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Pain management during labor
&
Second stage of labor
Objectives
At the end of this presentation student will be able
to :
Identify the etiology of pain during labor and birth
...
Etiology of pain during labor
Basic factors for pain in childbirth: physical and
emotional.
1. physical pain in labor is c...
Etiology of pain during labor
2. Emotional Factors
Many negative emotions can actually increase your perception of
pain:
...
Non pharmacological strategies
Emotional support
Instructional/informational support
Advocacy support
Pharmacological stra...
Endorphin
 Natural pain killer produced from pituitary gland released
during stressful events or in moment of grate pain ...
1. Nonpharmacologic strategies
1. Support from a Doula or coach
 Is a women who experienced in childbirth but without
pro...
2. Water therapy(hydrotherapy )
 Standing under warm shower or soaking in tube of warm water ,
the temperature of water u...
 In randomized controlled trial (RCT) to determine the efficacy of warm
showers on parturition pain and the birth experie...
3. Transcutaneous electrical
nerve (TENS) stimulation
 Two paired of electrodes attached to
women back T10-L1 .
 Low- in...
 Can be effective as epidural
anesthesia
 Not available in our hospital.
 Carries no risk to the mother and
fetus
 Wom...
4.Acupuncture
 Based on concept that illness result from an imbalance of
energy , to correct the imbalance needles are in...
A randomized controlled trial was conducted with 607 healthy
women in labor at term who received acupuncture, TENS, or
tra...
Result
 Use of pharmacological and invasive methods was significantly
lower in the acupuncture group (acupuncture vs trad...
5.Acupressure
Application of pressure or massage to heel of the hand
,fist or pads of the thumb and fingers
1. Nonpharmaco...
1. Nonpharmacologic strategies
6. Therapeutic touch and massage
 Based on concept that body contains energy field when
in...
7.Application of Heat and Cold
Heat Application :
• Effective in relief back pain and raises the pain threshold.
• To incr...
1. Nonpharmacologic strategies
9.Aromatherapy
 Their used based on the principle that the sense of smell
plays a signific...
A randomized controlled trial was conducted to determine
the effect of lavender
aromatherapy on pain intensity perception ...
Result
The mean of pain intensity perception in the aroma group was
lower than that of the control group at 30 and 60 minu...
9. Hypnosis
 Hypnosis is an altered state of conscious and awareness
 focus of attention to reduce awareness of the exte...
1. Nonpharmacologic strategies
10. Sterile water injections (SWI)
Sterile water injections (SWI) are an effective method f...
1. Nonpharmacologic strategies
 The injections cause a brief but intense stinging sensation, lasts
for about 30 seconds a...
1. Nonpharmacologic strategies
Benefits of SWI
 often immediate effect
 no effect on mother’s state of consciousness
 n...
case report
• The woman was given sterile water injections and required no
additional pain relief to cope with labor. The ...
The evidence
concluded that it was effective but it was based only on 4
studies they found suitable for analysis:
Ader et ...
11.Biofeedback
 use thinking and mental process (focus)to control body
response, to change the response of the stress and...
12. Double Hip Squeeze
 The double hip squeeze changes the shape of the pelvis and
releases tension on the sacroiliac joi...
1. Nonpharmacologic strategies
12.Birthball
Definition:
The ability of subject participate and share in the laboring client’s
feelings (Sauls, 2004).
Emotional LSB as...
1. Nursing Presence
Nursing presence is defined as being with the client rather than
performing tasks on the client and as...
2.partner care
Practice in Jordan
Companionship or social support during labour has been shown to be
one of the most benef...
Instruction and information on all aspects of labor and birth
provide clients with an opportunity to be a part of the deci...
Advocacy includes protecting the client, attending to needs,
and assisting in making choices related to health care; this
...
1. Narcotic analgesic (opioid analgesic)
 Act by decrease sensation of pain .
 Used for their analgesic effect , all dru...
Advantages and disadvantages of narcotic (opioid )
administration
Advantages
an increased ability for a woman to cope with...
Intrathecally (spinal) narcotic
Refer to injection into spinal cord
Opioid used alone:
 Ex: fentanyle 1.30-3hr with Multi...
2. Anesthesia
The use of medication to partially or totally block all sensation to
an area of the body
• Local anesthesia
...
1.Spinal (subarachnoid)anesthesia
local anesthetic agent such as (bupivacine or ropivacaine) injected
In subarachnoid spac...
pharmacological strategies
Complication
hypotension from sympathetic blockage lead to impaired
placental perfusion and ine...
pharmacological strategies
Complication
spinal headache
Occur because continuous leakage of CSF from the needle insertion
...
pharmacological strategies
If headache occurred :
 Ask women to lie flat
 Administer analgesic
 Blood patch technique :...
2.Epidural anesthesia
 Anesthetic agent placed inside
epidural space at :
L4-5
L3-4
L2-3
 Block not only nerve roots in
...
Patient control epidural analgesia
The newest method is the using PCA that will be programmed specially for the
patient by...
IT is more difficult to insert epidural catheter when the women is
obese , morbidly obese patients are more likely to have...
Advantages of Epidural anesthesia
Women remain alert and more comfortable
Able to participate and achieve good relaxation
...
