The way each woman perceives or interprets the pain of childbirth is influenced by ...
physical
emotional
psychosocial
cultural
environmental factors
The ___ helps explain how the pain-relief techniques taught in childbirth preparation classes work.
gate-control theory of pain
Effective nonpharmacologic techniques for managing discomfort include ___.
focusing and relaxation
breathing techniques
water therapy
A woman who experiences a prolonged latent phase of labor and needs to decrease anxiety or promote sleep may or may notbe given a sedative.
may
BUT, sedatives such as barbituates, e.g. secobarbital (Seconal) and side effects and are seldom used during labor.
Sedatives such as Benzodiazepines (e.g. diazepam [Valium], lorezepan [Ativan]) when given with an opioid analgesic seem to ___ and ___
enhance pain relief
reduce nausea & vomiting
Contraindications for epidural blocks
Extremely low platelet count
Active or anticipated serious hemorrhage
Coagulopathy
Infection at injection site
Intracraniolar pressure caused by mass lesion
"Some" heart conditions ???
Anesthesia by delivery type
Spinal and/or epidural for all* (i.e. vaginal birth, but not vaginal delivery)
General (if no one can give regional) for Ceasarean only
Vaginal ONLY:
local infiltration anesthesia
Pudendal block
Nitrous oxide
Emergency measures for maternal hypotension with decreased featal perfusion
Lateral or wedge under one hip
IV per protocol
O2 @ 10-12L/min
Elevate legs
Notify PHP
Admin IV vasopressor if above ineffective
Monitor vitals & FHR q5min until stable or PHP order
AFTER spinals are given
maternal vitals and FHR are documented every 5-10 minutes.
If baseline BP drops more than 20% or less than 100 systolic or fetal distress (bradycardia, minimal or absent variability, or late decelerations), emergency care must be given.
BEFORE spinals are given, women are ___ with ___ to decrease the potential for ___.
poreloaded
500-1000ml IV
hypotension
Pudendal nerve block
Can be administered late inthe second stage for episiotomy or forceps or vacuum
Can be admin in third stage for episiotomy or laceration repair
10-20 minurtes before anesthesia needed
Local infiltration anesthesia is used for...
Women without a regional who may require an episiotoy or lacerations to be sutured after birth, e.g. lidocain or clhloroprocain.
Their effects may be prolonged by the additon of epinephrine to the solution.
Opioid agonist-antagonist anlgestics (examples)
butorphanol (Stadol), nalbuphine (Nubain) are "all using"
However, these are not appropriate for women with opiod dependencies because they may cause withdrawal symptoms in mothers and babies that do, some of which are hard to distinguish from "normal" issues of labor.
Opioid agonist analgesics (examples)
hydromorphone hydrochloride (Dilaudid), meperidin (Demerol), fentanyl (Sublimaze) are generally not used.
Use of general anesthesia
Usually only if no one can give a regional or it is contraindicated
Almost never for vaginal deliveries
If used, preoxygenate w/ 100% O2 by facemask for 2-3 minutes beforehand
Opioid agonist analgesics provide ___
releif for severe, persistent, or recurrent pain.
Opioid agonist-antagonist analgesics provide ___
adequate analgesia without causing significant respiratory depression in the mother or neonate - in appropriate doses
Opioid ___ analgesics are not suitable for women with an opioid dependence because the antagonist activity could precipitate withdrawal symptoms in both the mother and her newborn.
agonist-antagonist
During spinal and epidural nerve blocks, the mother’s ___
fluid balance must be maintained.
In the United States, ___ is the most commonly used pharmacologic method for relieving the pain of labor.
epidural anesthesia and analgesia
General anesthesia is ___ used for vaginal birth but may be used for cesarean birth.
rarely
A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to:
C. Help the woman breathe into a paper bag.
The woman is exhibiting signs of hyperventilation. This leads to a decreased carbon dioxide level and respiratory alkalosis. Rebreathing her exhaled air would increase the carbon dioxide level.
T/F: A laboring woman becomes anxious during the transition phase of the first stage of labor and develops a rapid and deep respiratory pattern. She complains of feeling dizzy and light-headed. The nurse's immediate response would be to administer a sedative.
