warm hands and afterwards drench non-pharmacologic pieces ... · safe intervention, while under a...
TRANSCRIPT
2/24/2016
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Labor Support & Non-Pharmacologic Pain Management
Linda Robinson, MSN, RNC
Clinical Nurse Specialist, Northwest Hospital
Spring 2016
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Greek physician, 1st Century
“soothe pains by touching with warm hands and afterwards drench pieces of cloth with warm, sweet olive oil an put them over the abdomen as well as the labia and keep them saturated with the warm oil for some time, and one must also place bladders filled with warm oil alongside.”
HistoryMedical men may oppose for a time the
superinduction of anesthesia in parturition, but they will oppose it in vain; for certainly our patients themselves will force use of it upon the profession. The whole question is, even now, one merely of time”.
Sir John Simpson
History 1900’s doctor’s attending about 50% of births
Midwives took care of women who could not afford a doctor
Women started being attracted to hospitals as they offered pain relief
Women’s movement
Births move to hospitals
Scopolomine, twilight sleep 1914
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Labor results in severe pain for many
women. There is no other
circumstance where it is considered
acceptable for a person to experience
untreated severe pain, amenable to
safe intervention, while under a
physician’s care. In the absence of a
medical contraindication, maternal
request is a sufficient medical
indication for pain relief during labor.
ACOG, 20025
ObjectivesDiscuss the uniqueness of labor pain and
factors of pain response
Discuss the roles of nursing, doulas and
family in labor support
Discuss positions and movements for comfort
Discuss resources for effective coping during
labor without using pain-relieving medications
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Goals Safety for mom and baby
Emotionally satisfying
Physiologic approach
Vaginal birth
Empowering experience
Can we predict who will
have pain?
Level of Fear is related to her level of
preparation
Degree of fatigue
Anxiety
Her ability to distraction
Tension PainMore preparation showed a decreased pain
perception and less use of analgesia but an
increase in her level of confidence~
Lowe, 2002
Fear What does this mean for
you?
Labor Support Practices
Be Present
Reduce Anxiety
Consider Environment
Be PresentSpending time with the patient allows you to see
her needs and emotions as they change over time
In the active phase, she may become dependent
on others and express wavering self confidence.
Emotional support----use of voice, words, touch;
be aware of how your body language, tone of
voice, choice of words are making an
impression upon your patient and family
Environment
Allow for privacy
Fluids and Nutrition
Reduce noise; use music
Proper lighting, Proper temperature
Discomforts associated with the
technology of birth. 19
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Continuous Support in
Labor reduces the risk of:
medication use
longer labors
operative vaginal birth
C-Section
5 minute Apgar less than 7
(Hodnett, 2003, 2004)
Doula - “in service of”
Shorter labors
Less need for oxytocin to speed up
labor
Reduced use of forceps
Less post-partum depression
Mother more satisfied with birth
Women request less pain meds and epidurals
Informational support
Breathing
Relaxation
Imagery
Focal Point
Care of the partner
More ResourcesMovement
Positioning
Hypnosis - Hypnobirthing
TENS unit
Sterile Water Blocks
Acupuncture
Application of Heat or Cold
Hydrotherapy
Movement in LaborDecreases pain
Facilitates maternal-fetal circulation
Changes quality of contractions
Decreased length of labor
Facilitates fetal descent
Decreased perineal trauma
POSITIONS
FOR
LABOR
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Hypnosis
Is a state of attentive and focused concentration
During trance-like state, therapeutic suggestions can be given
Possible Benefits
Hypnosis
Shorter 1st stage
More spontaneous deliveries
Higher APGAR scores
Reduced perception & awareness of pain
Few side effects and risks
Possible Benefits of
Hypnosis
More satisfying birth experience
Less tension and anxiety
Less Analgesia & Epidural use
Can empower the woman
She may become very self-sufficient
Limits of Hypnosis
Most beneficial results to “good”
subjects (about 25% of population)
Variable skill and experience of the
hypnotherapist
5-31% may experience mild
dizziness, nausea & headache, r/t
failure to dehypnotize properly
TENS - Transcutaneous
Electrical Nerve
Stimulation
Low voltage electrical impulses are administered through flat electrodes applied to the skin.