Disadvantages of Epidural anesthesia
• Hypotension
• Urinary retention
• Backache
• soreness where the needle is inserted
...
epidural analgesia appears to be effective in reducing pain during
labour.
women who use this form of pain relief are at i...
 The use of epidural anesthesia is associated with a significant
increase in maternal temperature and in the incidence of...
 delay the administration of epidural analgesia in nulliparous
women until cervical dilatation reaches 4 cm to 5 cm and t...
3. Combined spinal-epidural analgesia CSE
• Combination of opioid and local anesthesia injected inside spinal cord and in
...
Inhalational analgesia
during labour involves the self-administered inhalation of
sub-anaesthetic concentrations of agents...
inhalational analgesia
• N2O does not interfere with
uterine contractions.
• No effect on fetus too.
• Premixed nitrous ox...
inhaled analgesia appears to be effective in reducing pain
intensity and in giving pain relief in labour
nitrous oxide app...
Begins with fully cervical dilation (10 cm) and complete effacement
(100%) and ends with the baby’s birth.
Duration of sec...
Second stage consist of 2phases:
1. latent phase: baby begins its journey through the birth canal, or
vagina, to the outsi...
2. Active phase(delivary
 mother's pushing produces crowning , fetal station +1
 The mother continues to push until the ...
The mechanisms of labor, also known as the cardinal movements
refer to the changes in position of fetal head during its pa...
Vaginal birth video
Nursing care during second stage
Sign that suggest onset of second stage
• 1. felling of urge to bush or need for bowel
mo...
Perform every 5-30 min v/s
Assess every 5-15min FHR
Assess every 10-15min vaginal show and signs of
fetal descent and mate...
Fundal pressure
Use of fundal pressure is not advised because there is no standard
techniques available for this maneuver ...
When the fetal head reaches the pelvic floor most women
experience the urge to bear down or push.
Monitor women’s breathin...
THE “OLD WAY”
pushing immediately at 10 cm regardless of whether the
woman has an urge to push.
closed-glottis pushing (Va...
This is when a woman, who in the second stage of labor or the
"pushing stage" has coached to push.
Instructs woman to hold...
The Best Way
A better approach based on current evidence is to delay pushing
until the woman feels the urge to push.
The l...
• The benefits of delayed pushing include less fetal
heart deceleration , fewer forceps and vacuum
assisted birth , less p...
Reaserch evidence
• More effective bearing down effort conserve maternal energy
and reduce the risk of operational vaginal...
Positioning is an important component of safe and effective pushing.
upright position or lateral position works better tha...
small cut in the vaginal opening to prevent tearing
during delivery.
This is often a routine procedure in primigravidas.
e...
Episiotomy is routinely practiced in 67% of the
hospitals in Jordan .
Sweidan et al., (2008)
Perineal (episiotomy) Classif...
There should be a policy of restricted episiotomy (episiotomy only
when necessary).
There is no evidence that a policy of ...
Episiotomy at first vaginal delivery significantly and independently
increased the risk of repeated episiotomy and spontan...
Episiotomy and laceration repair should always be
performed under adequate perineal anesthesia.
such as:
epidural.
local i...
A comparison of labor and birth outcomes in Jordan
with WHO guidelines
Pain relief (pethedin) 44% one of the practices tha...
Cultural Differences Among Birthing
Women
The Russian Culture
 Russian women prefer to be alone during labor and
birth.
...
Cultural Differences Among Birthing
Women
Cultural Differences Among Birthing
Women
The Russian Culture
 Using female relatives at the birth instead of the
husband...
Cultural Differences Among Birthing
Women
The Chinese culture
 Chinese women are encouraged to avoid heavy manual
,encour...
Cultural Differences Among Birthing
Women
 In the Chinese culture, eating during labor is the norm.
 When asking for wat...
Cultural Differences Among Birthing Women
African Culture
 It is typical for the woman to deliver while squatting on the
...
References
Lee, Nigel, Webster, Joan, Beckmann, Michael, Gibbons,
Kristen, Smith, Tric, Stapleton, Helen, & Kildea, Sue. (...
References
http://brendalane.suite101.com/cultural-differences-among-birthing-women-a211689
http://www.facebook.com/l.php?...
pain management during labor & second stage of labor
pain management during labor & second stage of labor
pain management during labor & second stage of labor
pain management during labor & second stage of labor
pain management during labor & second stage of labor
pain management during labor & second stage of labor
pain management during labor & second stage of labor
pain management during labor & second stage of labor
pain management during labor & second stage of labor
pain management during labor & second stage of labor
pain management during labor & second stage of labor
pain management during labor & second stage of labor
pain management during labor & second stage of labor
pain management during labor & second stage of labor
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  • Water at 34∼38◦C is comfortableagainst the skin, and at 37∼40◦C is best forcontrolling pain when used properly and appliedin sessions of 20∼30 minutes in length. Ling Lee,2012)
  • stimulate the acupoints on the body by using thin needles that are inserted into the skin. Done by trained certified therapist.
