Chapter 7: Pain Management During Labor and Birth

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Welcome back to the Deep Dive.

We are doing something a little different today.

Usually we're talking about these huge broad topics, but today we are really zooming in on a very specific, very intense slice of the human experience.

We are talking about labor.

And not just the, you know, the mechanics of it.

We're not just talking about dilation and descent.

We're looking specifically at the management of pain.

Right.

And for this, we're working out of chapter seven of Introduction to Maternity and Pediatric Nursing, eighth edition.

And I have to say, going into this, I kind of thought it was just going to be a list of drugs, you know, take this for that.

But it's really not.

It's this massive intersection of psychology, physiology, coaching,

and then yes, the pharmacology.

It is, I mean, it's arguably one of the most complex things a nurse has to manage because pain is so subjective.

But the safety parameters like blood pressure, fetal heart rate, those are very, very objective.

So you're constantly balancing the two.

And that's really the mission for this Deep Dive.

We want translate those dense textbook concepts into a guide that actually makes sense for you, the listener, whether you're a nursing student or just someone curious about how birth actually works.

We're going to cover the whole spectrum from the kind of mind over matter preparation classes all the way to the heavy duty anesthetics.

So let's start where the tech starts.

It feels like there's this real emphasis on the nurse, not just being a technician, but also like a coach.

Oh, absolutely.

The tech starts with the foundation, which isn't a drug or a procedure.

It's education.

And that brings us to a concept that I think is the key to this entire chapter.

What's that?

The fear, tension, pain cycle.

Ah, this is from Dr.

Dick Reed, right?

Correct.

It's an older theory, but it absolutely holds up.

The idea is, well, it's simple.

Fear causes physical tension.

When you're scared, you clench your muscles, you tighten up.

Fight or flight.

Exactly.

But in labor, if you tense up your abdominal muscles, you are literally working against your uterus.

You're creating resistance.

That resistance increases the pain.

And more pain just creates more fear.

And the cycle just spins out of control.

So the text argues that the number one way to break that cycle is education.

If a woman understands why she feels pain, oh, that's my cervix stretching.

That's supposed to happen.

She fears it less.

Less fear, less tension, less pain.

And that's where all these childbirth preparation classes come in.

I was looking at the menu of classes the text describes in figure 7 .1.

It is way more than just how to breathe.

It has to be.

One size doesn't fit all.

I mean, you have your standard classes.

Of course, they cover fetal development, nutrition, breastfeeding basics.

But the text makes a really big deal about the specialized classes.

The one that caught my eye was the refresher class.

Which makes total sense, right?

If you've had a baby three years ago, you don't need a lecture on what a uterus is.

Right.

You've been there.

You just need a quick reminder on breathing techniques.

Or maybe you want to talk about how to introduce the new baby to a toddler.

It respects the parent's time and their experience.

Then there's the VBAC class, vaginal birth after cesarean.

Why does that need its own dedicated space?

Well, the psychology is completely different.

The text notes that these women often have really unresolved feelings or a lot of anxiety about their previous c -section.

Might feel like their body failed them or something.

Exactly.

So they need a space to process that emotional baggage and also learn the very specific safety protocols for a trial of labor after a cesarean.

You just can't do that in a room full of excited first -time moms.

Speaking of specific needs, the text is blunt about adolescent childbirth classes.

It says teens have immature perceptions of birth.

It's harsh phrasing, I'll grant you, but it's clinically accurate.

A 14 -year -old's reality is just.

It's radically different from a 30 -year -old professional.

They often have different support systems or no support system.

And practical barriers too, I'd imagine, like transportation.

For sure.

But the biggest factor the text brings up is peer acceptance.

They need to be around other teenagers going through the same thing.

They need to feel safe.

A pregnant teenager in a standard class might feel judged or just incredibly out of place.

And if they're uncomfortable, they're not learning.

They're not breaking that fear, tension, pain cycle we talked about.

So separate classes let them open up.

Okay.

So they're in these classes.

What are they actually learning?

The text outlines three big methods.

Dick Reed, Bradley, and LaMaze.

I feel like LaMaze is the one everyone knows.

Yeah, it is.

It's the most common in the U .S.

by far.

But let's quickly break them down.

Dick Reed was the original natural advocate.

He focused almost purely on relaxation.

Then you have the Bradley method.

That's the husband coached childbirth.

Right.

And that one is very specific about the partner's role.

The partner isn't just a spectator.

They are the coach.

They're managing the environment, timing contractions, and the focus is on slow, deep abdominal breathing.

And then LaMaze, the text uses a big word for this one, psychoprophylaxis.

