L&D Pain Management 2

Question 1

Pharmacological methods of pain relief include (2).

To avoid slowing the progress of labor, prior to administering the nurse should assess?

Answer 1

Pharmacological methods of pain relief include analgesia and local/regional anesthetics. To avoid slowing the progress of labor, prior to administering analgesic pain relief, the nurse should verify that labor is well established by performing a vaginal exam that reveals a cervical dilation to be at least 4 cm with a fetus that is engaged.

Question 2

Pharmacological Management:
Goal?
Analgesia include: (3)

Answer 2

Pharmacological Management
◯ Alleviates pain sensations or raises the threshold for pain perception
◯ Analgesia includes 
opioid analgesics
epidural 
spinal regional analgesia

Question 3

Sedatives (barbiturates) examples

Answer 3

Sedatives (barbiturates) such as
secobarbital (Seconal),
pentobarbital (Nembutal),
phenobarbital (Luminal) are not typically used during birth, but can be used during the early or latent phase of labor to relieve anxiety and induce sleep.

Question 4

Sedatives (barbiturates)/Adverse Effects

Sedatives and pt pain?

Answer 4

Adverse effects of sedatives
X Neonate respiratory depression secondary to the medication crossing the placenta and affecting the fetus
X Unsteady ambulation of the client
X Inhibition of the mother’s ability to cope with the pain of labor.

Sedatives should not be given if the client is experiencing pain, because apprehension can increase and cause the client to become hyperactive and disoriented.

Question 5

Sedatives (barbiturates)/Adverse Effects
Client Education (2)

Answer 5

Client education
X Explain to the client that the medication will cause drowsiness.
X Instruct the client to request assistance with ambulation.

Question 6

Sedatives (barbiturates): Nursing Actions (4)

Answer 6

Nursing actions
X Dim the lights and provide a quiet atmosphere.
X Provide safety for the client by lowering the position of the bed and
elevate the side rails.
X Assist the mother to cope with labor.
X Assess the neonate for respiratory depression.

Question 7

Opioid analgesics:

1) Examples:
2) How they work?
3) Adm Route?
4) Best route during labor

Answer 7

1) Opioid analgesics such as meperidine hydrochloride (Demerol), fentanyl (Sublimaze), butorphanol (Stadol), and nalbuphine (Nubain)
2) act in the CNS to decrease the perception of pain without the loss of consciousness.
3) The client may
be given opioid analgesics IM or IV, but the IV route is recommended during labor because action is quicker.
4) IV route

Question 8

Name 2 opioid analgesics that provide pain relief without
causing significant respiratory depression in the mother or fetus. Both IM
and IV routes are used.

Answer 8

Butorphanol (Stadol)

nalbuphine (Nubain)

Question 9

Adverse effects of opioid analgesics (8)

Answer 9

Adverse effects of opioid analgesics
X Crosses the placental barrier; if given to the mother too close to the time of delivery, opioid analgesics can cause respiratory depression in the neonate.
X Reduces gastric emptying; increases the risk for nausea and emesis
X Increases the risk for aspiration of food or fluids in the stomach
X Sedation
X Tachycardia
X Hypotension
X Decreased FHR variability
X Allergic reaction

Question 10

Opioid analgesics: Client Education (2)

Answer 10

Client education
X Explain to the client that the medication will cause drowsiness.
X Instruct the client to request assistance with ambulation.

Question 11

Opioid analgesics: Nursing Actions (4)

Answer 11

☐ Nursing actions
X Prior to administering analgesic or anesthetic pain relief, the nurse should verify that labor is well established by performing a vaginal exam that reveals a cervical dilation of at least 4 cm with a fetus that is engaged.
X Have naloxone (Narcan) available to counteract the effects of respiratory depression in the newborn.
X Administer antiemetics as prescribed.
X Monitor maternal vital signs, uterine contraction pattern, and continuous FHR monitoring.

Question 12

Antimetics (2)

Hint: P, H, V

Answer 12

Phenothiazine medications such as promethazine (Phenergan) or
hydroxyzine (Vistaril) can control nausea and anxiety. They do not relieve pain and are used as an adjunct with opioids.

