[artlp]

I am going to be scheduled for a c-section soon and heard great things about duramorph but also heard about the itching problem. Would anyone share what their preference would be for pain relief.

Also, why choose a spinal instead of an epidural for a scheduled c-section?

Thanks.

[ShandyLynnRN]

Toradol, Toradol, Toradol!!!

Usually 30 mg IVSP X 1, 6 hours after delivery, then 15 mg IVSP q 4 or 6 hours routinely for 4-5 doses, then q 6 hours prn.

I have seen c/s patients that didn't require ANYTHING else post-op for pain.


If you do have the duramorph, be sure to ask for narcan to be added to your IV fluids post op for atleast 2 bags. Although I have used narcan and benadryl and other things for the itching in my patients, with very little relief.

[Jolie]

Meet with your anesthesiologist prior to surgery to discuss your concerns. I share your reservations regarding Duramorph. In my experience, it either works well, or not at all for pain relief, and it has a huge side-effect of itching. Because Duramorph itching is caused by irritation of nerve endings, and is not a histamine-mediated reaction, Benadryl is USELESS. All it does is make the mother sleepy and less bothered by the itching. (And also less able to interact with her baby!) ShandyLynn is correct that a Narcan drip can effectively relieve Duramorph itching, but it also lessens the pain-relieving effect of the drug.

The advantage of an epidural over a spinal is that a catheter is left in place, providing access should the anesthesiologist need to adjust your pain meds during surgery, and can also be used for post-op pain relief. One very progressive hospital where I used to work offered epidural PCA pumps to C-section patients. A happier and more comfortable group of fresh C-section moms I have never met! A spinal is a one-time injection with a limited duration of effect.

One other consideration is that afterbirth pains (cramping) occur after C-sections as well as vaginal births, and can cause significant discomfort. For patients experiencing them, Motrin works very well, and may be all that is needed in addition to Duramorph.

Good luck to you. Have a plan worked out in advance, and you will do fine!

[loisane]

Jolie,

I am glad you answered artlp's question, you obviously have some OB knowledge, of which I myself am totally lacking, since I have never done OB anesthesia.

HOWEVER, since you are posting on a CRNA board, I feel I just have to address the manner of your response.

Why so focused on the anesthesiologist? I myself have never done OB anesthesia, but there are PLENTY of CRNAs who are very skilled and knowledgable in this field. Depending on the institution's staffing patterns, artlp could very well be receiving her obstertrical anesthesia needs from a CRNA.

I assume you are a RN. We have to get better at supporting each other. I am glad you are here. Please read some of the posts, and get a feel for what nurse anesthetists do. We are complete anesthesia professionals, and are skilled for a full scope of anesthetic practice.

Let's all be advocates for nursing, in all its forms, at all its levels!!

Thanks,
loisane crna

[Tenesma]

duramorph is a wonderful pain adjunct for both spinal or epidural c-sections.... itching is a side effect, and both narcan and Nubain are absolutely great at getting rid of it... i am particularly fond of Nubain as it still assists w/ pain relief.

just out of curiosity Loisane - i understand this is a nursing board and you are very pro-AANA (which is great)... but your one point was kinda confusing: you write that you guys are complete anesthesia professionals and are skilled for a full scope of anesthetic practice - yet you admit that you have no OB anesthesia training... is OB Anesthesia taught to SRNAs or is this something you take extra elective courses in, or do you learn from Anesthesiologists... just curious

tenesma

[loisane]

Tenesma,

Oh, I had OB in school. I said I have never done OB anesthesia (outside of my school experience). My education qualifies me to work OB, I just never have in my work experience. (Of course, if I did so now, I would definitely have to get back up to speed).

I remember vaguely about duramorph and itching, and could have refreshed my memory if neccessary. But I was sure there would be some responses from true clinical experts, such as yourself and others. After all, that is what the poster needed, response from those with the hand on experience.

loisane crna

[Jolie]

Dear loisane,

I'm sorry if my reply left you feeling slighted; that was certainly not my intention!

I have worked OB in a number of different hospitals in various regions of the country, and have never yet attended a non-emergency C-section where a CRNA was attending the patient. I don't know why, and have often wondered why the scope of practice of CRNAs has seemed to be so limited in OB.

In my experience, when a labor patient desires an epidural, she is evaluated and then has the epidural placed by an anesthesiologist. From that point on, her continuing pain management may be performed by either an MD or CRNA. With scheduled C-sections, it is pretty much the same routine. With emergency C-sections, I have seen CRNAs crash the patient or administer epidural anesthesia through an existing catheter, but I have never seen a CRNA initiate an epidural or spinal for an OB patient, or attend a C-section unless there was no anesthesiologist available in house.

I don't know if there is any legal or practical reason for this, or whether it is indeed common throughout the country, but my reference to anesthiologists rather than CRNAs strictly comes from my experience.

[Jolie]

P.S.

I didn't know that I was answering a question on the CRNA board. I read the question on the home page where the 10 most recently posted threads are listed.

OK, let's not hijack this thread!

Any more suggestions for post C-section pain management?

[loisane]

Jolie,

I do understand that you are speaking from your experience. But one of the magical things about this electronic media, is we can gain insight outside of our personal experience.

I will not speculate on why you have never seen a CRNA do a spinal or epidural anesthetic. But let me assure you, the reasons are not legal.

It is only human nature to think that if we have only experienced things one certian way, then that must be the way things are everywhere. But as professionals, we have to rise above that, and educate ourselves.

I did not feel offended or slighted. And I do not want to sound argumentative. I only want to enlighten and educate, so that we can all be advocates for each other.

loisane crna

[Brenna's Dad]

Interesting comment regarding itching and the irritation of free nerve endings by Duramorph. It almost sounds like a chemical or mechanical irritation.

We were taught that the cause of opiod-related itching was unknown, but probably supraspinal. ie. Brainstem level. This is of course why Narcan and Nubain are effective; ie. competitive antagonist and partial agonist, respectfully, at the Opiod receptors.

Since the itching associated with opiods is not histamine induced, do you find people get the same degree of pruritis with fentanyl? And if not, would anyone like to comment why, ie. receptor affinities?