Ch 16 The Nursing Role in Providing Comfort During Labor and Birth

When developing a labor plan with the client, which outcome is the priority?

The client will direct her pain management techniques. Clients who have their pain managed report higher satisfaction with the birth experience. By working with the nurse in determining the labor plan, the health care provider, nurse and the client can work together to obtain a plan to manage labor pain. This puts the client in control of her care. The client nor the nurse is able to determine if a vaginal birth is feasible. It is rarely realistic to have a pain-free labor. Some discomfort is felt sometime within the labor process. It is strongly encouraged to have attended prenatal classes but not the priority.

The health care provider and nurse are assisting the client in the delivery of the fetus. The mother has been pushing with little effect. As the nurse obtains the instruments to assist with delivery, which method is used for pain relief?

A pudendal block A pudendal block is given just before the baby is born to provide pain relief for birth. Given at this time, the pudendal block does not impact the client's ability to push (which can prolong the labor). This block is also effective for births that require instruments to deliver the baby or complete an episiotomy. Though IV pain medication is rapid acting, it is not the analgesia of choice at this time. General anesthesia is used in emergency situations when the baby has to be delivered quickly. An epidural is for pain relief through the labor process.

Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia?

Difficulty breathing Total spinal blockade occurs when an inadvertent injection of a local anesthetic is placed into the intrathecal or epidural space. The resulting effect is that the anesthetic travels too high in the body causing paralysis of the respiratory muscles. Difficulty breathing is a sign. A decreased level of consciousness will occur later. A staggering gait or intense pain is not a primary symptom.

The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize?

Encourage her through the contractions, explaining why she cannot receive any pain medication. At this point, any medication would be contraindicated as it would pass to the fetus and may cause respiratory depression. The nurse will have to work with the mother through the contractions and pushing. The client has progressed too far to retry the epidural medication. No meperidine should be given due to the risk to the fetus.

The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?

Inability to push If the client is not able to push, her epidural dose may need to be adjusted to decrease the impact on the sensory system. Dry lips indicate that she may need fluids, so the nurse should give her some ice chips or a drink of water. Urinary retention and rapidly progressing labor should be directly reported to the obstetrician, not the anesthesiologist.

The pain of labor is influenced by many factors. What is one of these factors?

The woman is prepared for labor and birth. The woman who enters labor with realistic expectations usually copes well and reports a more satisfying labor experience than does a woman who is not as well prepared.

The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process?

Use a birthing ball and find a position of comfort. The position is very important during labor. Allowing the woman to assume the most comfortable position will facilitate natural birth. The birthing ball allows the woman to move and adjust her position so that she can remain comfortable. The Valsalva maneuver may result in dangerous increases in blood pressure, so the nurse should be sure to instruct the mother to breathe as she pushes. The nurse should not intervene with who comes in or what family members are present unless she is asked, or unless the visitation is upsetting the mother.

The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be effective at this point?

counterpressure against the sacrum Counterpressure against the sacrum is a way to provide support and comfort for a women having intense back labor. Effleurage is ineffective for true back labor, as it is conscious relaxation. Breathing will not diminish the pain of back labor.

The nurse is assessing a client in labor for pain and notes she is currently not doing well handling the increased pain. Which opioid can the nurse offer to the client to assist with pain control?

meperidine Meperidine is an opioid that is commonly used during labor and birth. Secobarbital and thiopental are barbiturates. Hydroxyzine hydrochloride is a tranquilizer which can be used to supplement the narcotic or reduce anxiety.

A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client?

respiratory depression Respiratory depression is a complication of epidural anesthesia and should be closely monitored in laboring clients. A failed block, accidental intrathecal block, and a postdural puncture (spinal) headache are all side effects of a spinal epidural block.

A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform?

Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask. In a pregnant woman, hypotension is best managed in the left lateral or semi-Fowler position owing to the risk of supine hypotension in the supine position and in Trendelenburg position. The sitting position could exacerbate hypotension. Naloxone is administered for respiratory depression. When the mother experiences a change in vital signs, this may affect the fetal heart rate.

A client has opted to receive epidural anesthesia during labor. Which of the following interventions should the nurse implement to reduce the risk of a significant complication associated with this type of pain management?

