Ch. 13: Pain Management During Childbirth.pdf

Chapter 13: Pain Management During Childbirth Learning Objectives Compare childbirth pain with other types of pain Describe how excessive pain affects the laboring client and fetus Describe the use of pharmacologic and nonpharmacologic pain management in labor Describe the wa...

Chapter 13: Pain Management During Childbirth Learning Objectives Compare childbirth pain with other types of pain Describe how excessive pain affects the laboring client and fetus Describe the use of pharmacologic and nonpharmacologic pain management in labor Describe the way medication affects the client and fetus Explain the risks and benefits of specific pharmacologic pain relief Explain the nursing care of the client using pharmacologic and nonpharmacologic method of pain relief in labor Unique Nature of Pain During Birth Pain is subjective and personal. No one can feel another’s pain, and no two people will manage it the same Pain involves two components: 1. Physiologic a. Includes reception by sensory nerves and transmission to the central nervous system (CNS) 2. Psychologic a. Involves recognizing the sensation, interpreting it as painful, and reacting to the interpretation Childbirth pain differs from other types of pain: Part of a normal process- not related to illness or injury Purposeful Anticipated and expected Self-limiting Intermittent- not constant Ends with the birth of a baby Adverse Effects of Excessive Pain Although expected during labor, pain that exceeds a client’s tolerance can have distressing effects on both the client and the fetus. Physiologic Effects Excessive pain can heighten a client’s fear and anxiety, which stimulates sympathetic nervous system activity and results in increased secretion of catecholamines (epinephrine and norepinephrine) Catecholamines stimulate alpha and beta receptors, causing effects on the blood vessels and uterine muscles. ○ Stimulation of Alpha receptors ○ Causes uterine/generalized vasoconstriction ○ Stimulation of Beta receptors ○ Relaxes uterine muscle ○ Increase in the uterine muscle tone ○ Causes systemic vasodilation ○ Excessive catecholamine secretions ○ Reduced blood flow to/from placenta, restricting fetal oxygen supply and waste removal ○ Reduced effectiveness of uterine contractions, slowing labor progress ○ Pain & anxiety increase the patient's already high metabolic rate ○ Can Lead To Metabolic Acidosis Psychological Effects Clients have a remarkable threshold for labor pain. However, poorly managed pain lessens the pleasure of this extraordinary life event for both partners. The client may find it difficult to interact with the infant because of exhaustion from painful labor and may report the labor as traumatizing Variables in Childbirth Pain A variety of physical and psychosocial factors contribute to a client’s pain perception and response during labor Physical Factors Visceral Pain - ○ Slow, deep, poorly localized pain that is often described as dull or aching  ○ Dominates during first-stage of labor (as the uterus contracts and the cervix dilates) Somatic Pain ○ Quick, sharp pain that can be precisely localized ○ Most prominent during late first-stage labor and during second-stage labor as the descending fetus puts direct pressure on the client’s tissue Sources of Pain Tissue Ischemia The blood supply to the uterus decreases during contractions, leading to tissue hypoxia and anaerobic metabolism Ischemic uterine pain has been likened to ischemic heart pain Cervical Dilation Dilation and stretching of the cervix and lower uterus are a major source of pain Pain stimuli from cervical dilation travel through the hypogastric plexus, entering the spinal cord at the T10, T11, T12, and L1 levels Pressure & Pulling on Pelvic Structures Some pain results from pressure and pulling on pelvic structures such as ligaments, fallopian tubes, ovaries, bladder, and perineum This type of pain is visceral pain; a client may feel it as referred pain in the back and legs Distention of the Vagina & Perineum Marked distention of the vagina and perineum occurs with fetal descent, especially during the second stage The client may describe a sensation of burning, tearing, or splitting (somatic pain) Pain from vaginal and perineal distention and pressure and pulling on adjacent structures enters the spinal cord at the S2, S3, and S4 levels Factors Influencing Perception or Tolerance of Pain Labor Intensity The client who has precipitous labor may complain of severe pain with a more rapid onset because each contraction does so much work (effacement, dilation, and fetal descent)  Precipitous labor may also decrease options for adequate pharmacologic pain relief Cervical Readiness If cervical changes such as thinning, shortening, and softening prior to labor are minimal, the cervix does not open, or dilate, as easily or efficiently once labor begins. Can increase labor duration and result in greater fatigue Fetal Position Labor is likely to be longer and more uncomfortable when the fetus is in an