Chapter 15: Pain Management During Childbirth Flashcards
(195 cards)
1
Q
Pain involves 2 components
A
Physiological and psychological
2
Q
Physiological component of pain
A
Includes reception by sensory nerves and transmission to the CNS
3
Q
Psychological component of pain
A
Involves recognizing the sensation, interpreting it as painful and reacting to the interpretation.
4
Q
How can excessive pain affect labor?
A
Can cause maternal fear and anxiety -> which stimulates SNS activity -> secretion of catecholamines (NE and epinephrine) -> can alter uterine blood flow and effectiveness of contractions.
5
Q
Stimulation of alpha receptors by NE and Epinephrine causes
A
- Uterine and generalized vasoconstriction in the uterine muscle tone.
- Reduced uterine blood flow as they raise the maternal blood pressure.
6
Q
Stimulation of the beta receptors by epinephrine causes
A
- Relaxation of the uterine muscle and causes vasodilation.
- Uterine vessels are already dilated in pregnancy, so dilation of other maternal vessels allows the woman’s blood to pool in them -> reduces the amount of blood available to perfuse to the placenta
7
Q
The combined effects of excessive catecholamine secretion are:
A
- Reduced blood flow to and from the placenta, restricting fetal oxygen supply and waste removal **
- Reduced effectiveness of uterine contractions, slowing labor progress**
8
Q
Labor increases maternal metabolic rate and O2 demand:
A
These changes alter placental exchange significantly if they are persistent.
9
Q
NE and Epinephrine stimulate what receptors?
A
Epinephrine: Alpha and Beta receptors
Norepinephrine: Alpha receptors
10
Q
How can increased maternal metabolic rate and O2 demand in labor affect the fetus?
A
- Fetus may have less O2 available for uptake and have less ability to unload carbon dioxide to the mother.
- This can cause the fetus to shift to anaerobic metabolism, with build up of hydrogen ions (acidosis)
11
Q
What are the two types of pain?
A
- Somatic
2. Visceral
12
Q
Somatic Pain Characteristics
A
- Quick, sharp, localized pain
- Occurs during the 1st & 2nd sage of labor
13
Q
What causes somatic pain during labor?
A
It is due to descending fetus putting pressure on maternal tissues
14
Q
Visceral Pain Characteristics
A
o Slow, deep, poorly localized pain
o “dull or achy”
o Common in 1st stage
15
Q
What can cause visceral pain during labor?
A
It can be due to uterine contraction and cervical dilation.
16
Q
What are the four sources of labor pain?
A
- Ischemia
- Dilation
- Pressure and pulling on pelvic structures
- Distention of the vagina and perineum
17
Q
How does ischemia cause pain during labor?
A
Blood supply to the uterus decreases during contractions -> tissue hypoxia and anaerobic metabolism.
18
Q
How does dilation and stretching of the cervix cause pain during labor?
A
Pain stimuli from cervical dilation travel through the hypogastric plexus and enters the spinal cord at the T10, T11, T12, and L1 levels**
19
Q
How does pressure and pulling on pelvic structures cause pain during labor?
A
- Causes a visceral pain.**
- Woman may feel it as referred pain in her back and legs.
20
Q
Pressure and pulling on pelvic structures during labor cause pain. What structures are they referring to?
A
Pressure and pulling occur on the ligaments, fallopian tubes, ovaries, bladder, and peritoneum
21
Q
When does distention of the vagina and perineum occur?
A
Occurs with fetal descent, especially during the second stage.
22
Q
How does distention of the vagina and perineum cause pain during labor?
A
-Causes women to feel a described sensation of burning, tearing or splitting. (Somatic pain)**
23
Q
Pain from vaginal and perineal distention and pressure and pulling on adjacent structures enters the spinal cords at what levels?
A
S2, S3 and S4 levels**
24
Q
What are factors that influence perception or tolerance of pain during labor?
A
- Labor intensity
- Cervical readiness
- Fetal position
- Pelvic readiness
- Fatigue and hunger
- Caregiver interventions
- Psychosocial factors
25
How does labor intensity influence perception or tolerance of pain?
- A short, intense labor may complain of severe pain (each contraction does so much work)
- A rapid labor may limit her options for adequate pain relief.
26
How does cervical readiness influence perception or tolerance of pain?
- If prelabor cervical changes are incomplete, cervix won’t open as easily.
- More contractions are needed resulting in a longer labor and greater fatigue.
