2145 Pharmacologic Management of Childbirth Pain

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What are some psychosocial aspects of childbirth pain?

1. As with all pain 'perception is reality'
2. Women experience birth in the context of their entire life
3. Perception is a blend of the physical & psychosocial
4. What birth stories has the mother heard?
5. What is she telling herself?

What are the adverse effects of excessive pain (5)?

1. stimulates sympathetic nervous system --> results in ↑ secretion of catecholamines
2. uterine vasoconstriction = ↓decreased blood flow to and from placenta
3. tenseness of uterine muscle = ↓ effectiveness of contractions
4. Hyperventilate
5. Exhaustion
Help by talking calmly, massage

What is the physiological basis of labor pain stage 1 (4)?

1. Uterine contractions- cervical effacement, dilation, uterine ischemia
2. Pain impulses transmitted via spinal nerve segment T11-12
3. Also accessory lower thoracic nerves
4. Also upper lumbar sympathetic nerves

What is the physiological basis of labor pain stage 2?

Stretching of perineum
-traction on perineum and uterocervical supports during contractions
-expulsive forces/ pressure from baby on other pelvic structures
-pain transmitted S1-4/ parasympathetic system from perineal tissues

What are some analgesic administraction principles for laboring patients?

First check insitutional policy
IV adminstration within scope?
Assess both mom and fetus first
Give slow over 3 mins, dilute to facilitate the slow delivery
Monitor mom and fetal rx during and after adminstration, be ready to take action
Goal is to decrease pain
What is the OPD of the med?
S/E? S/S of OD? Nursing interventions?
Many meds its antidote is narcan, naloxone
Timing of birth is critical to avoid respiratory depression in the infant- if infant born before 4 hours have passed risk is present

Stadal (Butorphanol)

Opioid analgesic
Dose: 0.5-2 mg IV/IM, repeat in 3-4 hours
Onset: 2-10 mins IV, IM longer
Duration: 3-4 hours, 'time' of birth
has some narcotic antagonist effects- do not give to opiate dependent women*
S/E: N/V, sedation, dizziness, confusion, HA, insomnia
FHR considerations- transient pseudosinusoidal

Nubain (Nalbuphine)

Dose: 10-20 mg q 3-6 hrs IV, Subq, IM
Onset: 2-3 min IV, IM <15 min
Duration: labor 2-3 hrs, compare to Morphine
Has some narcotic antagonist effects- do not give to opiate dependent women*
S/E: may cause resp. depression in the newborn
FHR- transient pseudosinusoidal pattern

Talwain (Pentazocine)

Opioid agonist
SE: sedation, dizziness, shock, respiratory depression
Do not give to pts w/ hx of abuse
Time delivery of infant to prevent respiratory depression
Labor- 30 mg dose IM or 20 mg IV given 2-3x q 2-3 hrs

Meperidine (Demerol)

Opioid analgesic
Dose: OB analgesia- 50-100 mg IM, SC in active labor may repeat q 1-3 hrs
- Adverse reactions: BRADYCARDIA, RESPIRATORY DEPRESSION/ARREST
- Nursing intervention = Narcan
- timing of birth critical to avoid respiratory depression in infant (>4hr)
- monitor mom & fetus -->cervical check, LOC, VS, FHR patterns before during & after administration
IV diluted given slowly over 3 minutes
St. johns wart increases sedation
'Old med' thats a 'poor' choice

Epidural Anesthesia (4)

Action achieved by:
1. Local anesthetics acting on nerve fibers as they cross the epidural space (L3-L4) causing sensory blockade
2. Narcotics crossing the dura into CSF and binding to opiate recepors in the dorsal horn of the spinal cord
"Pharmacological sympathetctomy"- decrease BP (vasodilates)
3. Ideally give in active labor 4-7cm or just prior to C/S
4. Continuous infusion

What are some risks of epidural anesthesia (10)?

1. possible maternal hypotension (lethargic, dizzy, weak, confused) that could lead to decreased placental flow and fetal distress. prevent by giving 1-2L bolus before epidural, positioning & monitor VS
2. inadvertent puncture of the dura (vs. epidural)
3. spinal or high spinal
4. resp. depression
5. research= does not lengthen labor
6. toxic rx/ seizures
7. Improper placement
8. Migration of catheter (should have black tip on end)
9. Spinal HA
10. too much = cannot move or push

What are some benefits of the epidural (2)?

