OB Ch15 Pain Management

Potential Adverse Side Effect of Controlled Breathing

Hyperventilation

PHARMACOLOGIC PAIN MANAGEMENT

-Requires the nurse to assess the woman's preferences for pain management throughout L&D. -Decision should be made by the woman in collaboration with her physician or midwife. -A risk vs. benefit analysis must be made when deciding what method of pain control is to be used.

Assessing Pain in the Laboring Woman

-Assessment of pain is an essential part of providing therapeutic nursing care and should include: 1. Standard 0-10 pain scale 2. Assessment of pain intensity, location, pattern, and degree of distress the woman is in. -The nurse has a professional as well as an ethical responsibility to advocate for the laboring woman and to support the decisions she has made concerning the use of various pain control methods.

Disadvantages of Epidural

-Can cause severe maternal hypotension leading to fetal hypoxia and acidosis. An IV fluid bolus prior to insertion of an epidural followed by continuous IV fluids is used to counteract this resulting hypotension. -Urine retention and inability to void usually requiring the use of a foley catheter or intermittent straight catheter -Weakness in lower extremities requires the woman to stay in bed. Patient safety is critical following an epidural and fall precautions must be implemented. -May slow the rate of labor and increases the likelihood for labor augmentation with Pitocin -May impair the woman's ability to push and require the use of forceps, vacuum, episiotomy, or c-section -Elevations in maternal temperature (for unknown reasons) that can be difficult to differentiate from fever associated with infection -Catheter migration resulting in absence of anesthesia, a unilateral block or even symptoms of intravascular injection such as a block that is too high and results in respiratory depression -Nausea, vomiting, and pruritis may be associated with epidural administration of opioids

Non-pharmacological Methods to Apply During Childbearing

-Childbirth preparation -Relaxation and breathing techniques -Hydrotherapy -Cutaneous stimulation (massage) -Mental stimulation -Presence of a support person

Combined Spinal Epidurals for Labor

-Consists of a combination of the two techniques and may be particularly beneficial for patients undergoing a cesarean birth. -Begins like the placement of an epidural catheter, but before the catheter is actually placed, a spinal needle is threaded through the Touhy needle and a dose of anesthetic (Marcaine or Fentanyl) is injected into the dura. Then the epidural catheter is placed and can be used following birth to administer a continuous dose of a long-acting opioid that will provide the woman with post-op pain relief. -Epidural catheter can be left in place for up to 72 hours following birth. -This method allows for rapid induction of anesthesia/analgesia.

What are the risks to the baby?

-Depends on the drug being used. -Can decrease fetal heart rate -Pain meds given to the laboring woman may cause sedation in the fetus or can even cause hypoxia and acidosis as a result of maternal hypotension.

What are the special considerations that need to be taken into account when deciding to medicate a pregnant woman?

-Drugs given to the mother will most likely affect the fetus (direct or indirect/secondary to drug effects on the mother). -Certain drugs may have a different effects when used in pregnancy -Drugs can affect the rate and length of labor (epidural block can slow progress during the second stage by reducing the urge to push) -Pregnancy complications may limit the choices of drugs that can be used (ex: if woman has heart disease, IV fluids could be detrimental). -Women who require other medications, use herbal or botanical preparations, or abuse drugs may have fewer safe choices in labor because of interactions between these substances and analgesics/anesthetics (ex: recent alcohol use increases depressant effects of opioid analgesics).

Nurse's Role in Nonpharmacologic Pain Management

-Education about nonpharmacologic pain management is the foundation of prepared childbirth classes -Nurse should know current methods of pain management taught in local childbirth classes, although they are often associated with medical rather than nursing interventions. -Don't teach her techniques that conflict with what she has learned and practiced as it may confuse her, however if her learned techniques are ineffective, explore other options with her.

Mental Stimulation

-Employs the use of focal points (i.e. picture of a loved one, pet, or stuffed animal), imagery, and music to distract the woman from pain and help her to concentrate on something outside her body. -With imagery, the woman is encouraged to bring into her mind a picture of a relaxing scene.

