1. Pain management Dhuha F Shamsaldeen 315-316

2. Objectives 1.Explain how the pain of labor and birth differs from other types of pain. 2.Describe sources of labor pain. 3.List factors influencing the womans experience of labor pain. 4.Discuss principles of labor pain management. 5.Compare nonpharmacologic interventions to manage labor pain. 6.Explain various relaxation techniques that help a woman cope with labor. 7.Differentiate analgesia from anesthesia. 8.Describe advantages and disadvantages of opioid administration. 9.Compare methods of regional anesthesia. 10.Explain major complications associated with epidural and spinal anesthesia. 11.Discuss reasons general anesthesia is risky for a pregnant woman and her fetus. 3. What is labor ? Labor is the process by which the fetus and the placenta leave the uterus. Delivery can occur in two ways, vaginally or by a cesarean delivery. 4. Signs of labor ? Some women experience very distinct signs of labor, while others do not. No one knows what causes labor to start or when it will start, but several hormonal and physical changes may indicate the beginning of labor: Lightening Passing of the mucus plug Contractions Water breaking Effacement and dilation of the cervix 5. The Pain of Labor and Childbirth Unique Different from other types of pain (usually pain is warning sign of injury) Increased intensity desired and positive (greater intensity is associated with approaching birth) Occurs in predictable pattern (begins without warning, but once established it is predictable, respite between) 6. Causes of pain in labor Stage One Stretching of the cervix during dilation & effacement Uterine Anoxia Stretching of the uterine ligaments 7. Causes of pain in labor Stage Two Distention of the vagina and Perineum Compression of the nerve ganglia in cervix & lower uterus Pressure on urethra, bladder, rectum during fetal descent Traction on and stretching of the perineum 8. Factors affecting Mothers Response to Pain in Labor Preparation - Knowledge and confidence gained through childbirth classes Cultural influences on expression of pain Previous experiences with pain Maternal fatigue, anxiety , sleep deprivation Support 9. The goal of pain management pain management prior to delivery may help ease your anxiety in the moment of labor. 10. Pain Management Principles and Techniques Principles of pain relief during labor Women are more satisfied when they have control over the pain experience Caregivers commonly underrate the severity of pain Women who are prepared for labor usually report a more satisfying experience than do women who are not prepared 11. Pain Management Principles and Techniques (cont.) Non-Pharmacologic Pain Interventions Continuous labor support-doula Acupressure and acupuncture Relaxation techniques-helps to facilitate labor process Patterned breathing Attention focusing (imagery) Movement and positioning Touch and massage Water therapy 12. Breathing pattern 13. Movement and positioning 14. Touch and massage 15. Water therapy 16. Pain Management Principles and Techniques (cont.) Advantages and disadvantages of non-pharmacologic interventions Advantages Noninvasive Address emotional and spiritual aspects of birth Promote womens sense of control over pain Disadvantages Many of the interventions require special training and/or practice before birth These methods are not effective for every woman 17. Pharmacological Interventions Analgesia and sedation The use of medication to reduce the sensation of pain Sedatives given to promote sedation and relaxation Opioids given to promote analgesia during labor Anesthesia The use of medication to partially or totally block all sensation to an area of the body Local, regional, general 18. Analgesics and anesthetics commonly used in labor and birth 19. Type Drug Usual dosage Effect on mother Effect on labor progress Effect on fetus or newborn Narcotic analgesic Meperidine (demerol) 25 mg IV, 50- 100 mg IM q3-4 hr: also epidurally Effective of analgesic: feeling of well- being Relaxation, possibly aiding progress during cervical relaxation. Slows labor contractions if given early Should be given 3 hr before birth to avoid respiratory depression and decrease heart rate Nalbuphine(nubai n) 10-20 mg IM q3- 6 hr, 0.3-3 mg/kg over 10- 15 min IV Slowing of respiratory rate; effective analgesic Mild maternal sedation Results in some respiratory depression Butorphinol (stadol) 1-2 mg IM or IV q3-4hr Withdrawal symptoms if woman is opiate dependent Possible slowing of labor if given early Results in some respiratory depression Morphine sulfate Intrathecally 0.2-1mg: 5 mg epidurally Pruritus; effective analgesia Possible slowing of labor contractions some respiratory depression Fentanyl (subilimaze) 50-100g IM or 25-50 g IV ; epidurally Hypotension; respiratory depression slowing of labor if given early respiratory depression 20. Type Drug Usual dosage Effect on mother Effect on labor progress Effect on fetus or newborn Lumbar epidural block Marcaine or Naropin Administered for first stage of labor; with continuous block, anesthesia will last through birth; injected at L3-4; Rapid onset, in minutes; lasting 60-90 min; loss of pain perception of labor contractions and birth; possible maternal hypotension slowing of labor if given early; pushing feeling obliterated resulting in possible prolonged second stage May result in respiratory depression. May be some differences in response in first few days of life. Pudendal block Local anesthetic lidocaine (Xylocaine) Administered just before birth for perineal anesthesia; injected through vagina Rapid anesthesia of perineum None apparent None apparent Local infiltration of perineum Local anesthetic lidocaine (Xylocaine) Injected just before episiotomy incision anesthesia of perineum Almost immediately None apparent None apparent General intravenous anesthetic thiopental Administered IV by anesthesiologist or nurse- anesthetist Rapid anesthesia; also rapid recovery Forceps required because abdominal pushing is no longer possible Results in infant being born with CNS deperssion 21. Pharmacological Interventions (cont.) Advantages and Disadvantages of Opioid Administration Advantages an increased ability for a woman to cope with labor The medications may be nurse-administered Disadvantages Frequent occurrence of uncomfortable side effects, such as nausea and vomiting, pruritus, drowsiness, and neonatal depression Pain is not eliminated completely 22. Pharmacological Interventions (cont.) Types of anesthesia Local anesthesia Used to numb the perineum just before birth to allow for episiotomy and repair Regional anesthesia Involves blocking a group of sensory nerves that supply a particular organ or area of the body General anesthesia Not used frequently in obstetrics because of the risks involved 23. Pharmacological Interventions (cont.) Types of regional anesthesia Pudendal block-pain relief for the birth Paracervical block-pain relief during labor Epidural anesthesia-pain relief during labor Intrathecal anesthesia-provides pain relief until the epirdural begins to work 24. Epidural Anesthesia Injection of an anesthetic agent into the epidural space Provides pain relief during labor and delivery 25. Spinal Anesthesia A local anesthetic is injected directly into the spinal fluid in the spinal canal to provide anesthesia for cesarean birth and occasionally for vaginal birth 26. Pudendal Anesthesia Anesthesia administered transvaginally and intercepts pudendal nerve. Provides pain relief for episiotomy and delivery. 27. Local Anesthesia Local injection of anesthetic agent in the perineum for episiotomy and repair 28. Pharmacological Interventions (cont.) Complications Associated With Epidural and Spinal Anesthesia Hypotension Maternal fever Shivering Pruritus Inadvertent injection into the blood stream Spinal headache Fetal distress 29. Pharmacological Interventions (cont.) Life-Threatening Complications Occurring With General Anesthesia Failed intubation-due to physiological changes: trachea and thorax Aspiration-often premedicated Malignant hyperthermia-(rare) inherited condition that causes sustained muscle contractions in the presence of certain anesthetic agents 30. Refrencess http://www.webmd.com/baby/guide/pregnancy-pain-relief http://www.webmd.com/baby/labor-signs Pilitteri, A.(2010) Maternal and Child Health Nursing, Philadelphia. J.B Lippincott Co. (6th edition) Pp 395- 414 ch16