Maximizing Comfort for the Laboring Woman

General anesthesia for L&D?

use of IV injection and/or inhaling anesthetic agents that make the pt. unconscious

Contraindications to spinal & epidural analgesia?

-Active or anticipated maternal hemorrhage (abruptios) -Maternal HTN -Coagulopathy (thrombocytopenia) -heparin? -Infection at site on -Inc. intracranial pressure -Allergy -Maternal refusal or inability to cooperate

What are some physiologic factors influencing pain responses?

-Fatigue -Anxiety -Beta-endorphins (endogenous opioids) -Fetal size and position -Maternal position

What Eloi said she wants us to know for this chapter:

-Go thru Ch. -more abt epidural -ci of epidural -who would and wouldnt qualify -what its used for -care for epi before & after

What are some complications of spinal and epidural block?

-Hypotension** -CV probs -Nasal stuffiness -N/V -Pruritis -Resp. depression -FHR changes -Leakage of CSF -Post dural Puncture Headache or Spinal Headache**

Preparation of the procedure: role of the nurse?

-Inform pt. of procedure -Ensure the consent form is signs -Give fluids (LR 500 ml) -Position patient to sitting or side lying -Back is curved & exposed -Emotional support -Check VS & FHR

Nitrous Oxide for anesthesia use?

-Inhaled gas (Nitrous oxide + O2 50:50) -Increases endorphin & dopamine -Diminishes pain & anxiety -Less invasive, less expensive -Woman can ambulate in labor

Vaginal birth labor pharmacological pain managment?

-Local infiltration anesthesia -Pudendal block -Epidural analgesias and anesthesias

General anesthesia nursing considerations?

-NPO x4 hrs before -Premedicate with antacid -IV fluids needed -Preoxygenate prior to giving the med -Intubate -Nitrous ox. & O2 given -C/s: foley catheter

Second stage pharmacologic pain management?

-Nerve block anesthesia and analgesia -Pudendal block -Spinal anesthesia -Epidural analgesia

What are examples of expression of pain?

-Pallor, diaphoresis -Pale -Nausea/vomiting -Anxiety -Crying -Clenching

First stage of labor pharmacologic pain management?

-opioids, epidural analgesia, combined spinal epidural anesthesia (CSE), nitrous oxideC

What stage of labor does visceral pain occur?

1st stage: the uterus contracts causing dilation and effacement of cervix. uterine arteries that supply the endometrium are compressed causing uterine ischemia

A nurse is working with a pregnant client who is inquiring about childbirth preparation. Based on current practice, which method should the nurse indicate as being most effective? a. Encouraging expectant parents to attend childbirth preparation in any or no specific method. b. The Dick-Read (natural) childbirth method. c. The Bradley (husband-coached) method. d. The Lamaze (psycho-prophylactic) method.

A

The nurse is monitoring a client in labor who is experiencing back labor and complains of intense pain in her lower back. Which relief measure should the nurse implement? A. Apply counterpressure against the sacrum B. Effleurage C. Biofeedback D. Encourage pant-blow (breaths and puffs) breathing techniques

A Counterpressure is steady pressure applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back. Pant-blow breathing techniques are usually helpful during contractions per the gate-control theory. Effleurage is light stroking, usually of the abdomen, in rhythm with breathing during contractions. It is used as a distraction from contraction pain but it is unlikely to be effective for back labor. Biofeedback-assisted relaxation techniques are not always successful in reducing labor pain. Using this technique effectively requires strong caregiver support.

A nurse administers an opioid agonist analgesic to a woman in active labor. Which medication should the nurse identify as being used cautiously due to potential impact on the fetus? a. Miperidine (Demerol) b. Fentanyl C. Promethazine D. Phenergan

A Meperidine is the most commonly used opioid agonist analgesic for women in labor throughout the world, however does cross the placenta causing neonatl sedation and behavioral changes. Phenergan is an ataractic (tranquilizer) that may be used to augment the desirable effects of the opioid analgesics but has few of those drugs' undesirable effects. Fentanyl as used in epidural administration provides adequate analgesia but is quickly metabolized by the fetus with little side affects. Nubain is an opioid agonist-antagonist analgesics that provide sufficient analgesia but does not impact fetal respiratory depression.

A group of nurses are discussing the concept of pain experience during labor. Which statement should the nurses identify as correct? a. Sensory pain for nulliparous women often is greater than for multiparous women during early labor. b. Affective pain for nulliparous women usually is less than for multiparous women throughout the first stage of labor. c. Women with a history of substance abuse experience more pain during labor. d. Multiparous women have more fatigue from labor and therefore experience more pain.

A Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple. Affective pain is greater for nulliparous women during the first stage but decreases for both nulliparous and multiparous women during the second stage. Women with a history of substance abuse experience the same amount of pain as those without such a history. Nulliparous women have longer labors and therefore experience more fatigue.

Your patient presents with a headache after receiving a spinal and epidural block during labor. What are you thinking it could be?

A Post-Dural Puncture headache or Spinal headache that resulted from a leakage of CSF from the dura mater

What is the treatment of a post dural puncture headache?

A blood patch (10-20 mL of blood is injected into the dural space to form a blood clot and stop the headache)

A (Counterpressure against the sacrum)

A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure is to use: a) Counterpressure against the sacrum b) Pant-blow (breaths and puffs) breathing techniques c) Effleurage d) Biofeedback

A nurse is providing information to a client in labor with regard to tactile approaches to comfort management. Which option should the nurse include in the plan of care? a. Acupuncture can be performed by a skilled nurse with just a little training. b. Hand and foot massage may be especially relaxing in advanced labor, when a woman's tolerance for touch is limited. c. Therapeutic touch (TT) uses handheld electronic stimulators that produce sympathetic vibrations d. Either hot or cold applications may provide relief, but they should never be used together in the same treatment.

B The woman and her partner should experiment with massage before labor to see what might work best. Heat and cold may be applied in an alternating fashion for greater effect. Unlike acupressure, acupuncture, which involves the insertion of thin needles, should be done only by a certified therapist. Therapeutic touch is a laying-on of hands technique that claims to redirect energy fields in the body.

What is fentanyl used for in labor?

Relief of pain

What are the maternal and fetal risks when giving systemic analgesia (opioids)?

Respiratory distress s/e of mother & fetus

What cardiovascular complications does the nurse observe for when giving spinal and epidural blocks?

Seizures Convulsions Arrhythmia Cardiac arrest

Who should the RN call during the time the mother in labor has spinal or epidural block and needs assistance?

Acute Pain Management team: the anesthesiologists

Pudendal nerve block is?

An anesthetic injected into the pudendal nerve (close to the ischial spines) via needle guide known as 'trumpet' during 2nd stage of labor

What is local perineal infiltration anesthesia?

Anesthetic injected into perineum at epiostomy site during 2nd stage of labor.

Epidural anesthesia or block is?

Anesthetic injected into the epidural space, given during 1st and 2nd stages of labor, used for vaginal and c/s

A nurse is reviewing the use of systemic analgesics administered during labor. Which statement should the nurse indicate as correct? a. Systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier. B. Effects on the fetus and newborn can include decreased alertness and delayed sucking. C. IV client-controlled analgesia (PCA) results in increased use of an analgesic. D. IM administration is preferred over IV administration.

B Effects depend on the specific drug given, the dosage, and the timing. Systemic analgesics cross the fetal blood-brain barrier more readily than the maternal blood-brain barrier. IV administration is preferred over IM administration because the drug acts faster and more predictably. PCAs result in decreased use of an analgesic.

______________ are secreted by the pituitary gland and reduce pain; the levels increase during pregnancy, and causes the mother to have an increased pain threshold.

Beta Endorphins (endogenous opioids)

Common medications used for spinal/epidural?

Bupivacaine, ropivacaine (most common), lignocaine (local) hydrocholoria

After change of shift report, the nurse assumes care of a multiparous client in labor. The woman is complaining of pain that radiates to her abdominal wall, lower back, and buttocks, and down her thighs. Before implementing a plan of care, the nurse should understand that this type of pain is: a. Somatic B. Afterpain C. Referred D. Visceral

C As labor progresses the woman often experiences referred pain. It occurs when pain that originates in the uterus radiates to the abdominal wall, the lumbosacral area of the back, the gluteal area, and the thighs. The woman usually has pain only during a contraction and is free from pain between contractions. Visceral pain predominates the first stage of labor. This pain originates from cervical changes, distention of the lower uterine segment, and uterine ischemia. Visceral pain is located over the lower portion of the abdomen. Somatic pain is described as intense, sharp, burning, and well localized. It results from stretching of the perineal tissues and the pelvic floor and occurs during the second stage of labor. Pain experienced during the third stage of labor or afterward during the early postpartum period is uterine. This pain is very similar to that experienced in the first stage of labor.

A woman in the active phase of the first stage of labor is using a shallow pattern of breathing, which is about twice the normal adult breathing rate. She starts to complain about feeling lightheaded and dizzy and states that her fingers are tingling. What action should the nurse implement? A. Slow pace of breathing B. Give O2 via nasal cannula C. Help her breathe into a paper bag D. Notify her physician

C This client is experiencing the side effects of hyperventilation, which include the symptoms of lightheadedness, dizziness, tingling of the fingers, and circumoral numbness. Notification of the physician is not necessary. The best approach is to have the client breathe into a paper bag held tightly around the nose and mouth to eliminate respiratory alkalosis. The woman can also breathe into her cupped hands if no paper bag is available. Slowing the pace of her breathing will not correct the problem, nor will administration of oxygen. Once the pattern of breathing is corrected, her partner can help the woman maintain her breathing rate with visual, tactile, or auditory cues.

