Lesson 10-Pain Management During Childbirth--TEST 2

psychosocial, physical

Pain can impact the mom's ________________ and _____________ functions

Phenergan

*** sometimes _______________ or Benadryl are given in conjunction to potentiate/increase the effects of Nubain or fentanyl

Decrease, increase, hypoxia, acidosis

**What will be the effects on the fetus?** Some drugs have a direct effect on the fetus. For example, when you administer an analgesic to a woman, what may happen to FHR? If I administer a narcotic, what will happen to the FHR? Some drugs have an indirect effect.If a drug causes hypotenstion to mom, the blood flow to the placenta is reduced, resulting in fetal __________ and __________ may result

10 minutes, 8 hours, 15, 30

-Frequency of assessments depends on stability of the patient =In an acute situation, assessment may be as often as every ______ ___________ or until pain goal is reached -At minimal needs, assessment should be done every _____ ________ -Laboring patient suggested every one hours -After an epidural placement, there is an assessment anywhere from _____ to _____ minutes after placement -Focus on determining any side effects form meds if administered or if more meds or another intervention is necessary

metabolic, oxygen, acidosis

-Labor increases a woman's _____________ rate and demand for _________. Pain and anxiety increases her already high metabolic rate. -These respiratory and metabolic changes after placental exchange significantly if they are persistent. The net result is ______________

Epidural anesthesia

-This involves the injection of local anesthetic and an opioid analgesic in to the lumbar epidural -Used for vaginal and cesarean section

General anesthesia

-This is Systemic pain control that causes loss of consciousness -C-section if contraindications to epidural or spinal anesthesia, emergent delivery, refuses regional anesthesia, inadequate pain relief form epidural or spinal anesthesia; used if spinal block and spinal anesthesia cannot be administered

Spinal anesthesia block

-This is a local anesthetic injected in the subarachnoid space which causes loss of sensory and motor function. -Used for scheduled cesarean sections and immediate prior to birth (c/s)

-Pain perception or threshold -Pain tolerance -analgesic -anesthesia -effeurage

-This is the lowest stimulus level perceived as painful -This is the highest/maximum pain one is willing to endure -Systemic agent to relieve pain -Loss of sensation -The rubbing of a woman's own abdomen, leg or back during labor to counteract discomfort

Pain

-This is the unpleasant sensory and emotional experience associated with actual or potential tissue change

Laboring down/nondirected pushing

-This term is referred to mom if she is fully dilated and baby is coming down to outlet. Have mom sit up and just have gravity help mom to come down so that mom doesn't work so hard to push Early decels could occur. Be mindful

differs

1.Child birth pain ___________ from any other types of pain Pain is Part of a normal childbirth process. It is important to let the mother know and support her through the pain. Atleast at the end of the pain, the mother will have something to look forward to and that is her baby. Having a baby and experiencing pain is a normal process of childbirth and it is important to let mother know and support mother through the pain

sensitivity, tolerate

2. Anxiety and fear -Influence the way mother experiences pain. Fear of unknown. If first time, it may be something mother may have never experienced. Mother may feel that the beginning labor is the worst pain but it only gets worse later in labor process -Mild or moderate anxiety can enhance attention and learning. However, high anxiety and fear magnify ______________ to pain and impair a woman's ability to ___________ pain

the cells that circulate in blood

2. Diagnostic lab test Ultrasound CBC -This test measures for ? -A mother's platelet count is also assessed

Breathing, preparation

2. Preparation time exists. -______________ exercises, having the pain of labor explained during classes and from other mothers can mentally prepare the mother for what is to come. -acquiring skills to help manage pain. Realistic ________________ and knowledge about the birth process help her develop skills to cope with labor pain

end, decrease

3. It's self limiting -Labor pain has a foreseeable _______ A woman can expect her labor to end in hours. Other kinds of pain may also be brief but the baby's birth brings a rapid _____________ in pain

primivara, painful

3. Previous experiences Second time moms may not feel as much pain compared to a _______________. But the woman having a second or higher vaginal birth may find late first stage and second stage labor to be more ______________ because the fetus descends faster

Administer IV fluids

A mother is having a hypotension episode. What can you do to relieve it?

