Maternity - L&D, part 4: Pain Management During Labor, Regional Anesthesia
by Meris Shuwarger BSN, RN, CEN, TCRN September 18, 2021 Updated: December 07, 2022 6 min read
This article focuses on different ways to manage pain during labor. The Maternity Nursing series follows along with our Maternity Nursing Flashcards, which are intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI, and NCLEX.
Pain management is especially important during labor, because labor, typically, is long-lasting and involves strong and intense pain. There are many options to help control this pain, and helping patients manage their pain during labor is a key responsibility of nursing.
Non-pharmacological measures of pain management
Pain management does not always require the use of medicines. There are many techniques to help distract or relieve patients who are in pain that are not dependent on drugs.
Remember, too, that some patients say they want “natural labor,” which means an unmedicated labor. It is just as important to be able to help them manage their pain.
Here are some non-pharmacological ways to help patients manage labor pain.
Effleurage is a technique that involves the light stroking of the abdomen in rhythm with the patient’s breathing during contractions. Pain is alleviated through tactile stimulation meant to help distract the brain.
Sacral counterpressure is a technique of pain management used often during labor. “Sacral” refers to the sacrum, located in the lower back, at the base of the spine. Counterpressure “counters” the “pressure” on the sacrum that the patient experiences from the inside as the baby moves down into the pelvis. Pushing the heel of the hand or the fist against the maternal sacrum can help to relieve pain in the lower back. This is especially helpful for patients experiencing back labor — when they feel most of their pain in their back.
Breathing techniques include patterned-paced breathing, beginning and ending with a cleansing breath.
These techniques are an important pain management tool during labor. They can be meditative, helping the patient focus on something other than the pain. And, though this sounds obvious, engaging in breathing techniques is a way to ensure the patient is breathing — sometimes when a person is in pain, they hold their breath, but breathing is much more beneficial for alleviating pain than holding your breath.
Breathing techniques are usually taught in classes that prepare pregnant people for labor. Often this includes a partner who learns these techniques alongside the pregnant person in order to help coach the patient’s breathing during labor.
Other pain management techniques
Other non-pharmacological pain management techniques include:
- Hydrotherapy: using water for pain relief (e.g., showers, baths)
- TENS (transcutaneous electrical nerve stimulation): a method of pain relief involving the use of a mild electrical current
- Acupressure or acupuncture
- Ambulation and position changes: sometimes having the patient walk the hall of their ward may help alleviate pain
- Imagery: visualizing somewhere calming (e.g, lying on the beach)
- Heat/cold: alternating heat and cold where it hurts
Pharmacological pain management measures
Knowing the options for pharmacological measures — and understanding what they are and how to use them — is very important when working with a patient in labor.
Systemic pain management measures
Opioids (e.g., meperidine) are strong and effective pain medicines because opioids target the pain itself.
Note that because the mother and baby are linked through their circulatory system, when administering opioids to the mother, the baby will get some as well. This means constantly assessing both mother and baby’s well-being when giving opioids. Look for respiratory depression rates (are mother and baby breathing enough?) or changes in level of consciousness, as well as a significant decrease in fetal heart rate. If the mother is having fewer than 10 breaths a minute, that may be a sign of potential opioid toxicity. The only antidote for opioid toxicity is naloxone.
Antiemetics (e.g., promethazine) may be given to combat nausea.
Benzodiazepines (e.g., diazepam) may be administered to help with some anxiety.
Inhaled pain management measures
These medications include nitrous oxide gas (sometimes called laughing gas), which may be self-administered by the patient. Nitrous oxide is delivered through the inhalation route, usually via a mask or something similar. Its effects are immediately reversible — as soon as the patient starts breathing regular air again, the effects of the drug dissipate. Nitrous oxide is an effective way to relieve pain for patients who don’t want opioids.
Regional anesthesia is what usually comes to mind when thinking of methods for pain relief during labor. They are called regional because these medications affect a specific region of the body and not the whole body (systemic medications affect the whole body). Regional anesthesia includes epidural or spinal blocks, which we discuss below.
Regional anesthesia also includes local infiltration. While less common, if the provider needs to do an episiotomy (a cut or a tear in the perineum) and make a suture, this would require lidocaine to locally infiltrate that area and numb it.
Pudendal nerve block
The pudendal nerve innervates the genitalia, so a pudendal nerve block provides pain relief in the lower vagina, the vulva, and the perineum. Pudendal nerve blocks would be used during an episiotomy or a vacuum/forceps-assisted birth. This specific nerve block does not affect the belly or help alleviate contraction pains.
For more information on the various types of pharmacological pain management measures, check out our Pharmacology Study Guide & Flashcard Index, a list of meds covered in our Pharmacology Flashcards for Nursing Students.
