ANESTHESIA & ANALGESIA FOR THE LABORING WOMAN

A BETTER PAIN SCALE

0: Hi. I am not experiencing any pain at all. I don’t even know why I am here.

1: I am completely unsure whether I am experiencing painor itching, or maybe I just have a bad taste in my mouth.

2: I probably just need a Band Aid.3: This is distressing. I don’t want this to be happening to

me at all.4: My pain is not f----ing around.5: Why is this happening to me???6: Ow. Okay, my pain is super legit now.7: I see Jesus coming for me and I’m scared.8: I am experiencing a disturbing amount of pain.

I might actually be dying.9: I am almost definitely dying.10: I am actively being mauled by a bear.11: Blood is going to explode out of my face at any moment!

WHAT DO WE NEED TO KNOW ABOUT PAIN CONTROL IN LABOR?

• Explain how gate-control theory applies to non-pharmacologic pain management

• Identify medications and side effects used for analgesia during labor

• List complications that can occur to the patient undergoing general anesthesia

• Describe nursing management during neuraxial anesthesia

“PAIN WITH A PURPOSE”

”Unlike other acute and chronic pain experiences,

labor pain is not associated with pathology but with

the most basic and fundamental of life’s

experiences – the bringing forth of new life.”

-Nancy Lowe, Ph.D., CNM, FACNM, FAAN

PAIN CONTROL

Nearly all women in labor will experience pain

Perception of pain is highly individual

Control pain without interrupting the labor process or doing harm to the woman or her fetus

FACTORS CONTRIBUTING TO PAIN IN LABOR

• Intensity and duration of contractions

• Rate of cervical dilation

• Perineal distention

• Size and position of fetus

• Procedures

• Fatigue

PSYCHOSOCIAL FACTORS CONTRIBUTING TO PAIN PERCEPTION

• Childbirth preparation

• Support persons

• Loss of control

CONTINUUM OF PAIN MANAGEMENT

Non-pharmacologic→→

Positioning

Walking

Massage

Relaxation

Hydrotherapy

Breathing techniques

Imagery

Music

Peanut/Birth Balls

Hypnosis

→→ Pharmacologic

Analgesics

Anesthetics

GATE-CONTROL THEORY OF PAIN TRANSMISSION

The gate control theory of pain asserts that non-painful input closes the "gates" to painful input, which prevents pain sensation from traveling to the central nervous system. Therefore, stimulation by non-noxious input is able to suppress pain.

Small and unmyelinated fibers: pain and pressure of uterus, cervix and pelvic joints

Large myelinated fibers: skin impulses

Habituation to sensation – use various techniques

PHARMACOLOGIC - ANALGESIA

Analgesia: Decreases or blunts pain sensation

• Opioids/Synthetic Opioids

• Agonist or Agonist/antagonist binding at opioid receptor sites

• Side Effects

Dry mouth, urinary retention, constipation

N/V, respiratory depression, sedation

Decrease FHR variability

Increased risk of neonatal respiratory depression requiring resuscitation

FDA PREGNANCY CATEGORIES

A no risk demonstrated to the fetus in any trimester

B no adverse effects in animals, no human studies available

C only given after risks to the fetus are considered: animal studies have shown adverse reactions, no human studies available.

D definite fetal risks, may be given in spite of risks if needed in life-threatening conditions.

X absolute fetal abnormalities; not to be used anytime during pregnancy

FETAL DEVELOPMENT

TIMING OF TERATOGENIC INSULT

• Week 1-2: all or nothing• Death or other cells assume its function

• No malformations

• Week 3-8: organogenesis• Major malformations

• Multiple systems are forming

• Week 9-term: organ systems damaged• IUGR

• Mental retardation

• Developmental / behavioral delays

COMMONLY USED PAIN MEDS IN LABOR

Drug Route Onset Duration Half-Life

Butorphanol 1-2 mg IV or IM 5-10 min IV30-60 min IM

4-6 hours 2-5 hours

Fentanyl 50-100 mcg IV or 2-4 minutes 30-60 minutes

3 hours

Morphine 2-5mg IV or5-10 IM

10 minutes IV30 minutes IM

1-3 hours 2 hours

Nalbuphine 10-20mg IM, IV, or SubQ 2-3 minutes IV15 minutes SubQ or IM

2-4 hours 2-5 hours

Remifentanil 0.15mcg-0.50 mcg/kg Q 2 minutes-PCA

20-90 seconds 3-4 minutes 9-10 minutes

PHARMACOLOGIC: INHALATIONAL ANALGESIA

Nitrous Oxide: 50:50 ratio of nitrous to oxygen• Colorless, Odorless• Administered via facemask or mouthpiece• Creates euphoric effect that decrease pain perception• Mostly used in UK, Australia, Finland, & Canada

