SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY TITLE: MANAGEMENT OF THE PREGNANT PATIENT WITH EPIDURAL ANESTHESIA POLICY #: EFFECTIVE DATE: REVISED DATE: POLICY TYPE: PAGE: 126.722 (maternal) 10/88 6/16 DEPARTMENTAL INTERDEPARTMENTAL DEPARTMENTS PROVIDING NURSING CARE 1 of 5 Job Title of Responsible Owner: Director, Women s and Children s Services PURPOSE: POLICY STATEMENT: To establish a plan of care and protocols related to the use of continuous epidural therapy. Role of the Nurse is in accordance with Association of Women s Health, Obstetric, and Neonatal Nurses, American Nurses Association, and State Nurses Association: 1. During the care of the pregnant woman the registered nurse may: Monitor the mother and the fetus. Stop the infusion. Initiate emergency therapeutic measures under protocol if complications arise. Remove the epidural catheter. 2. A qualified, credentialed, licensed anesthesia care provider is responsible for: Insertion of the epidural catheter. Initial injection, and/or initiation, and maintenance of a continuous infusion of analgesia Re-bolus of an epidural catheter. Increasing and decreasing the rate of the continuous infusion. EXCEPTIONS: Contraindications: None Refractory Maternal hypotension Maternal coagulopathy Maternal use of once-daily dose of low-molecular weight heparin within 12 hours Maternal use of 40 mg Lovenox within 12 hours, Maternal use of 80 mg Lovenox within 24 hours Untreated maternal bacteremia Skin infection over site of needle placement Increased intracranial pressure caused by a mass or lesion
With Epidural Anesthesia Page: 2 of 5 DEFINITIONS: Epidural Catheter: A soft, silastic catheter placed in the epidural space. Continuous Epidural Infusion: Analgesic administered via a closed infusion pump into an epidural catheter at a rate/quantity specified by qualified, credentialed, licensed anesthesia care provider (anesthesiologist, certified registered nurse anesthetist [CRNA]), and monitored by the same. PROCEDURE: 1. Verify epidural order set in SCM 2. Obtain appropriate lab-work ordered. The anesthesia care provider may review blood-work prior to procedure. 3. Continuous epidural solutions will be handled as all other controlled substances. The anesthesia care provider will sign out for the ordered substance for each patient. Two licensed nurses must countersign any wasted drugs. Pharmacy will stock epidural solutions in the Pyxis Medstations. Independent verification is required with the RN and CRNA/Anesthesiologist prior to initiating the pump. Document this verification in EMR. 2. Ensure proper patient identification and time out procedure, document in the EMR. 3. Administer prophylactic intravenous bolus of non-glucose containing, isotonic crystalloid solution (Lactated Ringers) as ordered. 4. Upon initiation of epidural infusion the LDR RN and CRNA will independently verify that the epidural tubing has been traced from the origin site in the patient to the pump to ensure that the tubing is connected to the epidural catheter. The RN will document the verification in EMR. 5. A label marked epidural must be on the filter of the epidural catheter. In addition, a yellow Epidural sign will be visual above the head of the bed. 6. Assess baseline maternal vital signs and fetal heart pattern. If a Category II or III FHR pattern is identified, or a change in Category is recognized initiate corrective measures as needed and notify the primary care provider and Anesthesia. 7. Encourage the patient to void prior to epidural initiation. 8. CRNA, LDR RN and the patient will don a mask during insertion of the epidural catheter. 9. Provide positioning assistance and emotional support to the woman during epidural initiation procedure. 10. If possible, assess the fetal heart rate during the procedure. If nonreassuring FHR pattern is identified, initiate corrective measures as needed and notify the primary care provider and anesthesia 11. Assess fetal heart rate and maternal vital signs approximately every 2 minutes for the first 15-20 minutes after the procedure. The frequency of subsequent assessment should be based on maternalfetal response to medication, maternal-fetal condition, and the stage of labor. Vital signs will be documented every 30 minutes for the duration of infusion per the intrapartum management of labor.
With Epidural Anesthesia Page: 3 of 5 Pulse oxygenation will be obtained during epidural insertion per anesthesia. 12. Facilitate the maternal position. After the procedure maintain uterine displacement using semi-fowler s position with hip wedge or lateral position. Upright positioning may be utilized once initial dose has taken effect. 13. Assess for complications that may be associated with epidural initiation. Local anesthetic toxicity: Assess for drowsiness, light headedness, tinnitus, circumoral paresthesis, metallic taste, slurred speech, blurred vision, unconsciousness, convulsions, cardiac dysrhythmias and/or cardiac arrest. High spinal: Assess for numbness or weakness of the upper extremities, dyspnea, weak speech or inability to speak, apnea, and/or loss of consciousness. Notify anesthesia immediately. Initiate cardiopulmonary resuscitation as needed. Maternal hypotension: Position mother in lateral position, administer IV fluid bolus as ordered, and notify anesthesia and/or primary care provider. 14. Continue to evaluate maternal pain levels with ongoing patient assessments. Assess for pruritis if an opioid was given. 15. Bladder distension caused by a decrease in the woman s sensation to void may be a side effect of epidural anesthesia. The bladder should be palpated regularly, and she should be encouraged to void. Intermittent catheterization or a Foley catheter may be needed per provider order if the woman s bladder is distended and she is unable to void. 16. Epidural may be removed post recovery period by an OB nurse unless otherwise ordered. Nurse to document removal and verify that black tip is intact in EMR. RESPONSIBILITY: 1. It is the responsibility of the Director of Women s and Children s Services to see that nursing personnel are aware of, and adhere to, this department policy. REFERENCES: American Congress of Obstetricians and Gynecologists. (2009). Compendium of selected Publications. Obstetric analgesia and anesthesia (Technical Bulletin No. 36), original date 2002. Washington, DC: Author. (Reaffirmed 2015). Association of Women s Health, Obstetric, and Neonatal Nurses. (2011) Nursing care of the woman receiving analgesia/anesthesia in labor Second edition. Evidence based Practice Clinical Guideline (Joint Committee Opinion, Practice and Education) Washington, DC: Author. Association of Women s Health, Obstetric and Neonatal Nurses. (2014). Templates for Protocols and Procedures for Maternity Services. Washington, DC: Author.
With Epidural Anesthesia Page: 4 of 5 Simpson, K.R. (2014). Labor and Birth. In Simpson, K.R. & Creehan, P.A., Perinatal Nursing (4 th Edition) (pp. 309-311). AWHONN Publisher. SMH Nursing Department Policy. Acute and Post-operative Epidural Pain Control. (126.169). SMH: Author. REVIEWING AUTHORS: Debbie Dietz, MSN, RNC-OB, C-EFM, Labor and Delivery Judy Cavallaro, RN, BSN, Clinical Manager, Women s and Children s Services Felice Baron, MD, Director, Maternal Fetal Medicine Jeff Torine, MD, Medical Director of Anesthesia
With Epidural Anesthesia Page: 5 of 5 APPROVALS: Signatures indicate approval of the new or reviewed/revised policy Date Committee/Sections (if applicable): Clinical Practice Council 6/2/16 6/7/16 Pam Beitlich, Director, Women s and Children s Services Vice President/Administrative Director (if applicable): Name and 6/10/16 Name and Jan Mauck, Vice President, Chief Nursing Officer