As noted above, regional anesthesias are types of anesthesia in which a local anesthetic is injected near the spinal cord and nerve roots. These block pain in a more broadly targeted region of the body (e.g., belly, hips, legs, or pelvis), but are not general anesthetics. The two common regional anesthesias are epidural and spinal blocks.
An epidural block is administered via a catheter that is inserted into the epidural space, typically between L3 and L4. This allows medication to be administered into that space to reduce or eliminate pain and/or sensation below the umbilicus (from the belly down). Note that while an epidural may provide pain relief, it will not prevent all sensation. Pain will persist. The epidural essentially dials down the pain to make it more manageable.
Epidurals can cause weakness, loss of sensation, and loss of strength, which means continuously monitoring the patient.
One side effect of an epidural block is maternal hypotension (low blood pressure). Monitor the patient’s blood pressure — note what their blood pressure was before the epidural was administered to see if it is fluctuating significantly following administration.
It is commonly necessary to give fluids before administering the epidural. This helps to increase the intravascular volume and increase the blood pressure to minimize a block.
A spinal block differs from an epidural in that it is administered into the cerebrospinal fluid in the subarachnoid space. This is a one-time injection — there isn’t a catheter that will allow for the continuous administration of medicine.
Spinal blocks affect a much larger area of the body, eliminating pain/sensation between the nipples (T6) and the feet.
A spinal block is typically used for C-sections, so it is administered just prior to birth.
Side effects of a spinal block can include maternal hypotension, fetal bradycardia, and (maternal) headache. It may also increase the risk of maternal bladder and uterine atony (a failure of the uterus to contract following delivery, which is a common cause of postpartum hemorrhage).
Nursing care for patients getting regional analgesia/anesthesia
Nursing care includes administering IV fluids and positioning the mother on their side (relieving pressure from the uterus on the vena cava) to prevent hypotension and allow for optimal blood flow. For a patient preparing to undergo a C-section (and who must remain on their back), place a pillow under their hip.
Monitor the patient’s blood pressure and vital signs continuously, as well as the fetal heart rate.
Hi. I'm Meris. And in this video, we're going to be talking about different ways to manage pain during labor. I'm going to be following along using our maternity flashcards. These are available on our website, leveluprn.com. And I would definitely encourage you to pick up a set for yourself. If you already have one, I would invite you to follow along with me. Okay, let's get started.
So first up, we're going to be talking about non-pharmacological pain relief interventions. We talk about non-pharmacological interventions for pain all throughout nursing because it's very, very important. And there's lots of ways to help control pain. But I feel like this is one of those places where it's especially important because labor, typically, will last for a while, and it's a really strong and intense pain. So we need to find ways to help our patients manage it.
So one of the first ones is effleurage. Let's be honest, I don't know if I said that right. It's a French word and I don't speak French, but what it means is basically lightly stroking the abdomen. Typically, this is going to be in rhythm with a patient's breathing during contractions. So if you imagine, it's going to be this kind of light touch. The idea here is we're providing additional tactile stimulation to help distract the brain.
But this one is the one that I feel like I see the most, sacral counterpressure. So let's break it down. Sacral meaning of the sacrum, right, in the very low back, and counterpressure. We have pressure on the sacrum already, but it's from inside going out. So if I can provide counterpressure pushing back against that pressure, that can help to relieve some of that pain. This is especially helpful for your patients who are having back labor, so where they're feeling most of their pain in their backs. If you watched my last video, tell me in the comments if you will remember what type of fetal presentation can lead to back pain especially. It's not part of this content. I just want to see if you were paying attention.
And then, of course, breathing techniques. You probably have seen this in popular culture, the hee hee hoo, that sort of thing. Those are going to be breathing techniques. Important for a couple of reasons. It's a little bit meditative, right? It helps our patients focus on something other than the pain, but it also helps to make sure that our patients are breathing. When you are in pain, breathing is actually going to be more beneficial for you than holding your breath. Well, what is your initial reaction? Think about stubbing your toe. You go, "Oh." You're not going to be taking deep breaths. Very important that our patients continue to breathe during the time that they are in labor, right? So these sort of breathing techniques usually involve taking classes prior and having someone there to help coach the patient's breathing, but they can be very beneficial. There's many other examples here, and I'll let you take a look at them. But there are just some really great ways to help distract your patients or help to provide pain relief that are not related to drugs. And remember that our patients may say, "I want a natural labor," meaning unmedicated, right? And that's great, and we need to still be able to help them with their pain. And those are some great ways to do it.
So let's move on now to pharmacological measures. Now, of course, this is going to be really important to understand because this is where I can really hurt somebody, right, is by giving them the wrong medicine or something like that. Probably not going to hurt somebody by doing effleurage on their belly. But with medications, I could cause serious damage, so I would really focus on this stuff.
So we have systemic ways of relieving pain. Big ones are going to be opioids, right? We know that these are very strong and effective pain medicines in general, but they can be used also during labor. Then there's other things that we can give, such as antiemetics for nausea. We can also give benzodiazepines to help with some anxiety.