Brow presentation is delivered how/

Cesarean

A nurse is working with a client who is in labor and providing information relative to breathing techniques. Which option should the nurse include in the plan of care? a. Controlled breathing techniques are most difficult near the end of the second stage of labor. b. The patterned-paced breathing technique can help prevent hyperventilation. c. By the time labor has begun, it is too late for instruction in breathing and relaxation. d. Breathing techniques in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction.

D First-stage techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity. Instruction in simple breathing and relaxation techniques early in labor is possible and effective. Controlled breathing techniques are most difficult in the transition phase at the end of the first stage of labor, when the cervix is dilated 8 to 10 cm. Patterned-paced breathing can sometimes lead to hyperventilation.

A nurse is reviewing spinal and epidural (block) anesthesia use during labor. Which statement should the nurse identify as being accurate? a. Epidural blocks allow the woman to move freely. b. This type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births. c. Spinal and epidural blocks are never used together. d. A high incidence of post-birth headache is seen with spinal blocks.

D The headaches may be prevented or mitigated to some degree by a number of methods. An autologous epidural blood patch is the most rapid, reliable, and beneficial relief measure for a spinal headache. Spinal blocks may be used for vaginal births, but the woman must be assisted through labor. Epidural blocks limit the woman's ability to move freely. Combined use of spinal and epidural blocks is becoming increasingly popular.

What are common opioid agonist analgesics for labor?

Demerol, Fentanyl

a woman with an epidural needs what patient teaching as a result of being a high fall risk?

Don't get out of bed; High fall risk since the epidural paralyzes the waist down

What are childbirth preparation methods?

Education and explanation of birth process

The nature of pain during the 3rd and 4th stage of labor are like those experienced during the early _______ stage of labor.

First stage of labor

What is the most common complication of spinal and epidural blocks?

Hypotension

How are systemic analgesia (opiates) administered?

IM or IV via PCA (most often is IV, rarely IM)

Anxiety ______ muscular tension.

INcreases

What is pain described as during the 2nd stage of labor?

Intense, sharp, and burning is localized

Due to the nerve impulses during the first stage of labor, where will women present with pain?

Lower back, thighs

Effleurage

Massage technique that involves gliding, stroking or circular movements, utilizing a light, slow consistent motion with either light or no pressure on the ABDOMEN during CONTRACTIONS

During transition 1st stage and 2nd stage, __________parous women experience MORE pain because flexible tissue increase speed of fetal descent.

Multiparous

What does High Block refer to when discussing complications of spinal and epidural block?

Nasal stuffiness,** respiratory distress, or arrest

________parous women may have poor coping skills; and have initial pains more than multiparous women.

Nulliparous

______- fear, lack of knowledge, culture, previous experience

Perception

Systemic analgesia (opiates) provide _____- but have limited effect in labor.

Provides sedation, limited effect in labor

In the 2nd stage of labor, the pain impulse is transmitted via the ______ nerve through the spinal nerve segments S__ to S__, and the parasympathetic nervous system.

Pudendal nerve S2 to S4

The following are examples of things that are responsible for causing __________ pain: -Distention & traction on the peritoneum & uterocervical supports -Pressure against the bladder & rectum -Stretching & distention of perineal tissue & pelvic floor -Lacerations of soft tissue (cervix, vagina, perineum)

Somatic pain

What kind of pain is experienced in the 2nd stage of labor?

Somatic pain

Cesearean Birth labor pharmacological pain management?

Spinal and epidural anesthesia, general anesthesia

Pain impulses are transmitted via T:__ - T: ___ & L__ spinal nerve segment and accessory lower _____ and upper lumbar sympathetic nerves that originate from the uterus and cervix.

T:10-T:12 ; L1

Do opioids cross the placenta?

Yes

Anesthesia pain mx?

abolish pain perception by blocking the nerve impulses to the brain (epidural)

Spinal anesthesia or block is?

anesthetic injected into the subarachnoid space during the 2nd stage of labor or before c/s

Counter-pressure is?

massage to sacral area or hips with the heel of a hand or fist to relieve back pain caused by internal pressure of the fetal head

How long is the pain relief from systemic analgesia (opiods)?

only temporary

Analgesia pain mx?

the alleviation of the sensation of pain without the loss of consciousness (narcotics)