Factors Affecting Pain Perception: Stages of Labor (Nursing)

00:01 So, let's break down the perception of pain by the stages of labor.

00:06 So, we want to know what physiology is contributing to the pain.

00:12 So, when we think about sources of pain in the first stage of labor.

00:16 So, remember, when we talk about the first stage, we're saying, zero centimeters dilated all the way up to 10.

00:23 So, in the first stage when we're experiencing cervical dilation, know that every time that cervix begins to open just a little bit more, it sends pain stimulus.

00:35 So, every time the cervix opens, we have pain.

00:38 And the more it dilates, the more painful it is. So, that's one source of pain.

00:43 The next thing we want to think about is the fact that the uterus is contracting.

00:47 So, when the uterus contracts, we're decreasing oxygen flow.

00:51 And that decrease of oxygen also known as hypoxia can also contribute to pain during first stage.

00:59 Also, stretching of the isthmus.

01:01 So, think about and I'm using these words just to kind of help you think about what's actually going on. We're stretching the lower uterine segment.

01:08 And so, that stretching also can cause discomfort.

01:12 And then, if you think about putting all of that together, the movement of the uterus, the movement of the baby, and all the pressure that that can cause to the surrounding structures, you begin to get a picture of where the pain may come from during the first stage of labor.

01:28 Now, let's break it down just a little bit more in terms of what's going on as we progress through that first stage.

01:34 So, in the latent phase, this is early in labor, so, remember, this is zero all the way up to five or six centimeters, the contractions may feel more like a backache or a little bit of pressure or gas.

01:46 Granted, pretty significant gas but gas nonetheless or cramps.

01:51 So, in the scheme of how this is going to be, this is going to be mildly uncomfortable.

01:56 Okay, the client in this case might feel very excited because labor's happening, a baby is coming, we've been waiting for a long time.

02:05 They may be a little bit anxious but generally speaking, they may be able to sort of continue on their activity that they've already been doing.

02:11 Some clients will be at work and they may stay at work or taking care of other family members during the latent phase.

02:18 And even though they're experiencing contractions, they're still able to carry on regular activity.

02:23 The contractions will overtime however become stronger and they will become more frequent.

02:29 Remember our 511 rule of knowing when someone's in true labor.

02:33 They may experience discomfort in the back or in the lower part of the legs.

02:38 They may find that they're experiencing some nausea and they may have some vomiting and for some clients, this is the trigger that it's time to come to the hospital.

02:47 Now, thinking more from a psychosocial standpoint, the client may feel some discouragement as we move through the active phase.

02:56 So, contractions are going to be stronger, things are going to become a little bit more uncomfortable and that realization sets in that it might be a while, a feeling like this, and some clients might say, you know what? I'm not sure if I can do that. This is when the nurse can really jump in and we can encourage them and we can encourage their support person to encourage them to keep going.

03:17 The client may become a little bit more serious.

03:20 So, at the beginning and the latent phase, we're quiet but we're excited and happy.

03:25 As the active phase begins to pick-up, so, thinking about that six centimeter point, the client may become a lot more serious, a lot more introspective and a lot more preoccupied with self.

03:37 Things are not feeling as comfortable as they were perhaps a few hours ago.

03:41 As we get to the end of the first stage, so, thinking about getting to eight, nine, and 10, we're in a transition phase. The contractions are really strong.

03:51 They're really close together. They're long.

03:53 The client may begin to experience some shaking or tremors.

03:57 That's very typical. The contractions may have more than one peak and when we say peak, the strongest point.

04:03 So, we might find that we have a peak, a little bit of relaxation, and then, another peak and a little bit of relaxation and then, another peak all as a part of one big contraction which feels about as fun as that just sounded.

04:15 They may have difficulty concentrating or a feeling of panic because the contractions are so much stronger and longer.

04:22 And absolutely, the nausea and vomiting may be a little more intense here at the end.

04:27 So, we always want to keep that encouragement going for our clients because this is hard work.

04:31 That's why it's called labor. They may feel exhausted or overwhelmed or want to give up.

04:37 And I've had clients say, "You know what? I'm not doing this. I'm going home." Even though a baby's coming. It happens.

04:44 So, we always want to be encouraging and calm and listening.

04:48 As we get to the end of the first stage, remember, we're eight, nine, 10 centimeters dilated.

04:54 Relaxation gets really tough.

04:57 So, the cervix is opening and every time the cervix opens just a little bit more, it sends pain sensation.

