Pain Flashcards
A laboring mother is very anxious, crying, and has a decreased perceptual field. You need her consent for the epidural. What should you do?
Wait until she calms down
What can influence pain perception
Childbirth education Cultural background Fatigue/lack of sleep Personal significance Anxiety Genetics Previous experiences Support
Does quietness mean there is no pain
No
What is effacement
Thinning of the cervical area
What are the three phases in the first stage of labor
Latent
Active
Transition
What phase of labor is the most painful in the first stage
Transition
What causes the pain during the first stage
Hypoxic uterine cells
Pressure-adjacent structures( due to child coming down through pelvis) distention of lower uterus
Dilation, effacement, stretching of uterus
When does the second stage of labor start
When mother is 10 cm dilated
What causes the pain in the second stage
Hypoxic uterine cells
Distention- vagina and perineum (child has to come through)
Pressure-adjacent structures
Lacerations
When does the third stage of labor begin
After child is born
What causes the pain during the third stage
Contractions (much less intense)
Cervical dilation
How long should it take for placenta to be delivers
5-30 ,minutes
If it takes longer they need to use a D&C (cervical scrapping) to get placenta out
What is the one thing that all non pharmacological pain management tools include
Education
What are the goals of breathing patterns
Oxygenate
Relaxation
Decrease pain and anxiety
Slow breathing to prevent hyperventilation
Lamaze
Mind prevention
Controlled breathing, toning, relaxation
Bradley
Partner coached
Slow controlled abdominal breathing
Teaching techniques directed towards coach vs mother
Dick-read
Believes fear built state of tension
Knowledge to decrease pain and abdominal breathing
Kitzinger
Strong believer in home births
Hypnobreathing
Hypnotized
Effleurage
Rhythmic stroking if abdomen during pain
What is sacral pressure
Back rubs during contractions
Should you encourage or discourage vocalization during labor?
Encourage
Can promote relaxation and help to relieve tension
What is the goal of analgesics during labor
Relieve pain
Minimal motor blockage
Use small amount possible because baby will get it too
What happens if analgesics are given too early?
Too late?
Early- May prolong labor
Late- little value and may cause neonatal respiratory depressions
Contraindications for an epidural
Allergy Compromised respiratory Drug dependence Fetal heart rate out of normal range Meconium stained fluid Infection/hypovolemia
Why is Meconium stained fluid a contraindication of epidural
That means the baby is already stressed and no more stress in the fetus is necessary
Does analgesia and anesthesia affect the fetus?
Yes, crosses placenta barrier
Fetal liver enzymes and renal system can’t metabolize drugs yet
Stress ____ amount of blood volume to fetus brain
Increases
Labor may ____ drug clearance and _____ half-life of some drugs
Decrease
Increase
Is oral route used for laboring mom as a means of medical administration
No
Very rarely
Who can prescribe analgesic agents
Physician
Anesthesiologist
CRNA
CNM
Who makes the decision about when to give analgesic
Staff nurse
What do you have to assess before giving analgesics
Willingness or mother Woman is uncomfortable Stable VS No allergies/ other contraindications Fetal heart rate 110-160; reactive NST Knowledge
When looking at results of an NST what is good; reactive or nonreactive
Reactive
What indicates a NST
Accelerations of 15 bpm lasting 15 seconds with each fetal movement
What does it mean if there are no accelerations in an NST
Bad results. Something could be wrong with fetus
What should you see with labor process after analgesics are given
Contractions: regular, increasing in intensity and duration
Cervical dilation
Station changing
Fetal presenting part descending
Side effects of analgesics
Decreased sensory perception
Maternal hypotension
Decreased fetal heart rate variability
Important things women need to know about pain relief medications before they are given
Type Route Expected effects Implications for fetus/newborn Side effects Safety measures
What would you expect to find during assessment for labor progress in a woman where analgesia/anesthesia is given?
Contraction pattern to be regular, increasing intensity, and longer duration; cervical dilation; fetal presenting part descending showing no signs of distress; station of the fetal presenting part to be changing
What are some side effects that can occur when using analgesics during labor?
Maternal hypotension, lethargy, subdued mood, decreased sensory perception, decreased fetal HR variability, maternal and/or neonatal CNS depression, sleepiness, urinary retention (rare)
Why do some woman get IV fluids before getting analgesics
To prevent hypotension
When should you use analgesics cautiously
Hepatic function impairment, drug&alcohol dependent, physical dependence on benzodiazepines
What should the woman understand and know about pain relief meds before getting them
Type of medication administered, route of administration, expected effects of medication, implication for fetus/newborn, safety measures needed, side effect/complications
When are sedatives rarely used
In true labor
When are Barbiturates used?
Very latent phase, if used. You may send woman back home with these so she can sleep before delivery. Used if cervix is long, closed, thick
What are Barbituates? Examples?
They are sedatives
Secobarbital (Seconal)
Ambien
When are sedatives used?
Only used to decease anxiety, fear, apprehensiveness, and to promote sleep
What are actions or Benzodiazepines
Minor tranquilizing, sedative effects
Examples of benzodiazepines
Diazepam (Valium)
versed
What should you assess in somebody getting benzodiazepines
Assess for CNS depression in mom and newborn
Why may you give Versed?
Amnesic effect in OR procedures ; does not produce analgesia
Why is Versed not advised prior to delivery?
To prevent low Apgars
What is Benzodiazepine antidote/antagonist
Flumazenil
Use is controversial
What are three types of sedatives
Barbiturates
Benzodiazepines
Ataractics
What do Ataractics block
Action of histamines
Examples of Atraractics?
promethazine (Phenergan)
prochlorperazine (Compazine)
hydroxyzine (Vistaril)
How are Ataractics used? Why?
