To outline nursing management of patients receiving epidural anesthesia during labor (Includes walking epidurals and combined spinal-epidurals).

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1 HOSPITAL NAME INSTITUTIONAL POLICY AND PROCEDURE (IPP) Department: Manual: Section: TITLE/DESCRIPTION POLICY NUMBER LABOR: EPIDURAL EFFECTIVE DATE REVIEW DUE REPLACES NUMBER NO. OF PAGES APPROVED BY APPLIES TO PURPOSE To outline nursing management of patients receiving epidural anesthesia during labor (Includes walking epidurals and combined spinal-epidurals). RESPONSIBILITY Interdependent (* requires M.D. order) CROSS REFERENCES POLICY SUPPORTIVE DATA: Discomfort in labor has two origins. In the first stage, discomfort is related to cervical effacement and dilation and uterine ischemia from the compression of uterine arteries which supply the myometrium. Discomfort is located over the lower abdomen and radiates to the lumbar area and down the thighs. Discomfort in the second stage is related to perineal pain from the stretching of the vagina and the perineum during delivery. Epidural anesthesia helps to relieve the pain of labor. Anesthetic agents injected through a catheter placed in the epidural space block primary neurosensory pathways from the uterus to the spinal cord and brain. Epidural anesthesia is a relatively safe method of relieving the discomfort of labor and results in neurosensory block and vasodilation. There may be a slight drop in maternal blood pressure which can alter maternal-fetal well-being by decreasing placental perfusion. The fetus response, if any, may be seen on the electronic fetal monitor (EFM) tracing. Other complications may include dural puncture (a wet tap ), an incomplete block, infection, back pain (especially at the insertion site), inability to void, and rarely a higher anesthetic level than needed (and possible respiratory compromise) and central nervous system toxicity. Once birth has occurred and the woman has fully recovered, the epidural catheter can be removed by anesthesia only. Contraindications for removal include: 1) Patient is not fully recovered from post-anesthesia care. 2) Patient has signs/symptoms of retained placenta. 3) Patient has a problem which will require further intervention Standards Page 1 of 5

2 ASSESSMENT: 1. Assess maternal baseline vital signs and a 20-minute electronic fetal monitoring (EFM) tracing prior to epidural insertion. 2. Assess maternal BP, pulse, respiration, and fetal heart rate (FHR) after the first dose of epidural anesthetic: every 2 minutes x 5 every 5 minutes x 3 every 15 minutes x 2 every 30 minutes for the duration of anesthetic administration (continuous infusion) 3. Assess maternal BP, pulse, respiration, and fetal heart rate (FHR) after each redose of epidural anesthetic every 2 minutes x 5, then every 30 minutes. 4. Assess for non-reassuring changes in the FHR with vital signs and per Maternal Fetal Monitoring protocol. 5. Assess effectiveness of epidural anesthesia every hour. 6. Assess for an increasing systemic level of local anesthesia (venous vs. epidural injection): ringing in the ears numbness around the mouth a metallic taste in the mouth visual changes complaints of a tightening feeling in the chest change in level of consciousness 7. Assess for a rising level of anesthetic block: shallow breathing, shortness of breath difficulty swallowing tingling or numbness in the breasts weakness or numbness in the hands or arms inability to move around in bed 8. Assess intake and output every 4 hours; observe for bladder distention every 2 hours after epidural placement until catheter is removed. REPORTABLE CONDITIONS: Standards Page 2 of 5