Administration of 500 mL of IV Ringer's lactate The chief concern with epidural anesthesia is its tendency to cause hypotension because of its blocking effect on the sympathetic nerve fibers in the epidural space. This risk can be reduced by being certain a woman is well hydrated with 500 to 1000 mL of IV fluid, such as Ringer's lactate, before the anesthetic is administered. Ringer's lactate is preferable to a glucose solution, because too much maternal glucose can cause hyperglycemia with rebound hypoglycemia in the newborn. Be certain a woman does not lie supine but remains on her side after an epidural block, to help prevent supine hypotension syndrome. Be sure to caution women not to take acetylsalicylic acid (aspirin) for pain in labor as aspirin interferes with blood coagulation, increasing the risk for bleeding in the newborn or herself.

In providing culturally competent care to a laboring woman, which is a priority?

Identify how the client expresses labor pain. Pain is a part of the labor process and management of the pain impacts the labor process itself. The nurse must effectively be able to assess the client's pain level to be able to provide care. Individuals from different cultures express pain in different ways. All of the other options are important to understand but they do not directly relate to the client and birth process.

General anesthesia is not used frequently in obstetrics because of the risks involved. There are physiologic changes that occur during pregnancy that make the risks of general anesthesia higher than it is in the general population. What is one of those risks?

Neonatal depression is possible. General anesthesia is not used frequently in obstetrics because of the risks involved. The pregnant woman is at higher risk for aspiration. It requires more skill to intubate a pregnant woman because of physiologic changes in the trachea and thorax. In addition, general anesthetic agents cross the placenta and can result in the birth of a severely depressed neonate who requires full resuscitation.

Which statement is true regarding analgesia versus anesthesia?

Regional anesthesia should be given with caution close to the time of birth because it crosses the placenta and can cause respiratory depression in the newborn. Systemic analgesia should be used with caution near the time of birth because it can cause respiratory depression, in addition to decreased FHR variability. Hypotension is a common side effect of regional anesthesia.

Which client statement is anticipated after immediately receiving an intrathecal injection of pain medication?

"I have no pain now." The advantage of intrathecal medication administration is that the medication is effective almost immediately. The medication is placed in the subarachnoid space. The other options still have the client feeling some discomfort.

A client is scheduled for a cesarean section under spinal anesthesia. After instruction is given by the anesthesiologist, the nurse determines the client has understood the instructions when the client states:

"I may end up with a severe headache from the spinal anesthesia." Cerebrospinal fluid (CSF) leakage from the needle insertion site and irritation caused by a small amount of air that enters at the injection site and shifts the pressure of the CSF causes strain on the cerebral meninges, initiating pain from a postdural puncture (spinal) headache.

A nurse recommends to a client in labor to try concentrating intently on a photo of her family as a means of managing pain. The woman looks skeptical and asks, "How would that stop my pain?" Which explanation should the nurse give?

"It distracts your brain from the sensations of pain." Concentrating intently on an object is another method of distraction, or another method of keeping sensory input from reaching the cortex of the brain. The other answers refer to other means of pain management.

When collecting data to devise a labor plan for a multiparous woman, which question best allows the nurse to develop individualized strategies?

"Tell me how you handled labor pain in your past deliveries." When the nurse is collecting data, it is best to discuss previous experiences with labor pain. Other questions may include, "What was helpful?" or "What did you not like?" While it is true that every labor is different, understanding the client's perspective from past experiences is valuable in developing individualized strategies. Developing a plan is best as a collaborative effort, not by picking pre-prepared options. It is important to include a support person if desired.

The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth?

"The baby is coming. I'll explain what's happening and guide you." Continuous labor support with a trained nurse or doula has been shown to be effective in increasing coping ability of laboring woman. To keep her calm, the nurse needs to explain all procedures and discuss all events to the mother. The nurse cannot know the final outcome and should be careful of making general statements indicating everything will be OK. It is the nurse's responsibility to calm the client down and not wait for the health care provider. While calling the family may help, there is no guarantee and the nurse needs to work to calm the client down.

An experienced nurse is mentoring a graduate nurse and critiquing the graduate's shift handoff. Which statement requires clarification?

"The client reports a pain level of 8. She has a low pain tolerance." Shift handoff includes a report of the client's pain assessment. Pain is a perceptive experience as individual pain tolerances vary. The nurse must do a complete pain assessment and not assume that the client has a low pain tolerance. Pain is an indication that a complication of labor is occurring. All of the other options are appropriate.