  • Barbiturate(seconal) should be avoid if birth is anticipated 12-24hrIt cause respiratory and vasomotor depression Valium : Significant maternal amnesia and disturbed thermoregulation on newborn
  • Neupain is agonist antagonist opioid analgesia
  • Achieve pain relief through block sodium and potassium transport in nerve membrane so stabilize nerve in polarized resting state , so unable to conduct sensation
  • quickly.
  • Because of the asymmetry of the shape of both the fetal head and the maternal bony pelvis, such rotations are required for the fetus to successfully negotiate the birth canal
  • Stool with bearing down increase the risk for infection and embarrassed the women , so they may reduce effectives of her pushing effortThe nurse should immediately clean perineal area to remove any stool, while reassuring the women that passage of stool at this time is normal and event, and birth will follow
  • Recommendations on episiotomyA routine episiotomy should not be carried out during spontaneous vaginal birth.Where an episiotomy is performed, the recommended technique is a mediolateral episiotomyoriginating at the vaginal fourchette and usually directed to the right side. The angle to thevertical axis should be between 45 and 60 degrees at the time of the episiotomy.An episiotomy should be performed if there is a clinical need such as instrumental birth orsuspected fetal compromise.Tested effective analgesia should be provided prior to carrying out an episiotomy, except in anemergency due to acute fetal compromise.
  • Transcript of "pain management during labor & second stage of labor"

    1. 1. Pain management during labor & Second stage of labor
    2. 2. Objectives At the end of this presentation student will be able to : Identify the etiology of pain during labor and birth Identify types of labor support and advanced nursing roles in normal labor and delivery care Define Of Second Stage Of Labor. Discuss The Mechanism Of Labor Discuss Cultural and social aspects of labor and delivery. Analyze labor and delivery care in Jordan.
    3. 3. Etiology of pain during labor Basic factors for pain in childbirth: physical and emotional. 1. physical pain in labor is caused by:  Muscle cramps/ uterine contraction.  Stretching of cervix and perineum .  Medical tests and procedures (pelvic exams,IVs, catheterization, and so forth)  Position of the baby and pressure of presenting part on tissue like bladder,urethra,back,lower colon
    4. 4. Etiology of pain during labor 2. Emotional Factors Many negative emotions can actually increase your perception of pain:  Fear of pain  Fear of the unknown  Anxiety  Self-doubt  Lack of education  Exhaustion  Dehydration  Hunger
    5. 5. Non pharmacological strategies Emotional support Instructional/informational support Advocacy support Pharmacological strategies Labor support
    6. 6. Endorphin  Natural pain killer produced from pituitary gland released during stressful events or in moment of grate pain it is responsible for euphoric feelings known as “runner’s high” and “adrenaline rush “ .  It secretion triggered by consumption of certain food “chochlate,chili peppers” also triggered by massage therapy or acupuncture .
    7. 7. 1. Nonpharmacologic strategies 1. Support from a Doula or coach  Is a women who experienced in childbirth but without professional credentials , who guides and assist women in labor .  Having a doula can increase women self-esteem as well as decrease rate of oxytocin augmentation ,epidural anesthesia and cesarean birth .  Doula can be women husband,mother,father..etc
    8. 8. 2. Water therapy(hydrotherapy )  Standing under warm shower or soaking in tube of warm water , the temperature of water used should be between 35-37c .  Several study have investigated the risk of using hydrotherapy with rupture membrane findings have shown no increase in chorioamnionitis , post partum indometraitis,neonatal infection or antibiotic use ( tournaire & theau-yonneau,2007,zwelling et al ,2006)  No limit to the time women can stay in bath and often they are encouraged to stay in it as long as desired 1. Nonpharmacologic strategies
    9. 9.  In randomized controlled trial (RCT) to determine the efficacy of warm showers on parturition pain and the birth experiences of women during the first stage of labor  participants in the experimental group received warm shower bath interventions full body or lower back shower, participants could spend 5 minute complete bath 15 minutes directing shower water toward any body region that felt most comfortable. Facilities allowed participants to stand and sit as desired. Water was constantly monitored and maintained at a temperature of 37◦C. Participants in the control group received standard care.  women who participated in warm showers reported significantly lower VAS pain scores at 4-cm and 7-cm cervical dilations, and higher birth experiences than the control group.  warm showers are a cost-effective, convenient, easy to perform ,non- pharmacological approach to pain reduction. This intervention helps women in labor to participate fully in the birthing process, earn continuous caregiver support, feel cared for and comforted, and have a more positive overall experience. (Lee, Liu, Lu, & Gau, 2013)
    10. 10. 3. Transcutaneous electrical nerve (TENS) stimulation  Two paired of electrodes attached to women back T10-L1 .  Low- intensity electrical stimulation is given continuously or applied by women herself as a contraction begin .  Block afferent fibers and preventing pain to travel from uterus to spinal cord synapses , and facilitate release of endorphin 1. Nonpharmacologic strategies
    11. 11.  Can be effective as epidural anesthesia  Not available in our hospital.  Carries no risk to the mother and fetus  Women can refuse to being “tied down “ to equipment 1. Nonpharmacologic strategies
    12. 12. 4.Acupuncture  Based on concept that illness result from an imbalance of energy , to correct the imbalance needles are inserted into the skin at specific body points , activation of these point lead to release of endorphins .  Helpful in first stage of labor 1. Nonpharmacologic strategies
