Pharmacologic Pain Relief: It s Use in Labor. Linda Robinson MSN, RNC Clinical Nurse Specialist, Northwest Hospital Spring, 2016

Transcription

1 Pharmacologic Pain Relief: It s Use in Labor Linda Robinson MSN, RNC Clinical Nurse Specialist, Northwest Hospital Spring, 2016

2 Objectives Recognize common medications used in the management of labor pain List the expected effects, side effects, and duration of action of medications Describe the appropriate nursing care before, during and after the administration of regional anesthesia. Recognize two major complications associated with epidural anesthesia

3 The Source and Origin of Childbirth Pain The International Association for the Study of Pain (IASP) has defined pain as: an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

4 2 Kinds of Pain 1st Stage of labor uterine muscle hypoxia lactic acid accumulation cervical stretching lower uterine segment stretching traction on ovaries, fallopian tubes uterine ligaments pressure on bony pelvis 2 nd Stage of labor Distention Pressure

5 Physiologic Responses To Pain Anxiety Increased catecholamines Increased metabolism Increased O2 consumption Excessive catecholamines = reduced contraction strength reduced duration and coordination

6 Our Goal To assist the woman to manage her pain while not interrupting labor or causing harm to her or the baby.

7 What Can We Do? Recognize signs of tension Frowning, Clenched Fists Stiff, straight posture Tense arms or legs Create a relaxed environment during labor Control the amount of light, noise, interruptions Use calm, slow, soft voice Maintain an unhurried demeanor

8 Definitions Analgesia - decrease of pain or awareness of pain without loss of consciousness or sensation Regional Analgesia inhibition of pain, or a partial sensory blockade, with or without partial motor blockade over a specific region of the body Regional Anesthesia loss of sensation & motor function over a specific region of the body

9 What Can We Do? Pharmaceuticals Analgesics Inhaled Gas ~ Nitrous Oxide Anesthetics

10 Drug Class Dose Onset Duration Comment Phenergan Phenothiazine Mg IV/IM Hydroxyzine (Vistaril) Pentobarbital (Nembutal) Antihistamine Mg IM Barbiturate mg PO/IM Secobarbitol Barbiturate 100 mg PO min 3-4 hours Commonly used with opioids to mitigate N&V 30 minutes 4 hours Commonly used with opioids to mitigate N&V minutes minutes 3 6 hours Hypnotic, used in early or prodromal labor 3 6 hours Hypnotic, used in early or prodromal labor

11 Common Medications Used in Labor Drug Dose Onset Peak Effects Duration of Action Morphine IV: 2-5 mg/4 H Demerol IV: mg/1-2 Hours IM: 10mg/4H minutes IM: mg/2-4 hours 5 minutes 20 minutes 1-3 hours 30 min 1 hour 3-5 hours 5 minutes 5 minutes 2-4 hours minutes minutes 2-4 hours Fentanyl IV: mg/1hour IM: mg/1 hour 1 minute 5 minutes min 7 15 minutes minutes 1-2 hours

12 Common Medications Used in Labor Drug Dose Onset Peak Effects Duration of Action Remifentanil PCA min 2 minutes 20 min Stadol IV: 1-2 mg q 3-4 H 2-3 min 5 10 min 4 6 Hours IM: 1-2 mg q 3-4- H minutes minutes 4 6 Hours Nubain IV: 10 mg/ 3 H 2 3 minutes 30 minutes 2 4 Hours IM: 10 mg/ 3 H Less than 15 min minutes 4 6 Hours

13 Common Medications Used in Labor Morphine is preferred over Demerol because it has a shorter half-life and more rapid plasma clearance in pregnant women. Demerol has unfavorable effects on newborn s breastfeeding, accumulates in breast milk and colostrom

14 Common Side Effects of Narcotics Maternal Allergic reaction Respiratory depression Nausea and vomiting Agitation Flushing Itching Orthostatic hypotension

15 Common Side Effects of Narcotics Fetal Decrease in variability Transient sinusoidal fetal heart rate pattern Respiratory depression

16 Regional Anesthesia Local Anesthetic Pudendal or Paracervical Neuraxial Umbrella term for Epidural Spinal Combined spinal/epidural (CSE)

