NRS 3026 Chapter 13 Pain Management During Childbirth

physiologic effects

fear, anxiety, increased maternal metabolic rate and demand for oxygen

psychological effects

maternal tolerance for pain

sources of pain

tissue ischemia, cervical dilation, pressure/pulling on pelvic structures, distention of vagine and perineum

perception of tolerance of pain

labor intensity → strength of contraction

cervical readiness

fetal position

pelvic anatomy → narrow/wide pelvis

fatigue and hunger

caregiver interventions

non-pharmacologic pain management: preparation

childbirth classes

ideal time to prepare = before labor

latent phase (early labor) of labor: best time for intrapartum teaching

cutaneous stimulation

self-massage, massage by others, counter-pressure, touch, thermal stimulation, acupressure

hydrotherapy

shower, tub, whirlpool

mental stimulation & breathing techniques

cleansing breaths and patterned breathing

pharmacological pain management

effects on the fetus → respiratory depression

maternal physiologic alterations

effects on the course of labor and complications

interactions with other substances

Epidural block

regional pain management: injecting local anesthetic agent into epidural space

analgesia rather than full anesthesia

must be administered before advanced dilation

regional pain: epidural block

epidural space: outside dura mater between the dura and spinal canal

• pain relief without motor block (aka no loss of voluntary movement)

  • onset: 20-30 mins after infection and lasts throughout labor

regional pain: epidural block adverse effects

maternal hypotension → can cause maternal and fetal distress (ephedrine)

prolonged 2nd stage → decreased urge to push may be less intense

• laboring down until the patient begins to feel the urge

bladder distention

regional pain: subarachnoid block AKA spinal

used for c-section, single injection into subarachnoid space

sensory & motor block for 2-3 hours (only feels pressure/pull, no leg movement)

regional pain: subarachnoid block AE

maternal hypotension

bladder distention

post-dural puncture headache AKA spinal headache → tx: caffeine, blood patch

regional pain: intrathecal opioid analgesic

injected into subarachnoid space at the time of a spinal block

duramorph: provides post-op pain relief, no motor block, rapid onset & no sedation (NO MORTIN ALLOWED if mother receives this)

AE: N/V, pruritis, delayed maternal respiratory depression (assess RR every hour for first 12hrs then every 2 hours for up to 24 hours)

regional pain systemic drugs: parental analgesia

demerol, stadol, nalbuphine (Nubain)

regional pain systemic drugs: opioid antagonists

naloxone (narcan)

regional pain systemic drugs: narcotic analgesics

reduce perception of pain → nubain, morphine

regional pain systemic drugs: sedative

induce sleep/relieve anxiety → ambien

vaginal birth anesthesia: local infiltration

local anesthetic (lidocaine)

just prior to episiotomy or perineal repair

does not alter pain from uterine contractions or distention of the vagina

rarely has adverse effects on either mother or infant

vaginal birth anesthesia: general anesthesia

systemic pain control, loss of consciousness

may be needed unexpectedly and quickly for emergency procedures (baby with no heart tones)

contraindications for anesthesia

coagulation defects → low platelets (PRBCs, PLT)

uncorrected hypovolemia

infection or tumor at injection site

allergy to -caine drugs

previous back surgery or spinal anatomic abnormality (scoliosis) —> general anesthesia is the only option even tho there is a huge risk for aspiration

prior to administration of anesthesia…

informed consent → MDA

assess appropriate lab: TYSC, platelet above >100k

administer IV bolus → ½ bag before epidural

patient positioning → cat/cow arch to open space

maternal BP

the most important nursing intervention after the injection of epidural anesthesia is monitoring:

urinary output

contractions

maternal BP

intravenous infusion rate