    13. 13. A randomized controlled trial was conducted with 607 healthy women in labor at term who received acupuncture, TENS, or traditional analgesics To compare the effect of acupuncture with transcutaneous electric nerve stimulation (TENS) and traditional analgesics for pain relief and relaxation during delivery.  Primary outcomes: were the need for pharmacological and invasive methods, birth experience and satisfaction with delivery.  Secondary outcomes : were duration of labor, use of oxytocin, mode of delivery, postpartum hemorrhage, Apgar score, and umbilical cord pH value. (Borup, Wurlitzer, Hedegaard, Kesmodel, & Hvidman, 2009)
    14. 14. Result  Use of pharmacological and invasive methods was significantly lower in the acupuncture group (acupuncture vs traditional, p < 0.001; acupuncture vs TENS, p = 0.031).  Acupuncture did not influence the duration of labor or the use of oxytocin.  Mean Apgar score at 5 minutes and umbilical cord pH value were significantly higher among infants in the acupuncture group compared with infants in the other groups. CONCLUSIONS Acupuncture reduced the need for pharmacological and invasive methods during delivery. Acupuncture is a good supplement to existing pain relief methods. (Borup, Wurlitzer, Hedegaard, Kesmodel, & Hvidman, 2009)
    15. 15. 5.Acupressure Application of pressure or massage to heel of the hand ,fist or pads of the thumb and fingers 1. Nonpharmacologic strategies
    16. 16. 1. Nonpharmacologic strategies 6. Therapeutic touch and massage  Based on concept that body contains energy field when increased lead to health and when decreased lead to illness  touch and massage work to relive pain by increase level of endorphins  Effleurage is a form of therapeutic touch of gentle abdominal massage
    17. 17. 7.Application of Heat and Cold Heat Application : • Effective in relief back pain and raises the pain threshold. • To increase blood flow and relieves muscle ischemia. • increases relaxation Cold application: • Applied to the back, chest, and face to increase comfort • slowing transmission of pain. 1. Nonpharmacologic strategies
    18. 18. 1. Nonpharmacologic strategies 9.Aromatherapy  Their used based on the principle that the sense of smell plays a significant role in over all health , when essential oil inhaled it’s molecule transported via olfactory system to the brain and the brain respond to particular aroma with emotional responses , when applied externally they absorbed to the skin and then carried throughout circulation .  The oils may be massaged into the skin, in a bath or inhaled using a steam infusion or burner
    19. 19. A randomized controlled trial was conducted to determine the effect of lavender aromatherapy on pain intensity perception and intrapartum outcome in primiparous women  The aroma group received 0.1 ml of lavender essential oil mixed with 1 ml of distilled water via tissues attached to their gowns close to their nostrils. Meanwhile, the control group received 2 ml of distilled water in a similar way.  Pain intensity perception was measured by Visual Analogue Scale (VAS) before the intervention and at 30 and 60 minutes afterwards (Kaviani, Azima, Alavi, & Tabaei, 2014)
    20. 20. Result The mean of pain intensity perception in the aroma group was lower than that of the control group at 30 and 60 minutes after the intervention (p←0.001). Conclusion This study revealed that aromatherapy decreased the labour pain, but did not affect the duration of labour phases Kaviani, Azima, Alavi, & Tabaei, 2014
    21. 21. 9. Hypnosis  Hypnosis is an altered state of conscious and awareness  focus of attention to reduce awareness of the external environment.  For childbirth, hypnosis is often used to focus attention on feelings of comfort or numbness as well as to enhance women's feelings of relaxation and sense of safety. 1. Nonpharmacologic strategies
    22. 22. 1. Nonpharmacologic strategies 10. Sterile water injections (SWI) Sterile water injections (SWI) are an effective method for the relief of back pain in labour. The procedure involves a small amount of sterile water (0.1 ml to 0.2 ml) injected under the skin at four locations on the lower back (sacrum).
    23. 23. 1. Nonpharmacologic strategies  The injections cause a brief but intense stinging sensation, lasts for about 30 seconds and then wears off completely.  To distract from the stinging sensation the injections are done during a contraction by two midwives.  SWI provides effective pain relief for up to two hours. http://www.matermothers.org.au/hospitals/mater- mothers-private-brisbane/labour-and- birth/switch/about-sterile-water-injections
    24. 24. 1. Nonpharmacologic strategies Benefits of SWI  often immediate effect  no effect on mother’s state of consciousness  no effect on baby  does not limit mobility  does not adversely affect labour progress  is a simple procedure that can administered by midwife  can be repeated as needed
    25. 25. case report • The woman was given sterile water injections and required no additional pain relief to cope with labor. The pain relief effect, measured by the VAS, was very powerful and she described her experience in highly positive terms. • The method is a good alternative for women who do not want pharmacological pain relief during childbirth (Ma°rtensson,2010) Evidence :Intradermal Water Block
    26. 26. The evidence concluded that it was effective but it was based only on 4 studies they found suitable for analysis: Ader et al compared sterile water to saline. Sterile water worked better but there was no difference in the requirement for pethedin (Demerol) Trolle et al compared sterile water to saline and found it twice as effective (89% vs. 45%). Martensson et al compared 0.1cc of intradermal water, 0.5 cc of subcutaneous water, and 0.1 cc of subcutaneous saline. The two water groups were equally effective and superior to the saline. Labreque et al. compared sterile water injections to TENS and to standard care (massage, etc.) Water worked better than the other two, but there was no difference in epidural requests, and fewer women said they would choose it again.
