ch 14: module 3d comfort care

pain in first stage

• type and how

visceral

The uterus contracts to help open (dilate) and thin (efface) the cervix.

These contractions compress blood vessels, reducing oxygen to the uterus (called ischemia), which causes pain.

Pain is also caused by the stretching and pressure on nearby organs and ligaments

how it travels

pain is transmitted via nerves

usually felt in lower abdomen

Even though pain starts in the uterus, it can be felt elsewhere—this is known as referred pain, like in the lower back, buttocks, thighs, etc.

usually only occurs during contractions, but women with babies in a posterior position may feel constant back pain

second stage

• type of pain

• description

• bearing down?

somatic pain

sharp, burning, intense, and well localized

Some women report less pain while pushing (bearing down), but others may experience more intense pain.

expression of pain: physiological 4

• what vs changes

• can result in what acid/base imbalance

• results in 2/4 (reproductive wise)

sympathetic NS

VS = inc BP, HR, RR

hyperventilation may lead to respiratory alkalosis

Can cause ↓ placental perfusion and ↓ uterine activity, possibly prolonging labor and impacting the fetus

assessment tip

Instead of asking for a pain scale number, ask “What did you feel during your last contraction?”

This approach gives better insight into how the woman is coping, not just how intense the pain is.

factors influencing pain

Physiologic factors

• fatigue, fetal size, position, mobility, fetal descent

age

previous exp: pain and labor

gravida/parity

support level

culture

anxiety

gate control theory

environment

• people, communication, stimuli, temp, privacy, etc

Nonpharmacologic pain management: sensory

• Aromatherapy

• Breathing techniques

• Music

• Imagery

• Use of focal points

nonpharmacological: Cutaneous stimulation strategies

• Counterpressure

• Effleurage (light massage)

• Therapeutic touch and massage

• Walking

• Rocking

• Changing positions

• Application of heat or cold

• warm baths, heat or ice packs

• Transcutaneous electrical nerve stimulation (TENS)

• Acupressure

• Water therapy (showers, baths, whirlpool baths)

• Intradermal water block

Effleurage

light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used to distract the laboring woman and has been found to decrease the sensation of pain

Counterpressure

steady pressure applied by a support person to the sacral area with a firm object (e.g., tennis ball) or the fist or heel of the hand. Pressure can also be applied to both hips (double hip squeeze) or to the knees

HEAT/COLD

Warmed blankets, warm compresses, heated rice bags, a warm bath or shower, or a moist heating pad

• relieves ischemia and incrreases blood flow

cold: cold cloths, frozen gel packs, or ice packs applied to the back, the chest, and/or the face

• reducing the muscle temperature and relieving muscle spasms.

healt/cold safety 3

can be alternated for greater effect

do not use over ischemic/anesthetized area = damage

1 or 2 layers of cloth to prevent damage

water/hydrotherapy safety 2

Because warm water can cause dizziness, a supportive bench or chair can be used in the shower.

The woman should be assisted when getting into or out of the tub or the shower.

nonpharmacological: cognitive

• Birth education

• Hypnosis

primary nurse’s role 3

Teach and offer nonpharmacologic options

Support the woman’s pain management goals

Help implement techniques like breathing, massage, or positioning

Methods of preparing for labor and birth 5

• 4 methods

• 1 importance

Early methods: Dick-Read, Lamaze, Bradley

Focus has shifted from strict methods to personalized coping strategies

Modern programs (e.g., Birthing From Within, HypnoBirthing, CAPPA) help build confidence and inner knowledge

Online classes are now more common due to convenience and cost

Education + birth plan = lower risk of cesarean birth

breathing techniques 5 total

• why/how does it work 3

• which type is better for what stage of labor:

  • early/passive vs late/active

why

• Helps shift focus away from contractions and reduces pain

• Aids muscle relaxation and reduces friction

• During second stage: Assists pushing (supports fetal descent) and prevents tearing

Slow breathing: Used in early labor (less intense)

Quick/light breathing: Used as labor becomes more active/intense

resp alkalosis

• from/cause?

• s/s (3)

from hyperventilation

lightheadedness/dizziness, tingling of the fingers, or numbness around the mouth

resp alk interventions 3

breathe into a paper bag or cupped hand held tightly around her mouth and nose

Maintaining a breathing rate that is no more than twice her normal rate will lessen chances of hyperventilation.

