chapter 13 pain management during childbirth

unique nature of childbirth pain

normal process

preparation time

self limiting

intermittent rather than constant

pain has a positive outcome

adverse effects of excessive pain

physiologic effects
-reduced blood flow to and from placenta
-ineffective contractions
-increased demand for oxygen

psychological effects
-detract from experience
-affect response to sexual activity

sources of pain

tissue ischemia rt decreased blood to uterus

cervical dilation: major source

pressure and pulling of pelvic structures: visceral in nature (deep, aching)

distention of the vagina and perineum: 2nd stage, somatic pain (quick, sharp, localized)

factors influencing perception of pain

intensity of labor: quick labor, no time for pain meds

cervical readiness: cervix won’t open as easily

fetal position

characteristics of the pelvis

fatigue (too tired to push) and hunger (decreased energy)

psychosocial factors influencing pain

culture: pre determined way to deal with and express pain

anxiety and fear: increase muscle tension, diverts oxygen to brain and skeletal muscles

previous experience

preparation for childbirth

support system

non pharm pain management

advantages: do not slow labor; no side effects or risk for allergy

limitations: if sole method of pain control, may not achieve desired level of pain control

gate control theory

preparation for pain management: ideal time is before labor

gate control theory

stimulating large diameter sensory nerve fibers in the skin blocks conduction of pain through the small diameters fibers

closes the gate to painful stimuli in the brain

non pharm techniques

relaxation: basis for all non pharm techniques

cutaneous stimulation

hydrotherapy

mental stimulation: guided imagery, focal point, distraction, self hypnosis

breathing techniques

special considerations for pharm pain management

fetal effects: differentiating between harmful and expected effects
direct effects: decelerations, mom sleepy → baby sleepy
indirect effects: maternal hypotension → reduced placental blood flow

effects rt pregnancy: can affect how drugs are metabolized and excreted

effect on labor

effects of complications: may limit available pain management options

drug interactions: therapeutic or illicit; may have fewer options of analgesics bc of interactions

nitrous oxide

systemic drug

advantages: safety; does not impact fetal well being or breastfeeding; self administered

delivered as 50% nitrous oxide, 50% O2

disadvantages: does not eliminate all pain sensations, side effects, long term use can result in B12 deficiency, some minimal risk to HC providers

SE: n/v, dizziness; similar to narcotics but shorter lasting

opioids

most common: fentanyl, buforphanol, nubain

given in small, frequent doses

IVP or IM administration (PCA for fetal demise)

administered with contractions; less med is transferred to fetus bc of limited blood flow to placenta during contraction

if given prior to 4 cm they can slow down the labor

have women empty bladder prior to administration; fall risk

provide for maternal and fetal safety; admin too close to delivery can cause resp depression

mixed opioid agonists and antagonists

nubain (nalbuphine) 10 mg every 3 hours IV

stadol (butorphanol) 1-2 mg every 3-4 hours IV

blocks another substance on brain receptor

pure opioid agonist

fentanyl (sublimaze) 50-100mcg IV every 1-2 hours

morphine

remifentanil

preferred with substance abuse pts; mixed opioids can cause withdraw symptoms

considerations for systemic drugs for labor

cautious use with clients who are dependent on opiates

may cause resp depression in the newborn

may be combined with other medications to enhance efforts

mixed opioids have ceiling effect

narcan (naloxone)

narcotic antagonist

adult dose to reverse resp dep is 0.4-2mg IV

adult dose to reverse pruritis from epidural narcotics is 40-80mcg IV

no longer used with neonate; instead treat with bag mask ventilation

action shorter than most narcotics; observe for signs of recurrent resp dep, dose can be repeated

phenergan (promethazine)

12.5-25mg every 4-6 hrs IV or IM

given for nausea in labor

potentiates the narcotic

may enhance resp dep of the narcotics

metoclopramide (reglan)

