Chapter 15: Pain Management Flashcards
1
Q
unique nature of pain during childbirth
A
- It is part of a normal process
- Preparation time exists
- It is self limiting – labor pain has a foreseeable end
- Is not constant but intermittent
- Labor ends with the birth of a baby à emotional significance for the child can make women tolerate more pain than she might expect
2
Q
Physiological Effects of Pain
A
- fear and anxiety–>stimulate sympathetic NS–>inc catecholamines–>stimulates alpha and beta receptors–>effects blood vessels and uterine muscles
3
Q
what can occur with excessive childbirth pain?
A
- Increases fear and anxiety
- Increases catecholamines
- Reduces uterine blood flow
- Reduces ability of uterus to contract
- Increases maternal blood pressure
- Increases maternal need for oxygen
4
Q
what are the 2 main effects excessive catecholamine secretions have?
A
- excessive catecholamine secretions occur due to fear and anxiety
- they cause:
- Reduced blood flow to and from the placenta, restricting fetal oxygen supply and waste removal
- Reduced effectiveness of uterine contractions, slowing labor progress
5
Q
what are psychological effects of pain?
A
- Mother may find it difficult to interact with infant b/c depleted from painful labor
- Unpleasant memories of the birth may affect her response to sexual activity or another labor
- Support person may feel inadequate during birth
- Partner may feel helpless and frustrated when her pain is unrelieved
6
Q
what are factors that affect a mother’s response to pain?
A
- childbirth education
- preparation for childbirth–allows woman to rehearse for labor
- cultural background
- fatigue/sleep deprivation–>interferes w/ attention and less energy
- personal significance of pain
- previous experience
- anxiety
- attention/distraction
- ie. touch, massage, stroking, music, focal points, imagery
7
Q
what type of pain dominates during the first stage of labor? what is it? why is that the type of pain?
A
- Visceral pain is a slow, deep, poorly localized pain that is often described as dull or aching
- Dominates during first stage labor as uterus contracts and cervix dilates
8
Q
what type of pain dominates during the late first stage and second stage of labor? what is it? why is that the type of pain?
A
- Somatic pain is quick, sharp and can be precisely localized
- Most prominent during late first-stage labor and during second stage labor as the descending fetus puts direct pressure on maternal tissues
9
Q
Physical Factors that influence perception/tolerance of pain Childbirth Pain
A
- labor intensity
- cervical readiness
- fetal position
- pelvic readiness
- fatigue and hunger
- caregiver interventions
10
Q
Psychosocial Factors that influence perception or tolerance of Childbirth Pain
A
- culture
- anxiety and fear
- previous experience
11
Q
what are the 4 physical sources of pain?
A
- tissue ischemia: blood supply to uterus dec during contractions
- cervical dilation: dilation and stretching of cervix
- pressure and pulling on pelvic structures: visceral pain and may be referred pain in back and legs
- distention of vagina and perineum: occurs w/ fetal descent especially during the second stage
12
Q
what are the standards for pain management?
A
- The rights of all pt to pain management
- Staff competency in pain assessment and management
- Establishment of policies and procedures that support prescription of appropriate pain medications
- Education of patients and families about effective pain management
- Discharge planning related to pain management
13
Q
what are some non-pharmacologic pain management techniques?
A
- relaxation
- cutaneous stimulation:
- massage
- counter pressure: sacral pressure may help with back pain that is intense when fetus is OP position
- touch
- thermal stimulation: warmth inc blood flow, relaxes muscles, and raises pain threshold
- acupressure: can be used to help with n/v
- hydrotherapy (need to be careful w/ infection risk)
- mental stimulation: imagery or focal point
- breathing techniques
14
Q
how to prepare for pain management?
A
- childbirth classes:
- ideal time to prepare is 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
15
Q
advantages of nonpharmacologic pain management
A
- does not slow labor
- no side effects or risk of allergy
- some pharmacologic methods may not eliminate labor pain
- may be only realistic option in advanced, rapid labor
16
Q
limitations of nonpharmacologic pain management
A
- desired level of pain control is not always achieved
- even a well prepared and highly motivated woman may have a difficult labor and need analgesia or anesthesia
17
Q
special considerations for medicating a pregnant woman
A
- Any drug taken by the woman is likely to affect the fetus
- Drugs may have effects in pregnancy that they do not have in the non-pregnant person
- Drugs can affect the course and length of labor
- Pregnancy complications may limit the choice of pharmacologic pain management methods
18
Q
what effects can pharmacologic pain management have on the fetus?