CONTRAINDICATIONS TO NITROUS

• Inability to hold or self administer

• Recent collapsed lung, hx of gastric bypass

• Increased ICP or intraocular pressure

• Low B12 levels, Crohns disease, pernicious anemia

REMIFENTANIL

• Short acting opioid

• IV/PCA

• onset of action in 1minute, peak effects in 2 minutes, a constant half-life of 3 minutes, and complete elimination in 10 minutes

• 1:1, CEFM

• Side effect Respiratory Depression

EXTENDED – RELEASE EPIDURAL MORPHINE

• PF Morphine: achieves 12 to 24 hours of post-op for C/S

• Monitor at least hourly for 12 hours, then every 2 hours for 12 hours

• Adequacy of ventilations (RR, Depth)

• Oxygenation (Pulse Ox)

• Level of Consciousness

• Adverse effects

• Pruritis

• Nausea

• Respiratory Depression

PHARMACOLOGIC - ANESTHESIA

Anesthesia: Complete loss of sensation

Local anesthesia: Infiltration of perineum and vagina or pudendal nerve block

Potent vasodilators

Neuraxial anesthesia: Blocks sensation from a certain region of the body

General anesthesia: Complete unconsciousnessNurse assist with cricoid pressure during rapid

induction sequence.

TYPES OF ANESTHESIA

• Neuraxial Anesthesia/Analgesia:

Blocks sensation from a certain region of the body.

• Spinal Block:

Single injection of local anesthetic into subarachnoid space.

• Epidural Block:

Needle and catheter placement in the epidural space – before crossing the dura

NEURAXIAL ANESTHESIA

• ContraindicationsCoagulation disordersInfection at siteHypovolemia/shock/hypotension

• Relative contraindicationsFHR pattern associated with u/p insufficiencySpinal deformityVentricular outflow obstruction – aortic stenosis, hypertrophic

cardiomyopathy

NURSING CARE OF PATIENT UNDERGOING NEURAXIAL ANESTHESIA

• Insure informed consent is completed

• Insure patient’s questions are answered

• Bolus of IV fluid (LR, NS)

NURSING CARE OF PATIENT UNDERGOING NEURAXIAL ANESTHESIA

• Time out verification

Correct person

Correct procedure

Correct equipment

*(site & position)

• Positioning/ support of patient

Sitting or lateral

• Monitoring

VS

Pain perception

Fetal response

LOC & Level of Mobility

Site/tubing/pump functioning

NURSING CARE OF PATIENT UNDERGOING NEURAXIAL ANESTHESIA

RN can:

• Monitor mother & fetus

• Replace empty infusion bags with new of same medications & concentration according to anesthesia orders

• Stop infusion if there is safety concern or after the birth

• Remove catheter according to institutional policy after education

• Initiate emergency measures as indicated and notify anesthesia & OB care providers

• Communicate assessments and changes to maternal status to OB and Anesthesia care providers

NURSING CARE OF PATIENT UNDERGOING NEURAXIAL ANESTHESIA

RN cannot:

• Bolus or Re-bolus by injection or increasing infusion rate

• Increase or decrease infusion rate

• Re-initiate infusion once stopped

• Manipulate dose or interval rates of PCEA

• Obtain informed consent – however, may witness consentOBN Policy/Guideline # P-04

EPIDURAL PROCEDURE

• Site selection

L 3-5

• Prep and drape

• Local site infiltration

• Insertion of needle

16-18G

loss of resistance technique

ANATOMY OF SPINE

EPIDURAL PROCEDURE

• Insertion of catheter

• Test dose

Detect subarachnoid or intravascular injection

• Secure catheter

• Assessment of block

Sensory & motor

Onset of action

Missed segments (windows)

This Photo by Unknown Author is licensed under CC BY-SA

EPIDURAL PROCEDURE

Epidural Drugs

• Act on nerve fibers crossing the epidural space

• Bupivacaine & Ropivacaine

• Fentanyl

Reduces requirement of local anesthetic

Spares motor fibers

Reduces hypotension

COMPLICATIONS OF ANESTHESIAMALIGNANT HYPERTHERMIA

• Potentially lethal complication of inherited muscular disorder

• Administering volatile anesthetics or neuromuscular blocking agents triggers hypermetabolic state

• Symptoms:

Rise in end-tidal CO2

Muscle rigidity – masseter spasm

Tachycardia & tachypnea

Ventricular fibrillation

Hyperthermia (104 F)

Acidosis

Rhabdomyolysis – breakdown of muscle excreted in the urine – may result in renal failure

Organ Damage, DIC, Death

MALIGNANT HYPERTHERMIA ETIOLOGY

• Caused by imbalance of intracellular and extracellular Ca+.