27
How does fetal position influence perception or tolerance of pain during labor?
- It is longer and more painful if baby is in an unfavorable position.
- Common variant is occiput posterior position.
28
How can occiput posterior position affect pain during labor?
- Each contraction pushes the fetal occiput against the woman’s sacrum
- Causes intense back discomfort (back labor) that persists between contraction.
- May not be able to deliver until it rotates to the occiput anterior position; makes labor longer.
29
How does pelvic readiness influence the perception or tolerance of pain during labor?
Size and shape of woman’s pelvis influences the course and length of her labor.
30
How does fatigue and hunger influence perception or tolerance of pain during labor?
- Oral intake is often limited, so her energy reserves are also likely to be depleted in a long labor
- Sleep is difficult during the last weeks of pregnancy due to SOB, frequent urination, and fetal activity are at their peaks.
31
How can caregiver interventions influence perception or tolerance of pain during labor?
- IV site can cause pain
- Fetal monitoring equipment is uncomfortable.
- Induced or augmented labors are often more painful.
- Vaginal manipulation often stimulates contraction.
32
Ferguson’s reflex**
....
33
What psychosocial factors can influence perception or tolerance of pain during labor?
1. Culture
2. Anxiety and fear
3. Previous experiences with pain
34
How can culture influence perception or tolerance of pain during labor?
o A woman’s sociocultural roots influence how she perceives, interprets, and responds to pain during birth
o Some encourage loud & vigorous expression of pain whereas others value self-control
o Should be encouraged to express themselves in any way they find comforting whether it is being loud or quiet
35
How does anxiety and fear influence perception or tolerance of pain during labor?
High anxiety and fear can magnify sensitivity to pain & impair toleration to it
36
In what ways can anxiety and fear magnify sensitivity to pain and impair toleration of it?
- Increases muscle tension, diverting oxygenated blood to brain & skeletal muscles.
- Tension in pelvic muscles counters the expulsive forces of uterine contractions and laboring woman’s pushing.
37
How ones prolonged tension affect pain perception during labor?
Prolonged tension results in general fatigue, increases pain perception or threshold (lowest stimulus level perceived as pain), and reduces ability to use skills to cope.
38
How does previous experiences with pain influence perception or tolerance of pain during labor?
-A woman who has given birth previously can have a different perspective because she knows labor sensations and is less likely to associate them with injury or abnormality.
o Woman with previously long and difficult labor can be anxious. They can find late first stage and second stage to be more painful b/c fetus descends faster.
39
Preparation for childbirth
- Does not ensure pain-free labor
- Woman should be prepared for pain realistically, including reasonable expectations about analgesia and anesthesia (loss of sensation)
40
What are the benefits for preparation for childbirth?
Reduces anxiety and fear of unknown and allows mother to rehearse for labor and learn variety of skills to master pain as labor progresses.
41
Why is it important to control anxiety in the mother’s support partner?
- Anxious partner is less able to provide support & reassurance that woman needs during labor
- Anxiety in others can be contagious and therefore anxious partners can increase woman’s anxiety.
42
What are advantages of nonpharmacological pain measures given to women during labor?
- Does not slow labor and has no side effects or risk of allergy.
- May be only realistic option for woman who enters hospital in advanced, rapid labor.
- Woman who receives analgesia may not eliminate labor pain & needs other techniques to control pain.
43
What are limitations to nonpharmacological measures used during labor?
- Women do not always achieve their desired level of pain control using these methods alone.
- B/c of many variables in labor, a well-prepared, highly-motivated woman may need analgesia or anesthesia.
44
Gate-control theory
Transmission of nerve impulses is controlled by neural mechanism in dorsal horn of spinal cord that acts like a gate to control impulses transmitted to the brain
45
Pain transmitted through small-diameter sensory nerve fibers
▪Stimulation of large-diameter fibers in the skin blocks conduction of pain through small-diameter fibers -> “closes gate” & decreases amount of pain felt
▪Impulses from brain can have similar ability to impede transmission through dorsal horn using visual & auditory stimulation -> use of focal point or breathing techniques
46
Ideal time to prepare for nonpharmacological pain control is
Before labor.
47
A nurse can teach an unprepared woman and support person nonpharmacological techniques during which point in labor?
Latent phase of labor is best time for teaching.