Physiologic Effects of Pain: Blood Flow

-Excessive pain heightens fear and anxiety, which stimulates SNS activity and results in increased secretion of Epi and NorEpi. These stimulate alpha and beta receptors. -Stimulated alpha receptors = uterine and generalized vasoconstriction and an increase in uterine muscle tone = reduce uterine blood flow as they raise maternal BP. -Stimulated beta receptors = relaxes the uterine muscle and causes vasodilation; vessels already dilated during pregnancy, so dilation of other maternal vessels allows the woman's blood to pool in them = reduces the amount of blood available to the fetus. -Combined effects are: (1) reduced blood flow to/from placenta, restricting fetal oxygen supply and waste removal, and (2) reduced effectiveness of uterine contractions, slowing labor progress.

Breathing Techniques

-Gives a woman a different focus during contractions, interfering with pain sensory transmission. -Begins with simple patterns and progress to more complex ones as greater distraction is needed. -No universal right time exists to change patterns during labor, however complex patterns are fatiguing if used for a long time. -For best results, should be practiced frequently but used only when needed, usually when a woman can no longer walk or talk during a contraction.

Childbirth Preparation

-Ideally, preparation occurs before labor, however reinforcing learned techniques is best done during the latent phase when she is attentive and comfortable. -Involves education and explanation of the birth process including pregnancy, painful aspects of labor and delivery, and possible methods for managing discomfort. -Usually provided in the form of a class attended by the woman and her partner during pregnancy. -Specific methods include: 1. Dick-Read: advocates birth w/o fear through education and environmental control and relaxation. 2. Lamaze: promotes psychoprophylaxis with conditioning and breathing. 3. Bradley: partner-coached childbirth support focused on managing the pain rather than attempting to be distracted from it.

Relaxation

-Improves uterine blood flow and improves fetal oxygenation -Promotes effective uterine contractions -Decreases maternal tension that can increase pain perception -Reduces muscle tension that can inhibit fetal descent What the nurse can do: -Reduce environmental irritants such as bright lights, uncomfortable temperature, and changing soiled underpads. -Provide accurate information and focusing on the normality of birth to help reduce anxiety and fear. Call her by name instead of "patient." -Give the couple choices which empowers the woman and her partner.

Physiologic Effects of Pain: Respiratory and Metabolism

-Increased metabolic rate and demand for oxygen = increased respiratory rate and excessive loss of CO2 = changes in PCO2 and PO2 alter placental exchange significantly if persistent. -Fetus may have less oxygen available for uptake and have less ability to unload CO2 to the mother. -Net result: fetus shifts to anaerobic metabolism, with buildup of hydrogen ions (acidosis). This type is metabolic and doesn't resolve as quickly after birth as respiratory acidosis, which results from shorter periods of hypoxia.

Spinal Anesthesia for Labor

-Inserted into the dura through the use of a spinal needle. -Administered as a one-time dose and generally cause a complete neuromuscular block at the level of insertion and below. -Often used when the length of time needed is known and limited, such as during a cesarean birth -Risks associated are similar to those observed with epidurals -Spinal headaches are an unpleasant (and not very common) side effect and may be caused when a slow, steady leak of spinal fluid following puncture of the dura occurs. These headaches can occur with epidurals (if the dura is accidentally nicked during the placement of the epidural catheter) but are much more common with spinal anesthesia.

What qualities differentiate pain in childbearing from other types of pain?

-It is part of a normal process -Preparation time exists -It is self-limiting with a foreseeable end -It is not constant and many women experience little discomfort between contractions -It ends with the birth of the baby

Cutaneous Stimulation

-Massage, effleurage (self-massage of the abdomen in time with breathing during contractions), thermal stimulation, and the application of counter pressure. -Counter pressure exerted to the woman's sacral area with the heal of the hand or fist to relieve the sensation of intense pain in the back caused by internal pressure of the fetal head. Often associated with posterior positioning of fetal head and is sometimes referred to as "back labor." -Thermal stimulation applied to the back, abdomen, or perineum is helpful during labor; increases local blood flow, relaxes muscles, and raises the pain threshold. -Remember, as labor progresses, the woman may not want to be touched.

