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Flashcards in Chapter 17 Deck (37):
1

unique nature of pain during birth

-Childbirth is a “normal” process
-Has months to prepare for labor
-Pain has a foreseeable end
-Pain is intermittent (with contraction, have it then goes away)
-Pain ends with birth of baby

2

pain during labor and birth

-Neurologic origins
-Perception of pain
-Expression of pain
-Factors that influence pain response (tolerating pain - how much pain someone is willing to induce; support? prepared? what methods individual wants)
peoples response in labor - blood pressure increase, n/v, can hyperventilate which increases pain level

3

Neurologic origins

1st stage visceral pain 2nd stage somatic pain

4

Physiologic Factors

dilation and effacement (thinning of cervix) - allow baby to leave uterus
pressure and pulling on pelvic structures
distention of the vagina and perineum
contractions - stop blood flow
fatigue - the more tired you are the less you can handle pain
support and help of caregivers
fetal position - face presentation can cause more pain

5

other factors

-culture
-anxiety - if pt is nervous and they don't know whats going to happen, muscles will tense
-pervious experience - will affect ability to cope
-gate-control theory of pain - paplov's, distract brain will decrease pain level
-comfort - position mom wants to be in will diminish pain
-support
-environment - comfortable? can see more around?

6

nonpharmacologic pain management advantages

no side effects to the fetus, risk for sedation decreases, don't slow down labor

7

nonpharmacologic pain management limitations

if doesn't work then between a rock and hard place if only method for pain, have to be educated before labor

8

childbirth preparation methods

if know whats going on makes everything better; education and participatory guidance are very important

9

relaxation

teach constant relaxation - how to relax complete body, think of some place you really enjoy, relax every body part complete, teach how to relax towards the touch

10

effeurage

rubbing abdomen as during breathing techniques

11

counterpressure

turn on side, push away from lower spine as counterpressure of the back of the head

12

breathing techniques

will speed up as contractions become more intense, swallow breaths, breathe above diagram

13

music

releases endorphines, so makes you happy

14

nonpharmacologic methods

HYDROTHERAPHY
NERVE STIMULATIO/ACUPRESSURE
HEAT AND COLD
TOUCH
HYPNOSIS
BIOFEEDBACK
AROMATHERAPY
WATER BLOCK

15

Criteria for pain relief

1. must be as safe as possible for mom/baby
2. must relieve pain
3. must not interfere with labor progress

16

pharmacologic pain relief

-if drug passes placenta will have some effect on baby
-epidural can compromise mom bp and then endanger fetus blood flow
-no pain relief until active stage of labor, if given too early then can stop labor
-some meds might not be okay depeds on mom and baby

17

opioid agonists drugs

Dilaudid (takes effect 10-15 min), Demerol (IV push, given over morphine but high rate of respiratory depression), Fentanyl (Sublimaze) (short acting), Sufenta

18

opioid agonists

reduces proceptions of pain w/o sedation, higher level of people vomiting, given IV some IM, usually if birth in 4 hours don't give IV meds, watch respiratory rate in mom

19

opioid (narcotic) agonist

stadol, nubain -- act to depress pain at certain receptor sites

20

opioid (narcotic) antagonists

narcan - give to newborn after delivery or to mom in labor

21

nerve block analgesia and anesthesia

-Local Perineal Infiltration
-Pudendal Block
-Epidurals
-Spinal (subarchnoid block)
-Combined Epidural/Intrathecal(spinal)
-General anesthesia/Nitrous Oxide (malpractice in the US, have to get baby out in 5 minutes)

22

local perineal infiltration

-Usually xylocain 1%
-Numbs perineum for repair of episiotomy
-No relief of contraction pain
-Fan like multiple injections
-Post delivery: ice to perineum (24hrs.) to decrease edema, hematoma formation then sitz baths

not to give relief from pushing or contractions, done for repair of epistotomy

23

pudendal block

-Numbs the lower vagina/perineum for vaginal birth
-No relief of contraction pain, done just before delivery for vacuum and forceps delivery
-Transvaginally inject the pudendal nerve through the vagina using a trumpet needle guide
-Usually xylocaine 1%
-not for relief of contraction for 2nd pushing stage

24

Epidural

-Pain relief for both contractions and delivery
-Type of regional anesthesia
-Usually a local anesthetic and an opioid analgesic are used together
-Injected into epidural space between the dura and the spinal canal,usally L3-L4 for vaginals and T4-T6 c-sections. Can reposition for c-sec. if it’s not expected
-most common in US
-epidural space- negative pressure space
-want mom laying straight or have hot spots where it goes to the side
-does not get rid of al sensations of done correctly
-have to have time for it to take affect
-watch for oxygenation so mom has pulse ox

25

pior to epidural

“cat” position
prep w/ Betadine
skin wheal to numb injection area
uses glass syringe with 18# needle
-has to be dead center in the epidural space to balance it

26

epidural requires

10x more med than spinal because it is outside the meninges


-Sooo…Give a test dose BEFORE starting large amounts of medication
-Test dose: to watch for improper placement in a vein or in the subarachnoid space
-Epinephrine (3 ml) is given before a full dose is given

27

With intravascular injection you have

tachycardia, Pulse O2 <95% , C/O Ringing in ears/tongue numbness
THEN lightheadness
THEN twitching
THEN coma THEN seizures

28

With insertion into spinal fluid

rapid & intense motor and sensory block

29

last steps of epidural

Then combination of drugs are given–
Local anesthetic (Naropin) with an analgesic (Fentanyl)
All drugs are preservative free to prevent paralysis by drug attaching to nerve root and sloughing off
Takes approximately 20 minutes to take affect and is positional
- needs to be preservative free so no damage to the nares

30

Adverse effects with epidural

Hypotension
Bladder distension
Prolonged 2nd stage
Catheter migration
Nausea and vomiting
Pruritus
Delayed respiratory depression
itching something ordered PRN

31

Nursing care for epidurals

Preload with RL 500-1000ml
Displace uterus to left manually with a wedge
Assess for hypotension
Assess FHR
Evaluate bladder regularly and empty PRN
Transfer and move with assistance
Up only after epidural has worn off

32

(spinal) subarchnoid block

Done when a stat c-section is needed and no epidural has been done
Major problems: hypotension, headaches, bladder distension
Advantages: simple, rapid, low failure rate

33

spinal care

Bed rest
Hydration
May need a blood patch- 10-15 mls of the woman’s blood is injected into the epidural space to close dura and stop spinal fluid leakage
CAN DO A EPIDURAL/SPINAL COMBINATION

34

general anesthesia

For c-section-- if epidural or spinal not possible or if woman refuses a regional
Leading cause of death is aspiration
Considered malpractice by many if used for a vaginal delivery
Meds do cross the placental barrier and end up w/ sleepy infants at delivery
To reduce amount of time with anesthesia till cord clamping, woman is prepped and draped before anesthesia is given
contraindicated unless mother won't let you do anything else or emergency

35

general anesthesia nursing implications

Check on last time food/fluid
Restrict fluid intake PO
Give ordered drugs (IV Pepcid) - prevent aspirating
Give O2 after extubation and evaluate O2 saturation after procedure (>95%)

36

general anesthesia steps

First, gives Penathol and O2- no pain relief but puts to sleep for intubation
Wedge under hip
SELLICK MANEUVER

Second, Nitrous Oxide and O2 till cord is clamped—procedure is timed to get baby out within 5 minutes

Third-After cord clamped meds to produce deep sleep-more Penathol, narcotics and inhalation agents

37

posible complications post delivery

Fetal depression
Uterine relaxation
Vomiting and Aspiration