48
Benefits of Relaxation
▫ Promotes uterine blood flow, which improves fetal oxygenation
▫ Promotes efficient uterine contractions
▫ Reduces tension that increases pain perception and decreases pain tolerance (maximum pain one is willing to endure)
▫ Reduces tension that can inhibit fetal descent
49
How can you enhance environmental comfort?
- Reduce irritants like bright lights and uncomfortable temperature
- Change soiled underpads
- Music can distract pain perception
50
How can you reduce anxiety and fear in a woman in labor?
Provide accurate information and focus on normality of labor.
51
Specific relaxation techniques work best when?
works best if mother practices before labor
52
Relaxation Techniques: Progressive relaxation
Woman contracts and then releases specific muscle groups until all muscles are relaxed.
53
Relaxation Techniques: Neuromuscular dissociation
Helps woman learn to relax all muscles except those that are working (uterus or abdominal muscles when pushing)
54
Relaxation Techniques: Touch relaxation
Response to partner’s touch
55
Relaxation Techniques: Relaxation against pain
Partner deliberately causes mild pain and woman learns to relax despite pain.
56
Cutaneous stimulation used in pain relief during labor include
1. Self-massage
2. Massage by others
3. Counterpressure
4. Touch
5. Thermal stimulation
6. Acupressure
57
Cutaneous Stimulation: Self-massage
- rub abdomen, legs or back during labor (effleurage) to counteract discomfort
- some benefit from firm palm or sole stimulation during labor
58
Cutaneous Stimulation: Massage by others
- Increases circulation and reduces muscle tension
| - Can rub back, shoulders, legs or any area where she finds massage helpful.
59
Cutaneous Stimulation: Counterpressure
sacral pressure can help when having back pain -> can be applied using palm of hand, fist or fists, or firm object like 2 tennis balls in sock
60
Cutaneous Stimulation: Touch
holding hand, stroking hair, or similar actions conveying caring, comfort, affirmation and reassurance can be helpful to some women
61
Cutaneous Stimulation: Thermal Stimulation
warmth applied to back abdomen or perineum during labor increases local blood flow, relaxes muscles and raises pain threshold.
62
Methods for thermal stimulation include
▫ Warm shower, tub bath or whirlpool
| ▫ Cool damp washcloths provide comforting coolness if woman feels hot
63
Benefits of Hydrotherapy
▪ Buoyancy afforded by immersion supports the body, equalizes pressure on the body & aids muscle relaxation
▪ Fluid shifts from extravascular space to intravascular space reduces edema as the excess fluid is excreted by the kidneys.
64
Methods for hydrotherapy include
Shower
Tub
Bath
Whirlpool
65
What is a concern about hydrotherapy?
Newborn and postpartum maternal infections caused by microorganisms in the water.
66
Breathing Techniques are beneficial because
▪ Gives woman different focus during contractions, interfering with pain sensory transmission
67
For the best result for breathing techniques, what should the woman do?
Woman and partner should practice frequently -> if patterns are to complicated or woman has not practiced, they may not be helpful
68
First stage breathing includes what breathing techniques?
1. Cleansing Breath
2. Slow-Paced Breathing
3. Modified-Paced Breathing
4. Patterned-Paced Breathing
5. Breathing to prevent pushing
69
Cleansing Breath
Each contraction begins and ends with deep inspiration and expiration -> helps release tension.
70
What are benefits of the cleansing breath technique?
· Provides oxygen to help reduce myometrial hypoxia
| · Helps clear mind to focus on relaxing and signals her labor partner that contraction is beginning and ending
71
Slow-Paced Breathing
Slow, deep breathing that increases relaxation.
72
Benefits of slow-paced breathing include?
➢ Concentrate on relaxing body rather than on regulating rate of breathing
➢ Use as long as possible during labor b/c promotes relaxation & oxygenation
73
Modified-Paced Breathing
Chest breathing at faster rate matches natural tendency to use more rapid breathing during stress or physical work like labor.
74
Benefits of modified-paced breathing include
➢ Allows oxygen intake to remain about the same although breaths are shallower
75
Patterned-Paced Breathing
Focusing on pattern breathing.
| Relaxation of entire body is the goal.
76
Patterned-Pace Breathing Instructions
➢ After certain number of breaths, woman exhales with slight emphasis or blow and then begins modified paced breathing again
➢ Mouth should remain relaxed and woman should try not to make specific sounds that would tighten vocal cords
➢ Set patterns include: “3-1, 5-1, 3-1” or “6-1, 5-1, 4-1, 3-1” (stair step pattern)
77
Breathing to Prevent Pushing
Blows repeatedly using short puffs when urge to push is strong.