unfavorable position in relationship to the birthing pelvis Some clients can deliver their fetus “straight” OP without difficulty; however, in other cases, the client may not be able to deliver the fetus until it rotates to the occiput anterior (OA) position A client who has an asynclitic fetus, meaning the head is tilted toward the shoulder and not in alignment with the birth canal, may also experience an insufficient labor pattern with increased discomfort with little to no cervical progress ○ Pain without progress is often more difficult to manage physically and mentally Pelvic Anatomy The size and shape of a client’s pelvis influences the course and length of labor Abnormalities and unique pelvic structure, such as a high pelvic arch or a narrow pelvic brim, may contribute to fetal malpresentation or malposition, resulting in a longer, more difficult labor Fatigue Fatigue reduces a client’s ability to tolerate pain and to use learned coping skills. Therefore, it is not only the pain of labor but the duration of labor that causes clients to lose their ability to manage pain effectively An extremely fatigued client may have an exaggerated response to contractions or may be unable to respond to sensations of labor such as the urge to push. The client’s energy reserves are likely to be depleted in a long labor Caregiver Interventions Although they may be appropriate for the well-being of a client and fetus, common interventions often add discomfort to the natural pain of labor  Intravenous (IV) lines cause pain when inserted A client whose labor is induced or augmented often reports more pain and discomfort Fetal monitoring equipment is uncomfortable to some clients, while others may find comfort in fetal heart rate sounds Interventions such as vaginal examinations, amniotomy (rupture of the amniotic membranes), or insertion of internal fetal or uterine monitoring devices also increase a client’s discomfort and perceptions of pain during the birth experience Psychological Factors Culture A client’s sociocultural roots influence the perception, interpretation, and response to pain during childbirth Some cultures encourage loud and vigorous expression of pain, whereas others value self-control Clients should be encouraged to express themselves in any way they find comforting, and the diversity of their expressions should be respected ○ Accepting a client’s individual response to labor and pain promotes a therapeutic relationship Race Racial and ethnic bias in health care, as well as disparities relating to maternal and infant mortality rates, may cause more fear and anxiety in clients of color This can lead to higher levels of fight-or-flight response in labor, increasing heart rate and blood pressure Anxiety & Fear Mild or moderate anxiety can enhance attention and learning. However, high anxiety and fear magnify sensitivity to pain and impair a client’s ability to tolerate pain. Anxiety and fear consume energy the client needs to cope with the birth process, including its painful aspects Can increase muscle tension, diverting oxygenated blood to the brain and skeletal muscles Prolonged tension results in general fatigue, increased pain perception or decreased pain threshold, and reduced ability to cope with pain Previous Experiences with Pain Learning about the normal sensations of labor, including pain, helps a client suppress natural reactions of fear and withdrawal, allowing the body to do the work of birth Preparation for Childbirth Preparation for childbirth does not ensure a pain-free labor, but it can encourage a positive perception and an enhanced ability to manage the pain. Labor is unpredictable, and it is ideal when the client has realistic expectations about pain management and options, such as analgesia and anesthesia. Preparation reduces anxiety and fear of the unknown. It allows a client to rehearse for labor and learn a variety of skills to cope with pain as labor progresses Support System An anxious partner may have difficulty providing the objective and subjective support and reassurance a client needs during labor. In addition, anxiety in others can be contagious, increasing the client’s anxiety and worry A doula is a professional labor support person and may be hired by the client as a source of support during pregnancy, labor, birth, and postpartum Clients who have continuous labor support have less interventions, have a decreased desire for pain medications, and are less likely to have an instrumental birth or a cesarean section Nonpharmacologic Pain Management The key word is management. Some clients will do well managing their pain using positional changes, breathing techniques, hydrotherapy, and other techniques, while others will not Advantages Does not slow labor No side effects or risk for allergy Unmedicated clients may feel the benefits of endorphin release from movement and frequent position changes May be only option during advanced, rapid labor Limitations May not achieve desired level of pain control Even a well-prepared and highly