ch 17 - labor pain Flashcards by McKenna Michael

2 big roles of the nurse during labor

-eliminate/minimize pain
-provide support for effective coping

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sources of pain during labor

-stretching
-pressure
-muscle hypoxia
-distention
-emotional tension

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factors affecting response to pain

-knowledge
-culture
-personal experience
-fatigue/sleep deprivation
-anxiety
-attention and distraction
-emotional support

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results of the work of labor (5)

-fatigue
-diaphoresis
-muscle cramps
-positional discomforts
-N/V

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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

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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)

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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

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2 theories in non-pharmacologic pain management

-fear tension pain syndrome
-gate control theory

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theory: brain can only process so many pain signals from a part of the body

gate control theory

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cognitive non-pharmacologic methods of pain control during labor (2)

-childbirth education
-hypnosis

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sensory non-pharmacologic methods of pain control during labor (5)

-aromatherapy
-breathing techniques
-music
-imagery
-focal points

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S+S hyperventilation (+resp alk)

-light headedness
-dizziness
-tingling of fingers
-numbness around mouth

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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”)

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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

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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

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positions for labor

-sitting/squatting
-lateral/side lying
-hands and knees

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pharmacologic categories of pain control during labor (3)

-systemic sedatives and analgesics
-nerve block analgesia and anesthesia
-general anesthesia

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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

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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

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barbiturate sedatives (2)

secobarbital
zolpidem (ambien)

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benzodiazepine sedatives (after delivery) (1)

diazepam (valium)

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phenothiazine sedative (opioid agonist) (1)

promethazine (phenergan)

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metoclopramide action

antiemetic
potentiates analgesics

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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