78
Benefits to breathing to prevent pushing
Blowing prevents closure of glottis and breath-holding, helping to overcome urge to push strenuously.
79
What are common problems when breathing techniques are used?
Hyperventilation
| Mouth dryness
80
Hyperventilation while using breathing techniques
- Rapid breathing that causes excessive loss of CO2 -> respiratory alkalosis -> can feel dizzy, lightheaded and may have impaired thinking.
- Vasoconstriction -> leads to tingling and numbness in fingers and lips.
81
If prolonged hyperventilation occurs, what can happen?
Tetany from decreased Ca++ in tissues and blood can result in stiffness of face and lips.
82
To avoid dryness from prolonged mouth breathing,
Place tongue gently against roof of mouth to moisturize entering air.
83
Second-Stage Breathing
Encourages physiologic completion of labor, assisting mother to respond to urge to push rather than directing her to push as soon as the cervix is completely dilated even if she does not feel the urge.
84
Lengthy pushing has been shown to result in
- greater maternal fatigue
- more operative births
- nonreassuring FHR patterns
85
Strenuous directed pushing increases the risk for
Structural and neurogenic injury to woman’s pelvic floor.
86
Closed glotting pushing causes an
Increase in intrathoracic pressure -> fall in CO and maternal BP -> causes less blood to be delivered to placenta -> fetal hypoxia.
87
What rate of pushing is likely to be effective in aiding descent and is safe for the baby?
Pushing 3-4 times for 6-8 secs
88
The best time for intrapartum teaching is when?
During the latent phase of labor, woman is anxious enough to be attentive.
89
Pharmacological methods to pain relief during labor include
o Regional pain management techniques (block of pain in localized area with consciousness)
o Systemic drugs
o General anesthesia
90
What are specific considerations that should be taken into account when medicating a pregnant woman?
o Any drug taken by the woman is likely to affect her fetus.
o Drugs may have effects in pregnancy that they do not have in the nonpregnant person.
o Drugs can affect the course and length of labor.
o Pregnancy complications may limit the choice of pharmacologic pain management methods.
o Women who require other therapeutic drugs, use herbal or botanical preparations, or practice substance abuse may have fewer safe choices for labor pain relief.
91
Direct effect of pain medications on the fetus
▪ Passage of the drug/metabolites across the placenta to the fetus
▪ After administration of an analgesic to the woman, there is a decrease in FHR variability
92
Indirect effect of pain medications on the fetus
Drugs can cause maternal hypotension -> blood flow to the placenta is reduced -> fetal hypoxia and acidosis
93
Fetal metabolism of analgesics
Fetus has inadequate ability to metabolize analgesic agent.
94
If mother must be temporarily supine, what should be done?
Uterus is displaced to one side with hands or small wedge or towel roll under one hip.
95
Respiratory changes during labor
Full uterus reduces respiratory capacity
▪ Compensates by breathing more rapidly and deeply
▪ more vulnerable to reduced arterial oxygenation during induction of general anesthesia (systemic loss of sensation and consciousness) & is more sensitive to inhalational anesthetic agents**
▪ edema in upper airways is normal, but may place difficulty if she needs to be intubated during general anesthesia
96
Gestation changes during labor
Stomach is displaced upward during pregnancy by large uterus and has high internal pressure.
97
Why is the woman more vulnerable to regurgitation & aspiration of gastric contents during general anesthesia? **
Progesterone slows peristalsis and reduces tone of sphincter at junction of stomach & esophagus.
98
Nervous system changes during labor include
▪Circulating levels of endorphins & enkephalins** are high
requirements for analgesia and anesthesia
▪Epidural and subarachnoid spaces b/w arachnoid mater & pia mater are smaller.
▪CSF pressure is higher during contraction when pushing
▪Nerve fibers more sensitive to local anesthetic agents
▪High intraabdominal pressure
99
High circulating levels of endorphins and enkephalins is important for
Modifying pain perception and reducing requirements for analgesia and anesthesia.
100
Smaller epidural and subarachnoid spaces between arachnoid and pia mater are important for
Enhanced spread of anesthetics used for epidural blocks or subarachnoid blocks.
101
Why is high intraabdominal pressure significant during labor?
Causes engorgement of epidural veins, therefore increasing the risk for intravascular injection of anesthetic agents.
102
When are analgesics given during labor?
