1
Analgesia and Anesthesia
Lecture 5
I.
Labor Pain
A.
Data Collection and Assessment
1.
Ask patient comfort level and current pain level
-0-10 scale or coping scale
-comfort level is when they can participate in
ADL’s without the need of pain meds
2.
Be aware of cultural differences in response to
pain
-Asian populations may not exhibit pain or ask
for pain medications
-Hispanic women may be very stoic until just
before the delivery of the baby
-Middle Eastern groups may be very vocal in
requesting early use of medications for pain
3.
Anxiety and fear of the unknown might
heighten their level of pain
4.
Previous experiences with childbirth or other
painful procedures may lead to higher levels of
concern about pain management needs
5.
Attendance to childbirth classes may aid in the
patient’s ability to cope through contractions
B.
First Stage
1.
Early phase-0-3 cm
a.
nonpharmacological methods
1.
focal points
2.
massage/counterpressure
3.
hydrotherapy/aromatherapy
4.
music
5.
breathing techniques
6.
Transcutaneous Electrical Nerve
Stimulation unit (TENS)
7.
heat/cold packs
8.
hypnosis
9.
changing positions/walk/rocker
b.
pain medications
1.
should be discouraged as they
could slow the labor process
2.
usually orals:
percocet
vicodin/norco
benadryl
acetaminophen
3.
occasionally IM:
morphine with phenergan
2
II.
2.
Active phase-4-7 cm
a.
may use many of the same
non-medication choices as above
b.
when pain is more intense, usually
requests IV medications for fast
action
-fentanyl
-nubain
-stadol
c.
may also request and receive an epidural
at this stage in labor
3.
Transitional phase-8-10 cm
a.
may request epidural
b.
may want to be out of bed and push on
toilet to relieve backache
c.
encourage position changes if possible
d.
short acting IV narcotics still ok but have
Narcan available for infant resuscitation
C.
Second Stage
1.
May continue pushing with epidural pump on if
efforts are affective
2.
May receive local anesthesia for repair of
perineal laceration or episiotomy
3.
If no epidural is in place, may receive a
pudendal block which relieve pain in the
vagina, vulva, and perineal regions
D.
Third Stage
1.
If placenta is retained, may receive IV pain
medications or be moved to OR for twilight
sleep
2.
For laceration/episiotomy repairs, use of local
anesthetics or pudendal block (less common)
Adverse Effects of Excessive Pain
A.
Physiological effects
1.
Effect on cervical change-more in pain, less
able to relax and let the labor progress
2.
Tensing up against the pain leads to muscle
and ligament strains in other parts of the body
3.
May not keep properly hydrated and nourished
R/T the intensity of the pain
4.
Inability to relax back muscles and do deep
breathing may lead to difficulty placing epidural catheter
3
B.
Psychological effects
1.
“I can’t do it”-ineffective pushing due to fear
of pain
2.
inability to make decisions R/T pain
3.
may become hostile to staff/family R/T
inability to cope
III.
Factors Influencing Perception of Discomfort
A.
Teens and Older Primigravidas
B.
Cultures/Religions
C.
Previous experiences with pain
D.
Support person
E.
Preparatory classes
F.
Fetal position-i.e.: OP presentation
IV.
Pertinent Nursing Diagnoses
A.
Pain R/T physiologic response to labor
1.
assess patient’s knowledge of labor and
relaxation techniques
2.
encourage support people to aid in comfort
measures
3.
teach alternative non-pharmacological
methods of pain relief
4.
assess need to void/defecate
5.
encouraging resting between U/C’s
6.
keep pt. and family notified of labor progress
7.
offer possible choices for pain medications if
all other methods have been unsuccessful
B.
V.
Other possible nursing diagnoses
1.
Ineffective airway
2.
Fluid volume deficit
3.
Fetal oxygenation
4.
Anxiety R/T pain
5.
etc. (see others in book)
Pharmacological Pain Management
A.
Considerations for the Pregnant Patient
1.
What medications you give the mom you give
the fetus
2.
Maternal concerns that she wasn’t
“strong enough” to make it thru without
pain meds
3.
Need to taper dosage to the patient
4.
If previous abuser of medications, will pain med
even be effective
5.
Cultural beliefs
4
B.
Analgesics, sedatives, and adjuncts
1.
Sedatives may be given in early labor to aid
With sleep and anxiety but can lead to a
Slowing of the labor progress and noted respiratory
depression in the patient along with vasomotor depression
of both mom and fetus.
2.
Analgesics
a.
can be systemic crossing the blood/brain
barrier as well as the placental barrier
b.
IV is preferred over IM due to rapid onset
but IM medications last longer
c.
narcotic compounds
-Demerol-meperidine
-Sublimaze-fentanyl
-Stadol-butorphanol
-Nubain-nalbuphine
-respiratory depression
-tachy/bradycardia
d.
analgesic potentiators
-usually antiemetics (Phenergan, Vistaril)
-decrease anxiety and apprehension
-helps reduce the amount of narcotic
needed for relief
C.
Anesthetics (Regional and General)
1.
Local block
a.
usually used on perineal region
b.
1% lidocaine used
c.
injected into skin and subcutaneous
d.
epinephrine may be added to intensify
anesthetic and decrease bleeding
2.
Pudendal block
a.
goal to anesthetize the pudendal nerve
located near the ischial spines
b.
may decrease ability to bear down R/T
lack of sensation
c.
doesn’t provide pain relief for manual
extraction of placenta or uterine
exploration
3.
Epidural block/PCEA
a.
needs IV bolus before insertion R/T
maternal hypotension due to
vasodilation
b.
done by CRNA or MD
c.
pt. awake for procedure/delivery
d.
pt. sitting up for placement
5
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
after insertion, may need frequent
position changes side to side to
keep anesthetic level equal
preferred block T10-S1
need Foley cath in bladder due to
inability to feel when to void
possibility of spinal headache if needle
placement is not correct
saturates pain receptors but not motor
one
may need to use Ephedrine
(a vasopressor) if maternal BP ↓
usually a local anesthetic alone or
mixed with a narcotic (fentanyl, etc.)
may increase labor time and need for
pitocin augmentation
antiemetics, antipruritics, and narcotic
antagonists should be handy to treat
possible side effects of epidural
as with any medication, be prepared for
possible severe adverse reactions such
as bronchospasms, sudden ↓ in BP, dyspnea, or
convulsions-crash cart should be available on unit
4.
Spinal block
a.
local anesthetic into the L3, L4, or L5
interspace→subarachnoid space
b.
medication mixes with CSF-saturates
pain and motor receptors
c.
used for cesarean sections
d.
risk of spinal headache due to leak
of CSF-may need to remain supine post delivery, IV
maintained, and possible blood patch
e.
IV bolus given prior to procedure R/T
risk of maternal hypotension, ↓ CO,
and placental perfusion
e.
maternal BP, pulse, resp. effort, and FHR
are assessed every 5 minutes for the first
15-30 post injection
5.
General anesthesia
a.
while rarely used, may be needed for C/S if unable to
access regional block or in
emergency cases
b.
NPO, IV, oral sodium citrate before start
c.
RN may be asked to give cricoid pressure
to aid anesthesiologist in tube placement
d.
normally recovered in PACU (recovery rm)
6
e.
f.
g.
so bonding with infant delayed
higher risk of complications vs. regional
blocks-mother unconscious during birth
of infant
as with all anesthesias used during C/S,
wedge should be placed under mom’s
R hip to displace uterus to the L
besides C/S, general anesthesia may be
needed during manual placenta removal
or D & C
01/16