ch 17 - labor pain Flashcards
2 big roles of the nurse during labor
-eliminate/minimize pain
-provide support for effective coping
sources of pain during labor
-stretching
-pressure
-muscle hypoxia
-distention
-emotional tension
factors affecting response to pain
-knowledge
-culture
-personal experience
-fatigue/sleep deprivation
-anxiety
-attention and distraction
-emotional support
results of the work of labor (5)
-fatigue
-diaphoresis
-muscle cramps
-positional discomforts
-N/V
maternal effects of pain in labor (4)
-increased maternal O2 consumption
-increased catecholamine secretion (epi/norepi)
-slows progress of labor
-decreases mom’s self confidence
S+S of pain in labor (6)
-request for meds/epidural
-ineffective use of pain control measures
-screaming, thrashing, crying
-hyperventilation
-sweating, shaking
-inability to relax (especially between contractions)
methods of pain management during labor
-comfort measures: support, environmental control, nursing care
-non-pharmacologic methods
-pharmacologic methods (systemic drugs, regional nerve blocks)
-combo of methods
2 theories in non-pharmacologic pain management
-fear tension pain syndrome
-gate control theory
theory: brain can only process so many pain signals from a part of the body
gate control theory
cognitive non-pharmacologic methods of pain control during labor (2)
-childbirth education
-hypnosis
sensory non-pharmacologic methods of pain control during labor (5)
-aromatherapy
-breathing techniques
-music
-imagery
-focal points
S+S hyperventilation (+resp alk)
-light headedness
-dizziness
-tingling of fingers
-numbness around mouth
breathing patterns (3)
-slowed: abdominal breathing (in 4 secs, out 4 secs)
-cleansing breath (deep breath in and out)
-modified: pant pant blow (“he he ho”)
other non-pharmacologic methods of pain control during labor
-counterpressure
-acupressure/acupuncture
-effleurage, therapeutic touch, massage
-heat and cold, TENS
-water therapy
POSITION:
-walking, rocking, position changes, labor dance
limitations/disadvantages of hydrotherapy
-infection (maybe can’t use with ROM)
-no electric fetal monitoring
-overheating
-underwater birth (unplanned)
-cleaning/universal precautions
-birth attendant discomfort
positions for labor
-sitting/squatting
-lateral/side lying
-hands and knees
pharmacologic categories of pain control during labor (3)
-systemic sedatives and analgesics
-nerve block analgesia and anesthesia
-general anesthesia
assessments for pharmacologic interventions during labor
-drug allergies, Hx of liver and kidney damage
-patient desires, birth plan
-stage of labor, cervical exam, contraction pattern
-lab values (Hgb, Hct, plts, clotting time)
-hydration status
-S+S infections
-degree of pain
-response to nonpharmacologic measures
-stable maternal VS
-good contraction pattern
-guideline: atleast 4-5 cm (1st time mom), 3-4 cm (2+ time mom)
-stable fetal VS
pharmacologic pain management: relieve anxiety and induce sleep; typically used for women in in a prolonged latent phase of labor when there is a need to lessen the intensity of the contractions, decrease anxiety, or promote sleep; generally contraindicated in active labor
sedatives
barbiturate sedatives (2)
secobarbital
zolpidem (ambien)
benzodiazepine sedatives (after delivery) (1)
diazepam (valium)
phenothiazine sedative (opioid agonist) (1)
promethazine (phenergan)
metoclopramide action
antiemetic
potentiates analgesics
2 classes opioids
OPIOID AGONIST
-takes edge off pain
-can cause significant resp depression in newborn
***not appropriate for right before birth
OPIOID AGONIST-ANTAGONIST
-pain relief
-don’t typically cause resp depression
opioid agonist meds (3)
-meperidine (demerol)
-fentanyl (sublimaze)
-remifentanil (ultiva)
opioid agonist-antagonist meds (2)
-butorphanol (stadol)
-nalbuphine (nubain)
opiate antagonist
naloxone (narcan)
*half life is less than half life of narcotics
why are meds preferably given IV during labor
-stomach isn’t emptying
