Maternity - L&D, part 4: Pain Management During Labor, Regional Anesthesia

September 18, 2021 Updated: December 29, 2021 8 min read

Full Transcript

Hi. I'm Meris. And in this video, we're going to be talking about different ways to manage pain during labor. I'm going to be following along using our maternity flashcards. These are available on our website, And I would definitely encourage you to pick up a set for yourself. If you already have one, I would invite you to follow along with me. Okay, let's get started.

So first up, we're going to be talking about non-pharmacological pain relief interventions. We talk about non-pharmacological interventions for pain all throughout nursing because it's very, very important. And there's lots of ways to help control pain. But I feel like this is one of those places where it's especially important because labor, typically, will last for a while, and it's a really strong and intense pain. So we need to find ways to help our patients manage it.

So one of the first ones is effleurage. Let's be honest, I don't know if I said that right. It's a French word and I don't speak French, but what it means is basically lightly stroking the abdomen. Typically, this is going to be in rhythm with a patient's breathing during contractions. So if you imagine, it's going to be this kind of light touch. The idea here is we're providing additional tactile stimulation to help distract the brain.

But this one is the one that I feel like I see the most, sacral counterpressure. So let's break it down. Sacral meaning of the sacrum, right, in the very low back, and counterpressure. We have pressure on the sacrum already, but it's from inside going out. So if I can provide counterpressure pushing back against that pressure, that can help to relieve some of that pain. This is especially helpful for your patients who are having back labor, so where they're feeling most of their pain in their backs. If you watched my last video, tell me in the comments if you will remember what type of fetal presentation can lead to back pain especially. It's not part of this content. I just want to see if you were paying attention.

And then, of course, breathing techniques. You probably have seen this in popular culture, the hee hee hoo, that sort of thing. Those are going to be breathing techniques. Important for a couple of reasons. It's a little bit meditative, right? It helps our patients focus on something other than the pain, but it also helps to make sure that our patients are breathing. When you are in pain, breathing is actually going to be more beneficial for you than holding your breath. Well, what is your initial reaction? Think about stubbing your toe. You go, "Oh." You're not going to be taking deep breaths. Very important that our patients continue to breathe during the time that they are in labor, right? So these sort of breathing techniques usually involve taking classes prior and having someone there to help coach the patient's breathing, but they can be very beneficial. There's many other examples here, and I'll let you take a look at them. But there are just some really great ways to help distract your patients or help to provide pain relief that are not related to drugs. And remember that our patients may say, "I want a natural labor," meaning unmedicated, right? And that's great, and we need to still be able to help them with their pain. And those are some great ways to do it.

So let's move on now to pharmacological measures. Now, of course, this is going to be really important to understand because this is where I can really hurt somebody, right, is by giving them the wrong medicine or something like that. Probably not going to hurt somebody by doing effleurage on their belly. But with medications, I could cause serious damage, so I would really focus on this stuff.

So we have systemic ways of relieving pain. Big ones are going to be opioids, right? We know that these are very strong and effective pain medicines in general, but they can be used also during labor. Then there's other things that we can give, such as antiemetics for nausea. We can also give benzodiazepines to help with some anxiety.

But really, I would focus on those opioids because that's targeting the pain itself. Now, because mom and baby are still linked through their circulatory system, baby will get some of the opioids as well. And that doesn't mean that we can't give it. It just means that we need to be aware to assess both mom and baby's well-being when giving opioids. Remember that the antidote for opioids is naloxone. Naloxone is the only antidote for acute opioid toxicity. And we're going to assess that because mom is having respiratory changes or changes in level of consciousness. Big one's going to be if I am not breathing enough. So usually, we say 10 or less than 10 breaths a minute. That is going to be our big sign there that we might have opioid toxicity.

