Ch 13 Pain management during childbirth

unique nature of birth pain

• no two ppl manage pain the same way

• differs from other types of pain!

• normal part of process - other pains r/t injury/illness

  • anticipated and expected → prepares client for labor

  • not infinite, will end when labor over

  • intermittent w/ contractions - usually all gone when contraction ends

• labor ends w/ birth of baby

  • emotional significance impacts response to pain

emotional significance of labor & pain

• impacts client’s response

• care abt fetus may impact a client’s response to pain

  • motivates client to tolerate more than they otherwise might be willing to

adverse effects of excessive pain

• physiologic

  • catecholamine secretion

• psychological

  • exhaustion & unpleasant memories

effects of catecholamine secretion on pain mgmt

• bc SNS triggered

• generalized vasoconstriction

  • increased uterine muscle tone

    • more tensing up → more pain

  • decreased blood flow → low oxygenation to baby

  • be aware while taking vitals! false increased BP

exhaustion & unpleasant memories & pain mgmt

• makes pushing/completing labor hard

• good memories may be overridden

  • trauma

nonpharmacologic pain mgmt

• many forms

  • focal points

  • relaxation

  • cutaneous stimulation

  • thermal stimulation

  • acupressure

  • hydrotherapy

  • imagery

• best time to educate is latent phase!

nonpharmacologic pain mgmt advantages

• Can be more mobile 

• More control over body & positioning 

• No side effects/allergy risks 

• Endorphin release! 

• Only realistic option for pts in advanced, rapid labor 

  • Sometimes no time for meds

nonpharmacologic pain mgmt limitations

• Don’t always reach lvl of pain control wanted

gate control theory

• Nerve impulses controlled by neural mechanism that acts like a gate 

  • Stimulation of large-diameter nerve fibers blocks pain conduction “Closing gate”

• Big on tactile things! Ie massage

focal points & pain mgmt

• 1 object mom focuses on thru contraction

• everyone be quiet!

  • may take mind off of pain

relaxation & pain mgmt

• easier said than done

• can always try

  • on all muscles (shoulders, hands, feet, etc)

• only use muscles that are working!

• + breathing!!!

• Helps get blood moving & reduces tension 

• Fix environment! 

relaxation & envrionment

• No bright lights, loud noises 

• Aromatherapy can help (lavendar) 

• Help promote comfort 

• Reduce anxiety 

• Follow specific techniques 

cutaneous stimulation & pain mgmt

• self abdominal massage most often

  • Circulation promoted 

  • Effleurage ! 

• lower back massages

  • palm & knead

• massaging thru foot/leg cramps

• done by self or someone else! any part!

• counter pressure

counter pressure

• pressure against where there is pain

thermal stimulation & pain mgmt

• heat packs on belly/back/perineum

  • not cold

• Cool, damp washcloths can help provide coolness if they feel hot

acupressure & pain mgmt

• pressure on the pressure points

  • hands, feet, toes, behind ears, etc

hydrotherapy & pain mgmt

• pt in shower/tub

• not too hot - avoid big temp changes

• increased infection risk w/ amniotic sac broken

• can be very comforting

• buoyancy!

imagery & pain mgmt

• close eyes & imagine self somewhere else

  • ie: laying on beach

• take self out of painful environment

breathing

• Cleansing breath

  • Before & after each contraction 

  • Help clear mind

• Slow-paced 

  • Helps relax 

  • Endorphin release 

• Breathing to prevent pushing 

  • Can damage servic 

  • Blow! Candle ! 

• Slowing down can solve common issues 

pharmacologic reigonal pain mgmt

• epidural

• intrathecal

• spinal

epidurals

• nerve block given thru epidural space in pt’s back

  • Just outside dura mater 

  • Fat, CT, veins

• great! blocks pain!

  • Analgesia w/o sedation/motor block 

  • For c-section & vaginal births

• typically mixed w/ opioid

• work by gravity

• want? given fluid bolus

• can cause hypotension

• not everyone can receive one

• can prolong 2nd labor stage

  • no urge to push

• no bladder awareness

epidural space

• surrounds whole spinal cord

• too far? in spinal canal

  • make sure you’re in right place

epidural work by gravity

• will affect side more laying on R or L

  • rotate!

  • can use wedges

epidural fluid bolus

• more hydrated vessels → more open

• goes in smoother

epidural hypotension

• can cause it

• bottoming out

• baby HR increases

• give ephedrine to help bring BP back up

epidural contraindications

• preeclampsia

  • low platelets - bleeding

• severe spinal issues

  • scoliosis

• spinal surgeries

  • determined by MD

epidural procedure

1. syringe used to get in btwn spinal vertebrae → epidural space

2. 1st numbing shot

3. use empty syringe w/ long needle

   1. press against space!

   2. looking for area of resistance

4. in? → leave needle → inject meds

5. insert catheter to give meds continuously

   1. tape down

   2. set up pump

epidurals & bladder awareness

• none!

  • foley, straight cath

• palpate bladder!

