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Pain Relief During Labor - PowerPoint PPT Presentation


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Pain Relief During Labor. Lecture 7. Principles of Pain Relief. Treatments for pain relief during labor depends on: 1. client’s tolerance for pain 2. ability to focus on labor 3. ability to remain motivated. Some of labor process done @ home:

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slide2

Principles of Pain Relief

Treatments for pain relief during labor depends on:

1. client’s tolerance for pain

2. ability to focus on labor

3. ability to remain motivated.

Some of labor process done @ home:

aromatherapy, warm bath, music, visualization, breathing exercises,

massage. hypnosis, acupuncture. ~ 70% clients ask for epidural

Method of Pain Relief Should Exhibit:

  • Simplicity
  • Safety
  • Preservation of fetal homeostasis

Monitor client closely: B/P, Pulse, RR, FHR, anesthetic levels,

maternal oxygenation.

slide3

Analgesia and Sedation During Labor

Analgesia: loss of sensitivity to pain.

  • Pain meds can be sufficient to get through labor along with: aromatherapy, music, visualization, etc.
  • Systemic drugs - 3 factors to consider
    • effects on mother
    • effects on fetus - all systemic drugs cross placenta by simple diffusion.
    • Fetal liver & kidney function immature, drugs metabolized slowly & effects last longer
    • Affect progress of labor; can slow labor.
slide4

Assessment

  • Maternal assessment
    • informed consent ; VS stable
  • Fetal assessment
    • FHR 110-160/min with no late/variable decels.
    • Variability average.
    • Normal fetal movement and accelerations present.
    • Term Fetus
    • No Meconium
  • Labor assessment
    • Contraction pattern well established.
    • Cervix 4-5 cm dilated in primips and 3-4 in multips
    • Progressive descent of presenting part
    • no complications
    • Delivery at least 2-3 hours away.
slide5

Narcotic Pain Relief:

Meperidine (Demerol) and Promethazine (Phenergan)

    • Demerol 25-100mg with Phenergan 25 mg IM or IVP q 2-4 hours
    • crosses placenta
    • Half-life is 2.5 hrs. (mother) & 13 hrs. (newborn)
    • Right > administration, FHR variability may decrease
    • Narcan (naloxone) antagonist

Butorphanol (Stadol) 1-2 mg IVP/IM x2.

  • Stronger than Morphine & Demerol. Starts working in < 5 min. Has minimal fetal effects; may cause hallucinations in mom.

Nalbuphine (Nubain) – 15-20 mg IVP/IM

  • does not cause neonatal depression.

Fentanyl –short-acting potent synthetic opioid.

  • 50-100 mcg IV q 1hr. Used in spinal/epidural.
slide6

Anesthesia

Anesthesia: reversible loss of sensation & movement in region of body.

Types of Anesthesia

  • Local anesthesia: local anesthetic directly into perineum. Used for minor procedures. No effects on newborn.
  • Lidocaine 1% typically used for NSVD
    • Relieves pain from episiotomies or when suturing episiotomy and/or lacerations from vaginal deliveries.
    • Rapid onset
    • Client awake
slide7

Pudendal Block

  • Relieves pain associated with 2nd (pushing) stage of labor. Lidocaine 1% used.
  • through vaginal wall and into pudendal nerve in pelvis, numbs area between vagina & anus
  • 22 gauge needle [bilateral]
  • Does not relieve pain of contractions.
  • Works quickly; does not affect baby.
  • Given shortly before delivery, but cannot be used if baby's head is too far down in birth canal.
  • Can prolong 2nd stage labor d/t loss of bearing-down reflex.
  • Provides satisfactory perineal anesthesia for normal delivery, low forceps manipulation, episiotomy. 
slide8

Regional anesthesia - injection of local anesthetic around

nerves of spinal cord to block pain from larger but still

limited part of body.

Types:

1. Epidural Anesthesia

Usuallyuses Marcaine (bupivicaine) - into epidural space

at 3rd - 4th lumbar interspace.