F: Administration of a sedative could lead to neonatal respiratory depression because this woman, being in the transition phase, is nearing the birth process.
A woman in active labor receives an analgesic, an opioid agonist. Which medication relieves severe, persistent, or recurrent pain; creates a sense of well-being; overcomes inhibitory factors; and may even relax the cervix but should be used cautiously in women with cardiac disease?
D. Meperidine (Demerol)
Meperidine used to be the most commonly used opioid agonist analgesic for women in labor throughout the world. It overcomes inhibitory factors in labor and may even relax the cervix. Because tachycardia is a possible adverse reaction, meperidine is used cautiously in women with cardiac disease. Other medication options with fewer side effects are now available for use during labor.
Promethazine is an ___ that may be used to augment the desirable effects of the opioid analgesics but has few of the undesirable effects of those drugs.
ataractic (tranquilizer)
Butorphanol tartrate is an ___.
opioid agonist-antagonist analgesic
Nalbuphine is an ___
opioid agonist-antagonist analgesic.
A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use:
D. Counterpressure against the sacrum.
applied by a support person to the sacral area with the fist or heel of the hand. This technique helps the woman cope with the sensations of internal pressure and pain in the lower back.
T/F: A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use pant-blow (breaths and puffs) breathing techniques.
F: Breathing techniques are usually helpful during contractions because they provide distraction; they are not necessarily targeted at back pain.
T/F: A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use effleurage.
F: Effleurage is usually helpful for relieving pain from contractions per the gate-control theory.
T/F: A woman is experiencing back labor and complains of intense pain in her lower back. An effective relief measure would be to use conscious relaxation or guided imagery.
F: Conscious relaxation or guided imagery techniques are usually helpful during contractions because they provide the opportunity to focus on a more pleasant situation; they are not targeted specifically toward back pain.
Nurses should be aware of the differences experience can make in how labor pain is perceived, such as:
A. Sensory pain for nulliparous women often is greater than for multiparous women during early labor.
Sensory pain is greater for nulliparous women because their reproductive tract structures are less supple.
Affective pain is greater for nulliparous women during the first stage and it ___ for nulliparous and ___ for multiparous women during the second stage.
decreases
decreases
Women with a history of substance abuse experience pain ___ those without such a history.
in the same amount as
Fatigue for nulliparous women compared to multi's is ___.
greater becauae thety have longer labors and therefore experience more fatigue.
With regard to breathing techniques used by a woman during labor, maternity nurses should be aware that:
C. Breathing techniques used in the first stage of labor are designed to increase the size of the abdominal cavity to reduce friction.
First-stage breathing techniques promote relaxation of abdominal muscles, thereby increasing the size of the abdominal cavity.
Providing instruction in simple breathing and relaxation techniques early in labor, i.e. once it has begun, is ___.
possible and effective
T/F: Controlled breathing techniques are most difficult to adhere to in the transition phase at the end of the first stage of labor when the cervix is dilated 8 to 10 cm.
True
T/F: The patterned-paced breathing technique can help prevent hyperventilation.
F: It can sometimes lead to it
With regard to systemic analgesics administered during labor, nurses should be aware that:
D. Effects on the fetus and newborn can include decreased alertness and delayed sucking
Effects depend on the specific drug given, the dosage, and the timing.
T/F: With regard to systemic analgesics administered during labor, nurses should be aware that systemic analgesics cross the maternal blood-brain barrier as easily as they do the fetal blood-brain barrier.
F: Systemic analgesics cross the fetal blood-brain barrier more readilythan the maternal blood-brain barrier.
T/F: With regard to systemic analgesics administered during labor, nurses should be aware that intramuscular administration (IM) is not preferred over intravenous (IV) administration.
T: IV administration is preferred over IM administration because the drug acts faster and more predictably.
PCA results in decreased or increaseduse of an analgesic.
decreased
With regard to spinal and epidural (block) anesthesia, nurses should know that:
D. A high incidence of after-birth headache is seen with spinal blocks.
A high incidence of after-birth headache can occur; headaches may be prevented or mitigated to some degree by a number of methods
T/F: With regard to spinal and epidural (block) anesthesia, nurses should know that this type of anesthesia is commonly used for cesarean births but is not suitable for vaginal births.
