Chapter 13: Promoting Patient Comfort During Labor And – Flashcards

**Local anesthetics: used in obsetrics may produce regional analgesia, which provides some degree of pain relief and motor block** **Anesthesia: Provides complete pain relief and motor block.** **Regional Anesthesia: a temporary and reversible loss of sensation is produced by injection of an anesthetic agent (a local anesthetic) into an area that brings the medication into direct contact with the nervous tissue.**

A regional anesthetic blocks sodium and potassium transport in the nerve membrane, causing stabilization of the nerve(s) in a polarized resting state, which prevents the initiation and transmission of nerve impulses. The nurse should ensure that emergency measures, including epinephrine, antihistamines, and oxygen are readily available in all patient areas where these medications are used. **Regional anesthetic blocks commonly: epidural, spinal or combined epidural-spinal.** Epidural blocks may be administered for analgesia during labor and vaginal birth and for anesthesia during cesarean birth. Combined epidural-spinal block may be used---the epidural provides analgesia for labor; the spinal provides anesthesia for birth or analgesia after the birth. During 1st stages of labor, an epidural relieves pain by blocking the sensory nerves that supply the uterus.

**Local perineal infiltration anesthesia is used to provide pain control when an episiotomy is to be performed or when suturing of lacerations is necessary in a patient who does not have regional anesthesia.** Epinephrine which causes vasoconstriction, may be added to the anesthetic agent to intensify the anesthesia effect to minimize bleeding and prevent system absorption.

**Pudenal nerve block provides pain relief in the lower vagina, vulva, and perineum.** Should be administered 10-20 minutes before perineal anesthesia is needed an may be used late in the second stage of labor. Anesthetic effect diminishes or completely removes the maternal bearing-down reflex. May be used during the third stage of labor for laceration repair.

**Spinal anesthesia block involves the injection of a solution containing a single local anesthetic or an anesthetic combined with fentanyl through the 3rd, 4th, 5th lumbar interspace into the subarachnoid space where it mixes with CSF.** **After administration of solution, PATIENTS ARE IMMEDIATELY PLACED IN A SUPINE POSITION with a left lateral tilt to enhance a cephalad spread of the anesthesia.** Advantages: -Easy to administer -Immediate onset -Requires smaller volume of medication -Excellent muscle relaxation -Maintenance of maternal consciousness -Associated with minimal blood loss **Because uterine contraction sensation is lost, patient must be instructed when to bear down during vaginal birth.**

-Proper positioning of patient in a lateral or sitting position with the back curved outward to widen intervertebral space. -After injection of solution, patient is positioned upright to allow downward flow of the solution to a prove a lower level of anesthesia suitable for vaginal birth. -** FOR A C-SECTION, PATIENT IS PLACED IN A SUPINE POSITION WITH HEAD AND SHOULDERS SLIGHTLY ELEVATED WITH A WEDGE PLACED UNDER ONE OF THE HIPS TO DISPLACE THE UTERUS**

Maternal hypotension Decreased placental perfusion Ineffective breathing patterns Before administration, patient's fluid balance is assessed, and IV fluids are administered to reduce the potential for sympathetic blockade( decreased cardiac output that results from vasodilation with pooling of blood in lower extremities). After administration of anesthetic, patients BP, pulse and respirations and FHR must be taken and documented every 5-10 mins. Post-dural puncture headache is a complication that may develop within 48 hours after puncture, is believed to occur from leakage of CSF. Typically intensifies when the patient assumes in the upright position after being supine. Accompanying symptoms include auditory (tinnitus), visual (blurred vision), problems. Interventions: oral analgesics, bedrest in a darkened room, caffeine and hydration. If not effective, 10-20 mL of the patient's blood patch is slowly injected into the lumbar epidural space. A clot forms in the hole in the dura matter around the spinal cord preventing leakage of CSF.

Maintain bedrest for 24-48 hours Apply cold packs to the area for pain relief Increase oral fluids -Avoid analgesics that affect platelet aggregation (NSAIDs) for two days Observe for signs of infection @ the site Observe for signs of neurological complications (pain, numbness, tingling in legs, and difficulty with ambulation)

Injection of local anesthetic such as bupivacaine, an opioid analgesic such as fentanyl or sufentanil, or both into the epidural space (L4 and L5) provide pain relief from uterine contractions and vaginal or C-section.

