Pain managment during labor and dilivery

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  1. Causes of pain during the stages of labor
    • First stage-labor pain is an internal visceral pain that may be felt as back and leg pain
    • Caused by:
    • *dilation, effacement, and stretching of the cervix
    • *distention of the lower segment of the uterus
    • *contractions of the uterus with resultant uterine ischemia
    • Second stage-labor pain that is somatic and occurs with fetal descent and expulsion
    • Caused by:
    • *pressure and distention of the vagina and the periueum, described by the patient as "burning, splitting, or tearing"
    • *pressure and pulling on the pelvic structures (ligaments, fallopian tubes, ovaries, bladder, and peritoneum)
    • *laceration of soft tissuew (cevix, vagina, and perineum)
    • Third stage-labor pain with the expelling ot the placena is similar to the pain experienced during the first stage
    • Caused by:
    • *uterine contractions
    • *pressure and pullig of pelvic structures
    • Fourth stage
    • Caused by:
    • *distention and stretching of the vagina and perineum incurred during the second stage with a splitting, burning, and tearing sensation
  2. Nonpharmacological managment
    • Interventions
    • *back rubs
    • *effleurage-light gentle circular stroking of the abdoment with the fingertips in rhythm with breathing during conractions
    • *sacral counterpressure-consistent pressure is applied by the support person using the heel of the hand or fist against the patients sacral area to counteract pain in the lower back
    • *heat or cold therapy
    • *hydrotherapy (whirlpool or shower) increases maternal endorphin levels
    • *intradermal water block
    • *hypnosis
    • *acupressure
    • *transcutaneous electrical nerve stimulation (TENS) unit
    • *frequent maternal position changes to promote relaxation and pain relief
    • semi-sitting, squatting, kneeling, kneeling and rocking back and forth, surpine postition only with the placement of a wedge under one of the patients hips to tilt the uterus and avoid supine hypotension syndrome

    • Patient teaching:
    • *Techniques to relieve labor pain, such as patterned breathing and progressive relaxation exercises
    • *Being prepared by childbirth classes helps the patient of relax and relieves tha anxiety these promote pattern breathing methods and relaxation techniques to relieve pain
  3. Pharmacological pain management during labor; Seditives (barbiturates)
    • secobarbital (Seconal)
    • pentobargital (Nembutal)
    • phenobarbital (Luminal)

    can be used during the early or latent phase of labor to relieve anxiety and induce sleep

    • Adverse effects:
    • *Neonate respiratory depression secondary to the medication crossing the placenta and affecting the fetus
    • *unsteady ambulation of the client
    • *inhibition of the mother's ability to cope with the pain of labor
    • *seditives should not be given if the patient is experiencing pain because apprehension can increase and cuase the patient to become hyperactive and disoriented

    • Patient education:
    • *explain to the patient that the medication will cause drowsiness
    • *instruct the patient to request assistance with ambulation

    • Nursing actions:
    • *dim the lights and provide a quiet atmosphere
    • *provide safety for the patient by lowering the position of the bed and elevate the side rails
    • *assist the mother to cope with labor
    • *assess neonate for respiratory depression
  4. Pharmacological pain mamagement during labor; Opioid analgesics
    • meperidine hydrochloride (Demerol)
    • fentanyl (Sublimaze)
    • butorphanol (Stadol)
    • nalbuphine (Nubain)

    act in the CNS to decrease the perception of pain without the loss of consciousness

    Can be given IV or IM the IM route is recommended during labor because it's action is quicker

    Butorphanol (Stadol and nalbuphine (Nubain) provide pain relief without causing significant respiratory depression in the mother or fetus (both IM and IV routes are used)

    • Adverse effects:
    • *crosses the placental barrier; if given to the mother too close to the time of delivery, opioid analgesics can cause respiratory depression in the neonate
    • *reduces gastric emptying; increases the risk for nausea and emesis
    • *increases the risk for aspiration of food or fluids in the stomach
    • *sedation
    • *tachycardia
    • *hypotention
    • *decreased FHR variability
    • *allergic reaction

    • Patient education:
    • *explain to the patient that the medication will cause drowsiness
    • *instruct the patient to request assistance with ambulation

    • Nursing actions:
    • *prior to administrating analgesic or anethetic pain relief verify that labor is well established by performing a vaginal exam that reveals a cervical dilation of at least 4 cm with a fetus that is engaged
    • *have naloxone (Narcan) available to counteract the effects of respiratory depression in the newborn
    • *administer antimetics as prescribed
    • *monitor maternal vital signs, uterine contrection pattern, and continuous FHR monitoring
  5. Phenothiazine medications to control nausea and anxiety
    These do not control pain and are used as an adjunct go opioids

    • Promethazine (phenergan)
    • hydroxyzine (Vistaril)

    • Adverse affects:
    • *dry mouth
    • *sedation

    • Nursing actions:
    • *provide ice chips or mouth swabs
    • *provide safety measures for the patient
  6. Epidural and spinal regional analgesia
    • fentanyl (Sublemaze)
    • sufentanil (Sufenta)

    short-acting opioids administered as a motor block into the epidural or intrathecal space without anesthesia

    provide rapid pain relief and allow the patient to sense contractions and maintain the ability to bear down

    • adverse effects:
    • *decreased gastric emptying resulting in nausea and vomiting
    • *inhibition of bowel and bladder elimination sensations
    • *bradycardia or tachycardia
    • *hypotention
    • *respiratory depression
    • *allergic reaction and pruritus

