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Pharmacologic Pain Management During Labor

Objectives. Identify several ways to help patients cope with labor painIdentify which method(s) of pain relief is appropriate for the different phases of laborDescribe the appropriate nursing care before, during, and after selected pain relief methods. Physiologic Responses to Pain. Release of C

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Pharmacologic Pain Management During Labor

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    1. Pharmacologic Pain Management During Labor By: Karina Schaub, RNC, MN

    2. Objectives Identify several ways to help patients cope with labor pain Identify which method(s) of pain relief is appropriate for the different phases of labor Describe the appropriate nursing care before, during, and after selected pain relief methods

    3. Physiologic Responses to Pain Release of Catecholamines BP HR RR Tension

    4. 2 Kinds of Pain Visceral (Internal) 1st stage of labor Lactic acid accumulation Cervical and lower uterine segment stretching Tension on ovaries and fallopian tubes Pressure on bony pelvis.

    5. Pharmacologic Coping Narcotics PO IM IV Epidural Walking Epidural Intrathecal Pudendal

    6. Assess Patient for Stage of Labor 1st Stage of Labor Early Labor Active Labor Transition 2nd Stage of Labor Impending Delivery

    7. Pregnancy Risk Categories Category A Studies in pregnant women have not shown and increased risk to fetus Category B Animal studies show no risk to fetus but there are no adequate studies of pregnant women OR Animal studies have shown an adverse effect to fetus but studies of pregnant women have shown no risk to fetus Category C Animal studies have shown an adverse effect to fetus but there are no adequate studies of pregnant women OR There are no animal studies or pregnant women studies done

    8. Pregnancy Risk Categories contd Category D Studies in pregnant women have shown a risk to fetus but the benefits of the drug may outweigh the risks Category X Studies in pregnant women and animals have shown evidence of fetal abnormalities The use of this drug in contraindicated in pregnancy

    9. Outpatient Pain Medications

    10. Outpatient Medications

    11. Inpatient Pain Medication

    12. Effects of Medication on Patient Alleviate some pain but not all Causes drowsiness Causes a lightheaded feeling Will help her to cope with labor

    13. Effect of Medication on Fetus Decreased Variability Depressed Respiratory System How long will it last? Look at peak of medication administered Look at duration of medication administered Consider O2

    14. Pain Medication Nursing Considerations Monitor before & after administration Fetal Wellbeing V/S BRP Ambulation

    15. Epidural (Regional Anesthesia) Preparation Provider Order Pt Consent Baseline v/s IV Bolus Alka Seltzer Gold or Bicitra Epidural Cart Call Anesthesiologist

    16. Special Considerations Allergies Unstable v/s Positive Blood Culture PIH labs (Platelets, PT/PTT/INR) Coagulation Disorders Fetal Distress

    17. Epidural Placement Pitocin On or Off ? Positioning

    18. Epidural Procedure: Betadine solution to clean area Local Anesthetic to numb area Placement of epidural between L2 & L5 Test dose

    19. Epidural Placement Test dose HR monitor Drug used is Lidocaine & Epinephrine Administered between contractions If in Spinal area: Legs suddenly go numb If in Blood Vessel: Sudden increase in HR Pt experiences palpitations Ringing in ears Metal taste in mouth

    20. Epidural Initial injection after test dose and continuous infusion of: Local Anesthetic (Bupivicaine or Ropivicaine) Narcotic (Fentanyl) May have option of PCEA for bolus of medicine

    21. Epidural Care Supine Position with Tilt Monitor B/P, HR, RR Closely Q 3-5 minutes per Anesthesiologist Per hospital protocol after stable Continuous Fetal Monitoring Dermatome level T6 or below

    22. Epidural Emergency #1 Pts B/P drops Is pt dizzy or lightheaded? IV open for bolus HOB down with pt tilted O2 Inform Anesthesiologist Fetal Heart Tones <90 SBP compromises baby