10mg IV; aspiration prophylaxis; sedative properties/enhances analgesics

treat n/v, heart burn, increases gastric motility. causes drowsiness

diphenhydramine (benadryl)

10-50mg every 4-6 hours IV

relieves itching from epidural narcotics

epidural analgesia

MOA: med diffuses into CSF from epidural space

role of dermatome levels: won’t feel coldness of cold glove, just the pressure of pressing by the glove. dermatome: area of sensory nerves near skin that are supplied by specific nerve roots/connections

insertion: sterile procedure by CRNA or anesthesiologist

positioning: sitting up and hunched over

meds used: local anesthetics, narcotics

insert between L3 and L4

advantages of epidural analgesia

consistent pain relief

improve pt satisfaction

reduce anxiety

allows for rest

may shorten 2nd stage

disadvantages of epidural analgesia

pt cooperation needed; sit up in proper position

incomplete block possible; epidural doesn’t work entirely or windows of pain

may lengthen 2nd stage or increased risk of forceps/vacuum assist or CS: too much block → can’t feel

contraindications of epidural

coagulation defects: low platelet count, uncorrected hypovolemia

lovenox use within 72 hours

infection at insertion site

scoliosis or spinal surgery: evaluated individually

adverse effects of epidural opioids

n/v: common in transition phase, due to low BP

pruritis of face and neck: can administer Benadryl or nubain

delayed resp dep: 12 hours after

adverse effect of epidural block

maternal hypotension: block can cause vasodilation of blood vessels
lightheaded, dizzy, n/v within 1st 15 mins of admin
can reposition, IVF, sup O2. if fails, administer ephedrine to increase BP

bladder distention: can cause pain, inhibit fetal distent

prolonged second stage

catheter migration

maternal fever: common, not sure why. not caused by infection

respond to adverse effects of opioids

admin IVF (LR) 1 hour prior to placement to counteract hypotension

n/v: immediately assess BP, administer antiemetic meds

pruritus: administer appropriate meds

delayed resp dep: careful evaluation of respiratory status

respond to adverse effects of block: hypotension

frequent assessment immediately post epidural

interventions for significant BP drops

increase IV fluids, repositioning

administer meds as necessary: ephedrine, phenylephrine

contact anesthesiologist if meds not working

respond to adverse effect of block: bladder distention

assess ability to void

intermittent catherization

indwelling catheter use discouraged (per book, but current practices use it)

respond to adverse effects of block: catheter migration

assess for possible migration; too much med

contact anesthesiologist or CRNA

call for rapid response or code team; if low RR

can migrate up and cause resp issues

respond to adverse effects of block: maternal fever

assess for signs of infection

contact physician

administer meds as orders

epidural complications

dural puncture: dura mater is punctured

postdural HA: CSF starts to leak; blood patch to fix

infection

hematoma

nsg care with epidurals

record baseline VS and FHR patterns

pre hydrate

ongoing VS and FHR assessment

respond to adverse effects

subarachnoid block (spinal)

pain relief for CS

procedure: done in OR; sterile procedure into L3 and L4
inject local anesthetic into subarachnoid space
correct placement: CSF in needle

contraindications and precautions: coagulation defects, infection, uncorrected hypovolemia, allergy

adverse effects: maternal hypotension, bladder distention, post dural puncture HA;
postural: feels worse when upright, disappear when lying flat

vaginal birth anesthesia

local infiltration anesthesia: infiltrate perineum with local anesthetic (lidocaine) before episiotomy or laceration repair

pudendal block: anesthesia of birth canal for delivery
less common; done before epidurals invented, doesn’t block pain from contractions

general anesthesia

indications: true emergency CS; not epidural/spinal candidate

technique:
cricoid pressure: prevent vomitus from entering the trachea while being intubated
light sedation until baby is out bc baby also gets anesthesia

adverse effects: maternal risks: aspiration, resp dep (client and baby), uterine relaxation (PPH)
fetal risks: neonatal depression