Chapter 14 - Pain Management for the Laboring Woman - Chapter 14

Mississippi College: NUR390 - Maternal, Newborn, and Women's Health

what are the two origins of pain during labor and birth?

visceral and somatic

what is visceral pain?

originates from lower uterine segments, stretching of tissues as the cervix dilates, pressure and traction on structures and nerves, and uterine ischemia

when does visceral pain occur?

first stage of labor

what is somatic pain?

intense, sharp, burning pain resulting from distension and traction on the peritoneum and uterocervical supports during contractions 

when does somatic pain occur?

second stage of labor

third stage of labor is similar to what stage?

first stage

what is subjective perception of pain?

personalized with each patient 

what are the factors influencing pain response?

• culture

• age

• previous experience

• parity

• available support

what is physiologic expression?

• pain threshold increases as endogenous endorphin levels increase enabling the women to tolerate acute pain. HR, BP, and RR increases

• sensory or emotional reactions

what are some factors that influence pain response?

• physiologic factors 

• culture 

• anxiety 

• previous experience 

• gate - control theory of pain 

• comfort and support 

• environment 

what is pharmacological pain management often used with?

nonpharmacologic strategies

when is pharmacological pain management implemented?

during the active phase of labor

use of anesthesia/analgesia is determined by _____ __ _____ and _____ _____ of mother?

stage of labor; birth plan

what are some anesthesia/analgesics?

• sedatives (barbiturates)

• systemic analgesia 

what do sedatives (barbiturates) do?

• relieve anxiety and induce sleep

• useful with prolonged early-phase labor

• avoid if birth imminent within 12-24 hours

what are the opioid agonist analgesics?

• meperidine

• fentanyl

• remifentanil

what are the opioid agonist-antagonist analgesics?

• stadol 

• nubain (nalbuphine)

what is an opioid antagonist?

narcan (naloxone) 

what do opioid agonists do?

• no amnesic effect (provides amnesia without causing significant respiratory depression in mom or baby)

• provides sedation and euphoria

• enhances woman’s ability to rest between contractions

• can inhibit uterine contractions

what adverse effect does the opioid, Meperidine, cause?

• fetal respiratory depression; it is not recommended for use in laboring patients because of this 

what effect does the opioid, fentanyl, cause?

• short acting synthetic opioid agonists

• rapid onset of action and minimal effect on fetus

what effect does the opioid, rimifentanil, cause?

• shorter acting synthetic opioid agonist with an onset of 1 minute

• metabolized quickly by the fetus

what is the effect of the opioid antagonist, naloxone (narcan)?

quickly reverses the CNS depressant effects of opioids 

what are the safety alerts in nurses’ roles in pharmacological pain management?

• nurses must remain alert for adverse reactions

• nurses must be prepared to administer antidote or summon assistance

• do not give medications PO

• nurses must assess maternal vital signs and FHR/patterns before and after administration of pain meds

• opioids decrease maternal heart, RR, and BP, which affects fetal oxygenation

• opioid agonist-antagonist analgesics such as nubain and stadol should not be given to opioid-dependent women

what are the two pharmacologic pain managements?

• nerve block analgesia

• nerve block anesthesia

what does pharmacologic pain management like nerve block analgesia and anesthesia do?

• temporarily interrupts nerve impulses 

• local perineal infiltration anesthesia 

• regional blocks

what is an episiotomy?

where the doctor has to make a laceration in the vagina opening to help get baby out

what are the three regional blocks?

• pudendal nerve block 

• epidural block 

• spinal block 

where is the pudendal nerve block given?

lower vagina and perineum

where is the epidural block given?

injection between L4-L5

when is the spinal block given?

given in second stage of labor 

_____ _____ effectively relieves the pain caused by uterine contractions. For most women, however, it does not completely remove the pressure sensations that occur as the fetus descends in the pelvis.

epidural anesthesia

where is spinal anesthesia injected?

thru 3rd, 4th, or 5th lumbar interspace into the subarachnoid space where the solution mixes with the CSF

what are the pros to spinal anesthesia?

• ease of administration 

• absence of fetal hypoxia 

• maternal consciousness is maintained 

• excellent muscular relaxation is achieved 

• minimal blood loss

what are the cons to spinal anesthesia?