Used with opioid to decrease N&V and anxiety
Concerns for fetus with use of sedatives?
Deceased FHR variability and CNS depression in neonate
What are Narcotic Analgesics?
Opioids. They are drugs that enter the circulatory system and are distributed throughout the body and to the brain.
How do narcotic analgesics reduce pain?
Decease transmission of pain impulses; bind to receptor site pathways and transmit the pain signal to the brain
What are four examples of Narcotic Analgesics (opioids)
Butophanol tartrate (Stadol) -IV
Nalbuphine (Nubain)- IV
Hydrochloride (Demerol)
Fentanyl
What is most commonly used opioid
Demerol
What is it important to assess for with Nubain
Decreased FHR variability, respiratory depression, drowsiness, dizziness, blurred vision, diaphoresis, urinary urgency
What should you assess for with Stadol?
Urinary retention and respiratory depression
What is important about Butorphanol tartrate (Stadol)?
Crosses placenta and can cause respiratory depression. It is given IV
Route Nubain is given?
IV
What can reverse depressive effects of narcotics?
Naloxone (Narcan)
What is drug of choice when depressant is unknown?
Naloxone (Narcan)
Effects of Narcan
Little or no agonistic effect, little Pharmacologic activity in absence of narcotic agent
What can Narcan do to a neonate if mother has been given narcotics before delivery, close to time of birth?
Can reverse neonatal respiratory depression
What side effect can occur with Narcan although it is rarely seen
Urinary retention. Watch mom and babies output
If there is a Narcotic addiction what will you see?
Extreme withdraw symptoms
What may Agonist-Antagonist precipitate?
Drug withdraw in woman physically dependent on narcotics
Is there loss of conscious with regional analgesia/anesthesia
No loss of conscious
There is _____&______ blockage of impulses with Regional Analgesia/Anesthesia
Temporary and reversible
Examples of Regional Analgesia
Epidural block, combined spinal-epidural, local infiltration, pudendal block, intrathecal (spinal)
What happens with Regional Anesthesia?
Partial or complete loss of sensation below T8-T10 of spinal cord
Side effects of local anesthetics
Hypotension, Palpitations, dizziness, apprehension, tinnitus, vertigo, pruitus, confusion, headache, metallic taste in mouth, N&V, seizures, coma, urinary retention
Severe reactions with local anesthetics
Seldom seen, we don’t let it get to this pint
Loss of consciousness, coma, severe hypotension, bradycardia, respiratory and cardiac arrest
Why and when do systematic toxic reactions most commonly occur ?
With an excessive dose because of too great a concentration or too large a volume
When is lumbar epidural administered?
1st and 2nd stage pain relief, administered in active labor
Where is lumbar epidural injected
Widest interspace below L2
Where does the lumbar epidural go into?
The epidural space (between the dura mater&vertebral canal)
Not into the dura!
Position for lumbar epidural
Left lateral best position. On side, back straight and vertical, shoulders square, upper leg prevented from rolling forward
What does lumbar epidural block
Entire pelvis: uterus, cervix, vagina, perineum
What are epidurals used for
Stage 1 through perineal repair
Considerations with epidural
Maternal hypotension, N&V, respiratory depression
What is it called when woman gets a epidural and she only feels pain on one side or a certain section
Spotty epidural
Epidurals administered for
_______ or _______ or ________
One time l&d.
Patient controlled using Indwelling catheter
Combined Spinal-Epidural Analgesia (CSE)
Characteristics of Combined Spinal-Epidural Analgesia (CSE)
Ability to bear down preserved; no loss of pushing reflex; motor power intact; can ambulate
What are nursing considerations with a traditional epidural
Increased incidence of forceps use or vacuum extractor; loss of sensation/bearing down reflex; considerably less risk than general anesthesia, may slow labor, increased incidence of oxytocin use, assist mom to avoid supine hypotension
Contraindications of regional epidurals
Risk of bleeding, coagulation disorders/defects, generalized sepsis, local infection @ needle site, back or spinal injury, maternal refusal
What should you remember needs to be done before regional anesthetics
Hydrate well prior to procedure. (500-2000cc)
Helps prevent hypotension
With general anesthetics what is mother at risk for
Hypotension, urinary retention, N&V, occasional HA or backache
Where is spinal block injected into
Subarachnoid space
What is advantage of spinal block
Immediate onset of anesthesia, smaller drug amount required
What may occur with spinal block
Headache
What should you know about pudenal block
Deep into lower side of vagina, blocks perineum and bathes pudenal nerve; for birth use forceps, vacuum extractor, episiotomy repair; No contraindications; coach client in pushing
When is pudenal block done
Just prior to birth inside pudendal nerve
What could be going on mother is complaining extra about pain in bottom
Could have hemorrhoids
What is anesthesia for laceration or episiotomy repair
Local infiltration
Does local infiltration require small or large amounts of agent
Large
When is local infiltration administered
Just prior to birth
What are side effects of local infiltration
No side effects for mom or newborn
What is general anesthesia
Induced unconsciousness, not used a lot, IV or inhalation, used in a ER situation that does not allow for other techniques
What are complications of general anesthesia
Fetal depression, failure to establish patent airway in woman, uterine relaxation which makes you watch for bleeding, maternal vomiting
When inserting tube for general anesthesia watch _________ during rapid induction of anesthesia
Cricoid pressure