The nurse is monitoring the client's vital signs and notes: 100.2oF (37.9oC), heart rate 82, respiratory rate 17, and blood pressure 124/78. The client has recently had an epidural. What is the best response when the client's partner asks if she is getting sick?

"The fever may be due to the epidural." A common side effect of epidural anesthesia is elevated temperature during labor. The client needs frequent assessment and to be observed for any other signs or symptoms of an infection, but it is premature to state it is related to an infection. If the mother has been exposed to any illness, it would be in the history. Oral fluids would not be advisable as they may result in nausea later.

A client in labor has requested the administration of narcotics to reduce pain. At 2 cm cervical dilation (dilatation), she says that she is managing the pain well at this point but does not want it to get ahead of her. What should the nurse do?

Advise the client to hold out a bit longer, if possible, before administration of the drug, to prevent slowing labor. The timing of administration of narcotics in labor is especially important as, if given too early (before 3 cm cervical dilatation), they tend to slow labor. If given close to birth, because the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered in the fetus for 2 to 3 hours after maternal administration. For this reason, narcotics are preferably given when the mother is more than 3 hours away from birth. This allows the peak action of the drug in the fetus to have passed by the time of birth.

The nurse is caring for a client who appears tense and apprehensive as labor progresses. Which nursing intervention is most helpful?

Initiate comfort measures Initiating comfort measures allows the tense client to relax which may decrease anxiety and apprehension. Comfort measures can include a variety of interventions such as ice chips, lip balm or touch, massage, and acupressure. This interaction between the nurse and client also conveys a caring, supportive attitude. This establishes a trusting relationship which again decreases anxiety. All other options are appropriate but not as helpful personally to the client in labor.

The nurse is aware that labor pain and contractions can lead to all of the following EXCEPT

Respiratory acidosis Labor pain can lead to hyperventilation, which can lead to respiratory alkalosis. Contractions can cause decreased blood flow to the uterus, and pain from contractions can cause sleep deprivation, which can lead to fatigue.

A laboring client is restless and moving frequently in the bed. She appears to be more uncomfortable with the contractions but refuses pain medication when offered. The client's partner has left the room to stretch his legs. Which response by the nurse is most helpful?

Stand next to the client at the side of the bed. The client is alone and progressing well in labor as evidenced by her restlessness. She is refusing analgesia but will benefit from awareness that the nurse is attending her at the bedside and that she is not alone. Standing behind her will not provide a sense of nursing presence. Turning up music or turning on the television is not appropriate unless the client requests them as distractions.

A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response?

Support the client's decision and call the obstetrician. Pain is subjective and its level is only what the client experiences. The nurse should support the desire of the client. Sedatives would be counterproductive as they may slow the labor process. It would be inappropriate to negate her feelings and remind her of earlier goals; that is the job of the support person and should be left up him or her to decide what to say and when to say it.

A full-term neonate delivered an hour after the mother received IV meperidine is showing signs of respiratory depression. The nurse should be prepared to administer which medication?

naloxone Naloxone is the drug used for reversal of opioids' adverse effects. If a narcotic is given too close to birth, the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be registered (respiratory depression, sleepiness) in the fetus for 2 to 3 hours after birth. Indomethacin is an analgesic and NSAID; ampicillin is an antibiotic; and epinephrine is a vasopressor.

A client at 41 weeks' gestation has been in labor for 18 hours and the fetus is now showing signs of distress. Due to prior back surgery, the client is to receive general anesthesia instead of an epidural. Which medication will the nurse prepare to give the client first?

Antacid Prior to intubation for a general surgery, the client should receive a dose of antacid to decrease the risk of aspiration of acidic stomach contents. Pain medication, NSAIDS, and sedative medications should not be given prior to a general anesthetic.

A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax?

Anxiety can slow down labor and decrease oxygen to the fetus. Out-of-control anxiety can decrease the oxygen of the mother by increasing her respiratory rate and increasing the demand on her body, and can have a negative impact on the fetus by decreasing the amount of oxygen reaching the fetus. Encourage control of the anxiety. Anxiety will not negatively affect the action of the epidural or the need for anesthesia. Trust in the nurse is not determined by the amount of anxiety the client experiences.

The labor nurse reports to the nurse on the oncoming shift, "The woman in labor room 2 is handling her pain very well. She smiles whenever I go in to talk to her, and she doesn't complain at all!" What assessment by the oncoming labor nurse would best reveal if the off-going labor nurse's observations were correct?

