1. Emergency Treatment Module 2 - Session 3 Pain Management

2. 2 Module 2 - Session 3 Objectives At the end of this session, participants will be able to: 1.Describe the goal of pain control 2.Describe the main counseling points when discussing pain management with the client 3.Describe the types of pain women may experience from incomplete abortion and from the different uterine evacuation procedures 4.List the types of pain control and available methods for each type 5.Describe symptoms of local anesthesia complications, and treatment 6.Demonstrate counseling related to pain management and integrate with care as appropriate

3. 3 Goal of Pain Management To help ensure that the woman experiences minimum physical pain and anxiety with the least risk to her health by working with her to develop an individualized plan for pain management. This can be accomplished through a combination of medications, emotional/verbal support and clinical techniques.

4. 4 Discussing Pain Management There are many factors that influence how a person perceives and expresses pain. Discuss basic information about the procedure, such as how long it will take and the level of pain the client might expect. Pain management options will vary with each client.

5. 5 Counseling and Discussion Points Any pre-existing pain (before procedure starts) Length of procedure (vacuum aspiration [VA] takes about 10–15 minutes) Overview of how the procedure is done: –You may show her samples of the instruments –Explain the degree of cervical dilatation Available pain medications: –How they are administered; side effects A critical counseling point is to emphasize that the woman has some control over the methods used.

6. 6 Counseling and Discussion Points (2) Anything in the client’s history or physical that may affect what method she chooses (e.g., contraindications, allergies or previous adverse reactions to medications) Any emotional or psychological concerns Encourage her to ask questions or communicate concerns

7. 7 Assessing Pain in the PAC Client: The Wong-Baker Faces Pain Rating Scale Face 0 – no pain at all Face 1 – hurts just a little Face 2 – hurts a little more Face 3 – hurts even more Face 4 – hurts a whole lot Face 5 – hurts as much as you can imagine; may or may not cry due to pain

8. 8 The Wong-Baker Faces Pain Rating Scale A visual description to help clients explain their level of pain or discomfort. To use this scale, explain that each face shows how a person in pain is feeling. Point to each face using the words to describe the pain intensity. The PAC client then chooses the face that best describes how she feels. It is important to observe the client’s face before, during and after the procedure to ensure adequate pain management.

9. 9 Assessing Pain in the PAC Client: Numerical Pain Scale Numerical pain scales may include words or descriptions to better label a client’s symptoms, from feeling no pain to experiencing excruciating pain. This type of combination scale may be most sensitive to gender and ethnic differences in describing pain.

10. 10 Client Emotions In addition to pain, PAC clients will likely have some anxiety from the circumstances surrounding the pregnancy loss and anticipation of the pending procedure.

11. 11 General Requirements of Pain Control: Uterine Evacuation with an Awake Client Successful pain management for PAC involves appropriate medication and supportive interaction in a relaxed environment: –A procedure room that is quiet and non-threatening –Staff who are calm, friendly, gentle and unhurried –Continuous attention to the client from the medical team –A clear explanation of what to expect before, during and after the procedure, including any pain/discomfort expected –A competent, efficient and well-trained team of providers who communicate well with the client Adapted from: EngenderHealth, 2003.

12. 12 Informed Consent Most pain medications do not require any written consent. Consent is usually required for procedures such as sharp curettage (SC) and vacuum aspiration (VA). In an emergency, informed consent may not be possible if the patient is unconscious or otherwise incapable: –Follow your local policies or protocols regarding informed consent. Because some pain medication (e.g., narcotics or some sedatives) can affect the level of consciousness or alertness, it is critical to obtain any consent before administering such drugs.

13. 13 Types and Origin of Pain PAC clients will experience two main types of pain: deep/tense pain and cramp-like pain. Deep and tense pain results from cervical dilatation and/or stimulation. Scraping of the uterine wall, muscle spasms or movement of the uterus during the evacuation procedure produce diffuse lower abdominal pain with cramping.