motivated woman may have a difficult labor and need analgesia or anesthesia Gate-Control Theory The Gate-Control Theory states that the transmission of nerve impulses is controlled by a neural mechanism in the dorsal horn of the spinal cord that acts like a gate to control impulses transmitted to the brain This mechanism opens or closes the “gate” to pain sensation by allowing or preventing some impulses from reaching the brain, where they are recognized as pain Pain is transmitted through small-diameter sensory nerve fibers Stimulation of large-diameter fibers in the skin blocks conduction of pain through small-diameter fibers, thereby “closing the gate” and decreasing the amount of pain felt Preparation for Pain Management The ideal time to prepare for nonpharmacologic pain control is before labor. Childbirth classes allow the opportunity to learn about a variety of coping mechanisms and prepare for the pain of labor The latent phase of labor is the best time for intrapartum teaching because the client is usually still relatively comfortable and able to engage, listen, and understand Most methods may become less comforting and effective (habituation) after prolonged use, and changing techniques counters this problem Knowing a variety of methods gives the nurse options and allows the client to feel more productive in managing the discomfort Application of Nonpharmacologic Techniques Relaxation Environmental Comfort Comfortable surroundings support relaxation, trust, and hormone release. A client needs an environment that exhibits feelings of safety and intimacy in order to suppress the fight-or-flight hormones, known as catecholamines  Reduce bright lights ○ Dim lighting increases the release of endogenous oxytocin Speak quietly and with intention ○ Allows client to move from a thinking brain to a more primal brain, increasing the ability to cope with pain Music ○ Music masks outside noise and courageous positive feelings and soothing imagery Aromatherapy ○Decreases anxiety ○ Nausea/vomiting relief ○ Pain relief ○ Aid in labor progression General Comfort & Dignity Promoting personal comfort and dignity for clients helps them focus on using pain management techniques during labor Client should be allowed to wear whatever feels comfortable (or nothing at all) Nurse should protect the client’s privacy and dignity at all times ○ Keep client covered ○ Maintain clean linens ○ Respect cultural & religious boundaries/expectations Reducing Anxiety & Fear The nurse may reduce a client’s anxiety and increase the pain threshold and self-efficacy by providing accurate information and focusing on the normality of the labor Establish trust ○ Listen to client’s hopes and expectations regarding birth experience Provide informed consent to clients Give client the ability to make choices that feel safe and necessary Specific Relaxation Techniques Progressive Relaxation ○ The client contracts and then releases specific muscle groups until all muscles are released Neuromuscular Dissociation ○ Helps the client learn to release all muscles except those that are working Touch Relaxation  ○ Relaxing in response to a partner’s touch Relaxation Against Pain ○ Partner deliberately causes mild pain and the client learns to release and relax despite the pain Cutaneous Stimulation Massage Massage increases the release of endorphins, promotes circulation, and reduces muscle tension Clients in labor may find firm stroking more helpful than light stroking With permission, the support person or nurse can rub the client’s back, shoulders, legs, or any area where massage is helpful Counterpressure Counterpressure, through sacral pressure, hip squeeze, or knee press, may help when the client has back pain Sacral pressure may be applied using the palm of the hand or a firm object A double hip squeeze is performed by placing palms on the client’s hips and pressing up and inward toward the symphysis Touch Nonclinical touch by the nurse or support person can be a powerful tool if the client does not object Eye-to-eye contact, holding the client’s hand, stroking hair, or similar actions convey caring, comfort, affirmation, and reassurance during this vulnerable time ○ Make sure to receive permission before touching a client Thermal Stimulation Warmth increases oxytocin release and local blood flow, relaxes muscles, and raises the pain threshold When using external heating devices, care should be taken to avoid burning the client’s skin. Cool, damp washcloths placed on the head, throat, or lower abdomen can provide comforting coolness if the client feels hot Acupressure Acupressure is a directed form of massage in which the support person applies pressure to specific points using hands, rollers, balls, or other equipment Acupuncture and acupressure have data to support effectiveness to relieve nausea and vomiting, including morning sickness of pregnancy, pain, anxiety, stress, headaches, and so on Hydrotherapy A shower, tub bath, or whirlpool bath is relaxing and provides thermal stimulation. Several studies