Most commonly used method of pain control during labor Advantages: Maternal relaxation, enhanced comfort, and pain relief, and an ability to remain alert and participate in the birth, little blood loss, respiratory reflexes remain intact, no delay in gastric emptying, partial degree of motor paralysis.

Advantageous for patients with diabetes, heart disease, pulmonary disease, and in some cases, gestational hypertension because they essentially eliminate the pain associated with labor and thus reduce the maternal stress associated with labor discomfort. Can be used with preterm pregnancies because of minimal effect on fetus.

**Maternal hypotension** **preload patient with rapid infusion of IV fluids which increase blood volume and cardiac output prevents this complication** VERY IMPORTANT** Nurse should be in continuous attendance after administration of epidural anesthetic. **Detect hypotension: BP should be monitored for the first 20 minutes after each new injection. BP should be monitored entire time anesthetic is in effect to ensure systolic does not drop below 100 or decrease 20 mm Hg in a hypertensive patient.**

lengthened duration of labor and increased requirements of oxygen and oxytocin and limited mobility because of medical interventions such as IV infusion. P/t may experience orthostatic hypotension, dizziness, sedation, and lower extremity weakness. Accidental injection into a blood vessel can cause CNS effects including bizarre behavior, disorientation, excitation and convulsions. Common SE >Orthostatic Hypotension >Dizziness >Sedation and lower extremity weakness >Ensure that full sensation has returned and patient is able to control her legs before ambulation >Intense pruritis (may need diphenhydramine) >Temporary elevation in temperature > Shiver response (physiological response- body believes it is colder than it actually is)

Assessment of maternal bladder to avoid bladder distention. Bedpan should be offered initially to minimize the potential for UTI. Actions: assisting patient in an upright position on the bedpan, raising the head of the bed to support the back, and providing privacy. Urinary retention and stress incontinence may also occur STAT postpartum. **Intense pruritus (itching of skin) is a common side effect of opioid use; this symptom is usually treated with benadryl**. **Common practice has become to insert a foley with the epidural. Wait until loss of sensation to make it more comfortable for patient**

Pain relief is IMMEDIATE Opioid such as fentanyl or sufentanil is injected into the subarachnoid space to rapidly activate opioid receptors Patients may ambulate, but often choose not to because of fatigue, sensation of weakness in legs, and fear of falling. Should be encouraged to change positions frequently and assisted in upright position to enhance bearing-down efforts. GREATER RISK FOR INFECTION AND POST-PUNCTURE HEADACHE

This method eliminates the effects of local anesthesia Advantages: No maternal hypotension or alteration in vital signs Aware of contraction but does not feel pain More often used for post-op pain control Early ambulation is associated with enhanced bladder emptying, more rapid return of peristalsis, and decreased risk of respiratory complications and thrombophlebitis.

On going nursing assessments essential--should have continuous pulse ox on >Monitor and record respiratory rate every hour X 24 hours >Monitor saturation X 24 hours >If respiratory rate drops below 10 bpm or O2 saturation Pruritus >N/V >Urinary Retention >Delayed Respiratory Depression

Induced unconsciousness for unplanned, rapid (emergency) C-section. Major risks: -increased maternal blood loss r/t to uterine relaxation, hypoxia, and possible inhalation of vomitus during administration. -Gastroesophageal valve may be displaced, allowing upward passage of stomach contents -Not recommended when fetus is considered high risk, especially in preterm birth. Nurse ensures: -IV infusion is in place and if time permits, premedicates her with an oral antacid (sodium citrate, citric acid/sodium citrate, or effervescent aspirin/citric acid) to neutralize the acidic contents in the stomach. -Some anesthesiologists order zantac or tegamet to decrease acid production and reglan for gastric emptying -Before adminstration, a wedge is placed under the right hip to displace the uterus to prevent aortocaval compression and decreased placental perfusion) Thiopental sodium (barbiturate) is usually given. This agent causes rapid induction of anesthesia and minimal postpartal bleeding. Succinyl choline is a muscle relaxant used to facilitate the passage of the endotracheal tube. To prevent gastric reflux and aspiration before the woman fully loses consciousness, the nurse may be asked to assist with applying cricoid pressure. Recovery room care is focused on the maintenance of an open airway, continuous monitoring of cardiopulmonary function, and prevetion of postpartum hemorrhage. Nurse offers emotional support, answer questions concerning the birth provides updates regarding maternal/neonatal status, and assess the patient's readiness to interact with her newborn.