Most useful early in labor
Most useful for back pain
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TENS - benefitsMay provide some beneficial pain
relief in early labor
Non-invasive
Mom can be mobile
Doesn’t interfere with labor
If fail, can use other methods
TENS – Drawbacks
Can interfere with fetal monitor
Requires education of patient
and staff
Finding institutional support for
use of TENS can be a hurdle
Sterile Water
Blocks2 intracutaneous injections are made on each
side of back about 2 cm below and 1 cm
medically to superior iliac spines.
Does not need to be precise placement
A fine needle used to inject 0.1 ml of sterile
water at each point.
A small white papule surrounded by a red zone
should be produced.46
Sterile Water
Injections - BenefitsInstant and complete relief of low
back pain in many women.
Pain relief lasted as long as 3 hours
Less pain than TENS users
May help women attain a goal of birth
without an epidural
Sterile Water
Injections - Drawbacks
Stinging pain can last 30 seconds
Short Acting
Warn her and help her focus during administration.
Use helper and inject two at a time
Acupressure
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Application of Heat
Increased local blood flow
Increased local skin and muscle temperature
Increased tissue metabolism
Decreased muscle spasm
Relaxation of tiny muscles in the skin
Elevated pain threshold
Application of Cold
Decreased local blood flow
Decreased local skin and muscle temperature
Decreased tissue metabolism
Decreased muscle spasm
Slowed transmission of impulses, leading to decreased sensation, numbing effects
Be careful!
Weakness
Dizziness
Nausea
Maternal or fetal tachycardia
Maternal hypotension
To Prepare
Childbirth Classes
Hypnosis
Acupuncture
TENS unit
Self-education
How could you empower her to
enhance her ability to cope with
labor?
Positive attitude re childbirth.
Faith in her
Emphasize Fundamental strategies for which
she has control.
Let her know she has control by choosing to
focus on coping strategies versus the pain.
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Scene: Woman in early labor,
breathing at peak of contractions,
appears relaxed.
What does she need?
Praise, Praise, Praise, Praise, Praise
Reassurance, Reassurance
Express Confidence in her ability
Mom is well, baby is well and process is going well.
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Scene: Woman in early labor,
her back is hurting.
Positions
Back Massage
Hip Press
TENS unit
Sterile Water Injections
Scene: First time mother in early labor.
Strategies to encourage labor.Fluids, Oral with calories
Position change
Upright positions
Walking, Showering, Rocking, Dancing
Reassurance and Praise
Focus her on coping.
Active Labor Signs
Intense contractions, requiring her
full attention from beginning to end.
Facial flushing
Frequent q 2-4 minute contractions
Decreased ability to talk/chat
Decreased ability to self analyze and
objectively plan strategies to cope.
Active Labor HelpRecognize it, let her know her progress
Reassure her about labor progress
Reassure her that these sensations are normal
Consider all or part of Take Charge Routine
Guide partner in coaching strategies
When to consider
another method?
Her birth-plan states epidural, so when
eligible
At her request, when eligible, if desire
for pain medications was wait-and-see,
or neutral.
Long hard labor and a delivery is not
expected within 1-2 hours, and patient
requests.
When to try longer?
Normal progress, delivery expected within 1-2
hours
In early labor, she is just beginning to
experience active labor. She wanted natural
childbirth, but has not started to utilize a coping
strategy. Teach and support, then reevaluate.
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The Take Charge Routine
Routinefrom Penny Simkin, The Birth Partner.
She hits an emotional low
Despair, crying
Wants to give up
Very tense and cannot relax
The Take Charge Routinefrom Penny Simkin, The Birth Partner.
Remain calm (touch and voice)
Stay close
Anchor her. Hold her shoulders or her head in your hands - gently, confidently , firmly - or hold tightly in your arms
Make eye contact - “open your eyes and look at me”
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The Take Charge Routinefrom Penny Simkin, The Birth Partner.
Change the ritual she has been using
during contractions: - position, breathing.
Help pace her breathing
Encourage her every breath. “Breathe
with me, that’s the way, just like that.
Good, stay with it, breathe with me, look
at me, just like that, it’s going away. Good.
Good. Now a deep breath and let it go.
Good work.” 69
The Take Charge Routinefrom Penny Simkin, The Birth Partner.
Talk to her between contractions -
“what is helping? Let me help you
more. Take a deep breath and look at
me with the beginning of the next
contraction.”
Repeat yourself.
References Zwelling. E. (2010). Overcoming the Challenges:
Maternal Movement. American Journal of Maternal Child Nursing 35:2, March-April.
Positions for Labor & Birth by Simkin and Anchetta
http://www.transitiontoparenthood.com//ttp/parented/pain/positions.htm