Download Pain Management - Postabortion Care

Emergency Treatment
Module 2 - Session 3
Pain Management
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
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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.
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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.
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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.
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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
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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
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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.
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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.
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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.
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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.
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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.
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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.
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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)
T12
L1
L2
L3
L4
-- Utero-vaginal plexus: cervix and
upper vagina (S2, S3, S4)
Uterus
S2
S3
S4
Cervix
Vagina
Hypogastric plexus: body, fundus of uterus
Uterovaginal plexus: cervix, upper vagina
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Types of Pain Control Medication
Analgesia
Eases sensation of pain
(e.g., paracetamol)
Anesthetic
Deadens all physical sensation
(e.g., lignocaine)
Anxiolytic
Depresses nervous system functions,
reduces anxiety and relaxes muscle
(e.g., diazepam)
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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.
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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.
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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.
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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
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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
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Use of Anesthesia
General
Affects pain receptors in the brain; client
unconscious
Regional
Blocks sensation from a specific point on the spine;
client awake
Local
Interrupts transmission of sensations in local tissue
only; safest for MVA
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Characteristics of Anesthesia
Type
Possible Complications
Local
Drug allergy or seizure (rare), vaso-vagal reaction
Regional
Hypotension, cardiac arrest, central nervous system
infection, spinal cord injury, drug allergy, seizure
General
Hypoxia, cardiac arrest, drug allergy, aspiration of drug
contents
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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
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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.
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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.
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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.
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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.
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Paracervical Block: Injection Sites
Optional
Injection
Sites
Injection
Sites
See reference manual for instructions for
performing paracervical block.
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