Pain Relief During Pain Relief During LaborLabor

Principles of Pain ReliefPrinciples of Pain ReliefTreatments for pain relief during labor depends on: Treatments for pain relief during labor depends on: client’s tolerance for pain client’s tolerance for pain ability to remain motivated. ability to remain motivated. ability to focus on labor ability to focus on labor Some of labor measures that can be taken at home are:Some of labor measures that can be taken at home are:aromatherapy, warm bath, music, visualization, breathing aromatherapy, warm bath, music, visualization, breathing

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

epidural epidural

Method of Pain Relief Should Show:Method of Pain Relief Should Show: SimplicitySimplicity SafetySafety Preservation of fetal homeostasisPreservation of fetal homeostasisMonitor client closely: B/P, Pulse, RR, FHR, anesthetic Monitor client closely: B/P, Pulse, RR, FHR, anesthetic

levels, maternal oxygenation.levels, maternal oxygenation.

Analgesia and Sedation Analgesia and Sedation During LaborDuring Labor

Analgesia:Analgesia: loss of sensitivity to pain. loss of sensitivity to pain. Pain meds can be sufficient to get through labor Pain meds can be sufficient to get through labor

along with: aromatherapy, music, visualization, along with: aromatherapy, music, visualization, etc.etc.

Systemic drugs - 3 factors should be considered Systemic drugs - 3 factors should be considered – Produces effects on mother and fetus.Produces effects on mother and fetus.– All systemic drugs cross placenta by simple All systemic drugs cross placenta by simple

diffusion. diffusion. – Fetal liver & kidney function are immature.Fetal liver & kidney function are immature.– Drugs are metabolized slowly & its effects last Drugs are metabolized slowly & its effects last

longer longer – Drugs affect progress of labor and can slow Drugs affect progress of labor and can slow

labor.labor.

Assessment Assessment – Maternal assessment Maternal assessment

Informed consent ; VS stable Informed consent ; VS stable

– Fetal assessment Fetal assessment FHR 110-160/min with no late/variable decels. FHR 110-160/min with no late/variable decels. Variability average. Variability average. Normal fetal movement and accelerations present. Normal fetal movement and accelerations present. Term FetusTerm Fetus No Meconium No Meconium

– Labor assessment Labor assessment Contraction pattern well established. Contraction pattern well established. Cervix 4-5 cm dilated in primips and 3-4 in multips Cervix 4-5 cm dilated in primips and 3-4 in multips Progressive descent of presenting part Progressive descent of presenting part no complicationsno complications Delivery at least 2-3 hours away. Delivery at least 2-3 hours away.

Narcotic Pain Relief:Narcotic Pain Relief:Meperidine (Demerol) and Promethazine Meperidine (Demerol) and Promethazine

(Phenergan) (Phenergan) – Demerol 25-100mg with Phenergan 25 mg IM Demerol 25-100mg with Phenergan 25 mg IM

or IVP q 2-4 hours or IVP q 2-4 hours – crosses placentacrosses placenta– Half-life is 2.5 hrs. (mother) & 13 hrs. Half-life is 2.5 hrs. (mother) & 13 hrs.

(newborn)(newborn)– Right > administration, FHR variability may Right > administration, FHR variability may

decreasedecrease– Narcan (naloxone) antagonist Narcan (naloxone) antagonist

Butorphanol (Stadol) 1-2 mg IVP/IM x2. Butorphanol (Stadol) 1-2 mg IVP/IM x2. Stronger than Morphine & Demerol. Starts Stronger than Morphine & Demerol. Starts

working in < 5 min. Has minimal fetal effects; working in < 5 min. Has minimal fetal effects; may cause hallucinations in mom. may cause hallucinations in mom.

Nalbuphine (Nubain) – 15-20 mg IVP/IM Nalbuphine (Nubain) – 15-20 mg IVP/IM does not cause neonatal depression. does not cause neonatal depression. Fentanyl –short-acting potent synthetic opioid. Fentanyl –short-acting potent synthetic opioid. 50-100 mcg IV q 1hr. Used in spinal/epidural.50-100 mcg IV q 1hr. Used in spinal/epidural.

AnesthesiaAnesthesiaAnesthesia:Anesthesia: reversible loss of sensation & reversible loss of sensation &

movement in region of body. movement in region of body.

Types of AnesthesiaTypes of Anesthesia Local anesthesia: local anesthetic directly into : local anesthetic directly into

perineum. Used for minor procedures. No effects perineum. Used for minor procedures. No effects on newborn.on newborn.

Lidocaine 1% typically used for NSVDLidocaine 1% typically used for NSVD– Relieves pain from episiotomies or when Relieves pain from episiotomies or when

suturing episiotomy and/or lacerations from suturing episiotomy and/or lacerations from vaginal deliveries.vaginal deliveries.

