Pain Management
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| Pain and discomfort of labor have two origins: | Visceral and somatic
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| ______ pain is caused by distention of the lower uterine segment stretching of cervical tissue pressure and traction of adjacent structures and nerves uterine ischemia during the first stage of labor. | Visceral
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| Viseral pain is located here | lower portion of the abdomen
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| pain that originates in the uterus radiates to the abdomen wall, lumbosacral area of the back, illiac crests, gluteal area, thighs, and lower back. | referred pain
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| _______ pain is described as intense sharp burning and well localized. | somatic pain
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| Type of pain felt in the first stage of labor | visceral
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| Type of pain felt in the second stage of labor | somatic
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| This type of pain is caused by the streching of the perineal tissues and pelvic floor, from distension and traction of the peritoneum and uterocervical supports, from pressure against the bladder and rectum, and from lacerations of soft tissue. | somatic
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| Pain impulses during the second stage of labor are transmitted through the | pudendal nerve
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| The meaning of pain and the verbal and non-verbal expressions are learned from interactions within | the primary social group
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| The level of pain a laboring woman is willing to endure | pain tolerance
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| Factors that influence pain tolerance and request of meds include: | desire for a natural vag delivery
childbirth preparation
support during labor
willingness and ability to participate in non pharm measures for comfort
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| _____ and ______ are common in the active and transition phases of the first stage of labor | Nausea and Vomiting
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| Maternal respiratory pattern changes related to increased _________________ | o2 consumption
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| These are endogenous opoids secreted by the pituitary gland that act on the CNS and PNS to reduce pain | endorphins
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| Edorphins are associated with feelings of ________ and __________. | euphoria and analgesia
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| As endorphin levels rise during labor, __________ may increase. | pain tolerance
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| This is associated with increased pain during labor | anxiety
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| excessive _______ and _______ magnifies pain perception | anxiety and fear
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| increased anxiety and fear causes increased _________, effectiveness of contractions __________, discomfort _________ and a cycle of _________ fear and anxiety being. Which slows the progess of labor. | muscle tension
decrease
increases
increased
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| _________ magnifies pain | fatigue
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| ________ and ________ techniques are forms of care that are effedtive to some degree in releiving labor pain. | attention-focusing and distraction
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| a woman focuses her attention on a pleasant scene, a place where she feels relaxed, or an activity she enjoys | imagery
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| this is performed at approximately half the womans normal resp rate and is initiated when she can no longer walk to talk through contractions | slow-paced breathing (6-8 bpm,no fewer than 3-4 bpm)
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| This respiratory pattern is shallower and faster than the womans normal resp rate, but should not exceed 2x her normal rate | modified-paced breathing (32-40 bpm)
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| Relaxed breath in through the nose and out through the mouth. Used at the beginning and end of each contraction. | cleansing breath
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| The most difficult time to maintain control during contractions comes during the ________ phase of the ________ stage of labor, when the cervix dialates from ____ cm to _____ cm. _________ breathing is suggested during this phase. | transition
first
8
10
patterned-paced (pant-blow)
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| This breathing patteren consists of panting breaths combined with soft blowing breaths at regular intervals | patterned-paced
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| light stroking, usually of the abdomen, in rhythm with breathing during contractions. (thigh or chest may be used if monitor attached to abd) | Effleurage
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| steady pressure that is applied by a support person to the sacral area with a firm object. Pressure can also be applied to the hips and knees. | counterpressure
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| This stimulates the release of endorphons, relaxes fibers at the gate on pain, promotes better circulation and oxygenation and helps to soften the perineal tissues | warm water (hydrotherapy)
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| Women in labor often report that pain and discomfort ______ while in water | subside
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| Hydrotherapy is usually initiated when the woman is in __________, at approximately 5 cm. | active labor
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| assuming _____ and ______ position or a ________ lying position in the tub enhances spontaneous fetal rotation to the OA position as a result of increased buoyancy | hands and knees
side lying
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| placement of _________ is contraindicated for jet hydrotherapy. | internal electrodes
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| during hydrotherapy the temp of the water should stay between _____ and _____ with the water covering the womans abd and shoulders uncovered to dissipate heat | 36C-37C
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| Because warm water can cause dizziness, a shower stool should be used and the woman should be assisted when getting in and out of the tub. | SAFETY ALERT
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| The placing of two pairs of flat electrodes on either side of the womans thoracic and sacral spine | TENS
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| accupressure points | tsubos