It sounds super intimidating, but if you break it down, psycho refers to the mind.

Prophylaxis means prevention.

So mental prevention of pain.

Basically brain training.

The LaMaze method conditions the woman to respond to a contraction with a specific learned behavior, like a breathing pattern.

Instead of just tensing up, it gives the brain a job to do.

If your brain is busy counting breaths, it has less bandwidth to process the pain signal.

You got it.

That's a perfect segue into the next section.

The nature of pain,

because the text goes out of its way to say that labor pain is, well, it's weird.

It's not like breaking your leg.

It's distinct in three key ways.

First, it's physiologic.

If you break your leg, that pain tells you something is very wrong.

Labor pain is pretty much the only pain that tells you everything is going right.

It's a normal process.

Okay.

What's the second?

Preparation time.

You get nine months to get ready for it.

You don't get nine months to prepare for a car accident.

And third, it's self -limiting.

It ends.

It's not chronic pain that might last forever.

I want to clear up two terms that I think a lot of people, myself included, use interchangeably.

The text says we shouldn't.

Pain threshold and pain tolerance.

Yes.

The classic NCLEX question.

So pain threshold is the point at which you first perceive a sensation as being painful.

It's biological.

It's remarkably constant across different people.

So it's pretty much the same for everyone.

Roughly, yeah.

But pain tolerance,

that is the amount of pain you are willing to endure.

And that varies wildly.

And it's not just about being tough, right?

Not at all.

A woman who is rested, who feels supported, who's been educated will have a much higher pain tolerance.

Take that same woman, but she's been awake for 24 hours.

She's alone and she's terrified.

Her tolerance will be on the floor.

So as a nurse, you can't really change her threshold, but you can massively influence by managing the environment, offering support, and helping with fatigue.

So let's get into the nitty gritty of what physically hurts.

The text lists the sources of pain.

I mean, obviously the cervix opening is number one, but it also lists uterine ischemia.

What is that?

Think of a heart attack.

Heart attack hurts because the heart muscle isn't getting enough oxygen.

That's ischemia.

In labor, when the uterus contracts, it squeezes so hard that it temporarily cuts off its own blood supply.

That lack of oxygen in the muscle tissue,

it hurts.

Wow.

So it's like a cramp from hell.

Pretty much.

Plus you have the stretching of the vagina and pressure on all the pelvic structures.

But knowing the source helps us understand the solution.

And that brings us to maybe the most important theory in this whole chapter, the gate control theory.

I love this concept.

It feels like you're hacking your own nervous system.

That's a great way to put it.

Imagine your spinal cord is a gateway to your brain.

Pain signals travel along these small diameter nerve fibers.

They're kind of slow nagging little signals, but other sensations like touch, heat, cold, pressure, they travel on large diameter nerve fibers.

These are the express highways.

So if you stimulate the big fibers.

You create a traffic jam at the gate.

If you flood the system with all these touch and pressure signals, they get to the gate first and close it.

The pain signal from the small fibers just can't get through to the brain as effectively.

This is literally why we rub our shin when we bang it on a coffee table.

Exactly.

You're not fixing the injury.

You're just distracting the nerves.

In labor, this is the physiological basis for why massage and counter pressure and even warm water work so well.

We are mechanically closing the gate on pain.

The body has its own chemical way of doing this too, right?

Endorphins.

Right.

The body's natural morphine.

And the text notes that endorphin levels actually peak during labor.

It's this amazing biological safety net.

It helps women tolerate pain that would otherwise be unbearable.

But even with all that, pain varies so much.

Section three covers the factors influencing pain perception.

Why does one person have a relatively easy time and another one just suffers?

Well, there are a lot of mechanical factors.

Cervical readiness is a big one.

Think of the cervix like a piece of fruit.

If it's ripe, meaning soft and ready to go, it opens easily.

If it's unripe, hard and firm, the uterus has to work so much harder to force it open.

More work equals more pain.

Absolutely.

And then there's labor intensity.

This was one that you mentioned was counterintuitive.

A precipitous labor, a really, really fast one, can actually be more painful.

Yeah.

You'd think get it over with quick would be better.

Not always.

In a precipitous labor, there's no recovery time.

It's just contraction on top of contraction.

The woman can't catch her breath.

She can't relax her muscles in between.

It's intense and it can be really panic inducing.

And then there's the baby's position,

the dreaded back labor.

This is so critical for the nurse to recognize.

Ideally, the baby is occiput anterior.

That means the back of its head is against mom's front and it's looking at her spine.

But if the baby is occiput posterior, sunny side up, looking at the belly,

then the hard bony back of the baby's skull is grinding directly against the mother's sacrum.