intermittent, contractions

4. Labor pain is not constant, but _______________. Onset is slow, gradual, peak then decline. There is a relief of pain between the ________________. A mother can get relief from then. If pain is continuous, you must think of other reasons why and think of interventions

birth, baby,

5. Labor ends with the _________ of the _________. Some lingering pai may be there but the bulk of it goes away with the baby's birth.

full bladder

9. Monitor for distenstion of the bladder. 10. After epidural, mom doesn't know if her bladder is full which could interfere with the pushing of the baby and descent. ***Once a mom gets an epidural, a foley is inserted, no intermittent (in some hospitals) 11. A _________ _____________ interferes with baby descent

back, legs, ischemia

Causes of Labor Pain 1. First Stage of labor includes -(internal visceral pain located in the _______ and _______) -Cervical changes -Distention of the lower uterine segment -Contraction resulting in uterine ______________

before,

Childbirth classes -Helps mom prepare by giving them information about labor, including its painful aspects in childbirth classes. -Ideal time to prepare nonpharmacologic techniques is ____________ labor. -Mom can learn a variety of skills to use during labor. Her support persons learns specific methods to encourage and support her.

Phenergan reduces nausea and vomiting Pruritus-itching of the face and neck--Benadryl

Complications of Epidural opioids -Nausea and vomiting (What is given to treat this?) -Hypotension -Fever -Pruritus (What is this and what is given to stop this?) -Intravascular injection -Maternal fever -Allergic reaction -_______________ depression

M: GI aspiration*** respiratory depression*** uterine relaxation which can lead to postpartum hemorrhage** review methods to reduce adverse effects p. 298-300

Complications of general anesthesia includes:

platelets

Contraindications of epidural block: -Spinal cord injury -Spinal abnormalities -Coagulation defects (low __________) -Cardiac disease -Obesity -Infections -Hypovolemia

delay, treatment

Diagnostic lab test should not ___________ appropriate _____________ of pain

B/c it crosses the placenta and have an effect on the fetus. For example, Narcotics is given when the mother is 6cm. Now she's 8cm in less than an hour, this drug is going to affect the fetus by increasing its heart rate and affecting respiratory rate If you gave narcotic to baby, Do extra monitoring. Baby can be respiratory distress

Do not give narcotics close to delivery. Why?

Benadryl (diphenhydramine) Nubain (nalbuphine)

Given to treat pruritus

tactile,

Examples of gate theory that actually works: -__________ stimulation (applying pressure) -Hydrotherapy (pool) -Thermal stimulation -Acupuncture -Visual or auditory stimulation -Attention focusing and imaging or focal point -Implementing various -Breathing techniques

cleansing

First Stage Breathing Techniques -When a mother feels the beginning and ending of a contraction, instruct her to take a ______________ breath. -This breath eases tension -Breathing in the first stage pf labor consists of a cleansing breath and progressively more complex techniques of paced breathing if needed

lingering

Fourth Stage -Pain caused by _______________ symptoms from pain resulting from second stage of labor

Fetus will have a rise in baseline, become tachycardic, have late decels if mother is hypotension To treat mom, we will have rapid infusions of a non-dextrose IV solution such as LR or NSS before initiation of the block fills the vascular system to offset vasodilation If hypotension occurs and techniques such as rapid IV fluid bolus, maternal repositioning and oxygen administration is ineffective, IV ephedrine in 5-10mg increments promotes vasocontstriction to raise BP

Hypotension occurs within the first 15 minutes of epidural's initiation or injection of intermittent bolus. What will happen to the fetus? How can we treat the mom when this happens?

vaginal or c-sections

Labor Pain & Epidural Anesthesia Overview -Involves injection of local anesthetic and an opioid analgesic in to the lumbar epidural -60% of women receive an epidural in the U.S. -Given continuously throughout labor -Can be used for why type of procedures? -Can potentially increase the duration of 2nd stage of labor -Contraindications -Complications

Fentanyl (sublimaze) Morphine (morphine sulfate) Demerol (meperidine) Nubain (nalbuphine)

Narcotic Analgesics includes:

Gate-control theory

Non-pharmacological This theory proposes that local physical stimulation can interfere with pain stimuli by closing a hypothetical gate in the spinal cord, thus blocking pain signals from reaching the brain

Support patient during procedure*** -Assess fetal heart rate, ** -Monitor vital signs, -Monitor intake & output, -Monitor sensory or motor level, -Nursing care for spinal -Headache, ** -Corrective measures to reduce or alleviate complications or adverse affects