Given when labor is well established to avoid slowing progress.
103
How can regional anesthesia, esp. epidural block, affect labor during the second stage?
Can slow progress during second stage by reducing woman’s spontaneous urge to push.
104
What are the effects of complications during labor on the use of analgesia or anesthesia?
Can limit choices of analgesia or anesthesia.
105
Women who ingest drugs, herbal or botanical preparations or other substances may
Have fewer options b/c of interactions between these substances and analgesics or anesthetics.
106
Regional pain management techniques can be used
- for intrapartum analgesia, surgical anesthesia or both
| - to provide pain relief without loss of consciousness.
107
Four types of regional pain management techniques
1. Epidural block - pain control during much of labor and for birth itself
2. Intrathecal opioids - used for pain control during labor
3. SAB (subarachnoid block) - used only at birth
4. Combined spinal epidural (CSE) analgesia
108
Combined Spinal Epidural
Allows subarachnoid injection of opioids via spinal needle followed by ongoing pain relief from anesthetics injected through epidural catheter.
109
What are advantages of regional pain management methods?
Woman can participate in birth while having good pain control.
110
Epidural Block
▪ Provides analgesia and anesthesia for labor and birth without sedation of woman and fetus
▪ Vaginal & cesarean births
111
Epidural space
- Outside dura matter between dura and spinal canal.
| - Loosely filled with fat, CT and epidural veins that are dilated during pregnancy.
112
Epidural block is performed by
Injecting local anesthetic agent often combined with opioid into epidural space. **
113
Analgesia rather than full anesthesia that results in complete loss of movement and sensation is preferred during labor because:
▫ Lower concentrations of anesthetic agent & epidural opioid = pain relief without complete motor block
▫ Higher concentrations used for abdominal surgery = result in loss of both motor and sensory functions
(might have to modify flash card)
114
Epidural Block Technique
......... In notes...
115
Epidural opioid used during labor include
➢ fentanyl (Sublimze)
➢ sufentanil (Sufenta)
➢ ropivicaine (Naropin)
➢ morphine (Duramorph, Astramorph)
116
All drugs injected into epidural or subarachnoid space must be
Preservative free
117
Dural Puncture
▫ Tough dura and arachnoid membranes close together, dura puncture also punctures arachnoid
???
118
If dura is punctured
leakage of CSF can occur -> can result in postdural puncture (“spinal”) headache
119
Contraindications and Precautions for epidurals include
- Coagulation defects
- Uncorrected Hypovolemia
- Infection in area of insertion or severe systemic infection
- Allergy
- Fetal condition that demands immediate birth
120
Adverse Effects of Epidural Block
1. Maternal Hypotension
2. Bladder Distention
3. Prolonged Second Stage
4. Catheter Migration
5. Maternal Fever
121
Maternal hypotension after epidural block
Sympathetic nerves are blocked along with pain nerves that can result in vasodilation and hypotension.
122
What treatment can offset maternal hypotension from epidural block?**
➢ Rapid infusion of non-dextrose IV solution (warmed) (i.e LR or NS) before initiation of block fills vascular system to offset vasodilation
➢ 500-1000mLs (1-2L) infused rapidly
123
Interventions for maternal hypotension include
- Maternal reposition
- Rapid non-dextrose IV fluid bolus and oxygen administration is used.
- IV ephedrine if non-dextrose IV solution is ineffective. ***
124
Bladder distention after epidural block
Fills quickly because of large quantity of IV solution but sensation is reduced -> can cause pain.
125
Prolonged second stage after epidural block
- Delayed pushing and urge to push may be less intense
- Pelvic muscles may be relaxed which can interfere with mechanism of internal rotation.
- Increase change for vacuum extractor-assisted births or forceps-assisted births
126
Catheter migration after epidural block
Epidural catheter can move.
127
Catheter migration may have symptoms of
o intravascular injection
o intense block or one that is too high
o absence of anesthesia
o unilateral block
128
Maternal fever after epidural block
May result from reduced hyperventilation and decreased heat dissipation.
129
Maternal fever effect on fetus
- Increases fetal temperature and fetal demand for oxygen.
| - Causes tachycardia, hypoxia and acidosis.