• possible medication reaction

• hypotension

• ineffective breathing pattern

• increased incidence of bladder and uterine atony

• post-dural puncture headache aka spinal headache

what is a post-dural puncture headache?

headache that can occur after a spinal procedure such as a lumbar puncture (spinal tap) or an epidural for anesthesia

what is the mechanism of action for a post-dural puncture headache?

1) needle can cause a small tear or hole in the dura which is the membrane that protects the spinal cord

2) hole in the dura can lead to leak of cerebrospinal fluid (CSF), reducing the pressure around the spinal cord

what are the adverse effects of a post-dural puncture headache?

• pressure changes cause a severe headache that is often relieved by lying or sitting down but returns or worsens when standing or sitting

what is the treatment for a post-dural puncture headache?

blood patch

how does a blood patch work for a post-dural puncture headache?

helps by physically sealing the hole, stopping the CSF leak and restoring the spinal fluid pressure

explain the blood patch procedure

preparation: the procedure is performed in a sterile environment by a healthcare provider, who may use imaging guidance to locate the exact spot of the original puncture 

blood draw: a small amount of blood is drawn from a vein in the patient’s arm and is collected in a sterile manner 

injection: a needle is carefully inserted into the epidural space near the spinal cord. The patient’s own blood is then slowly injected into this space

Sealing the hole: the injected blood forms a clot that seals the hole in the dura, stopping the spinal fluid leak 

Recovery: the headache may be relieved immediately or within a day or two. Some people may require a second blood patch if the first is unsuccessful 

what is the most effective pain relief available?

epidural anesthesia or analgesia

how should we position mom for an epidural?

on her side

how often should we rotate mom after she receives an epidural?

rotate from side-to-side every 1 hour 

what are the pros to an epidural?

• mom remains alert and more comfortable

• good relaxation is achieved

• airway reflexes remain intact

• only partial motor paralysis

• gastric emptying not delayed

• minimal blood loss

what are the cons to an epidural?

• limited ability to move freely

• higher rate of fever

• hypotension

• possible urinary retention and stress incontinence in the immediate postpartum period

what does a combined spinal-epidural analgesia do?

blocks pain transmission without compromising motor ability 

what is combined spinal-epidural analgesia associated with?

greater FHR abnormalities that epidural analgesia alone

what are the pros to epidural and intrathecal opioids?

• does not cause maternal hypotension or alter VS

• mom feels contractions but not pain

• ability to bear down during 2nd stage of labor remains because the pushing reflex is not lost

what are the cons to epidural and intrathecal opioids?

risk of respiratory depression 

what are the contraindications to subarachnoid and epidural blocks?

• fear or refusal

• anticoagulant therapy of bleeding disorder

• hemorrhage/acute hypovolemia

• infection or tumor at injection site

• allergy to meds

• CNS disorders

• previous surgery

• spinal anatomic abnormalities

what are the epidural effects on a newborn?

• little to no lasting effect on newborn

• no evidence that this has significant effect on the child’s later mental and neuro development

what are some interventions for maternal hypotension associated with anesthesia?

• turn to lateral position, place pillow/wedge under one hip to displace the uterus, or raise legs 

• assess fluid balance and give 500 or 1000 mL bolus of LR or NS 15-30 minutes prior to epidural/spinal anesthesia 

• maintain IV infusion rate at specified rate, or increase rate per protocol 

• notify HCP

• keep bladder empty

• assess pain level 

• administer vasopressor per protocol (ephedrine) or per HCP’s orders

• monitor BP and FHR every five minutes until condition is stable o healthcare provider gives other orders 

• report return of pain sensation/incomplete anesthesia 

• assist client with pushing 

what is the pharmacologic pain management nitrous oxide for analgesia?

laughing gas

what are the side effects for laughing gas?

N/V

does laughing gas affect uterine activity?

no

what is used to self-administer laughing gas?

face mask

what is general anesthesia used during?

• delivery complications

• emergency delivery

• regional block anesthesia is contraindicated

what are the 3 routes for administration of anesthesia?

• IV = preferred

• IM = takes longer

• regional anesthesia

what is some safety and general care for anesthesia?

• nurse monitors and records woman’s response 

• determines fetal response after administration 

• monitor uterine contractions 

• monitor bladder filling and state of hydration 

• monitor for hypotension