    23. Epidural Emergency #2 Drop in Fetal Heart Tones Drop in maternal B/P? Baby may show signs before mom does Pt position change IV open for bolus Oxygen Inform Anesthesiologist

    24. Epidural Emergency #3 Pt c/o Shortness of Breath Positioning in bed O2 Saturations Check Dermatome Level If continues, report to Anesthesiologist

    25. Epidural Emergency #4 You walk in and assess your patient to find: RR < 10 / min Shallow RR Decreased LOC

    26. Epidural Patient Teaching

    27. Epidural Patient Teaching contd Bedrest Continuous Monitoring Alteration in Elimination Itching Breathing

    28. Walking Epidural Injection of the concentration of epidural medication Local Anesthetic Narcotic Pt can ambulate Injected into same space as Epidural Same needle size Continuous gtt of low dose local anesthetic & narcotic

    29. Removing Epidural Discontinue gtt after delivery of baby Removing the catheter Is pt having a tubal ligation? Positioning Look for black tip

    30. Intrathecal Single injection Injection into Subarachnoid Space (Dura) Same area spinals are given Same needle size as spinals Medications injected are Local Anesthetic (Marcaine) Narcotic (Fentanyl) Wears off in 2 hrs

    31. Spinal Headache Occurs most often 24 hrs post procedure Occurs most often with Epidural as opposed to Spinal or Intrathecal HA is worse sitting up Treatment is a blood patch Anesthesiologist performs 10ml of blood injected into epidural space Pt stays supine for 10 minutes Immediate HA relief

    32. Pudendal Used shortly before delivery Single injection of Lidocaine Blocks pain in vaginal and anal area (Somatic pain) Does not relieve contraction pain Takes effect instantly Lasts about an hour May affect breastfeeding immediately after birth

    33. Conclusion Follow the recommended guidelines for monitoring the patient and fetus when administering medications Keep patient informed of normal side effects of medications they will be receiving Report any abnormal side effects to the appropriate provider

    34. Questions ?

    35. References Adam. Positions for an Epidural. [Online Image] Retrieved June 25, 2010 from http://www.pennmedicine.org/health_info/pregnancy/graphics/images/en/19169.jpg . American Pregnancy Association (2007). Pudendal Block. Retrieved June 18, 2009 from http://www.americanpregnancy.org/labornbirth/pudendalblock.htm. American Society of PeriAnesthesia Nurses (1992). Standards of Post Anesthesia Nursing Practice. Association of Womens Health, Obstetric and Neonatal Nurses. (2001). Evidence-Based Clinical Practice Guidelines, Nursing Care of the Woman Receiving Regional Analgesia/Anesthesia in Labor. Barnett, A. & Ochroch, E. (2003). Epidural Analgesia: Management and Outcomes. Annals of Long-term Care, 11(11). Dermatomes. [Online Image] Retrieved June 25, 2009 from http://www.anatomyatlases.org/AnatomicVariants/NervousSystem/Images/63H.jpg. Gabbe, S., Niebyl, J., & Simpson, J. (1997). Obstetrics- Normal and Problem Pregnancies.

    36. References contd Gambling, D. (1996). Epidural Analgesia. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 25(8), 650. Gambling, D. (2000). Fourth Annual Perinatal Conference. Controversies in Obstetric Anesthesia. Nagoette, M. (1999). How Does An Epidural Affect the Cesarean Section Rate? Contemporary OB/GYN, 24-36. Olds, S., London M., & Ladewig, P. (1988). Maternal Newborn Nursing - A Family Centered Approach. Perineal Nerves. [Online Image] Retrieved June 21, 2009 from http://www.atlasofpelvicsurgery.com/1VulvaandIntroitus/9alcoholinjection/chap1sec9images/chap1sec9image1.jpg. Pudendal Block. [Online Image] Retrieved June 25, 2010 from http://hetv.org/resources/reproductive-health/impac/Images_P/fig79vaginal.gif Wild, L. & Coyne C. (1992). The Basics and Beyond: Epidural Analgesia. American Journal of Nursing.

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