Labor Pain Management

Question 1

Sources of Labor Pain

Answer 1

emotional (fear, tension, pain)

functional (dilation and contractions)

physiologic (maternal and fetal position)

Question 2

Visceral Pain

Answer 2

pain related to internal organs

related to changes in cervix, uterine ischemia during contractions

Question 3

Referred Pain

Answer 3

pain felt in one part of body is caused by pain in another part

pain originates in uterus but pt may feel in abdominal wall, lower back, hips, butt and thighs

Question 4

Somatic Pain

Answer 4

localized pain from muscles, bones or soft tissues

stretching of perineum during second stage, soft tissue lacerations, fetal pressure on structures

Question 5

Non-Pharmacological Pain Relief

Answer 5

hydrotherapy
birthing ball
peanut ball
open vs closed knee position (rotation of femur)
cub
paced breathing and relaxation
guided breathing exercises

Question 6

Non-Pharmacological Pain Relief

Answer 6

hydrotherapy
birthing ball
peanut ball
open vs closed knee position (rotation of femur)
cub
paced breathing and relaxation
guided breathing exercises
music/guided meditation (relaxing environment, decreases anxiety by stimulating release of endorphins, can lower pain intensity when used during latent phase of labor, promotes increased O2 intake)
guided imagery
aromatherapy
acupuncture/counter pressure/massage (reduces labor pain and time; effleurage)
yoga (lower pain intensity)
heat and cold application (warm to perineum to help discomfort from stretching and prevent tearing)

Question 7

Non-Pharmacological Pain Relief Benefits

Answer 7

no limitations to mobility during labor and after delivery
fastest recovery for pt and baby
facilitates partner participation
minimal intervention

Question 8

Analgesia

Answer 8

pain relief

Question 9

Anesthesia

Answer 9

partial/complete loss of sensation with or without LOC

Question 10

Parenteral Analgesia

Answer 10

assess maternal, fetal and labor prior to admin
timing: stage of labor?

opioid agonists for intermittent relief: reduces awareness of pain (butorphanol, meperidine, hydromorphone, nalbuphine)

opioid antagonists (naloxone)

antiemetics (zofran, phenergan)

Question 11

Parenteral Analgesia Advantages

Answer 11

ease of administration (dose can be titrated, pain relief begins in minutes, no LOC, increased relaxation and decreased pain)

RN can administer

Question 12

Maternal Disadvantages of Parenteral Analgesia

Answer 12

may not relieve pain
n/v
drowsiness
confined to bed
continuous EFM

Question 13

Fetal Disadvantages to Parenteral Analgesia

Answer 13

CNS depression; decreased FHR variability
respiratory depression
decreased reflexes (suckling)
can impair early breastfeeding
decreased ability to regulate temp

Question 14

Nitrous Oxide

Answer 14

colorless and odorless gas that is mixed 50/50 with O2; alternative to epidural

when breathed in, reduces anxiety and increases feelings of relaxation and well being

inhaled through mask/mouthpiece

can use at any stage of labor and delivery!

Question 15

Nitrous Oxide Advantages

Answer 15

doesn’t impair patient mobility
no additional monitoring required
self admin provides pt with control
med effects stopped as soon as mask is removed

Question 16

Nitrous Oxide Disadvantages

Answer 16

n/v
dizziness
drowsiness

Question 17

Nitrous Oxide Safety Concerns

Answer 17

risk of respiratory depression when combined with opioids (may increase likelihood of maternal hypoxemic episodes)

rapidly crosses placenta but rapidly eliminated by neonate upon commencement of breathing

Question 18

Local Anesthesia

Answer 18

episiotomy/laceration and repair (lidocaine)

Question 19

Pudendal Anesthesia (Regional)

Answer 19

local anesthesia to perineum, vulva, and rectal areas during delivery, episiotomy and episiotomy repair (lidocaine, bupivacaine)

administered transvaginally into space in front of pudendal nerve

Question 20

Epidural Anesthesia (Regional)

Answer 20

bupivacaine/fentanyl on PCA pump; analgesia and anesthesia

epidural space located between the dura mater and ligamentum flavum

Question 21

Spinal Anesthesia (Regional)

Answer 21

intrathecal opioids/duramorph

spinal anesthesia agent is administered into the CSF in the subarachnoid space

Question 22

General Anesthesia

Answer 22

stat Cesarean, other emergencies

regional CI/impossible

Question 23

Epidural Nursing Care PRIOR to Admin

Answer 23

educate, consent, safety check

prep pt (positioning, monitors)

report HTN, bleeding disorder, systemic infection

administer fluid bolus to stabilize BP

Question 24

Epidural Nursing Care DURING/AFTER Administration

Answer 24

BP Q5 min or per protocol

review labor progress, FHR and CTX patterns

keep bladder empty (Foley!!)

position for Pain and Passenger (don’t leave supine for an extended period of time)

Question 25

Epidural CI

Answer 25

previous spinal injury/surgery severe scoliosis BMI of 50+ ICP (space occupying brain lesion) local/systemic infection thrombocytopenia/coagulation disorders actual or anticipated maternal hemorrhage **anesthesia consult before labor!!**

Question 26

Epidural Advantages

Answer 26

indefinite duration (*continuous pain relief, relaxation, excellent coverage in labor*) titratable in relation to state of labor (**pt can administer bolus**) remain alert and participate in birth no blood loss, no delay in gastric emptying, respiratory reflexes remain intact fetal complications rare!

Question 27

Epidural Disadvantages

Answer 27

risk of hypotension (**leads to fetal brady or maternal cardiac arrest**) strict bedrest: IV infusion, monitoring equipment, lower limb weakness (**may interfere with pushing and fetal descent; longer labor or C/S or help progress labor**) possible post-dural puncture HA (**rare; blood patch as treatment**) longer maternal recovery (**can’t ambulate as early; palpitations, vertigo, tinnitus, HA, infection, fever, convulsions**)

Question 28

Hypotension Nursing Action

Answer 28

left side, elevate legs bolus of IV fluids monitor BP O2 by face mask get help (provider, anesthetist)

Question 29

Spinal Block for C/S

Answer 29

anesthetic into CSF various dermatomes (*red block for vaginal; blue block for C/S*) rapid onset (*preload with fluid; hypotension*) higher risk for spinal HA (blood patch treatment!)

Question 30

General Anesthesia Complications

Answer 30

fetal depression (*anesthetic agents reach fetus in minutes; need to delivery immediately and not advised for preterm babies*) greater blood loss due to uterine relaxation aspiration; increased chance of emesis amnesia hypoxia

Question 31

General Anesthesia Nursing Interventions

Answer 31

give antacids pre-op wedge under right hip for L lateral tilt pre-O2 3-5 min of 100% IV fluid bolus cricoid pressure during ET tube placement

Question 32

1st Stage of Labor Pain Relief

Answer 32

opioid agonist and agonist-antagonist analgesics epidural analgesia combined spinal-epidural analgesia nitrous oxide

Question 33

2nd Stage of Labor Pain Relief

Answer 33

epidural analgesia combined spinal-epidural analgesia nitrous oxide local infiltration anesthesia pudendal block spinal block anesthesia

Question 34

Vaginal Birth Pain Relief

Answer 34

same as 2nd labor stage but with epidural anesthesia as well

Question 35

C/S Pain Relief

Answer 35

epidural anesthesia spinal block anesthesia general anesthesia