Question 13

Antimetics: Adverse effects

Answer 13

Adverse effects include dry mouth and sedation

Question 14

Epidural and spinal regional analgesia consists of using analgesic

1) example of short-acting opiods
2) How does it work?
3) Where is it administered? (2)
4) Benefit (2)

Answer 14

Epidural and spinal regional analgesia consists of using analgesics such as
fentanyl (Sublimaze) and sufentanil (Sufenta), which are short-acting opioids that
are administered as a motor block into the epidural or intrathecal space without anesthesia. These opioids produce regional analgesia providing rapid pain relief
while still allowing the client to sense contractions and maintain the ability to bear down.

Question 15

Adverse effects of epidural and spinal analgesia (6)

Answer 15

☐ Adverse effects of epidural and spinal analgesia
X Decreased gastric emptying resulting in nausea and vomiting
X Inhibition of bowel and bladder elimination sensations
X Bradycardia or tachycardia
X Hypotension
X Respiratory depression
X Allergic reaction and pruritus

Question 16

Epidural and spinal analgesia: Client education (1)

Answer 16

Client education

X Provide the client with ongoing education related to expectations for procedure.

Question 17

Epidural and spinal analgesia: Nursing Actions (5)

Answer 17

Nursing actions
X Institute safety precautions, such as putting side rails up on the client’s bed. The client may experience dizziness and sedation, which increases maternal risk for injury.
X Assess the client for nausea and emesis and administer antiemetics as prescribed.
X Monitor maternal vital signs per hospital protocol.
X Monitor for allergic reaction.
X Continue FHR pattern monitoring.

Question 18

Pharmacological Anesthesia
◯ Pharmacological anesthesia eliminates?
◯ Anesthesia used in childbirth includes? (2)
■ Regional blocks are most commonly used and consist of pudendal block, epidural
block, spinal block, and paracervical nerve block.

Answer 18

Pharmacological Anesthesia
◯ Pharmacological anesthesia eliminates pain perceptions by interrupting the nerve
impulses to the brain.
◯ Anesthesia used in childbirth includes regional blocks and general anesthesia.
■ Regional blocks are most commonly used and consist of pudendal block, epidural
block, spinal block, and paracervical nerve block.

Question 19

Pharmacological Anesthesia: Regional blocks

1) Common? or uncommon use?
2) Examples (4)

Answer 19

Pharmacological Anesthesia
■ Regional blocks are most commonly used and consist of pudendal block, epidural block, spinal block, and paracervical nerve block.

Question 20

Pharmacological Anesthesia: Regional blocks

Pudendal Block:

1) Examples
2) Adm route
3) Benefit?
4) Areas that are numb
5) Used for procedures such as (3)
6) Administered when (what stage)?
7) Used for procedures such as (nonstandard) (2)

Answer 20

1) Pudendal block consists of a local anesthetic such as lidocaine (Xylocaine)
or bupivacaine (Marcaine)
2) being administered transvaginally into the space
in front of the pudendal nerve.
3) This type of block has no maternal or fetal
systemic effects,
4) but it does provide local anesthesia to the perineum, vulva, and rectal areas
5 )during delivery, episiotomy, and episiotomy repair.
6) administered during the second stage of labor 10 to 20 min before delivery
7) providing analgesia prior to spontaneous expulsion of the fetus or forceps assisted or vacuum-assisted birth.
☐ Adverse effects of pudendal block
X Broad ligament hematoma
X Compromise of maternal bearing down reflex
☐ Nursing actions
X Instruct the client about the method.
X Coach the client about when to bear down.
X Assess the perineal and vulvar area postpartum for hematoma.

Question 21

Pharmacological Anesthesia: Regional Blocks

Pudendal Block: Adverse Effects (2)

Answer 21

Adverse effects of pudendal block
X Broad ligament hematoma
X Compromise of maternal bearing down reflex

Question 22

Pharmacological Anesthesia: Regional blocks

Pudendal Block: Nursing Actions (3)

Answer 22

Nursing actions
X Instruct the client about the method.
X Coach the client about when to bear down.
X Assess the perineal and vulvar area postpartum for hematoma

Question 23

Epidural Block
Pharmacological Anesthesia: Regional Blocks

1) 2 step
2) Local eg?
3) Epidural med eg? (2)
4) Injected where?
5) Result?..Where is sensation lost
6) Relieving the discomfort of (4)
7) Adm when?
8) What type of infusion?