– Rapid onsetRapid onset– Client awakeClient awake

Pudendal BlockPudendal Block

- Relieves pain associated with 2nd (pushing) Relieves pain associated with 2nd (pushing) stage of labor. Lidocaine 1% used.stage of labor. Lidocaine 1% used.

- through vaginal wall and into pudendal nerve through vaginal wall and into pudendal nerve in pelvis, numbs area between vagina & anusin pelvis, numbs area between vagina & anus

- 22 gauge needle [bilateral]22 gauge needle [bilateral]– Does not relieve pain of contractions.Does not relieve pain of contractions.– Works quickly; does not affect baby. Works quickly; does not affect baby. – Given shortly before delivery, but cannot be Given shortly before delivery, but cannot be

used if baby's head is too far down in birth used if baby's head is too far down in birth canal.canal.

– Can prolong 2Can prolong 2ndnd stage labor d/t loss of bearing- stage labor d/t loss of bearing-down reflex. down reflex.

– Provides satisfactory perineal anesthesia for Provides satisfactory perineal anesthesia for normal delivery, low forceps manipulation, normal delivery, low forceps manipulation, episiotomy.  episiotomy. 

Regional anesthesia - injection of local anesthetic Regional anesthesia - injection of local anesthetic around around

nerves of spinal cord to block pain from larger but nerves of spinal cord to block pain from larger but still still

limited part of body. limited part of body.

Types:Types:1. Epidural Anesthesia1. Epidural Anesthesia UsuallyUsually uses Marcaine (bupivicaine) - into epidural uses Marcaine (bupivicaine) - into epidural

space space at 3rd - 4th lumbar interspace. at 3rd - 4th lumbar interspace. single dose to be repeated or as continuous single dose to be repeated or as continuous

infusion; common in USAinfusion; common in USA administered > active labor established administered > active labor established Good analgesia without CNS depression in mom Good analgesia without CNS depression in mom

or fetus; or fetus; Relieves pain from uterine contractions, vaginal Relieves pain from uterine contractions, vaginal delivery, C/Sdelivery, C/S

Analgesia block from T-10 to S-5Analgesia block from T-10 to S-5 Epidurals slow labor and may require Pitocin Epidurals slow labor and may require Pitocin

(oxytocin) augmentation.(oxytocin) augmentation.

Most common complications: Most common complications: Maternal hypotension > can lead to> fetal Maternal hypotension > can lead to> fetal

bradycardia and late decelerations. bradycardia and late decelerations. Preloading 1000ml of RL IVFPreloading 1000ml of RL IVF Tx hypotension with ephedrine. Tx hypotension with ephedrine. Less w. continuous infusion than single dose Less w. continuous infusion than single dose Other complications: total spinal block & Other complications: total spinal block &

respiratory paralysis (improper placement of respiratory paralysis (improper placement of catheter)catheter)

Does not prolong 1Does not prolong 1stst stage labor if established stage labor if established Can interfere with woman's ability to push. May ^ Can interfere with woman's ability to push. May ^

C/SC/S Can elevate maternal temp. Can elevate maternal temp. Bladder sensation lost – insert foley catheter Bladder sensation lost – insert foley catheter Interfere with descent and rotation of fetus Interfere with descent and rotation of fetus Long-term problemsLong-term problems

– Backache; headaches; Migraine headacheBackache; headaches; Migraine headache– Neckache; Tingling in hands or fingersNeckache; Tingling in hands or fingers

Technique for Epidural AnalgesiaTechnique for Epidural Analgesia

Get informed consentGet informed consent Monitor BP, P, FHR, q 1-2 min. for 15 min. > bolus Monitor BP, P, FHR, q 1-2 min. for 15 min. > bolus

of local anesthetic.of local anesthetic. Maintain verbal communication with patient.Maintain verbal communication with patient. Hydrate w. RL 500-1000 cc. to maintain BP.Hydrate w. RL 500-1000 cc. to maintain BP. Patient maintains lateral or sitting positionPatient maintains lateral or sitting position Epidural space identified - catheter threaded 3cmEpidural space identified - catheter threaded 3cm Test dose given - observe for s/s of toxicity Test dose given - observe for s/s of toxicity

(metalic taste, ringing in ears, palpitations)(metalic taste, ringing in ears, palpitations) Place in lateral or semifowler to prevent Place in lateral or semifowler to prevent

aortocaval compression.aortocaval compression. Maternal BP monitored q 5-15 min. Maternal BP monitored q 5-15 min. Analgesia level assessed.Analgesia level assessed.

2. Spinal Anesthesia2. Spinal Anesthesia– Subarachnoid space [lumbar region] - provides Subarachnoid space [lumbar region] - provides

spinal block. Passes through dura & CSF spinal block. Passes through dura & CSF reached. Meds inserted, needle removed.reached. Meds inserted, needle removed.