The partner can help the woman maintain her breathing rate with visual, tactile, or auditory cues.

Pharmacologic pain mgt

• when should it be used

• how should it be used

• results in?

use before pain becomes severe

when used with nonpharm

inc pain relief and more positive experience

sedatives

• how do they work (labor context) 3

• group examples

relieve anx

induce sleep

do not have analgesic effect but can enhance it

barbiturates, benzos, phenothiazines

sedatives:

• who is it usually given to 2

• a/e 1

• fetal consideration

given to

• hypertonic uterine dysfunction (tachysystole)

• prolonged early phase of labor to dec anx and promote sleep

CNS depression : RR

can cross placenta: long half life

sedatives: drug specific

• Phenothiazines/promethazine 1/2

• Metoclopramide (Reglan) 2

• Benzodiazepines 3

Phenothiazines/promethazine:

• avoid use with opioids

• excess cns depression and sedation

reglan: Better option to reduce nausea and boost pain relief effects

Benzodiazepines:

• also reduces n/v

• enhance pain relief when given with opioid but cause CNS dep

• Avoid during labor—cause amnesia and affect baby’s body temperature.

analgesia vs anesthesia

analgesia: pain relief; raises threshold; fully conscious

anesthesia: analgesia + amnesia, relaxation, and reduced reflexes.

• interrupting nerve signals

Systemic analgesia (opioids)

• routes 3

• use/function: 3

• a/e 5/9

• caution in what conditions/systems

can be iv/im/pca

Sedation, euphoria, limited pain relief

resp depression, sedation, dizziness, fall risk

confusion/ams

delayed gastric emptying = n/v, aspiration, urinary/bowel retention

caution in women with resp and cv disorders

opioid safety alert

• opioid effect on mother 3

• can cross placenta and cause ___ in fetus 2

• therefore, you must

opioids cause: ↓ Maternal HR, RR, BP

• ↓ FHR variability

• Neonatal respiratory depression (may need treatment after birth)

Monitor and document maternal vitals, FHR and pattern before & after giving opioids

Opioid (narcotic) agonist analgesics

• how do they work

no amnesic effect, but provide euphoria & rest between contractions

meperidine/demerol

also normeperidine

• causes 2

• important consideration(s)

can cause respiratory depression and neurobehavioral changes

Effects can last up to 72 hours and aren’t reversed by naloxone

morphine considerations 4

• NOT CNS/RR dep

Safety: Use side rails, assist with ambulation, fall precautions

Continue nonpharmacologic pain relief methods

Watch for allergic reactions, especially in sulfite-sensitive/asthmatic patients

To reduce newborn effects, aim for birth ≥1 hr or >4 hrs after opioid administration

sensitivity/allerry to opioids/any anesthetic/analgesic products?

• can result in?

• tx with? 3

results in: resp dep, hypotension

tx

• Oxygen

• antihistamine

• ephedrine

Remifentanil Hydrochloride (Ultiva)

• route and why

• special/specific considerations 3

fast onset and short acting

only via PCA pump

• Requires 1:1 monitoring

• continuous O2 sat monitoring

• Use a dedicated IV line

Opioid (narcotic) agonist-antagonist analgesics

• pros 2

anesthesia without significant resp dep

• higher doses do not produce additional respiratory depression

less likely to cause n/v

cons 3

Sedation may be significant

May reduce effectiveness of other opioids

Not for opioid-dependent women → can cause withdrawal/abstinence syndrome

eg

Nalbuphine (nubain)

Butorphanol

a/e of ag/ant

pretty much the same as opioids

just at a less/lower extent

other nursing considerations 2

• other than VS, FHR, resp dep, safety (same as opioids)

assess UA

butorphanol can increase blood pressure, it should not be given to women who have hypertension or preeclampsia.

opioid antagonist (narcan/naloxone)

• a/e 6

BP changes

tachycardia

hyperventilation

N/V

sweating

tremors

considerations 3/4

Don’t give to opioid-dependent women or newborns → can trigger withdrawal

Monitor closely—shorter half-life than opioids → may need repeat dosing

• pain can return

Delay breastfeeding for ~2 hrs after last dose

signs of opioid withdrawal 14

cold turkey

C: cold and hot flashes

O: ocular and nasal tearing

L: loss of apetite

D: Dilated pupils (Mydriasis)

