Pain Management During Child birth

Lecture Seven: Pain Management During Child birth

NURS 2208
T. Dennis RNC, MSN
Objectives

• Discuss categories of pain relief methods
• Discuss types and pro’s and con’s
• Discuss commonly used meds during labor and childbirth
• Discuss regional analgesia and anesthesia
• c and select interventins appropriate for the client receiving pharmacologic pain relief

Methods of Pain Reliefv

• Nursing measures
• Relaxation techniques
• Breathing techniques
• Systemic analgesia
• Regional nerve blocks
• Local anesthetics
• General anesthesia

Assessment of the Client

• Three major factors influence the administration of pharmacologic pain relief: 1) effect on the client , 2) effect on the fetus, and effect on the contraction pattern.
• The use of electronic fetal monitoring may influence administration of medication.
• All systemic drugs used for pain relief during labor cross the placental barrier by simple diffusion.

Systemic Analgesics

• 1) Stadol
• 2) Nubain
• 3) Demerol
• 4) Seconal
• 5) Nembutal
• 6) Phenergan
• 7) Vistaril
• 8) Narcan

Stadol (Butorphanol Tartrate)

• Agonist/Antagonist, Schedule IV
• Synthetic (similar to morphine)
• Hx of drug use may cause reversal of other opioids or narcotics
• Used in moderate to severe pain
• Can be given IV , IM (1 to 2mg) or as nasal spray
• Peaks within 30-60 minutes
• May cause respiratory depression, drowsiness, nausea & vomiting
• Give IV during a contraction

Nubain (Nalbuphine Hydrochloride)

• Agonist/Antagonist
• Synthetic (similar to morphine)
• Hx of drug use may cause reversal of other opioids or narcotics
• Used in moderate to severe pain
• Given IM or IV (10 mg IV slow over 3-5 min.)
• May cause respiratory depression, sedation, sweating, headache, psychotic symptoms
• Peaks within 30-60 minutes
• Give IV during a contraction

Demerol (Meperidine)

• Agonist, Schedule II
• Synthetic(similar to morphine)
• Used in moderate to severe pain
• May cause sedation and respiratory depression
• Give IV or IM 12.5 to 25 mg
• Peaks in 1 hour
• Give during a contraction

Seconal (Secobarbital)

• Hypnotic, sedative (short acting barbituate), Schedule II, Category D
• Contraindicated in pregnancy
• 100 mg PO for sleep
• May cause respiratory depression, hangover, dependence, nightmares, vivid dreams, hallucinations
• Monitor vital signs frequently

Nembutal (Pentobarbital)

• Hypnotic/sedative, Schedule II, Category D
• Contraindicated in pregnancy
• PO 100mg at HS
• May cause drowsiness, lethargy, hangover, respiratory depression, nausea and vomiting and/or rash
• Monitor vital signs frequently

Phenergan (Promethizine Hydrochloride)

• Antiemetic, sedative/hypnotics, Category C
• 12.5mg to 25 mg IV or IM
• For N&V, adjunct to analgesics for pain
• May cause confusion, disorientation, sedation, dizziness
• Monitor BP, respirations and respiratory rate frequently, assess level of sedation

Vistaril (Hydroxyzine HCL)

• Anti-anxiety/antihistamine, Category C
• IM, PO
• 25mg – 100mg
• Causes sedation, relief of anxiety, decreased nausea and vomiting
• May cause drowsiness, dizziness, dry mouth, and lightheadedness, pain at IM site
• Assess for profound sedation and provide safety precautions

Narcan (Naloxone )

• Narcotic/Opiate antagonist, Category B
• IV, IM, SC or ET
• Onset 1–2 min (IV), duration 1-4 hrs
• 0.4mg to 2mg, may repeat q 2-3 minutes until max of 10 mg
• Reverse the respiratory and CNS depression caused by narcotics
• May cause nausea, vomiting, sweating, elevated BP, tachycardia
• Monitor vital signs frequently

Regional Analgesia and Anesthesia

• Analgesia: regional analgesia is obtained by injecting a narcotic agent along with only a small amount of local anesthetic to provide pain relief without the side effects associated with anesthesia.
• Anesthesia: regional anesthesia is the temporary and reversible loss of sensation produced by injecting an anesthetic agent into an area that will bring the agent into direct contact with nervous tissue.

Lumbar Epidural Block

• Local anesthetic placed in the into the epidural space.
• Blood pressure should be monitored during administration of the block.
• Obtain baseline vital signs.
• Obtain drug history.
• Monitor vs, urine output, sensorium
• Usually administered after 5 cms.

Spinal Block

• Requires a local anesthetic be injected in the subarachnoid space at the third or fourth lumbar space.
• Blood pressure should be monitored during administration of the block.
• Obtain baseline vital signs.
• Obtain drug history.
• Monitor vs, urine output, sensorium
• Usually administered at 10 cms, prior to delivery, on perineum.

Pudendal Block

• Blood pressure should be monitored during administration of the block.
• Obtain baseline vital signs.
• Obtain drug history.
• Monitor vs, urine output, sensorium
• Usually administered at 10 cms (complete) and pushing prior to delivery.

Local Infiltration Anesthesia

• Block pain at the site where the drug is administered.
• Blood pressure should be monitored during administration of the block.
• Obtain baseline vital signs.
• Obtain drug history.
• Monitor vs, urine output, sensorium
• Usually administered just prior to delivery (prior to episiotomy or repair after delivery).

General Anesthesia

• May be needed for C-section or surgical intervention
• May be intravenous injection, inhalation of anesthetic agents, or a combination of both methods
• Primary danger is fetal depression (reach the fetus in approximately 2 minutes)
• At risk for aspiration pneumonia
• Usually administered immediately prior to incision.

Nursing Care for General Anesthesia

• Prophylactic antacid therapy (Bicitra)
• Wedge/roll placed under right hip for left uterine displacement
• Preoxygenate 3 to 5 minutes prior to induction with 100% O2
• IVF’s readily available
• May apply cricoid pressure prior to intubation

Nursing Diagnosis

• Fluid volume deficit (Indications)
• Injury, risk for (Side effects)
• Knowledge deficit, related to medication regimen (Patient/Family teaching)
• Sleep pattern disturbance
• Pain related to labor

Planning

• Client will receive adequate sleep without hangover when taking hypnotic.
• Client will be free of pain, or the intensity of pain will be lessened.
• Client will receive adequate fluid prior to insertion of regional anesthesia.
• Client will have adequate knowledge of analgesia/anesthetic procedures.

Nursing Interventions

• Monitor vital signs, especially respirations and blood pressure.
• Raise bedside rails.
• Observe for adverse reactions: skin rash, hangover, hallucination
• Have naloxone available
• Check urine output
• Check bowel sounds
• Hip roll to right hip for left uterine displacement
• Monitor bladder status

Evaluation of Outcome Criteria

• Evaluate the effectiveness of the narcotic analgesic in lessening or alleviating the pain.
• Evaluate the stability of vital signs. Abnormal signs, such as decreased blood pressure should be reported.
• Determine if side effects or adverse reactions to the drug have occurred.

Question

A client in labor has received an epidural for pain control. Identify a nursing intervention that would be appropriate for this client.

1. Limit fluid intake
2. Assist with ambulation
3. Observe for tetanic contractions
4. Monitor bladder status   
      
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