Bone on bone.

Ouch.

It causes this intense continuous back pain that doesn't go away when the contraction stops.

It is grueling.

All right.

So we have a woman in pain.

Let's open the nurse's toolkit.

Section four.

Non -pharmacological pain management.

Why did we start here?

Why not just jump to the meds?

Two big reasons.

Safety and timing.

These methods have zero side effects for the baby.

And sometimes you just don't have a choice.

If a woman walks in the door and she's nine centimeters dilated, it is way too late for an epidural.

You have to rely on these tools.

The tech starts with relaxation techniques, specifically something called neuromuscular dissociation.

It's a fancy term for relax everything that isn't working.

The uterus has to contract, but your hands don't.

Your jaw doesn't.

Your shoulders don't need to be up by your ears.

So the nurse's job is to spot that tension.

Yes.

Drop your shoulders, unclench your jaw.

It saves a huge amount of energy for the actual work of labor.

Then we get into cutaneous stimulation.

This is the gait control theory in action.

It is.

The classic one is effleurage.

Figure 7 .3 shows it really well.

It's this light, rhythmic, circular stroking of the abdomen with just the fingertips.

But the text has a little warning here.

It can stop working.

Yeah.

In late labor, women often become hyper aesthetic.

Their skin gets super, super sensitive.

And that light touch that was soothing before now starts to feel annoying or even ticklish.

So you have to read the If she swats your hand away, you stop.

Okay.

So for that back labor we mentioned, the text suggests sacral pressure.

This is an absolute lifesaver.

It's just firm, steady pressure on the lower back.

It physically counters the force of the baby's head.

The text even suggests using a tennis ball.

A tennis ball?

Yeah.

Tennis ball and a sock.

It's a great tool.

The sport person can roll it firmly over the sacrum and it saves their thumbs from getting exhausted.

That is a total pro tip.

What about mental stimulation?

This is all about giving the brain a different job.

Using a focal point is common.

Staring at a specific spot, a picture, a crack in the ceiling, anything to keep the mind steady.

And then there's imagery.

Right.

Like visualize your cervix opening like a flower bud.

It might sound a little cheesy, but it's really effective.

If you visualize the pain as a productive opening, you're more likely to work with it.

If you visualize it as tearing, you're going to fight it.

And finally, hydrotherapy.

Just getting in the water.

The buoyancy takes so much weight off the muscles, but there's a really specific clinical note here about showers and nipple stimulation.

Oh, right.

The text says the force of the water on the nipples can release oxytocin.

And what does oxytocin do?

Causes contraction.

Exactly.

So a shower isn't just relaxing.

It can actually speed up a slow labor.

The nurse needs to know that.

If labor is already super intense, you might want to suggest keeping the water off her chest.

Let's move to section five, breathing techniques.

The text seems to have a clear philosophy here.

Don't start too early.

Yes, that is so important.

These breathing patterns are work.

If you start doing the complicated hee -hoo breathing when you're only like two centimeters dilated, you'll be completely exhausted by the time you actually need it at eight centimeters.

You have to save your energy.

You do.

So it starts with the cleansing breath.

The bookends.

The bookends.

A deep inhale and a big sigh at the beginning of the contraction to signal, okay, here we go.

And another one at the end to signal it's over.

Let it go.

It resets your whole system.

Then we get into the pacing patterns.

Slow paced, then modified paced.

Slow paced is about half your normal breathing rate.

Nice and relaxed.

Modified is faster.

Up to twice your normal rate.

You use that when the intensity really starts to build.

And then the one we always see in the movies.

Pattern paced breathing.

The hee -hoo.

Or maybe a three to one pattern.

Pam pam pam blow.

This is for the centimeters.

It requires serious focus, which is the whole point.

It forces you to concentrate on the rhythm, not the pain.

But there is a huge safety alert right here in the text about hyper ventilation.

Yes.

If she breathes too fast and too deep for too long, she blows off too much carbon dioxide.

This causes something called respiratory alkalosis.

What does that look like?

How would you know?

She'll tell you she feels dizzy or lightheaded.

She might say her face feels numb or her fingers are tingling.

And the fix is surprisingly low tech.

No oxygen mass needed.

You just need her to re -breathe some of that CO2 she's blowing off.

The easiest way is to have her breathe into her own cupped hands or into a small paper bag.

It balances her blood chemistry almost instantly.

This section wraps up with second stage breathing.

So pushing.

The text really advocates for open glottis pushing.

Right.

The old way was telling women to take a deep breath, hold it, and push until they turn purple.

That's closed glottis.

We really don't do that anymore.