Advantages of Epidural

-May be used for both vaginal and cesarean section deliveries -Has the potential to provide 100% pain block -Non-sedating allowing the woman to participate in the birth experience -Minimal risk to the fetus

Support Person

-May include a significant other and/or a doula (an assistant hired to give woman support during pregnancy, labor/birth, and postpartum) who provides emotional support and physical comfort. -Research shows that support early in labor significantly reduces maternal pain, improves overall outcomes, decreases interventions and complications, and improves maternal satisfaction.

Nursing Care Guidelines for Epidurals

-Nurses monitor, but do not manage, the care of women receiving epidural anesthesia. -Catheter dosing of intermittent and continuous infusion of regional analgesia/anesthesia is outside the scope of practice for the registered nurse. -Only qualified, licensed anesthesia providers should perform insertion, injection, and the increasing or decreasing of infusion rates of epidurals.

Psychological Effects of Pain During Childbirth

-Poorly relieved pain lessens the pleasure of the life experience. -Mother may find it difficult to interact with her infant because she is depleted from a painful labor. -Unpleasant memories of birth may affect her response to sexual activity or another labor. -Support person may feel inadequate and woman's partner may feel helpless and frustrated when her pain is not relieved.

Epidural Anesthesia for Labor

-Provides analgesia and anesthesia for labor and birth without sedation of the woman and fetus. -Performed by injecting a local anesthetic agent (to numb the skin at the insertion site) followed by the insertion of an epidural needle (Tuohy needle) into the epidural space. An epidural catheter is then threaded through this needle. The needle is removed but the catheter is left in place to allow the continuous infusion of local anesthetic (and possibly a rapid acting opioid) into the epidural space providing pain relief throughout labor.

How does culture influence pain perception and response during childbearing?

-Some cultures may accept loud, vocal expressions of pain -Others value a more stoic response -It is important for the nurse to be in tune to the patient's cultural beliefs -However, each woman is an individual and the nurse should avoid making assumptions based on culture. The laboring woman should be encouraged to express herself in whatever manner she finds comforting.

Factors That Impact a Woman's Perception/Response to Pain During Childbirth

-Strong contractions and rapid cervical dilation -If prelabor cervical changes (softening with some dilation and effacement) are not complete, the cervix does not open as easily and more contractions are needed -Large and/or poorly positioned fetus (ex: occiput posterior position pushes the fetal occiput against the woman's sacrum with each contraction) -Long labor, hunger, and late-pregnancy sleep deprivation leads to maternal exhaustion -Fetal monitoring systems and IVs cause discomfort -Culture influences pain response because pain behaviors tend to be culturally bound -A solid maternal support system can decrease maternal anxiety/fear and reduce pain perception. Excessive anxiety and fear decreases pain threshold and has negative physiologic effects on labor. -Previous birth experiences may have a (+) or (-) influence on pain -Childbirth prep can reduce maternal anxiety and fear of the unknown, and shape expectations

Woman are usually taught to-

-Take a deep "cleansing" breath at the beginning of the contraction -Breath slowly during the contraction -Finish the contraction with a final slow deep breath -As labor progresses, the woman may need to breathe in a more rapid and shallow pattern.

Hydrotherapy

-The use of water to promote relaxation -Shower, tub, or whirlpool -Benefit of tub or whirlpool is that the buoyancy provided by immersion in water supports the woman's body, relieving muscle tension and supporting relaxation -Also, fluid shifts from the extravascular space to the intravascular space, reducing edema as the excess fluid is excreted by the kidneys.

