Epidural analgesia for labour

dr rajesh burjeel Pregnancy Delivery Pain during labour Epidural analgesia for labour Drugs Complications Epidural information card

1. EPIDURAL ANALGESIA FOR
LABOUR
DR RAJESH T EAPEN
BURJEEL HOSPITAL
MUSCAT

9. Education on methods of pain relief:
•Pregnant women should be counseled and informed (verbal & written) about
available choices for pain relief in labour during their antenatal visits
•Further discussions on Pain Relief should take place when the patient is
admitted in labour
•Patient information leaflets may be provided

Responsibilities of Anesthetist:
•Obtain consent for the procedure including appropriate discussion with the
patient
•Ensure there are no contraindications to the procedure
•Performing the Epidural procedure and establishing effective analgesia
•Ensuring correct setting up of the infusion and connecting the infusion line to
the patient
•Acting on the concerns of Labour Room staff
•Managing complications appropriately
•Ordering Top Ups
•Completing relevant documentation

12. Epidural procedure

Pre-procedural checks
•Take a history and confirm there are no contraindications
•Obtain verbal consent.
•Ensure at least 20 minutes of normal CTG has been obtained and continue
monitoring. Vaginal examination must be done prior to Epidural procedure
•Record a pre-insertion heart rate, blood pressure, respiratory rate,
temperature and Fetal Heart Rate (FHR)
•Ensure midwife is trained in epidural management
•Check blood test results if coagulopathy suspected
•Platelets should be greater than 80,000
•International Normalised Ratio (INR) should be 1.4 or lower
•Check thromboprophylaxis state
•Prophylactic Low molecular Weight Heparin (LMWH) should be given
more than 12hrs ago
•Therapeutic LMWH should be given more than 24h ago
•For the obese woman careful consideration should be given to larger doses
of LMWH

13. IV access
 Insert a 18G cannula preferably on left side of the
woman and ensure it is patent (Epidural catheter must
be fixed over woman’s right shoulder – to reduce very
serious risk of wrong drug delivery to patients)
 Have a crystalloid infusion available

Patient positioning
 Woman is assisted by the nurse to adopt an optimum
position: left lateral position or sitting position with feet
supported on a stool, head flexed forward with elbows
resting on pillow on knees
 Examine insertion site before scrubbing up

14. Aseptic technique
 Use thorough hand washing with surgical
scrub solution
 Barrier measures should be applied
including: cap, face mask, gown,
sterile gloves and use of sterile drape
 Consider eye protection

15. Skin preparation
 Use 0.5% chlorhexidine spray
 Spray the back and allow to dry before skin
palpation or puncture
 Keep chlorhexidine well away from drugs and
equipment to be used and change gloves if
contaminated
 If patient allergic use 10% povidone iodine
solution

16. Insertion technique
 In the lumbar region
 Infiltrate needle path with lidocaine
 Site epidural catheter with technique of your choice
using normal saline for loss of resistance if possible
 Long Tuohy needles 12cm and 14cm are available for
obese women
 Leave 4-5cm catheter in space (consider leaving more
in obese women)
 Aspirate catheter as an aid to confirm no Cerebral
Spinal fluid (CSF) or blood
 Attach the anti-bacterial filter as all injections must be
through this
 Secure with appropriate dressing
 The catheter should be clearly labeled as 'epidural line’

17. Consider asking for advice or help if:
 A dural tap is performed. (A consultant
anaesthetist should be informed within 24 hrs).
 If you cannot successfully site the epidural
within 20 minutes
 If the patient is becoming distressed

20. Initial dose
 "Every dose is a test dose"
 Ensure maternal and fetal monitoring
 Allow at least 5 minutes to pass before
ensuring blood pressure is stable and giving
further drug
 There should be no significant loss of
power in legs

Loading dose: Take 5 ml of 0.5% Marcaine
& dilute to 10ml to get 0.25% Marcaine.
Add 25mcg Fentanyl viz. 0.5 ml

