Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Pain Relief During Labor Lecture 7 Principles of Pain Relief Treatments for pain relief during labor depends on: 1. client’s tolerance for pain 2. ability to focus on labor 3. ability to remain motivated. Some of labor process done @ home: aromatherapy, warm bath, music, visualization, breathing exercises, massage. hypnosis, acupuncture. ~ 70% clients ask for epidural Method of Pain Relief Should Exhibit: Simplicity Safety Preservation of fetal homeostasis Monitor client closely: B/P, Pulse, RR, FHR, anesthetic levels, maternal oxygenation. Analgesia and Sedation During Labor Analgesia: loss of sensitivity to pain. Pain meds can be sufficient to get through labor along with: aromatherapy, music, visualization, etc. Systemic drugs - 3 factors to consider – effects on mother – effects on fetus - all systemic drugs cross placenta by simple diffusion. – Fetal liver & kidney function immature, drugs metabolized slowly & effects last longer – Affect progress of labor; can slow labor. Assessment – Maternal assessment informed consent ; VS stable – Fetal assessment FHR 110-160/min with no late/variable decels. Variability average. Normal fetal movement and accelerations present. Term Fetus No Meconium – Labor assessment Contraction pattern well established. Cervix 4-5 cm dilated in primips and 3-4 in multips Progressive descent of presenting part no complications Delivery at least 2-3 hours away. Narcotic Pain Relief: Meperidine (Demerol) and Promethazine (Phenergan) – Demerol 25-100mg with Phenergan 25 mg IM or IVP q 2-4 hours – crosses placenta – Half-life is 2.5 hrs. (mother) & 13 hrs. (newborn) – Right > administration, FHR variability may decrease – Narcan (naloxone) antagonist Butorphanol (Stadol) 1-2 mg IVP/IM x2. Stronger than Morphine & Demerol. Starts working in < 5 min. Has minimal fetal effects; may cause hallucinations in mom. Nalbuphine (Nubain) – 15-20 mg IVP/IM does not cause neonatal depression. Fentanyl –short-acting potent synthetic opioid. 50-100 mcg IV q 1hr. Used in spinal/epidural. Anesthesia Anesthesia: reversible loss of sensation & movement in region of body. Types of Anesthesia Local anesthesia: local anesthetic directly into perineum. Used for minor procedures. No effects on newborn. Lidocaine 1% typically used for NSVD – Relieves pain from episiotomies or when suturing episiotomy and/or lacerations from vaginal deliveries. – Rapid onset – Client awake Pudendal Block - Relieves pain associated with 2nd (pushing) stage of labor. Lidocaine 1% used. - through vaginal wall and into pudendal nerve in pelvis, numbs area between vagina & anus - 22 gauge needle [bilateral] – Does not relieve pain of contractions. – Works quickly; does not affect baby. – Given shortly before delivery, but cannot be used if baby's head is too far down in birth canal. – Can prolong 2nd stage labor d/t loss of bearing-down reflex. – Provides satisfactory perineal anesthesia for normal delivery, low forceps manipulation, episiotomy. Regional anesthesia - injection of local anesthetic around nerves of spinal cord to block pain from larger but still limited part of body. Types: 1. Epidural Anesthesia Usually uses Marcaine (bupivicaine) - into epidural space at 3rd - 4th lumbar interspace. single dose to be repeated or as continuous infusion; common in USA administered > active labor established Good analgesia without CNS depression in mom or fetus; Relieves pain from uterine contractions, vaginal delivery, C/S Analgesia block from T-10 to S-5 Epidurals slow labor and may require Pitocin (oxytocin) augmentation. Most common complications: Maternal hypotension > can lead to> fetal bradycardia and late decelerations. Preloading 1000ml of RL IVF Tx hypotension with ephedrine. Less w. continuous infusion than single dose Other complications: total spinal block & respiratory paralysis (improper placement of catheter) Does not prolong 1st stage labor if established Can interfere with woman's ability to push. May ^ C/S Can elevate maternal temp. Bladder sensation lost – insert foley catheter Interfere with descent and rotation of fetus Long-term problems – Backache; headaches; Migraine headache – Neckache; Tingling in hands or fingers Technique for Epidural Analgesia Get informed consent Monitor BP, P, FHR, q 1-2 min. for 15 min. > bolus of local anesthetic. Maintain verbal communication with patient. Hydrate w. RL 500-1000 cc. to maintain BP. Patient maintains lateral or sitting position Epidural space identified - catheter threaded 3cm Test dose given - observe for s/s of toxicity (metalic taste, ringing in ears, palpitations) Place in lateral or semifowler to prevent aortocaval compression. Maternal BP monitored q 5-15 min. Analgesia level assessed. 2. Spinal Anesthesia – Subarachnoid space [lumbar region] - provides spinal block. Passes through dura & CSF reached. Meds inserted, needle removed. – Spinal cord above this site. – Used in C/S. Block level from 8th thoracic dermatome [ xiphoid process/breast. Longer anesthetic effects. – Anesthetics used: bupivacaine, lidocaine, fentanyl. Duramorph {morphine} side effects include urinary retention (foley), pruritis, nausea, hypotension. Preload with RL (1000cc). Maintain IVF. Complications: Hypotension [20% decrease from baseline]; may occur > administration of local anesthetic Vasodilatation & obstructed venous return from uterine compression of vena cava and large veins – Manage: L side, hydrate with 500-1000 cc of RL/NS, ephedrine 5-10 mg IV Spinal Headache (low volume/low pressure in spinal column) – CSF leaks from site of puncture @ dura mater. – Treatment: lie flat for few hours. Vigorous IV hydration. Blood patch – very effective – 5 mL of blood without anticoagulunt - injected into epidural space - forms clot & stops leakage – VS observed for ~ 2 hrs. Post-op Pain Management: administered either by IVP, IM or PCA (Patient control anesthesia) Medications such as: Fentanyl ; Morphine ; Demerol Duramorph/astromorph- systemic effects ~ 24 hours without PCA/IM medication. – Vital signs monitored closely Monitor q 15 minutes for first hour: – BP, P, RR, HR – Pain, Motor Sensory, Alertness, Epidural access – PCA bolus/infusion amount and VTBI Then, 30 minutes x2 , q hour X 4 hours, q 4 hrs. X 24 hrs. Patient education - Inform patient – PCA is continuous programmed infusion pump. Patient may self-administer medication – Reassure patient - overdose can’t occur; Infusion programmed – delivers additional med q 10 - 15 minutes; lock out system. General Anesthesia (total induced unconsciousness) C-sec → fetal distress, failed epidural/spinal/allergy Prophylactic antacid – 30 cc Bicitra Pre-O2; wedge under R hip - prevents venacaval compression. Induced unconsciousness [inhalation or IV therapy] Halothane, ketamine, nitrous oxide, thiopental Endotracheal intubation Cricoid pressure on trachea - occludes esophagus & prevents aspiration. After intubation, additional meds given via IV & ET tube - maintains anesthesia for rest of surgery. Used for emergency delivery Complications: Pulmonary aspiration of gastric contents, failed intubation, aspiration pneumonia, neonatal depression. NPO for about 8 hours.