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Chapter 17 Pain Mgmt
Pain Management During Labor
| Question | Answer |
|---|---|
| What is pain? | Whatever and whenever the patient says it is |
| What causes pain with contractions? | -Anoxia to muscle fibers -Stretching of cervix and perineum -Afferent nerves stimulated activated by chemical, mechanical, or thermal stimuli |
| What does PAIN stand for? | P-purposeful A-anticipated I-intermittent N-Normal |
| What are the sources of discomfort in stage 1? | -Cervical changes (dilation and effacement caused by ctx) -uterine ischemia -visceral pain |
| Description of pain and where in stage 1? | -Pain can be local and referred -May be felt as intense burning, stretching sensations -discomfort in back, flanks, and thigh |
| What is uterine ischemia? | decreased blood flow and local O2 deficit--> result from compression of the arteries supply the myometrium during uterine ctx |
| What is referred pain in stage 1 discomfort? | pain originates in uterus and radiates to abdominal wall, lower back, etc |
| What are the sources of discomfort in stage 2? | -some as stage one plus descent of the fetus -perineal stretching and distention -fetal pressure on other structures (bladder and rectum) |
| What can be done in stage 2 discomfort to reduce pain intensity? | Bear down |
| What type of pain is in stage 2? | somatic pain (intense, burning, local, sharp) and caused by stretching and distention of perineal |
| What are the sources of discomfort in stage 3? | -uterine ischemia, contracting 'afterpains similar to early labor' |
| What is the physiology of pain? SEE POWERPOINT | -Pain impulses travel along large&small sensory fibers to the spinal cord -Pain from uterus, cervix, & pelvic joints travel on small fibers; skin impulses travel on large fibers -pain impulse then travels up spinal cord to cerebral cortex where its pain |
| What is the pain cycle? | --> lactic acid--->pain---> tension ---> contracting muscle---> |
| What impacts pain perception? | -Knowledge -Culture -Past experience -Anxiety -Fear -Sense of control -Confidence |
| How does severe anxiety affect pain? | ^anxiety ->^fear-> ^muscle tension -> decreased uterine ctx effectiveness --> ^discomfort --catecholamine increased secretion decreases blood flow and increase muscle=increased pain |
| What is Gate Control Theory? | Pain travels along sensory nerve pathways to the brain but only a limited number of sensations can travel thru these nerve pathways at one time. |
| Gate control therapy Pain can be stopped at three points... which are? | -Peripheral end terminals -Synapse joint -Paint the impulse is interpreted as pain |
| Gate Control Theory How is pain stopped at the three points? | -Naturally occurring endorphins -Add stimulations such as massed (impulse from large fibers travel faster than small fibers) -Block transmission to spinal neurotransmitters -Distract the cerebral cortex with imagery, yoga, hypnosis |
| Gate Control Theory What are some distractions that can be taught? | massage, hair stroking, music, focal points |
| What are non-pharmacologic methods can be used to decrease labor discomfort? | -relaxation -breathing -music -water therapy -TENS Unit (Transcutaneous electrical nerve stimulation) -ACUpressure and puncture -massage -heat/cold -hypnosis -biofeedback -effleurage -counterpressure |
| What is efflourage? | Light stroking of abdomen in rhythm with breathing |
| Childbirth preparation classes What is Dick Reed? | "Natural Birth" -knowledge, relaxation and breathing |
| Childbirth preparation classes What is lamaze? and what does it entail? | psychoprophylactic -conditioning, relaxation/breathing, maintaining control |
| Childbirth preparation classes What is Bradley? What does it entail? | Husband Coached -natural experience, quiet, dark, breath control |
| What is included in labor support? | Emotional Support -presence -encouragement -reassurance -empowerment Tangible assistance -physical comfort Advice and information -support for partner -knowledge of progress |
| Causes of Emotional Dystocia? | -Lack of support system -previous difficult birth -sexual abuse -domestic violence -cultural -age -lack of knowledge -"Horror Stories" |
| Signs of emotional Dystocia | -writhing -muscle tension -activity is unfocused and random -panic -expressions of discouragement, dismay, anxiety |
| interventions during latent phase | -be supportive, orient to the environment -review breathing techniques -provide diversional activities |
