Pain Management During Labor
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| What is pain? | Whatever and whenever the patient says it is
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| What causes pain with contractions? | -Anoxia to muscle fibers
-Stretching of cervix and perineum
-Afferent nerves stimulated activated by chemical, mechanical, or thermal stimuli
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| What does PAIN stand for? | P-purposeful
A-anticipated
I-intermittent
N-Normal
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| What are the sources of discomfort in stage 1? | -Cervical changes (dilation and effacement caused by ctx)
-uterine ischemia
-visceral pain
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| 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
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| What is uterine ischemia? | decreased blood flow and local O2 deficit--> result from compression of the arteries supply the myometrium during uterine ctx
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| What is referred pain in stage 1 discomfort? | pain originates in uterus and radiates to abdominal wall, lower back, etc
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| 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)
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| What can be done in stage 2 discomfort to reduce pain intensity? | Bear down
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| What type of pain is in stage 2? | somatic pain (intense, burning, local, sharp) and caused by stretching and distention of perineal
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| What are the sources of discomfort in stage 3? | -uterine ischemia, contracting
'afterpains similar to early labor'
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| 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
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| What is the pain cycle? | --> lactic acid--->pain---> tension ---> contracting muscle--->
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| What impacts pain perception? | -Knowledge
-Culture
-Past experience
-Anxiety
-Fear
-Sense of control
-Confidence
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| 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
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| 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.
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| Gate control therapy Pain can be stopped at three points... which are? | -Peripheral end terminals
-Synapse joint
-Paint the impulse is interpreted as pain
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| 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
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| Gate Control Theory What are some distractions that can be taught? | massage, hair stroking, music, focal points
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| 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
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| What is efflourage? | Light stroking of abdomen in rhythm with breathing
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| Childbirth preparation classes What is Dick Reed? | "Natural Birth"
-knowledge, relaxation and breathing
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| Childbirth preparation classes What is lamaze? and what does it entail? | psychoprophylactic
-conditioning, relaxation/breathing, maintaining control
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| Childbirth preparation classes What is Bradley? What does it entail? | Husband Coached
-natural experience, quiet, dark, breath control
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| 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
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| Causes of Emotional Dystocia? | -Lack of support system
-previous difficult birth
-sexual abuse
-domestic violence
-cultural
-age
-lack of knowledge
-"Horror Stories"
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| Signs of emotional Dystocia | -writhing
-muscle tension
-activity is unfocused and random
-panic
-expressions of discouragement, dismay, anxiety
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| interventions during latent phase | -be supportive, orient to the environment
-review breathing techniques
-provide diversional activities
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| 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
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| Attention focusing for supportive labor care (Active labor) | Utilizing the senses and the mind
-tactile
-Auditory
-visual
-kinesthetic
-mental stimuli
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| What is tactile supportive labor? | Touch
Massage
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| What is auditory supportive labor? | music
verbal encouragement
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| What is Visual supportive labor? | Supporter's face
Focal object
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| What is kinesthetic supportive labor? | Movement pattern
rocking
swaying
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| What is mental stimuli supportive labor? | Silently concentrating
guided imagery
self hypnosis
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| Assess coping for supportive labor care (active labor) | Rhythmic activity
Ritual
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| What is rhythmic activity supportive labor? | rocking
swaying
breathing
moaning
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| What is ritual supportive labor care? | repetition of motions
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| Positions used? | Side lying and semi sitting
Upright
Leaning forward
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| What is advantage of side lying and semi sitting? | gravity neutral and restful
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| 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
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| What is advantage of leaning forward position? | -Rotate fetus
-relieves back pain
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| 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
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| Comfort measures? | -Try different positions
-stimulate different senses
-empty bladder frequently
-Ambulation/standing
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| 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
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| Goal of pharmacological pain relief | To effectively promote relaxation and pain relief without adversely effecting uterine contractions, pushing effort or the fetus
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| What are classes of systemic analgesia? (NARCOTIC) | -Opioid Agonist
-Opioid Agonist-Antagonist
-Opioid Antagonist
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| What are opioid agonist? | -they activate or stimulate a receptor
Meperidine (Demerol)
Fentanyl (Sublimaze)
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| 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
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| What are opioid agonist-antagonist? | Stimulates some receptors and blocks some receptors
-Butorphanol (Stadol)
-Nubain
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| What are advantages of using an agonist-antagonist? | -adequate analgesia without causing significant resp. depr.
-little to no nausea and vomiting
-increase sedation
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| What are opioid antagonist? | Blocks receptors
Naloxone hydrochloride (Narcan)
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| What would an opioid antagonist be used for? | antidote for opioid agonist (reverse CNS depression)
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| When would the nurse not administer an opioid antagonist? | in opioid dependent women causes abstinence syndrome
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| Signs and symptoms of abstinence syndrome | -yawning
-rhinorrhea
-lacrimation (tearing)
-sweating
-Anorexia
-irritable
-tremors
-chills
-violent sneezing
-N&V&D
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| 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
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| 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
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| 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)
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| 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
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| Pharmacologic pain management for active labor? | Systemic analgesia
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| 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
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| 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
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| 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
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| 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
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| Mixed narcotic agonist/antagonist Nalbuphine (Nubain) benefits? | Can last up to 6 hours depending on dose/client tolerance
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| Rescue drugs to reverse narcotics | -Naloxone (Narcan)
-Naltrexone (Trexan)
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| How can epidural anesthesia be administered? | -One shot
-Intermittent bolus
-Continuous infusion
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| What can epidural anesthesia be combined with? | Interthecal narcotics
-Fentanyl
-preservative free morphine
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| 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
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| disadvantages of epidural analgesia? (4) | -Spinal headache
-Urinary retention
-Possibly ineffective (or patchy)
-Decreased sensation of urge to push
-Maternal Hypotension
-Inadvertent IV injection
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| 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)
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| What causes a spinal headache? (epidural) | >Rare >caused by leaking CSF >blood patch administered by anesthesia
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| Intervention for urinary retention? (epidural) | >encourage to void q 2 hours or foley
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| Interventions for maternal hypotension caused epidural | >TX: increasing fluids, and/or 5-10 mg of ephedrine, and position on side
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| The most common side effects of epidural anesthesia? | Maternal hypotension and Fetal bradycardia
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| 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.
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| 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
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| 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
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| What is normal platelets? | 150,000-400,000
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| Normal WBC | 4,500-10,000
remember that WBC may normally be elevated during labor
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| How much of isotonic IV solution before an epidural? | 500 cc bolus
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| 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
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| Other Nerve block anesthesia? | -Spinal
-Saddle block
-pudendal
-paracervical
-local
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| 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
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| 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
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| 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.
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