Pain Relief During Labor

ANALGESIA AND ANESTHESIA

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.

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.

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 FetusNo 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 complicationsDelivery 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 placentaHalf-life is 2.5 hrs. (mother) & 13 hrs. (newborn)Right > administration, FHR variability may decreaseNarcan (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 AnesthesiaLocal anesthesia: local anesthetic directly into perineum. Used for minor procedures. No effects on newborn.Lidocaine 1% typically used for NSVDRelieves pain from episiotomies or when suturing episiotomy and/or lacerations from vaginal deliveries.Rapid onsetClient 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 USAadministered > active labor established Good analgesia without CNS depression in mom or fetus; Relieves pain from uterine contractions, vaginal delivery, C/SAnalgesia block from T-10 to S-5Epidurals 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 IVFTx 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/SCan elevate maternal temp. Bladder sensation lost – insert foley catheter Interfere with descent and rotation of fetus Long-term problemsBackache; headaches; Migraine headacheNeckache; Tingling in hands or fingers

Technique for Epidural Analgesia

Get informed consentMonitor 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 positionEpidural 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 AnesthesiaSubarachnoid 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 anestheticVasodilatation & obstructed venous return from uterine compression of vena cava and large veinsManage:L side, hydrate with 500-1000 cc of RL/NS, ephedrine 5-10 mg IVSpinal 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 effective5 mL of blood without anticoagulunt - injected into epidural space - forms clot & stops leakageVS observed for ~ 2 hrs.

Post-op Pain Management:

Administered either by IVP, IM or PCA (Patient control anesthesia) Medications such as:Fentanyl ; Morphine ; DemerolDuramorph/astromorph- systemic effects ~ 24 hours without PCA/IM medication. Vital signs monitored closelyMonitor q 15 minutes for first hour:BP, P, RR, HRPain, Motor Sensory, Alertness, Epidural accessPCA bolus/infusion amount and VTBIThen, 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/allergyProphylactic 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 deliveryComplications: Pulmonary aspiration of gastric contents, failed intubation, aspiration pneumonia, neonatal depression. NPO for about 8 hours.

Elements of Reproductive Health.

The following are the priority health care services identified as the Ten Elements of RH:

1) Family Planning (FP)2) Maternal & Child Health and Nutrition (MCHN)3) Prevention & Management of Abortion and its Complications (PMAC),4) Prevention and Management of Reproductive Tract Infections (RTIs)5) Education and Counseling on Sexuality and Sexual Health6) Breast & Reproductive Tract Cancers & other Gynecological Conditions7) Men's Reproductive Health8) Adolescent & Youth Health9) Violence Against Women & Children10) Prevention & Treatment of Infertility & Sexual Dysfunction

1. Family planning, information and services; 2. Maternal, infant and child health and nutrition including breastfeeding; 3. Proscription of abortion and management of abortion complications; 4. Adolescent and youth reproductive health guidance and counselling; 5. Prevention, treatment and management of reproductive tract infections – HIV and AIDS; 6. Elimination of violence against women and children; 7. Age-and development-appropriate education and counselling on sexuality and RH; 8. Treatment of breast and reproductive tract cancers and other gynaecological conditions and disorders; 9. Male responsibility and involvement and men’s RH; 10. Prevention, treatment and management of infertility and sexual dysfunction; 11. Age-and development-appropriate RH education for adolescents in formal and non-formal educational settings; and 12. Mental health aspect of reproductive health care.

OPERATIVE OBSTETRICS

DefinitionPreoperative care is the preparation and management of a patient prior to surgery. It includes both physical and psychological preparation.

Purpose

Patients who are physically and psychologically prepared for surgery tend to have better surgical outcomes. Preoperative teaching meets the patient's need for information regarding the surgical experience, which in turn may alleviate most of his or her fears. Patients who are more knowledgeable about what to expect after surgery, and who have an opportunity to express their goals and opinions, often cope better with postoperative pain and decreased mobility. Preoperative care is extremely important prior to any invasive procedure, regardless of whether the procedure is minimally invasive or a form of major surgery.

Preoperative teaching must be individualized for each patient. Some people want as much information as possible, while others prefer only minimal information because too much knowledge may increase their anxiety. Patients have different abilities to comprehend medical procedures; some prefer printed information, while others learn more from oral presentations. It is important for the patient to ask questions during preoperative teaching sessions.

