Pain Management During Birth

1. - Tie everything together Pain Management During Birth Linda L. Franco RN MSN NE-BC

2. Systemic Drugs • All systemic drugs cross the placenta • Maternal Assessment • Woman is willing to receive medication • Stable VS • Fetal Assessment • FHR 110 – 160 • Good variability • No late or variable decelerations • Labor Assessment • Labor pattern established • Cervical dilatation • Progressive descent of baby

3. Systemic drugs are absorbed into the blood stream and distributed to all areas of the body. • Review of the function of the placenta • Extra-corporeal life support system – which means it provides life outside the body for the baby. • Fetal lung (respiration) • Kidney (excretion) • GI tract (nutrition) • Skin (heat exchange) • Endocrine organ – steroid hormones (estrogen/progesterone) and protein hormones (HPL/HCG) • Barrier against some substances – NOT MUCH OF A BARRIER ACTUALLY • Placenta vessels are normally dilated 10 x’s more than maternal vessels and allows for increased exchange surface areas. Transport based on concentration gradients. Particles move from area of higher to lower concentration. • Typically things of lower molecular weight • Requires no energy • O2, CO2, most electrolytes (na, Cl), lipids, fat soluble vitamins • Cocaine – LIPID SOLUBLE • NARCOTICS/ANTIBIOTICS can easily cross over placental barrier.

4. Maternal assessment – Check for allergies, respiratory compromise, or current drug dependency. Will talk about this later in the presentation. • Fetal Assessment – No late or variable decelerations (late (are gradual) and variable (are abrupt) decreases in the FHR of equal to or greater than 15 bpm lasting equal to or greater than 15 seconds but less than 2 minutes). Late decelerations are associated with intrauterine growth restriction (IUGR), chronic hypertension, severe pregnancy induced hypertension, diabetes, and hyperstimulation. To correct this matter, nursing interventions would focus on enhancing uterine blood flow, improve umbilical circulation, improve oxygenation, and reduction of uterine activity. • Labor Assessment – Pain medication given too early may prolong labor and depress the fetus; if given too late it is of minimal use to the woman and may lead to respiratory depression in the newborn. Check to see if the cervix is dilating and is there progressive descent of the fetal presenting part.

5. 5:40 Narcotic Analgesics • IV preferred method of administration • Demerol – 12.5mg – 25mg • Neonatal depression • Narcan to reverse effects • Stadol – 1mg - 2mg • DO NOT GIVE TO OPIATE DEPENDENT PATIENT – can cause withdrawal*** • Narcan to reverse effects • Nubain – 10mg – 20mg • Narcan to reverse effects • Analgesic Potentiators (tranquilizers, and enhance the effects) • Compliment Analgesic • Main use- sedation

6. Narcotic analgesic agents that are injected into the circulation have their primary action at sites in the brain, activating neurons that descend to the spinal cord. • Demerol is used commonly. • Stadol used with caution. If the patient does not give a thorough history and has an opiate dependency, it may precipitate withdrawal. • Analgesic Potentiators – commonly referred to as tranquilizers and decrease anxiety and increase the effectiveness of analgesics. Commonly used potentiators are phenergan, vistaril, sparine, and reglan.the main side effect associated with these medications is sedation.

7. Regional Anesthesia and AnalgesiaPain meds given too early- may prolong it Pain meds given too late- minimal use • Epidural- admin as soon as labor is established. relieves pain assoc w/ 1st stage of labor by blocking sensory nerves supplying uterus. Not having a Csection have the options of getting an epidural. • Spinal • Pudendal • Local Infiltration

8. Anesthesia vs. analgesia – • Analgesic – an agent that alleviates pain without causing loss of consciousness. Pain medication administered too early may prolong labor progress. Pain medication given too late is of minimal use to the woman and may lead to respiratory depression in the newborn. • Regional anesthesia is the temporary loss of sensation produced by injecting an anesthetic agent into direct contact with nervous tissue. Loss of sensation happens because the local agents stabilize the cell membrane, which prevents initiation and transmission of nerve impulses. • Epidural – relieves pain associated with the first stage of labor, ( from the beginning of labor to the full opening (dilatation) of the cervix (10 centimeters) by blocking the sensory nerves supplying the uterus. Until the past few years, the same anesthetic agents used for regional epidurals were also used to produce regional analgesia (pain relief to a body region) during labor. This practice became problematic because the anesthesia agents used alter the transmission of impulses to the bladder, making voiding difficult. The agents also interfere with blood pressure stability and leg movement. The descent of the fetus was slowed because of the woman’s decreased ability to push during the second stage of labor. To address these difficulties, regional analgesia is now obtained by injecting a narcotic such as fentenyl along with only a small amount of anesthetic agent.

