Flashcards in Chapter 17 Deck (37):
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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
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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
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Neurologic origins
1st stage visceral pain 2nd stage somatic pain
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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
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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?
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nonpharmacologic pain management advantages
no side effects to the fetus, risk for sedation decreases, don't slow down labor
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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
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childbirth preparation methods
if know whats going on makes everything better; education and participatory guidance are very important
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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
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effeurage
rubbing abdomen as during breathing techniques
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counterpressure
turn on side, push away from lower spine as counterpressure of the back of the head
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breathing techniques
will speed up as contractions become more intense, swallow breaths, breathe above diagram
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music
releases endorphines, so makes you happy
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nonpharmacologic methods
HYDROTHERAPHY
NERVE STIMULATIO/ACUPRESSURE
HEAT AND COLD
TOUCH
HYPNOSIS
BIOFEEDBACK
AROMATHERAPY
WATER BLOCK
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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
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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
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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
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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
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opioid (narcotic) agonist
stadol, nubain -- act to depress pain at certain receptor sites
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opioid (narcotic) antagonists
narcan - give to newborn after delivery or to mom in labor
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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)
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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
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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
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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
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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
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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
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With intravascular injection you have
tachycardia, Pulse O2 <95% , C/O Ringing in ears/tongue numbness
THEN lightheadness
THEN twitching
THEN coma THEN seizures
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With insertion into spinal fluid
rapid & intense motor and sensory block
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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
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Adverse effects with epidural
Hypotension
Bladder distension
Prolonged 2nd stage
Catheter migration
Nausea and vomiting
Pruritus
Delayed respiratory depression
itching something ordered PRN
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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
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(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
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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
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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
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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%)
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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
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