PRENATAL PART 3

Class Outline

Discomforts of Labour

Managing Discomfort

Breathing Patterns

Preconceived Ideas

Ethnic & cultural practices

Beliefs & Myths

Expectations

Reports from peers or older women

Psychological factors eg. anxiety

Previous experience

Physiological Reasons

Fatigue leading to muscular & emotional

irritability

Fear leads to tension, which increases

pain, resulting in more fear

MANAGING DISCOMFORT

Learning to Relax

How do you feel when you are resting or

falling asleep?

How are you breathing?

Determine your personal signs of tension

2 Types of Relaxation

Passive

◦ Sit, lay down or stand & relax through imagery

Touch

◦ Still touch

◦ Firm touch

◦ Massage

Only use verbal relaxation for those who don’t like to be touched

Managing Discomforts of Labour

Labour Positions

Comfort Measures

Medication

Labour Positions

Change positions frequently (at least

every 20-30 mins), especially if labour

progress is slow

When progress is normal, adopt whatever

position is most comfortable

If progress slows with a change in

position, movement will aid progress

Standing

Gravity

Fetus well aligned with angle of pelvis

Contractions less painful

May speed up labour process

Standing, standing & leaning forward on:

◦ partner, bed, birthing ball

Slow-dancing

Disadvantage: tiring

Walking

Gravity

Movement causes changes in pelvic joints,

encourages rotation & descent

Contractions less painful & more

productive

Relieves back labour

Disadvantage: tiring

Sitting/Semi-sitting

Can be used with fetal monitoring

Good resting position

Relieves backache

Vaginal exams may be possible

Sitting upright, on toilet, in rocking chair,

on birthing ball

Disadvantage: can slow labour

Hands & Knees

Can assist in rotating baby into correct position

Takes pressure off hemorrhoids

Allows for pelvic rocking & body movements

Helps relieve backache

Disadvantages: can’t sleep, can interfere with external monitoring

Back Labour

Mother should stay off of her back

Pelvic rocking, especially in upright positions

Frequent position changes can encourage descent &/or movement of offending fetal part or rotation of the fetal head to OA

Suggested positions include:

◦ Sitting – leaning forward with support

◦ Lunges (standing or kneeling)

◦ Squatting

◦ Kneeling forward

◦ Hands & knees

◦ Side-lying

◦ ‘Frog’ position

Counterpressure

Steady pressure in one spot, applied with

fist, tennis ball or heel of hand

Mom tells us where pressure feels best &

how much pressure to apply

Applied during contractions, rest b/w

contractions

Double Hip Squeeze

Purpose to support hips & tilt pelvis

forward

Usually done while kneeling forward or in

hands & knees position

Steady pressure with palms of hands

directed diagonally towards center of the

pelvis

Managing Discomforts of Labour

Relaxation Techniques

Labour Positions

Comfort Measures

Medication

Comfort Measures

Focal Points

Massage

Heat & Cold

Hydrotherapy

Fluids

Diversional Activities/Doula

Medications

Focal Points

External Focal Point

◦ Partner’s face

◦ Pictures

◦ May be the same thing for each contraction or it may change

Internal Focal Point

◦ Eyes closed and something calm & pleasant is visualized

◦ Some women visualize what is happening

◦ Music, soothing voices, etc. may help maintain focus

Massage

Light or firm stroking, kneading, deep

circular pressure or friction motions

Using fingertips, entire hand &/or various

devices that roll, vibrate or apply pressure

In theory, stimulates a variety of sensory

receptors in skin & deeper tissues,

preventing the transmission of pain signals

Types of Massage

Hand

Personal

Perineal

Hand Massage

Kneading, pressure, friction over entire

hand

Very soothing

Welcomed by moms who have a

tendency to grip their fists

Personal Massage

Otherwise called Effleurage:

Rhythmic gentle stroking or circling

motion on abdomen

Constantly or only with contractions

Some moms like when support person

applies light fluttering motion to abdomen

during contractions

Perineal Massage

Use water-based lubricant

U-shaped stroking motion at base of vagina & rubbing area of skin b/w vagina & rectum (perineum)

Softens tissue around vagina & elasticity of the perineum

Encourages relaxation of pelvic floor muscles, need for episiotomy?

Start 6 weeks prior to delivery

Heat Cold

Hot water bottle

Warm, moist towels

Electric heating pad

Heated silica gel

packs

Heated rice-filled

packs warm blanket

Ice packs

Gel packs

Pop bottles

Hydrotherapy

Water-therapy via bath or shower

Even the thought or anticipation of water-therapy has some of the same psychological effects as actually getting into the water

Hearing the water run has calming effect

Body releases more oxytocin, labour progresses without increased discomfort

Hydrotherapy

Used during active labour

Unless clinical reasons exist (bleeding,

fetal distress), mom may stay in

tub/shower for as long as she wishes

In hospital, not allowed to deliver in tub,

although not uncommon at birth centers

or home births

Fluids

Fluid loss through sweating,

hyperventilating, vomiting, breathing

Water, tea, juice, popsicle, ice chips, wet

face cloth, lollipops…brush teeth

Empty bladder frequently (every 1-2 hrs)

Diversional Activities & Doula

Diversional activities

◦ TV, talking, playing cards, music, aromatherapy, etc.