-quicker absorption
-N/V
IV onset, peak, and duration times
onset: 5 or less mins
peak: 30 min
duration: 1-2 hr
IM onset, peak, and duration times
onset: within 30 mins
peak: 1-3 hr
duration: 4-6 hr
who should not receive opioid agonist-antagonist med (highly contraindicated)
patient with narcotic dependency
*puts mother and fetus into drug withdrawal
side effects nitrous oxide (3)
-N/V
-drowsiness, dizziness, hazy memory
-LOC (especially if combined with narcotics)
2 types regional nerve blocks
REGIONAL ANALGESIA
-some pain relief and motor block
REGIONAL ANESTHESIA
-complete pain relief and motor block
agents used in local anesthetic agents
“-caine”
-bupivacaine
-chloroprocaine
-lidocaine
when is local infiltration anesthetic used during labor
right before birth if dr knows tearing or episiotomy will happen
when is pudendal block anesthetic used during labor
“extended local anesthetic”
-injected in pudendal nerve
-takes 10-20 mins to kick in
-often given when vacuum/forceps will be used
when is spinal block anesthetic used
for C-section
effective immediately, shorter duration
when is epidural block anesthetic used
for vaginal delivery
runs continuously, but can take a bit of time to kick in
where is spinal block anesthetic needle placed
subarachnoid space in CSF
where is epidural block anesthetic needle placed
epidural space between dura mater and fascia
CLE
continuous lumbar epidural
CLE
continuous lumbar epidural
epidural level determinants (3)
-location of catheter tip
-dose and volume of anesthetic agent used
-woman’s position
advantages to epidural (4)
-effective
-decrease catecholamines
-decrease hyperventilation
-awake and alert
disadvantages to epidural (5)
-cost
-continuous EFM, IV
-loss of sensation and limited movement
-bladder atony with urinary retention
-increased risk: PPH, operative vaginal birth (forceps, vacuum)
epidural complications
-toxicity (gets into bloodstream)
-total spinal/high spinal
***hypoTN
-post dural puncture headaches (PDPH)
-neuropathy
-backache
most common epidural complication
hypotension
S+S regional anesthesia toxicity (5)
-tingling of extremities
-metallic taste in mouth
-ringing in ears
-confusion/uneasy feeling
-convulsion
Tx post dural puncture headache (5)
-hydration
-caffeine
-dark room
-lie flat on bed
-possible postdural blood patch
rare epidural complications (6)
-hyperthermia
-length of labor (increased)
-second stage (mom can’t feel urge to push/if they’re pushing)
-increases fetal malpositions (OP)
-use of oxytocin (bc epidural slows contractions)
-increased risk operative birth (forceps, vacuum, C/S)
epidural and intrathecal opioid meds (“walking epidural”)
(used for postop C/S pain)
-fentayl
-sufentanil
-morphine
advantages of opioid epidural/intrathecal meds
-no effect on bp
-can feel contractions but not pain
-pushing more effective
-motor function intact
side effects of opioid epidural/intrathecal meds (4)
-pruritis
-N/V
-urinary retention
-resp depression (up to 24 hours)
contraindications to epidurals (8)
-actual/anticipated serious hemorrhage
-uncorrected hypoTN
-infection at insertion site
-coagulopathy
-increased ICP
-drug allergy
-refusal/inability to cooperate
-certain cardiac conditions
S+S maternal hypoTN with decreased placental perfusion
-maternal hypoTN
-fetal bradycardia
-decreased FHR variability
nursing interventions for maternal hypoTN after epidural (7)
-turn mom to side
-maintain IV infusion, increase rate/give bolus
-O2 8-10 L/min
-elevate legs
-notify hcp
-possibly administer IV vasopressor (ephedrine 5-10 mg)
-monitor maternal bp and FHR q5mins until stable
when is general anesthesia used during labor
C/S and no time/contraindication to epidural
meds to minimize risks of aspiration with general anesthesia during labor
MEDS:
-nonparticulate antacid
-possible H2 receptor blocker (famotidine/ranitidine)
-possible metoclopramide
how to minimize fetal exposure to general anesthetic agent
all surgical prep done before mom is anesthetized