Answer 23

An epidural block consists of a local anesthetic bupivacaine (Marcaine) along
with an analgesic morphine (Duramorph) or fentanyl (Sublimaze)
4) injected into the epidural space at the level of the fourth or fifth vertebrae.
5) This eliminates all sensation from the level of the umbilicus to the thighs,
6) relieving the discomfort of uterine contractions, fetal descent, and pressure and stretching of the
perineum.
7) It is administered when the client is in active labor and dilated to at least 4 cm.
8) Continuous infusion or intermittent injections may be administered through an indwelling epidural catheter. Patient-controlled epidural analgesia is
a new technique for labor analgesia and is becoming a favored method of acute
pain relief management for labor and birth.

Question 24

Epidural Block: Adverse effects of epidural block (4)

Pharmacological Anesthesia: Regional blocks

Answer 24

Adverse effects of an epidural block
X Maternal hypotension
X Fetal bradycardia
X Inability to feel the urge to void
X Loss of the bearing down reflex

Question 25

Epidural Block: Nursing Actions (11)

Pharmacological Anesthesia: Regional blocks

Answer 25

☐ Nursing actions
X Administer a bolus of IV fluids to help offset maternal hypotension as prescribed.
X Help to position and steady the client into either a sitting or sidelying modified Sims’ position with her back curved to widen the intervertebral space for insertion of the epidural catheter.
X Encourage the client to remain in the side-lying position after insertion of the epidural catheter to avoid supine hypotension syndrome with compression of the vena cava.
X Coach the client in pushing efforts and request an evaluation of epidural pain management by anesthesia if pushing efforts are ineffective.
X Monitor maternal blood pressure and pulse, observe for hypotension, respiratory depression, and oxygen saturations.
X Assess FHR patterns continuously.
X Maintain the IV line and have oxygen and suction ready.
X Assess for orthostatic hypotension. If present, be prepared to administer an IV vasopressor such as ephedrine, position the client laterally, increase IV fluids, and initiate oxygen.
X Provide client safety such as raising the side rails of the bed. Do not allow the client to ambulate unassisted until all motor control has returned.
X Assess the maternal bladder for distention at frequent intervals and catheterize if necessary to assist with voiding
X Monitor for the return of sensation in the client’s legs after delivery but
prior to standing. Assist the client with standing and walking for the first time after a delivery that included epidural anesthesia.
View Media Supplement: Epidural Catheter Placement (Video)
☐ Client education
X Provide ongoing instructions related to the procedure and nursing
actions.
■ Spinal block consists of a local anesthetic that is injected into the sub

Question 26

Epidural Block: Client Education (1)

Pharmacological Anesthesia: Regional blocks

Answer 26

☐ Client education
X Provide ongoing instructions related to the procedure and nursing
actions.

Question 27

Spinal Block:
Pharmacological Anesthesia: Regional blocks

1) What is it?
2) Used alone or in combo with another med?
3) Med Example (1)
4) How does it work? What areas are numb?
5) Used for?
6) Lower spinal block use for?
7) Lower spinal block NOT used for?
8) When is this administered?

Answer 27

1) Spinal block consists of a local anesthetic that is injected into the subarachnoid space into the spinal fluid at the third, fourth, or fifth lumbar interspace.
2) This can be done alone or in combination with an analgesic such as
3) fentanyl (Sublimaze).
4) The spinal block eliminates all sensations from the level of the nipples to the feet.
5) It is commonly used for cesarean births.
6) A low spinal block may be used for a
vaginal birth,
7) but is not used for labor.
8) A spinal block is administered in the late
second stage or before cesarean birth.

Question 28

Spinal Block: Adverse Effects (5)

Pharmacological Anesthesia: Regional blocks

Answer 28

☐ Adverse effects of a spinal block
X Maternal hypotension
X Fetal bradycardia
X Loss of the bearing down reflex in the mother with a higher incidence
of operative births
X Potential headache from leakage of cerebrospinal fluid at the puncture site
X Higher incidence of maternal bladder and uterine atony following birth

Question 29

Spinal Block: Nursing Actions (6)

Pharmacological Anesthesia: Regional blocks

Answer 29

Nursing actions
X Assess maternal vital signs every 10 min.
X Manage maternal hypotension by administering an IV vasopressor, positioning the mother laterally, increasing IV fluids, and initiating oxygen.
X Assess the client’s uterine contractions.
X Assess level of anesthesia.
X Assess FHR patterns.
X Provide client safety to prevent injury by raising the side rails of the bed, and assisting the client with repositioning and ambulating.