Nurse NEVER assumes that all pain experiences during labor is uterine in origin. Instead a physical assessment that includes an evaluation of characteristics of the patient's pain (location, intensity, quality, frequency, duration, and effectiveness of all relief measures) must be performed. Physical Examination includes assessment of maternal vital signs, fetal heart rate and pattern, uterine contractions, amniotic membranes and fluid, cervical effacement and dilation, and fetal descent. Nurse also evaluates the patient's hydration status and palpates for bladder distention. Maternal assessment for evidence of allergic reactions to meds include vital signs, respiratory status, platelet and WBC count and observing for integumentary changes. Lsb data are analyzed to identify anemia, coagulopathy or bleeding disorders or infection. Fetal status is also assessed and non-reassuring changes in heart rate or pattern are promptly reported to the patient's primary HCP.

Anxiety r/t lack of knowledge about labor experience Ineffective coping r/t to the combination of uterine contractions and anxiety Acute pain r/t to the processes of labor and birth Expected outcomes of nursing interventions include: Patient verbalizes understanding of what is happening with her labor; she is able to identify the beginning and ending of contraction and demonstrates confidence instead of confusion with the labor process. Patient verbalizes confidence in her ability to participate actively in her labor experience; she demonstrates effective breathing techniques, guides her labor support person in providing effective comfort measures, readily engages in position changes and other strategies to enhance comfort and remain in control; and expresses confidence in her labor nurse and other care providers The patient verbalizes that with the methods used, her pain has been relieved to a tolerable level; she is responsive to questions and suggestions and demonstrates an ability to deal with her contractions. A plan of care individualized to each patient is developed and modified as needed. A collab. approach that includes the patient, her primary care provider, and labor support person is important in ensuring that safe effective care is provided that promotes a positive child-birth experience for the woman and her family.

Place patient in a lateral position or use a wedge under the hip to displace the uterus, elevate the legs Maintain or increase IV infusion rate, according to institution protocol Administer oxygen by face mask at 10-12 L/min according to protocol. Alert the primary care provider, anesthesiologist, or nurse anesthetist. Administer IV vapopressor according to protocol if above measures are not effective Remain calm, offer reassurance, and continue to assess maternal BP and FHR every 5 mins until stable or per order from provider.

Affected Area: Perineum Used: Immediately before birth for episiotomy, after birth for repair of lacerations Nursing implications: Assess patient's knowledge and understanding; provide information as needed. Observe perineum for bruising, discoloration, hematoma, or signs of infection during the recovery period

Affected area: Perineum and lower vagina Used: Late in the second stage for the episiotomy, forceps, or vacuum extraction, during third stage for repair of episiotomy or lacerations Nursing implications: Assess patient's level of knowledge and understanding; provide additional information as needed. Monitor for signs of infection, urinary retention.

Affected area: Uterus, cervix, vagina, and perineum Used: First stage for both elective and emergent cesarean births; low spinal anesthesia block may be used for vaginal birth--not suitable for labor Nursing Implications: Assess patient's level of knowledge and understanding and level of pain relief; provide additional information as needed. Monitor maternal vital signs (hypotension most common complication) and FHR status. Assess for urinary retention, itching, nausea, vomiting, headache. Monitor site for leakage of spinal fluid or development of a hematoma

Affected area: Uterus, cervix, vagina, and perineum Used: First and second stages Nursing implications: Assess patient's level of knowledge and understanding and level of pain relief; provide additional information as needed. Monitor maternal blood pressure--major complication is hypotension---and FHR status. Provide ongoing support. Assess for urinary retention, itching, nausea, vomiting, and headache.

Affected area: uterus, cervix, vagina, and perineum Used: Spinal analgesia may be administered during the latent phase for pain relief. **Epidural is given when active labor begins** Nursing implications: Perform assessments as listed above for spinal and epidural anesthesia.

