EPIDURAL ANALGESIA FOR LABOUR

DR RAJESH T EAPEN

BURJEEL HOSPITAL

MUSCAT

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

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

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

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

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

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’

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

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

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

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

• 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

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

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

Warning Signs to Call Anesthetist

• Difficulty in breathing

• Difficulty in rousing patient

• Heaviness & tingling in arms & legs

• Marked fall in blood pressure & Heart rate

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

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

• 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

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

• 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.