But really, I would focus on those opioids because that's targeting the pain itself. Now, because mom and baby are still linked through their circulatory system, baby will get some of the opioids as well. And that doesn't mean that we can't give it. It just means that we need to be aware to assess both mom and baby's well-being when giving opioids. Remember that the antidote for opioids is naloxone. Naloxone is the only antidote for acute opioid toxicity. And we're going to assess that because mom is having respiratory changes or changes in level of consciousness. Big one's going to be if I am not breathing enough. So usually, we say 10 or less than 10 breaths a minute. That is going to be our big sign there that we might have opioid toxicity.
There's other ways that we can relieve pain that you don't see as often elsewhere. Inhalation. So there are medications such as nitrous oxide, sometimes called laughing gas, which can be delivered through the inhalation route, so usually with a mask or something similar. These are really great because they're reversible immediately. So as soon as mom starts breathing regular air again, the effects are going to go away. This was very popular at one point. It is making a little bit of a comeback, and it is still very popular in some other countries as well. It's a great way to relieve pain for patients who don't want opioids. Maybe they just don't want to take them or they are in opioid recovery. But it's a really great option for helping to kind of give that patient a little bit of dissociation from the pain.
And then we have regional anesthesia. So these are going to be the things that you think of the most when you think of pain relief for labor. So regional, meaning it is going to affect a certain region of the body, not the whole body, which would be systemic. So regional, this is going to be something like your epidural or a spinal.
An epidural is going to be a catheter that is inserted into the epidural space, right? And it allows for medication to be administered into that space, and it's going to basically provide pain relief from the belly down. It's also going to cause some weakness, loss of sensation, loss of strength. So this is not something where I would want to have my patient have an epidural and then just leave them alone and never check on them, right? I wouldn't want to do that with any patient, but you understand what I'm saying. This is something where I need to make sure that my patient is being moved frequently, offered toileting, that kind of experience because I don't want her to be lying motionless in that bed and unable to move. Now, we also have spinals. And we'll talk a little bit more about that in the next card, but it is slightly different.
We have local infiltration. I would say that you're not going to see this as much, except for if the provider needs to do an episiotomy and make a cut or suture, a cut or a tear in the perineum. Then we would use lidocaine to locally infiltrate that area and numb it up.
And then we have the pudendal nerve block. So if you remember the pudendal nerve, that's going to be innervating the genitalia, essentially. So this is going to be providing pain relief in the low vagina, in the vulva, the perineum, in that sort of general area, but it's not going to affect the belly or any of those contraction pains. So this can be helpful also for patients who are having an episiotomy or some kind of local procedure in the genital region.
Now, this card here, we're talking more about epidural and spinal blocks. Now epidurals, like I said, it's going in the epidural space, typically between L3 and L4. But there's one big side effect that you just have to know because you need to be able to assess your patient, and that's going to be maternal hypotension. Any time you hear epidural, I need you to think blood pressure. I need to check my patient's blood pressure. So I need to know what their blood pressure was before. I need to know what it is now. And typically, we may even give fluids, IV fluids, before administering the epidural so that we can help to increase the intravascular volume and increase the blood pressure so that there is less of a block. This is going to provide that pain relief, usually from the level of the umbilicus down. But it's not going to necessarily get rid of all sensation. It may just kind of turn the dial down.
Now, a spinal block is a little bit different. This is actually going to be administered into the cerebrospinal fluid in the subarachnoid space. And this is a one-time injection. There's not a catheter where I can keep putting medicine in. It's a one-time injection, and this is typically used for C-sections. So it's a limited window that it's going to work, but it is going to take away pain and sensation from the nipples down. So much larger, right, of an area than the epidural from the belly down. So we're getting a lot more pain relief and an absence of sensation there. For me, personally, I felt no pain whatsoever, but I could feel pressure. So that was kind of a weird sensation. I could not move my feet. I could not feel any sort of severe surgical pain or anything. But when they did go to pull my children out, I felt a lot of pressure. So not pain but pressure. This also can cause hypotension in your patients. So remember, we're checking that blood pressure.
Now, if I saw that mom just got an epidural or spinal and started to have hypotension, what can I do about it? Well, we talked about one intervention already, right? IV fluids need to increase. Give a fluid bolus that's going to get their blood pressure back up. But another thing we can do is reposition the patient, right? Optimal blood flow. So we're going to put the patient on their side, and that's going to relieve that pressure of the uterus on the inferior vena cava. But also, I can't really do that if my patient is getting a C-section right now. So we may just have to place a pillow under the hip. And we always want to have a pillow under the hip because of that compression of the vena cava.
All right. I hope that review was helpful. If it was, please go ahead and like this video so that I know. And if you have a great way to remember something, I really want to hear it. So please be sure to leave me a comment. I hope I see you in the next one. Happy studying.
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