Asking the woman to describe her pain and rate it on a scale of 0 to 10 It is important to be nonjudgmental when assisting a woman to cope with pain. Some nurses feel strongly that a woman should have a "natural" childbirth without medication. Other nurses do not understand why any woman would want to "suffer" through labor without an epidural. In both situations, the nurse is in danger of not providing the support that the laboring woman needs and deserves. Rarely is there a completely pain-free labor. Even when a woman plans for an epidural, she frequently reports severe pain before the epidural is administered. Caregivers commonly underrate the severity of pain when compared with the woman's ratings (Prkachin, Solomon, & Ross, 2007). It is important to accept the woman's description of the severity of the pain, even when she may not appear to be in pain.

The nurse has just applied a sterile pressure dressing to an epidural site after removing the epidural catheter in a client who is now recovering from a standard delivery. Which action should the nurse now prioritize?

Assess return of sensory and motor functions to the lower extremities. After removal of the epidural catheter and medication is terminated, the nurse needs to assess for return of motor function to ambulate the mother. The mother will not be able to walk for some time (at least until the medication wears off). Do not elevate the legs; the goal is to maintain normal circulation. Fluids are important, but they are not related to the epidural or to the metabolism of the medication.

A client has just received combined spinal epidural. Which nursing assessment should be performed first?

Assess vital signs. The most common side effect of spinal and epidural anesthesia is hypotension, which can lead to fetal bradycardia, decelerations, or fetal distress. Although each is important, assessment of vital signs should be performed first.

A client received epidural anesthesia and developed a postdural spinal headache. Which of the following should the nurse know about a postdural spinal headache?

Client should be encouraged to drink plenty of fluids A client with a postdural spinal headache should be encouraged to drink plenty of fluids. Treatment of postdural spinal headache usually includes proper hydration. Sitting upright increases the severity of the headache. The headache is usually very severe. Without a treatment, it may last for days to weeks.

The nurse is admitting a client who is in labor who reports her husband and doula will be arriving shortly. Which action should the nurse prioritize in response?

Continue with the admission assessment The nurse should continue with the assessment to establish a baseline for the client and determine her status. This could include asking any personal questions that might be inappropriate to ask in front of the doula. Doulas are birth coaches who provide one-on-one support in labor and throughout birth. A doula does not take the place of a nurse or client's partner but is there to assist in the process. There would be no need to print off any instructions for the doula to sign.

A gravida 3 para 2 client has been in labor for 4 hours and is experiencing severe back pain with each contraction. She is extremely uncomfortable and distressed because she never had this type of pain with her other labors. Which intervention can the nurse point out is best for this client to try to address her pain?

Effleurage Effleurage or massage would be an appropriate technique to use at this point. It is used as a distraction and relaxation technique. It increases the production of endorphins which reduce the transmission of signals between nerve cells and thus lower the perception of pain. Imagery is another technique but may not be as effective for relieving the pain if it is intense. A change of position may help with the pain as the woman finds a position of comfort, lying still may not be effective. The use of oral pain medication presents a danger to the fetus depending on what is used as it can pass through the placenta and adversely affect the heart and lungs of the fetus.

The nurse is caring for a client who is diagnosed with a postdural puncture (spinal) headache. When completing a nursing assessment, which position would exacerbate the symptoms?

Fowler position A postdural puncture (spinal) headache occurs when the client is in an upright position and is relieved when the client is laying down and still. The nurse is correct to avoid placing the client in the Fowler or upright position. The other positions may be attempted to assess client symptoms.

A client in labor receiving epidural anesthesia develops hypotension. Which of the following would the nurse do first?

Give an intravenous bolus of fluid On detecting maternal hypotension as a result of epidural anesthesia, the nurse should administer a bolus of IV fluid to the client. This generally raises the BP to normal. If this is ineffective, the nurse should consider injecting ephedrine to raise the BP only after notifying the anesthesiologist and receiving an order for the drug. There is no need to call the anesthesiologist immediately. Injection of propranolol will decrease the BP further and is not recommended.

Which nursing action is required before a client in labor receives an epidural?

Giving a fluid bolus of 500 ml One of the major adverse effects of epidural administration is hypotension. Therefore, a 500-ml fluid bolus is usually administered to help prevent hypotension in the client who wishes to receive an epidural for pain relief. Checking maternal reflexes, pupil response, and gait aren't necessary.

