maximizing comfort

increases catecholamine secretion > lowers blood flow and increases muscle tension > decreases oxygen to the uterus > increases stimuli to the brain > magnifies pain perception

fear

during first stage of labor and usually only during contractions: originates from internal organs: usually deep, dull, aching, gnawing, or twisting, not localized - diffused, comes from: Cervical changes, Distension of lower uterine segment, Uterine ischemia

visceral pain

end of first stage and the second stage of labor: originates from the bodies musculoskeletal system: bones, joints, muscles tendons etc. Localized, sharp, throbbing may be associated with pressure, Intense, sharp, burning, well localized, Distention & traction, Pressure against bladder & rectum, Stretching & distention of perineal tissues & pelvic floor, Lacerations of soft tissues – cervix, vagina, perineum

somatic pain

—pain can be more painful than not having an epidural at all

breakthrough

Best thing to stretch perineum is the —- over mechanical stretch from nurses/physicians 

baby’s head

not prenatal visits - it’s the classes they take, books they read, Best thing for classes is learning how to relax - need to put in the hard work of practicing relaxation techniques 

childbirth prep

lightly rubbing the abdomen, non pharm pain management technique

effleurage

pushing against body part in pain, good for back pain not really for abdominal pain

counter pressure

a non pharmacological pain management technique (so don’t need a prescription) for severe, continuous lower back pain, sterile water is injected into the lower back near the sacrum intradermally, causing the body to release natural pain endorphins

intradermal water block

specific classes for this - need to know in birth plan to maybe adopt terminology for this birth - non pharm pain management

hypnosis

If couples don’t want to use drugs - need ——to be able to tell when mom is really asking for the meds now

safe word

encompasses analgesia, amnesia, relaxation, and reflex activity

anesthesia

the alleviation of the sensation of pain or the raising of the threshold for pain perception without loss of consciousness, The type chosen is determined in part by the stage of labor of the woman and by the method of birth planned.

analgesia

relieve anxiety and induce sleep; typically used for women in a prolonged latent phase of labor when there is a need to lessen the intensity of the contractions, decrease anxiety, or promote sleep (mom and baby rest), not really used, include: barbiturates, phenothiazines, benzos

sedatives

sedative, helpful, especially when given with an opioid, used more often in obstetrics (Valium, Atavan), may disrupt thermoregulation in newborns

benzos

used to produce sensory blockade and various degrees of motor blockade over a specific region of the body

nerve blocks

Route: IV, IM or IV PCA, Readily cross placenta: Opioid (narcotic) agonists, Opioid (narcotic) agonist-antagonist, have to get the timing right, can’t give too close, Mixed meds - agonist/antagonist are safer because mom and baby getting lower amount of each 

systemic analgesia

systemic analgesia, IM, slow IV, or subcut, mu opioid receptor agonist, moderate to severe pain, post op shivering, not first line pain relief, can cause maternal hypotension and slowed breathing, crosses placenta and can alter FHR, respiratory depression, and poor feeding, aka demerol

meperidine

systemic analgesia, opioid agonist, blocks substance P, moderate to severe pain, short acting relief in first stage of labor when an epidural is not wanted or cannot be used, aka sublimaze

fentanyl

systemic analgesia, opioid agonist-antagonist, kappa + mu receptors for moderate to severe pain in early labor of full term pregnancies (37 wks or more), when labor is not expected in the next 4 hrs, aka Stadol

butorphanol

systemic analgesia, opioid agonist-antagonist, kappa + mu receptors, moderate to severe pain, can be used before epidural or when patient does not want regional anesthesia or doesn’t want it yet, can slow uterine contractions, can lower fetal oxygen (cyanosis), only give in early active labor, aka nubain

nalbuphine

opioid antagonist, To reduce excessive CNS depression from opioid agonists, Adverse effects: maternal hypotension and hypertension, tachycardia, hyperventilation, nausea and vomiting, sweating, tremulousness, ALWAYS read label to verify adult versus neonatal drug concentrations, If given to a woman who is opiate dependent, pain will return suddenly

narcan

Spinal anesthesia is not an

epidural

Currently the most effective pharmacologic pain relief method for labor, Effectively relieves the pain caused by uterine contractions but does not completely remove the pressure sensations

epidural

IV PCA pumps - patient can hit button as much as they want but the medication can only be actually administered q —- mins

