannerism and do client teaching to help her understand other ways of expressing her fear and pain.

C Women should be encouraged to express themselves in any way they find comforting. The cultural diversity of their expressions must be respected. Accepting a woman's individual response to labor and pain promotes a therapeutic relationship. Belittling her, praising her falsely, or trying to show her a "better way" of dealing with the pain will interfere with the therapeutic relationship and lower the woman's self-esteem.

The nurse should realize that the most common and potentially harmful maternal complication of epidural anesthesia would be: a. Severe postpartum headache. b. Limited perception of bladder fullness. c. Increase in respiratory rate. d. Hypotension.

D Epidural anesthesia can lead to vasodilation and a drop in blood pressure that could interfere with adequate placental perfusion. The woman must be well hydrated before and during epidural anesthesia to prevent this problem and maintain an adequate blood pressure. Headache is not a common side effect because the spinal fluid is not normally disturbed by this anesthetic as it would be with a low spinal anesthetic. Option B is an effect of epidural anesthesia but is not the most harmful. Respiratory depression is a potentially serious complication.

The laboring woman may rub her abdomen during a contraction to counteract discomfort. This is called ______________________.

effleurage