    27. 27. 11.Biofeedback  use thinking and mental process (focus)to control body response, to change the response of the stress and pain  Women who are interesting in using this method must attend several sessions during pregnancy to condition themselves to regulate their pain response  If women response to pain during contraction with frowning and breath holding her partner use verbal feedback to help her to relax 1. Nonpharmacologic strategies
    28. 28. 12. Double Hip Squeeze  The double hip squeeze changes the shape of the pelvis and releases tension on the sacroiliac joints.  Place hands on each side below iliac crest and over gluteal muscle with fingers pointing toward midline. 1. Nonpharmacologic strategies
    29. 29. 1. Nonpharmacologic strategies 12.Birthball
    30. 30. Definition: The ability of subject participate and share in the laboring client’s feelings (Sauls, 2004). Emotional LSB assist to occupy the client’s mind with positive thoughts and diminish or block feelings of fear, and anxiety 2. Emotional LSB
    31. 31. 1. Nursing Presence Nursing presence is defined as being with the client rather than performing tasks on the client and as complete physical, emotional, psychological, and spiritual engagement between nurse and client. Nursing presence includes: high level of nursing skill. being open honest. nonjudgmental with the client. listening carefully to her needs and concerns. 2. Emotional LSB
    32. 32. 2.partner care Practice in Jordan Companionship or social support during labour has been shown to be one of the most beneficial practices in maternity care( Hodnett E,2007) None of the public hospitals in Jordan allowed the presence of a birth companion including the husband during labour and birth. Evidence show that : mothers who had received support during labour were significantly less likely to have pharmacological pain relief. and significantly more likely report a good birth experience Shaban et al., 2011
    33. 33. Instruction and information on all aspects of labor and birth provide clients with an opportunity to be a part of the decision- making process, which fosters a positive birth experience. Verbal communication must be culturally sensitive 3. Instructional/Informational LSB
    34. 34. Advocacy includes protecting the client, attending to needs, and assisting in making choices related to health care; this requires the establishment of a therapeutic relationship. Being an advocate for the client, the nurse empowers the client to give birth with dignity. 4. Advocacy LSB
    35. 35. 1. Narcotic analgesic (opioid analgesic)  Act by decrease sensation of pain .  Used for their analgesic effect , all drugs in this category cause CNS depression , respiratory depression . Narcotic analgesic includes: pethidine (meperidin) , fentanyl remifentanil, morphine, tramadol pethedin is the most commonly used analgesic in labor because it has additional sedative and antispasmodic actions , these make it effective not only for reliving pain but also for relaxing cervix and providing feeling of euphoria and well-being Narcotic antagonist : naloxon (Narcan) Pharmacological strategies
    36. 36. Advantages and disadvantages of narcotic (opioid ) administration Advantages an increased ability for a woman to cope with labor The medications may be nurse-administered It has no amnesic effect but create a felling of well-being or euphoria Disadvantages Frequent occurrence of uncomfortable side effects, such as nausea and vomiting, pruritus, drowsiness, and neonatal depression Pain is not eliminated completely pharmacological strategies
    37. 37. Intrathecally (spinal) narcotic Refer to injection into spinal cord Opioid used alone:  Ex: fentanyle 1.30-3hr with Multipara  morphine 4-7 hr with Nullipara or women with history of long labor Excellent pain relief for labor pain they take effect 15-30min and last 4-7hr Don’t cause maternal hypotension or affect VS Women can fell contraction but no pain , her ability to bear down during second stage of labor is preserved because the bushing reflex is not lost and her motor power remain intact pharmacological strategies
    38. 38. 2. Anesthesia The use of medication to partially or totally block all sensation to an area of the body • Local anesthesia  Reduce ability of local nerve fiber to conduct pain  Used to numb the perineum just before birth to allow for episiotomy and repair • Regional anesthesia injection of local anesthetic agent such as tetracaine or bupivacine to block specific nerve pathways that supply a particular organ or area of the body spinal analgesia  epidural analgesia  combined spinal epidural • General anesthesia  Intra Venous Analgesia  Inhalational Analgesia pharmacological strategies
    39. 39. 1.Spinal (subarachnoid)anesthesia local anesthetic agent such as (bupivacine or ropivacaine) injected In subarachnoid space through 3dr ,4th or 5th lumber interspaces by using lumber puncture technique . Anesthesia mixed with CSF, used on elective and emergent CS birth not suitable of vaginal birth because it useful for shorter and simpler procedures. Anesthesia normally raise to level of T10 , up to umbilicus and including both legs. pharmacological strategies
    40. 40. pharmacological strategies Complication hypotension from sympathetic blockage lead to impaired placental perfusion and ineffective breathing pattern may occur during spinal anesthesia Turn the women to her left side I.V fluid administration to increase blood volume Vasopressin to increase BP O2 may be used Check V/S every 5-10min
    41. 41. pharmacological strategies Complication spinal headache Occur because continuous leakage of CSF from the needle insertion site or by instillation of air into CSF , shift in pressure of CSF cause strain in vertebral meanings. Incidence reduced by using of :  small-gauge needle  Increase fluid intake to replace spinal fluid
    42. 42. pharmacological strategies If headache occurred :  Ask women to lie flat  Administer analgesic  Blood patch technique : withdraw 10ml of venous blood and then immediately injected into the epidural space over spinal injection site , injected blood clot and seals of any further leakage of CSF .