-Shaped by past experiences -Assessing pain >Physiological, psychological indicators >Patient responses >May be intensified by fear, anxiety, fatigue **PAIN IS WHATEVER THE PATIENT TELLS YOU**

-Highly Personal and subjective -Affected by gender, culture, ethnicity, and past experiences -**Physiological/affective expression** >Increased catecholamines >Increased BP & HR >Altered respiratory pattern

Physical >Fatigue Physiological >Freedom to ambulate >Circulating endorphins (act as opiates) >Demonstrated with spontaneous, natural childbirth Psychological >Anxiety, fear, previous experience >Support systems, childbirth preparation Environmental >Need privacy, comfort and sense of security

Maternal position and movement >Gravity assists in fetal descent down the birth canal >Birthing ball >Ambulation Breathing techniques: >Slowed respirations to enhance relaxation >**BLOWING METHOD** Music: >Releases endorphins which provides comfort and decreases maternal anxiety Relaxation Techniques: >Frequent assessment of pain Other attention-focusing strategies: >Guided imagery

**Effleurage** >Gentle stroking performed with contractions **Counterpressure** >**Especially effective with lower back pain** Therapeutic touch: >Based on the body's energy fields >Enhances relaxation & reduces anxiety and pain Healing Touch: >Also based on the body's energy fields > Helps align and balance energy field and enhances the body's ability to heal itself

Hydrotherapy Hypnotherapy Aromatherapy Application of heat and cold Biofeedback, TENS, Intradermal water block Acupressure/Acupuncture

Timing: >Early labor usually nonpharmacological measures are affective >As labor intensifies, pain increases > Medication should be provided before the pain intensifies to the point that catecholamines are released and labor is prolonged Nonpharm. and pharm measures: >Provide pain relief >Enhance patient comfort and sense of control over her situation >Promote a positive birthing experience Informed Consent: >Options available & advantages/disadvantages >Patient must give consent without coercion or manipulation of the care provider

Sedatives and Antiemetics >Relieve anxiety and induce sleep >Mainly used during latent phase of labor >Can cause respiratory depression in the infant Barbiturates (Seconal) >Rarely used during labor >Fast-acting (lasts 3-4 hours) > If given with analgesic, pain is increased > Causes respiratory and vasomotor depression Benzodiazepines (ativan and valium) >When given with opioids, enhances pain relief and decrease n/v H-receptor Antagonists: >Blocks the action of histamines at the receptor sites causing drowsiness Promethazine >**Cross the placental pathway and may decrease FHR variability** >**Binds with bilirubin binding sites in the neonate (Increase risk of jaundice)** Hydroxyzine (Vistaril) >Used during early & prodromal labor >Exerts a sedative effect Diphenhydramine > Sedative and antiemetic effect > Given during early labor

Analgesia- relief from pain Anesthesia- partial or complete loss of sensation with or without the loss of consciousness Determined by stage of labor and method of birth anticipated Nurses role: >Monitor the progress of labor >Identify cues that suggest a patient would benefit from administration of analgesic medication as prescribed by provider

Opioid agonist analgesics >Stimulate receptors to act (hydromorphone, meperadine, fentanyl, sufentanil) Nursing Considerations: > Monitor vitals, FHR & contraction pattern before, during, and after administration of meds >Best given 4 hours before birth to decrease neonatal respiratory depression >Delay bowel and bladder elimination >N/V is a common side effect

Stimulate some receptors to act while blocking or causing a weak stimulation in others (Nalbuphine) and butorphanol (Stadol) **MORE COMMONLY USED THAN OPIOID AGONISTS** Monitor vitals, FHR & contraction pattern before, during, and after administration **Never give to women with an opioid dependence---can illicit withdrawal symptoms in both mother and baby** Opioid Antagonists: >Blocks receptors or medications designed to activate the receptor (Naloxone/Narcan)

Most common side effect Prevention >Preload IV fluids then continuously until delivery >Use dextrose free solution to decrease risk of fetal hyperglycemia with rebound hypoglycemia Requires constant nursing attendance: >Monitor BP continuously x 20 after each new injection of anesthetic >Systolic BP should not fall below 100 mmHg or decrease 20mmHg in a hypertensive patient Monitor Vital Signs