Management of Discomfort in Labor & Birth (exam 2) Flashcards
components of physiologic pain
- dilation and stretching of cervix
- distention of lower uterine segment
- uterine muscle cell ischemia
- pressure by presenting part on abdominal structures
- referred pain -> nearby structures
originates in the uterus and radiates to the abdominal wall, lumbar sacral area of the back, iliac crests, gluteal area, and down the thighs
referred pain
differences in pain in people
individual behavioral responses to pain
factors influencing pain response
- culture
- anxiety
- previous experience and learned coping skills
- childbirth preparation
- support and environment
- people tend to react in ways that are acceptable in their culture
- some women react to pain by becoming silent and avoiding interaction with others, some scream/verbalize distress, some may be verbally abusive to those around her
strategies of pain management
- relaxation (relax selected muscle groups)
- distraction (focal imagery)
- touch and massage
- effleurage and counter pressure
- music
- water therapy (hydrotherapy)
light stroking of abdomen or back in rhythm with the patient’s breathing during a contraction
effleurage
steady pressure applied to sacral area
esp. helpful when back pain is caused by the baby in the occiput posterior position
counterpressure
lifts the occiput off the nerves -> some relief
provides distraction and reduces the perception of pain during UC
controlled breathing techniques
controlled breathing techniques during 1st stage of labor
relaxation -> increases size of abdominal cavity -> promotes fetal descent
controlled breathing techniques in the 2nd stage of labor
used to increase abdominal pressure and assist in bearing down (pushing with UC)
all breathing patterns begin and end with
relaxing cleansing breath in through the nose and out through the mouth
breathing techniques
- slow-paced breathing
- modified-paced breathing
- pant-blow (used during transition to help control urge to push SE -> hyperventilation and resp alkalosis)
most difficult time to maintain control of breathing
transition phase of 1st stage of labor when cervix is dilating 8-10cm
- the pant-blow technique is suggested during this time
symptoms of respiratory alkalosis
Lightheaded
Dizzy
Tingling of fingers
Circumoral numbness or blueness
pharmacologic pain management effects on fetus
- drugs may cross placenta
- drugs -> maternal hypotension and reduce placental perfusion
pharmacologic pain management effects on the course of labor
- may slow progress If given too early
- may impair natural urge to push
given to take away perception of contractions (does not stop them) until they get an epidural
Stadol (narcan will not reverse)
systemic analgesia
- Goal is adequate pain relief without increasing maternal or fetal risks
- Pain relief without affecting the progress of labor
- Stage/phase and progress of labor determines type of analgesia or anesthesia
Pentobarbital (Nembutal) or Secobarbital
Barbiturates
- Relieve anxiety… induce sleep
- May be administered in early labor to alter a dysfunctional pattern
- Not used in active labor because of CNS depression in newborn
- Prolonged latent phase of labor…woman get tired and frustrated but hurts just enough can’t sleep or rest.
- Often sleep/awake can cope with active labor better.
- Seconal is no longer available, but is discussed in the book
Promethazine (Phenergan) and Hydroxyzine (Vistaril)
Ataractics
- Reduces anxiety, apprehension & N&V
- Increases sedation
- Thought to potentiate opioid analgesic medication effects (actually impairs efficacy of opioids)
- Antiemetic effect
- May contribute to maternal hypotension and neonatal depression
antiemetic that potentiates the effects of opioids
Reglan
why should you not use benzodiazepines
disrupts newborn thermal regulation
1 stress to newborn
COLD
administration of systemic medications during labor
- IV preferred over IM because onset of action is faster and duration more predictable
- IV medication injected slowly through the distal port (nearest the IV insertion site)
- or an epidural pump
- deliver while a patient is at the top of the contraction so that mother gets most of the drugs (fetal vasoconstriction)
agent that stimulates a receptor to act
agonist
agent that blocks a receptor
antagonist
antidote/antagonist to narcotic analgesic -> reverses CNS depressant effects
Narcan
contraindicated for narcotic addicted patients because may precipitate withdrawal symptoms
Stadol (Butorphanol Tartrate)
and
Nubain (Nalbuphine Hydrochloride)
Mixed opioid agonist-antagonist analgesics
- Provides adequate analgesia without respiratory depression in mom or baby
- Used more in labor than narcotic analgesics
- May precipitate withdrawal symptoms in narcotic dependent women and baby
- Narcan will not reverse the effects
- can be given IV, IM, or SQ
If baby has respiratory depression ____
stimulation and fluids
- baby can come out floppy (stimulate - get blood moving)
Regional analgesics/anesthesia
Epidural block
(in some areas, 90% of laboring patients receive epidural analgesia)
Combined spinal-epidural block (aka epidural intrathecal)
Local infiltration of perineal area (lidocaine)
- intensity of block depends on the type of local anesthetic used and volume
Pudendal nerve block
Spinal nerve block (spinal fluid)
What they do if they accidentally do a spinal epidural?
