Week 1 Pain Management during labor Flashcards
What are the 5 main contraindications of a epidural/block?
- Anticoagulant therapy or bleeding diathesis
- Hemorrhage or shock
- Infection at insertion site
- Tumor
- Increased ICP
What are the characteristics of Butorphanol?
- Is both an opiate agonist and antagonist
- May cause opioid withdraw
- Resp. depressant
- May be given to relieve pruitus associated with epidural
What are vasopressors used for during labor?
to correct hypotension r/t epidural or subarachnoid block
How does pain affect the pulmonary system?
increased O2 demand leads to hyperventilation
What does a Subarachnoid (spinal) Block alleviate?
pain from
- uterus
- Perineum
- Lower back
- Vagina
Where can T6 sensation be checked?
Xiphoid
Cortisol causes a _____ system responce
Sympathetic NS
What is first stage breathing?
Breathing that is done during contractions. rapid respiration
How is a epidural catheter test dose done?
A short acting anesthetic is administered into the epidural catheter. Correct placement is determined by area od numbness as well as absence of adverse effects
How is proper epidural placement confirmed?
Through an epidural catheter test dose
What are the characteristics of pushing and pulling pain on pelvic structures?
- Visceral
- Transfers to back and legs
What indicates a positive intravascular test dose during a epidural catheter test dose
20 bpm increase of heart rate within 45 seconds of administration
- Circumoral numbness
- Tinnitus
What labs are done prior to a Block?
-Platlets
-PT
-INR
All R/T clotting
When sound the initial dose be given for the block?
Between contractions
where does pain from Distention of the vagina and perineum enter the spinal cord?
s2-s4
Platelets must be below ___ before the catheter is removed
100,000
Where can T10 sensation be checked?
Umbilicus
What is the dose and frequency of Butorphanol?
1-2mg every 3-4 hours (range of 0.5-2mg IV)
What five interventions are to be done prior to a block?
FVLPI
- Nonglucose fluid bolus of 500-1000cc
- Baseline vitals of mom and baby
- Labs
- Positioning
- Keep Pt informed of sensations they may feel
What are the adverse effects of a Subarachnoid (Spinal) Block?
- Hypotension
- Bladder distention
- Post-Dural punture HA
What is a Intrathecal opioid analgesics
- Medications injected into the subaracnoid space
- Rapid onset
- can be used in conjunction with an epidural
When is an epidural given?
After labor is established
During an epitural, VS and Neuro status should be checked every_____
hour
What is the dose and frequency of Nalbuphine?
10mg every 3 hours IV may be given as a PCA
What are the three regional pain management types?
- Epidural
- Intrathecal opioid analgesics
- Subarachnoid (spinal) Block
What are the 5 assessments after injections through epidurals?
- BP
- VS/Neuro
- Fetal/Contraction
- Bladder distention
- Activity (bedrest unless only opioids)
When should pain meds be given during the contraction cycle?
Second half of the contraction
What is the dose and duration of Chloroprocaine?
-6 to 10ml
30-45minutes
What are two common anesthetic solutions used in a block?
- Chloroprocaine
- Bupivacaine
What are the 3 main pharmocologic meds given to women during labor?
- Fentanyl
- Butorphanol
- Nalbuphine
Where can T12 sensation be checked?
Pubis
What are the advantages of a Spinal (intrathecal) injection
- Rapid onset
- No sedation
- No motor block
- No sympathetic block (no hypotension effects)
What are the psychological disadvantages of pharm. pain relief in labor?
- Loss of “natural” childbirth
- Pt not feeling in control of her body
- Husbands may feel a lack of participation and may feel left out of the labor and delivery experience
What is the normal dose of Phenylephrine during labor?
50-100 mcg
If maternal hypotension occurs, what should be done?
- Position change
- Bolus of IVF
- Vasopressors: Ephedrine 5-10 mg) does not affect blood flow to the uterus) or phenylephrine
- Oxygen via face mask (8-10L/min)
What is the other name for Nalbuphine?
Nubain
What spinal locations is perineal pain transmitted?
s2-s4
What are the con’s of an epidural?
- hypotension
- Bladder distention
- prolonged second stage
How is Nitrous oxide administered?
- Patient self administers
- 50-50 blend with oxygen
How does pain effect the GI system?
Delayed emptying
How can Opioid induced pruritis be treated?
- Opioid agonist-antagonist (Nalbuphrine)
- 5-HT3 receptor antagonist (ondansetron)
What two vital signs need to be monitored while a patient has a epidural?
O2 sat and BP
What are the four main sources of pain during pregnancy?
- Tissue ischemia
- Cervical dilation
- Pressure and pulling on pelvis
- Distention of the vagina and perineum
Describe the gate control theory
Pain is transmitted through small fibers. If you activate the large fibers near them, the small fibers will not be able to transmit
What are the 4 main non-pharmacologic pain control methods?
- relaxation
- cutaneous stimulation
- Hydrotherapy
- Mental stimulation
How can N/V be treated in a pregnant/laboring mother?