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| Accupressure points are found: | neck
shoulders
wrists
lower back
hips
area below the kneecaps
ankles
nails on the small toes
soles of feet
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| insertion of fine needles into specific areas of the body to restore flow of energy and decrease pain. | accupuncture
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| ______ relieves muscle ischemia and increases blood flow to the area of discomfort | heat therapy
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| _____ relieves pain by reducing the muscle temp and relieving muscle spasms | cold therapy
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| ______ and _____ should never be applied over ischemic or anesthetized ares because tissues can be damaged and one or two layers of cloth should be placed in between the skin and heat/cold to prevent damage. | heat and cold therapy
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| Therapeutic touch uses the concept of energy fields within the body called _______ which are thought to be deficient in people in pain. | prana
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| _______ uses laying-on of hands to redirect energy fields associated with pain. | Therapeutic touch
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| hyperesthesia | causes a woman to become intolerable of touch during advanced labor.
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| The injection of small amounts of sterile water by using a fine needle in four locations on the lower back to relieve low back pain. | Intradermal water block
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| The injections should raise a bled on the skin and simultaneous injections by two clinicians will decrease the pain of the injections. Intense stinging for about 20-30 seconds after procedure with pain relief for up to 2 hours. | Intradermal water block NOTE
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| These are given to relieve anxiety and induce sleep. they are given to women expierencing prolonged labor when there is need to decrease anxiety or promote sleep | Sedatives
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| ______ may be give to augment analgesics and reduce nausea when an opiod is used. | Sedatives
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| ____________ should be avoided if birth is anticipated within 12 to 24 hours. (these are seldom used during labor) | barbiturates
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| encompasses analgesia, amnesia, relaxation, and reflex activity. it abolishes pain perception by interrupting the nerve impulses to the brain. The loss of sensation may be partial or complete, sometimes with the loss of consciousness. | anesthesia
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| the alleviation of the sensation of pain or the raising of the threshold for pain perception with out the loss of consciousness | analgesia
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| _____ administration is perferred over _____. meds kick in faster and they are more predictable. | IV
IM
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| These have no amnesic effect but create a feeling of well being and enhance a womans ability to relax in between contractions, they should not be administered until labor is well established unless used to increase rest during a prolonged latent phase. | opiod agonist
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| These are effective for relieving severe, persistant or recurrent pain by blunting the perception of the pain not eliminating it. (dilaudid, demerol) | opiod agonist
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| Opioids decrease maternal heart and resp rate and BP which affects fetal oxygenation. maternal VS and FHT must be assessed and documented prior to and after administration. | SAFETY ALERT
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| Birth should occure less than _____ or more than ____ after administration of an __________ analgesic so that neonatal CNS depression is minimized. | 1 hour
4 hours
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| an agent that activates or stimulates a receptor to act | agonist
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| an agent that blocks a receptor or a med designed to activate a receptor | antagonist
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| these mixed opioids provide adequate analgesia without significant resp depression in the mother and baby | opioid agonist-antagonist
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| this classification of opioid analgesics is not suitable for women with an opioid dependency because they could precipitate withdrawl symptoms in both mom and baby. | opioid agonist-antagonist
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| Anecdote for opioid agonist | Naloxone
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| If birth occurs within 1-4 hours after administration of an opioid agonist-antagonist observe the newborn for respiratory depression | SAFETY ALERT
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| Do not give this to a woman or newborn if the woman is opioid dependant- it may cause abrupt withdrawl | narcan (Naloxone)
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| Opioid agonist-antagonist such as stadol and nubain should not be given to opioid dependant mothers because it may precipitate withdrawl symptoms | SAFETY ALERT
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| these can reverse the CNS depressant effects of opioids. | opioid antagonist
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| a state of CNS depression in the newborn produced by an opioid. | neonatal narcosis
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| this may be used when an episiotomy is to be performed or when lacerations must be sutured after birth in a woman who does not have regional anesthesia | local perineal infiltration anesthesia
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| this is administered late in the second stage of labor and is useful if an episiotomy is to be performed or if foreceps or a vacuum extractor are to be used to facilitate birth. This can cause the bearing down reflex to be lessened or completely lost | pudendal nerve block
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| The pudendal nerve block does not relieve pain stemming from the uterine contractions, it does relieve pain in the: | lower vagina, the vulva, and the perineum
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| an anesthetic solution containing a local anesthetic alone or in combo with an opioid agonist. this is injected through the 3rd,4th, or 5th lumbar interspace into the subarachnoid space. | spinal anesthesia (block)
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| these side effects may occur during spinal anesthesia | Marked hypotension, impaired placenta perfusion, and an ineffective breathing pattern.
