Chapter 13: Promoting Patient Comfort During Labor and Birth Flashcards
1
Q
What is Pain
A
whatever the person who is experiencing it says it is
-an unpleasant sensory and emotional experience arising from actual or potential tissue damage
-pain includes the perception of an uncomfortable stimulus and also the response to that perception
>perception of pain is influenced by psychosocial and cultural factors
2
Q
Physiological and psychological changes that are indicative of maternal pain
A
- increased pulse rate and blood pressure
- changes in mood
- increased anxiety and stress
- marked agitation
- confusion
- decreased urine output
- decreased intestinal motility
- guarding of the target area of discomfort
3
Q
These factors can intensify pain
A
-fear, anxiety, and fatigue
4
Q
When Caring for a laboring woman, the nurse must recognize that unlike other sources of pain, childbirth pain:
A
- is part of a normal process (not associated with illness or injury)
- can be anticipated and thus prepared for (through childbirth education and the practice of distraction techniques and comfort measures)
- has an end point (the babies birth brings relief on a physical and emotional level)
5
Q
Pain Neurology
A
pain associated with birth has visceral and somatic properties
-uterine contractions during the first stage of labor bring about cervical dilation and effacement; during each contraction, arteries that supply the myometrium are compressed, causing uterine ischemia (oxygen deficit that results from decreased blood flow)
>during first stage of labor, pain impulses are transmitted via the T11 and T12 spinal nerve segments and accessory lower thoracic and upper lumbar sympathetic nerves; these nerves originate in the uterus
6
Q
Visceral Pain
A
slow, deep, poorly localized pain that occurs over the lower abdomen; dull aching pain
- describes the predominant discomfort experienced during the first stage of labor
- r/t changes in the cervix (i.e. dilation and effacement), distention of the lower uterine segment, and uterine ischemia
7
Q
Referred Pain
A
describes pain that originates in the uterus and then radiates to the abdominal wall, the lumbosacral area of the back, the iliac crests, the gluteus maximus, and down the thighs
- usually discomfort felt only during contractions
- a period of pain relief can occur between contractions
8
Q
Somatic Pain
A
faster, well-localized intense, sharp, burning, prickling pain
- occurs during second stage of labor
- associated with stretching and distention of the perineal body to allow for birth
- r/t distention and traction placed on the peritoneum and uterocervical supportive tissue during contractions and can result from soft tissue lacerations that occur in the cervix, vagina, or perineum
- may also occur from maternal expulsive forces during the second, or “pushing” stage of labor or by fetal pressure on the bladder, bowel, or other pelvic structures
9
Q
Recognizing Cultural Influences on the experience of Pain
A
nurses must recognize that culture strongly influences how one perceives and copes with pain
-woman from certain cultures seek pain relief through prayer; others rely on herbal remedies, the application of cold or warmth, acupuncture, the “laying on of hands”, and therapeutic massage
>Assessment of cultural beliefs and practices, questions to identify specific needs and encouragement, and support to use safe interventions is key in providing culturally sensitive care that empowers the patient to maintain her sense of control over her labor and childbirth experience
10
Q
Sympathetic Nervous System Response to Pain
A
during labor and childbirth, the sympathetic nervous system responds to pain with increased levels of catecholamines (e.g. epinephrine and norepinephrine–biologically active substances that produce a marked effect on the nervous and cardiovascular systems, metabolic rate, temperature, and smooth muscle)
-rise in blood pressure and heart rate
-increased maternal oxygen consumption results in an altered respiratory pattern that may produce hyperventilation and respiratory alkalosis
-woman may be diaphoretic, and nausea and vomiting are common during the active phase of labor
>throughout this process, decreased placental perfusion and uterine activity can prolong labor and adversely affect fetal well-being
11
Q
Assessment of Pain During Labor
A
throughout the process of labor and birth, the nurse continuously assesses the patient and addresses her needs for comfort measures
- conducting an initial and ongoing pain assessment lays the foundation for intrapartal nursing care
- once the beginning assessment has been completed, the nurses uses the information to develop an individualized plan of care that includes pain relief interventions acceptable to the patient
- may be modified or adapted as needed
12
Q
Benefits of comfort and support on pain perception
A
- support during labor has a major impact
- support includes both pharmacological and non-pharmacological measures
- nurse’s attitude, expressions of caring, and supportive actions play a role
- patients who feel they have control over their situation (self efficacy) and who are actively engaged in decision-making process concerning interventions and pain relief measures during labor and birth report a greater sense of satisfaction with their birth experience
- spend as much time as you can at patients bedside (e.g. charting in the room and assessing the woman’s comfort level and satisfaction with birth plan) is an important nursing strategy
- offering verbal support, touch, and eye contact ca help keep the woman centered and in control
13
Q
Non-Pharmacological Pain Relief Measures
A
- maternal position and movement
- breathing techniques
- music
- relaxation
- other attention-focusing strategies
- massage and touch
- hydrotherapy
- hypnotherapy
- aromatherapy
- application of heat and cold
- biofeedback
- transcutaneous electrical nerve stimulation
- intradermal water block
- acupressure and acupuncture
14
Q
Maternal Position and Movement
A
find a position of comfort; as patient changes positions, gravity assists the fetus’s decent down the birth canal
- slow dancing during labor; can be comforting and relaxing; the woman can lean on her coach (this helps support her) and they can sway and dance together through the contractions
- use a “squatting bar” or assume a squatting position at the edge of the bed; helps open the pelvic outlet, which facilitates the fetus’s downward movement
- “hands and knees” position is comforting for woman who have back labor or whose fetus is in a posterior position; decreases the patient’s back pressure and helps the fetus rotate in to an anterior position
- use of a “birth ball”; with help, the patient carefully sits on the birth ball and rhythmically rocks back and forth or moves the ball around in a circular motion; assuming a sitting position on the birth ball facilitates a supported squatting position that opens the pelvis to allow fetal descent in preparation for birth; warm compresses applied to the back and perineum while balancing on the ball enhance relaxation and promote comfort; the birth ball should be large enough to allow the woman to sit comfortably on it with her knees bent to a 90 degree angle with her feet flat on the floor approximately 2 feet apart; may also place birth ball against the wall behind the small of her back and gently lunge from side to side to open the pelvis; when needed, assuming a kneeling position while leaning forward on the ball may encourage rotation of the fetus from posterior to an anterior position
