ch. 17 comfort during labor

Question 1

types of pain during labor and birth (neurological (2) origins, perception of pain (8), expression (2))

Answer 1

1) neurological origins:
- visceral: distention of lower uterine segment, cervix (opening up), pressure
- somatic (affects muskuloskeletal, soft tissues, bones, muscle, skin, mucous membranes): intense, sharp, burning, local

2) perception of pain:
- culture, age, previous experiences, parity (# of babies), emotional support, previous trauma (childhood trauma), length of labor, # medical procedures

3) expression of pain:
- physiologic reactions -> affect of labor contractions, ability to cope, maternal positioning (nursing intervention to decrease pain)
- sensory or emotional reactions: Beta endorphins

TIP:
- beta endorphins DECREASE pain, give pleasure, eating chocolate

Question 2

factors that influence pain (8)

Answer 2

• physiologic factors
• culture: nurse must understand how culture mediates the response to pain (family background, expectations)
• anxiety: increased pain, more catecholamine (epi, norepi release), ability to cope (distraction therapy, deep breathing, COUNTER PRESSURE ON LOWER BACK)
• previous experience
• gate control therapy: neural system capacity (explains how everyone has limits, want to decrease perception of pain via distraction)
• comfort: music, aromatherapy, water, hot/cold, breathing
• support: FOB, family, nurse
• environment: SHUT DOWN ROOM (dim lights, low noise level, music)

Question 3

gate control therapy of pain (3)

Answer 3

spinal cord sends signal to brain to be processed and accentuate perception of pain
- nervous system has a capacity for pain and decides what is percieved as pain and what isn’t
- important to use distraction therapy!

Question 4

methods for preparing for labor and birth (11)

Answer 4

1) relaxing and breathing techniques
- focusing and relaxation techniques: focal point to focus on when breahting
- breathing techniques (upon contraction):
(a) slow breathing (4/4 breathing in and out)
(b) quick breathing (“hee-ho”, rapid breathing, tongue on top palate)
(c) patterned breathing (rhythmic breathing - be careful -> can become alkaloic and decrease CO2)

2) effleurage and counter pressure
- light massage around belly and with both hands
- push pelvic bone in (at side of abdomen), pain in lower back (counter pressure)

3) touch and massage

4) application of heat and cold: can be either, ,medical injury (ice first)

5) acupressure and acupuncture

6) transcutaneous electrical nerve stimulation (TENS)

7) water therapy (hydrotherapy)

8) intradermal water block:
- used to decrease pain perception
- inject small amounts of water -> lower back cause labor reject) (1/2 cc, 4 points)

9) aromatherapy

10) music

11) hypnosis

Question 5

effective comfort measures (non pharm) (8)

Answer 5

• providing information
• encouragement
• back rubs, shoulder rubs
• clean linen
• positional changes (ambulation)
• relaxation, breathing techniques
• heat/cold
• aromatherapy, music

Question 6

effective comfort measures induction pharm (3)

Answer 6

• decrease discomfort
• increase relaxation
• reestablish ability to participate more actively in the labor and birth experience

Question 7

pharmacologic pain mgmt types (3)

Answer 7

1) systemic analgesia
2) nerve block analgesia, anesthesia
3) sedatives

Question 8

systemic analgesia (what, types (3))

Answer 8

opioids readily cross the placenta
- has effects on the fetus/newborn can be profound
- analgesic effect in labor is LIMITED
- quick acting, usually effective

types:
1) opioid (narcotic) agonist analgesics
2) opioid (narcotic) agnostic-antagonistist analgesics
3) opioid (narcotic) antagonists (narcan)

TIP:
- most substance users use before coming in to decrease anxiety

Question 9

nerve block analgesia and anesthetics (what, types (3) )

Answer 9

used to produce sensory blockade and various degrees of motor blockade over a specific region of the body
- local perineal infiltration anesthesia (sensory)
- pudendal nerve block (sensory)
- spinal anesthesia (block) (sensory/motor)
(a) post dural puncture headaches (complicaion of puncture to dura mater)
(b) epidural blood patch (procedure done to stop leakage of CSF and spinal headaches)

Question 10

sedatives (what, 3 types)

Answer 10

relieve anxiety and induce sleep
- may be given to a woman experiencing a prolonged early phase of labor when there is a need to decrease anxiety and promote sleep (amniotic sac released, no contractions though)

(a) barbiturates:
- seldom used in obstetrics (seconal, ambien)

(b) phenothiazines:
- seldom used in obstetrics (compazine, prolixin)
- used for psychosis

(c) benzodiazepines:
- when given with an opioid analgesic, pain relief is enhanced, and nausea/vomiting are reduced (valium, versed) (sometimes given together)

Question 11

opioid analgesics: fentanyl (sublimaze) (what, onset, dosage, usage, nursing, must confirm, critical, if neccessary)

