CH 17 Pain Management during Labor – Flashcards
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CH 17 Pain Management (OB)
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CH 17 Pain Management (OB)
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Pain
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is personalized for each individual. If hyperventilating they need to breath into paper bag. it is a common occurance. If no brown bag is available. Ask pt to cup their hands over their face.
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Neurologic
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pain if first stages are transmitted via T1 to T 12 spinal nerve.
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Referred pain
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occurs when the pain originates in the uterus and radiates to the lower abdominal wall, lumbosacral area, back, iliac crest, gluteal area, thighs, and lower back. Some may always have pain in their backs.
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Second stage -somatic pain
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intense, sharp, burning, and well localized.
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Perception
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NTK: what ever patient tells you pain feels like. Key point. Pain is subjective.
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Factors influencing pain response
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Physiologic factors- how big is the baby, back injuries Culture (Page 388) - READ THIS Anxiety - hearing horror stories from friends Previous experience Gate-control theory of pain Comfort Support (Table 17-1) family supportive providing calming environment. Environment
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Even if mothers do not attend a birthing class the nurse can still
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assist with simple breathing and relaxation. Tx- hyperventilation with brown bag
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Lamaze
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birthing method focusing on *partner-coached breathing techniques* and relaxation with the woman panting and using outside focal points during labor. Blow out your candles. Hee hee ha ha. Psychoprophylatic method.
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Nonpharmacologic Managementof Discomfort
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Childbrith preparation methods Relaxing and breathing techniques Focusing and relaxation Effleurage and counter pressure Music Water therapy (hydrotherapy) TENS, Acupressure, Acupuncture BOX 17-2 (10-2)
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Bradley method
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*(all natural labor)* a method that prepares a mother for natural childbirth by providing education and exercises and nutrition and techniques of *breathing and relaxation* (with the assistance of the father). *NO PAIN MEDS*
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Systemic analgesic
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is major pharmacology method of relieving pain of labor when people trained in epidural analgesic are unavailable.
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Why would you use opioid cautiously with heart disease?
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Ideally birth should occur less than one hour or more than 4 hours after administration of an opioid analgesic so that Neonatal depression is decreased.
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Medication Guide Pt 1
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Opioid Agonist Analgesics *FENTANYL CITRATE (SUBLIMAZE)* *SUFENTANIL CITRATE (SUFENTA)* Action- Opioid agonist analgesics that stimulate both mu and kappa opioid receptors to decrease the transmission of pain impulses, rapid action with short duration (0.5-1 hr IV; 1-2 hr epidural); sufentanil citrate has a more potent analgesic action than fentanyl citrate with less passage across the placenta to the fetus.
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Medication Guide Pt 2
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*Indication* Because of their short duration of action when given intravenously, they are most commonly administered epidurally or intrathecally, alone or in combination with a local anesthetic agent, to relieve moderate to severe labor pain and postoperative pain after cesarean birth.
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Medication Guide Pt 3
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Dosage and route *Fentanyl citrate*: 25 to 50 mg IV; 1 to 2 mg with 0.125% bupivacaine at rate of 8 to 10 ml/hr epidurally *Patient should be lying on her side* *do not give less than 1 hour before hour* *Sufentanil citrate*: 1 mg with 0.125% bupivacaine at rate of 10 ml/hr epidurally *Adverse effects*Dizziness, drowsiness, allergic reactions, rash, pruritus, maternal and fetal or neonatal respiratory depression, nausea and vomiting, urinary retention
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Analgesia and anesthesia
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Systemic analgesia Opioid agonist analgesics ( page 398)- Demerol-Dilaudid Opioid agonist-antagonist analgesics- Stadol and Nubain Opioid antagonists (Narcan)- page 400
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Signs of Potential Complications of Opioids Abstinence Syndrome
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Yawning Anorexia Rhinorrhea Tremors Chills and hot flashes Violent sneezing
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what do you not give to opioid dependent women?
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opioid agonist (narcan). It will bring on this Opioids Abstinence syndrome. opioid withdrawal.
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Opioids
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can inhibit uterine contractions so do not start till in a good labor pattern. Opioids decrease heart, respiratory rate, and blood pressure which affects fetal oxygenation. *(opioids can inhibit labor - normal is contractions every 2 mins lastly 60 secs)*
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Meperidine
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is the most commonly used for women in labor, It works by relaxing the cervix and overcomes inhibitory factors, Should be used with caution in women with heart conditions it causes tachycardia. If causes CNS problems with baby Narcan should be administered to reverse respiratory depression.
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neonatal narcosis
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Opioid produced CNS depression in infants
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Nerve block analgesia and anesthesia
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Local perineal infiltration anesthesia Pudendal nerve block Spinal anesthesia (block) Hypotension - Emergency ( pg 403) Regional for emergency situations.