    • Patient education:
    • expectaion of the procedure

    • Nursing actions:
    • *safety precautions
    • *assess for nausea and emesis and administer antimetic as prescribed
    • *monitor maternal vital signs
    • *monitor for allergic reaction
    • *monitor FHR
  7. Pudendal block
    • Lidocain (xylocaine)
    • bupicacaine (Marcaine)

    administered transvaginally into the space in front of the pudendal nerve

    no maternal or fetal systemic effects, but it does provide local anesthesia to periueum,vulva and rectal areas during delivery, episiotomy and episiotomy repair

    during the second stage of labor 10-20 min before delivery

    • adverse effects:
    • *broad ligament hematoma
    • *compromise of maternal bearing down reflex

    • Nursing actions:
    • *instruct patient about the method
    • *coach patient about when to bear down
    • *Assess the perineal and vulvar area postpartum for hematoma
  8. epidural block
    • local anesthetic
    • bupivacaine (Marcaine) along with and analgesic morphine (Duramorph or fentanyl (Sublimaze)

    injected into the epidural space at the level of the fourth or fifth vertebrae

    eliminates all sensation from the level of the umbilicus to the thighs, relieving the discomfort of uterine contractions, fetal decent, and pressure and stretching of the perineum

    • administered to the patient in active labor and dilated to at 4 cm
    • can be administered through a continious cathater that is patient controlled

    • adverse effects of an epidural block
    • *maternal hypotension
    • *fetal bradycardia
    • *inability to feel the urge to void
    • *loss of the bearing down reflex

    • Nursing actions:
    • *administer a bolus of IV fluids to help offset maternal hypotension as prescribed
    • *help position and steady the patient into either a sitting or side-lying modified sims' position with her back curved to widen the intervertebral space for insertion of the epidural catheter
    • *encourage the patient to remain in the side-lying position after the insertion of the epidural catheter to avoid supine hypotension syndrome with compression of the vena cave
    • *coach the patient in pushing efforts and request and evaluation of epidural pain management by anesthesia if pusing efforts are ineffective
    • *monitor maternal blood pressure and pulse, observe for hypotension, respiratory depression, and oxygen stauration
    • *assess FHR patterns continuously
    • *maintain the IV line and have oxygen and suction ready
    • *assess for othostatic hypotension if present be prepated to administer an IV vasopressor such as ephedrine, position the patient laterally, increase IV fluids, and initiate oxygen
    • *provide patient safety measures, do not allow the patient to ambulate unassisted until all motor control has returned
    • *assess maternal bladder for distention at frequent intervals and catheterize if necessary to assist with voiding
    • *monitor for the return of sensation in the patients legs after delivery but prior to standing
    • *assist the patient with standing and walking for the first time after a delivery tha included epidural anesthesia
  9. Spinal block
    local anesthetic that is injected into the subarachnoid space into the spinal fluid at the third, fourth or fifth lumbar interspace

    fentanyl (Sublimeze)

    eliminates all sensation from the level of the nippples to the feet

    used in cesarean births, a low spinal block may be used for vaginal births

    administered late in the second stage of labor

    • Adverse effects:
    • *maternal hypotention
    • *fetal bradycardia
    • *loss of the bearing down reflex in the mother with a higher incidence of operative births
    • *potential headache from leakage of cerebrospinal fluid at the puncture site (worse when sitting up, blood patch)
    • *higher incidence of maternal bladder and uterine atony following birth

    • Nursing actions:
    • *assess maternal vital signs every 10 min
    • *manage maternal hypotension by administering an IV vasopressor, postiong the mother laterally, increasing IV fluids, and initiating oxygen
    • *assess uterine contractions
    • *assess level of anesthesia
    • *assess FHR
    • *provide patient safety
    • *recognize signs of inpending birth sitting on one buttock, makeing grunting signs, and bulging of the perineum
    • *encourage interventions to relieve a postpartum headache resulting from a cerebrospinal fluid leak. Interventions include placing the client in a supine position, pormoting bed rest in a dark room, administering oral analgesics, caffeine, and fluids. An autologous blood patch is the most beneficial and reliable relief measure for cerebrospinal fluid leaks
  10. General anesthesia
    rarely used for vaginal or cesarean births whin thaer are no complications present

    only used in the event of a dilivery complication or emergency when there is a contrindication to nerve block analgesia or anesthesia

    gerneral anesthesia produces unconsciousness

    • nursing actions:
    • *monitor maternal VS
    • *monitor FHR patterens
    • *ensure that the patient stays NPO
    • *ensure that the IV infusion is in place
    • *premedicate the patient with clear oral antacid to neutralize acidic stomach contents
    • *administer H2 receptor blocker such as ranitidine (Zantac) to decrease gastric acid production
    • *administer metoclopramide (Reglan) to increase gastric emptying as prescribed
    • *administer a short-acting barbiturate, such as thiopental soduim (Pentothal), to render the patient unconscious as prescribed
    • *administer succinylcholine chlotide (Anectine), a muscle relaxant to facilitate passage of an endotracheal tube as prescribed
    • *place a wedge under the patients hips to displace the uterus
    • *assist with appplying cricoid pressure before intubation
    • *maintain an open airway and cardiopulmonary function
    • *assess the patient postpartum for maternal signs of decreased uterine tone, which can lead to hemorrhage and fetal narcosis, both of wihch can be produced by pharmacological agents used in general anesthesia

    • Patient education for general anesthesia
    • facilitate parent-newborn attachment as soon as possible
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Pain managment during labor and dilivery
2011-12-01 21:55:38
Pain managment during labor dilivery

Pain managment during labor and dilivery
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