PHARMACOLOGIC MANAGEMENT

Learning Outcome

Describe the use of systemic drugs to promote pain relief during labor.

Goal of Pharmacologic Pain Relief

• Goal is to provide maximum pain relief with minimum risk to mother and fetus

• Goal is impacted by following factors– All systemic drugs used in labor for pain relief

cross placental barrier by simple diffusion– Drug action in body depends on rate at which

substance is metabolized by liver– Fetus has inadequate ability to metabolize

analgesic agent

What Women Need to Know About Pain-Relief Medications

• Before receiving medications, the woman should understand the following– Type of medication administered– Route of administration– Expected effects of medication– Implications for fetus or newborn– Safety measures needed (e.g., stay in bed

with side rails up)

Timing of Medication

• After complete assessment, analgesic agent generally administered when cervical change has occurred – pain medication given too early may prolong labor and depress fetus

Nursing Management

• Drugs may cause fetal respiratory depression at birth if given too late in labor

• Maternal and fetal vital signs must be stable before systemic drugs may be administered

• Assess mother and fetus and evaluate contraction pattern before administering prescribed medications

Learning Outcome

Compare the major types of regional analgesia and anesthesia, including area

affected, advantages, disadvantages, techniques, and nursing implications.

Epidural Injection

• Injection of anesthetic agent into epidural space

• Produces little or no feeling to area from uterus downward

• Pushing during second stage of labor may be impaired due to lack of sensation

• Hypotension is most common side effect

Epidural Injection

• May preload with crystalloid solution bolus

• Woman may need urinary catheterization due to loss of bladder sensation

• Assess sensation motor control and orthostatic blood pressure

Technique for Lumbar Epidural Block

Epidural Space

Continuous Epidural Analgesia

• Provides good analgesia

• Produces less nausea and provides greater ability to cough

• May produce breakthrough pain, sedation, respiratory depression

• Itching and hypotension are side effects

Spinal Block

• Local anesthetic agent injected directly into spinal canal

• Level of anesthesia dependent upon level of administration

• May be administered higher for cesarean birth or lower for vaginal birth

• Onset of anesthesia is immediate

Spinal Block

• Side effects include– Maternal hypotension, which can lead to fetal

hypoxia, requiring frequent blood pressure monitoring for health changes

– Indwelling urinary catheter usually needed due to decreased bladder sensation and tone

– Woman’s legs must be protected from injury for 8 to 12 hours after birth of baby due to decreased movements and sensation

Pudendal Block

• Local anesthesia injected directly into pudendal nerve, which produces anesthesia to lower vagina, vulva, perineum

• Only produces pain relief at end of labor

• Has no effect on fetus or progress of labor

• May cause hematoma, perforation of rectum, trauma to sciatic nerve

Pudendal Block

Local Infiltration

• Local anesthesia injected into perineum prior to episiotomy

• Provides pain relief only for episiotomy incision

• There is no effect on maternal or fetal vital signs

• Requires large amounts of local anesthetic agents

Local Infiltration

Local Infiltration

Learning Outcome 20-3

Explain the possible complications of regional anesthesia.

Complications

• Regional anesthesia administered per spinal or epidural route has similar possible complications– Maternal hypotension from hypovolemia or

effects of anesthesia – treat with bolus of crystalloid IV fluid and notify anesthetist

– Bladder distension– Inability to push during second stage of labor– Severe headache with spinal anesthesia

Complications

• Regional anesthesia administered per spinal or epidural route has similar possible complications– Elevated temperature with epidural

anesthesia– Possible neurologic damage

Learning Outcome

Describe the nursing care management for the laboring woman and her fetus related to

general anesthesia.

Nursing Care Related to General Anesthesia

• Nurse should– Assess when mother ate or drank last– Administer prescribed premedication such as

antacid– Place wedge under mother’s right hip to

displace uterus and prevent vena cava compression

Nursing Care Related to General Anesthesia

• Nurse should– Provide oxygen prior to start of surgery– Ensure IV access is established– Assist anesthesiologist by applying cricoid

pressure during placement of endotracheal tube

Proper Position for Cuffed Endotracheal Tube

Learning Outcome 20-5

Describe the major complications of general anesthesia during labor in nursing care

management of the woman in labor and her fetus.

Major Complications

• Fetal depression– If mother receives general anesthesia, infant

may have respiratory depression– Method not advocated when infant is

considered high risk

Major Complications

• Uterine relaxation: Most general anesthetic agents cause some uterine relaxation

• Vomiting

• Aspiration: Agents may also cause vomiting and aspiration