14. 14 Types and Origin of Pain (2) There are two different pathways that transmit pain from the cervix and uterus: -- Hypo-gastric plexus—body and fundus of the uterus (L1, L2, L3, L4, T12) -- Utero-vaginal plexus: cervix and upper vagina (S2, S3, S4)

15. 15 Types of Pain Control Medication AnalgesiaEases sensation of pain (e.g., paracetamol) AnestheticDeadens all physical sensation (e.g., lignocaine) AnxiolyticDepresses nervous system functions, reduces anxiety and relaxes muscle (e.g., diazepam)

16. 16 Types of Pain Control Medication (2) Effective pain control for vacuum extraction is usually some combination of drug types along with gentle handling, reassurance and clear communication. However, in many cases of incomplete abortion where the cervix is already open, analgesics at least 30 minutes before the evacuation will be sufficient.

17. 17 Use of Analgesia Analgesia with non-steroidal anti-inflammatory drugs, such as ibuprofen or naproxen, will reduce cramping and uterine pain during and after the procedure. These are given orally, are relatively inexpensive and may provide adequate analgesia for many women. Analgesia with narcotics, such as meperidine or fentanyl, may be given IV, IM or PO, depending on the narcotic. Providers must know safe dose limits, duration of action and how to reverse the effects if needed.

18. 18 Anxiolytics Anxiolytics, such as diazepam or midazolam, decrease anxiety and provide amnesia, though they do not reduce actual pain. The woman’s anxiety level should be assessed, and, when needed, the dose should be individualized. Providers need to know safe upper limits, interaction with narcotics and duration.

19. 19 Anxiolytics (2) When anxiolytics or narcotics are used, back-up is required in case of any adverse reactions. Required back-up includes: Clinicians trained in resuscitation Appropriate antagonistic drugs Resuscitation equipment on hand: –Ambu bag –Oral airway –Oxygen

20. 20 Complications of Narcotic Analgesics and Anxiolytics Respiratory depression: –Treatment: assisted respiration with Ambu bag and oxygen –Reverse pethidine or fentanyl: With naloxone 0.4 mg IV –Reverse benzodiazepines: With flumazenil 0.2 mg IV

21. 21 Use of Anesthesia GeneralAffects pain receptors in the brain; client unconscious RegionalBlocks sensation from a specific point on the spine; client awake LocalInterrupts transmission of sensations in local tissue only; safest for MVA

22. 22 Characteristics of Anesthesia TypePossible Complications LocalDrug allergy or seizure (rare), vaso-vagal reaction RegionalHypotension, cardiac arrest, central nervous system infection, spinal cord injury, drug allergy, seizure GeneralHypoxia, cardiac arrest, drug allergy, aspiration of drug contents

23. 23 Complications of Local Anesthetics and Appropriate Treatment Allergic reaction (rare): –For hives or rash, give Benadryl (diphenhydramine) 25–50 mg IV –For respiratory distress, give epinephrine 0.4 mg subcutaneously and support respiration Toxic reaction (rare): –Prevention: use smallest effective dose; aspirate before each injection –Mild reactions: give verbal support; monitor closely for a few minutes –Severe reactions: give oxygen immediately; give diazepam 5 mg IV slowly

24. 24 Integrating Counseling Arrange the setting to ensure audio/visual privacy. Ask the client if there is anyone else that she would like to have involved in the discussion. Be sure the client understands what level of pain and discomfort to expect for the procedure she will have. Acknowledge that feeling scared, confused or worried are common for most women in the same situation.

25. 25 Integrating Counseling (2) Explain pain management options with simple terms and explanations. Include pre- and post-procedure pain control, benefits and possible side effects. Be sure that the client demonstrates understanding of all explanations by having her repeat or summarize the information in her own words. Follow local or institutional protocols for documenting informed consent for the procedure and pain control.

26. 26 Paracervical Block A form of local anesthesia that markedly reduces pain, nausea and vomiting for patients who need VA — especially if extensive cervical dilatation is needed. Correct infiltration technique and adherence to maximum limits of drugs are necessary for safe use. The medication is injected directly into the tissues surrounding the cervix and may be effective for as long as 60–90 minutes.

27. 27 Paracervical Block: Precautions In some settings, this technique is not used if the cervix is open; follow local protocol. Make sure there are no known allergies to lignocaine or related drugs. Do not inject into a vessel. Maternal complications are rare but may include hematoma.

28. 28 Paracervical Block: Injection Sites See reference manual for instructions for performing paracervical block.