- Metochlpramide
- Ondansetrol
- Scopolamine
How does an epidural cause maternal hypotension?
When does this occur?
- Sympathetic NS fibers are blocked resulting in vasoconstriction
- Usually occurs immediately but can be delayed up to 20 minutes following injection
What drug is given if respiratory depression occurs?
Narcan
Full oral intake may be resumed after block is below ____ level
T10
What causes tissue ischemia during labor and what are the detrimental effects?
- Caused by decreased blood flow to uterus during contractions
- Can cause tissue hypoxia and fetal anaerobic metabolism
Where does cervical dilation pain travel?
through the hypogastric plexis entering the SC at T10-L1
How is epidural placement verified prior to administration of meds?
Aspiration. Absence of blood or CSF is a positive result
What narcotic can be given to pregnant women in a PCA?
Fentanyl
BP should be checked every ___ minutes for ____ minutes after each bolus dose
5
15-30minutes
Where is a Subarachnoid (spinal) Block placed?
L3 to L5
What spinal locations is uterine contraction pain transmitted?
T10-L1
What sensations may a PT feel during the procedure of getting a block>
- Burning/stinging on skin
- Pressure with insertion
- Crazy bone sensation in legs as catheter is advanced
Where is the common location of an epidural?
Between L3 and L4
What are the characteristics of fentanyl?
- Quick onset
- Short duration
- Less associated N/V
- Low risk of resp. depression
What are the CON’s of a Subarachnoid (spinal) Block?
May cause HA
May cause maternal hypotension
What are the two common vasopressors used during labor?
Phenylephrine and ephedrin
What is the other name for Butorphanol?
Stadol
What are some potential adverse effects of a test dose?
heart palpitations, tachycardia, tachydysrhythmias, hypotension, motor blockade, and, in rare cases, seizures
How does pain effect the CV system?
- increased BP
- Increased CO
- Increased vascular resistance
What are the four Epidural opioids?
- Fentanyl
- Sufentanil
- Ropivacaine
- Morphine (Duramorph or Astramorph)
What are the disadvantages of Spinal (intrathecal) injections
- Short acting
- Inadequate pain control
When are Spinal (intrathecal) injections considered?
-PT’s who require pain relief but did not have time for an epidural
Give some examples of using gate control to relieve pain
Massage, thermal stimulation, hydrotherapy, focal point, breathing, environmental control
What is the normal dose of ephedrin during labor?
5-10mg
What are the signs of accidental durai puncture in a epidural?
- Respiratory depression
- Circulatory collapse with hypotension
- Decreased uterine blood flow
How should BP be monitored after epidural doses?
When should you contact the provider?
- Monitor BP every 3-5 mins for the first 15 min; then q 15 min thereafter
- Notify Anesthesia provider: systolic BP <100 mm HG or a fall of 20% or more from baseline, pallor, or diaphoresis
- Assess FHR: Tachycardia >160 bpm for 10 min, brady <110 bpm for 10 min, late decel
What relief does an epidural give?
- Pain from contractions
- Numbs the vagina and perineum
- No HA because dura mater is not penetrated
What are the 6 main complications of an epidural/block?
- Hypotension
- Durai puncture resulting in total spinal anestheasia
- Resp. depression
- Catheter migration
- Maternal Fever
- Seizure
Respiratory depression is a RR below
12 breaths per minute
What are the characteristics of Nalbuphine
- Is both an opiate agonist and antagonist
- May cause opioid withdraw
- Resp. depressant
- May be given to relieve pruitus associated with epidural
What is second stage breathing?
Closed glottis: causes recurrent increases in intrathoracic pressure with resulting fall in cardiac output and maternal BP
Open-glottis: pushing 3-4 times for 6 to 8 seconds likely to be effective in aiding descent and safe. Adjust the pushing process depending on fetal status
Where can T8 sensation be checked?
Costal
What are the benefits of regional pain management during pregnancy?
- The veins are dilated during pregnancy
- Prevents full motor block
What is the dose and frequency of Fentanyl?
50-100 mcg every hour
What indicates a positive subarachnoid placement during a epidural catheter test dose
Rapid onset of sensory and motor blockade with or without Hypotension
Blocking the bodies reaction vasoconstriction reaction to a hemmorrhage or shock using a epidural or block will cause _____
Vasodilation thus causing BP to bottom out and increased bleeding
____must be done prior to ambulation
Sensory-motor assessment
What is maternal fever?
A fever of unknown cause that is related to epidurals
What is the dose and duration of Bupivacaine? how about for a c-section?
- 6 to 10ml
1-2 hours
-0.75% in doses of 15-20ml
What are the three main effects of catecholamines on a laboring mother?
- Reduced blood flow to and from placenta
- Increased maternal metabolic rate and O2 demand. Can cause fetal acidosis
- Reduced effectiveness of contractions causing slow labor progress
What can cause seizures from an epidural?
- Accidnetal injection of meds into venous system. Toxic levels of medicaiton
- Also, total spinal anesthesia
