NHS FORTH VALLEY. Epidural in Labour / Intrathecal Diamorphine

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1 NHS FORTH VALLEY Approved 20/07/2015 Version 2.0 Date of First Issue 01/06/2006 Review Date 20/07/2017 Date of Issue 20/07/2015 EQIA 20/07/2015 Author / Contact Debbie Forbes Group / Committee Final Approval Unit Clinical Governance This document can, on request, be made available in alternative formats Version 2 16 th July 2015 Page 1 of 5

2 Consultation and Change Record Contributing Authors: Consultation Process: Distribution: Change Record Debbie Forbes, Margaret Baggott, Linda Hamilton, Dr K MacIntosh Circulation to all Midwives, Obstetricians, Supervisors Of Midwives, Team Leaders, Clinical Shift Co-ordinators, Department Managers and Head of Midwifery Midwives, Obstetricians, Supervisors Of Midwives, Team Leaders, Clinical Shift Co-ordinators, Department Managers and Head of Midwifery 1) Name of pump changed 2) Document observations for 12 hours 3)PCEA added 4) Bolus and top up deleted Version 2 16 th July 2015 Page 2 of 5

3 Women & Children s Unit 1 NHS Forth Valley provides an on demand Epidural service. Women may opt for an Epidural as their primary choice of pain relief in labour. Before choosing epidural analgesia, women should be informed about the risks, benefits and the implications for their labour. Information should include: epidural provides more effective pain relief than opoids, will be accompanied by a more intensive level of monitoring, intravenous access required and is sometimes associated with a longer second stage of labour and a slightly higher chance of an instrumental vaginal delivery. Following discussion the midwife should inform: The Obstetric Anaesthetist Bleep 1029 should be contacted when it is established that a woman wishes or requires for an epidural for pain relief in her labour and it is appropriate ODP on Bleep 1098 to assist the anaesthetist The Bodyguard 545 is the only pump that can be used for epidural infusion; they are situated in store cupboard 3. Maternal Preparation The woman should have on a tie back gown. A theatre hat should be put on when the epidural is being sited Site Venflon (16g) Take bloods for Group & Save (Pink Tube) & FBC (Purple Tube) - these can be retained in the labour room if not required at that time. If her FBC was normal at 36 weeks then this does not require to be repeated. If a woman has Pre-Eclampsia or PIH, FBC and Clotting Screen (Blue Tube) do not need to be repeated if they have been done within the previous 6 hours. Commence Intravenous Hartmanns Solution - 6 hourly bag - if Syntocinon infusion is required use a non return valve Y connector If woman has Pre-Eclampsia or PIH discuss with anaesthetist rate of intravenous infusion Prepare Equipment Epidural Trolley Bodyguard 545 this should be positioned on the opposite side of the woman to all other pumps/iv fluids BP Monitor Catheterise bladder once the woman is comfortable Commence continuous CTG monitoring during the procedure, with low threshold for using FSE if monitoring problems anticipated Patient Controlled Epidural Analgesia (PCEA) The anaesthetist will set up the pump, usual dose 8mls with lock out time 15min of Levobupivicaine 0.1% / Fentanyl 2 mcg/ml Observations as per epidural chart, this now includes number of demands Break through Pain Assist woman to move into the position that will give the desired analgesic effect i.e. to a semirecumbent position on the side the breakthrough pain is experienced. Or upright if experiencing rectal pressure Encourage use of the PCEA button as able Contact anaesthetist if no relief from patient administered boluses During establishment of regional analgesia blood pressure should be measured every 5 minutes for 25 minutes. Version 2 16 th July 2015 Page 3 of 5

4 Women & Children s Unit 2 Observations and Documentation Details of observations required are detailed on the Labour Ward Epidural Infusion Order & Monitoring Chart BP should be measured every 5 min for 25 min after initial bolus then every hour thereafter if normal Epidural giving set should be labelled following procedure Second Stage Upon confirmation of full dilatation unless the woman has an urge to push or the baby s head is visible, pushing can be delayed for at least 1 hour if CTG reassuring and no sensation to push. After which pushing during contractions should be actively encouraged A plan should be agreed with the woman in order to ensure that birth will have occurred within 4 hours regardless of parity Augmentation with syntocinon should not be used as a matter of routine in the second stage of labour for women with regional analgesia Anyone with concerns re CTG should not have active pushing delayed if fully with an epidural. Post Delivery Epidural is switched off after 3 rd stage complete, or in the event of perineal repair, after suturing is complete Epidural infusion bag is a controlled drug therefore should be disposed by 2 midwives who should document and sign for disposal on the Labour Ward Epidural Infusion Order and Monitoring Chart under the section removal of epidural catheter The epidural catheter should be removed at the time of bed bath and details including presence of the blue tip should be documented and signed on the monitoring chart. If the woman has had a PPH, Pre-Eclampsia, abnormal platelets or coagulation contact the anaesthetist before removing the catheter The epidural catheter should not be removed within 12 hours of Enoxaparin having been administered Enoxaparin 40 mg should not be administered within 4 hours of the epidural catheter having been removed In the event of a caesarean section being carried out under epidural Enoxaparin should be prescribed by the anaesthetist 4 hours post removal of catheter caesarean section IV access should be maintained until the woman fully mobile Intrathecal Diamorphine Document observations on intrathecal observation chart Hourly for 12 hours unless otherwise instructed by anaesthetist Health & Safety Issues Cot sides should be used when the woman is unattended Woman instructed not to attempt to get out of bed due to loss of lower limb sensation Following delivery woman instructed not to attempt to get out of bed until full sensation has returned Woman will be accompanied the first time they get out of their bed Pressure Area Care Follow Protocol for pressure area care in labour References: NICE clinical guideline 190 Intrapartum care: care of healthy women and their babies during childbirth December 2014 July 2015 Review July 2017 or sooner Debbie Forbes Version 2 16 th July 2015 Page 4 of 5

5 Publications in Alternative Formats NHS Forth Valley is happy to consider requests for publications in other language or formats such as large print. To request another language for a patient, please contact For other formats contact , text , fax or - Version 2 16 th July 2015 Page 5 of 5

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