    43. 43. 2.Epidural anesthesia  Anesthetic agent placed inside epidural space at : L4-5 L3-4 L2-3  Block not only nerve roots in the space but also sympathetic nerve fibers that travel with them pharmacological strategies
    44. 44. Patient control epidural analgesia The newest method is the using PCA that will be programmed specially for the patient by anesthesiologist indwelling catheter and programmed pump that allow women to control the dose of analgesic , this method provide optimal analgesia with higher maternal satisfaction and enhance sense of control during labor. (saito et al,2005) pharmacological strategies
    45. 45. IT is more difficult to insert epidural catheter when the women is obese , morbidly obese patients are more likely to have failed epidural placement and accidental Dural puncture. (valleyo,2007) pharmacological strategies
    46. 46. Advantages of Epidural anesthesia Women remain alert and more comfortable Able to participate and achieve good relaxation Airway reflex remain intact Gastric empty not delay Blood loss not excessive The most effective pain relief. Fetal complication are rare but may occur pharmacological strategies
    47. 47. Disadvantages of Epidural anesthesia • Hypotension • Urinary retention • Backache • soreness where the needle is inserted • nausea and vomiting • epidural may prolong second stage of labor ,pushing more difficult and additional interventions such as Pitocin, forceps, vacuum extraction or cesarean might become necessary • baby might experience respiratory depression, fetal malpositioning, and an increase in fetal heart rate variability pharmacological strategies
    48. 48. epidural analgesia appears to be effective in reducing pain during labour. women who use this form of pain relief are at increased risk of having an instrumental delivery having an epidural was also associated with a longer second stage of labour, more use of augmentation of labour, more frequent very low blood pressure readings, problems passing urine, fever, and being unable to move for a period of time after the birth What evidence say about epidural analgesia Cochrane Database of Systematic Reviews
    49. 49.  The use of epidural anesthesia is associated with a significant increase in maternal temperature and in the incidence of intrapartum maternal fever. (Passini, Amorim, Almeida, & Barros, 2011)  Sever hypotension (systolic BP 100mmHg or less or more than 20% decrease from base line blood pressure ) as a result of sympathetic block can be an outcome of epidural block . (anim-somuah,smyth,&howell,2008) What evidence say about epidural analgesia Cochrane Database of Systematic Reviews
    50. 50.  delay the administration of epidural analgesia in nulliparous women until cervical dilatation reaches 4 cm to 5 cm and that other forms of analgesia be used until that time to avoid suppressing the progress of labor 2002, the American College of Obstetricians and Gynecologists  It is recommended that the administration of systematic opioid analgesia be delayed until labor is well established. (creehan,2008)  Women in labor most no longer reach a certain level of cervical dilatation or fetal station before receiving epidural analgesia. (aab&acog,2007,cunningham et al ,2010) Time of adminestration of epidural analgesia
    51. 51. 3. Combined spinal-epidural analgesia CSE • Combination of opioid and local anesthesia injected inside spinal cord and in subarachnoid space , used to block pain transmission without compromising motor ability • It is associated with greater incident with FHR abnormalities than epidural analgesia alone pharmacological strategies
    52. 52. Inhalational analgesia during labour involves the self-administered inhalation of sub-anaesthetic concentrations of agents while the mother remains awake and her protective laryngeal reflexes remain intact pharmacological strategies
    53. 53. inhalational analgesia • N2O does not interfere with uterine contractions. • No effect on fetus too. • Premixed nitrous oxide &oxygen. • N2O 50% and O2 50% • ENTONOX-cylinders with a capacity of 500 L are available. • Inhalation should begin 45 seconds before the onset of pain. pharmacological strategies
    54. 54. inhaled analgesia appears to be effective in reducing pain intensity and in giving pain relief in labour nitrous oxide appears to result in more side effects compared with flurane derivatives. Flurane derivatives result in more drowsiness when compared with nitrous oxide. nitrous oxide appears to result in even more side effects such as nausea, vomiting, dizziness and drowsiness (Trudy Klomp, Leanne Jones, Di Nisio.2012) Cochrane Database What evidence say about inhaled anelgesia
    55. 55. Begins with fully cervical dilation (10 cm) and complete effacement (100%) and ends with the baby’s birth. Duration of second stage Multiparous women 1-2hr Nulliparous women 2-3hr Second stage of labor
    56. 56. Second stage consist of 2phases: 1. latent phase: baby begins its journey through the birth canal, or vagina, to the outside. The power for this movement is provided by the contracting uterus, the diaphragm, and the abdominal and respiratory muscles of the mother. With each contraction the baby's head moves down until part of the baby's head is visible at the entrance of the birth canal . Second stage of labor
    57. 57. 2. Active phase(delivary  mother's pushing produces crowning , fetal station +1  The mother continues to push until the entire head is delivered  The shoulders emerge next, first one and then the other  Finally, the medical attendant slowly eases the rest of the body out of the birth canal and the baby is born. Second stage of labor
