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OB/Community Health > Management of Discomfort > Flashcards

Management of Discomfort Flashcards

1
Q

What can cause visceral pain during the 1st stage of labor (dilating) ?

A
  • distension of lower uterine segment
  • stretching cervix
  • traction on adjacent structures and nerves
  • uterine ischemia (no oxygenation to uterus during contraction) which can cause an intensification of pain
  • pain comes from organs so can’t exactly pinpoint pain
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2
Q

What can cause somatic pain during the 2nd stage of labor (pushing) ?

A
  • stretching and distension of perineal tissue and pelvic floor
  • pressure against bladder and rectum
  • lacerations of soft tissue
  • intense, sharp, burning (ring of fire and it starts to burn)
  • localized pain and specific to body part
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3
Q

What is some physiologic responses to pain ?

A
  • increase BP and HR
  • increased O2 consumption
  • hyperventilation can occur: blows off too much CO2 (dioxide) so we can have her put hands in front of mouth to breathe back in some of that CO2
  • increased gastric acidity
  • N/V during transition
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4
Q

What is some affective responses to pain ?

A
  • increased anxiety
  • writhing
  • crying
  • screaming
  • groaning/moaning
  • gesturing (clenching hands or teeth)
  • avoidance/withdrawal
  • inability to follow instructions
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5
Q

What are some physiological factors affecting pain ?

A
  • contraction interval: if there is more time in-between contractions then more time to prepare for next wave of pain
  • fatigue: longer labor can cause you to feel the pain stronger
  • fetal size
  • position (fetus and mom)
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6
Q

What happens in the Anxiety and Fear cycle ?

A
  • pt feels anxiety and fears pain
  • increases in catecholamines (stress hormone)
  • decreased blood flow to uterus and increases muscle tension
  • magnifies pain perception
  • slows labor progression
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7
Q

What is the gate-control theory ?

A

only a limited number of sensations can travel along the nerve pathways at any given time
- use distraction techniques (counter pressure and massages) to send alternative signals through these pathways
- this can cause the pain signals to be blocked and inhibits perception and sensation of pain

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8
Q

What are some cognitive strategies to promote relaxation ?

A
  • childbirth education/prep classes
  • doulas
  • hypnosis
  • biofeedback
  • progressive relaxation: contract 1 muscle group at a time and then relax them
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9
Q

What is some sensory stimulation strategies to promote relaxation ?

A
  • aromatherapy
  • breathing techniques
  • imagery: picture of something positive to focus on to take mind off pain
  • music
  • focal points
  • subdued lighting
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10
Q

What is the slow-paced breathing technique ?

A
  • slow breathing to 1/2 normal rate
  • introduce when she can no longer walk or talk through contractions
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11
Q

What is the modified-paced breathing technique ?

A
  • twice the normal breathing rate (32-40 bpm)
  • combo of slow breathing and faster, shallower breaths
  • requires more concentration
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12
Q

What is the patterned-phase breathing technique ?

A
  • combo of panting breaths with soft blowing (at peak of contraction to prevent hyperventilation)
  • same rate as modified-paced (32-40 bpm)
  • watch for hyperventilation
  • transition phase
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13
Q

What is effleurage ?

A

light stroking of the skin usually at the abdomen
- may become sensitive to touch as labor progresses

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14
Q

What is counter pressure ?

A

steady pressure applied to sacral area
- helps with back labor/pain (OP presentation)
- utilizes support person
- Double Hip Squeeze: pressure on both hips (relieves internal pressure)

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15
Q

What is Hydrotherapy ?

A

use of bathing. showering and jet hydrotherapy
- calming and reduces anxiety and pain
- use shower stream on abdomen or back
- water immersion increases buoyancy and sense of weightlessness

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16
Q

What are some contraindications for hydrotherapy ?