130
Indicators of Maternal Infection in fetus
Fetal tachycardia
Amniotic fluid with cloudy or yellow color
Foul odor
131
Possible signals that may result in maternal fever after epidural block include:
oDecreased hyperventilation, sweating and activity after onset of pain relief reduce maternal heat production & signal hypothalamus to raise temperature
oVasodilation redistributes heat from core to periphery of body where it is lost to environment -> lower core temperature signals hypothalamus to increase heat production
oShivering occurs with sympathetic blockade -> body believes temperature is lower than true temperature & raises thermostat to produce heat by shivering -> increases core temp.
132
Adverse effects of epidural opioids
1. N/V
2. Pruritus
3. Delayed respiratory depression (possibly exists for up to 12 hours after administration)
133
Promethazine/Phenergine**
...
134
Pruritus caused by epidural opioids are common on the
Face and neck
135
Pruritus can be relieved by
```
o diphenhydramine (Benadryl)
o naloxone (Narcan)
o nalbuphine (Nubain), or naltrexone (Trexan)
```
136
Nursing Care for Epidural Block
▫ Record baseline maternal vital signs and FHR patterns for comparison with prenatal levels and those after block
▫ Preload of fluid given
▫ Support woman in correct position, assist to remain still until block is completed
▫ Observe for signs of subarachnoid puncture
▫ Assess maternal BP & FHR
▫ Assess bladder frequently b/c large IV fluid load and reduced sensation
▫ Observe for signs associated with catheter migration from epidural space
▫ adverse effects from epidural opioids like n/v, pruritus
137
How often should maternal BP and FHR be assessed?
➢ every 5 minutes during first 15 minutes
| ➢ then repeat at 30 minutes and 1 hour
138
Subarachnoid (Spinal) Block
Simpler procedure than epidural block, and may be performed for prompt birth if epidural catheter isn’t in place.
139
Subarachnoid (Spinal) Block Technique
▫ Injected into subarachnoid space in single dose
▫ Appearance of CSF at needle hub ensures correct placement
➢ 25-27 gauge needle
▫ Level of anesthesia is determined by volume concentration & density of drug
▫ Woman loses both sensory and motor function below SAB
140
Contraindications and Precautions for Subarachnoid (Spinal) Block
- Woman’s refusal
- Coagulation defects
- Uncorrected hypovolemia
- Infection in area of insertion
- Systemic infection
- Allergy
141
Major Adverse Effects of Subarachnoid Block
- Maternal Hypotension (most likely with SAB)
- Bladder distention
- Postdural puncture headache
142
Postdural Puncture Headache
- Can occur from CSF leakage at site of dural puncture.
| - Less likely to occur if small-gauge needle is used.
143
Postdural Puncture Headache is worse when
Woman is upright**
144
Postdural Puncture Headache can disappear when
Lying flat**
145
What can be done to relieve postdural puncture headache?
Bed rest with oral or IV hydration helps relieve the postdural puncture headache.
146
System Drugs for Labor
Include opioid analgesics, adjunctive drugs, nitrous oxide.
147
Nitrous Oxide
“Laughing gas”
- For labor pain.
- Gas is delivered as 50% nitrous oxide and 50% oxygen.
148
What are some possible side effects of nitrous oxide?
Nausea
Vomiting
Dizziness
149
Analgesics that can be used for labor are
1. Pure opioid agonists
| 2. Mixed opioid agonists
150
What mixed opioid agonists can be used during labor?
➢ butorphanol (Stadol)
| ➢ nalbuphine (Nubain)
151
What pure opioid agonists can be used for labor?
- Meperidine (Demerol)
| - Fentanyl (Sublimaze)
152
Meperidine (Demerol)
o dysphoric rather than analgesic effect
o Restless or irritable & have twitching, jerking, shaking, tremors or delirium
o Produces long-lasting active metabolite (normeperidine) with half life of 3-6 hours in women but 3 days in newborn
153
Women dependent on opioids (like heroin) should avoid
Agonist-antagonist Drugs b/c may cause withdrawal effects in her and her newborn.
154
Primary effect of opioids is
Respiratory depression -> more likely to affect newborn.
155
Infant born at peak of drug’s action are more likely to
Have respiratory depression than if born earlier or later.
156
Normeperidine
Can cause delayed respiratory depression in newborn.
157
Opioid analgesics are given in
Small, frequent doses by IV route during labor provide a rapid onset of analgesia and predictable duration of action.
158
Injection of opioids are started at
The onset of contractions when blood flow to placenta is reduced; limits transfer to the fetus.
159
Opioid Antagonists include
Naloxone (Narcan)
160
Naloxone (Narcan)
- Reverse opioid-induced respiratory depression but does not revere respiratory depression from other causes.