| interventions during latent phase | -avoid unnecessary distractions -assist mother to conserve energy -facilitate attention focusing during uterine contractions -limit conversation -coach breathing techniques as needed |
| Attention focusing for supportive labor care (Active labor) | Utilizing the senses and the mind -tactile -Auditory -visual -kinesthetic -mental stimuli |
| What is tactile supportive labor? | Touch Massage |
| What is auditory supportive labor? | music verbal encouragement |
| What is Visual supportive labor? | Supporter's face Focal object |
| What is kinesthetic supportive labor? | Movement pattern rocking swaying |
| What is mental stimuli supportive labor? | Silently concentrating guided imagery self hypnosis |
| Assess coping for supportive labor care (active labor) | Rhythmic activity Ritual |
| What is rhythmic activity supportive labor? | rocking swaying breathing moaning |
| What is ritual supportive labor care? | repetition of motions |
| Positions used? | Side lying and semi sitting Upright Leaning forward |
| What is advantage of side lying and semi sitting? | gravity neutral and restful |
| What is advantage of upright position? | -takes advantage of gravity to apply pressure of presenting part on cervix -improves quality of contractions -enhances fetal descent |
| What is advantage of leaning forward position? | -Rotate fetus -relieves back pain |
| Interventions during transition phase? | -provide firm, directional coaching -have cool cloth, emesis basin, fan available -remind mom to rest b/w ctx -breath w/ mom prn -avoid convo -observe for signs of the urge to push, fetal descent |
| Comfort measures? | -Try different positions -stimulate different senses -empty bladder frequently -Ambulation/standing |
| Benefits of ambulation/standing? | -drive angle-angle formed by axis of fetal spine and axis of birth canal -Gravity -Improved blood flow to uterus -Improved fetal circulation |
| Goal of pharmacological pain relief | To effectively promote relaxation and pain relief without adversely effecting uterine contractions, pushing effort or the fetus |
| What are classes of systemic analgesia? (NARCOTIC) | -Opioid Agonist -Opioid Agonist-Antagonist -Opioid Antagonist |
| What are opioid agonist? | -they activate or stimulate a receptor Meperidine (Demerol) Fentanyl (Sublimaze) |
| What are side effects of opioid agonist? (9) | -inhibit uterine ctx -decrease gastric emptying -increase nausea and vomiting -inhibit bowel/bladder elimination -brady/tachycardia -Hypotension -Resp. Depr. -Sedation -Dizziness |
| What are opioid agonist-antagonist? | Stimulates some receptors and blocks some receptors -Butorphanol (Stadol) -Nubain |
| What are advantages of using an agonist-antagonist? | -adequate analgesia without causing significant resp. depr. -little to no nausea and vomiting -increase sedation |
| What are opioid antagonist? | Blocks receptors Naloxone hydrochloride (Narcan) |
| What would an opioid antagonist be used for? | antidote for opioid agonist (reverse CNS depression) |
| When would the nurse not administer an opioid antagonist? | in opioid dependent women causes abstinence syndrome |
| Signs and symptoms of abstinence syndrome | -yawning -rhinorrhea -lacrimation (tearing) -sweating -Anorexia -irritable -tremors -chills -violent sneezing -N&V&D |
| What are considerations of Systemic Analgesia? | -Drug potency -possible side effects on mom and fetus -Avoid before 4 cm's if the mother is not in active labor or if delivery is anticipated in less than one hour -When women are being induced they may receive analgesics when they have an active labor |
| Advantages of Narcotic analgesics (Demerol, Stadol, Sublimaze, Nubain, Morphine)? | -Generally fast acting (IV) -Aids in relaxation -Takes edge off pain, but does not take pain completely away |
| disadvantages of Narcotic analgesics (Demerol, Stadol, Sublimaze, Nubain, Morphine)? | -May be sedating -May Cause maternal resp. dep. -hypotension -may cause decreased variability -may cause neonatal resp. dep. if given too close to delivery (Have Narcan ready) |
| Pharmacologic pain management for early/latent labor? | Sedatives occasionally used for prolonged latent period and to increase the power of narcotics -recommended to use other methods first to encourage sleep |
| Pharmacologic pain management for active labor? | Systemic analgesia |