Question 30

Spinal Block: Client Education (2)

Pharmacological Anesthesia: Regional blocks

Answer 30

☐ Client education
X Instruct the client about the method.
X Instruct the client to bear down for expulsion of the fetus because during a vaginal birth, the mother will not feel her contractions.

Question 31

General anesthesia

1) Only used in event of?
2) Result?

Answer 31

1) General anesthesia is rarely used for vaginal or cesarean births when there are no complications present. It is only used in the event of a delivery complication or emergency when there is a contraindication to nerve block analgesia or
anesthesia.
2) General anesthesia produces unconsciousness.

Question 32

General Anesthesia

1) Monitor (2)
2) Ensure (2)
3) Premedicate pt with?
4) Adm a histamine H-2 receptor blocker. Why? Eg?
5) Admin _?__ to increase gastric emptying
6) Adm short acting barbiturate eg? Why?
7) Adm muscle relaxant Why? eg?
8) How do to displace uterus
9) Apply ? pressure before intubation
10) Maintain open airway and __?___ fxn?
11) Assess pt postpartum for signs of uterine tone which can lead to ____ and fetal ___

Answer 32

☐ Nursing actions
X Monitor maternal vital signs.
X Monitor FHR patterns.

X Ensure that the client has had nothing by mouth.
X Ensure that the IV infusion is in place.

X Premedicate the client with clear oral antacid to neutralize acidic stomach contents.

X Administer a histamine H2-receptor blocker such as ranitidine (Zantac)
to decrease gastric acid production.
X Administer metoclopramide (Reglan) to increase gastric emptying as prescribed.
X Administer a short-acting barbiturate, such as thiopental sodium (Pentothal), to render the client unconscious as prescribed.
X Administer succinylcholine chloride (Anectine), a muscle relaxant to facilitate passage of an endotracheal tube as prescribed.
X Place a wedge under one of the client’s hips to displace the uterus.
X Assist with applying cricoid pressure before intubation.
X Maintain an open airway and cardiopulmonary function.
X Assess the client postpartum for maternal signs of decreased uterine tone, which can lead to hemorrhage and fetal narcosis, both of which can be produced by pharmacological agents used in general anesthesia.

Question 33

General Anesthesia: Client education for general anesthesia (1)

Answer 33

Client education for general anesthesia

X Facilitate parent-newborn attachment as soon as possible.

Question 34

Phenothiazine medications such as promethazine (Phenergan) or
hydroxyzine (Vistaril)

Answer 34

can control nausea and anxiety. They do not relieve pain and are used as an adjunct with opioids.

Question 35

fentanyl (Sublimaze) and sufentanil (Sufenta),

Answer 35

Epidural and spinal regional analgesia consists of using analgesics such as
fentanyl (Sublimaze) and sufentanil (Sufenta), which are short-acting opioids that
are administered as a motor block into the epidural or intrathecal space without anesthesia. These opioids produce regional analgesia providing rapid pain relief
while still allowing the client to sense contractions and maintain the ability to bear down.

Question 36

histamine H2-receptor blocker such as ranitidine (Zantac)

X Administer metoclopramide (Reglan)

used via General anesthesia

Answer 36

Administer a histamine H2-receptor blocker such as ranitidine (Zantac)
to decrease gastric acid production.
X Administer metoclopramide (Reglan) to increase gastric emptying as prescribed.

Question 37

An epidural block consists of a local anesthetic bupivacaine (Marcaine) along
with an analgesic morphine (Duramorph) or fentanyl (Sublimaze)

Answer 37

consists of a local anesthetic bupivacaine (Marcaine) along

with an analgesic morphine (Duramorph) or fentanyl (Sublimaze)

Question 38

bupivacaine (Marcaine) plus
morphine (Duramorph) or fentanyl (Sublimaze)
equals

Answer 38

EPIDURAL BLOCK

Question 39

Opioids and Epidural administered during this phases?

Answer 39

Active phase