Potential Adverse Side Effect of Hydrotherapy

-There is a concern that immersion in water may place the woman and fetus at risk for infection from ascending bacteria present in the woman's vagina or an improperly cleaned tub. More research is needed.

Why are pharmacological methods generally not advisable during advanced labor?

-There is a limited amount of time remaining for the medications to take affect and there is the potential for respiratory depression in the newborn when medications are given too close to delivery.

What are the physiologic causes of pain in childbirth?

-Tissue ischemia and uterine contractions that lead to a decrease in blood supply to the uterus. -Dilation and stretching of the cervix and lower uterus results in stimulation of the nerve ganglia. -Pressure and stretching of the pelvic structures that leads to the pulling and expansion of the ligaments, muscles, and the peritoneum. This is a visceral pain and may be felt in her back and legs. -Distention of the vagina and perineum that occurs with fetal descent, especially during the second stages. She may describe the sensation as burning, tearing, or splitting (somatic pain).

General Anesthesia

-Used only in the case of an emergency c-section -Uses an IV injection and/or inhalation of anesthetic agents that render the patient unconscious. -Risks include: fetal depression, uterine atony, maternal vomiting and aspiration. -To reduce risk for vomiting and aspiration, the nurse should verify that the woman is NPO and she may also need to administer medication to decrease gastric acidity such as antacids (Bicitra) or PPIs (Protonix). -If a large bore IV catheter has not already been placed, one will be needed. -An indwelling urinary catheter will also be necessary. -Nurse may need to assist with supportive care of the newborn and consider the emotional needs of the woman's family, particularly if the cesarean was an emergency and if the outcome was not good.

NONPHARMACOLOGIC PAIN MANAGEMENT

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Categories of Pain Medication

1. Analgesia: a systemic agent that relieves pain without causing loss of consciousness 2. Anesthesia: an agent that causes loss of sensation, especially pain, with or without loss of consciousness. *Informed patient consent is a must whenever considering the use of either analgesia or anesthesia for a pregnant woman.

Patterns of Breathing

1. Cleansing Breath: deep inspiration and exhalation at beginning and end of contractions; helps to relieve tension 2. Slow-Paced Breathing:slow, deep breathing that increases relaxation; woman should concentrate on relaxing her body rather than regulating the rate of her breathing 3. Modified-Paced Breathing: chest breathing at a faster rate; used when slow-paced breathing is no longer effective 4. Patterned-Pace Breathing: aka Pant-Blow Breathing; involves focusing on the pattern of breathing and after a certain number of breaths, the woman exhales with a slight emphasis or blow and then begins the modified-paced breathing again. 5. Breathing to Prevent Pushing: helps to overcome the urge to push; woman uses shorts puffs when the urge to push is strong

Nerve Pathways

1. Pain source (contraction of uterus) 2. Pain messages move through peripheral nerves and up the spinal cord 3. Your brain interprets the messages as pain, including its location, intensity, and nature (burning, aching, or stinging) 4. Your brain sends pain-suppressing chemicals to the pain source and triggers other responses.

Types of Relaxation Techniques That Can Be Practiced Prior To Labor

1. Progressive relaxation: woman contracts and then releases specific muscle groups until all muscles are relaxed. 2. Neuromuscular dissociation: helps the woman learn to relax all muscles except those that are working (ex: the uterus or the abdominal muscles while pushing). 3. Touch relaxation: response to her partner's touch 4. Relaxation against pain: partner deliberatly causes mild pain and the woman learns to relax despite the pain

What are the two types of pain associated with childbirth?

1. Visceral: slow, deep, poorly localized pain typically described as dull or aching; associated with the first stage of labor as the uterus contracts and the cervix dilates. 2. Somatic: quick, sharp, and precisely located; often experienced late in first stage and during second stage of labor as fetus descends, placing pressure on the maternal tissues such as the perineum.

What are the advantages and limitations of non-pharmacological pain management during childbirth?