T: tremors

U: upset stomach- n/v/d/abd cramps

R: Restlessness, irritability, anxiety

K: kicking, muscle pain and spasms

E: excess sweats

Y: yawning

with cold:

Piloerection (“gooseflesh” or “chill bumps”)

Violent sneezing

Rhinorrhea (runny nose)

fatigue

Local perineal infiltration anesthesia

• what/who is it for

• when is it given

• extras/may include

• effect

• area affected

For episiotomy or laceration repair in women without regional anesthesia

given before birth and for perineal effects; After birth (for episiotomy or repair)

May include epinephrine to ↓ bleeding & ↑ effect

Rapid, localized pain relief

Immediate site only (skin/subcutaneous tissue)

Pudendal nerve block

• use

• when is it given

• Effect

• area affected

given/used in 2nd and 3rd labor stages of labor

Given before birth procedures (episiotomy, vacuum or forceps, etc.)

Pain relief in lower vagina, vulva, perineum; not contractions

alternative for those avoiding regional anesthesia

Spinal anesthesia

• what is it used for

• what is in it

• position

C-section or vaginal birth procedures (not labor)

Local anesthetic ± opioid agonist

Sitting or side-lying (e.g., modified Sims), curved back

rn role spinal anesthesia

• before (4)

• after 2/3

Support the woman, encourage breathing/relaxation techniques (she must stay still)

Bolus 500–1000 mL IV fluid (no dextrose)

Obtain and evaluate EFM strip

assess vitals

AFter

• Position woman upright to allow anesthetic to settle downward for vaginal birth

• Continue monitoring vitals and FHR

  • q5min x15 min

Side Effects of Neuraxial Anesthesia 5

• maternal/fetal

Hypotension

bladder distention/Urinary retention

prolonged second stage labor (15 mins)

fetal bradycardia

absent or minimal fetal heart rate (FHR) variability

prolonged labor =

Increased use of oxytocin

Increased likelihood of forceps- or vacuum-assisted birth

PDPH

• what is it

• how does it happen

• worsens? makes it better?

• s/s

  • time

spinal headache

dura is accidentally punctured during the process of administering an epidural block.

assuming an upright position triggers or intensifies the headache, whereas assuming a supine position offers relief

headache, auditory problems (e.g., tinnitus), and visual problems (e.g., blurred vision, photophobia) within 2 days of the puncture and may persist for days or weeks.

mgt 6

Hydration

use of an abdominal binder

bed rest in the prone position

oral analgesics

methylxanthines (caffiene)

blood patch

epidural pain mgt

• adv 2 vs disdvan

AD: least resp dep; relieves the pain caused by uterine contractions

DISA: does not completely remove the pressure sensations that occur as the fetus descends in the pelvis.

post epidural hypotension? what to do 7

Positioning: Turn to lateral or place wedge under one hip to displace uterus

IV fluids: Maintain or increase rate per protocol

Oxygen: 10–12 L/min via nonrebreather mask

Legs: Elevate

Notify: OB and anesthesia providers

Meds: Administer vasopressor (e.g., ephedrine or phenylephrine)

Monitor: Stay with patient; assess BP & FHR q5min until stable

post epidural int

position on side and turn every hour

hypotension precautions: o2, iv fluids, vasopressors, elevation

CARE MGT/what do nurses do

• general

• can just read

pain assessment

informed consent

timing of admin

prep for procedure

med admin

safety/general care

• continuous assessments

• ensure safety

informed consent

• First, the procedure and its advantages and disadvantages must be thoroughly explained in a manner and language the woman can understand.

• Second, the woman must agree with the plan of pain management as explained to her.

• Third, her consent must be given freely without coercion or manipulation from her health care provider.

neonatal narcosis

• what is it

• how long

• important info

• cms 5

cns depression by narcotics/anesthesia

may continue despite narcan

lasts 2-4 days

cms

• resp dep

• dec alertness/resp

• hard to console

• unstable thermoregulation

• hypotonia

anesthetic side effect/toxicity 5/8

think reular anesthesia a/e

• Lightheadedness/Dizziness

• Slurred speech

• Loss of consciousness

Tinnitus (ringing in the ears)

Metallic taste

Numbness of the tongue and mouth

Bizarre behavior

Convulsions

BOX 14.1

Suggested Nursing Measures for Supporting a Woman in Labor