    58. 58. The mechanisms of labor, also known as the cardinal movements refer to the changes in position of fetal head during its passage through the birth canal. Engagement Descent Flexion Internal Rotation Extension External Rotation Expulsion Cardinal Movements in Labor
    59. 59. Vaginal birth video
    60. 60. Nursing care during second stage Sign that suggest onset of second stage • 1. felling of urge to bush or need for bowel movement • 2. sudden appearance of sweat on upper lip • Episodes of vomiting • Increase bloody show • Checking of extremities • Increase restlessness • Involuntary bearing down
    61. 61. Perform every 5-30 min v/s Assess every 5-15min FHR Assess every 10-15min vaginal show and signs of fetal descent and maternal appearance Assess every contraction and bearing down effort Nursing care during second stage
    62. 62. Fundal pressure Use of fundal pressure is not advised because there is no standard techniques available for this maneuver also no current legal or regulatory standard exist for it’s use and no evidence related to it effectives in facilitating a safe vaginal birth is available.(simbson,2008) Nursing care during second stage
    63. 63. When the fetal head reaches the pelvic floor most women experience the urge to bear down or push. Monitor women’s breathing. Should not hold breath more than 5 to 7 sec. Remained her to take deep breathing Bearing Down (pushing)
    64. 64. THE “OLD WAY” pushing immediately at 10 cm regardless of whether the woman has an urge to push. closed-glottis pushing (Valsalva's Maneuver). woman lies in the supine Lithotomy position. These techniques have the potential to cause harm to the mother and baby. (AWHONN,2010) When and how to push
    65. 65. This is when a woman, who in the second stage of labor or the "pushing stage" has coached to push. Instructs woman to hold her breath and push for 10 counts/seconds. But holding breath for 10 seconds not good during pushing. Because of: increase intrathoracic and cardiovascular pressure. reducing cardiac output. inhibiting perfusion of the uterus and the placenta. resulting in fetal hypoxia. Closed Glottis pushing/Valsalva's Maneuver
    66. 66. The Best Way A better approach based on current evidence is to delay pushing until the woman feels the urge to push. The latent phase is an ideal time to allow the woman to rest in preparation for pushing efforts at the appropriate time. When the time is right for pushing? the best approach based on current evidence is to encourage the woman to do whatever comes naturally. (AWHONN,2010) When and how to push
    67. 67. • The benefits of delayed pushing include less fetal heart deceleration , fewer forceps and vacuum assisted birth , less perenial damage • The longer length of second stage doesn’t associated with poor neonatal outcomes , as long as fetal status during this time is normal. (berghella et al ,2008 ,brancato,church,&ston,2008) Reaserch evidence
    68. 68. Reaserch evidence • More effective bearing down effort conserve maternal energy and reduce the risk of operational vaginal birth. (robert,2002,simbson&james,2005) Based on this evidence it is essential that prenatal nurse advocate for the practice of delayed and spontaneous bearing down effort.
    69. 69. Positioning is an important component of safe and effective pushing. upright position or lateral position works better than supine positioning. Forcing women's legs back against their abdomen during pushing should be avoided because this results in stretching the perineum and increases the risk of perineal lacerations. International Journal of Gynecology and Obstetrics (2012) Position & Pushing
    70. 70. small cut in the vaginal opening to prevent tearing during delivery. This is often a routine procedure in primigravidas. episiotomy is a painless procedure done just before the baby's head is born. Episiotomy
    71. 71. Episiotomy is routinely practiced in 67% of the hospitals in Jordan . Sweidan et al., (2008) Perineal (episiotomy) Classified as one of the practices that is frequently used and should be avoided as a routine. Khresheh et al., (2009) Practice in Jordan for Episiotomy
    72. 72. There should be a policy of restricted episiotomy (episiotomy only when necessary). There is no evidence that a policy of routine episiotomy resulted in significant: Reductions in laceration severity. pain. pelvic organ prolapse. better maternal outcomes. International Journal of Gynecology and Obstetrics (2012) Episiotomy
    73. 73. Episiotomy at first vaginal delivery significantly and independently increased the risk of repeated episiotomy and spontaneous perennial tears in subsequent delivery. (Lurie,2012) Avoiding routine episiotomy in unnecessary condition would increase the rate of intact perineal and minor perineal trauma and reduce postpartum delivery pain with no adverse affect nether on maternal nor neonatal morbidities .(shahraki,2011) Evidence show that
    74. 74. Episiotomy and laceration repair should always be performed under adequate perineal anesthesia. such as: epidural. local infiltration. International Journal of Gynecology and Obstetrics (2012) Episiotomy
    75. 75. A comparison of labor and birth outcomes in Jordan with WHO guidelines Pain relief (pethedin) 44% one of the practices that is frequently used inappropriately.  Low Apgar Score  Admission to NICU  Interrupts mother–baby bonding and disrupts breast feeding initiation.  Respiratory depression for both mother and infant. Perineal (episiotomy) 53% Classified as one of the practices that is frequently used and should be avoided as a routine. Khresheh et al., (2009)
    76. 76. Cultural Differences Among Birthing Women The Russian Culture  Russian women prefer to be alone during labor and birth.  They view labor and birth as a private experience.  They prefer not to have their partners present because they were afraid for their husbands!