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| Before the induction of a spinal block maternal VS are assessed and a 20-30 min EFM strip is obtained and evaluated. a bolus of 500-1000cc of LR is administered 15-30 minutes before to decrease the potential for hypotension. | NOTE
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| vasodilation with pooling of blood in the lower extremities which decreases cardiac output. | sympathetic blockade
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| After spinal block initiated these are monitored and must be documented Q5-10m | Maternal: HR BP and RR
Fetal: HR and Pattern
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| Because the woman is unable to sense her contractions after spinal anesthesia, she must be: | instructed when to bear down during a vaginal birth
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| s/s of maternal hypotension with decreased placental perfustion | maternal hypotension <=100mmhg systolic
fetal bradycardia
absent or minimal FHR variability
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| Interventions for maternal hypotension with decreased placental perfusion | lateral position, maintain IV hydration, administer o2 (nonrebreather @ 10-12L/min) elevate legs, notify PCP or anesthesia team, IV vasopressor if other stuff doesnt work, remain with patient, monitor VS FHT Q5m until stable or per order.
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| Postdural puncture headache is caused by | Leakage of CSF from the site of puncture of the dura mater
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| assumming and _______ position triggers or intensifies the headache, whereas assuming a ______ position acheieves relief of a spinal headache | upright; supine
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| Spinal headace: The resulting headache, auditory problems, and visual problems begin within ______ of the puncture and may persist for days or weeks. | 48 hours/2 days
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| First treatment for spinal headache | hydration and caffiene
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| this is the most rapid, reliable, and beneficial relief of a spinal headache | blood patch
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| after a blood patch the woman should be instructed to avoid _____ or _____ for several days. Also to avoid taking analgesics that affect platelet aggregation like NSAIDS for 2 days, drink plenty of fluids. | coughing or straining
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| injection is made between the fourth and fifth lumbar vertebrae | epidural block
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| Epidural anesthesia effectively relieves pain caused by uterine contractions. For most women, however, it does not completely remove the pressure sensations that occur as the fetus descends into the pelvis | NURSING ALERT
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| What is used to increase maternal blood pressure r/t epidural/ | ephedrine and increased fluids
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| What must be monitored after an epidural that is not related to the VS of the mother (because the mother may not be aware of the changes in strength of the contractions or of the descent of the baby. | FHR and pattern, contraction pattern, and progress in labor.
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| Contraindications to Epidural | hypovolemia (or risk of)
hypotension
coagulopathy
infection at injection site
increased ICP
allergy to drug
refusal or inability to cooperate
some cardiac conditions
abnormal FHT that require immediate birth
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| Epidural block effects on newborn | little or no lasting effect on the physiologic status of the newborn
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| When is general anesthesia used in L&D | only if there are contraindications to a spinal or epidural or when immediate birth is necessary and there is not enough time or staff to perform a block
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| Prior to the induction of anesthesia how much o2 should a patient get, by what mode and for how long? | 100% o2 by non-rebreather mask for 2-3 minutes
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| this maneuver blocks the esophagus and prevents aspiration should the woman vomit or regurgitate | cricoid pressure
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