management of pain for second trimester dilatation evaluation d e abortion l.
Skip this Video
Loading SlideShow in 5 Seconds..
Management of Pain for Second-Trimester Dilatation & Evaluation (D&E) Abortion PowerPoint Presentation
Download Presentation
Management of Pain for Second-Trimester Dilatation & Evaluation (D&E) Abortion

Loading in 2 Seconds...

play fullscreen
1 / 20

Management of Pain for Second-Trimester Dilatation & Evaluation (D&E) Abortion - PowerPoint PPT Presentation

  • Uploaded on

Management of Pain for Second-Trimester Dilatation & Evaluation (D&E) Abortion Objectives State specific goals for pain management Describe different approaches and routes for pain control List pain medications commonly used in second-trimester procedures

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

PowerPoint Slideshow about 'Management of Pain for Second-Trimester Dilatation & Evaluation (D&E) Abortion' - adamdaniel

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
  • State specific goals for pain management
  • Describe different approaches and routes for pain control
  • List pain medications commonly used in second-trimester procedures
  • Choose appropriate and optimal medication combinations
goal of pain management

To help women remain as comfortable as possible, while minimizing medication-induced risks and side effects

Goal of pain management

first versus second trimester procedures
First- versus second-trimester procedures

More pain with D&E

  • Greater depth of uterine exploration and manipulation
  • Greater dilatation of cervix
  • Emotional factors

(Smith et al 1979; Belanger et al 1989)

choosing pain management
Choosing Pain Management

Factors to consider:

  • How severe will the pain be?
  • How long will the woman wait between taking the medication and having the procedure?
  • What systems are in place to ensure safe use of medications?
  • Don’t make assumptions regarding a woman’s perception of pain – ask her how she is doing.
choosing pain management6
Choosing Pain Management

Staffing needs:

  • Trained provider assigned only to pain management and support during the procedure
  • Should be knowledgeable about the medications’ pharmacology
  • Able to monitor vital signs/physical status and verbally support client
  • Trained in cardiopulmonary resuscitation
non pharmacologic approaches
Non-pharmacologic approaches
  • Verbal support
    • Person present during procedure dedicated to supporting the woman
    • Does not replace pain medications
  • Hot water bag/heating pad
pharmacologic approaches
Pharmacologic approaches
  • Local
    • Paracervical block
  • Oral medications
  • Intravenous medications
  • Intramuscular medications
paracervical block
Paracervical Block

10 to 20mL of 0.5 to 1% lidocaine

Inject 1 to 2mL at 12 o’clock

Place tenaculum through center of speculum grasping cervix vertically at 12 o’clock

Using tenaculum, gently pull cervix outward and to one side to expose lateral fornix for injection at junction of cervix and vagina

Insert tip of needle at 4 o’clock, aspirate, then slowly inject 2-5mL; repeat at 8 o’clock.

Inject to a depth of 2.5 to 3.8cm

Source: Ipas Woman-Centered Abortion Care Reference Manual

safety lidocaine dosing
Safety: Lidocaine Dosing

Maximum dose 4.5 mg/kg body weight

For a 40 kg woman this is 18-20 mL of 1% lidocaine

1% solution is 10 mg per 1 mL

15 mL of 1% is 150 mg of lidocaine

20 mL of 1% is 200 mg lidocaine

Most unsedated women given this dose report some effects: numbness around the mouth, ringing in ears, voices sound distant, and rarely, anxiety

(Blanco et al 1982)

lidocaine toxicity
Lidocaine Toxicity

To avoid toxicity:

Be aware of your client’s weight

Always aspirate before injecting

If blood is encountered (i.e. you are in a vessel), move needle and aspirate again before injecting

Know signs of toxicity/overdose: convulsions, then cardiovascular collapse

lidocaine toxicity13
Lidocaine Toxicity
  • Stop injection
  • Benzodiazepines raise seizure threshold and can be protective
  • Supportive care
    • Reassurance, administer oxygen, intubate if necessary (anesthesia consultation)
  • True lidocaine overdose: persistent seizures, cardiovascular collapse
    • If cardiovascular collapse, closed chest cardiac massage
pharmacologic approaches14
Pharmacologic approaches

Most women should receive one from each category:

  • Non-narcotic analgesics
    • Non-steroidal anti-inflammatory drugs (NSAIDS), like ibuprofen
  • Narcotic analgesics
    • Pethidine, morphine, or fentanyl
    • If IV not available, consider IM or oral narcotics
  • Anxiolytics
    • Benzodiazepines such as Diazepam
    • Helpful because they reduce anxiety and relax muscles
conscious sedation
Conscious Sedation

In addition to oral NSAIDs, the woman should receive one drug from each category:

Narcotic: initial doses

Pethidine 25-50 mg IV or 50-125 mg IM

Morphine 1-2 mg IV or 0.1-0.2 mg/kg IM

Fentanyl 50-100 mcg IV or 50-100 mcg IM

Anxiolytic (benzodiazepine): initial doses

Diazepam 2-5 mg IV or 10 mg PO

Midazolam 2-3 mg IV or 0.07-0.08 mg/kg IM

Lorazepam 2 mg IV or 0.05 mg/kg IM (maximum dose 4 mg)

conscious sedation16
Conscious Sedation

Administer each IV dose slowly, over 30-60 seconds

Monitor vital signs

IV medications effects are rapid in onset, but not instantaneous

Wait a few minutes after giving medications to begin the procedure

  • Respiratory depression caused by anxiolytics (benzodiazepines) and narcotics
    • Assist with breathing (oxygen, ambu bag) as needed
    • Administer reversal agents
  • Benzodiazepine sedation reversal
    • Flumazenil 0.2 mg IV over 15 seconds, then 0.2 mg every 1 minute as needed up to 1 mg total dose

Narcotic reversal

  • Naloxone 0.1-0.2 mg IV every 2-3 minutes as needed
quality assurance
Quality Assurance
  • Important to have emergency medications with dilutions/dosage information easily accessible
  • Check inventory of emergency medications regularly
  • Conduct emergency drills with staff
  • Need systems in place for adverse event monitoring and reporting