05:04 So, it's important for the nurse to continue to remind the client they're doing a great job and encourage them to take a deep breath and encourage them to continue to breathe and let them know that they absolutely are going to be successful.

05:18 And not just the nurse but encourage the support person to also provide that support.

05:23 That's why they're there. Let's move on to second stage.

05:27 So, now, we're at the point where the cervix is completely dilated and the client might be ready to push.

05:33 So, we're still going to have hypoxia of the muscles.

05:36 So, that still continues as it did during first stage.

05:39 We're also going to have distention of the vagina and the perineum.

05:43 So, remember, during second stage, Cletus the Fetus is trying to make their debut.

05:48 So, the baby has to descend into the vaginal vault and that's going to push those tissues out and that's going to feel a little tight and like lots of pressure.

05:59 We're going to have pressure both on the rectum and sometimes, on the thighs and into the legs.

06:04 So, this is going to be something you may hear the client actually say.

06:08 I'm feeling pressure in my bottom like I have to go to the bathroom.

06:12 Okay, they may be tired but guess what? When you get to push, sometimes you get a burst of energy that says, "Hooray, this is coming to an end." So, they may have been super tired before but all of a sudden, a second wind comes out and they're ready to push which is great.

06:30 Again, remember, pressure on the rectum and on the perineum is normal and you want to remind the client that they're going to feel that because that feels very scary.

06:39 So, it feels like you need to go to the bathroom, so, think about the fact that you may feel that while you're in a bed or standing up and that's not something that really computes well with our brain.

06:51 So, we want to make sure the client knows, this is normal and you're doing great.

06:56 They may also experience an uncomfortable, uncontrollable urge to actually begin to push.

07:04 And this is good. So, as the baby descends into the vagina, their baroreceptors there that send the message to the brain, "Hey, Cletus is coming. Time to push." So, that's a really wonderful thing. It's not so wonderful when your client comes in for a visit and they're in the bathroom and that uncontrollable urge to push happens while they're in the bathroom and you haven't finished your admission assessment.

07:27 That's not the best time. But it can happen.

07:30 So, make sure you're using your listening ears.

07:33 There may be a sensation of bulging or splitting or stretching as the baby really gets to the very end of second stage.

07:40 So, if you remember those pictures from our conversation on labor when the baby begins to crown and the perineum is stretched around the baby's head, the mom or the birthing person may feel that and that doesn't feel that great but it does mean that the end is near.

07:58 There may also be an intense back ache as the baby begins to descend into the pelvis.

08:02 When we get to third stage, the baby has come out which is wonderful but the work is not done.

08:10 So, in third stage, we await the delivery of the placenta.

08:14 So, in order to facilitate that, the uterus is going to contract and it's going to contract really hard.

08:20 Now, at this point, it's not important to have a rest in between the contractions because, well, Cletus is no longer in the uterus.

08:29 So, the uterus is actually going to begin to contract and those contractions are going to become longer and closer and closer together until the point where the uterus actually stays contracted.

08:40 Those contractions because they're stronger, remember the hypoxia that happens, we're going to have pain from that. And what are we doing during this process? Often, the provider is massaging the fundus.

08:52 So, massaging a uterus that's already working really hard sometimes doesn't feel so great.

08:58 So, sometimes, the fundal massage may also be a source of pain in the third stage.

09:03 And finally, when the placenta finally delivers, it's a fairly large piece of tissue.

09:10 And so, just the passing of that placenta through the vagina and out of the body sometimes will cause a quite a bit of pressure and that may be uncomfortable as well.

09:20 Now, during the third stage, the nice thing is that Cletus is out and hopefully, we're doing skin to skin care.

09:26 Maybe we're beginning to breastfeed and that may offer some distraction from all of those sources of pain that we just talked about.

09:34 So, that's a good thing. But often, the birthing person will still feel that increase in pain or they may stop breastfeeding to say, "Oh, I'm feeling some cramping." And that's normal.

09:44 Again, encouragement is going to be key.

09:46 Another thing to think about in terms of third stage pain is a reminder that with every delivery, the afterbirth pains get a little bit stronger.

09:57 The uterus has to work extra hard in order to get down to a non-pregnant state.

10:02 So, a reminder of that for the multiparous birthing person is really important.

10:07 And finally, thinking about pain during repair of a laceration.

10:11 If the client has had a tear or maybe they've had an episiotomy, this is going to be repaired during the third stage.

10:18 So, being mindful of the fact that this is a needle that's going to go in to repair this tissue and that can also be a source of pain.