15
Q
Birth Ball
A
- use of a “birth ball”; with help, the patient carefully sits on the birth ball and rhythmically rocks back and forth or moves the ball around in a circular motion; assuming a sitting position on the birth ball facilitates a supported squatting position that opens the pelvis to allow fetal descent in preparation for birth
- warm compresses applied to the back and perineum while balancing on the ball enhance relaxation and promote comfort
- the birth ball should be large enough to allow the woman to sit comfortably on it with her knees bent to a 90 degree angle with her feet flat on the floor approximately 2 feet apart
- may also place birth ball against the wall behind the small of her back and gently lunge from side to side to open the pelvis
- when needed, assuming a kneeling position while leaning forward on the ball may encourage rotation of the fetus from posterior to an anterior position
16
Q
Breathing Techniques
A
the woman is instructed to take slow, deep cleansing breath in through the nose and out through the mouth at the beginning of every contraction
- slow-paced breathing
- modified-paced breathing
- pattern-paced breathing
17
Q
Breathing Techniques: Slow-paced breathing
A
used during early labor, when the woman is no longer able to walk or talk through contractions
>following a cleansing breath, the woman begins to slowly breathe in and out through her mouth while her coach slowly counts out loud
>the breathing rate is half the woman’s normal breathing rate— 6 to 8 breaths per minute
>she is prompted to slowly breathe in while the coach counts “one, two, three, four”, and then slowly breathe out to the same rhythm as the couch counts “one, two, three, four”
18
Q
Breathing Technique: Modified-paced
A
uses this as the labor progresses and the contractions increase in frequency and intensity
- shallower an twice the woman’s normal rate of breathing—32 to 40 breaths per minute
- after a deep cleansing breath, the woman inhales slowly, but exhales at a faster pace
- ex: the coach instructs her to take a cleansing breath, then breathe in a count of one, two, three, four and breathe out to a count of one, two , three
19
Q
Breathing Technique: Pattern-paced
A
during the transition phase of labor, when contractions are most intense, patients usually find it difficult to concentrate on breathing techniques
- this technique requires increased concentration
- following a cleansing breath, the woman begins with a 3:1 pattern; breathe in, breathe out, breathe in, breathe out, breathe in, then blow (as if blowing out a candle)
- as needed, ratio may be increased to 4:1
- as with the other breathing patterns, a cleansing breathe is taken at the end of each contraction
20
Q
Recognizing Hyperventilation
A
the pattern-paced breathing may result in maternal hyperventilation
-nurse should alert the patient and support person to symptoms of respiratory alkalosis: light-headedness, dizziness, tingling of the fingers, or circumoral numbness
>strategies to eliminate respiratory alkalosis focus on replacement of the bicarbonate ion by rebreathing carbon dioxide; breathe into paper bag held tightly around mouth and nose, or, if no bag is available, breathe into her cupped hands
21
Q
Use of Music
A
help to create a relaxing environment and boosts spirits
- provides comfort and decreases maternal anxiety by stimulating release of endorphins
- encouraged to supply music of their choice
- promotes maternal relaxation thereby increasing oxygen intake
22
Q
Promote Relaxation
A
diminish the level of anxiety also reduces stress and tension
-when tension is reduced, the woman breathes more deeply, resulting in improved maternal and fetal oxygenation
-when experiencing increased anxiety, stress levels and tension build and trigger a cascade of events that heighten the sensation of pain; pain impeded ability to relax
>nurses ongoing assessment of maternal pain should be conducted throughout labor and birth; use of a visual analog scale for assessment of pain
23
Q
Other Attention-focusing strategies: Guided Imagery
A
state of intense, focused concentration that one uses to create persuasive mental images
-distracts the laboring woman and transports her to a place that is special to her
>nurse or labor support person asks the laboring woman to focus on a place where she likes to be; next, the nurse or labor support person verbalizes sights and sounds of that unique place in an attempt to relax and distract the patient
24
Q
Other Attention-Focusing strategies: Focal Points
A
may be a picture, photograph, stuffed animal, or piece of needlework
- concentrates or “focuses” on the object while breathing during the contractions
- “internal” focal point= thought or visual image— closes her eyes and focuses on the mental image
25
Use of Massage and Touch
reduces pain and improve woman's emotional experience of labor
- effleurage
- counterpressure
- therapeutic touch
- healing touch
26
Massage and Touch: Effleurage
(to touch lightly)
-gentle stroking technique performed in rhythm with contractions
-massages abdomen using light circular motions
>massage of the hands, feet, and back may be effective in diminishing tension and in enhancing comfort
27
Massage and Touch: Counterpressure
enhances woman's ability to cope with discomfort from internal pressure and lower back pain
- involves use of labor support person's fist or heel of hand to apply steady pressure to the sacral area
- helpful when maternal back pain results from pressure of the occiput against spinal nerves when the fetal head is in a posterior position
- counterpressure lifts the occiput off of the spinal nerves
28
Massage and Touch: Therapeutic Touch
use of "prana", the body's energy fields
-specially trained persons use laying-on of hands to provide therapeutic touch to redirect the energy fields thought to be associated with the pain
29
Massage and Touch: Healing Touch
-based on use of body's energy fields
-combination of techniques from multiple disciplines
-persons trained in healing touch are taught energetic diagnosis and treatment forms and how to document the patient's response and progress
>the various techniques align and balance the human energy field, enhancing the body's ability to heal itself
30
Hydrotherapy
(water therapy)
-use of warm water to promote comfort and relaxation
>may involve showering or soaking in a regular tub or whirl pool bath
-fetal heart rate monitoring may be intermittent or continuous; conducted via doppler technique, fetoscope, or use of wireless external monitor device; internal electrode placement may not be used with whirlpool baths
31
Hydrotherapy: If showering as a selected method
-patient stands in a warm shower and allows the water to gently glide over the abdomen
-may wish to sit in a shower chair
