1. Pain Relief Measures Used in Labor

2. Theories of Pain Gate control theory Endorphins
pain can be controlled by tactile stimulation and modified by activities controlled by CNS (backrub, effleurage, suggestion, distraction, and conditioning).
Endorphins
endogenous morphine-if endorphins are released pain will be decreased-relaxed environment and positive thoughts. Endorphin levels act on central and peripheral system to decrease pain.

3. Sources of Pain
First Stage-cervical dilation causes visceral pain-contractions
Second Stage-perineal pressure on structures, stretching, burning (somatic pain)
Factors affecting response to pain
culture
fatigue/sleep deprivation-less pain tolerance and reserve
previous experience-coping mechanisms for pain past experiences
anxiety-mild good for focusing, excessive causes catecholamine secretion which increases stimuli to brain causing fear, muscle tension, increased discomfort

4. Psychoprophylaxis Lamaze-grew from Pavlov’s work on conditioning
Relaxation techniques relax all muscle groups
Breathing patterns
Effleurage- light stroking of the abdomen, thigh or chest
Water therapy buoyancy and warmth fosters relaxation
Web link to breathing patterns

5. Psychoprophylaxis Other Methods
Grantley Dick-Read-3 techniques-exercise, relaxation, breathing techniques
Bradley-husband coached childbirth-relaxed, quiet, slow breathing controlled
Hypnosis (hypno birthing)
Positioning-pillows, support
Transcutaneous Electrical Nerve Stimulation (TENS)-based on gate control theory

6. Analgesia (IV, IM)
Goal: Pt. has maximum pain relief at minimal risk to mother and fetus. Pt. is conscious but sedated and retains full motor function.

7. Systemic Analgesia
Narcotics-all narcotics may cause respiratory depression in mom &/or CNS depression in fetus
Meperidine HCL (Demerol) may be give IV or IM in 1st stage of labor
Fentanyl (Sublimaze)may be given IV or IM in 1st stage of labor
Mixed narcotic agonist-antagonists
Stadol may be give 0.5 mg -2mg IV or IM. 1st stage
Nubain 5-10 mg IV or IM in 1st stage of labor. Only until 4 cm without order

8. Systemic Analgesia Cont’d
Analgesic Potentiators (ataractics). Do not decrease pain but decrease anxiety and apprehension and potentiate the action of narcotics
Phenothiazines-Phenergan, compazine, vistaril, used to promote relaxation, allay anxiety, control emesis, and potentiate narcotic effect.
Narcotic Antagonists: Narcan reverses the action of narcotics both adults and neonates.
Dose for infant= 0.01mg/kg IM, IV, SQ may be repeated
Dose for adult= mg IV q 2-3 minutes prn

9. Sedatives and Tranquilizers
Benzodiazepines
valium, versed-used to reduce anxiety, sedative /hypnotic (C-section)
Butyrophenones
inapsine, haldol-used to produce profound amnesia and post--op sedation
Barbituates
seconal, pentobarbital-used to promote relaxation and sleep in early or false labor.

10. Nursing Care Maternal Status Fetal status Labor Status
check BP, watch for decreased respirations, encourage rest b/t contractions.
Fetal status
note a decrease in beat to beat variability
Try to administer narcotic IV during the contraction over appropriate time frame. Why?
Labor Status
relaxation fosters dilation

11. Anesthesia
A total loss of sensory capability, may be regional or centrally to brain (consciousness is lost); usually implies that one or more vital organ functions are under partial or total control of anesthesia provider.
Regional Blocks-differentiate site of insertion in each type

12. Epidural Anesthesia Epidural: Advantages Disadvantages
mom alert and cooperative, only partial paralysis, gastric emptying delay, blood loss minimal, decrease effect on fetus
Disadvantages
maternal hypotension ☺, need for IV, numbness heaviness of legs, may make labor longer increase pushing.

13. Epidural Anesthesia
Note that the needle does NOT cross the dura mater

14. Spinal Anesthesia Spinal Block Advantages Disadvantages
good pain control, alert and awake, no resp. effects
Disadvantages
marked hypotension,  cardiac output, spinal H/A, loss of motor function and sensory function
Complications-spinal H/A—constant H/A when HOB elevated, sx alleviated when lying flat.
Treatment-Blood patch, caffeine intake

15. Spinal Anesthesia

16. Nursing Care with Epidural Anesthesia
Careful hemodynamic monitoring
Assess BP q5 minutes at beginning of procedure and continue til 20minutes after insertion of catheter. Longer if BP is decreased.
Bolus with 1000ml of fluid, commonly Lactated Ringers solution, prior to beginning procedure.
Positioning
Client is asked to sit at the side of the bed. Have ct relax, drop shoulders, use relaxation breathing during contractions.
Help ct stay still and push lower back out towards the anesthesiologist

17. Link for information on Blood Patch for post Spinal Headache

18. Anesthesia cont’d
Pudendal Block numbs the nerves that run along vaginal canal
Advantages
alert, motor control, complete perineal anesthesia, no maternal hemodynamic changes
Disadvantages
lack pushing sensation, increase change of forceps or vacuum.
Local infiltration numbness of area for epis, used at time of delivery
rapid anesthesia 10 min.
none

19. Pudendal Anesthesia

20. Local Infiltration

21. Anesthesia cont’d Use of epidural and intrathecal narcotics
short-acting
Fentanyl or Sufenta-short term pain relief good for rapid laboring patients
long-acting
Morphine (Duramorph or Astromorph—long-acting)☺
Risks to mother and common side effects —resp depression, decreased motor function, itching, dizziness.
Essential nursing assessments—assess respiratory status and sensorimotor status q 1hr X 24hr.
Interventions-Benadryl, Nubain for itching
Use of nitrous oxide

22. Anesthesia cont’d General Anesthesia –emergencies only
IV anesthesia-NaPenthothal
Complications
fetal depression-fast delivery
uterine relaxation-increase bleeding due to relaxation
vomiting and aspiration-Bicitra 30 min before
Nursing Care
use of antacid (Bicitra)
Positioning mother-assist intubation

23. Anesthesia cont’d Types of anesthetics
Amides-Lidocaine, Mepivacaine, Bupivicaine (Marcaine):
more powerful and longer acting, placental transfer and affect on fetus
Esters-Procaine(novacaine), Nesacaine, Pontocaine,
metabolize quickly, placental transfer

24. Whew that’s all!!!!