Chapter 13 Flashcards
Exam 1
What are the 2 components of pain during birth?
Physiologic and Psychological
Pain is…
subjective and personal
Physiologic effects of pain
*fear and anxiety
*increases maternal metabolic rate and demand for oxygen
Psychological effects of pain
*maternal tolerance for pain
Pain during labor can either be…
visceral or somatic
mostly occurs during the 1st stage of labor due to uterine contractions that lead to hypoxia of the uterine muscles, dilations of the cervix, distension of the lower uterine segment, as well as pressure and pulling on pelvic structures such as the fallopian tubes, ovaries, and bladder
visceral pain
mostly occurs during the later part of the 1st stage and 2nd stage of labor, as the uterine contractions become more intense, During this time, pain is increased as the fetus pushes directly on maternal
somatic pain
sources of pain in childbirth
1.) tissue ischemia
2.) cervical dilation
3.) pressure and pulling on pelvic structures
4.) distention of the vagina and perineum
Factors affecting PERCEPTION or tolerance of pain
1.) labor intensity
2.) cervical readiness
3.) fetal position
4.) pelvic anatomy
5.) fatigue
6.) caregiver interventions
severe pain occurs quickly as each contraction is highly effective, limiting options for pain relief and reducing the client’s ability to cope due to shorter recovery time
in precipitous labor
minimal changes to the what before labor can make dilation slower and less efficient, prolonging labor and causing greater fatigue for the client
cervical/ cervical readiness
labor is likely to be longer and more uncomfortable when the fetus is in what?
an unfavorable fetal position in relationship to the birthing pelvis
What of the client’s pelvis influences the course and length of labor?
size and shape (pelvic anatomy)
What can improve a client’s pain coping ability?
past pain experiences unless previous births were challenging they may feel more anxious
How do some clients manage pain?
*positional changes
*breathing techniques
*hydrotherapy
What is foundation for preparation for childbirth?
education
What should be initiated before administering pharmacologic treatment for pain management in labor?
nonpharmacologic measures
examples of nonpharmalogical measures for pain management
*ambulation
*effleurage and counter-pressure
*touch and massage
*changing positions and rocking
*engaging in support persons
*breathing and relaxation techniques
*transcutaneous electrical nerve stimulation
*application of heat and cold
*aromatherapy
*hydrotherapy
What are some advantages of nonpharmalogic measures?
*does not slow labor
*no side effects or risk of allergy
*some pharm methods may not eliminate labor pain
*may be the only realistic option in advanced rapid labor
limitations of nonphar measures
*desired level of pain control is not always achieved
*even in well-prepared and highly motivated woman may have difficult labor and need analgesia or anestheisa
Transmission of nerve impulses controlled by a neural mechanism in the dorsal horn of the spinal cord that transmits impulses to the brain
gate control theory
is transmitted through small-diameter sensory nerve fibers
pain
stimulations of large- diameter skin fibers blocks pain signals from what?
small- diameter fibers, “closing the gate” and reducing pain perception
preparation for pain management
*childbirth classes
*ideal time to prepare- before labor
*support person learns specific methods to encourage and support
*nurse can teach or reinforce
*latent phase of labor is the best time for intrapartum teaching
What begins with prenatal education?
management of labor pain
application of nonpharm techniques
*relaxation
*environmental comfort
*general comfort and dignity
*reducing anxiety and fear
relaxation techniques
cutaneous stimulation, massage, counter-pressure, touch, thermal stimulation, acupressure
includes relaxation techniques that can be used to conserve energy and decrease fatigue
the cognitive process
can be used to modulate the intensity of pain by helping to block pain impulses and stimulating the release of endorphins; these include back, shoulder, or sacral massages
ex: the use of the birthing ball
cutaneous techniques
where the client focuses on a pleasant mental scene or experience; as well as breathing techniques that can be done either during or between contractions, such as taking a deep breath through the nose then gently exhaling through pursed lips- first stage of breathing
guided imagery
uses warmth and buoyancy to promote relaxation and increase pain intolerance
hydrotherapy
is usually about half the client’s normal respiratory rate (in 2-3-4; out 2-3-4) This breathing style should be used as long as possible as it promotes relaxation and oxygenation
slow-paced breathing
uses non-directed open-glottis pushing
second- stage breathing
pharmacologic pain management
-effects on the fetus
-maternal physiologic alterations (cardiovascular, respiratory, gastrointestinal, nervous system, obesity, advanced maternal age)
-effects on the course of labor
-effects of complications