-the labor coach or nurse may use a handheld sprayer to direct a steady stream of water over the abdomen or back
-the support person provides reassurance and encouragement, assists with breathing techniques during contractions, and offers touch and massage
>flow of warm water enhances feelings of relaxation, reducing muscle tension
>reduced discomfort empowers the woman to have more control over her labor
32
Hydrotherapy: If immersion in a tub of warm water filled up to shoulder level is selected method
promotes comfort and relaxation
-production of catecholamines is decreased, prompting an increase in the release of oxytocin (stimulates uterine contractions) and endorphins (reduced perception of pain)
>if the woman is experiencing "back labor" from a fetal occiput posterior or transverse position, she may be assisted to a side-lying or hands-and-knees position in the tub; enhance comfort and help to facilitate fetal rotation into a occiput anterior position
>patients may stay in tub as long as desired; mostly 40 to 60 minutes; if maternal temperature or FHR increase, if the labor slows or becomes too intense, or if comforting effects of the water diminish, patients may come out and return at a later time
>avoid overheating= water temp kept at 96.8 to 100.4 degrees F
33
Hydrotherapy: Whirl pool ("jet hydrotherapy")
pulsating flow of warm water from the whirlpool jet is soothing and delivers continuous massage to the legs, abdomen, and back
-provides a soothing sound that aids in relaxation
-some institutes require approval for use from primary care provider
>in some settings, women with ruptured membranes are allowed to use jet hydrotherapy, provided that the amniotic fluid is clear
34
Hypnotherpay
enables the patient to achieve a state of heightened awareness and focused concentration that can be used to alter the perception of pain
-emphasis is placed on promoting maternal relaxation while decreasing fear, anxiety, and the perception of pain
>the woman may be given direct suggestions about pain relief or indirect suggestions that she is experiencing decreased discomfort
35
Aromatherapy
use of essential oils, derived from plants, flowers, herbs, and trees, whose aroma is thought to have a therapeutic effect in treating illnesses and promoting health and well-being
-rose, lavender, frankincense, and bergamot oils are believed to promote comfort and relaxation and decrease pain
-adding a few drops to a warm tub bath, add to body compresses and massage lotions, or to an aroma therapy lamp
-drops of lavender and other essential oils may also be massaged into the woman's temples or forehead or placed on a pillow to induce relaxation
>never apply to the skin in full-strength form; must be diluted, usually in vegetable oil base, before application
>not all are safe; some oils when inhaled cause side effects such as nausea and vomiting
36
Application of Heat and Cold
promote comfort and help decrease pain
-may be used alternately
>Heat:
-relieves muscle ischemia and increasing blood flow to the area of discomfort; applied to the perineum help to relieve the discomfort associated with stretching and may help prevent tearing during second stage of labor;
-socks or bags that are sewn from cloth can be filled with uncooked rice and heated in a microwave oven; once warmed, can be placed on neck, lower back, or where discomfort is felt; when desired, lavender oil may be added before heating
>Cold:
-placed on forehead, chest, or face, may be comforting to laboring women who feel warm
-may also be applied to areas of pain where they exert a therapeutic effect by reducing muscle temperature and relieving muscle spasms
-during contractions, ice massage to the acupuncture point on the hand (Hoku point) may help reduce pain
37
What you should know when using heat and cold therapy
- avoid over body areas that have been anesthetized because of the risk for tissue damage
- be used only after one to two layers o cloth have been placed between the pack and the patient's skin
38
Biofeedback
based on the concept that the mind controls the body
-during the prenatal period, the woman is taught body awareness, how to recognize responses to stimuli, and various relaxation techniques; practices using strategies such as concentration, focal points, and breathing to control her response to uncomfortable stimuli
-labor partner learns to recognize cues (e.g. grimacing, tensing, frowning, moaning, and breath holding) indicative of pain and uses verbal feedback and touch to help the woman to achieve relaxation
>formal biofeedback involves the use of a recording device to measure physiological responses, requires special training by a biofeedback therapist
39
Transcutaneous Electrical Nerve Stimulation (TENS)
involves the delivery of an electrical current through electrodes that are applied to the skin over the panful region of a peripheral nerve
-relieves pain by producing counterirritation on the nociceptors
-two pairs of flat electrodes are placed on the patients thoracic and sacral spine
>high-intensity levels maintained for at least 1 minutes to release endorphins
>woman report a pleasant buzzing or tingling sensation that offsets the pain
>doctor or certified nurse midwife prescribes; usually applied by physical therapist; nurse explains use of device, assists with application, and evaluates effectiveness
40
Intradermal Water Block
technique that involves use of a small (e.g. 25-gauge) needle to inject small amounts (e.g. 0.05 to 0.1 mL) of sterile water into four locations (two over each posterior superior iliac spine and two 3 cm below and 1 cm medial to each of the first sites) on the patients lower back to relieve back pain
>two people perform injection simultaneously to decreased pain of injections
>may be used during early labor to delay initiation of pharmacological pain relief methods
-experience a brief, intense stinging sensation immediately after injections, but the back pain is generally relieved for 45 minutes to 2 hours
41
Acupressure
"Chinese massage"
-involves the application of pressure, or heat or cold to identified acupuncture points to decrease the sensation of pain
-pressure may be applied by the support persons hands, tennis balls, or by the application of pressure bands--cloth covered elastic bands that contain rigid plastic inserts-- to provide pressure
>during labor, pressure is applied to various acupressure points, located on neck, shoulders, wrists, lower back, hips, area below kneecaps, ankles, toenails, and soles of feet; Co4 (Hoku or Hegu point), which is located between the first and second metacarpal bones on the back of the hand
-another is located between the inner anklebone and the Achilles' tendon ; applying pressure for 1 minute on each ankle to relieve labor pain
42
Acupuncture
involves insertion of fine, sterile, stainless steel needles into specific points in the body (e.g. those associated with labor pain) to control the flow of "chi" or life energy
- activation of the insertion points is believed to trigger release of endorphins
- performed only by trained acupuncturist
- safe but invasive, = risk for infection
43
When should Pharmacological methods of pain be initiated?