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Maternal hypotension
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may occur from anesthesia or analgesia. TX: lateral position, administer oxygen and increase IV fluids.
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Local perineal infiltration anesthesia
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used when episiotomy is to be performed or when lacerations must be sutured afterbirth in woman who *does not have anesthesia block.* Lidocaine
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Pudendal nerve block
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late in second stage- useful for episiotomy, vacuum, forceps to facilitate birth. *pelvic area* *Does not relieve pain from the contraction.* It does relieve pain the lower Vagina, vulva, and perineum. Relieves for couple hours. * helps numb area late stage & to help open up pelvic area* *risk of sticking baby because has to work around the head to inject the local*
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Spinal anesthesia or block
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injected thru 3,4, or 5th lumbar interspace into subarachnoid space. Used for elective & emergent c-sections. (*sitting or lying for procedure)* - block takes affect in about *5 to 10 minutes* & continue to *creep upward in about 20 minutes*, *last about 1 to 3 hours.* *block should go up to nipple level*
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Anesthesiologist
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should wear mask during the procedure. (marked hypotension, impaired placental perfusion and ineffective breathing pattern may occur during spinal anesthesia) Must have bolus of 500 to 1000 LR or NS prior to spinal or epidural - decreases risk for hypotension)
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After induction of anesthesia
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maternal v/s q5-10 min., along with FHT. Considered hypotension if below 100 mm/hg or 205 reduction of the baseline.
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Leakage of CSF fluids from the site of the dura mater
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is thought to be a causative factor of *Postdural puncture headache ( PDPH).* TX: oral analgesics, methylxanthines ( ex: IV caffeine or theophylline) or an epidural blood patch.
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Hispanic Patients during labor
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quiet during much of the labor until the second stage. Hit dilation 10 the patient will verbalize more, ventilate their pain, chant, scream.
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Gate-control theory of pain
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endorphines released but stimulations has to happen to open the gate. LIke with effleurage. table 10-1
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Focus point breathing
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A therapeutic communication technique where nurse focuses birthing mother to breathing.
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Grantly Dick-Reed Method
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persistent, progressive relaxation. Relaxing each muscle group through the body
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Stadol
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A pt. may have _______ 2-3 hours before delivery
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Narcan
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Opioid antagonists can give to baby at delivery or to mom before delivery, given to reverse respiatory depression caused from an opiate page 400
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Epidural anesthesia/analgesia Cont.
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Lumbar epidural anesthesia/analgesia Combined spinal-epidural analgesia (received to much) Epidural and spinal opioids TENS units can provide impulses to release endorphins. ( box 17-6)
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Epidural is contraindicated
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*in women with low platelets.* •Active or anticipated serious maternal hemorrhage (Acute hypovolemia leads to increased sympathetic tone to maintain the blood pressure. Any anesthetic technique that blocks the sympathetic fibers can produce significant hypotension that can endanger the mother and baby.) •Coagulopathy (If a woman is receiving anticoagulant therapy or has a bleeding disorder, injury to a blood vessel may cause the formation of a hematoma that may compress the cauda equina or the spinal cord and lead to serious CNS complications.) •Infection at the injection site (Infection can be spread through the peridural or subarachnoid spaces if the needle traverses an infected area.) •Increased intracranial pressure caused by a mass lesion. •Maternal refusal. •Some types of maternal cardiac conditions.
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contraindication to subarachnoid and epidural blocks.
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( page 406)
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general anesthesia.
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is rarely used for uncomplicated vaginal birth and is infrequently used for elective cesarean birth. It may be necessary if a contraindication to a spinal or epidural block exists, if regional anesthesia (e.g., epidural or spinal block) is ineffective, or if indications necessitate rapid birth (vaginal or emergent cesarean) without sufficient time or available personnel to perform a block. In addition, being awake and aware during major surgery may be unacceptable for some women having a cesarean birth. The major risks associated with general anesthesia are difficulty with or inability to intubate and aspiration of gastric contents
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Expected outcome of preparation for childbirth and parenting:
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"education for choice"
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Informed consent on medication
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page 408
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Spinal blocks are easier
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*for anesthesiologists to hit the spot. Epidural is more subjective and does not go to nipple line.*
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Nonpharmacologic pain and stress management strategies
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alone or in combination with pharmacologic methods manage discomfort
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*EPIDURAL*
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*must be 4cm* first n/I should be to check dilation, not to call physician. Give opiates if not 4cm. *if
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If patient continues to have hypotension, what are the nursing interventions to be given?
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*lie patient on her side* *increase the fluids- open IV line* (make sure it is in a separate line than pitocin) *administer O2* *these are standards orders, you do not have to have an extra order*
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How will we know if mom is ready to move around have epidural?
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mom's should be able to raise or move legs. there may be some numbness but it is ok as long as they have some *flexion in both legs.* They then will go to mother-baby unit. Will be transported by stretcher.