- Respiratory depression can recur.
161
What intervention takes precedence in treating respiratory depression caused by opioids in newborns?
Airway management (bag & mask ventilation) takes precedence over use of Naloxone for newborn. Drug is not routinely given to baby. **
162
Small doses of opioid antagonists in postpartum woman
Can be given o relieve pruritus that occurs with intrathecal or epidural narcotics.
163
Adjunctive Drugs for Pain during Labor include
Includes those with antiemetic and tranquilizing effects and sedatives. Given to reduce nausea and anxiety to promote rest.
Promethazine and Hydroxyzine.
164
Promethazine
Relieves N/V**
165
Hydroxyzine**
Is also antihistamine with antiemetic effects.
166
Vaginal Birth Analgesia include
- Local infiltration anesthesia
- Pudendal block
- General anesthesia
167
Local Infiltration Anesthesia
▪ Done just before performing episiotomy or sutures a laceration
▪ Does not alter pain from uterine contractions or distension of vagina
▪ Local agent provides anesthesia in immediate area of episiotomy or lacerations
▪ Burning feeling before anesthetic action begins
▪ Rarely has adverse effects
168
Pudendal Block
▪ Anesthetizes lower vagina and part of perineum to provide anesthesia for an episiotomy and vaginal birth, suing low forceps is needed
▪ Does not block pain from uterine contractions and mother feels pressure
169
Possible maternal complications of pudendal block
- Toxic reaction to anesthetics
- Rectal punctures
- Hematoma
- Sciatic nerve block
170
General Anesthesia
Involves loss of consciousness and rarely used for vaginal birth but more used for c-sections
171
General Anesthesia: Technique
▫ Before induction, woman breathes oxygen for 3-5 minutes or at least 4 deep breaths to increase oxygen stores and those of fetus for short period of apnea during rapid anesthesia induction
172
Adverse Effects of General Anesthesia
▫ Maternal aspiration of gastric contents
▫ Respiratory depression
▫ Uterine relaxation
173
Maternal aspiration of gastric contents can result in
Airway obstruction.
174
Aspiration of acidic secretions results in
Chemical injury to airways -> pneumonitis
175
Respiratory depression in general anesthesia
More likely in baby/ more likely to occur if interval between induction of anesthesia and cord clamping is long.
176
Uterine relaxation from general anesthesia
Can be good for treating some complications but postpartum hemorrhage can occur if uterus relaxes after birth.
177
Methods to minimize adverse effects of general anesthesia
➢ Restrict intake to clear fluids or maintaining NPO status if surgery expected
➢ Administering drugs: to RAISE gastric pH and make secretions less acidic, to REDUCE sections and to SPEED gastric emptying
➢ Using cricoid pressure (sellick maneuver) to block esophagus by pressing rigid trachea against it
178
Sellick maneuver**
...
179
You can prevent neonatal respiratory depression caused by general anesthesia by
➢ Reducing time from induction of anesthesia to clamping of umbilical cord
➢ Keeping use of sedating drugs & anesthetics to minimum until cord is clamped
180
Nursing Process: Assessment for Pain
o Preferences for pain management
o Previous surgeries, type of anesthesia, and anesthesia-associated problems
o Maternal vital signs
o FHR & electronic fetal monitor patterns
o Allergies (esp with opioid analgesics, dental anesthetics and iodine)
o Oral intake – time and type of last intake
o Evidence of pain
o Labor Status
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Assessing Labor Status
▪ Assess pain by clarifying words the woman uses (ex: discomfort, cramping, aching, pressure)
▪ Ask to rate pain on scale may underrate pain because they have little experience
▪ Assess body language moaning, crying, thrashing, and inability to use nonpharmacologic techniques
▪ Evaluate labor status to help determine appropriate method of pain control
▪ Avoid making assumptions about woman’s pain level based on labor progress, cervical dilation or apparent intensity (can not be equated together)
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Interventions for Pain focuses on
o Focuses on reducing factors that hinder woman’s pain control & enhancing those that benefit it
o Promoting Relaxation
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Interventions for Pain include
▪ Make environment comfortable
▪ Suggest music or television to make noise
▪ Warm blanket, cool cloth or warm pack
▪ Change linens & underpads as needed
▪ Offer warm shower or bath, walking and water therapy
▪ Reduce intrusions as much as possible (ex: wait until contraction is over to ask questions)
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Interventions for Reducing Outside Sources of Discomfort
▪ Anesthetize the IV site with lidocaine before inserting line
▪ Remind to change position regularly to reduce tension & discomfort from constant pressure
▪ Support with pillows
▪ Observe for bladder distention hourly and encourage to void every 2 hours or more often
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Interventions for Reducing Anxiety and Fear
▪ Tell woman about her labor and its progress
▪ Woman may be willing to endure more discomfort than she otherwise would if she is making progress
▪ Be honest if problems do occur
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How can you help women use nonpharmacologic techniques during labor?