before the pain intensifies to the point that catecholamines are released and labor is prolonged
-usually as labor progresses and contractions and discomfort intensify
44
Legal Alert: Ensure the patient is informed about available pharmacological methods of pain relief
- ensure the woman understands the alternative methods of pain relief that are available in the birth facility and, when indicated, by asking primary care provider for further detail or clarification
- obtaining an informed consent for interventions means that the procedure and its advantages and disadvantages are fully explained; the patient must agree with the plan of care as it is described to her, and patients consent must be given freely without coercion or manipulation from health-care provider
45
Sedatives
Sedatives are agents that relieve anxiety and induce sleep
-used during the early latent phase of labor, when the cervix is long, closed, and thick and rest has been prescribed for the patient
-sedatives may also be used to augment analgesics and reduce nausea after the administration of opioids
-induce sleep for a few hours; once woman awakens, either contractions have ceased (i.e. person experienced false labor) or regular, effective contractions that produce cervical change occur
>Sedatives should not be used during active labor because they can cause respiratory depression in the neonate
46
Legal Alert: Assess and Reassess during the intrapartal period
it is important to assess the laboring patient and her fetus following each intervention to promote comfort
- assess for risk factors: bleeding, infection, ruptured membranes, fetal presentation, prolapsed cord, precipitous labor, meconium-stained amniotic fluid, postmaturity, prematurity, or fetal heart rate irregularities
- assess maternal vital signs per facility protocol
- assess the patient's anxiety level, coping mechanisms, and labor support
- assess the progress of labor
- assess the fetal heart rate, lie, and presentation
- assess the maternal and fetal response to each comfort measure
- carefully document all findings
47
Barbiturates
rarely used in labor
-most common: Secobarbital sodium (Seconal); fast-acting oral agent that produces mild sedation within 15 minutes after administration; effects last for 3 to 4 hours
>undesirable effects: maternal and neonatal respiratory and vasomotor depression; effects are intensified if barbiturate is administered with another CNS depressant
48
Benzodiazepines
agents primarily used to treat anxiety (e.g. diazepam (Valium) and lorazepam (Ativan))
>mechanism similar to barbiturates; when given with an opioid analgesic, benzodiazepines enhance pain relief and decrease nausea and vomiting
>Flumazenil to reverse the effects of benzodiazepine sedatives
49
What is used to reverse the effects of benzodiazepine sedatives?
-Flumazenil
>is an agent that reverses the effects of benzodiazepine sedatives. IV administered; should be readily available in any childbirth setting where benzodiazepines are sued
50
H1-Receptor Antagonists
medications that block the action of histamines at the receptor sites
-produce sedative, anti-Parkinson, and antiemetic effects
-cause drowsiness and often use during early labor to promote sleep and decrease anxiety
>promethazine (Phenergan)
>hydroxyzine (Vistaril)
>diphenhydramine (Benadryl)
51
Promethazine (Phenergan)
H1-Receptor Antagonist
- produces marked sedation and has strong antiemetic effects
- frequently combined with opiates because it potentiates heir effects
- readily cross the placenta and may produce decreased FHR beat-to-beat variability
- bind to bilirubin binding sites in the neonate and may caused increased hyperbilirubinemia and jaundice in term infants who were exposed to the drug during the intrapartal period
52
Hydroxyzine (Vistaril)
H1-Receptor Antagonist
- used during early or prodromal labor to decrease nausea and anxiety
- exerts a sedative effect
- women who receive this IM medication awaken to increased contraction intensity that produces cervical change (i.e. active labor)
53
Diphenhydramine (Benadryl)
H1-Receptor Antagonist
-a nonprescription medication with sedative and antiemetic properties that is given during early labor
-because this rug is readily available, nurse can advise women to use it at home although it may cause agitation in some patient
>half life: 1 to 4 hours
>may last up to 8 hours
54
Recognizing the anxiety-tissue anoxia- pain connection
pain can trigger the body's general stress response, called the "flight or fight" reaction
-the release of epinephrine causes peripheral and uterine vasoconstriction, which results in tissue anoxia and increased pain
>decreasing the patients anxiety through assistance with relaxation techniques or administration of antianxiety medications reduces vasoconstriction and helps to decrease pain
55
Analgesia
relief, to some degree, of pain
-pain may be entirely eliminated or only lessened
>analgesia may be accomplished via medications, application of heat or cold, massage, or electrical stimulation
>When given too early= may prolong labor and cause fetal depression
>When given too late= provides no benefit to the woman and may cause depression in the neonate
56
Anesthesia
partial or complete loss of sensation with or without the loss of consciousness
57
Pharmacological Interventions For Intrapartal Pain Control According to Stage of Labor
1. First Stage of Labor
>Systemic Analgesia
-Opioid agonists (e.g. hydromorphone hydrochloride (Dilaudid); meperidine hydrochloride (Demerol); fentanyl citrate (Sublimaze); sufentanil citrate (Sufental)
-Opioid agonists-antagonists (e.g. butorphanol (Stadol); nalbuphine (Nubain)
>Nerve Block Analgesia
-Epidural
-Combined spinal-epidural
2. Second Stage of Labor
>Nerve Block Analgesia and Anesthesia
-local infiltration, pudendal block, spinal block, epidural block, combined spinal-epidural
58
Pharmacological Interventions for Intrapartal Pain Control According to Birth Method
>Vaginal Birth:
- local infiltration anesthesia
- pudendal block
- epidural block analgesia/anesthesia
- spinal block anesthesia
- combine spinal-epidural analgesia/anesthesia
>Cesarean Birth:
- spinal block anesthesia
- epidural block anesthesia
- general anesthesia
59
Systemic Analgesia
provide central analgesia to the patient and fetus because they readily cross the placenta
>fetal-neonatal effects= respiratory depression, decreased alertness, and delayed sucking; depending on agent used, dose given, and the route and timing of administration
>IV preferred over IM because actions is more rapid and predictable, pain relief is obtained in smaller doses, and the duration of the effect is more predictable
60
Administering Intravenous Medications During Labor
-given slowly, in small doses during a contraction
-when necessary, the medication may be given over a period of four to five consecutive contractions to complete a dose
>administering the medication during a contraction decreases fetal exposure to the drug because uterine blood vessels are constricted during contractions and the medication remains in the maternal vascular system for several seconds before the uterine blood vessels reopen
61
Agonists
stimulate receptors to act
62
Antagonsists
block receptors or medications designed to activate receptors
63
Opioid Agonist Analgesics
-hydromorphone hydrochloride (Dilaudid)
-meperidine hydrochloride (Demerol)
-fentanyl citrate (Sublimaze)
-sufentanil citrate (Sufenta)
>promote feelings of euphoria (feelings of intense excitement and happiness)
>delay gastric emptying time: nausea and vomiting common side effects; bladder and bowel elimination diminished
