1. C.LUTKENHAUS,MSN,RNC-OB,C-EFM UPDATED 8/2015 CHAPTER 18 – PAIN MANAGEMENT FOR CHILDBIRTH buzzfeed.com

2. KNOCKED UP PLAY: http://www.homebirth.net.au/2010/06/absurd-birth- scenes-knocked-up.html http://www.homebirth.net.au/2010/06/absurd-birth- scenes-knocked-up.html anythingbaby.co.nz

3. PAIN DURING CHILDBIRTH: KNOCKED UP How did the woman’s attitude change from when the Dr. first came in, to when he came “back in,” to when she was actively pushing? What did the woman’s partner do throughout the scene? What did the doctor do wrong, both before hand and during the delivery? Did you see any nurses in the scene? What did they do? What advice do you give when a woman wants to “change” her birth plan? How do you think this clip compares to the “real” world of L&D?

4. UNIQUE NATURE OF PAIN DURING BIRTH Childbirth pain is unique because: It is normal and self-limiting. It can be prepared for. It ends with the baby’s birth. Pain is a complex physiologic and psychological experience. Subjective and personal

5. PAIN DURING BIRTH Pain of childbirth differs from any other pain Normally, woman has time to prepare for the pain, pain has a foreseeable end, pain is usually intermittent. Adverse effects of excessive pain Fear and anxiety reduces blood flow to fetus Woman’s metabolic rate increases Increases respiratory rate and disturbs normal gas exchange; can lead to fetal acidosis. Adversely affects psychological thoughts Lessens pleasure of experience, difficulty with bonding blogs.babble.com healthypro.org webmd.com

6. VARIABLES IN CHILDBIRTH PAIN Physical factors Sources of pain Tissue ischemia, cervical dilation, pressure on pelvic structures, distension of vaginal and perineum Factors influencing pain perception/tolerance Intensity of labor, cervical readiness, fetal position, pelvis size and shape, fatigue, intervention of caregivers Psychosocial factors Culture Anxiety and fear Increases muscle tension, diverts O 2 from placenta Previous experiences with pain Preparation for childbirth Provides reasonable expectations about pain interventions, reduces anxiety and fear Support system

7. STANDARDS FOR PAIN MANAGEMENT Pain management is essential part of care. Client has the right to effective pain management. See www.jointcommission.orgwww.jointcommission.org

8. NON-PHARMACOLOGIC PAIN MANAGEMENT Relaxation – promotes uterine blood flow, reduces anxiety and fear Types – progressive, neuromuscular dissociation, touch, relaxation against pain, water therapy Cutaneous stimulation – effleurage, massage, thermal stimulation, acupressure Mental stimulation – imagery, focal point

9. NON-PHARMACOLOGIC PAIN MANAGEMENT Breathing – always preceded and followed by cleansing breath First-stage Slow-paced, modified paced, pattern-paced, blowing Common problems – hyperventilation, dry mouth Second-stage Traditional pushing (Valsalva/Purple Pushing) Open glottis pushing Open-glottis pushing, allows the patient to exhale while bearing down and leads to minimal increase in maternal blood pressure and intrathoracic pressure, maintained blood flow, and decreased fetal hypoxia. Long Valsalva pushing can adversely affect maternal hemodynamics, which in turn adversely affects fetal oxygenation.

10. HISTORY: PHARMACOLOGIC MANAGEMENT Twilight Sleep: Morphine and Scopalamine http://blog.ctnews.com/elwood/2009/09/29/going-back-in-time-twilight-sleep/

12. PHARMACOLOGIC PAIN MANAGEMENT Epidural block – local anesthetic and small amount of opioid injected into epidural space Complication: dural puncture requires blood patch SE: Maternal hypotension d/t vasodilation Catheter migration (facial numbness, dyspnea) Bladder distension, place foley Fever N&V, itching, tinnitus, delayed respiratory depression (up to 24 hrs) Nursing care: BP and VS, rapid preload of IV fluid, support correct positioning, monitor for adverse effects, assess bladder status

13. PHARMACOLOGIC PAIN MANAGEMENT Spinal block – local anesthetic and/or opiate injected into spinal space just before birth (usually a c/s) Adverse effects: Maternal hypotension Spinal headache Nausea Bladder distension Nursing care: monitor VS, treat spinal headache (bedrest, oral and IV fluids, blood patch)

15. PHARMACOLOGIC PAIN MANAGEMENT Opioid analgesics Meperidine (Demerol): respiratory depression in mom and baby. Fentanyl (Sublimaze): very short duration of action but causes less respiratory depression. Butorphanol (Stadol) and nalbuphine (Nubain) less respiratory depression, but has ceiling of pain relief. Others may be used depending on provider preference. OPIOIDS-- Should be administered at onset of contraction to limit transfer to fetus. Do not give if EFM shows late decelerations ! buy-stadol.com

16. PHARMACOLOGIC PAIN MANAGEMENT Opioid antagonists Naloxone (Narcan) Given after birth to neonate Adjunctive drugs Antiemetics – promethazine (Phenergan) and ondansetron (Zofran) Sedatives to reduce anxiety and fear, only prior to a cesarean in rare cases savalife.com

17. PHARMACOLOGIC PAIN MANAGEMENT Vaginal birth anesthesia Local infiltration – injections into perineal tissues before episiotomy or suturing Pudendal block –into pudendal nerve for episiotomy or vaginal birth General anesthesia- used when woman is not candidate for epidural or spinal anesthesia and emergency delivery is necessary Restrict intake and keep NPO Administer drugs to reduce GI secretions and speed gastric emptying lnx.mednemo.it

18. CRITICAL THINKING WHAT WOULD YOU DO? A woman presents to the labor suite in labor. She is 3 cm dilated, 90% effaced, and at -1 station. Her contractions are every 3-5 minutes apart and of moderate intensity. a.What non-pharmacologic pain interventions are most helpful at this time? b.Several hours later, she is 5 cm dilated, 100% effaced, at 0 station. She is requesting IV analgesia. How will you reply? c.When she reaches 8 cm, she is screaming at the peak of contractions. She says, “I can’t stand the pain anymore. I want an epidural.” How will you reply?