NURS358 Exam 2 - Pharm mgmt and comfort measures

What is the pain in labor acroynm?

P - purposeful
A - anticipated
I - intermittent
N - normal

What are the physiological downsides of too much pain in labor?

Catecholamines inhibit the uterus responding to oxytocin, which can prolong labor and reduce blood flow to the placenta

The increase in cortisol and glucagon increase the metabolic rate and therefore demand for oxygen

We might hyperventilate at this point, but the CO2 build up will decrease the amount of O2, only making things worse.

What can hyperventilation of the mom in labor lead to?

maternal hypoxemia, dizziness, loss of consciousness, with less O2 to fetus.

This can decrease BF to the uterus via uteroplacental vasoconstriction

What EFM reading does decreased oxygenation (in this case associated with stress) lead to?

Late decels

Unrelieved pain during labor increases risk of what mental health issues?

PPD
PTSD

What are the 4 main sources of pain during pregnancy?

Tissue ischemia -- blood supply to the uterus decreases with each CX

Cervical dilation

Pressure and pulling on pelvic structures

Distension of the vagina and perineum with fetal descent, especially in the second stage

What types of pain are felt in the stages of labor?

Burning, tearing, spitting

Visceral and somatic!!

Visceral is mostly the cramping of stage 1, somatic is the burning and tearing of stage 2

When using pharmacological management for labor pain, what should be considered?

Some meds may slow down labor or increase the length of the second stage

Analgesics go right to the fetus -- may decrease RR

What are the types of pain relievers?

Regional
Systemic (opioids, sedatives, etc).
General anesthesia

What are the advantages of regional pain relievers?

mom is awake, participates, and maintains airway with good pain control

What in included as regional pain managers?

Pudendal block
Local infiltration anesthesia
NEURAXIAL REGIONAL BLOCKS:
- Epidural block
-Subarachnoid block/spinal
- Combined spinral epidural

What is a pudendal nerve block?

Local injection into the pudendal nerve thru the vagina -- in second stage, NOT USED NOW

What is local infiltration anesthesia?

An anesthetic like lidocaine injected into the perineum for episiotomy, laceration, or repair

-- risk for hematoma and infection

What is an epidural block?

AN EPIDURAL -- usually a COMBINATION OF ANALGESIA AND ANESTHETIC -- patient can feel only the pressure

How is an epidural given

Constant medication with catheter and infusion pump sends meds into the EPIDURAL SPACE BETWEEN THE 3RD AND 4TH VERTEBRAE BELOW THE SPINAL CORD
Directly effected by gravity, may have bolus setting for breakthrough pain

What is the MAIN side effect of epidural? What are other little side effects?

HYPOTENSION!! in 40% of women -- give fluids to offset the hypotension

N/V, pruitis, and bladder distension may also occur (MOM GETS FOLEY!)

What nursing actions should be taken if mom experiences hypotension after epidural?

Turn on LEFT SIDE
increase the IV rate
give O2 as ordered
Notify anesthetist/aneswhatever

Where is a spinal given? What is its NUMBER ONE SIDE EFFECT?

Spinal is put into subarachnoid space -- side effect = HEADACHE!!!
Worst when they sit up, get relief when they are lying down

What are spinals used for? What is the onset and duration?

Usually for scheduled C/S's

no catheter involved, onset is faster than with an epidural (5 min)
Pain relief lasts for 90 min-3 hrs

What are the other common side effects of spinals?

#1 is headache,
then hypotension (like epidural)
bladder distension
fetal bradycardia

WHAT SHOULD BE GIVEN/DONE prior to a spinal or epidural???

FLUID BOLUS -- hypotension is a symptom of both
Consent, pain level, etc.
Stable vitals
Allergies, contraindications
FHR
Contraction patten
Platelets, CBC
TIME OUT!! make sure this is the right patient and procedure
Anticipate placing a foley

Why do we give foleys with this stuff?