>should be given either less than 1 hour or greater than 4 hours before birth to minimize neonatal depression
-Fentanyl Citrate and Sufentanil Citrate require more frequent administration because of their short duration of action (30 to 60 minutes, compared with 2 to 4 hours for hydromorphone hydrochloride and meperidine hydrochloride)
>can be administered intrathecally or epidurally, alone or in combination with a local anesthetic
64
Safety Measures for women who receive opioid analgesics
may cause bradycardia/tachycardia, hypotension, and respiratory depression and should be administered cautiously in women with respiratory or cardiovascular disorders
-patients may experience sedation and dizziness following administration; nurses should assist with ambulation and observe for adverse effects
65
Opioid-Agonist Analgesic Medication: Hydromorphone hydrochloride (Dilaudid)
- IV or IM
- monitor vital signs, FHR pattern and uterine activity prior to and during administration
- observe for maternal respiratory depression
- encourage voiding q 2 hours
- palpate for bladder distention
- if birth occurs within 1-4 hours after administration, observe neonate for respiratory depression
66
Opioid-Agonist Analgesic Medication: Meperidine hydrochloride (Demerol)
- IV or IM
| - common side effects include pruritis (itching), dizziness, sedation, nausea, constipation
67
Opioid-Agonist Analgesic Medication: Fentanyl citrate (Sublimaze)
- IV, IM, or epidural
| - contraindications: hypersensitivity to the drug, convulsive disorders
68
Opioid-Agonist Analgesic Medication: Sufentanil (Sufental)
-epidural
69
Opioid Agonist-Antagonist Analgesics
>butorphanol (Stadol)
>nalbuphine (Nubain)
-during labor, provide satisfactory pain control
-the incidence of respiratory depression is similar to that associated with morphine
-associated with less nausea and vomiting
-used more often than opioid agonist analgesics
-administered IV or IM (parenteral route is preferred)
-should not be given to women with a opioid dependence because the antagonist activity may precipitate maternal/neonatal withdrawal symptoms
>symptoms of hypersensitivity (pruritis, urticaria, and/or burning sensation) may be treated with naloxone or diphenhydramine
70
Medication: Fentanyl (Sublimaze)
- Pregnancy category C
- supplement to regional/local anesthesia; often administered epidurally or intrathecally to relieve moderate to severe labor pain and postoperative pain after cesarean birth
- binds to opiate receptors in the CNS, alters the response to and perception of pain, produces CNS depression
- contraindicated in hypersensitivity; known intolerance; opioid dependency
- Side Effects: bradycardia, hypotension, confusion, drowsiness, dizziness, rash, maternal and fetal/neonatal respiratory depression, nausea and vomiting, urinary retention
- Nursing Implications: assess for respiratory depression; naloxone as antidote
71
Medication: Butorphanol (Stadol)
- pregnancy risk category C
- used for moderate to severe labor pain; postoperative pain after cesarean birth
- produces generalized CNS depression
- contraindicated in: hypersensitivity, patients dependent on opioids (may precipitate withdrawal), chronic hypertension, preeclampsia
- Side Effects: confusion, drowsiness, sedation, blurred vision, headache, dizziness, dysphoria, hallucinations, hypotension, hypertension, sweating, maternal palpitation/tachycardia or bradycardia, respiratory depression, transient nonpathological sinusoidal-like FHR rhythm, urinary retention and urgency
- Nursing Implications: may precipitate withdrawal symptoms, protect medication from light and store at room temperature
72
Opioid Antagonist
Naloxone
- reverse the CNS depressant effects of opioids
- IM or IV
- of benefit when labor progresses more rapidly than anticipated and birth is expected to occur when the opioid is at its peak effect
73
Regional Anesthesia
temporary and reversible loss of sensation
- provides complete pain relief and motor block
- produced by injection of an anesthetic agent (a local anesthetic) into an area that brings the medication into direct contact with nervous tissue
- respiratory depression and hypotension can occur but rarely
- nurse should ensure emergency agents, epinephrine, antihistamines, and oxygen are readily available
74
Recognizing Local anesthetic agents
most local anesthetic agents are chemically related to cocaine, their names end with suffix, -caine.
>lidocaine, mepivacaine, bupivacaine, ropivacaine, and chloroprocaine
75
The regional anesthetic blocks commonly used
-epidural, spinal, or combined epidural-spinal
76
Local Perineal Infiltration Anesthesia
used to provide pain control when an episiotomy is performed or when suturing of lacerations is necessary in a patient who does not have regional anesthesia
>epinephrine, which causes vasoconstriction, may be added to the anesthetic agent to intensify the anesthesia effect and to minimize bleeding and prevent systemic absorption
77
Pudendal Nerve Block
provides pain relief in the lower vagina, vulva, and perineum
- should be administered 10 to 20 minutes before perineal anesthesia is needed and may be used late in the second stage of labor if an episiotomy is to be performed or if forceps or vacuum extraction will be used to facilitate birth
- the anesthetic effect diminishes or completely removes the maternal bearing-down reflex
- may also be sued during the third stage of labor for laceration repair
78
Spinal Anesthesia Block
involves the injection of a solution containing a single local anesthetic or an anesthetic combined with fentanyl through the third, fourth, or fifth lumbar interspace into the subarachnoid space, where it mixes with cerebrospinal fluid
- used for elective or emergent cesarean births
- the differences in the levels of spinal anesthesia for vaginal and cesarean birth are created by the dosage of the anesthetic agent administered and the position of the patient after placement of the medication in the dural sac
79
Level of Spinal Anesthesia for a Vaginal Birth
a low spinal anesthesia block provides anesthesia from level T10 (hips) to the feet
-patients remain in a sitting position for a brief period of 1 to 2 minutes after administration to facilitate downward migration of the anesthetic solution toward the sacral area
80
Level of Spinal Anesthesia for a Cesarean Birth
coverage extends from the nipples (T6) to the feet
- after administration of the anesthetic, patients are immediately assisted to a supine position with a left lateral tilt to enhance a cephalad spread of the anesthesia (and a higher level of sensory blockade)
- anesthetic agent may be "weighted" with glucose to make it heavier than CSF; this prevents the medication from rising too high in the spinal canal and interfering with motor control of the uterus or with maternal respiratory muscles
81
Advantages to Spinal Anesthesia Block
-easier to administer
-has an immediate onset
-requires a smaller volume of medication
-produces excellent muscular relaxation
-allows for maintenance of maternal consciousness
-associated with minimal blood loss
>because uterine contraction sensation is lost, the patient must be instructed when to bear down during a vaginal birth
>because voluntary maternal expulsive efforts are compromised, there is an increased likelihood of an operative (e.g. episiotomy, forceps-assisted, or vacuum-assisted) birth
>after childbirth, increased incidence of bladder and uterine atony and post-dural puncture headache
82
Nursing Care During Administration of Spinal Anesthesia
-proper positioning of the patient in a lateral or sitting position with the back curved outward to widen the intervertebral space