21. Epidural infusion
 After loading dose start infusion
 Take 12ml of 0.5% Marcaine & dilute to 48ml to get
0.125% Marcaine. To this add 2ml (100mcg) Fentanyl
to get total volume of 50ml. Start infusion at 8ml/hour
using an infusion pump
 Measure and record maternal heart rate (HR),
blood pressure (BP) and FHR at 5 minute intervals
for first 15 min then half hourly
 Assess and record the sensory level of the block
hourly
 The anaesthetist should be immediately available
for review of women and management of initial
complications for at least 20 minutes after initial dose

22. Maintenance epidural doses
 50ml epidural mix dose can be repeated at
intervals as required
 These can be given by appropriately trained
nurses
 An appropriate position should be adopted
 Vital signs monitoring and block level
assessment should continue as for
initial dose
Vital signs – Pulse, BP, Respn Rate – every 5 minutes
for first 15min. If stable thereafter every hourly

23. •Responsibilities of the Labour room staff nurse: Monitor
Sensory block, Motor score, Pain score, Sedation score
& Vital signs
•Monitor sensory block hourly by using ice pack wrapped
in gauze
•Explain procedure to pt
•Place the ice from the thigh up to the neck on both sides
of the body
•Record the level from which pt feels the cold sensation
–T10- at midpoint of umbilicus – Level A –inadequate level
–T8- from umbilicus to fundal region – Level B- safe level
–T4-from fundal region to above the nipples – Level C –
caution
–Above nipple line – Level D - DANGER

24. If at DANGER ZONE :
•Switch off Epidural infusion
•Administer Oxygen @ 10 lt/min
•Call Anesthetist
•Have crash cart ready with Naloxone Injection
Level A – pt uncomfortable, block height inadequate:
Inform Anesthetist
Administer top-up from infusion pump & increase infusion
rate by 5ml/hr
Level B – Analgesia Zone – continue care
Level C – Block in Caution Zone:
Reduce infusion rate by 5ml/hr & repeat reassessment in
30 minutes
Inform Anesthetist if level is increasing

25. Pain score – recorded hourly
0- No pain / unaware of contraction
1- Aware of contraction but not distressing
2-Contraction distressing
3- Perineal pain
Inform Anesthetist if pain distressing or unbearable

Motor score – recorded hourly
0- Full movement
1- Partial weakness
2-Very slight movement
3- No movement
Inform doctor for 2 & 3

Sedation score – recorded hourly
0- Fully alert
1- Drowsy but easily aroused (responds to name)
2- Only aroused with difficulty (requires shaking)
3- Un-arousable

26. Warning Signs to Call Anesthetist
•Difficulty in breathing
•Difficulty in rousing patient
•Heaviness & tingling in arms & legs
•Marked fall in blood pressure & Heart rate

27. Documentation
 Document epidural insertion data in maternal
notes using 'yellow epidural sticker'
 Complete the obstetric audit form
 Ensure labeling of epidural mixture bag as '
for epidural use only' plus patients name, date
of birth, hospital number and date and time of
opening.
 Prescribe intravenous fluids on the
appropriate chart
 Prescribe epidural doses on the electronic
drug chart

28. Removal of epidural catheters
 Ensure timing is appropriate with regard to
thromboprophylaxis and that coagulation
parameters are within normal range
 Remove dressing and carefully withdraw
catheter ensuring it is intact
 Check catheter and its integrity with a
second person and document in records

29. •Notify the anaesthetist if it is not intact and
retain catheter for inspection
 If there is anything unusual about the
insertion site alert the anaesthetist
 Once the epidural has been removed the
woman must be informed that she must not
attempt to get out of bed unaided, even if she
has the feeling coming back to her legs
•Monitor vital signs every 4 hours for 12 hours
after removal of epidural catheter

30. Follow up

All women should receive information about when and how
to seek help if complications should arise
All women will need to have voided normally before discharge
Complaints that should be reported to the anaesthetist
immediately include
Severe headache
Severe backache
Progressive numbness or weakness in the legs more
than 3 hours following removal of an epidural catheter

33. •Intravenous (IV) catheter placement
 Be aware of signs of local anaesthetic
toxicity these may include: Light
headedness, circumoral tingling, tinnitus,
odd taste in mouth, seizures,
cardiovascular collapse
 If you suspect an IV epidural catheter do
not use it, call for senior help, consider
re-siting epidural.