Answer 11

short acting opioid with moderate analgesia & mild sedation qualities
- rapid onset; short half life
- dosage: 50-100 mcg Hour
- usage: woman in active labor
- nursing: drug dependency?
- must confirm that patient has no opioid dependency or addiction
- CRITICAL: OBSERVE FOR RESPIRATORY DEPRESSION in mother and baby
- use narcan if necessary

Question 12

nubain (nalbuphine hydrochloride) (class, dose/route/frequency, side effects (5), life threatening reactions (2), contraindications)

Answer 12

1) class: CNS agent, analgesic, narcotic agonist, antagonist

2) dose, route, frequent: 10-20 mg every 3-6 hours PRN SQ/IM/IV

3) common side effects: sedation, sweaty, clammy skin, nausea/vomiting

4) life threatening reactions: respiratory depression, all opioids life threaten reaction

5) contraindication: hypersensitivity to drug

TIP: opiate analgesic not as strong as fentanyl
- narcotic analgesic

Question 13

epidural anesthesia or analgesia (block) (what, disadvantages)

Answer 13

1) most effective pharmacologic pain relief method for labor
- effectively relives the pain caused by uterine contractions but does NOT completely remove the pressure sensations (TIP: sensory, NOT MOTOR)

2) disadvantages:
- MATERNAL HYPOTENSION
- generalized itching: give Benadryl
- variations in level of relief: sometimes doesn’t work!

TIP:
maternal hypotension tx:
- increase IV fluids
- meds to increase BP
HOWEVER: if early renal failure, can bolus to prevent maternal hypotension, question fluid intake and length of labor

Question 14

combined spinal epidural (CSE) (what, 2)

Answer 14

analgesia, aka “walking epidural”
- most women don’t walk however due to sedation and fatigue, abnormal sensations in and weakness of LE, feeling of insecurity
- go into dura space/spinal column to place epidural

TIP:
caution women on blood thinners as it can cause patient to bleed into spinal cavity

Question 15

epidural and intrathecal (spinal) opioids (4)

Answer 15

• continuous infusion of fentanyl and morphine
• may affect fetus
• usually used for post op pain
• usually given in combination with local anesthetic due to not providing adequate analgesia

Question 16

lumbar epidural anesthesia (4)

Answer 16

• sensory and motor block
• continuous infusion fentanyl and morphine
• outside of spinal column (air pocket)
• if reached CSF -> gone too far

Question 17

contraindications to subarachnoid and epidural blocks (9(

Answer 17

• active or anticipated serious maternal hemorrhage
• maternal hypotension
• maternal coagulopathy: thrombocytopenia (decreased clotting, increase bleeding chance)
• infection at the injection site
• increased intracranial pressure: spinal headaches
• allergy to anesthetic drug
• maternal refusal or inability to cope
• some types of maternal cardiac conditions
• spinal surgeries, severe scoliosis (CAN CAUSE CHRONIC PAIN)

Question 18

nitrous oxide for analgesia (what, OB, route, side effects (4))

Answer 18

• nitrous oxide mixed with oxygen can be inhaled in a low concentration (50% or less) to provide analgesia during labor ad birth (only given during contractions)
• OB: 50% nitrous oxide with 50% oxygen
• route: inhaled with contractions or DURING procedures
• side effects: sedation, nausea, dizziness, inactivates vitamin B12 (can be enough to get her through)

Question 19

general anesthesia (ER situation) (3)

Answer 19

• rarely used to control uncomplicated vaginal birth
• woman should be premeditated with (clear) oral antacid to neutralize acidic contents of the stomach
• d/t risk of neonatal narcosis, critical that baby is delivered ASAP after inducing anesthesia, to reduce the degree of fetal exposure to the anesthetic agents and the CNS depressants administered to the mother

TIP:
- can cause fetus to go into CNS depression
- may need to vent due to baby going into respiratory depression!!
- once given, doctor has 5-10 minutes to get baby out d/t baby receiving general anesthesia too!

Question 20

care mgmt for nonpharm interventions (3)

Answer 20

1) pain assessment during labor and birth
- a pain scale (or COPING SCALE) is often used to evaluate a women’s pain before and after interventions are implemented
- pain assessment should also evaluate her ability to cope with labor and her overall satisfaction with the labor and birth experience

Question 21

care mgmt for pharm interventions (7)

Answer 21

• general informed consent (risk vs. benefit, surgery, must educate)
• informed consent for anesthesia (surgery)
• timing of administration (e.g. stage of labor, fetal status) (2-5 min break between contractions)
• preparation for procedures
• administer of medication (IV route, IM route, regional (epidural or spinal) anesthesia)
• professional standards for nurses
• safety and general care

Question 22

a woman in labor has just received an epidural block. the most important nursing intervention is to:

Answer 22

monitor the maternal blood pressure for possible hypotension

Q2min -> Q5min -> Q10min