have shown benefits of water therapy during labor, including immersion in a tub or whirlpool The buoyancy afforded by immersion supports and equalizes pressure on the body and aids muscle relaxation Clients who used water therapy effectively during the first stage of labor had decreased use of anesthesia, analgesia, decreased duration of labor, and improved satisfaction Mental Stimulation Mental techniques occupy the client’s mind and compete with pain stimuli. They also aid relaxation by providing a tranquil imaginary atmosphere. These techniques use the CNS control method, also known as “power of the mind.” Imagery Most clients find images of warmth, softness, security, and total relaxation comforting. Imagery can help the client dissociate from the painful aspects of labor Breathing Technique Breathing techniques give a client a different focus during contractions, interfering with pain sensory transmission and activating the parasympathetic nervous system The parasympathetic nervous system releases anti stress hormones, such as acetylcholine, prolactin, oxytocin, and vasopressin, helping a client to stay calm and relax First-Stage Breathing Breathing in the first stage of labor consists of a deep cleansing breath in through the nose and out through the mouth  Taking a Cleansing Breath ○ Each contraction begins and ends with a deep inspiration and expiration known as the cleansing breath. Like a sigh, a cleansing breath helps the client release tension It provides oxygen to help reduce myometrial hypoxia, one cause of labor pain Helps clients clear their mind to focus on relaxing Slow-Paced Breathing ○ Slow, deep breathing increases relaxation It lowers their heart rate and blood pressure, and redirects blood flow away from the locomotive muscles and toward digestive and reproductive organ Can increase the release of endorphins, activating the immune system and creating sleepiness or a “dream-like” state in clients Breathing to Prevent Pushing ○ If a client begins pushing before the cervix is completely dilated, it increases risk of cervical edema and injury to the cervix and fetal head. ○ Blowing prevents the closure of the glottis and breath holding, creating pressure on the pelvic floor Overcoming Common Problems ○ Hyperventilation and mouth dryness are common when breathing techniques are use Encourage client to slow down their breathing Eye-to-eye contact and modeled deep breathing can help Second-Stage Breathing Care in the second stage of labor encourages a physiologic completion of labor, assisting the client to respond to their urge to push rather than directing them to push as soon as the cervix is completely dilated Closed-glottis pushing (Valsalva pushing) causes recurrent increases in intrathoracic pressure with a resulting fall in cardiac output and blood pressure Pharmacologic Pain Management Pharmacologic methods for pain management include: Systemic medications Regional pain management techniques (blockage of pain in localized area without loss of consciousness; includes neuraxial anesthesia—epidural and spinal blocks)  General anesthesia (the loss of consciousness and protective reflexes) Effects on the Fetus Before administering medications to a pregnant client, it is important to be prepared for the effects the medicine may have on the fetus Effects on the fetus may also be indirect, or secondary to medication effects in the clients Physiologic Changes There are six body changes in the pregnant client that have the greatest implications for pharmacologic pain management methods Cardiovascular Changes Compression of the aorta and inferior vena cava by the uterus can occur when a client lies in the supine position (aortocaval compression) ○ If the client must be in the supine position temporarily, the uterus should be displaced to one side with either a pillow or a towel roll under one hip. Respiratory Changes A full uterus reduces the functional residual respiratory capacity of the lungs ○ To compensate, the client breathes more rapidly and therefore is more vulnerable to reduced arterial oxygenation Edema caused by pregnancy may also present in the upper airway, causing difficulty if the client must be intubated GI Changes During pregnancy, the normal release of progesterone slows peristalsis and reduces the tone of the sphincter at the junction of the stomach and esophagus ○ These changes make a pregnant client vulnerable to regurgitation and aspiration (inhalation) of gastric contents during general anesthesia Nervous System Changes During pregnancy and labor, circulating levels of endorphins and enkephalins, natural substances with analgesic properties, are high ○ These substances modify pain perception and should reduce requirements for analgesia and anesthesia.  