Why not?

It can decrease oxygen flow to the baby.

Open glottis means you're letting air escape while you push.

You're grunting, groaning, moaning.

It's much safer for the baby.

The nurse has to be absolutely sure she's fully dilated before she starts pushing.

Oh, that's critical.

If you push against a cervix that isn't fully open, you cause it to swell up.

That's called edema.

And a swollen cervix will not open.

You can actually make things go backward.

Wow.

Okay.

We've done the breathing, the tennis balls, the visualization.

Now we get to the heavy hitters.

Section six, pharmacological management.

The drugs.

We start with systemic drugs, which affect the whole body.

Right.

And first we need to split this into two categories.

Analgesics and anesthetics.

An analgesic just reduces the perception of pain.

It takes the edge off.

An anesthetic blocks sensation entirely.

It so the systemic analgesics are usually opioids, demoral, fentanyl.

These are very common, but the timing is absolutely everything.

The text has a really strict rule.

Avoid giving these within one hour of birth.

And why is that?

Because opioids cross the placenta.

They make the mom sleepy, which is fine, but they also make the baby sleepy.

If the baby is born with a peak level of demoral in its system, it will have respiratory depression.

It won't breathe properly.

It won't breathe.

So if that happens, let's say labor moved way faster than anyone expected, what do you do?

There's an antidote.

There is.

Naloxone.

The brand name is Narcan.

How does it work?

It's an opioid antagonist.

It literally kicks the opioid molecules off the receptor sites in the brain.

It rapidly reverses the respiratory depression.

You can give it to the mom just before birth or directly to the baby after.

But the text has a massive blinking red warning sign about Narcan.

A huge one.

Do not give Narcan to a woman or a baby who is opioid dependent.

If the mother has an addiction to heroin or methadone and you give her or her baby Narcan, you will trigger immediate severe withdrawal.

And for a newborn, and that can cause seizures.

It can be catastrophic.

So the nurse has to know the patient substance use history inside and out before even thinking about giving that drug.

Assessment is everything.

Okay, let's move on to section seven, regional anesthesia, the blocks.

This is where the anatomy gets really important.

Yeah, you have to picture the spinal cord.

It's covered by these layers called the meninges.

The dura mater is the tough outer layer.

Think of it like a sleeve.

And the most common block is the epidural.

Right.

And the epidural space is outside that dural sleeve.

The needle goes in, finds that space, and then a tiny flexible plastic capiter is threaded in.

It stays in place, which allows for a continuous infusion of medication.

But putting a needle that close to the spine,

it's risky.

The tech spends a lot of time on something called the test dose.

This is so important.

Before they start the main infusion, the anesthesiologist injects a tiny amount, just two or three milliliters of medication.

And then everyone just watches the patient like a hawk.

What are they looking for?

They're looking for signs that the catheter is in the wrong place.

If it's accidentally in a vein, the little bit of epinephrine in the test dose will make her heart race.

She might get ringing in her ears, which is called tinnitus or a metallic taste in her mouth.

And what if it's too deep?

If it's actually in the spinal fluid, then her legs will get numb almost instantly.

A proper epidural should take about 15, 20 minutes to work.

If it's instant, it means it's a spinal and the dose they plan to give would be way too high.

The test dose confirms the catheter is in that safe epidural space.

Okay, so assuming it's in the right place, what are the side effects?

The text flags hypotension, low blood pressure as the number one risk.

It happens because the epidural blocks the sympathetic nerves that tell your blood vessels to stay squeezed.

So all the vessels in the lower body just relax and dilate.

The pipes get bigger.

Exactly.

You have the same amount of blood in a much bigger container, so the pressure drops.

And if mom's blood pressure drops, the blood flow to the placenta drops, and that can cause fetal distress.

So how do we prevent that?

We fill the tank before we expand the pipes.

The standard procedure is to give the patient a bolus of 500 to 1 ,000 mL of IV fluids rapidly before the block is even placed.

That makes perfect sense.

Just basic physics.

It is.

And then we monitor her blood pressure every five minutes for the first 15, 20 minutes after it's in.

The second big side effect listed is urinary retention.

Right.

She's numb from the waist down, so she can't feel her bladder filling up.

A full bladder acts like a roadblock for the baby's head.

It can literally stop labor from progressing.

So the nurse has to check.

The nurse has to physically check the bladder and will likely have to catheterize her periodically.

Now, how does the epidural compare to the suberacnoid block, which is also called a spinal?

The spinal goes deeper.

The needle actually pierces through the dura and the anesthetic is injected directly into the cerebrospinal fluid.

When would you use that one?