  • single dose to be repeated or as continuous infusion; common in USA
  • administered > active labor established
  • Good analgesia without CNS depression in mom or fetus; Relieves pain from uterine contractions, vaginal delivery, C/S
  • Analgesia block from T-10 to S-5
  • Epidurals slow labor and may require Pitocin (oxytocin) augmentation.
slide9

Most common complications:

  • Maternal hypotension > can lead to> fetal bradycardia and late decelerations.
  • Preloading 1000ml of RL IVF
  • Tx hypotension with ephedrine.
  • Less w. continuous infusion than single dose
  • Other complications: total spinal block & respiratory paralysis (improper placement of catheter)
  • Does not prolong 1st stage labor if established
  • Can interfere with woman's ability to push. May ^ C/S
  • Can elevate maternal temp.
  • Bladder sensation lost – insert foley catheter
  • Interfere with descent and rotation of fetus
  • Long-term problems
    • Backache; headaches; Migraine headache
    • Neckache; Tingling in hands or fingers
slide10

Technique for Epidural Analgesia

  • Get informed consent
  • Monitor BP, P, FHR, q 1-2 min. for 15 min. > bolus of local anesthetic.
  • Maintain verbal communication with patient.
  • Hydrate w. RL 500-1000 cc. to maintain BP.
  • Patient maintains lateral or sitting position
  • Epidural space identified - catheter threaded 3cm
  • Test dose given - observe for s/s of toxicity (metalic taste, ringing in ears, palpitations)
  • Place in lateral or semifowler to prevent aortocaval compression.
  • Maternal BP monitored q 5-15 min.
  • Analgesia level assessed.
slide11

2. Spinal Anesthesia

  • Subarachnoid space [lumbar region] - provides spinal block. Passes through dura & CSF reached. Meds inserted, needle removed.
  • Spinal cord above this site.
  • Used in C/S. Block level from 8th thoracic dermatome [ xiphoid process/breast. Longer anesthetic effects.
  • Anesthetics used: bupivacaine, lidocaine, fentanyl. Duramorph {morphine} side effects include urinary retention (foley), pruritis, nausea, hypotension. Preload with RL (1000cc). Maintain IVF.
slide12

Complications:

  • Hypotension [20% decrease from baseline]; may occur > administration of local anesthetic
      • Vasodilatation & obstructed venous return from uterine compression of vena cava and large veins
    • Manage:
      • L side, hydrate with 500-1000 cc of RL/NS, ephedrine 5-10 mg IV
  • Spinal Headache (low volume/low pressure in spinal column)
    • CSF leaks from site of puncture @ dura mater.
    • Treatment:
      • lie flat for few hours.
      • Vigorous IV hydration.
      • Blood patch – very effective
        • 5 mL of blood without anticoagulunt - injected into epidural space - forms clot & stops leakage
        • VS observed for ~ 2 hrs.
slide13

Post-op Pain Management: administered either by IVP, IM or PCA (Patient control anesthesia) Medications such as:

      • Fentanyl ; Morphine ; Demerol
      • Duramorph/astromorph- systemic effects ~ 24 hours without PCA/IM medication.
    • Vital signs monitored closely
      • Monitor q 15 minutes for first hour:
        • BP, P, RR, HR
        • Pain, Motor Sensory, Alertness, Epidural access
        • PCA bolus/infusion amount and VTBI
      • Then, 30 minutes x2 , q hour X 4 hours, q 4 hrs. X 24 hrs.
  • Patient education - Inform patient – PCA is continuous programmed infusion pump. Patient may self-administer medication
    • Reassure patient - overdose can’t occur; Infusion programmed – delivers additional med q 10 - 15 minutes; lock out system.
slide14

General Anesthesia (total induced unconsciousness)

C-sec → fetal distress, failed epidural/spinal/allergy

  • Prophylactic antacid – 30 cc Bicitra
  • Pre-O2; wedge under R hip - prevents venacaval compression.
  • Induced unconsciousness [inhalation or IV therapy]
  • Halothane, ketamine, nitrous oxide, thiopental
  • Endotracheal intubation
  • Cricoid pressure on trachea - occludes esophagus & prevents aspiration.
  • After intubation, additional meds given via IV & ET tube - maintains anesthesia for rest of surgery.
  • Used for emergency delivery
  • Complications: Pulmonary aspiration of gastric contents, failed intubation, aspiration pneumonia, neonatal depression. NPO for about 8 hours.