Pain Relief Measures Used in Labor

Theories of Pain Gate control theory Endorphins pain can be controlled by tactile stimulation and modified by activities controlled by CNS (backrub, effleurage, suggestion, distraction, and conditioning). Endorphins endogenous morphine-if endorphins are released pain will be decreased-relaxed environment and positive thoughts. Endorphin levels act on central and peripheral system to decrease pain.

Sources of Pain First Stage-cervical dilation causes visceral pain-contractions Second Stage-perineal pressure on structures, stretching, burning (somatic pain) Factors affecting response to pain culture fatigue/sleep deprivation-less pain tolerance and reserve previous experience-coping mechanisms for pain past experiences anxiety-mild good for focusing, excessive causes catecholamine secretion which increases stimuli to brain causing fear, muscle tension, increased discomfort

Psychoprophylaxis Lamaze-grew from Pavlov’s work on conditioning Relaxation techniques relax all muscle groups Breathing patterns Effleurage- light stroking of the abdomen, thigh or chest Water therapy buoyancy and warmth fosters relaxation Web link to breathing patterns

Psychoprophylaxis Other Methods Grantley Dick-Read-3 techniques-exercise, relaxation, breathing techniques Bradley-husband coached childbirth-relaxed, quiet, slow breathing controlled Hypnosis (hypno birthing) Positioning-pillows, support Transcutaneous Electrical Nerve Stimulation (TENS)-based on gate control theory

Analgesia (IV, IM) Goal: Pt. has maximum pain relief at minimal risk to mother and fetus. Pt. is conscious but sedated and retains full motor function.

Systemic Analgesia Narcotics-all narcotics may cause respiratory depression in mom &/or CNS depression in fetus Meperidine HCL (Demerol) may be give IV or IM in 1st stage of labor Fentanyl (Sublimaze)may be given IV or IM in 1st stage of labor Mixed narcotic agonist-antagonists Stadol may be give 0.5 mg -2mg IV or IM. 1st stage Nubain 5-10 mg IV or IM in 1st stage of labor. Only until 4 cm without order

Systemic Analgesia Cont’d Analgesic Potentiators (ataractics). Do not decrease pain but decrease anxiety and apprehension and potentiate the action of narcotics Phenothiazines-Phenergan, compazine, vistaril, used to promote relaxation, allay anxiety, control emesis, and potentiate narcotic effect. Narcotic Antagonists: Narcan reverses the action of narcotics both adults and neonates. Dose for infant= 0.01mg/kg IM, IV, SQ may be repeated Dose for adult= 0.1-0.2 mg IV q 2-3 minutes prn

Sedatives and Tranquilizers Benzodiazepines valium, versed-used to reduce anxiety, sedative /hypnotic (C-section) Butyrophenones inapsine, haldol-used to produce profound amnesia and post--op sedation Barbituates seconal, pentobarbital-used to promote relaxation and sleep in early or false labor.

Nursing Care Maternal Status Fetal status Labor Status check BP, watch for decreased respirations, encourage rest b/t contractions. Fetal status note a decrease in beat to beat variability Try to administer narcotic IV during the contraction over appropriate time frame. Why? Labor Status relaxation fosters dilation

Anesthesia A total loss of sensory capability, may be regional or centrally to brain (consciousness is lost); usually implies that one or more vital organ functions are under partial or total control of anesthesia provider. Regional Blocks-differentiate site of insertion in each type

Epidural Anesthesia Epidural: Advantages Disadvantages mom alert and cooperative, only partial paralysis, gastric emptying delay, blood loss minimal, decrease effect on fetus Disadvantages maternal hypotension ☺, need for IV, numbness heaviness of legs, may make labor longer increase pushing.

Epidural Anesthesia Note that the needle does NOT cross the dura mater

Spinal Anesthesia Spinal Block Advantages Disadvantages good pain control, alert and awake, no resp. effects Disadvantages marked hypotension,  cardiac output, spinal H/A, loss of motor function and sensory function Complications-spinal H/A—constant H/A when HOB elevated, sx alleviated when lying flat. Treatment-Blood patch, caffeine intake

Spinal Anesthesia

Nursing Care with Epidural Anesthesia Careful hemodynamic monitoring Assess BP q5 minutes at beginning of procedure and continue til 20minutes after insertion of catheter. Longer if BP is decreased. Bolus with 1000ml of fluid, commonly Lactated Ringers solution, prior to beginning procedure. Positioning Client is asked to sit at the side of the bed. Have ct relax, drop shoulders, use relaxation breathing during contractions. Help ct stay still and push lower back out towards the anesthesiologist

Link for information on Blood Patch for post Spinal Headache

Anesthesia cont’d Pudendal Block numbs the nerves that run along vaginal canal Advantages alert, motor control, complete perineal anesthesia, no maternal hemodynamic changes Disadvantages lack pushing sensation, increase change of forceps or vacuum. Local infiltration numbness of area for epis, used at time of delivery rapid anesthesia 10 min. none

Pudendal Anesthesia

Local Infiltration

Anesthesia cont’d Use of epidural and intrathecal narcotics short-acting Fentanyl or Sufenta-short term pain relief good for rapid laboring patients long-acting Morphine (Duramorph or Astromorph—long-acting)☺ Risks to mother and common side effects —resp depression, decreased motor function, itching, dizziness. Essential nursing assessments—assess respiratory status and sensorimotor status q 1hr X 24hr. Interventions-Benadryl, Nubain for itching Use of nitrous oxide http://midwife.org/ACNM/files/ACNMLibraryData/UPLOADFILENAME/000000000080/Nitrous_Oxide_12_09.pdf

Anesthesia cont’d General Anesthesia –emergencies only IV anesthesia-NaPenthothal Complications fetal depression-fast delivery uterine relaxation-increase bleeding due to relaxation vomiting and aspiration-Bicitra 30 min before Nursing Care use of antacid (Bicitra) Positioning mother-assist intubation

Anesthesia cont’d Types of anesthetics Amides-Lidocaine, Mepivacaine, Bupivicaine (Marcaine): more powerful and longer acting, placental transfer and affect on fetus Esters-Procaine(novacaine), Nesacaine, Pontocaine, metabolize quickly, placental transfer

Whew that’s all!!!!