ALWAYS document that the tip is intact when taking out an epidural
Epidural Advantages
- Patient remains alert, which can allow the mother more opportunity to participate
- Good relaxation techniques are achieved
- Only partial motor paralysis occurs (allows the patient to push)
- Airway reflexes remain intact
- Gastric emptying is not delayed
- Blood loss is not excessive
Epidural Disadvantages
- Limited mobility
- May increase duration of second stage of labor
- Not effective for some patients (second form of analgesia required)
- If ineffective, may also need to repeat the procedure and replace existing epidural (the catheter can come dislodged and/or may not be in the right location)
- Urinary retention
- Pruritus
- High or Total Anesthesia
- Increase chance of forces or vacuum assisted delivery because mother cannot feel the urge to push
epidural block medications
bupivacaine (Sensorcaine)
ropivacaine (Naropin)
- Usually a combination of a “-caine” drug and an opioid analgesic (replacing lidocaine)
- drug concentrations have been lowered
- fentanyl, sufenta, or preservative-free morphine may be added (opioid)
- Continuous infusion pumps are used to administer (gives woman control)
Nerve Block Analgesia: Epidural
- Administered after labor is well established (5-7cm, typical)
- Injection of medication or combination of meds through a catheter inserted into epidural space
- Meds administered by continuous infusion or intermittent injections
- Patient controlled epidural anesthesia allows the patient to control the dosing
airway remains intact
only partial motor paralysis
gastric emptying not delayed
blood loss not excessive
epidural space location
outside the dura mater between the dura and the spinal column
epidural injection
a needle is threaded through the 3-4 vertebrae and a catheter is threaded into the epidural space
-> the needle is removed and the catheter is left in place
where does the spinal cord end in adults
L1
where is the epidural placed in the spine
between L2 to L5 so the epidural does not go near the spinal cord
does the epidural go near the spinal cord
NO
what you always do prior to giving an epidural
fluid bolus
fluid bolus prior to an epidural purpose
maintain blood pressure
epidural insertion techniques
- Preload with IV fluids -> volume expansion to prevent maternal hypotension
- Position in modified Sims or upright with back curved and legs dangling from bedside
- After insertion, assist to alternate side lying position to prevent supine hypotension and help distribute medication evenly
position for epidural insertion or spinal anesthesia
modified sims or upright with back curved and legs dangling from bedside
- practitioners will sometimes ask patient to get in a “mad cat” or “angry shrimp” position - this makes the spinous processes open up, allowing the epidural needle to be inserted easier
- nurse helps patient assume and maintain position (sitting or side-lying) during procedure
- always under strict sterile technique
what do you do after epidural insertion
assist patient to alternate side lying position to prevent supine hypotension and allow medication to distribute evenly
Post Epidural Block Nursing Interventions
- Assess maternal VS and FHR and O2 sat (protocol)
- Observe for bladder distention
- measure urinary output to ensure the bladder is completely emptied
- Protect from injury
- Assist woman to change position using pillows to prop if necessary
- Record the response to medications
- Monitor for adverse or allergic reaction
Epidural Complications
- Accidental injection of epidural dose in the subarachnoid space (“high spinal”)
- Significant maternal hypotension -> to newborn endangerment
- Watch for maternal hypotension -> decreased placental perfusion -> non-reassuring FHR pattern
- Post dural puncture headache
- Infection
- fever can be related to thermoregulatory changes and/or infection
risks of “high spinals”
accidental injection of epidural in the subarachnoid space
can lead to respiratory arrest
s/s epidural intravascular injection
A test dose will be given to assess
- increased HR
- numbness
- tingling of mouth
- ringing in ears
- disorientation
- excitation
- bizarre behavior
Nursing Care for Hypotensive Episode with epidural block
- Turn to lateral position or wedge hip
- Increase IV infusion rate
- O2 by FACE MASK at 10-12 L/min
- Elevate client legs 10-20 degrees
- Alert physician
- Be prepared to administer vasoconstrictor drugs (ephedrine) per order
Tara’s BP has been stable at 130/80 mmHg when assessed between contractions. The FHR has consistently exhibited criteria of a reassuring pattern. A lumbar epidural block is initiated, and Tara is assisted to a side-lying position. Shortly afterward, during assessment of maternal VS and FHR, Tara’s BP is 102/60 and the FHR pattern has decreased in rate and variability. What is the nursing diagnosis?