– Spinal cord above this site.Spinal cord above this site.– Used in C/S. Block level from 8Used in C/S. Block level from 8thth thoracic thoracic

dermatome [ xiphoid process/breast. Longer dermatome [ xiphoid process/breast. Longer anesthetic effects.anesthetic effects.

– Anesthetics used: bupivacaine, lidocaine, Anesthetics used: bupivacaine, lidocaine, fentanyl. Duramorph {morphine} side effects fentanyl. Duramorph {morphine} side effects include urinary retention (foley), pruritis, include urinary retention (foley), pruritis, nausea, hypotension. Preload with RL (1000cc). nausea, hypotension. Preload with RL (1000cc). Maintain IVF.Maintain IVF.

Complications:Complications: Hypotension [20% decrease from baseline]; may Hypotension [20% decrease from baseline]; may

occur > administration of local anestheticoccur > administration of local anesthetic Vasodilatation & obstructed venous return Vasodilatation & obstructed venous return

from uterine compression of vena cava and from uterine compression of vena cava and large veinslarge veins

– Manage:Manage: L side, hydrate with 500-1000 cc of RL/NS, L side, hydrate with 500-1000 cc of RL/NS,

ephedrine 5-10 mg IVephedrine 5-10 mg IV Spinal Headache Spinal Headache (low volume/low pressure in spinal (low volume/low pressure in spinal

column)column)– CSF leaks from site of puncture @ dura mater. CSF leaks from site of puncture @ dura mater. – Treatment:Treatment:

lie flat for few hours.lie flat for few hours. Vigorous IV hydration.Vigorous IV hydration. Blood patch – very effectiveBlood patch – very effective

– 5 mL of blood without anticoagulunt - 5 mL of blood without anticoagulunt - injected into epidural space - forms clot & injected into epidural space - forms clot & stops leakagestops leakage

– VS observed for ~ 2 hrs.VS observed for ~ 2 hrs.

Post-op Pain ManagementPost-op Pain Management: administered : administered either by IVP, IM or PCA (Patient control either by IVP, IM or PCA (Patient control anesthesia) Medications such as:anesthesia) Medications such as: Fentanyl ; Morphine ; DemerolFentanyl ; Morphine ; Demerol Duramorph/astromorph- systemic effects ~ 24 hours Duramorph/astromorph- systemic effects ~ 24 hours

without PCA/IM medication. without PCA/IM medication.

– Vital signs monitored closelyVital signs monitored closely Monitor q 15 minutes for first hour:Monitor q 15 minutes for first hour:

– BP, P, RR, HRBP, P, RR, HR– Pain, Motor Sensory, Alertness, Epidural accessPain, Motor Sensory, Alertness, Epidural access– PCA bolus/infusion amount and VTBIPCA bolus/infusion amount and VTBI

Then, 30 minutes x2 , q hour X 4 hours, q 4 hrs. X 24 Then, 30 minutes x2 , q hour X 4 hours, q 4 hrs. X 24 hrs. hrs.

Patient education - Inform patient – PCA is continuous Patient education - Inform patient – PCA is continuous programmed infusion pump. Patient may self-administer programmed infusion pump. Patient may self-administer medicationmedication– Reassure patient - overdose can’t occur; Infusion Reassure patient - overdose can’t occur; Infusion

programmed – delivers additional med q 10 - 15 programmed – delivers additional med q 10 - 15 minutes; lock out system.minutes; lock out system.

General Anesthesia General Anesthesia (total induced unconsciousness)(total induced unconsciousness)

C-sec → fetal distress, failed epidural/spinal/allergyC-sec → fetal distress, failed epidural/spinal/allergy Prophylactic antacid – 30 cc Bicitra Prophylactic antacid – 30 cc Bicitra Pre-O2; wedge under R hip - prevents venacaval Pre-O2; wedge under R hip - prevents venacaval

compression.compression. Induced unconsciousness [inhalation or IV Induced unconsciousness [inhalation or IV

therapy] therapy] Halothane, ketamine, nitrous oxide, thiopental Halothane, ketamine, nitrous oxide, thiopental Endotracheal intubation Endotracheal intubation Cricoid pressure on trachea - occludes esophagus Cricoid pressure on trachea - occludes esophagus

& prevents aspiration. & prevents aspiration. After intubation, additional meds given via IV & After intubation, additional meds given via IV &

ET tube - maintains anesthesia for rest of surgery.ET tube - maintains anesthesia for rest of surgery. Used for emergency deliveryUsed for emergency delivery Complications: Pulmonary aspiration of gastric Complications: Pulmonary aspiration of gastric

contents, failed intubation, aspiration pneumonia, contents, failed intubation, aspiration pneumonia, neonatal depression. NPO for about 8 hours.neonatal depression. NPO for about 8 hours.