Systemic Analgesics – Medications for Pain Relief During Labor and Delivery (Nursing)

00:01 So, now, let's break down our medication options into three groups, opioid, opioid agonists and opioid agonists/antagonists.

00:10 Now, I know I said three groups but I'm going to first start-off by grouping opioids and opioid agonists together.

00:17 And the reason I'm going to do that is because they act exactly the same.

00:21 Opioids and opioid agonists bind to the opioid receptors all over our body.

00:27 Now, when you mind to your opioid receptors, you get a feel good, right? You feel better. You feel pain free. You feel wonderful.

00:35 So, opioids really provide that feel good feeling.

00:39 Opioid agonists bind to the same sites, so, they do exactly the same thing.

00:43 Now, in terms of the goods, there's also a flipside which are the bads.

00:49 So, the side effects that we may experience both from opioids or opioid agonists and those side effects include things like itching, sedation, that part might be good, respiratory depression, not so great.

01:02 And we're thinking respiratory depression not only for the birthing person but also for the fetus.

01:08 Nausea may also be a side effect, as are fetal heartrate changes and we'll talk about that in just a minute.

01:15 We can also experience a little bit of delayed gastric emptying and this is important for someone who receives long-term opioid or opioid agonist medications.

01:25 Now, some options for opioid or opioid agonist medications include morphine, meperidine or fentanyl.

01:33 There are lots more. There's a long list but these are going to be the most popular.

01:37 Now, let's talk about opioid agonist/antagonists.

01:42 So, you see those two words together and what it tells us is that it has the properties of the opioid agonists.

01:48 So, all the good feeling, all the pain relief but if we want to get rid of some of those side effects we just talked about, we want to bind some of those receptors so that we don't get the full expression of the opioid.

02:01 So, in this case, we have a medication that has both properties of the agonists and also properties of the antagonists.

02:09 So, in this case, the side effects might be dizziness, headache, fetal heartrate changes and that's it.

02:17 So, less respiratory depression and less likely to experiencing long-term symptoms of slow gastric emptying.

02:24 So, medications that are opioid agonists/antagonists with both properties include medications like Butorphanol or Stadol and Nalbuphine, also known as Nubain.

02:36 Now, let's talk about Butorphanol and Nalbuphine in a bit more detail.

02:40 The first thing we have to consider is that Butorphanol crosses the placenta and this is important both from the standpoint of educating the birthing person and their support team about the potential effects of the medication but also, from the assessment standpoint for the nurse.

02:56 They need to understand that the same effects the birthing person experienced are also going to be experienced by the fetus.

03:03 Butorphanol is often given in early labor because of its sedative effects, so, can allow the client to feel a little bit more restful and a little bit less pain.

03:13 So, it's still an analgesic. So, it provides some pain relief but it also allows them to rest.

03:19 So, using this in early labor is a really good strategy for that.

03:22 Also, because it's an opioid agonist/antagonist, the effect of the respiratory depression is going to be diminished. Now, it doesn't mean that it goes away.

03:32 So, we want to be careful about administering Butorphanol when we get close to delivery because the baby is going to need to breathe air and not experience respiratory depression.

03:42 So, if we give this medication close to delivery, the baby may come out and be slower to take a breath.

03:48 Next, let's talk about Nalbuphine or Nubain. So, Nubain is also given IM or can be given IV.

03:57 It's also an opioid agonist/antagonist and it really does a really good job of relieving pain without the side effects of the nausea and vomiting.

04:07 So, it's often more popular than even the Butorphanol.

04:11 It does however decrease fetal heartrate and variability.

04:14 So, the nurse needs to be aware that after this medication is given, the fetal heartrate tracing may change somewhat.

04:21 Also, in terms of respiratory depression however, because it's an opioid agonist/antagonist, this effect is going to be diminished.

04:30 So, it's going to be a bit safer to give closer to delivery because of that effect.

04:36 One quick note I want to make here.

04:38 If you have a client who has a known substance use disorder, specifically, an opioid substance use disorder issue, we don't want to give an opioid agonist/antagonist.

04:48 Because if they're using an opioid and that's what their body is used to and we give an antagonist, then, it actually causes a rapid withdrawal symptom and we don't want to do that.

04:59 So, make sure you've done a really good job of taking that social history before you give these medications because we don't want to cause that problem in labor.

05:09 I want to talk about one more medication and this is the fentanyl.

05:13 And you remember this one from our discussion about the types of opioids that might be out there and I'm talking about this not because nurses tend to give it but you may see it.

