Normal L&D: Comfort for the Laboring Woman

Visceral pain

from cervical changes, distention of lower uterine segment, and uterine ischemia

Located over lower portion of abdomen

Referred pain originates in uterus, radiates to abdominal wall, lumbosacral area of

back, iliac crests, gluteal area, down thighs, lower back

First stage of Labor

epidural/spinal block only helps a little

Somatic Pain

pain described as intense, sharp, burning, and localized

Stretching and distention of perineal tissues and pelvic floor to allow passage of fetus from distention and traction on peritoneum and uterocervical supports during contractions and lacerations of soft tissue

Second stage of labor

epidural and spinal block helps with this

c section or tearing

Perception of Pain

Threshold remarkably similar in all, regardless of gender, social, ethnic, or cultural differences

Expression of Pain

Pain results in physiologic effects and sensory/emotional (affective) responses

Emotional expressions of suffering often seen

Increasing anxiety

Writhing, crying, groaning, gesturing (hand clenching and wringing), and excessive

muscular excitability

Cultural expression of pain varies

Factors Influencing Pain Response

Physiologic factors

Culture

Anxiety

Previous experience

Early labor may be more painful for nullips

Gate-control theory of pain: Hypnosis, childbirth prep

Comfort and support

Environment: People and tone in the room

Nonpharmacologic Pain management

measures often simple, safe, few adverse reactions, and inexpensive

Provide sense of control over childbirth

Methods require practice for best results (classes)

Try variety of methods and seek alternatives, including pharmacologic methods, if measure used is not effective

Nonpharmacologic Pain management: Alternative Therapies

Relaxation

Imagery and visualization

Breathing techniques

Effleurage and counterpressure

Touch and massage

Applications of heat and cold

Acupressure and acupuncture

Nonpharmacologic Pain management: Alternative Therapies Continued

Transcutaneous electrical nerve stimulation

Water therapy (hydrotherapy)

Intradermal water block- sterile saline water injected and provides pain relief

Aromatherapy

Hypnosis

Biofeedback

Music

What should you keep in mind w/breathing techniques?

make sure they dont pant too much

can cause hyperventilation which leads to tingling sensation

Pharmacological Pain Management

Should be implemented before pain becomes so severe that catecholamines increase and labor is prolonged

Combinations of pharmacologic and nonpharmacologic measures increased pain relief and create a more positive birth experience

Pharmacological Pain Management: Sedatives

relieves anxiety and induce sleep

if staying overnight

Pharmacological Pain Management: Anesthesia

Rids pain perception by interrupting nerve impulse to the brain

Pharmacological Pain Management: Analgesia

Alleviates sensation of pain orraises threshold for pain perception without LOC

Systemic Analgesia: Opioid agonist analgesics

Stimulate major opioid receptors - create a feeling of euphoria

meperidine (demerol) and fentanyl (sublimaze)

meperidine (demerol)

rarely used

Crosses placenta, can cause prolonged neonatal sedation/respiratory depression and neurobehavioral changes

Metabolite related effects not reversible with naloxone

fentanyl (sublimaze)

commonly used

Rapid onset, short half life, short duration

Commonly given by PCA, epidural

safer compared to systemic analgesia

must timed (dont give if 9cm already; can cause resp depression for baby)

count RR, VS and get narcan

Systemic Analgesia: Opioid agonist-antagonists analgesics

Agonists activate/stimulate a receptor to act

Antagonists block a receptor/medication designed to activate a receptor

Ceiling effect for respiratory depression, increased dose doesn’t cause additional respiratory depression.

butorphanol (Stadol)- avoid if pt has hx of opioid dependence

nalbuphine (Nubain)

IM, IV, SubQ

Contraindicated for women with opioid dependence --> can cause withdrawal in mother and baby

Rapid onset, short half life, short duration

Consider for Pain management

Consent

Timing of administration

Preparation for procedures

Administration fine skills: IV, IM, Regional

IV Med Admin

Given slowly

Small amounts

During a contraction or over a period of three to five consecutive contractions

Naloxone (Narcan) is your antidote

Can reverse most CNS depressant effects (opioid induced respiratory depression).

IV, IM, intranasal

Pharmacological Pain Management: Nerve Block Analgesia and Anesthesia

Local perineal infiltration anesthesia

Pudendal block (rare now)- no pain relief

Regional analgesia (Epidural) - some pain relief and motor block

Regional anesthesia (Spinal) - complete pain relief and motor block (c section)

Disadvantages/SE of Nerve Block Analgesia and Anesthesia

Hypotension- #1 SE; why large bolus is given

Itching: alone its normal

Headache: spinal headache; if they sit up it hurts, lay down it stops

Inadequate pain relief

Ineffective pushing

Contraindications of of Nerve Block Analgesia and Anesthesia

Hemorrhage- no epidural

Hypotension

Coagulopathy- thrombocytopenia (<150,000)

Infection at injection site

Allergy to anesthetic drug

Maternal refusal or inability to cooperate

BP and Epidural

done every 5 mins after epidural is started

if bp drops too fast even after bolus, we need to start another bolus

Pharmacological Pain Management: Nitrous Oxide

“Laughing gas”

Used extensively in other countries

Increasing popularity in the United States as an alternative

Safe for mother and fetus

Self-administered

Side effects: nausea and dizziness

Pharmacological Pain Management: General Anesthesia

Infrequently used for elective cesarean sections.

May be necessary if a spinal or epidural block is contraindicated or if circumstances necessitate a rapid birth.

It is critical that the baby is delivered as soon as possible after inducing anesthesia to reduce the degree of fetal exposure