9. Epidural • Provides relief of pain without sedation of mom and baby • Epidural space between dura mater and ligamentum flavum - L3 - L4 • Catheter remains in place for continuous infusion • Adverse effects – hypotension, prolonged second stage, respiratory depression, bladder distention, allergic response • Nursing care – fluid bolus, positioning patient, monitor VS, assess bladder, Ephedrine for hypotension • Can be given as soon as active labor is established. • Level os anesthesia is below .. To • Most common… Most Maternal hypotension. b/c if the mom gets hypotension  bradycardia to the fetus

10. A lumbar epidural block involves injection of an anesthetic agent into the epidural space to provide pain relief throughout labor. It is estimated that 50% of all women in the US receive an epidural during their labor. An epidural can be given as soon as active labor is established. Level of anesthesia is below umbilicus to toes. • Advantages are discomfort is relieved, the woman is fully awake and a part of the birth process. The most common complication of an epidural is maternal hypotension. Maternal hypotension, results in decreased blood flow to the fetus, which in turn, results in fetal bradycardia. Contraindications are client refusal, infection at the site of the needle puncture, maternal problems with blood coagulation, drug allergy to the agent and hypovolemic shock. • Nursing intervention – Infuse 500-1000 ml of fluids for preload. • Indications of Ephedrine – Releases norepinephrine which increases BP due to arteriolar constriction and cardiac stimulation. More stable and longer-lasting than epinephrine.

11. 14:20 Medications • Anesthetics • Marcaine, Xylocaine, Carbocaine, Novocaine, Nesacaine • Negative SE: affect your breathing, heartbeat, blood pressure, and other body functions • Narcotics • Fentanyl, Morphine, Duramorph, Stadol, Demerol • Negative SE: drowsiness, dizziness, breathing problems, and physical or mental dependence

12. Anesthetics • Absorption of local anesthetics depends primarily on the vascularity of the area of injection. The agents themselves contribute to increased blood flow by causing vasodilation. High concentrations of drugs cause greater vasodilation. The addition of vasoconstrictors such as epinephrine delays absorption and prolongs the anesthetic effect. Epinephrine decreases uteroplacental blood flow, making it an undesirable additive in many situations. • Marcaine, Xylocaine, Carbocaine are amides and they readily cross the placenta, can be measured in the fetal circulation, and affect the fetus for a prolonged period.

13. Spinal • Anesthetic injected directly into spinal fluid canal • Immediate onset of anesthesia • Blocks sensory and motor function; T4 – T6 for C/S • Small gauge 25-26g helps decrease spinal fluid leakage • Side effects - hypotension, bladder distention, spinal headache • Nursing care – fluid bolus, assess VS & FHR, remains in bed 6 to 12 hours after • Hypotension- Decr FHR & BP • Don’t give spinal if : CNS dx, Allergy, coagulation problems

14. Csection?  spinal instead of epidural • Easy to admin., smaller drug vol, area affected: breast to the toes (> greater coverage) • Caution fetal hypoxia. • Anemia, don’t do a spinal • Ex: Lost a lot of blood vol = gen anesthesia and Csection. • Advantages – Immediate onset of anesthesia, relative ease of administration, a need for a smaller drug volume, and maternal compartmentalization of the drug. Level of anesthesia with spinal is below the breast to toes. • Disadvantages – Primary disadvantage is blockage of sympathetic nerve fibers, resulting in a high incident of hypotension which can lead to alterations in the fetal heart rate and fetal hypoxia. • Contraindications – Severe hypovolemia, regardless of the cause, central nervous system disease; infection over the puncture site; allergy to local anesthetic agents; coagulation problems; and client refusal.

15. 18:30 Pudendal Block • Anesthesia for late 1st stage, delivery & episiotomy repair • Relief of perineal distention but not uterine contractions • Anesthetic injected directly into the pudendal nerve • Given in late stage around delivery for epiostomy repair • Administered transvaginally and intercepts the signal to the prudenal nerve. • Advantages – ease of administration and absence of maternal hypotension. • Disadvantages – possible broad ligament hematoma, perforation of the rectum, and trauma to sciatic nerve. • A moderate dose of anesthetic agent has minimal ill effects on the course of labor, but the urge to push may decrease.

16. Prudendal Block

17. Area of perineum affected by prudendal block

18. Local InfiltrationSame as prudendal block, but not as deep • Anesthesia for the episiotomy or repair of episiotomy or lacerations • Anesthetic injected into perineum • Generally used at the time of birth, both in preparation for an episiotomy if one is needed and for episiotomy repair

19. General Anesthesiafetal depression is greatest danger • Used for C/S if pt refuses spinal or for emergency C/S • Nursing care – prophylactic antacid therapy, wedge under right hip, cricoid pressure, physician gowned prior to induction, O2 3-5 min before intubation • Side effects – fetal depression, aspiration of gastric contents, light anesthesia until infant born, uterine ATONY b/c of relax- if really flaccid, then will bleed

20. Maj of gen anest causes uterine relaxation  puts client at risk for uterine apnea & hemorrhage.*** • Wedge under rt hip, to get the mom of the Vena Cava • Primary danger of general anesthesia is fetal depression. Most general anesthetic agents reach the fetus in about 2 minutes. Another risk – the majority of general anesthetics cause some degree of uterine relaxation which in turn makes the client at risk for uterine atony and hemorrhage • Wedge under right hip tilts the patient to displace the uterus and prevent vena caval compression in the supine position.