Ineffective uteroplacental perfusion r/t maternal hypotension associated with epidural block medications
Interventions: Tara’s BP has been stable at 130/80 mmHg when assessed between contractions. The FHR has consistently exhibited criteria of a reassuring pattern. A lumbar epidural block is initiated, and Tara is assisted to a side-lying position. Shortly afterward, during assessment of maternal VS and FHR, Tara’s BP is 102/60 and the FHR pattern has decreased in rate and variability.
- Turn to opposite side or wedge hip
- Elevate hips (blood back to heart)
- Increase IV fluids (oxygenated blood)
- Discontinue oxytocin (Pitocin) if infusing
- Administer O2 at 8-10L/min via face mask
- Notify physician
- Be prepared to administer meds to elevate BP
- Be prepared for possible delivery
post dural puncture headache
May be seen within 2 days of puncture but may continue for days to weeks
- Assuming an upright position intensifies headache
- Lying flat for 30min or less relieves h/a
- Can be accompanied by blurred vision, ringing in ears, and/or light sensitivity
- r/t intentional (spinal anesthesia) or accidental (epidural anesthesia) puncture of the dura
- May be caused by a leak in the CSF
- Spinal fluid h/a (SF leak, patch, does not go away)
most rapid, beneficial, and reliable relief measure for PDP headache
- the woman’s blood is injected into the epidural space which creates a clot that patches the tear or hole
- pain relief can be almost instantaneous
Epidural Blood Patch
10-20mL blood injected into the lumbar space
(oral or IV fluids may also be administered)
other treatment:
- bedrest
- lying flat
- increased caffeine intake (some HCPs use Mountain Dew or excedrin migraine, which has high caffeine levels)
nerve block site: suitable during second and third stages of labor and for repair of episiotomy
pudendal block
nerve block site: suitable during all stages of labor and for repair of episiotomy
epidural block
pudendal block
- Blockage of pudendal nerve
- Used for birth & post-delivery repairs (NOT LABOR)
- Does not depress fetus
- No relief from UC - only from perineum distention
injection of medication into the CSF in spinal canal
spinal block
spinal block advantages
- Rapid pain relief without sedation (useful for urgent c-sections)
- Low incidence of adverse effects
- Small gauge needle can reduce likelihood of post spinal h/a
- Position flat x8hrs
spinal block disadvantages
- Short duration of action
- Post spinal headache r/t leakage of CSF
- Increased incidence and degree of hypotension
- Urine retention
local infiltration of perineum
- Used frequently for episiotomy
- Epinephrine added to “-caine” drug to prevent excessive bleeding by constricting bv’s (blood vessels?)
- Does not affect pain of UC
- No adverse fetal, newborn, or maternal effects
i. e., local anesthetic (e.g., lidocaine) injected into the skin and the SQ into into region to be anesthetized (episiotomy or repair of laceration)
general anesthesia
- Used only if regional anesthesia is contraindicated or if an emergency situation develops suddenly
- Inhaled anesthetics include nitrous oxide, Halothane, and Fluothane
- Fetal adverse reactions include:
Respiratory depression
Hypotonia
Lethargy - oral antacids given if time (alka-seltzer gold or bicetra) neutralizes the gastric acids in the stomach
- anesthesia may also give Reglan, Pepcid, or Zantac IV
advantage of tilting the patient during general anesthesia
displaces the uterus, keeping the aorta & vena cava from being compressed -> good placental flow and CO