-interactions with other substances
nitrous oxide or laughing gas
*increases feeling of well-being
*decreases pain and anxiety
*may be used indep. before regional anesthesia administration or in combo
*does not enter the bloodstream
*excreted via lungs
Parenteral analgesia (opioid analgesics)
*butorphanol tartrate (Stadol)
*nalbuphine (Nubain)
adjunctive drugs: tranquilizers, sedatives, antiemetics
Side effects of butorphanol tartrate and nalbuphine
respiratory depression
Side effects of Nitrous Oxide
n/v, dizziness
Opioid antagonist
naloxone (Narcan)
Given prior to an episiotomy or perineal repair for the client who does not have an epidural
infiltration of the perineum with a local anesthesia/ local anesthesia
advantages of local anesthesia
*does not alter contractions or vaginal distention
*rarely has adverse effects on either mother or infant
regional pain management
includes prudendal blocks, epidurals, spinals (subarachnoid blocks), combined spinal- epidurals, and continuous spinals
advantages of regional pain management
*safest form of analgesia for client and fetus
*provides pain relief without loss of consciousness
disadvantages of regional pain management
*depends on specific techniques and on how the mother responds
Regional Pain Management- Pudendal Block
*anesthetizes the lower vagina and part of the perineum
*provides anesthesia for an episiotomy and vaginal birth
*does not block pain from uterine contractions
*mother feels pressure
Regional Pain Management- Epidural Block
*injecting a local anesthesia agent. often combined with an opioid, into epidural space
*provides substantial relief of pain from contractions and birth canal distention
*can be extended upward
*analgesia, rather than full anesthesia
*adequate pain relief without complete motor block
Adverse effects of Epidural Block
*maternal hypotension
*bladder distention
*prolonged second stage
*maternal fever
*shivering
*catheter migration
Epidural injection of an opioid analgesic such as morphine (duramorph)
Neuraxial Opioid Analgesics
Neuraxial Opioid Analgesic Advantages
*rapid pain relief
*less risk on fetus
*decreased dose of local anesthesia
*produces sedating effect with relaxation without halting labor
Adverse effects of Neuraxial Opioid Analgesics
*n/v
*pruritis
*delated maternal respiratory depression
Regional Pain Management- Intrathecal Opioids
injected into the intrathecal (subarachnoid) space
Advantages of Intrathecal Opioids
*much smaller doses than if given systemically
*woman can feel her contractions
*rapid onset of pain relief without sedation
*no increase to motor block- can ambulate during labor
*no sympathetic block
*less risk on fetus
Disadvantages- Intrathecal Opioids
*limited duration of action
*inadequate pain relief for late labor and the birth
Adverse effects- Intrathecal Opiods
*n/v
*pruritis
*delayed maternal respiratory depression
Regional Pain Management- Spinal or Subarachnoid Block (SAB)
*simpler procedure than the epidural block
*may be performed when a quick cesarean birth is nec., and an epidural catheter is not in place
*like local infiltration and pudendal block
*performed just before birth, providing no pain relief during most of the labor
Contraindications and precautions- Spinal or Subarachnoid Block (SAB)
*like epidural blocks
*increased intracranial pressure secondary to mass lesion
*client refusal or inability to cooperate during placement
*uncorrected coagulation condition
*infection
*fetal condition requiring immediate birth
Nursing considerations- Spinal or Subarachnoid Block (SAB)
*like client with epidural
*administer vasopressors prior to offset hypotension (if ordered)
*adequate IV hydration prior to SAB
*vial signs every 5 min for 30 min or per agency guidelines
*if c-section, viral signs every 5 min until end of surgery
Quick onset of med admin and access to the epidural catheter if needed such as with c-section
Combined- spinal epidural *CSE) block
Continuous spinals
*catheter is less likely to migrate decreasing “hot spots”
*placement like CSE
*risks like spinal
General Anesthesia (vaginal birth anesthesia)
*systemic pain control
*loss of consciousness
*rarely used for vaginal births
*still has a place in cesarean birth
*may be needed unexpectedly and quickly for emergency procedures at any stage of pregnancy
adverse effects- general anesthesia (vaginal births)
*failed intubation
*aspiration
*adverse reaction to med
*malignant hyperthermia
*respiratory depression
*increased risk of bleeding of also on magnesium sulfate
*uterine relaxation
Methods to decrease adverse maternal effects- General anesthesia (vaginal births)
*accurate history/ screening prior to admin
*restrict intake to clear liquids
*admin meds to increase gastric pH and emptying
*Sellick’s maneuver
Methods to decrease adverse fetal effects- General anesthesia (vaginal births)
*reduce time from induction to clamping of cord
*minimize admin of sedating meds and anesthetics until cord is clamped
Priority nursing goals of pain management during birth/ labor are to
safely manage your client’s pain through non-pharm and pharm methods
