Maximizing comfort for the laboring woman

What are some nonphamacologic pain managements?

• Childbirth preparation methods: education and explanation of birth process

• Relaxation & Breathing Techniques

• Focusing and Relaxation Techniques (using imagery)

• Breathing techniques

• Effleurage: lightly stroking abdomen in rhythm with breathing during contractions.

  • distracts the laboring person and decreases pain sensation

• Counterpressure: massage to sacral area with heel of

• hand or fist relieve back pain caused by internal pressure of fetal head.

  • Direct pressure applied to the sacrum or hips to counteract stretching of ligaments.

• Touch & Massage

• Application of Heat and Cold; warm & moist is good when there is a burning sensation/fetal head crowns

• Hydrotherapy, Aromatherapy, Music therapy

• Epidurals are used more than nonpharmacological methods because it is less complex & time-consuming

What is effleurage?

Lightly stroking the abdomen in rhythm with breathing during contractions

• Distracts the laboring person and decreases pain sensation

What is counterpressure?

When the sacral area is massaged with the heel of the hand/fist in order to relieve back pain caused by the internal pressure of the fetal head

• Direct pressure applied to the sacrum/hips to counteract stretching of ligaments

What are the general types of anesthesia discussed in lecture?

• Local perineal ifniltration anesthesia

• Pudenal nerve block

• Spinal anesthesia or block

• Epidural anesthesia or block

• CSE

• General anesthesia

In what instance would you use sedatives?

To relieve anxiety and to induce sleep

In what instance would you use analgesia?

Alleviation of the sensation of pain without loss of consciousness

In what instance would you use anesthesia?

Abolishes pain perception by interrupting the nerve impulses to the brain

What types of anesthesia could you use during the first stage of labor

• Opioids

• Epidural analgesia

• Combined spinal-epidural analgesia (CSE)

• Nitrous oxide

What types of anesthesia could you use during the second stage of labor

• Nerve block analgesia and anesthesia

• Pudendal block

• Spinal anesthesia

• Epidural

What types of anesthesia could you use during VAGINAL BIRTH

• Local infiltration anesthesia

• Pudendal block

• Epidural analgesia and anesthesia

• Spinal anesthesia

• CSE analgesia and anesthesia

• Nitrous oxide

What types of anesthesia could you use during Cesarean birth?

• Spinal and epidural anesthesia

• General anesthesia 

What is local perineal infiltration anesthesia?

Anesthetic injected into perineum at episiotomy site during 2nd stage of labor

• Numbs only the immediate tissue

What is pudenal nerve block?

Anesthetic injected in the pudendal nerve (close to ischial spines) via needle guide known as ‘trumpet’ during 2nd stage of labor

• blocks pain from vagina, perineum, and rectum

What is spinal anesthesia or block?

Anesthetic injected in the subarachnoid space; during 2nd stage or prior to cesarean section.

• Injection is made in the lumbar region at the L2/3 or L3/4 space.

• When used for c/s it provides anesthesia from T6 (nipple) to the feet

• Fast onset, dense block

What is epidural anesthesia or block/what is it used for?

Anesthetic injected in the epidural space L4L5 using epidural catheter.

• Located outside the dura mater between the dura and spinal canal.

• Given during 1st and 2nd stages of labor, and cesarean births

What is general anesthesia and what is it used for (in this context)

• Use of IV injection and/or inhalation of anesthetic agents that render the patient unconsciousness.

Nursing actions prior to block?

• Assist anesthesiologist with explanation of procedure and obtaining informed consent

• Assess maternal vital signs and fetal heart rate, level of hydration and pain

• Assist patient to void/insert foley catheter

• Ensure patency of IV line and infuse bolus prior to injection of medication

• Ensure most current lab results are available (CBC) = if platelets are low, hold that!!

Nursing actions DURING initiation of block?

• Assist the patient in assuming and maintaining proper position

• Verbally guide the patient through the procedure

• Provide anesthesiologist with patient’s current vital signs, particularly BP and FHR

• have crash cart readily available

• q4h suction

Nursing observations WHILE block is in effect

• Continue to monitor maternal vital signs and FHR

• Continue to reassess pain level (use pain scale 0 – 10).

• Assist with change of position every hour. ensure epidural site is clean, dry and intact

• Monitor of s/e of epidural

• Promote safety = do not get out of bed, use of bedrails, keep personal items within reach

Nursing observations WHEN block is wearing off?

• Assess return of sensory and motor function

• Continue to monitor maternal vital signs

• Monitor for bladder distension or output = especially with foley catheter

• Continue to keep catheter site clean, dry and intact

How does the neuraxial anesthesia method work?

• Causes sympathetic blockade (vasodilation of blood vessels w/ pooling of blood in lower extremities → decreased cardiac output)

• Partial motor paralysis then develops (numbness)

• Consists of either epidural OR spinal methods

Anesthesia ADR & Complications

• Most common is hypotension

• Cardiovascular = seizures or convulsions, arrhythmias, cardiac arrest

• High block = nasal stuffiness, respiratory distress or arrest

• others = n/v, pruritis, respiratory depression, alterations in FHR

• Post-dural puncture headache or spinal headache d/t CSP

  • blood patch (10 – 15 ml blood injected into dural space)

C/L????

• hemorrhage = because of blood drop

• coagulopathy = if ability to form clots is impaired, heparin or bleeding disorder

• cardiac conditions

• hypotension = don’t want to bring BP any lower

• infection at site of injection = tattoo in the area = NO

• increased intracranial pressure

• allergy to anesthetic drug

• maternal refusal or inability to cooperate – cannot force anyone to take it

What is nitrous oxide?

• Inhaled gas

  • Nitrous oxide & O2 (50/50)

• Laughing gas

• Less invasive w/ less s/e

• Less expensive than epidural

What does nitrous oxide help with?

• Increases endorphin & dopamine levels

• Diminishes pain & anxiety

• Less invasive w/ less s/e

• Less expensive than epidural

• Woman can ambulate in labor

• CONTRA: VB12 deficiency, pernicious anemia, impaired LOC, tension pneumothorax

General anesthesia things to know

• NPO x4 hours

• Premedicate w/ antacid if ordered

• IV fluids needed

• Pre-oxygenated prior to giving meds

• Intubate & place wedge under 1 hip

• Nitrous oxide & O2 given (50/50

• NO ambulation in “labor”