Almost always for scheduled c -sections.

It's a one -shot injection.

There's no catheter left in.

It works instantly and it provides a profound heavy block.

You are completely numb from about the chest down.

But because you punctured the dura, there's a risk of that spinal fluid leaking out.

Which leads to the infamous post -spinal headache.

It's a severe headache that gets much worse when you sit or stand up and feels better when you lie flat.

And the cure for this sounds wild.

The blood patch.

It sounds medieval, I know, but it is highly effective.

They draw about 10 to 15 milliliters of the woman's own blood from her arm and then they inject it back into her epidural space.

Into the space outside the dura where the original leak is.

The blood forms a clot like a natural biological patch over the hole in the dura.

It stops the leak.

The relief from the headache is almost instantaneous.

That is amazing.

Science is pretty cool.

Let's quickly wrap up the pharmacology with section 8, local and general anesthesia.

Local is simple.

It's just numbing the skin with an injection like at the dentist for stitches after delivery.

But the pudendal block is more specific.

It is.

It targets the pudendal nerves deep in the pelvis.

It's often used for the delivery itself, especially if they need to use forceps or a vacuum.

But here's the key thing for a student to remember.

It numbs the vagina and the perineum, but it does not block contraction pain.

The uterus is on a completely different nerve circuit.

She will still feel the contractions.

Okay.

And finally, general anesthesia being put completely to sleep.

This is very rarely used for a vaginal birth.

It's reserved for true emergency c -sections where there's no time for a spinal or if the mom has a clotting disorder or a back issue that prevents a regional block.

And what's the major risk here?

Aspiration.

Pregnant women have delayed gastric emptying.

Their stomach is almost always considered full.

If they vomit while they're unconscious,

that acidic stomach content can go into the lungs.

It's called chemical pneumonitis and it can be fatal.

Wow.

So how do we prevent that?

Well, ideally they're NPO nothing by mouth.

We give drugs to neutralize the stomach acid.

And during intubation, the nurse's job is to apply cricoid pressure, which is also called the cellic maneuver.

Can you describe that?

You use your thumb and index finger to press down firmly on the cricoid cartilage in her throat.

It physically pinches the esophagus shut against the spine so nothing can come up from the stomach while the anesthesiologist is putting the breathing tube in.

And what about the baby?

It's a race against the clock.

The anesthesia goes right to the baby too.

So the surgeon has to get the baby out immediately, usually within just a few minutes of induction.

So the baby isn't born heavily sedated and unable to breathe.

This brings us perfectly to the final section, the nursing care plan.

We've talked about a hundred different interventions, but what is the nurse actually doing through all this?

The addition assessment is the foundation of it all.

We need to know about allergies,

specifically to any of the cane drugs, like what they use at the dentist.

We need to know when she last ate because of that aspiration risk.

And we need to know about any history of back surgery, which might make an epidural impossible.

And during the procedures themselves?

We are the positioning experts.

For an epidural, the woman needs to arch her back like an angry cat, we call it the C -shape, to open up the spaces between the vertebrae.

But she's in pain and has a giant belly in the way.

The nurse is often the one physically holding and supporting her in that position.

And then afterward, it's all about the safety checks.

Always.

We already mentioned checking the bladder, but also assessing leg sensation.

After an epidural, she cannot just hop out of bed to go to the bathroom.

Her legs might completely give out from under her.

We have to assess her sensation and her motor strength before we let her even try to stand.

The text summarizes a few of these as critical thinking highlights, kind of like NCLEX alerts.

Exactly.

If she's hyperventilating, get her to breathe into her hands.

If she becomes hypotensive after an epidural, flutter with IV fluids and change her position.

If he wants to walk to the bathroom, you have to check her leg sensation first.

These are the non -negotiable safety protocols.

It is a lot.

We've gone all the way from simple breathing techniques to literally injecting blood into someone's spine.

It really shows that pain management is a huge spectrum.

And ultimately, pain is personal.

The text really emphasizes that the nurse's role isn't to push one method over another.

It's to support the woman's goals.

So if her goal is an unmedicated birth, we're there with the counter pressure and the coaching.

And if she decides at seven centimeters that she wants an epidural, we're there with the IV fluids and the blood pressure cuff.

Our job is to be the guardian of safety, no matter which path she chooses.

That's a perfect place to leave it.

Whether you're a student prepping for exams or just amazed by what the human body can do, I think understanding these mechanisms really changes how you see the process of birth.

It really does.

It's not just random suffering.

It's physiology at work.

Well, from the Last Minute Lecture team, thanks for trusting us with your study time and for diving deep with us.

Good luck out there.

Take care.