Doula

◦ Trained, experienced female who’s focus should

be the laboring woman

◦ Training is limited, aware of basic physiology of

labour & delivery, not in position to give medical

advice

◦ Main role is providing supportive care in labour

Managing Discomforts of Labour

Relaxation Techniques

Labour Positions

Comfort Measures

Medication

Medications

Drugs used in labour have specific

characteristics that make them

appropriate only during particular stages

of labour

Some may slow labour progress if given

too early

Others should be given early as they may

affect baby if given close to delivery

Medications

Anesthetics: eliminate pain

◦ Regional

Epidural & Spinal

◦ General

◦ Nitrous Oxide (‘laughing gas’)

Analgesics: reduce pain

Anesthetic: Regional (Epidural)

4+ cm dilated

Good for intolerable labour pain, c-sections

& rest/relief in long labour

Minimal anesthetic enters bloodstream &

crosses placenta

0.25% Bupivicaine mixed with Fentanyl

(narcotic)

Anesthetic: Regional (Epidural)

Usually sitting, sometimes laying on side

Catheter inserted, connected to pump & continuously infuses anesthesia

Can get extra doses through pump or catheter if needed

Requires use of continuous EFM, IV fluids, bedrest, frequent monitoring of VS & usually urinary catheter

Anesthetic: Regional (Epidural)

Advantages:

Freedom from pain

Doesn’t cause drowsiness

Safe for mom & baby

Disadvantages:

Have to stay in bed for monitoring

Attached to many cables

Not enough time to administer, if labour progressing quickly

Doesn’t always work or can be ‘patchy’

Possible prolonged labour, urge to push can be impaired

Anesthetic: Regional (Epidural)

Side Effects:

BP (significant drop can indirectly affect baby’s heart rate, usually temporary & manageable)

Minor backache from injections

‘Spinal headache’ – instant or when epidural catheter removed, usually resolves on own in a few days

Extremely rare: nerve damage or paralysis (better chance of getting struck by lightening)

Anesthetic: Regional (Spinal Block)

Usually given in late 1st stage or 2nd stage

labour

Used for c-sections

Injection of anesthesia med between 2 vertebra

Loss of sensation in trunk & legs

Same advantages & disadvantages as epidural

Anesthetic: General

Total loss of sensation & consciousness

Given through IV, immediate effect

Used in emergency c-sections

Side effects: (reversible)

◦ Nausea/vomiting

◦ BP

◦ Respiratory & cardiac depression

◦ Baby can have respiratory depression, and alertness, sucking & motor activity

Anesthetic: Nitrous Oxide

‘Laughing gas’, Entonox, 50/50 mix with

oxygen

Breathed in during contractions, through

mask attached to a tank/canister

Good for advanced labour 6+ cm dilated

throughout transition

If used in early labour, body would get used

to gas & wouldn’t be as effective later

Nitrous Oxide

Advantages

Safe for mom & baby, no obvious side effects

Quick-acting (effective in 10-15 secs)

Short-lasting (lungs get rid of 100% in < 1min)

Remain awake & in control of own pain relief

Disadvantages

Nausea from the slight odour

Not a reliable form of pain relief

Can become drowsy or disorientated

Face mask can make you feel claustrophobic

Analgesia

Pain reducing medications can be given via:

◦ Subcutaneous tissue (fat)

◦ Muscle tissue

◦ Intravenous access

Promote relaxation b/w contractions

Used in early (Morphine) or active (Fentanyl) labour

Effective in a short period of time, lasting 2-4 hours

May speed up labour that was slowed by tension

Analgesia

Fentanyl 100x stronger than morphine

Morphine good for early labour, lasts up

to 2 hrs

Fentanyl (IV only) shorter-acting lasting

30-60 mins, doses can be repeated to a

certain point

Analgesia

Side Effects:

Nausea/vomiting

Drowsiness & dizziness

May make fetal heart rate less reactive

May cause respiratory depression in newborn if delivery shortly after administration, before med can wear-off

◦ Reversed with Narcan injection into leg muscle

BREATHING PATTERNS

Breathing Patterns

Patterned breathing simply means breathing at any rate & depth in order to relieve the pain of labour

The pattern you choose depends on the nature & intensity of your contractions, your preference and your need for oxygen

It’s not where you breath that is important…but that breathing calms & relaxes you

Patterned Breathing 1st Stage

Early Labour

◦ Slow deep breaths, inhale through nose &

exhale through mouth, while trying to relax

body

◦ Instinct is to tense up & hold breath in

response to pain, really need to focus in order

to fight this natural reaction

Patterned Breathing 1st Stage

Active Labour

◦ Slow deep breaths if able

◦ Any method that works for you, as long as

you don’t begin hyperventilating

◦ Try using low-toned sounds such as humming

◦ Heeee, hoooo pattern or anything else that

works for you

Patterned Breathing 1st Stage

Transition

◦ Focus, draw on inner strength, heavily relying on support person

◦ Don’t panic, stay in control of breaths

◦ Shorter, lighter breaths

◦ Hee, hee, hoo or breath, breath, blow

◦ Panting when very close to fully dilated but not advised to push yet

Patterned Breathing 2nd Stage

Your response depends on what you feel, often a strong irresistible urge to push lasting a few seconds, several times in each contraction

Breath in whatever pattern you choose until your body begins to bear down

Push by tightening your abdomen & holding your breath or gradually releasing air

No urge to push – take 2-3 deep breaths, hold the last one, tuck your chin on your chest & bear down by tightening your abdominal muscles

Support Person Take Charge

Use whatever parts of the following seem

appropriate:

Remain calm

Stay close by her side, your face near hers

Anchor her

Make eye contact

Change your ritual during contractions

Encourage her every breath

Talk to her between contractions

Repeat yourself

Labour Positions & Breathing

Exercise

Bring to hospital with you:

◦ Pillow

◦ Comfort items

◦ Massage tools

◦ Favorite music

◦ Essential oils, etc.

References

Slide32 lifeinpain.org

Slide38 spinal yoursurgery.com