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Chapter 17 Pain Mgmt

Pain Management During Labor

QuestionAnswer
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