-after injection of anesthetic solution, patient positioned upright to allow downward flow of the solution to provide a lower level of anesthesia suitable for a vaginal birth
>for cesarean birth, patient is placed in a supine position with the head and shoulders slightly elevated with a wedge placed under one of the hips to displace the uterus (to obtain a higher level of anesthesia coverage)
>effects from the anesthesia occur within 1 to 2 minutes after injection and last 1 to 3 hours, depending on agent used
83
Complications that may occur with Spinal Anesthesia Block
maternal hypotension, decreased placental perfusion, and an ineffective breathing pattern
>before administration, the patients fluid balance is assessed, and IV fluids are administered to reduce the potential for sympathetic blockade (decreased cardiac output that results from vasodilation with pooling of blood in the lower extremities)
>after administration of anesthetic, BP, pulse, and respirations and FHR must be taken and documented every 5 to 10 minutes
-if indicators of severe maternal hypotension (a drop in baseline BP of more than 20%) or fetal compromise (e.g. bradycardia, decreased variability, or late decelerations) develop, emergency measures must be taken
84
In the Event of Severe maternal hypotension, the nurse takes the following actions:
-place the patient in a lateral position or use a wedge under the hip to displace the uterus; elevate the legs
-maintain or increase the IV infusion rate, according to institution protocol
-administer oxygen by face mask at 10 to 12 L/min or according to institution protocol
-alert the primary care provider, anesthesiologist, or nurse anesthetists
administer an IV vasopressor (e.g. ephedrine 5-10 mg) according to institutional protocol, if the above measures are ineffective
-remain calm, offer reassurance, and continue to assess maternal blood pressure and FHR every 5 minutes until stable or per order from the primary care provider
85
Post-dural Puncture Headache
complication that may develop 48 hours after puncture from spinal anesthesia block
-occur from leakage of cerebrospinal fluid (CSF) from the puncture site in the dura mater
-headache is intensified when assume an upright position
-accompanying symptoms: auditory (tinnitus) and visual (blurred vision or photophobia) problems
-Interventions: oral analgesics, bedrest in a darkened room, caffeine, and hydration
>if these are not effective--> an autologous epidural blood patch may be administered; 10 to 20 mL of the patients blood is slowly injected into the lumbar epidural space, a clot forms in the tear or tole in the dura mater around the spinal cord, effectively sealing the area from further CSF leakage
86
Discharge Planning After Administration of an Autologous Epidural Blood Patch
- maintain bedrest for 24 to 48 hours
- apply cold packs to the area as needed for pain relief
- increase oral fluids
- avoid the use of analgesics that affect platelet aggregation (e.g. non-steroidal anti-inflammatory drugs) for 2 days
- observe for signs of infection at the site
- observe for signs of neurological complications (e.g. pain, numbness, tingling in the legs, and difficulty with ambulation)
87
Epidural Anesthesia or Analgesia Block
injection of a local anesthetic such as bupivacaine, an opioid analgesic such as fentanyl or sufentanil, or both into the epidural space (between L4 and L5) provides pain relief from uterine contractions and vaginal or cesarean birth
-combining an opioid with a local anesthetic agent reduces the total amount of anesthetic required and helps to preserve a greater amount of maternal motor function
88
Lumbar Epidural Anesthesia and Analgesia Block
most commonly used method of pain control during labor
- Advantages: maternal relaxation, enhanced comfort and relief, and an ability to remain alert and participate in the birth
- little blood loss
- respiratory reflexes remain intact
- no delay in gastric emptying
- partial degree of motor paralysis occurs
- fetal complications rare; and are related to maternal hypotension or effects from the rapid absorption of the medication
- Post-dural puncture headaches, caused by leakage of CSF, are rare because with epidural anesthesia, the CFS space is not entered
89
Epidural Blocks are Advantageous to?
- patients with diabetes, heart disease, pulmonary disease, and gestational hypertension because they essentially eliminate the pain associated with labor and thus reduce the maternal stress associated labor discomfort
- patients energy level is preserved because she does not feel the contractions
- epidural blocks may be used with preterm pregnancies because there is minimal effect on the fetus
90
Most Common Complication of Epidural Anesthesia
Maternal Hypotension
-preloading the patient with a rapid infusion of IV fluids, which increases the blood volume and cardiac output, can usually prevent this complication
-IV fluids are then infused continuously; most use dextrose-free solutions because dextrose can cause fetal hyperglycemia with rebound hypoglycemia during the first several hours after birth
>nurse should be in continuous attendance after administration of epidural anesthetic
-to detect hypotension: BP should be continuously monitored for at least the first 20 minutes and after each new injection of the anesthetic; BP should be monitored during the entire time the anesthetic is in effect to ensure that the systolic pressure does not fall below 100 mm hg or decrease in 20 mm Hg in a hypertensive patient (a drop greater than this may be life-threatening to the fetus unless effective intervention (e.g. maternal position change or administration of anti-hypotensive agents) are implemented
>severe maternal hypotension resulting from sympathetic blockade can cause a decrease in uteroplacental perfusion and the delivery of oxygen to the fetus
91
Some Other Disadvantages to Epidural Anesthesia besides maternal hypotension
-lengthened duration of labor and increased requirements for oxygen and oxytocin and limited mobility because of medical interventions such as IV infusion and electronic monitoring equipment
-may experience orthostatic hypotension, dizziness, sedation, and lower extremity weakness
>the accidental injection of a local anesthetic into a blood vessel can cause CNS effects including bizarre behavior, disorientation, excitation, and convulsions
-severe maternal hypotension resulting from sympathetic blockade can cause a decrease in uteroplacental perfusion and the delivery of oxygen to the fetus
92
Nursing Insight- Shiver response after epidural block administration
may exhibit a shiver response after administration of the epidural block anesthesia
-can result from heat loss r/t increased peripheral blood flow
-also be r/t an alteration of thermal input to the CNS when warm but not cold sensations have been suppressed
>the body believes that the temperature is lower than the true temperature and raises the "thermostat" to generate heat by shivering
-apply warm blankets for comfort and offer reassurance
93
Nursing Actions for Maternal Bladder after Administration of Epidural Anesthesia
perform frequent assessments of the maternal bladder to avoid bladder distention
- patient may be unable to void and require catheterization
- bedpan should always be offered to minimize potential for UTI
- Nursing Actions to Facilitate voiding: position the patient to an upright position on the bedpan, raising the head of the bed to support the back, and provide privacy
- urinary retention and stress incontinence may occur immediately postpartum
94
What is a common side effect of opioid use?