05:22 So, fentanyl is a medication that can be given IV or given via epidural.

05:27 One of the side effects that's pretty significant from fentanyl would be maternal hypotension which is one of the reasons why this is not typically given by a nurse unless the provider's in the room.

05:38 Another thing to think about when fentanyl is given is that one of the side effects, respiratory depression can actually outlast the pain relief.

05:46 So, the client can become really uncomfortable but still be a little bit groggy.

05:50 So, if you have a client that's been given fentanyl, knowing this will help you do an adequate assessment.

05:57 Again, this is typically used by anesthesia or by the provider and not something that the nurse is going to just give as a standing order.

06:05 Now, I mentioned the opioid agonist/antagonist. Narcan is an opioid antagonist.

06:12 There's no agonist part that goes with Narcan.

06:14 So, this is a medication that we can give to counteract immediately the effects of an opioid or an opioid agonist.

06:22 So, this is going to be something we may give to the baby once they're delivered if we find their residual effects of an agonist or an opioid.

06:31 So, this is Narcan, also known as Naloxone.

06:35 Now, I want to talk to you about a classification of drugs called ataractics.

06:39 Ataractics are used to help potentiate or strengthen the effect of analgesics.

06:45 So, they can be used in combination with opioids.

06:49 They can help to lessen the nausea and the anxiety.

06:52 Remember, those are common side effects. It's not used for pain control.

06:57 So, that's not one of the things that happens but because it potentiates or makes the other medications stronger, it does have a positive effect.

07:07 It also makes it possible to use lower doses of opioids because it potentiates the pain relief factor that is received from opioid or opioid agonists.

07:18 So, two options for ataractics that are used commonly in the labor suite.

07:23 The first one is Hydroxyzine and Hydroxyzine is given 50 milligrams.

07:27 It can be given by mouth or IM. Again, it reduces the anxiety and it potentiates.

07:33 It means it makes the opioid stronger.

07:35 So, those pain relieving effects are going to be intensified.

07:39 The other one is Promethazine and it's usually given 25 milligrams p.o. or IV.

07:45 So, promethazine is also an antiemetic.

07:48 So, it really does help to decrease that sensation of nausea.

07:52 Again, it potentiates the action of the opioids, makes it stronger.

07:56 But it is incredibly toxic, so, you want to make sure that it's diluted and given slowly, especially, when it's given IV because it will burn otherwise.

08:06 Let's talk about the category of inhaled analgesics.

08:09 Meaning that it's going to be breathed in.

08:12 Nitrous oxide is a medication that's been around in Europe for a really long time.

08:17 But in the United States, we started using it about 15 years ago with regularity.

08:22 So, you may have heard of nitrous oxide if you have a big fear of dentists which would be me.

08:27 But what we know about using nitrous oxide in labor is that the mixture is a little bit different.

08:33 In the dental office, it's usually a 75/25 mix.

08:36 But in labor, it's a 50/50 mix with nitrous and oxygen.

08:40 So, nitrous oxide can be used during all four stages of labor.

08:45 So, that means early in labor or even post-labor when someone is perhaps receiving a repair.

08:51 It can be used all throughout which is definitely a benefit. It's also self-administered.

08:57 So, this is not something that the nurse is going to put on the patient's mouth or the provider's going to do or the support person.

09:04 The client has to be able to control giving themselves the nitrous oxide and that consists of putting the mask on their face.

09:11 It's non-invasive which is also a benefit.

09:14 You don't have to have IV access or an epidural, only a face mask and that's it.

09:20 The way the nitrous oxide works is that as soon as the client begins to notice that their abdomen is tightening, so, they know a contraction is coming, they will take the face mask and cover their nose and mouth completely.

09:32 You want to make sure there's a tight seal so that none of the nitrous oxide leaks out of the side and they'll begin to take some nice deep breaths and within 30 seconds, they will be at peak efficacy of the effectiveness of the nitrous oxide.

09:45 Once the contraction is over, they'll remove the mask and within two minutes, all the nitrous oxide has cleared the system.

09:52 One thing that's really important to let the client know when they're using nitrous oxide is that some people do experience nausea and some clients even more rarely, may experience some amnesia where they forget what happens.

10:05 Now, I do want to add one more note of safety that it's important that you don't prop the mask.

10:11 So, if for instance, your client is leaning up against the side bed rails and they have the mask on their face, the mask has to come off between the contractions because you can get too much of the nitrous oxide and that's a whole different situation.