Advantages: -No side effects to the mother or fetus -No risk for allergy -Will not slow the progression of labor -May be the only realistic options for a woman who enters the hospital in advanced rapid labor Limitations: -Women do not always achieve their desired level of pain control using these methods alone.

Drugs Commonly Used With Labor Analgesia

Antiemetics -Promethazine (Phenergan): relieves N&V from opioids; potentiates effects of narcotics and may increase respiratory depression; dilute and infuse into a large vein to reduce the risk of tissue necrosis. Vasopressors -Ephedrine: corrects maternal hypotension related to epidural or spinal block Narcotic Antagonist -Naloxone (Narcan): reverses effects of narcotics; used to relieve maternal or neonatal respiratory depression from opioids (not barbs, anesthetics, nonopioid drugs, or pathologic conditions); MAY PRECIPITATE WITHDRAWAL IN OPIATE-DEPENDENT WOMEN OR NEONATES; shorter acting than most narcotics- so observe for recurrent respiratory depression; additional doses may be required.

What is the Valsalva maneuver?

Closed-glottis pushing causes recurrent increases in intrathoracic pressure with a resulting fall in cardiac output and BP = less blood is delivered to the placenta = fetal hypoxia that is reflected in non-reassuring fetal heart rate patterns.

How does the Gate Control Theory work during childbirth?

Due to the limited number of nerve pathways, only a limited number of sensations can travel along these pathways at a time. Therefore, according to this theory, an alternate stimulus can replace or block the travel of a painful sensation. In other words, application of a stimulus such as pressure, heat, or cold can close the gates thus limiting the transmission of painful stimuli.

Gate Control Theory

Model that proposes that a neural gate in the spinal cord (more specifically, the dorsal horn) can modulate incoming pain signals. The gate is opened and closed by messages from the brain, allowing or preventing some impulses from reaching the brain where they are recognized as pain. Stimulation of large-diameter nerve fibers in the skin blocks conduction of pain through small-diameter fibers, thereby "closing the gate" and decreasing the amount of pain felt.

Labor Analgesia: Regional Anesthesia (Epidural/Spinal Block)

Opioid: Sublimaze (Fentanyl- rapid acting) or Morphine (Duramorph-long acting) -Potential for RESPIRATORY DEPRESSIONS Local Anesthetic: Bupivacaine hydrochloride (Marcaine) ** Often epidurals involve the use of Marcaine plus Fentanyl (or another combination of local anesthetic and rapid acting opioid) mixed together and infused through the epidural catheter providing both anesthesia and analgesia from the level of the insertion site and below. However, it's important to note that epidurals may contain only marcaine or another local anesthetic agent. The technique is really dependent upon the anesthesia provider. **Intramuscular route is avoided during labor.

Pain stimuli from vaginal/perineal distention traven through the what nerve and enter the spinal cord at which segments?

Pudendal nerve; S2-S4

Labor Analgesia: Systemic (Intravenous)

Pure Opioids: meperidine (Demorol) and fentanyl (Sublimaze) -Produces a dysphoric rather than an analgesic effect (restlessness, irritability, twitching, jerking, shaking, etc.) -May cause maternal and neonatal central nervous system and respiratory depression, so SHOULD NOT be used close to delivery (within 1-2 hours). -Infrequently used for labor because it produces a long-lasting active metabolite, normeperidine, which as a half-life of 3-6 hours in the mother but 3+days in the newborn. Opioid Agonist-Antagonist: nalbuphine (Nubain) and butorphanol (Stadol) -Produce limited analgesic effects while blocking some opioid receptors, so may cause central nervous system and RESPIRATORY DEPRESSION as above, but can reverse analgesic effects of other opioids or PRECIPITATE WITHDRAWAL IN OPIATE-DEPENDENT WOMEN AND NEONATES. Check maternal history for opiate use. AVOID USE CLOSE TO DELIVERY. May be used to relieve pruritis associated with epidural narcotics.

Pain stimuli from cervical dilation enters the spinal cord at what segments?

T10 through L1