anesthesia

Factors contributing to pain:
  - Dilation of the cervix.
  - Stretching of the lower uterine segment.
  - Pressure on adjacent structures.
  - Hypoxia of uterine muscle cells during contractions.

Factors contributing to pain:
  - Hypoxia of contracting uterine muscle cells.
  - Distention of the vagina and perineum.
  - Pressure on adjacent structures.

Factors contributing to pain:
- Uterine contractions.
- Cervical dilation as the placenta is expelled.

The American College of Obstetrics and Gynecology (2006) states:
- A woman’s request for pain medication is sufficient justification for pain relief during labor.

Offer analgesia as needed:
  - Analgesia Options:
    - IV Opioid Narcotics:
      - Nalbuphine (Nubain)
      - Butorphanol (Stadol)
      - Hydromorphone (Dilaudid)
    - Ataractics:
      - Analgesic potentiators that enhance the effects of narcotics, e.g., Promethazine (Phenergan).
Administration Notes:
- Nubain and Phenergan often given together IV every 2-3 hours as needed in active labor.

Assessment Before Administration:
- Vital signs (VS), fetal heart rate (FHR), contraction pattern, pain level, and any allergies must be assessed prior to administering medications.
Cross-limited prominence:
- Medications cross the placenta and can sedate both mother and baby, leading to decreased FHR variability.
Timing Considerations:
- Avoid giving medications close to delivery to prevent sedation in the baby at birth.
- Avoid giving too early in labor to not prolong labor in the latent phase.
Patient Instructions:
  - Instruct the mother to stay in bed.
  - Maintain a call bell within reach.
  - Create a quiet environment conducive to rest.

Regional Anesthesia:
  - Epidural Anesthesia:
    - Anesthetic agent is injected into the epidural space for pain relief in labor.
    - Administered by an anesthesiologist, CRNA, or obstetrician.
Anatomical Consideration:
  - The epidural space is accessed below the point where the spinal cord ends, using:
    - Components of the technique:
      - Spinous process, needle, vertebral body, catheter, and epidermal space represented diagrammatically.

The mother remains awake and part of the birthing process.
Less fetal sedation compared to IV medications.
Allows for resting and regaining strength during labor.
Provides excellent pain relief from the uterus down.
Often preserves the urge to bear down during delivery.
Can be administered through a continuous infusion pump allowing patient-controlled analgesia.

Steps Involved:
  1. Obtain informed consent prior to the procedure.
  2. Administer IV fluid bolus (1000 cc of lactated Ringer's) to prevent hypotension.
  3. Monitor vital signs and fetal heart rate continuously.
  4. Position patient laterally post-insertion with a wedge under the hip to displace the uterus.
  5. Observe the legs, ensuring proper positioning to prevent injuries since the patient will have diminished sensation.
  6. Do not forget the bladder, as the patient may be unable to feel the urge to void.
  7. Encourage rest until pushing begins in the second stage of labor.

Used at the time of birth and in preparation for episiotomy or perineal laceration repair to anesthetize the involved tissues.
Commonly uses Lidocaine (ensure to assess allergies first).
No common adverse effects, and additional nursing assessments are usually unnecessary.

Nitrous Oxide:
  - Combination of 50% O2 and 50% nitrous oxide gas.
  - Administration via self-controlled mask/mouthpiece.
  - Well-researched in terms of fetal and maternal safety.
  - Rare side effects may include nausea, vomiting, dizziness, and dysphoria.

Local anesthetic directly injected into spinal fluid in the spinal canal.
Provides anesthesia from the nipple line downward, particularly effective for cesarean sections.
Immediate onset of anesthesia with common side effects including hypotension.
Contraindicated in cases of coagulation problems; side effects and preparations are similar to those discussed for epidurals.
Notable risk for spinal headaches.

Can be utilized for cesarean section but will have different dosing by the anesthesiologist.
Procedure, side effects, and precautions are the same as previously discussed for labor.

Induced unconsciousness, reserved for cases where no other anesthesia options are viable for C-sections.
Risks include:
- Vomiting and aspiration for the mother.
- Risk of fetal depression related to medications given to the mother—rapid delivery is crucial to mitigate this risk.

Explain the process to the patient.
Place a wedge under the right hip to displace the uterus to the left.
Assess the last oral intake before anesthesia.
Administer antacids (as ordered) prior to induction to reduce the acidic content of the stomach in case of aspiration (e.g., Bicitra, Tagamet).
Initiate IV fluids.
Pre-oxygenate with 3-5 minutes of 100% oxygen.
Proper application of cricoid pressure may be necessary until a cuffed endotracheal tube is placed by the anesthesia provider or certified nurse-anesthetist.

Proper positioning involves depressing the cricoid cartilage 2 to 3 cm posteriorly to occlude the esophagus.