There's other ways that we can relieve pain that you don't see as often elsewhere. Inhalation. So there are medications such as nitrous oxide, sometimes called laughing gas, which can be delivered through the inhalation route, so usually with a mask or something similar. These are really great because they're reversible immediately. So as soon as mom starts breathing regular air again, the effects are going to go away. This was very popular at one point. It is making a little bit of a comeback, and it is still very popular in some other countries as well. It's a great way to relieve pain for patients who don't want opioids. Maybe they just don't want to take them or they are in opioid recovery. But it's a really great option for helping to kind of give that patient a little bit of dissociation from the pain.

And then we have regional anesthesia. So these are going to be the things that you think of the most when you think of pain relief for labor. So regional, meaning it is going to affect a certain region of the body, not the whole body, which would be systemic. So regional, this is going to be something like your epidural or a spinal.

An epidural is going to be a catheter that is inserted into the epidural space, right? And it allows for medication to be administered into that space, and it's going to basically provide pain relief from the belly down. It's also going to cause some weakness, loss of sensation, loss of strength. So this is not something where I would want to have my patient have an epidural and then just leave them alone and never check on them, right? I wouldn't want to do that with any patient, but you understand what I'm saying. This is something where I need to make sure that my patient is being moved frequently, offered toileting, that kind of experience because I don't want her to be lying motionless in that bed and unable to move. Now, we also have spinals. And we'll talk a little bit more about that in the next card, but it is slightly different.

We have local infiltration. I would say that you're not going to see this as much, except for if the provider needs to do an episiotomy and make a cut or suture, a cut or a tear in the perineum. Then we would use lidocaine to locally infiltrate that area and numb it up.

And then we have the pudendal nerve block. So if you remember the pudendal nerve, that's going to be innervating the genitalia, essentially. So this is going to be providing pain relief in the low vagina, in the vulva, the perineum, in that sort of general area, but it's not going to affect the belly or any of those contraction pains. So this can be helpful also for patients who are having an episiotomy or some kind of local procedure in the genital region.

Now, this card here, we're talking more about epidural and spinal blocks. Now epidurals, like I said, it's going in the epidural space, typically between L3 and L4. But there's one big side effect that you just have to know because you need to be able to assess your patient, and that's going to be maternal hypotension. Any time you hear epidural, I need you to think blood pressure. I need to check my patient's blood pressure. So I need to know what their blood pressure was before. I need to know what it is now. And typically, we may even give fluids, IV fluids, before administering the epidural so that we can help to increase the intravascular volume and increase the blood pressure so that there is less of a block. This is going to provide that pain relief, usually from the level of the umbilicus down. But it's not going to necessarily get rid of all sensation. It may just kind of turn the dial down.

Now, a spinal block is a little bit different. This is actually going to be administered into the cerebrospinal fluid in the subarachnoid space. And this is a one-time injection. There's not a catheter where I can keep putting medicine in. It's a one-time injection, and this is typically used for C-sections. So it's a limited window that it's going to work, but it is going to take away pain and sensation from the nipples down. So much larger, right, of an area than the epidural from the belly down. So we're getting a lot more pain relief and an absence of sensation there. For me, personally, I felt no pain whatsoever, but I could feel pressure. So that was kind of a weird sensation. I could not move my feet. I could not feel any sort of severe surgical pain or anything. But when they did go to pull my children out, I felt a lot of pressure. So not pain but pressure. This also can cause hypotension in your patients. So remember, we're checking that blood pressure.

Now, if I saw that mom just got an epidural or spinal and started to have hypotension, what can I do about it? Well, we talked about one intervention already, right? IV fluids need to increase. Give a fluid bolus that's going to get their blood pressure back up. But another thing we can do is reposition the patient, right? Optimal blood flow. So we're going to put the patient on their side, and that's going to relieve that pressure of the uterus on the inferior vena cava. But also, I can't really do that if my patient is getting a C-section right now. So we may just have to place a pillow under the hip. And we always want to have a pillow under the hip because of that compression of the vena cava.

All right. I hope that review was helpful. If it was, please go ahead and like this video so that I know. And if you have a great way to remember something, I really want to hear it. So please be sure to leave me a comment. I hope I see you in the next one. Happy studying.

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