Reigonal anesthesia adverse effects

• Hypotension 

• Bladder distention 

• Prolonged 2nd stage of labor 

• Fever

• Shivering 

• Catheter migration 

Reigonal anesthesia hypotension

• Sympathetic nerves blocked -> vasodilation 

• Happens in first 15 min 

• Can decrease oxygenation 

• IV fluids typically given 

• Still not helping? IV phenylephrine

Reigonal anesthesia bladder distention

• Bc of IV sltn 

• Sensation of void reduced 

• Can cause pain that interferes w/ fetal descent 

• Monitor UO! 

• Bedpan, straight cath, indwelling 

Reigonal anesthesia prolonged 2nd labor stage

• Urge to push less intense 

• Pelvic muscles relaxed 

• Frequency & intensity of uterine contractions slowed 

• Increase chance need for vaccum/forceps for delivery

Reigonal anesthesia fever

• Can be from reduced hyperventilation & decreased heat dissipation

  • Vasodilation & heat redistribution

  • Shivering common!

• Reduced swelling 

• Assess other things to r/o infection!

• Try to lower temp 

Reigonal anesthesia shivering

• Warmed fluids & distraction help 

• Can be given IV meperidine to help decrease 

  • Even demerol

• body thinks its colder than it is

Reigonal anesthesia catheter migration

• Can move out of space bc of venous engorgement 

• Can cause 

  • Intravascular injection 

  • Intense block in wrong place 

  • Increased pain 

  • Absence of anesthesia in one sport 

• Fixed w/ bolus, repositioning, or readujusting of cather 

intrathecal pain mgmt

• into subarachnoid space

• binds to opiate receptors

• much smaller doses given

• not used super often

spinal pain mgmt

• drug of choice for c-sections

• goes into spinal cord

• injected thru syringe

  • have pt hunch over for vertebral access

• numb skin & tissue → goes deeper within spinal cord

  • inject!

• no catheter, non continuous

• numbs pt thru surgery → recovery completely

• given foley

• doesn't rlly drop BP

special considerations for medicating a pregnancy woman

• not a very simple process

  • all drugs likely to affect fetus

  • may have effects during pregnancy they don’t normally have

  • can affect cause & length of labor

  • complications can change med options

  • herbals/supplements/substance abuse can limit safe choices

epidural complications

• intravascular injections

• dural puncture

• contraindications & precautions

intravascular injection epidural complications

• may need large amts of local anesthetic bc cathether lays outside meninges

• before giving any epidural meds, test dose w/ lidocane & epi to determine if catheter has punctured blood vessels or dura

• if bloodstream reached, HR elevation of 20bpm in 45 indicates its intravascular

  • pain may also cause increase

• rapid, intense motor & sensory block if subarachnoid space reached

signs of intravascular injection

• usually only occur if large vol of local anesthesia reaches blood

  • 20bpm increase in HR in 45sec

  • numbness of tongue & lips

  • metallic taste in mouth

  • lightheadedness, dizziness

  • tinnitus

  • feeling of impending doom

epidural in subarachnoid space

• rapid, intense motor & sensory block

  • loss of sensation

• may cause client to experience sensation of not breathing

  • necessary to give O2 & monitor pulse ox readings

• reassurance can help reduce anxiety

  • medication may be needed

epidural dural puncture

• puncture of this also punctures arachnoid

• leakage of CSF most likely will occur

  • postdural puncture headaches

    • can also happen w/o leakage

postdural puncture headache

• differ from most headaches

• usually will get worse when sitting/standing up or in bright lit rooms

• treated w/ epidural blood patch

  • myth that PO/IV fluids, caffeinated bevs, time, or analgesics will help

epidural blood patch

• when autologous blood from client obtained

  • sterile procedure!

• injected into epidural space

• blood creates tamponade effects & makes gelatinous seal over dura hole

  • stops fluid leakage

reigonal anesthesia contraindications & precautions

• reigonal block not for all laboring pts

  • increased intracranial pressure secondary to mass lesion

  • refusal/inability to cooperate during placement

  • bleeding issues

  • fluid vol issues

  • infection in area of insertion

  • systemic infection

  • fetal conditions that require immediate birth

• iffy abt spinal surgery pts

general anesthesia

• super rare!

  • ABSOLUTE emergencies → c-section done

• super quick baby removal

  • when mom anesthesized & intubated, baby is too!

    • baby at risk of decreased oxygenation & put to sleep

• have seconds, maybe 1 min to get baby out

• N/V a big thing! not good w/ c-section incisions

opioid pain mgmt

• not super common

• usually stadol for natural/not ready for epidural moms

• need 4hrs btwn admin & baby being born

  • mom becomes completely relaxed, sleepy, respiratory depression

    • so is baby ! they get opioids too

• always have narcan available

  • esp in cases of respiratory depression

types of opioids for pregnancy

• demerol

• stadol

• nubain

stadol

• most commonly used opioid in laboring pts

• injection

• effective immediately

• mom doesn’t rlly care when in pain

  • if mom delivers within hr of admin, baby needs respiratory support!

    • maintain airways!

pudendal block pain mgmt

• not often used

  • maybe if birthing naturally, but known difficulty will be difficult

    • face presentation, malrotated, hand presentation w/ face → lots of perineum manipulation

• anesthesizes lower part of vagina & part of perineum

• pt still feels contractions

• long ass needle → gets pudendal nerve