The nurse is preparing a client in labor to receive a pudendal block with lidocaine. The nurse would place the client in which position for administration?

Lithotomy Pudendal anesthesia is typically administered to anesthetize the lower vagina, vulva, and perineum. The obstetrician or certified nurse midwife injects the anesthetic agent, such as lidocaine, through the lateral vaginal walls into the area near both the right and left pudendal nerve behind the sacrospinous ligament at the level of the ischial spines. The injection is made through the vagina with the client in lithotomy or dorsal recumbent position. The left lateral, prone or Trendelenburg positions would be inappropriate.

A client in labor has been given an epidural anesthetic. Which nursing assessment finding is most important immediately following the administration of epidural anesthesia?

Maternal blood pressure decreases from 130/70 to 98/50 mm Hg. As the epidural anesthetic agent spreads through the spinal canal, it may produce hypotensive crisis, which is characterized by maternal hypotension, decreased beat-to-beat variability, and fetal bradycardia. The respiratory rate, pulse rate, and temperature are within normal limits for a laboring client.

The nurse is preparing an educational event for pregnant women on the topic of labor pain and birth. The nurse understands the need to include the origin of labor pain for each stage of labor. What information will the nurse present for the first stage of labor?

Pain originates from the cervix and lower uterine segment. Pain sensations associated with labor originate from different places depending on the stage of labor. During the first stage of labor, the stretching required to efface and dilate the cervix stimulates pain receptors in the cervix and lower uterine segment.

Which nursing suggestions are options for the client experiencing intense pain in the active phase of labor? Select all that apply.

Patterned breathing Hypnosis Pain medication Massage Acupressure Depending upon the client's labor plan and the preparation she and her partner have received prior to the labor experience, patterned breathing, hypnosis, pain medication, massage and acupressure are all options to improve relaxation and pain management. Effleurage is also a technique used in pain management; however, it is only used in the early phase of labor.

The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic?

This may prolong labor and increase complications. Administration of pharmacologic agents too early in labor can stall the labor and lengthen the entire labor. The client should be offered nonpharmacologic options at this point until she is in active labor. At this point in labor, the fetus would not be affected by analgesia. The effects would wear off and the drug would need to be re-administered, which would increase the risk to the fetus. There is no link between maternal hypertension and analgesia.

A client in labor has administered an epidural anesthesia. Which assessment findings should the nurse prioritize?

maternal hypotension and fetal bradycardia Epidural anesthesia conveys the risk of hypotension, especially if the client has not received an adequate amount of fluid before the procedure is performed. A sudden drop in maternal blood pressure can cause uterine hypoperfusion, which may result in fetal bradycardia. The other choices are not an adverse effect of epidural anesthesia.

The coach of a client in labor is holding the client's hand and appears to be intentionally applying pressure to the space between the first finger and thumb on the back of the hand. The nurse recognizes this as which form of therapy?

acupressure Acupressure is the application of pressure or massage at designated susceptible body points. A common point used for a woman in labor is Co4, which is located between the first finger and thumb on the back of the hand. Women may report their contractions feel lighter when a support person holds and squeezes their hand because the support person is accidentally triggering this point. Acupuncture involves insertion of needles into the same body points. Effleurage, the technique of gentle abdominal massage often taught with Lamaze in preparation for birth classes, is a classic example of therapeutic touch. Biofeedback is based on the belief that people have control and can regulate internal events such as heart rate and pain responses.

A client in active labor is given spinal anesthesia. Which information would the nurse include when discussing with the client and family about the disadvantages of spinal anesthesia?

headache following anesthesia The nurse should inform the client and her family about the possibility of headache after spinal anesthesia. The drug is retained in the mother's body and not passed to the fetus. There may be uterine atony, and not excessive uterine contractions, following spinal anesthesia. Spinal anesthesia may lead to bladder atony, and not an increased frequency of micturition.

Early in labor, a pregnant client asks why contractions hurt so much. Which answer should the nurse provide?

lack of oxygen to the muscle fibers of the uterus due to compression of blood vessels During contractions, blood vessels constrict, reducing the blood supply to uterine and cervical cells, resulting in anoxia to muscle fibers. This anoxia can cause pain in the same way blockage of the cardiac arteries causes the pain of a heart attack. Endorphins are naturally occurring opiate-like substances that reduce pain, not cause it. Distraction and mechanical irritation of nerve fibers are also methods of reducing pain, not causes of pain.