DescriptionPreoperative care involves many components, and may be done the day before surgery in the hospital, or during the weeks before surgery on an outpatient basis. Many surgical procedures are now performed in a day surgery setting, and the patient is never admitted to the hospital.

Physical preparationPhysical preparation may consist of a complete medical history and physical exam, including the patient's surgical and anesthesia background. The patient should inform the physician and hospital staff if he or she has ever had an adverse reaction to anesthesia (such as anaphylactic shock), or if there is a family history of malignant hyperthermia. Laboratory tests may include complete blood count , electrolytes, prothrombin time, activated partial thromboplastin time, and urinalysis . The patient will most likely have an electrocardiogram (EKG) if he or she has a history of cardiac disease, or is over 50 years of age. A chest x ray is done if the patient has a history of respiratory disease. Part of the preparation includes assessment for risk factors that might impair healing, such as nutritional deficiencies, steroid use, radiation or chemotherapy, drug or alcohol abuse, or metabolic diseases such as diabetes. The patient should also provide a list of all medications, vitamins, and herbal or food supplements that he or she uses. Supplements are often overlooked, but may cause adverse effects when used with general

anesthetics (e.g., St. John's wort, valerian root). Some supplements can prolong bleeding time (e.g., garlic, gingko biloba).

Latex allergy has become a public health concern. Latex is found in most sterile surgical gloves, and is a common component in other medical supplies including general anesthesia masks, tubing, and multi-dose medication vials. It is estimated that 1–6% of the general population and 8–17% of health care workers have this allergy. Children with disabilities are particularly susceptible. This includes children with spina bifida, congenital urological abnormalities, cerebral palsy, and Dandy-Walker syndrome. At least 50% of children with spina bifida are latex-sensitive as a result of early, frequent surgical exposure. There is currently no cure available for latex allergy, and research has found that the allergy accounts for up to 19% of all anaphylactic reactions during surgery. The best treatment is prevention, but immediate symptomatic treatment is required if the allergic response occurs. Every patient should be assessed for a potential latex reaction. Patients with latex sensitivity should have their chart flagged with a caution label. Latex-free gloves and supplies must be used for anyone with a documented latex allergy.

Bowel clearance may be ordered if the patient is having surgery of the lower gastrointestinal tract. The patient should start the bowel preparation early the evening before surgery to prevent interrupted sleep during the night. Some patients may benefit from a sleeping pill the night before surgery.

The night before surgery, skin preparation is often ordered, which can take the form of scrubbing with a special soap (i.e., Hibiclens), or possibly hair removal from the surgical area. Shaving hair is no longer recommended because studies show that this practice may increase the chance of infection. Instead, adhesive barrier drapes can contain hair growth on the skin around the incision.

Psychological preparationPatients are often fearful or anxious about having surgery. It is often helpful for them to express their concerns to health care workers. This can be especially beneficial for patients who are critically ill, or who are having a high-risk procedure. The family needs to be included in psychological preoperative care. Pastoral care is usually offered in the hospital. If the patient has a fear of dying during surgery, this concern should be expressed, and the surgeon notified. In some cases, the procedure may be postponed until the patient feels more secure.

Children may be especially fearful. They should be allowed to have a parent with them as much as possible, as long as the parent is not demonstrably fearful and contributing to the child's apprehension. Children should be encouraged to bring a favorite toy or blanket to the hospital on the day of surgery.

Patients and families who are prepared psychologically tend to cope better with the patient's postoperative course. Preparation leads to superior outcomes since the goals of recovery are known ahead of time, and the patient is able to manage postoperative pain more effectively.

Informed consentThe patient's or guardian's written consent for the surgery is a vital portion of preoperative care. By law, the physician who will perform the procedure must explain the risks and benefits of the surgery, along with other treatment options. However, the nurse is often the person who actually witnesses the patient's signature on the consent form. It is important that the patient understands everything he or she has been told. Sometimes, patients are asked to explain what they were told so that the health care professional can determine how much is understood.

Patients who are mentally impaired, heavily sedated, or critically ill are not considered legally able to give consent. In this situation, the next of kin (spouse, adult child, adult sibling, or person with medical power of attorney ) may act as a surrogate and sign the consent form. Children under age 18 must have a parent or guardian sign.

Preoperative teaching

Preoperative teaching includes instruction about the preoperative period, the surgery itself, and the postoperative period.

Instruction about the preoperative period deals primarily with the arrival time, where the patient should go on the day of surgery, and how to prepare for surgery. For example, patients should be told how long they should be NPO (nothing by mouth), which medications to take prior to surgery, and the medications that should be brought with them (such as inhalers for patients with asthma).