The epidural and subarachnoid spaces between the arachnoid mater and pia mater are smaller during pregnancy, enhancing the spread of anesthetic agents used for epidural blocks or subarachnoid blocks (SABs) Cerebrospinal fluid (CSF) pressure is higher during contractions and when the client is pushing Nerve fibers are more sensitive to local anesthetic agents during pregnancy ○ A reduced amount of analgesics and local anesthetics is needed to achieve satisfactory pain management with either an epidural block or SAB Obesity These clients are at increased risk for obstetric, anesthetic, neonatal, surgical, and postoperative complications. Cardiovascular changes may become even more pronounced, and an increased incidence of hypertension may occur Breathing may be more difficult due to the decrease in chest wall and lung compliance Obese pregnant clients are at increased risk of pulmonary aspiration Obese laboring clients have increased gastric volumes, a higher incidence of gastroesophageal reflux (GERD), and hiatal hernias Advanced Age For each 5-year increase in client age beyond 34 there is a linear upward trend in the potential complications. The increased risks were often related to cardiac compromises, vascular issues, coagulopathies, and other medical conditions Effects of the Course of Labor Epidurals may actually help labor progress in the second stage by relaxing the client’s muscles Studies suggest the early onset of severe pain and the need for more analgesia are a better predictor of abnormal labor and delivery by cesarean section Effects of Complications Local anesthetics may cause antisympathetic effects, which lead to vasodilation once the medication starts to take effect  In order to offset the hypotension that is often experienced, a large volume of intravenous fluid is infused prior to or with initiation of epidural placement ○ With certain medical conditions, such as preeclampsia or cardiac disease, large fluid boluses are contraindicated and may cause pulmonary edema If the coagulation values are low, the client may develop a hematoma at the site of the introducer needle, thus leading to possible paralysis if not identified timely Interactions with Other Substances Clients on certain medications, illicit drugs, or herbal supplements may have fewer pain management options because of interactions between these substances and analgesics or anesthetics Recent alcohol, marijuana, or narcotic use increases the depressant effects of some analgesics and sedatives, making both the client and the newborn susceptible to respiratory depression Clients taking pain medications may require a higher dose of opioid analgesics, and this can make postoperative pain management challenging Illicit drugs, such as cocaine, may cause cardiac collapse once the local anesthetics take effect Systemic Medications for Labor Nitrous Oxide (“Laughing Gas”) Increases feeling of well-being Decreases pain and anxiety May be used independently, before regional anesthesia administration, or in combination Does not enter the bloodstream Excreted via lungs Side effects ○ Nausea ○ dizziness ○ Vomiting Parenteral Analgesia Opioid analgesics are the most common parenteral medications given to reduce perception of pain and can be used to promote therapeutic rest during an unusually long labor.  Parenteral analgesics often used for labor include morphine, fentanyl (Sublimaze), butorphanol (Stadol), remifentanil, and nalbuphine Opioid Agonist-Antagonists Butorphanol (Stadol) Nalbuphine (Nubain) A client who is dependent on opiates, such as narcotics and heroin, should avoid agonist–antagonist medications because they may cause withdrawal effects for the client and newborn Agonist–antagonist drugs have a “ceiling effect” on the amount of analgesia they provide and may not be suitable for the increasing pain of labor Side Effects ○ Respiratory depression ○ Vomiting ○ Nausea ○ Dysphoria Since opioids cross the placenta, they are likely to affect the newborn ○ An infant born during the drug’s peak is more likely to have respiratory depression Opioid Antagonists Naloxone (Narcan) ○ It reverses opioid-induced respiratory depression ○ It does not reverse respiratory depression from other causes such as normeperidine, benzodiazepines, nonopioid drugs, anesthetics or pathologic conditions Can cause an opiate-dependent client/newborn to have withdrawal symptoms Airway management takes precedence over naloxone usage Adjunctive Medications Ondansetron (Zofran) Promethazine (Phenergan) Metoclopramide (Reglan) These medications are given to reduce nausea and anxiety and to promote rest ○ Although they are frequently given, both promethazine and metoclopramide may cause both psychological effects and decreased cardiac output Metoclopramide (Reglan) increases gastric motility, reducing nausea and vomiting  ○ It may also cause hypotension, drowsiness, and the feeling of impending doom. Sedatives Diazepam (Valium) Midazolam (Versed) Lorazepam (Ativan) A small dose of a short-acting benzodiazepine may be given to promote rest if a client is fatigued from false labor or a prolonged latent phase ○ They cause prolonged depressant effects on the neonate Birth Analgesics Local Infiltration Anesthesia Infiltration of the perineum with a local anesthetic is performed before an episiotomy