| What is a big side effect of systemic analgesia | crosses the blood brain barrier and placenta-crosses fetus blood brain barrier and cause resp. dep., decrease alert, delayed sucking |
| What route is preferred for systemic analgesia? | IV-because the drugs are faster onset, greater control is possible if labor progresses more rapidly than anticipated |
| What are analgesic potentiators? And examples? | -Used to treat nausea and vomiting (also increase sedation) -Promethazine (Phenergan) note this drug can potentiate the respiratory depressant effect of narcotics -Hydroxyzine (Vistaril) given IM only |
| Mixed narcotic agonist/antagonist Butorphanol (Stadol) benefits? | -shorter action -may be repeated if delivery is not anticipated w/in 1 to 2 hours -last 3-4 hours depending on dose/client tolerance |
| Mixed narcotic agonist/antagonist Nalbuphine (Nubain) benefits? | Can last up to 6 hours depending on dose/client tolerance |
| Rescue drugs to reverse narcotics | -Naloxone (Narcan) -Naltrexone (Trexan) |
| How can epidural anesthesia be administered? | -One shot -Intermittent bolus -Continuous infusion |
| What can epidural anesthesia be combined with? | Interthecal narcotics -Fentanyl -preservative free morphine |
| Advantages of epidural analgesia? (4) | -Completely relieves pain -may relax patient-->improve uteroplacental blood flow->dilates cervix -Advantageous for women with heart disease, pulmonary disease, PIH--> reduces stress of labor and may decrease BP -Little neonatal effect |
| disadvantages of epidural analgesia? (4) | -Spinal headache -Urinary retention -Possibly ineffective (or patchy) -Decreased sensation of urge to push -Maternal Hypotension -Inadvertent IV injection |
| What is the Chief concern of epidural analgesia? | -Maternal Hypotension > can cause fetal distress due to decreased uteroplacental blood flow >prophylactic IV volume expansion with non glucose isotonic crystalloid (LR) |
| What causes a spinal headache? (epidural) | >Rare >caused by leaking CSF >blood patch administered by anesthesia |
| Intervention for urinary retention? (epidural) | >encourage to void q 2 hours or foley |
| Interventions for maternal hypotension caused epidural | >TX: increasing fluids, and/or 5-10 mg of ephedrine, and position on side |
| The most common side effects of epidural anesthesia? | Maternal hypotension and Fetal bradycardia |
| Following epidural anesthesia administration what do you do? | -Bladder status -LOC -Level of anesthesia -Labor status -BP, P, R -Fetal heart rate -Maintain safety -Change positions freq. |
| What to do prior to epidural anesthesia administration? | -Establish baseline BP, pulse, and FHR -Prehydrate the mother with IV bolus -Encourage woman to empty bladder -Obtain supplies and pump for continuous administration -Remove EFM |
| What are nursing considerations for epidural anesthesia? | -historical factors >clotting factor disease >fetal factors >previous poor outcomes -lab tests >low platelets >infection (fever ^WBC) -physiologic status fo the laboring woman and fetus including maternal VS -timing of procedure -Hydration |
| What is normal platelets? | 150,000-400,000 |
| Normal WBC | 4,500-10,000 remember that WBC may normally be elevated during labor |
| How much of isotonic IV solution before an epidural? | 500 cc bolus |
| If the FHR drops during epidural administration what do you do? | -Discontinue oxytocin -reposition mother, assess BP -increase fluids -elevate the legs if indicated -observe and document fetal response -administer O2 as needed |
| Other Nerve block anesthesia? | -Spinal -Saddle block -pudendal -paracervical -local |
| What is Spinal Anesthesia? Results in? Given? | -Nursing care and procedure much the same as for epidural except the anesthesia goes into the cord space -Results in loss of motor/sensory sensation -Not given until just prior to delivery, vaginal or cesarean >not used for labor |
| What is Pudendal Anesthesia? | Used for episiotomy, forceps or vacuum used -Both sides must be blocked -Injections done transvaginally. Given in second stage for pressure sensations and perineal anesthesia -If ischial spines are blunt, may be hard to place |
| Local Anesthesia-where is it injected and when is it administered | -Injected directly into the perineal body -administered just prior to cutting an episiotomy or for repair of lacerations following delivery. |
Created by:
ygwallace
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