A
  • non reassuring FHR
  • fever
  • infectious diseases (HIV, active HSV)
  • vaginal bleeding that is more then normal
  • gestation less than 37 weeks (pre-term baby’s are more sensitive to temp of water and could increase temp)
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17
Q

What are some medications to use as pain intensifies and pt can’t cope during labor ?

A
  • opioids
  • nitrous oxide
  • epidural
18
Q

What meds may we used during the 2nd phase (pushing) ?

A
  • pudendal block
  • local anesthesia
19
Q

What meds may be used during surgery ?

A

spinal or general anesthesia

20
Q

What is an Analgesia ?

A

med that reduces/alleve pain by raising the threshold for pain perception
- no loss of consciousness
- Ex.) opioids, nitrous oxide

21
Q

What is anesthesia ?

A

alleviation of pain by interrupting nerve impulse to the brain
- complete or partial
- can have loss of consciousness
- epidural, spinal, or general

22
Q

What is a opioid agonist ?

A

binds to the opioid receptor which activates it
- provides pain relief
- Ex.) morphine, meperidine (Demerol), fentanyl

23
Q

What is a opioid agonist-antagonist ?

A
  • Antagonist: blocks opioid receptors or meds designed to activate it
  • combines both types to provide a limited ceiling (effect) of med
    • reduces side effects (N/V, respiratory depression)
  • Ex.) Nalbuphine (Nubain),
24
Q

What are some symptoms of Maternal Opioid Abstinence Syndrome ?

A
  • yawning
  • rhinorrhea (runny nose)
  • sweating
  • lacrimation (crying)
  • mydriasis (dilated pupils)
  • anorexia
  • irritability,, restlessness, generalized anxiety
  • tremors
  • chills and hot flashes
  • piloerection (goosebumps)
  • violent sneezing
  • weakness, fatigue, drowsiness
  • N/V
  • diarrhea, abdominal cramps
  • bone and muscle pain
25
Q

What are some considerations for Nalbuphine (Nubain) ?

A

opioid agonist-antagonist
- IM or IV
- best given IV during peak of contraction
- side effects: drowsiness, respiratory depression, N/V
- FHR: minimal variability (sleep, sedation, sick)
- crosses the placenta and can cause neonatal respiratory depression
- still feels contractions but doesn’t really faze them
- consider # of previous times pt has delivered a baby because increased past deliveries causes future deliveries to go by faster

26
Q

What are some contraindications for Nalbuphine (Nubain) ?

A
  • women who are opioid dependent (going to make them go through withdrawal)
  • don’t want to give to pt who will deliver in the next 4 hrs because it can cause the baby to be born without the drive to take 1st breathe (NICU team nearby)
27
Q

What information is needed for opioid administration ?

A
  • allergies
  • respiratory rate, BP, all other VS
  • level of consciousness
  • opioid history
  • previous deliveries
  • cervical exam
  • FHR reassuring or not
28
Q

What are some considerations for nitrous oxide ?

A

inhaled anesthetic gas (laughing gas)
- used more in other countries but increased interest in US
- reduces perception of pain & feelings of euphoria and decreased anxiety
- S/E: nausea and dizziness
- masks is a 1 way valve (only releases when a big breathe is taken)
- 50:50 with O2 using blender device
- useful in perineal repair or manual removal of placenta

29
Q

What is a Pudendal nerve block ?

A

injection of anesthetic in pudendal nerve
- for 2nd stage of labor
- only relieves pain in vagina, vulva, and perineum
- given 10-20 mins before it is needed
- transvaginal approach
- given for forceps or vacuum delivery
- helps relieve that ring of life or if need a assisted delivery

30
Q

What are some advantages of a epidural ?

A
  • airway is intact
  • pt is alert
  • only partial motor paralysis (up to belly button)
  • limited blood loss
  • very effective
31
Q

What are some disadvantages of a epidural ?

A
  • decreased mobility: can’t get out of bed and lose advantage of gravity helping get fetus into position
  • inhibits bladder elimination sensation/urinary retention: need someone to empty bladder for q3-4 hrs (I&O cath)
  • hypotension: blood pools in peripheral limbs so it decreases circulation of blood which can decrease BP
  • fever
  • increases need for assisted delivery
  • potential for spinal headache
32
Q

What causes a spinal headache with a epidural ?