10

Active or anticipated serious maternal hemorrhage, Maternal hypotension, Maternal coagulopathy, Infection at the injection site, Increased intracranial pressure, Allergy to the anesthetic drug, Maternal refusal or inability to cooperate, Some types of maternal cardiac conditions

contraindications for epidural

mixed with oxygen can be inhaled in a low concentration (50% or less), Patient controlled analgesia, First and second stages of labor, only use it during contraction - only mom can hold mask on her own face no one else can hold it for her, May be lightheaded and dizzy 

nitrous oxide

anesthesia only used in severe emergent situations (prolapsed cord, abruption), Readily crosses placenta, anticipate neonatal resuscitation, Wedge to displace uterus, The woman should be premedicated with (clear) oral antacid to neutralize the acidic contents of the stomach - sodium citrate/citric acid (Bicitra), famotidine (Pepcid) or ranitidine (Zantac), metoclopramide (Reglan), Risk for fetal exposure > neonatal narcosis, for if mom does not have epidural already, If mom does have epidural they can try to just up that instead

general anesthesia

PO antacid to neutralize existing stomach acid and increase gastric pH, used for aspiration prophylaxis during c-section, given before surgery, caution for hypertension because of sodium load, aka bicitra

sodium citrate

IV or IM, anti-nausea to prevent severe N/V especially in C-sections, reduces aspiration risk, also used for hyperemesis gravidarum, dopamine antagonist, serotonin agonist, monitor for EPS symptoms, assess BP and HRs, aka Reglan

metoclopramide

administered in perineum; adequate for episiotomy and perineal repair, can be given in second stage of labor

local anesthesia

administered in vagina; adequate anesthesia for episiotomy, forceps, vacuum, episiotomy repair

pudendal block

Contains local only or may be in combination with opioid agonist (fentanyl) - can ask for it without, Injected into the subarachnoid space and mixes with CSF, For elective C/S, May be used for vaginal birth (not for labor)

spinal anesthesia

Bupivacaine (Marcaine) or Ropivicaine, Injected into epidural space with insertion of epidural catheter, Catheter connected to continuous pump or PCA pump, For relief of pain of uterine contractions and birth (vaginal or cesarean)

lumbar epidural

Needle in subarachnoid space using fentanyl and bupivacaine (Marcaine), Faster onset of action, synergistic effect of opioids and local anesthesia, lower total dose of required medication reduces motor blockade response, Same advantages as lumbar epidural but in addition, woman feels vaginal and rectal pressure and is usually able to push

combined spinal epidural

Disadvantages: Ability to move freely and to maintain control of labor limited, related to degree of anesthesia and use of other medical interventions, i.e. continuous monitoring, IV, IV pump), Vasodilation and hypotension, bladder distention, unequal uptake of medication, pruritis, shivering.

combined spinal epidural

used to treat severe spinal headache caused by an accidental puncture of the protective membrane (dura) during an epidural, doctor draws patient’s blood and injects it into the epidural space in the lower back, look to where spinal fluid is leaking out for injection, Mom should be still for at least 1-2 hrs after this

blood patch

nursing role for —-: Review prenatal history for any contraindications, Check for signed informed consent, Review prenatal labs, especially CBC and platelets, Review maternal vital signs and FHR before and after administration (be alert for hypotension) - q 5 mins for 30 mins after, Pre-load with 1000-2000 cc’s Lactated Ringers Before Procedure

spinal/epidural

Monitor —-, especially if maternal hypotension is present

FHR

a neurological “gate” in the spinal cord can open or close to allow or block pain signals from reaching the brain

gate control theory