Instruction about the surgery itself includes informing the patient about what will be done during the surgery, and how long the procedure is expected to take. The patient should be told where the incision will be. Children having surgery should be allowed to "practice" on a doll or stuffed animal. It may be helpful to demonstrate procedures on the doll prior to performing them on the child. It is also important for family members (or other concerned parties) to know where to wait during surgery, when they can expect progress information, and how long it will be before they can see the patient.

Knowledge about what to expect during the postoperative period is one of the best ways to improve the patient's outcome. Instruction about expected activities can also increase compliance and help prevent complications. This includes the opportunity for the patient to practice coughing and deep breathing exercises, use an incentive spirometer, and practice splinting the incision. Additionally, the patient should be informed about early ambulation (getting out of bed). The patient should also be taught that the respiratory interventions decrease

the occurrence of pneumonia, and that early leg exercises and ambulation decrease the risk of blood clots.

Patients hospitalized postoperatively should be informed about the tubes and equipment that they will have. These may include multiple intravenous lines, drainage tubes, dressings, and monitoring devices. In addition, they may have sequential compression stockings on their legs to prevent blood clots until they start ambulating.

Pain management is the primary concern for many patients having surgery. Preoperative instruction should include information about the pain management method that they will utilize postoperatively. Patients should be encouraged to ask for or take pain medication before the pain becomes unbearable, and should be taught how to rate their discomfort on a pain scale. This instruction allows the patients, and others who may be assessing them, to evaluate the pain consistently. If they will be using a patient-controlled analgesia pump, instruction should take place during the preoperative period. Use of alternative methods of pain control (distraction, imagery, positioning, mindfulness meditation, music therapy) may also be presented.

Finally, the patient should understand long-term goals such as when he or she will be able to eat solid food, go home, drive a car, and return to work.

PreparationIt is important to allow adequate time for preparation prior to surgery. The patient should understand that he or she has the right to add or strike out items on the generic consent form that do not pertain to the specific surgery. For example, a patient who is about to undergo a tonsillectomy might choose to strike out (and initial) an item that indicates sterility might be a complication of the operation.

Normal resultsThe anticipated outcome of preoperative care is a patient who is informed about the surgical course, and copes with it successfully. The goal is to decrease complications and promote recovery.

Read more: http://www.surgeryencyclopedia.com/Pa-St/Preoperative-Care.html#ixzz3jSPuj88l

INTRA OPERATIVEDefinition

The intraoperative phase extends from the time the client is admitted to the operating room, to the time of anesthesia administration, performance of the surgical procedure and until the client is transported to the recovery room or postanethesia care unit (PACU). Throughout the surgical

experience the nurse functions as the patient’s chief advocate. The nurse’s care and concern extend from the time the patient is prepared for and instructed about the forthcoming surgical procedure to the immediate preoperative period and into the operative phase and recovery from anesthesia. The patient needs the security of knowing that someone is providing protection during the procedure and while he is anesthetized because surgery is usually a stressful experience.

Goals during the Intraoperative Phase

Promote the principle of asepsis HomeostasisSafe administration of anesthesiaHemostasisThe Surgical Team

The intraoperative phase begins when the patient is received in the surgical area and lasts until the patient is transferred to the recovery area. Although the surgeon has the most important role in this phase, there are key members of the surgical team.

Surgeon – leader of the surgical team. He or she is ultimately responsible for performing the surgery effectively and safely; however, he is dependent upon other members of the team for the patient’s emotional well being and physiologic monitoring.

Anesthesiologist or anesthetist – provides smooth induction of the patient’s anesthesia in order to prevent pain. This member is also responsible for maintaining satisfactory degrees of relaxation of the patient for the duration of the surgical procedure. Aside from that, the anesthesiologist continually monitors the physiologic status of the patient for the duration of the surgical procedure and the physiologic status of the patient to include oxygen exchange, systemic circulation, neurologic status, and vital signs. He or she then informs and advises the surgeon of impending complications.

Scrub Nurse or Assistant – a nurse or surgical technician who prepares the surgical set-up, maintains surgical asepsis while draping and handling instruments, and assists the surgeon by passing instruments, sutures, and supplies.

Circulating Nurse – respond to request from the surgeon, anesthesiologist or anesthetist, obtain supplies, deliver supplies to the sterile field, and carry out the nursing care plan.