Nursing Interventions/actions that needs to be implemented for spinal anesthesia block

hypotension

Nursing Management for an epidural is VERY important Nursing Management 1. Monitor vital signs *You want complete set of vitals before epidural placement 2. Obtain/ review labs *Need to know platelet levels before giving epidural 3. Preventive measures for ______________ (COMMON ADVERSE RXN OF EPIDURAL ADMINISTRATION) 4. Support the client for placement 5. Help her into position for epidural placement 6. Monitor fetus 7. Manage side effects and/or complications as a result of the epidural 8. Mom becomes anxious because she didn't know/ is not use to the loss of feeling in legs

separated, conjunction

Nursing Management of Pain/ Application of Nonpharmacological techniques -Involves interventions to treat pain -Non-pharmacologic pain management can be used _____________ and/or in __________________ with pharmacologic pain management

right

Nursing implentations for general anesthesia -Monitor vital signs, assess fetal heart rate, make sure patient titled to ________ side with wedge (done on all C-section under to increase uteroplacental blood flow,(NO SPUINE HYPOTENSION) -Be prepared for a "depressed baby"-baby coming out limp and need some resuscitation measures

positioning

Nursing interventions for epidural anesthesia would include: -Monitor vital signs -Help patient maintain correct ________________ for procedure, -Check lab values prior to procedure -Corrective measures to reduce or alleviate complications or adverse affects -Evaluate intervention

subjective, personal

Pain is always what the client says it is -Pain is ______________ and ____________. -You never want to tell a p/t how they feel

ask,

Pharmacologic pain management -Move from non- pharmacologic to pharmacologic -Always _________ the laboring woman if has any preferences to pain management modalities -Ask mom's preferences because some mom do not want pharmacological implementations -Nurses' Promote safety

regional

Pharmacological methods for pain management include systemic drugs ___________ pain management techniques (block of pain in localized area with consciousness) and general anesthesia

oxygen, uterine contractions

Physiological effects -Excessive pain can heighten a woman's fear and anxiety which stimulates SNS, secreting NE and E . This results in reduced uterine blood flow, raising mom's BP. The combined effects of excessive NE and E in the blood will result in: 1. Reduced blood flow to and from placenta--decr. fetal ______ supply 2. Reduced effectiveness of ___________ _______________ , slowing labor -Fear and anxiety makes the pain feel much more worse and can put the fetus and mom in danger

anesthesia

Preparation -Preparation for childbirth does not ensure a pain-free labor. A woman should be prepared for pain realistically, including reasonable expectations about analgesia and _______________ (loss of sensation) Child birth classes, coping implementations

fear, anxiety

Preparation reduces ____________ and _________ of the unknown. It allows a woman to rehearse for labor and learn a variety of skills to master pain as labor progresses

tolerance, depleted

Psychological Effects -Women have a surprising high mental _____________ for labor pain -Factors whether mom has coping strategies or support to help ease -However, poorly relieved pain lessens the pleasure of this extraordinary life event for both partners -The mother may find it difficult to interact with her infant because she is ______________ from a painful labor

chronic pain

Risk Factors Women have a higher incidence of ____________ _________ when compared to men in general

descent, expulsion, lacerations

Second Stage -somatic pain occurring from fetal ___________ and ______________ -Pressure and distention of the reproductive and genital tract -Pressure and pulling on the pelvic structures -_______________ of the soft tissue

decrease, stretching, descent

Sources of Pain -Four sources of labor pain exist in most labors 1. Tissue ischemia *The blood supply to the uterus ________ during contractions. Ischemic uterine pain has been linked to ischemic heart pain 2. Cervical Dilation *Dilation and _______________ of the cervix and lower uterus are a major source of pain 3. Pressure and Pulling on pelvic structures *Some pain results from pressure and pulling on pelvic structures such as ligaments, Fallopian tubes, ovaries, bladder and peritoneum 4. Distention of the Vagina and Perineum *Marked distention of the vagina and perineum occurs with fetal ___________, especially during the second stage

ignored

Support system -An anxious partner will not be able to provide the support needed to the mother. -Anxiety is contagious. If partner is anxious, mom will be contagious -The birth experiences of a woman's family and friends cannot be _______________. Include them. Help mom to experience pai nand how to deal with it

1. Reduce myometrial hypoxia 2. Helps woman clear mind to focus on relaxing 3. Signals partner that a contraction is beginning

The cleansing breath does what to the mother:

ANS: C Epidural anesthesia may produce maternal hypotension due to vasodilation. The mother is prone to bladder distention and this needs to be monitored. However, this does not become a problem until 1 to 3 hours later. Continuous monitoring of the contractions is important because they may be altered by the epidural. However, this is not the most important nursing intervention after the epidural is administered. The intravenous infusion needs to be maintained before, during, and after the epidural. However, it is not the most important nursing intervention at this point.