• Increased breakdown of muscle extracellular K+ = dysrhythmia

• Sustained muscle contraction increase muscle work - load, oxygen consumption, lactic acid production acidosis and elevated temp. tachycardia, cardiac dysrhythmia, hypotension, reduced cardiac output and arrest.

COMPLICATIONS OF ANESTHESIA

MALIGNANT HYPERTHERMIA TREATMENT• Discontinue triggering anesthetic agents

• 100% oxygen

• Dantrolene sodium (Dantrium)/Ryanodex to restore Ca+ balance

• Cool – ice packs, cooling blanket, lavage

• Antiarrhythmics – no calcium channel blockers (may cause hyperkalemia)

• Post emergency care:

Blood gases, electrolytes, coag profile and UA

ICU 12-48 hours

Family education and referral for testing

MH Hotline: 1-800-644-9737

COMPLICATIONS OF ANESTHESIA

POST DURAL PUNCTURE HEADACHE

• 1-2% with epidural

• 70% of Dural puncture with 16G Tuohy needle

• Symptoms

Severe HA - sitting/standing, supine

Nausea/vomiting

Vertigo

• Treatment goal: replace lost CSF, seal puncture, control cerebral vasodilatation

Caffeine & opioids

Hydration

Epidural blood patch – 90+% effective

COMPLICATIONS OF ANESTHESIA

INTRATHECAL INJECTION

• Anesthesia level ascends toward the brain stem resulting in:

Severe hypotension

Bradycardia

Apnea

Cardiac arrest

Reversal within 1-2 hours with proper support ; IV fluids, ventilation, vasopressors

COMPLICATIONS OF ANESTHESIA

INTRAVASCULAR INJECTION

• Epidural space is richly vascular – negative aspiration is not a guarantee

Test dose – observe closely – wait 5 min – inject in small increments

Large doses of LA intravenously cause seizures, arrhythmias, and cardiac arrest

Act quickly: ABCD’s of resuscitation

Meds: thiopental or propofol for seizure activity

amiodarone, vasopressin, or epinephrine for arrhythmia

Bupivacaine Toxicity: intralipid emulsion

COMPLICATIONS OF ANESTHESIA

OTHER COMPLICATIONS• Spinal hematoma

Pain, muscle weakness, bowel/bladder dysfunctionMRISurgical intervention

• Spinal abscessHigh temperature, backache, malaiseRequires urgent surgical intervention

• Anaphylaxis SymptomsTreatment :Epinephrine & IV fluids

* Don’t Forget Fall

Risk

SPECIAL CONSIDERATIONS IN OPIOID DEPENDENT WOMEN WITH NEURAXIAL LABOR PAIN MANAGEMENT

• Avoid antagonists and agonist like Nalbuphine, Naloxone, or butorphanol

• If taking methadone or buprenorphine, should be continued at the usual dose during the peripartum period

SUMMARY

All have pros and cons & risk & benefits

Women who received neuraxial

anesthesia still need and can benefit from nonpharmacological

nursing interventions

Labor Pain is unique and individual with added components

of physiological, social, and

emotional stressors.Burke (2021). pg. 503

REFERENCES

ACOG (2019). Practice Bulletin 209. Obstetric Anesthesia and Analgesia.

American Society of Anesthesiologists. 2018. Statement on the role of registered nurses in the management of continuous regional analgesia. https://www.asahq.org/standards-and-guidelines/statement-on-the-role-of-registered-nurses-in-the-management-of-continuous-regional-analgesia

Association of Women’s Health, Obstetric and Neonatal Nurses. (2020) Analgesia and Anesthesia in the Intrapartum period. Washington, DC: Author. doi: 10.1016/j.nwh.2019.12.002

Association of Women’s Health, Obstetric and Neonatal Nurses. 2015. Role of the registered nurse (RN) in the care of the pregnant woman receiving analgesia/anesthesia by catheter techniques (epidural, intrathecal, spinal, PCA catheters) (Position Statement). Washington, DC:Author.

Burke, C.(2021). Pain in Labor: Nonpharmacologic and Pharmacologic Management. In Simpson, K.R., Creehan, P.A., O’Brien-Abel, N., Roth, C.K., & Rohan, A. J. (4th Eds), Perinatal Nursing (pp 466-508). Philadelphia: Lippincott Williams & Wilkins.

Oklahoma Board of Nursing (2018). Registered Nurse Monitoring Obstetrical Patients Receiving Analgesia/Anesthesia by Catheter Techniques (Epidural, PCEA, and Intrathecal Catheters) Guidelines. Retrieved from: https://nursing.ok.gov/prac-epidurob.pdf.

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