A
- they can have direct effects (if crosses placenta) or indirect effects (if mother then baby)
- can cause bradycardia or late decelerations
19
Q
effects of pharmacologic pain management on the course of labor
A
- Primarily the epidural block can slow progress during the second stage by reducing a woman’s spontaneous urge to push
- Ideally analgesics are given when labor is well established to avoid slowing progress
20
Q
regional pain management
A
- Used for intrapartum analgesia, surgical anesthesia or both – provides pain relief without LOC
- anagesia and anesthesia are usually given in active phase
- drugs given in latent phase may slow labor
- drugs given in transition phase may affect newborn
- no PO meds
- IV best choice–slowly given at beginning of contraction
- butorphanol or fentanyl
21
Q
advantages of regional pain management
A
- Can still participate in birth yet have good pain control
- awak and alert during birth
- Can still feel pressure and discomfort but sensations are greatly reduced
22
Q
disadvantages of regional pain management
A
- Depend on the technique
- Effects on the fetus depend primarily on how the woman responds rather than on direct drug effects
23
Q
lumbar epidural
A
- Regional block
- Given during active phase for vaginal birth
- Given right before a C/S
- Given by anesthesiologist or CRNA
- A local anesthetic and opiod into the tiny epidural space
- Varied “levels”
- Goal is analgesia, not anesthesia
- Placed at L3-L4
- Continuous with PCEA
24
Q
epidural block risks
A
- improper placement
- medication in subarachnoid space
- dural puncture
- causes spinal fluid leak and severe HA
- maternal hypotension
- bladder distention
- prolonged 2nd stage (b/c less urge to push)
- epidural catheter migration
- maternal fever
25
what to do for a severe HA caused by a dural puncture?
* use a blood patch
* so draw blood and inject that back into epidural space
* worse upright, but less severe if lying flat
* tx with bedrest, hydration, caffeine
* more likely with SAB, but possible with epidural
26
explain what to do for maternal hypoTN when using an epidural block
* MUST preload with 500-1000 mL of LR before administration of epidural
* if hypoTN crisis occurs, call for _ephedrine_
* give IV bolus
* reposition and give O2
* monitor for late or prolonged decels
27
what are ADRs of epidural opioids?
* n/v
* so give ondansetron
* pruritis
* so give diphenhydramine
* delayed respiratory depression
* have Naloxone ready
28
nursing care with epidurals
* baseline V/S and FHR patterns
* IV preload
* assist w/ positioning
* sidelying
* sitting
* maternal BP and FHR
* every 5 min for 15 min, then 30 min, then 1 hour
* assist with urination
* assess for need for catheter
29
intrathecal opioid analgesics
* walking epidural
* opioid is injected into subarachnoid space
* small doses, but big effect
* fast, but short acting
* fentanyl, sufentanil, morphine
* watch for delayed respiratory depression
30
subarachnoid (spinal) block (SAB)
* performed by physician or CRNA
* spinal fluid will be seen at needle hub to confirm placement
* sensory and motor functions lost
* watch for hypoTN and postdural puncture HA
31
combined spinal and epidural (CSE)
* primarily used for scheduled C/S
* longer pain relief
* often use Duramorph
32
Duramorph
* can be used in postpartum b/c lasts for 24 hours OR also used with CSE
* causes a lot of pruritis so often give diphenhydramine
* long acting morphine derivative
33
systemic drugs used in labor
* Nitrous Oxide--NO-often used in vaginal birth
* pareteral analgesia:
* usually Butorphanol
* opioid agonist and antagonist
* never give to opioid dependent women--\>causes withdrawal in both woman and newborn
* likely to cause respiratory depression in newborn, depending on when it is given
* small frequent doses IV push
34
opioid antagonists used in labor
* Narcan (Naloxone)
* used to reverse opioid induced respiratory depression in mother or baby
* maternal dose: 0.4-2 mg IV
* neonatal dose: 0.1 mg/kg
35
adjunctive drugs used in labor
* antiemetics: ondansetron
* tranquilizers and sedatives (rare)
* used to promote rest, reduce anxiety, and reduce nausea
36
local infiltration anesthetic
* given just before birth for epsiotomy by provider
* ie. bupivicaine, lidocaine
* numbs perineum
* burning sensation before effective
* can give w/ epinephrine to reduce bleeding
37
pudendal block
* given during the 2nd stage of labor
* useful for episiotomy and/or low forceps
* anesthetizes lower vagina/perineum
* minimal effect on fetus unless it is placed intravascularly
38
general anesthesia
* mother will be unconsious
* useful when rapid anesthesia is required, such as for an emergency C/S
* ADRs:
* maternal aspiration of gastric contents
* usually give famotidine before C/S
* respiratory depression of mom and/or baby
* uterine relaxation and post partum hemorrhage
39
nursing care for general anesthesia
* place wedge under R hip
* pre-oxgenate w/ 3-5 min of 100% O2
* may depress fetus (reaches fetus in 2 min)