The most important nursing intervention after the injection of epidural anesthesia is monitoring A. urinary output. B. contractions. C. maternal blood pressure. D. intravenous infusion rate.

M: -hypotension** -bladder distention** -anxiety** (mom loses feelings in the lower part of their body can cause anxiety attack which can be really bad—have support person in the room*, post-dural puncture headache (aka spinal headache) **NAUSEA due to hypotension---Can lead to fetal badycardia F: Fetal bradycardia

What complications of spinal anesthesia block can occur?

**-Refusal by p/t* **-coagulation issues/platelet issues -uncorrected hypovolemia, -infection at the injection site -systemic infection, allergy

What contraindications come from spinal anesthesia block?

Lidocaine, bupivacaine, fentanyl, duramorph

What drugs are included in a spinal anesthesia block?

Lidocaine, bupivacaine, Morphine or fentanyl

What drugs consists of epidural anesthesia?

-Prolong second stage** -Limits mobility; increase chance of instrument delivery, or augmentation w/ oxytocin can be given in any stage

What effects does epidural anesthesia have on labor?

Sodium Bicarbonate

These drugs are given to reduce gastric reflux

Narcan

These drugs are given to the mom, not the baby opioid antagonist used for the complete or partial reversal of opioid overdose, including respiratory depression

Zofran (ondansetron) Reglan (metoclopramide)

These drugs are given to treat nausea and vomiting

expulsion, pressure

Third Stage -_________________ of the placenta mimics 1st stage pain -Uterine contractions causes ______________ and pulling of the pelvic structures

Phenylephrine Ephedrine

This drug is given as a vasopressor given to correct hypotension induced form epidural

Post dural puncture headache/spinal headache, blood patch

This is a side effect of spinal anesthesia block. Its symptom includes a sharp H/A when sitting upright but it goes away when lying down. What is this and how can we treat it?

Pudendal Block

This is anesthetizes for the lower vagina and part of the perineum by injecting local anesthetic into the pudendal nerves near the ischial spines -Often used for vaginal birth especially those requiring instrumentation, and for episiotomy

Demerol (meperidine)

This is given to treat Shivering after anesthesia. (Rigors) given to correct process

Not much effect on labor since mother is having a C-section

What effects on labor do spinal anesthesia block have?

Newborn and postpartum maternal infections caused by microorganisms in the water

What is the major concern about home hydrotherapy?

General anesthesia

What will be the physiological/psychological effects? Some drugs will have systemic effects on pregnant woman and compared to nonpregnant woman -systemic loss of sensation and consciousness

-Coagulations defects; platelet deficiency*** -Uncorrected hypotension -Infection at the insertion site, -Allergy -Fetal condition that demands imminent birth -Spinal curvatures and tattoos evaluated individually

What are a few contraindications of epidural anesthesia

M: **Hypotension N/V **Pruritis, **Respiratory distress **Bladder distension Fever **Catheter migration Cesarean birth Shivering F: Fetal distress (hypoxia & acidosis), Changes in EFM

What complications can occur from epidural anesthesia?

Latent phase b/c woman is usually anxious enough to be attentive and interested and yet comfortable enough to understand

When is the best time for intrapartum teaching? Why?

mind

With gate-control theory, -To help relieve pain, implement some other form of pain/distraction to occupy mom's ________ on something else

Slow Modified Patterned

_________-paced breathing -With this type of breathing, the main focus promotes relaxation and oxygenation. Effleurage may help prolong the effectiveness of it ___________-paced breathing -Chest breathing at a faster rate and is shallower -Goal is to release tension ____________-paced breathing -Pant blow breathing -Woman exhales with a slight emphasis or blow and then begins the modified breathing -Relaxation is the goal