▪ Encourage woman to do effleurage on uncovered areas of her abdomen or stroke thighs
▪ Use low, soothing voice when helping to use imagery & music can enhance stimulation techniques
▪ Encourage woman to change breathing techniques when she feels it is necessary but save complex ones for later labor
▪ If she hyperventilates, breathe into paper bag or hands or a washcloth placed over her nose and mouth
▪ Teach breathing techniques to unprepared women and her coach when admitted
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When teaching pain management techniques to unprepared women, follow these guidelines?
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▫ Teach one method at a time
▫ Demonstrate method b/w contractions
▫ Use breathing techniques with woman while maintaining eye contact
▫ Give her control over her labor
▫ Speak in soft, calm tone of voice
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Epidural Anesthesia: Assessment
o Focus on possible allergies to local anesthetics or opioid drugs that might be used
o Determine baseline maternal vital signs & FHR and pattern
o Assess for any skin infection in the area of back where epidural will be inserted
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Epidural Analgesia: Interventions for Maternal Hypotension
▪ Infuse prescribed IV solution, at least 500-1000 mL before block’s initiation notify anesthesia professional if doesn’t receive full amount before epidural started
▪ If in sitting position while getting block, have her hug a billow or birth ball to hold correct position
▪ Tell anesthesiologist when she is having a contraction
▪ After started, maintain position so aortocaval compression is avoiding
▪ Measure BP & pulse rate every 2-3 minutes for 15-20 minutes after initial injection
▫ Significant decrease = 20% fall from baseline or drop to 100 mmHg or lower systolic
▪ If hypotension occurs increase IV fluid infusion & keep position to avoid aortocaval compression
▫ Ephedrine if hypotension is significant (5-10 mg)
▪ Observe FHR signs of reduced perfusion can occur before woman shows signs of hypotension (fetal tachycardia or bradycardia, late decelerations)
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Epidural Analgesia: Interventions for Avoidance of Injury
▪ To prevent falls, women should not walk alone -> most must remain in bed or sit in nearby chair after epidural is begun
▪ Assess degree of motor block & sensation hourly -> report any increase or change
▪ Woman who has reduced mobility and sensation should be moved so maintains anatomic position -> avoid prolonged pressure on one area -> changing positions often improves labor progress
▪ Before ambulation, test ability to raise and move her legs as well as strength -> have her sit before standing to evaluate for orthostatic hypotension
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Assessment for Respiratory Compromise
o Document type and time of woman’s last food intake
| o Question closely if she reports an unusually long interval since her last oral intake
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Interventions for Respiratory Compromise: Identify Risk Factors
▪ Report oral intake both before and after admission to anesthesia provider
▪ Oral intake should be restricted to medications, clear liquids like water and ice, clear fruit juices, carbonated drinks, clear tea and coffee, sports drinks and popsicles or hard sugar-free candies
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Interventions for Respiratory Compromise: Perioperative Care
▪ Restrict oral intake if surgery expected
▪ Give ordered medications
▪ Apply cricoid pressure (Sellick maneuver) to block esophagus until woman is intubated and cuff of endotracheal tube is inflated
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Interventions for Respiratory Compromise: Postoperative Care
▪ Woman is extubated when her protective laryngeal reflexes have returned, often before transfer from operating table
▪ Suction equipment and Ambu bag with appropriate-size mask should be immediately available
▪ Administer oxygen by mask or face tent for 2-5 minutes until woman is awake and alert b/c agents used for general anesthesia are respiratory depressants
▪ Monitor oxygen saturation if falls below 95%, have her take several deep breaths deep breathing also helps her eliminate inhalational anesthetics and reduces stasis of pulmonary secretions
▪ Assess pulse rate, respiration and BP every 15 minutes for 1 hour until stable
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Why would you use general anesthesia?
- If they have low platelet count.
- If they had spinal fusion where they can’t bend over.
- Scoliosis