A

epidural needle punctures the dura and causes the cerebrospinal fluid to leak so when sat up is causes bounding HA
- Tx: insert another epidural needle and instead of injecting more med you will inject pt’s blood that will act as a patch over the hole (relief in 1 hr)

33
Q

Where is the catheter threaded with a epidural ?

A

between L4 and L5 into the epidural space
- not through the dura
- can be used with a PCEA (pt controlled epidural anesthesia): optimal control

34
Q

What are some RN considerations for someone with a epidural ?

A
  • must have IV site and fluid bolus (500 mL LR usually but NS too)
  • monitor BP/Spo2 and pulse regularly/consider pt’s baseline BP from prenatal records &
  • monitor FHR & BP continuously
  • have O2 and ephedrine available
  • urinary retention: I&O cath q3-4 hrs
  • turn pt q1-2hr to promote fetal decent and avoid “one-sided” pain relief
  • anticipate longer 2nd stage (don’t when where to push because can’t feel so may push with their legs instead of perineal)
  • left wedge after placement to keep pt’s off vena cava
  • safety
35
Q

When is spinal anesthesia used ?

A

scheduled, non-emergent C-sections or tubal ligations

36
Q

How does spinal anesthesia work ?

A

go past the dura and inject a intrathecal opioid (duramorph) or another med into the cerebrospinal fluid and it mixes with it
- smaller needle then in epidural
- through dura at the 3rd, 4th, or 5th lumbar interspace
- sudden onset of numbness, lasts 1-3 hrs
- blockage up to breastbone

37
Q

What are some side effects of spinal anesthesia ?

A

Immediate
- marked maternal hypotension
- fetal bradycardia
- block can be too high
Postpartum
- N/V
- pruritus
- respiratory depression

38
Q

What are some RN considerations for someone with a Spinal anesthesia ?

A
  • VS and EFM strip for 20-30 min after placement
  • bolus of 500-1000 mL LR or NS 15-30 min before placement
  • evaluate FHR immediately after placement
  • assess RR, pulse ox every hour for 24 hrs
39
Q

Why is general anesthesia only used in emergency situations ?

A

med goes to the baby as well and cause them to be resuscitated
- NICU needs to be in delivery room and once given you have to immediately cut pt and get baby out
- faster baby is out the less general anesthesia they are exposed to
- immediate intubation
- may be given with additional inhalation gases for increased pain relief and reduce of maternal awareness and recall
- IV meds render pt unconscious and inhalation gas a muscle relaxer

40
Q

What are some RN considerations for general anesthesia ?

A
  • NPO x8 hrs ideally
  • IV needs to be in place
  • pre-medicate with oral antacids (bicitra) to neutralize stomach content, Pepcid to decrease stomach acid and Reglan to promote gastric emptying (these meds neutralize stomach acid and won’t burn trachea in cases of aspiration)
  • wedge under left hip
  • cricoid pressure during intubation (RN can help anesthesiologist with this)
  • promote bonding ASAP
41
Q

What are some recover considerations for someone who has general anesthesia ?

A
  • maintain airway (want gag reflex)
  • monitor VS
  • breath sound and O2 sat
  • pain management: will need to set up PCA pump for postpartum (seen less) or given pain med (as soon as you unhook them they will feel pain)
  • assess readiness to see baby and promote bonding
  • discuss events leading to general anesthesia and c/section (if emergent)
42
Q

What is local perineal infiltration anesthesia ?

A

“local”
- 2nd/3rd stage: given when episiotomy is going to be performed or lacerations need repair
- injection of 1 lidocaine (burns when injected and also put before insertion of epidural)
- epinephrine added to intensify effect, and prevent excessive bleeding and systemic absorption

OB/Community Health (12 decks)

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