    77. 77. Cultural Differences Among Birthing Women
    78. 78. Cultural Differences Among Birthing Women The Russian Culture  Using female relatives at the birth instead of the husband is a common practice.  This is popular among many women in Arabic cultures as well as traditions of Pacific Islanders, Cambodians, Chinese, Filipinos, Indonesians, and Koreans
    79. 79. Cultural Differences Among Birthing Women The Chinese culture  Chinese women are encouraged to avoid heavy manual ,encourage rest.  Infant boys are considered more valuable than infant girls.  The Chinese avoid “cold” foods such as bean sprouts and bananas because they believe it increases the risk of miscarriage.
    80. 80. Cultural Differences Among Birthing Women  In the Chinese culture, eating during labor is the norm.  When asking for water, they prefer warm water. If given ice chips they are not eaten for fear of upsetting the hot-cold balance.  They may not choose to use ice on episiotomies for this reason  Upsetting the hot-cold balance is thought to cause arthritis in old age. The “Sitting Month” is the month after delivery where women are encouraged to rest and recover.
    81. 81. Cultural Differences Among Birthing Women African Culture  It is typical for the woman to deliver while squatting on the ground surrounded by female relatives. Squatting is representative of the mother’s connection with the earth.  Midwives only get paid if delivery is successful. Some relatives act as midwives.  In the Yoruba tribe, in Nigeria, the name given to the child must reflect circumstances around the birth.
    82. 82. References Lee, Nigel, Webster, Joan, Beckmann, Michael, Gibbons, Kristen, Smith, Tric, Stapleton, Helen, & Kildea, Sue. (2013). Comparison of a single vs. a four intradermal sterile water injection for relief of lower back pain for women in labour: A randomised controlled trial. Midwifery, 29(6), 585-591. Lee, Shu-Ling, Liu, Chieh-Yu, Lu, Yu-Yin, & Gau, Meei-Ling. (2013). Efficacy of warm showers on labor pain and birth experiences during the first labor stage. Journal Of Obstetric, Gynecologic, And Neonatal Nursing: JOGNN / NAACOG, 42(1), 19-28. doi: 10.1111/j.1552- 6909.2012.01424.x Wang, FuZhou, Shen, XiaoFeng, Guo, XiRong, Peng, YuZhu, Gu, XiaoQi, & Group, The Labor Analgesia Examining. (2009). Epidural Analgesia in the Latent Phase of Labor and the Risk of Cesarean Delivery: A Five-year Randomized Controlled Trial. Anesthesiology, 111(4), 871-880 810.1097/ALN.1090b1013e3181b1055e1065. Hodnett E, Gates S, Hofmey G, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev 2007; (3): Art. No.: CD 003766 Cochrane Pregnancy and Childbirth Group’s Trials Register (31 January 2012) Thorp, James A., Hu, Daniel H., Albin, Rene M., McNitt, Jay, Meyer, Bruce A., Cohen, Gary R., & Yeast, John D. (1993). The effect of intrapartum epidural analgesia on nulliparous labor: A randomized, controlled, prospective trial. American Journal of Obstetrics and Gynecology, 169(4), 851-858. doi: http://dx.doi.org/10.1016/0002- 9378(93)900
    83. 83. References http://brendalane.suite101.com/cultural-differences-among-birthing-women-a211689 http://www.facebook.com/l.php?u=http%3A%2F%2Fmedia.gamerevolution.com%2Fimages%2Fmisc%2Fima ge%2Frussian-birth.jpg&h=YAQF1dqp3 http://www.facebook.com/l.php?u=http%3A%2F%2Fomgghana.com%2Fwp- content%2Fuploads%2F2012%2F03%2FPREGNANT-512x340.jpg&h=0AQFanJIT http://www.facebook.com/l.php?u=http%3A%2F%2Fwww.charischildbirth.org%2Fnewsletter%2F0510%2Fim ages%2FDRachel1.jpg&h=kAQH_XAcv http://www.facebook.com/l.php?u=http%3A%2F%2Fedinfo.med.nyu.edu%2Fmc%2Fculture%2FPreganacy.ht ml&h=FAQHJTs4P http://www.facebook.com/l.php?u=http%3A%2F%2F2008gamesbeijing.com%2Fchinese-pregnant-women- paint-olympic-mascots-on-their-stomachs%2F&h=fAQGMc9JV http://www.facebook.com/l.php?u=http%3A%2F%2Fwww.kaliyogainc.com%2Fcommunity%2Fshanti-uganda- society%2F&h=9AQGJUlo5 Lee, Nigel, Webster, Joan, Beckmann, Michael, Gibbons, Kristen, Smith, Tric, Stapleton, Helen, & Kildea, Sue. (2013). Comparison of a single vs. a four intradermal sterile water injection for relief of lower back pain for women in labour: A randomised controlled trial. Midwifery, 29(6), 585-591.
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