Chapter 17

Question 1

unique nature of pain during birth

Answer 1

• 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

Question 2

pain during labor and birth

Answer 2

-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

Question 3

Neurologic origins

Answer 3

1st stage visceral pain 2nd stage somatic pain

Question 4

Physiologic Factors

Answer 4

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

Question 5

other factors

Answer 5

• 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?

Question 6

nonpharmacologic pain management advantages

Answer 6

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

Question 7

nonpharmacologic pain management limitations

Answer 7

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

Question 8

childbirth preparation methods

Answer 8

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

Question 9

relaxation

Answer 9

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

Question 10

effeurage

Answer 10

rubbing abdomen as during breathing techniques

Question 11

counterpressure

Answer 11

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

Question 12

breathing techniques

Answer 12

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

Question 13

music

Answer 13

releases endorphines, so makes you happy

Question 14

nonpharmacologic methods

Answer 14

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

Question 15

Criteria for pain relief

Answer 15

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

Question 16

pharmacologic pain relief

Answer 16

• 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

Question 17

opioid agonists drugs

Answer 17

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

Question 18

opioid agonists

Answer 18

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

Question 19

opioid (narcotic) agonist

Answer 19

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

Question 20

opioid (narcotic) antagonists

Answer 20

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

Question 21

nerve block analgesia and anesthesia

Answer 21

• 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)

Question 22

local perineal infiltration

Answer 22

• 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

Question 23

pudendal block

Answer 23

• 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

Question 24

Epidural

Answer 24

• 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

Question 25

pior to epidural

Answer 25

``` “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 ```

Question 26

epidural requires

Answer 26

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

Question 27

With intravascular injection you have

Answer 27

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

Question 28

With insertion into spinal fluid

Answer 28

rapid & intense motor and sensory block

Question 29

last steps of epidural

Answer 29

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

Question 30

Adverse effects with epidural

Answer 30

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

Question 31

Nursing care for epidurals

Answer 31

``` 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 ```

Question 32

(spinal) subarchnoid block

Answer 32

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

Question 33

spinal care

Answer 33

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

Question 34

general anesthesia

Answer 34

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

Question 35

general anesthesia nursing implications

Answer 35

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%)

Question 36

general anesthesia steps

Answer 36

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

Question 37

posible complications post delivery

Answer 37

Fetal depression Uterine relaxation Vomiting and Aspiration