```
Intense Pruritis (itching)
-usually treated with Diphenhydramine (Benadryl), 25 mg IV or 50 mg IM
```
95
What may occur after the administration of Epidural Anesthesia?
elevation in temperature
96
Optimizing Outcomes-During the Second Stage of Labor after administration of an epidural block
patient who has received an apidural block may require assistance with pushing because of the inability to feel the contractions or experience the urge to push
-also need someone to hold or control her legs to push
>after birth, the nurse MUST ensure that full sensation has returned and the patient is able to control her legs before ambulation is permitted; depending on the agent used and the dose administered, this may take several hours
97
For relief of labor pain and a vaginal birth, a block from ___ to ___ is performed
T10 to S5
| -usually when the cervix is dilated to 5 to 6 cm
98
For a Cesarean birth, a epidural block from ____ to ___ is required
T8 to S1
99
How is the patient positioned to Receive an Epidural?
on her side with her legs slightly flexed, or, asked to sit on the edge of the bed
- instructed to drop her shoulders, round out the small of her back (arch the back like a cat), and put her chin to her chest
- medication is injected between contractions to minimize the risk of tachycardia that can occur if the drug is unintentionally injected directly into a vessel
- the diffusion of the epidural anesthesia is dependent on the placement of the catheter tip, dose and volume of medication used, and the position of the patient (e.g. horizontal or upright)
- once epidural has been administered, a side-lying position (alternating sides each hour) is maintained to prevent compression of the vena cava
100
Methods for Epidural Anesthesia Block
continuous: achieved by use of a pump to infuse solution into an indwelling catheter; in many areas, patients are allowed to control the dosing with a programmed pump (patient controlled epidural anesthesia (PCEA)); empowers the patient to achieve some degree of control over her labor comfort and has been shown to decrease the total amount of medication needed
- a Lock-out period after each self-administration prevents over dosage
101
Combined Spinal-Epidural Analgesia
combination of spinal-epidural analgesia may be used to block pain transmission without interfering with motor ability
-pain relief is immediate, unlike the 20-30 delay associated with epidural alone
-an opioid such as fentanyl or sufentanil is injected into the subarachnoid space to rapidly activate the opioid receptors
-a catheter inserted in the epidural space extends the duration of the analgesia by using a lower dose of a local anesthetic agent alone or in combination with an opioid agonist analgesic
>patients may ambulate; often choose not to do so because of fatigue, sensation of weakness in the legs, and a fear of falling; encouraged to change positions frequently ad assisted to an upright position to enhance bearing-down efforts
-because this method is associated with puncture of the dura and placement of a catheter in the epidural space= greater risk of infection and post-dural headache
>be used for both labor analgesia and Cesarean birth
102
Epidural and Intrathecal Opioids
use of opioids alone
-eliminates the effects of local anesthetic
-Advantages: no maternal hypotension or alterations in vital signs; aware on contractions but does not feel pain thus able to bear down during second stage of labor; motor power remains intact
>fentanyl, sufentanil (short-acting agents; effects last 1.5 to 4 hours) and preservative free morphine (long-lasting; up to 7 hours) may be used
>Drawback: potential need for a pudendal nerve block or local perineal infiltration anesthesia because intrathecal opioids do not provide adequate anesthesia for the second-stage labor pain, episiotomy, or birth for most women
>used for post-operative pain control
103
Nursing Responsibility when epidural and intrathecal opioids are administered
- monitor and record respiratory rate every hour for 24 hours (or per protocol) after administration of epidural or intrathecal opioids
- Naloxone (Narcan) should be administered if the respiratory rate decreases to less than 10 breaths per minute or if the maternal oxygen saturation rate decreases to less than 89%
- oxygen may be administered by face mask and the anesthesiologist should be notified
104
General Anesthesia
induced unconsciousness
-used for unplanned, rapid (emergency) cesarean birth, when they are contraindications to an epidural or spinal block, or when surgical interventions is required for certain obstetric complications
105
Major Risks Associated with General Anesthesia administered for childbirth
-increased maternal blood loss r/t uterine relaxation, hypoxia, and the possible inhalation of vomitus during administration
>pregnant women are prone to gastric reflux because of increased stomach pressure from the gravid uterus beneath it; also the gastroesophageal valve may be displaced, allowing the upward passage of contents
-fetal depression r/t depth and duration of anesthesia; not considered for high-risk fetuses )e.g. preterm)
>measures to reduce respiratory depression in neonate; reducing the time from induction of the anesthesia until the umbilical cord is clamped and using a minimum of sedating drugs and anesthetics until after the cord has been clamped
106
Preparing the Patient for General Anesthesia
-nurse ensures that an IV infusion is in place, and if time permits, premedicates with an oral antacid (e.g. sodium citrate, citric acid/ sodium citrate, or effervescent aspirin/ citric acid) to neutralize the acidic contents of the stomach
>some anesthesiologist order ranitidine hydrochloride (Zantac) IV or cimetidine (Tagamet) to decrease production of stomach acid
>metoclopramide (Reglan) may also be prescribed to increase gastric emptying
-Before administration of the anesthesia, a wedge is placed under the right hip to displace the uterus; when possible, patient is preoxygenated with 3 to 5 minutes of 100% oxygen
-Thiopental sodium (Pentothal), an ultra-short acting barbiturate is given (causes rapid induction of anesthesia and minimal postpartal bleeding
-Succinyl Choline (Anectine) is a muscle relaxant used to facilitate passage of endotracheal tube
-to prevent gastric reflux and aspiration before the woman fully loses consciousness, the nurse may be asked to assist with applying cricoid pressure
107
To prevent gastric reflux and aspiration before the woman fully loses consciousness with general anesthesia the nurse may be asked to assist with applying cricoid pressure
this maneuver seals off the esophagus by compressing it between the cricoid cartilage and the cervical vertebrae