or perineal repair if the client doesn’t have an effective epidural Advantages Does not alter contractions or vaginal distention Rarely has adverse effects on either mother or infant Disadvantages Burns as it is injected Regional Pain Management Techniques Regional pain management includes pudendal blocks, epidurals, spinals (SABs), combined spinal–epidurals, and continuous spinals. Advantages Safest forms of analgesia for client and fetus Provides pain relief without loss of consciousness in the client ○ Allowing the client to be fully present for the birth experience Pudendal Block A pudendal block anesthetizes the lower vagina and part of the perineum  It is often used to provide anesthesia for an episiotomy and vaginal birth, especially one that requires using low forceps The pudendal block is a highly localized type of regional block, like a dental anesthetic provides numbness for dental procedures Disadvantages Does not block pain from uterine contractions The client will feel pressure Possible complications: ○ toxic reaction to the anesthetic ○ rectal puncture ○ Hematoma ○ Sciatic nerve block Neuraxial Anesthesia Epidural blocks, SABs or spinals, continuous spinals, and combined spinal–epidurals (CSE) are all placed and managed by an anesthesia provider, either an anesthesiologist or a certified registered nurse anesthetist (CRNA) Epidural Block The lumbar epidural block is a popular regional block that provides analgesia and anesthesia for labor and birth It is used for both vaginal and cesarean section births Performed by injecting a local anesthetic agent, often combined with an opioid, into the small epidural space Advantages Can be extended upward Does NOT sedate client or fetus Provides substantial relief of pain from contractions and birth canal distention Adequate pain relief without complete motor block Technique Potential The client’s back should be curved outward (like an angry cat) for epidural placement ○ This is achieved in a sitting or side-lying position In the sitting position, hugging a pillow or small birth ball helps the client hold the correct position The epidural space is created at the L3–L4 interspace (below the end of the spinal cord), and a catheter is passed through the needle into the epidural space  ○ The catheter allows for continuous or intermittent injection of medication to maintain pain relief during labor and vaginal or cesarean birth ○ The infusion of epidural medication during labor may be regulated by a patient-controlled epidural analgesia (PCEA) pump ​ Potential Complications Intravascular Injections If the test dose reaches the bloodstream, an immediate elevation in the client’s heart rate is notes ○ Signs of an intravascular injection include: Numbness of the tongue and lips A metallic taste in the mouth Lightheadedness/dizziness Tinnitus A feeling of impending doom If the test dose reaches the subarachnoid space instead of the epidural space, the client experiences rapid, intense motor and sensory block (loss of sensation) Dural Puncture If the dura is unintentionally punctured with the needle used to introduce the epidural catheter, leakage of CSF will most likely occur, which may result in a postdural puncture (PDPH or “spinal”) headache C/I & Precautions Contraindications include: ○ increased intracranial pressure secondary to a mass lesion ○ client refusal or inability to cooperate during the regional placement ○ uncorrected coagulation conditions ○ uncorrected hypovolemia ○ an infection in the area of insertion ○ a severe systemic infection (sepsis) ○ a fetal condition that demands immediate birth Adverse Effects of Regional Anesthesia Hypotension Sympathetic nerves are blocked along with pain nerves, which may result in vasodilation and hypotension This hypotensive state has the potential to interrupt the fetal oxygenation pathway by reducing placental perfusion causing indeterminate or abnormal FHR tracings Bladder Distention A client’s bladder fills quickly because of the large quantity of IV solution, but the sensation to void is reduced by regional anesthesia Bladder distention may cause pain that remains after initiation of the block and may interfere with fetal descent in labor Prolonged Second Stage Delayed pushing is often intentional for second-stage labor, and the urge to push may be less intense for the client who has an epidural block, particularly if the motor block is dense Pelvic muscles may be relaxed, which can interfere with the mechanism of internal rotation The frequency and intensity of uterine contractions may also decrease during second stage due to regional anesthesia Maternal Fever The fever associated with epidural analgesia is usually not caused by infection but may result from the reduced hyperventilation and decreased heat dissipation, for example, reduced sweating, which can occur when the client’s pain is relieved Shivering Shivering is common in labor and sometimes is associated with neuraxial anesthesia Warmed fluids and distraction are helpful interventions to decrease