3 9. Notify M.D. for: BP <90/50 or systolic BP <15% from baseline RR <10 bladder distention with inability to void signs of systemic local anesthesia increasing level of motor/sensory block continuing discomfort or pain non-reassuring fetal heart rate despite measures to correct maternal hypotension removal of epidural catheter after delivery and repair approval of patient transfer to the maternity floor CARE: 10. Encourage the patient to void prior to epidural insertion. *11. Start an IV of Lactated Ringer s and administer a bolus of 500mL. 12. Implement Monitoring: Maternal/Fetal protocol. 13. Assist with the positioning and support of the patient during the placement of the epidural catheter. 14. Position the patient in a lateral or lateral tilt position after the initial placement of the Depidural catheter, as permitted by patient condition. 15. Change the patient's position every hour if she is non-ambulatory. *16. Assist patient with walking epidurals to ambulate if: systolic BP decrease is < 15% from baseline no obstetric contraindications exist, e.g. non-reassuring fetal status no CNS effects exist, e.g., tinnitus, vertigo no subjective report of weakness exists per patient patient is 30 minutes post any intervention or event prior to walking no CNS effects occur when patient sits on side of bed for 5 minutes to dangle legs prior to ambulation a competent, communicative, responsible adult accompanies patient at all times, e.g., partner or other support person, doula, nurse an anesthesiologist or designee verifies the absence of motor blockage and clears the patient for ambulation NOTE: Patient should ambulate in Labor and Delivery unit only. 17. Encourage patient to void every 2 hours. *18. Perform in-and-out (straight) catheterization for inability to void. Standards Page 3 of 5

4 NOTE: If more than 2 straight catheterizations are required, consider an indwelling catheter to straight drain. 19. Utilize correct positioning of the legs in the second stage of labor and provide support to the legs during pushing and delivery; do not hyperflex the hips. EMERGENCY MEASURES: 20. MATERNAL HYPOTENSION: Turn patient to left (preferable) or right lateral position Increase maintenance IV rate to 200 ml/hr Administer O2 at 8 to 10L/min. via tight non-rebreather face mask Take BP every 2 minutes until stable Notify physician *Ephedrine 5mg IV push if FHR decelerations appear and/or BP decreases below 90 mmhg systolic and anesthesiologist not immediately available 21. RISING ANESTHETIC LEVEL: Stop continuous anesthetic infusion. Notify physician. SAFETY: 22. Keep the bed s side rails up, to assist patient in positioning after the procedure until epidural catheter is removed and/or sensation returns. 23. Have suction and oxygen available in the room. 24. Assist with the first ambulation after the effects of the medication have worn off. NOTE: The patient must be able to bend her knees and to lift her buttocks off the bed independently before ambulation is attempted. PATIENT/CAREGIVER TEACHING: 25. Reinforce instruction on the epidural procedure, effects, side effects, and complications. 26. Instruct the patient or caregiver to call the nurse for any signs and symptoms of hypotension, signs of a rising anesthetic block, increasing pain, or ambulation after the procedure. DOCUMENTATION: 27. Document implementation of Labor Epidural protocol and Maternal/Fetal Monitoring protocol on Patient Care Statement. 28. Document the following on the Labor and Delivery flowsheet: Standards Page 4 of 5

5 placement, time, and the name of the physician performing the procedure assessments care given and maternal/fetal responses to interventions side effects, emergency measures, and resolution/continuation of symptoms patient/caregiver teaching, response, and level of understanding. 29. Document intake and output on I & O Record. PROCEDURE FORMS EQUIPMENT REFERENCES Bachman, J.A. (2000). Management of discomfort. In D.L. Lowdermilk, S.E. Perry, & I.M. Bobak, Maternity and Women s Health Care (7th ed.) (pp ). St. Louis: Mosby. Mahlmeister, L. (2003). Nursing Responsibilities in Preventing, Preparing for and Managing Epidural Emergencies. Journal of Perinatal and Neonatal Nursing, 17, Mayberry, L.J., Clemmens, D., De, A. (2002). Epidural analgesia side effects, co-interventions, and care of women during childbirth: A systematic review. American Journal of Obstetrics and Gynecology, 186, Vincent, R.D., Chestnut, D.H. (1998) Epidural Analgesia During Labor. American Family Physician, APPROVAL: Prepared by Reviewed by Approved By Approved By Latest Revision Approved By Name Signature Date Standards Page 5 of 5

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