>the cricoid ring is located immediately above the thyroid isthmus
>cricoid cartilage is depressed 2 to 3 cm posteriorly, and pressure is maintained until the cuffed endotracheal tube is securely in place
-while applying pressure, use the other hand to support the neck
108
After Intubation of the Endotracheal tube
a 50:50 mixture of oxygen and nitrous oxide is usually administered
-small amounts of halogenated agent such as isoflurane or methoxyflurane may be given to enhance pain relief and to reduce maternal awareness and recall
>halogenated agents produce rapid uterine relaxation to facilitate intrauterine manipulation and extraction; at high concentrations they readily cross the placenta and can produce fetal necrosis and an increased risk for postpartal maternal hemorrhage because of uterine relaxation
109
Recovery Room Care
- maintenance of open airway, continuous monitoring of cardiopulmonary function, and the prevention of postpartum hemorrhage
- facilitate parent-infant bonding ASAP
- nurse offers emotional support, answers questions concerning the birth, provides updates regarding maternal/neonate status, and assesses the patients readiness to interact with her newborn
110
Nursing Assessment
- factors such as maternal-fetal status, the progress of labor, and the patients level of comfort, must be taken into consideration before a decision is made concerning whether non-pharmacological methods, pharmacological methods, or a combined approach will be used
- never assume pain experienced during labor is uterine in origin; physical assessment that includes an evaluation of characteristics of the pain (location, intensity, quality, frequency, duration, and effectiveness of all relief measures) must be performed
- parents prenatal record is reviewed to identify obstetric information, drug allergies, hx of tobacco or alcohol, or other substances, and spinal or neurological disorders
111
The Patients interview focuses on?
info concerning the onset of labor: most recent oral intake (time and amount), present illnesses, allergies, and events that occurred since her last visit with her primary care doctor
>asked about attendance in childbirth education classes and preferences for intrapartum comfort measures
-when available, the birth plan is reviewed and updated or modified as needed
112
The Physical Examination Includes
assessment of maternal vital signs, FHR and pattern, uterine contractions, amniotic membranes and fluid, cervical effacement and dilation, and fetal descent
- evaluates hydration status and palpates for bladder distention
- after administration of pharmacological agents, provide ongoing assessment of patient, fetus, and labor progress according to policy
- Maternal Assessment for evidence of allergic reaction to medications include monitoring vital signs, respiratory status, platelet, and white blood cell count, and observing for integumentary changes
- Laboratory data analyzed to identify anemia, coagulopathy or bleeding disorders, or infection
- Fetal status also assessed and non-reassuring changes in heart rate or pattern are reported
113
Nursing Diagnoses Relevant to anxiety, discomfort, and pain relief during labor and birth
- anxiety r/t lack of knowledge about the labor experience
- ineffective coping r/t the combination of uterine contractions and anxiety
- acute pain r/t the process of labor and birth
114
Contraindications to Spinal/Epidural Block Anesthesia
- maternal refusal
- local or systemic infection
- coagulation disorders
- actual or anticipated maternal hemorrhage
- allergy to specific anesthetic agents
- lack of trained staff available
115
Regional Block: Local Perineal Infiltration
>Area Affected: Perineum
>When used during labor and birth: immediately before birth for episiotomy; after birth for repair of lacerations
>Nursing Implications: assess patients knowledge and understanding; provide information as needed
-observe perineum for bruising, discoloration, hematoma, or signs of infection during recovery period
116
Regional Block: Pudendal Nerve Block
>Affected Area: perineum and lower vagina
>When used: late in the second stage for episiotomy, forceps, or vacuum extraction; during third stage for repair of episiotomy or lacerations
>Nursing Implications: assess patients level of knowledge and understanding; provide information as needed
-monitor for signs of infection, urinary retention
117
Regional Block: Spinal Anesthesia Block
>Affected Area: uterus, cervix, vagina, and perineum
>When used: first stage of both elective and emergent cesarean births; low spinal anesthesia block may be used for vaginal birth--not suitable for labor
>Nursing Implications: assess patients level of knowledge and understanding and level of pain relief; provide additional info as needed
-monitor maternal vital signs (hypotension) and FHR status
-assess for urinary retention, itching, nausea, vomiting, headache
-monitor site for leakage of spinal fluid or development of hematoma
118
Regional Block: Lumbar Epidural Block
>Affected Areas: uterus, cervix, vagina, and perineum
>When used: first and second stages
>Nursing Implications: assess patients level of knowledge and understanding and level of pain relief; provide additional information as needed
-monitor maternal BP (hypotension), and FHR status
-provide ongoing support
-assess for urinary retention, itching, nausea, vomiting, headache
119
Regional Block: Combined-Spinal Epidural
>Areas Affected: uterus, cervix, vagina, and perineum
>When used: spinal analgesia may be administered during the latent phase for pain relief, epidural is given when active labor begins
>Nursing Implications: monitor vital signs and FHR status, assess urinary retention, itching, nausea, vomiting, headache
-monitor site for leakage of spinal fluid or development of hematoma
120
Summary Points
- pain during labor is unique in that it is normal, can be anticipated and prepared for, and ends with a birth
- every individual perceives pain differently
- the better prepared a woman is for childbirth, the less likely is the need for analgesia and anesthesia
- relaxation, massage, breathing techniques, and other nonpharmacological strategies should be encouraged in conjunction with prescribed analgesics
- the type of analgesic or anesthetic to be used depends on stage of labor and the method of birth
- sedatives are used during a prolonged early labor when there is a need to decrease anxiety and promote rest
- regional anesthesia can be extremely effective for pain; the nurse must ensure adequate maternal hydration and normal blood pressure before administration
- general anesthesia is rarely used for vaginal birth because of risks for both the woman and her neonate