1. Excellent pain relief while being awake and alert
2. improved intervillous blood flow in PIH (vasoconstriction) patients b/c epidural vasodilates

What are some contraindications for an Epidural (7)?

1. Coagulation disorders/ anticoagulation therapy--Heparin
-Platelets <75,000 always notify if <150,000- MD makes call
2. Local infection at site
3. Major abnormalities of the spine (spina bifida)
4. Maternal hypotension/shock
5. Nonreassuring FHR pattern- birth now
6. Diseases of nervous system
7. some tattoo (red ink)

What is supine hypotension- term pregnancy (2)?

1. Uterus pushes on the inferior vena cava decreasing venous return to the mother
2. As a result mothers BP drops

What is maternal hypotension after epidural & how do you monitor?

1. Monitor BP, P, O2, q 5 mins for 1st 30 mins of adminstration- expect anesthesia to stay 1st 15 mins
2. Prevent potential injury by giving 1000cc LR prior to block
3. If hypotension occurs:
-increase 'plain' IV solution over the current rate
-be sure maternal position is sidelying
-evaluate fetal response- take action prn
-contact MD, be ready w/ Ephedrine (brings BP up) 5 mg slow IVP, monitor pts response, if hypotension continues contact MD

What should you do if maternal hypotension occurs after epidural (4)?

1. increase 'plain' IV solution over the current rate
2. be sure maternal position is sidelying
3. evaluate fetal response- take action prn
4. contact MD, be ready w/ Ephedrine (brings BP up) 5 mg slow IVP, monitor pts response, if hypotension continues contact MD

What are some rare complications and nursing actions for an epidural (3)?

1. Spinal catheter inadvertantly punctures dura- best if catheter withdrawn by anesthesia
2. Subarachnoid placement (too high in vertebra): inadvertant: hypotension, ascending paralysis, pt will need resp. support (crash cart)
3. Toxic rx: inadvertent IV injection of anesthetic: tinnitus, drowsiness, disorientation, SEIZURE, may need respiratory support

What is Duramorph and Astromorph (5)?

1. Spinal Opiates
2. Used for relief of post-op pain C/S- given during C/S by anesthesia
3. Therapeutic effect: high concentration of narcotic receptors along spinal cord brain stem and thalamus: 4. small quanitity of narcotics lasts a long time (24hrs)
5. Pts experience much less post-op pain, are able to ambulate and care for infant

What are some potential Complications and nursing actions of spinal opiates (5)?

1. Resp depression: monitor RR for 24 hours if <12/min notify MD, Narcan IV is antidote but then pt. will be in pain
2. N/V: antiemetics comfort measures
3. Pruritus: Benadryl, comfort measures, cold compress
4. Urinary Retention: assess for and tx prn
5. Keep IV and foley in for 24 hours post C/S
Monitor I&O

What are 4 sources of labor pain?

1. Tissue ischemia = ↓ blood supply to uterus
2. cervical dilation
3. pressure on pelvis structure
4. distention of vagina and perineum

6 factors influencing tolerance of pain

1. intensity of labor
2. cervical readiness, pre-labor preparation
3. fetal position - anterior vs. posterior
4. characteristics of pelvis
5. fatigue/hunger
6. intervention of caregivers = IVs, VE, fetal monitors

5 psychosocial factors that effect pain perception

1. culture
2. anxiety/fear
3. previous experiences with pain
4. preparation for childbirth
5. support system

What are 4 narcotics for pain?

1. Nubain (nalbuphine)
2. Meperidine (Demerol)
3. Stadol (Butorphanol)
4. Talwin (Pentazocine)

What is subarachnoid (spinal) block?

1. simpler to give than epidural
2. given just prior to birth
3. one time admin

What are 3 adverse reactions to a spinal

1. maternal hypotension
2. bladder distention
3. postdural puncture headache (spinal HA) = cerebral spinal fluid leakage at puncture site

What are 4 treatments for spinal headache?

1. bed rest = lay down, sitting up may ↑ HA
2. oral fluids
3. IV hydration
4. blood patch: 10-15mL of woman's own blood injected into epidural space

how do you monitor a patient who was given Duramorph?

1st 12 hours q 1 hr
2nd 12 hours q 2 hr

What is a Pudendal block (5)?

1. anesthetizes lower vagina/perineum
2. used for episiotomy or forcep delivery
3. does not block pain from UC
4. anesthetic injected into pudendal nerves near ischial spine
5. maternal complications: rectal puncture, hematoma sciatic nerve block, toxic reaction

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