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. clients 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 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 cant 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.

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 Health
6) Breast & Reproductive Tract Cancers & other Gynecological
Conditions
7) Men's Reproductive Health
8) Adolescent & Youth Health
9) Violence Against Women & Children
10) 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 mens 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
Definition
Preoperative 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.
Description
Preoperative 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 preparation
Physical 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 16% of the general population and
817% 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 preparation
Patients 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 consent
The 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.
Preparation
It 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 results
The 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 OPERATIVE
Definition
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 patients chief advocate. The nurses 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
Homeostasis
Safe administration of anesthesia
Hemostasis
The 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 patients emotional well being and physiologic monitoring.
Anesthesiologist or anesthetist provides smooth induction of the patients 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.