F: Spinal blocks may be used for vaginal births, but the woman must be coached when to push while she is in labor since she cannot sense her involutary contractions.
T: F: With regard to spinal and epidural (block) anesthesia, nurses should know that combined use of spinal and epidural blocks is becoming increasingly popular.
True
Maternal hypotension is a potential side effect of regional anesthesia and analgesia. What nursing interventions could you use to raise the patient's blood pressure if hypotension occurs? Choose all that apply.
A. Place the woman in a supine position.
B. Place the woman in a lateral position.
C. Increase intravenous (IV) fluids.
D. Administer oxygen.
E. Perform a vaginal examination.
B, C, D
Nursing interventions for maternal hypotension arising from analgesia or anesthesia include
Turning the woman to a lateral position
Increasing IV fluids
Administering oxygen via face mask
Elevating the woman's legs
Notifying the physician
Administering an IV vasopressor
Monitoring the maternal and fetal status at least every 5 minutes until these are stable.
analgesia
Absence of painwithout loss ofconsciousness
anesthesia
Partial or complete absence of sensationwith or without loss ofconsciousness
epidural block
Type of regional anesthesia produced by injection of a local anesthetic alone or in combination with a narcotic analgesic into the epidural (peridural) space
epidural blood patch
A patch (a clot) formed by a ~20 mL injection into the epidural space of the mother's (autologous) blood occluding a tear in the dura mater around the spinal cord that occurs during induction of spinal or epidural block; its purpose is to relieve headache associated with leakage of spinal fluid.
It is the most rapid, reliable relief measure for PDPH (posTdural pucture headache). It is considered if the headache is sever and debilitating or does not resolve after conservative managemnt (oral analgesics and caffeine or theophylline)
neonatal narcosis
depression in the central nervous system of a newborn caused by an opioid (narcotic); may be signaled by respiratory depression, hypotonia, lethargy, and delay in temperature regulation
opioid (narcotic) agonist analgesics
Medications that relieve pain by activating opioid receptors
opioid (narcotic) agonist-antagonist analgesics
Medications that combine agonist activity (activates or stimulates a receptor to perform a function) and antagonist activity (blocks a receptor or medication designed to activate a receptor) to relieve pain without causing significant maternal or fetal or newborn respiratory depression
pudendal nerve block
Injection of a local anesthetic at the pudendal nerve root to produce numbness of the genital and perianal region
spinal anesthesia (block)
Regional anesthesia induced by injection of a local anesthetic agent into the subarachnoid space at the level of the third, fourth, or fifthlumbar interspace
Chinese women consider taking someing the first time it is offered as impolite, so it must be offered ___
more than once.
Somatic pain results during the ___ stage of birth from the ___.
second
distension of perineal and other tissues
Epidural anesthesia is affected by ___. ___ are effective at combating this effect.
gravity
Position changes, especially left/right side changes,
systemic analgesia
Pain relief induced when ananalgesic is administered parenterally (e.g.,subcutaneous [SC], intramuscular [IML orintravenous [IV] route) and crosses the blood-brain barrierto provide central analgesic effects
Cleansing breath
Relaxed breath in thru nose and out thru mouth. Used at beginning and end of each contraction.
Slow-paced breathing
Aproximately 1/2 the normal rate, but no less.
Modified-paced breathing
32 to 40 breaths oper minute but bno more than twice the normal rate.
Watch for light-headedness, dizziness, or tingling of the fingers.
Patterned-paced or pant-blow
Same as modified, i.e. not more than twice nortmal rate, but 3:1 or 4:1,e.g. in-out/in-out/in-out/in-blow
Watch for light-headedness, dizziness, or tingling of the fingers.
Water therapy should be ___ relative to body temperature.
at or below
Heat and cold can be used alternately and as the women desires. Note the folowing:
Neither should be used over ischemic or anesthitized skin
Both should have one or two layers of cloth between the source and the skin
Some cultures make the use of cold unacceptable
Intradermal water block for back pain during labor
Starting to be done
Like a TB test (raised bleb) with 0.1 ml sterile water
Probably effective because of counterirritation
relief for up to 2 hours reported
Pharmacologic measures should be implemented before pain becomes so sever that ___ increase and ___ is prolonged.