Bladder is the last thing to come back to sensation after, but we have also given fluids to offset the hypotension, so bladder distension is likely, and also will interfere with CXs

What are other adverse effects of an epidural block?

bladder distension due to the amount of fluids being given

decreased need to push (LESS FERGUSON REFLEX in second stage)

fever

Migration of the epidural catheter -- might have adverse effects that can decrease respiratory effort or be an inadequate block

What is duramorph

Another injection into the spinal area what is used IN COMBINATION with epidural/spinal to extend the pain relief without loss of motor or sensory -- opioid analgesic similar to morphine but lasts 24 hours

What are the adverse effects of duramorph? Nursing imp?

repiratory depression (opioid) -- so check respiratory status HOURLY for the first 24 hrs

Pruitis -- benadryl!

give antinausea for the nausea

What are contraindications for epidurals and spinals?

rash or back infection

history of back surgery

scoliosis

taking anticoagulants such as warfarin

thrombocytopenia

What are systemic drugs for labor?

inhalants -- NITROUS OXIDE (50/50 -- mom must hold for use!!!!!!! Stop breathing it in when the contraction ends)

opioids -- watch for respiratory depression in neonate

opioid antagonists are needed!

Adjunctives

sedatives

WHAT systemic opioid analgesics are used in labor??

MFS DN

Morphine
Fentanyl
Demoral (meperidine)
Nubaine (nalbuphine)
Stadol (butorphanol)

Why isn't demoral used much anymore?

prolonged half-life in baby (2.5 days)
Max concentration in the baby occurs between 2-3 hrs after administration

How are these analgesics given? Onset, peak? Do they cross the placenta and affect the fetus?

usually IV push, sometimes IM

Take 1-3 min to begin working

Usually short acting
fentanyl peak 3-5 min
nubain peak 30 min
morphine peak 20 min


YES THEY CROSS and affect the fetus -- dont' give these to mom if you expect she will deliver soon

What are the side effects for mom and baby for systemic analgesics/opioids

MOM:
not so good pain relief
itching
n/v
CNS depression

FETUS:
decreased variability in HR
respiratory depression (why we don't want to give if delivery soon)

Mom is having too many side effects from opioids. What are we giving? How are we giving? What is implication of giving?

NARCAN/NALAXONE
IM, SQ, IV

give under close supervision

Has a shorter duration of action than the opioid it is reversing -- might have the opioid come back after narcan wears off and cause respiratory depression again

What are side effects of narcan?

N/V
tremors
tachycardia
hyper or hypoTN
V-fib
seizures
cardiac arrest

ADJUNCTIVE MEDS: What is promethazine/phenergan given for? Nursing implications?

N/V

analgecis effect when given with opioid

MIX with saline and push slow, might make drowsy

ADJUNCTIVE MEDS: What is reglan and zofran used for

N/V

What emergency analgesia can be given with a doctors order already in place? What is the last resort?

epidural if already in place and working can be adjusted

GENERAL ANESTHSIA -- last resort because it causes rapid uterine relaxation and repiratory depression in baby.
Possible placenta retention and uterine inversion due to uterus no longer contracting

What is the goal of nonpharm techniques for pain mgmt?

minimize suffering/prevent suffering -- not eliminate pain

What are the 6 healthy birth practices?

PASIUT

Patience
Active
Supported
Individualized
Upright
Togetherness

What is the combining breath technique?

fast, slow, fast breathing to help take mind off the contraction pain -- try a big breath before a contraction and at the end, with small breaths during it

Does water birth require a doctor's order? Acupuncture too? TENS? HOT AND COLD THERAPY

YES -- for all -- and TENS = transcutaneous eletrical nerve stimulation -- electrodes that control pain?

What is the most common cause of back labor? What positions can encourage the baby to turn?

What comfort actions can be done?

OP baby!!! sunny side up -- face against mom's spine

Mom can go on hands and knees or one foot on a chair and lean into it, or just remain upright (lying is not good)

COMFORT: pelvic rock, double hip squeeze, shower, one contraction at a time, stay relaxed!