shivering If the shivering becomes excessive and uncomfortable, and the delivery is not eminent, the client may be given IV meperidine (Demerol) in small doses to the desired effect Catheter Migration Due to epidural venous engorgement, the epidural catheter may move out of the original space after placement  Interventions may include a bolus dose, client repositioning, or readjusting the epidural catheter ○ If these interventions fail, the epidural catheter may need to be replaced Neuraxial Opioid Analgesics Epidural injection of an opioid analgesic provides another option for pain management. The drugs bind to opiate receptors, allowing much smaller doses than would be adequate if given systemically Morphine (Duramorph) Advantages Rapid pain relief Less risk on fetus Decreased dose of local anesthetic Produces sedating effect with relaxation without halting labor Adverse Effects Nausea/vomiting Pruritus Delayed respiratory depression Intrathecal Opioid Analgesics Intrathecal (Subarachnoid) injection of an opioid analgesic provides another option for pain management without sedation. The medications bind to opiate receptors, allowing much smaller doses than would be adequate if given systemically or through the epidural Advantages Much smaller doses than if given systemically Woman can feel her contractions Rapid onset of pain relief without sedation No increase in motor block- can ambulate during labor  No sympathetic block Less risk of fetus Disadvantages Limited duration of action Inadequate pain relief for late labor and the birth Adverse Effects Nausea/vomiting Pruritus Subarachnoid (Spinal) Block (SAB) The SAB, or spinal, is a much quicker procedure than the epidural block and may be performed when a quick cesarean birth is necessary and an epidural catheter is not in place Similar to local infiltration and pudendal block Performed just before birth, providing no pain relief during most of labor Advantages Simpler procedure than the epidural block May be performed when a quick cesarean birth is necessary and an epidural catheter is not in place C/I & Precautions Similar to epidural blocks Increased intracranial pressure secondary to a mass lesion Client refusal or inability to cooperate during placement Uncorrected coagulation conditions Uncorrected hypovolemia Infection Fetal condition requiring immediate birth Nursing Considerations Similar to client with epidural Administer vasopressors prior to offset hypotension (if ordered) Adequate IV hydration prior to SAB Vital signs every 5 minutes for 30 minutes or per agency guidelines If c/section, vital signs every 5 minutes until end of surgery Combined-Spinal Epidural (CSE) Blocks A combined spinal–epidural (CSE) allows for rapid pain relief and the ability to provide ongoing pain relief with additional anesthetics, which can be injected through the epidural catheter Quick onset Access to epidural catheter to provide additional anesthesia Continuous Spinals Catheter is less likely to migrate decreasing “hot spots” Placement similar to CSE Risks similar to spinal General Anesthesia General anesthesia is a systemic pain control method involving both loss of consciousness and loss of protective reflexes Some clients either refuse or are not good candidates for either the epidural block or SAB for cesarean birth, and, occasionally, a planned epidural block or SAB proves to be inadequate for surgical anesthesia Rarely used for vaginal births May be needed unexpectedly and quickly for emergency procedures at any stage of pregnancy Adverse Effects  Failed intubation ○ The failed intubation rate in pregnancy is 10 times higher than in the nonpregnant population Aspiration ○ Regurgitation with aspiration of acidic gastric contents is a potentially fatal complication of general anesthesia. Adverse reaction to med ○ Anaphylaxis ○ Malignant hypothermia ○ Respiratory depression ○ Magnesium sulfate (increased risk of bleeding) ○ Uterine relaxation Methods to Minimize Adverse Effects Accurate history/screening prior to administration Restrict intake to clear liquids Administer meds to increase gastric pH and emptying Sellick’s maneuver (cricoid pressure) Reduce time from induction to clamping of cord Minimize administration of sedating meds and anesthetics until cord is clamped Application of the Nursing Process Pain Management Assessment ○ Labor status Identification of patient problems Planning ○ Pain is subjective. ○ Outcomes need to be realistic. Interventions ○ Promoting relaxation ○ Reducing outside sources of discomfort ○ Reducing anxiety and fear ○ Helping the woman use nonpharmacologic techniques ○ Incorporating pharmacologic methods ○ Patient teaching Evaluation Epidural Analgesia Assessment Identification of patient problems Planning Interventions ○ Maternal hypotension ○ Avoidance of injury Evaluation Respiratory Compromise Assessment Identification of patient problems Planning Interventions ○ Identifying risk factors ○ Reducing risk for aspiration or lung injury ○ Perioperative care ○ Postoperative care Evaluation