17 Inhaled Gas ~ Nitrous Oxide Odorless, colorless, tasteless 50% oxygen and 50% nitrous Self administered No known ill effects on baby Lasts minutes

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19 Pudendal Nerve Block Blocks the lower vagina, perineum, and vulva 1% lidocaine Given close to delivery Lasts minutes Complications

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21 Paracervical Block

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24 Neuraxial Analgesia Epidural Spinal Combined Spinal Epidural

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26 Epidural Continuous Lumbar Epidural Complete analgesia for pain of labor and delivery and cesarean delivery Decrease anxiety, rest Level of anesthesia is dependent on placement of the catheter tip, the dose, and volume of local anesthetic

27 Epidural Anesthetic agents Bupivicaine Lidocaine Ropivacaine + Plus narcotic

28 Epidural/Spinal Anesthesia Contraindications No patient consent Refractory maternal hypotension Untreated maternal bacteremia Maternal coagulopathy Skin infection at site of placement Increased intracranial pressure caused by a mass lesion Non reassuring fetal status Maternal use of once daily dose of lowmolecular weight heparin within 12 hours

29 Epidural-Nursing Assessment Fetal assessment Patient desire Maternal assessment Baseline vital signs Lab values platelets, clotting studies Maternal history Drug allergies

30 Epidural Placement Patient education Physician order/informed consent IV fluid bolus mLs LR Empty bladder Positioning ******* Monitoring equipment (BP, O2 Sat, EKG) FHR monitoring Emergency equipment

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33 Combined Spinal Epidural Rapid pain relief with less motor blockade Opioid injected into the subarachnoid space Repeated dosing with epidural catheter Contraindications Fetal bradycardia

34 CSE

35 Patient teaching - consider early placement Epidural - Initiation of Block Catheter placement Test dose Initial dose, titrated to desired effect Maintain optimal uterine blood flow Continuous monitoring per hospital policy BP, HR, RR, sensory level, motor function, Fetal well being

36 Continuous EFM Nursing Management for Labor Positioning Epidural Monitor I & O Bladder Patient comfort - dermatome level/motor function Vital signs every 30 minutes after stabilization Check level Q 1 hour Labor progress

37 Dermatome Levels Assess dermatome levels every hour Alcohol swab Compare to arm

38 Epidural Management Continuous infusion PCEA

39 Second Stage Labor Management Labor down Reposition patient frequently Assess for descent Turning epidural down or off Increases pain Does not change the rate of assisted delivery Not useful

40 Local Anesthesia Perineal infiltration 1% lidocaine Episiotomy Repair Episiotomy Lacerations

41 Post Partum Management Turn off pump Remove epidural tubing inspect for tip Chart appropriately Assess for motor blockade prior to ambulation Stay with patient during first ambulation

42 Complications Maternal Hypotension Total spinal Intravascular injection of local anesthetic Fever Allergic reaction Headache Itching central Urinary retention

43 Hypotension Sympathetic blockade Vasodilation Pooling of the blood in the extremities Supine hypotension Aorto-caval compression

44 Supine Hypotension

45 Management of Maternal Hypotension Assume lateral position Increase IV fluids Monitor maternal vital signs every 2 minutes Continuous fetal monitoring Oxygen if indicated for FHR or maternal condition Notify Anesthesia Ephedrine or phenylephrine Check anesthesia level

46 Fever Dysregulation of body temperature Vasodilation by the block redistributes body heat from core to the periphery Intrapartum infection

47 Headache or Post-Dural S/S Puncture Headache? Painful frontal headache Worse when sitting or standing N/V Treatment Hydration Blood patch

48 Obtain informed consent AWHONN 2012 AWHONN Position Statement Non-anesthetist RN should not: Insert an epidural catheter Administer initial injection, initiate continuous infusion, or rebolus the epidural Increase or decrease the rate of continuous infusion Initiate or reinitiate an infusion once it has been stopped Manipulate PCEA doses or dosage intervals

49 AWHONN Position An RN may: Statement Replace empty infusion syringes with new pre-pared solutions containing the same medication and concentration, according to standing orders provided by anesthesia care provider

50 Objective Recognize common medications used in the management of labor pain List the expected effects, side effects, and duration of action of medications Describe the appropriate nursing care before, during and after administration of meds Recognize two major complications associated with epidural anesthesia

51 Questions?