Supporting the Woman with an Epidural

Slide layout and designby

Gertrude L. Welsh, CNM

Penny Simkin, PT

Light and Late Segmental Epidural Block1. IV Fluids +

Pitocin

Infusion Pump EFM

2. Continuous BP Cuff3. O2 Mask

4. Bladder Catheter + Bag

5. Scalp Electrode

6. IUPC

Plus (not shown) : 7. Epidural catheter + syringe8. Pulse Oximeter9. EKG

Research Findings: Outcomes of Labors with Epidurals -Eltzschig et al, NEJM, 1/03

Due to: inability to push; fetal OP position at delivery; in teaching hospitals, without indication, to teach residents; (Delayed pushing reduces instrumental delivery)

Yes↑Instrument delivery

Trials flawed by little difference between groups (“early” = 3 cm; “late” = 4 cm)

?↑ C/S w. early (vs late) epidural

Trials flawed by high cross-over rates; findings influenced by different ob. practices (re: duration of labor, protocols for Pit, etc.)

?↑ C/S rate

CommentsYes/No

Outcome

For maternal fever, newborn tachycardia, increase in newborn temperature.

Yes↑ NB septic workups and antibiotics

3 British studies; we need U.S. studies (differences in pushing positions?)

No↑ P-P back pain

4 x (15% vs 4%) more Tº>100.4º F overall, & 5 x (24% vs 5%) in nullips(1 study, 1999); Due not to infection, but to alteration in production and dissipation of heat.

Yes↑Maternal Tº >100.4ºF

On average, adds one hour, more with less aggressive use of Pitocin

YesProlonged labor?

CommentsYes/ No

Outcome

3% of all epidurals are inadvertent spinals, 2.1% of which become spinal headaches

Yes↑ Spinal headache

Am Soc Anes now recommends “limited” amounts of clear liquids w. an epidural.

No↑Maternal aspiration of gastric acid

Is OP caused by the epidural, or do more women w. OPs have epidurals?

Yes↑ Fetal OP at delivery

CommentsYes/ No

Outcome

Joint Statement: American College of Obstetricians

& Gynecologists and

American Society of Anesthesia

“A woman’s request for pain relief is sufficient medical indication

for its use.”

Prehydration with IV Fluids

• Anesthesiologists now question the routine practice of a preload bolus of 500-1000ccs of Ringer’s Lactate.

• Why? There is no evidence that it prevents drops in blood pressure.

• New recommendations: Reduce the preload to avoid fluid overload.

• --Frolich M. Review: Crystalloid prehydration: Time to change our practice? SOAP. (www.soap.org/newsletters/spring2003/crystal.html)

• [Cochrane Review says not enough evidence to know]

Reducing Side-Effects of an Epidural

•Remind her she is in labor –point out contractions –have her feel them

with her fingers.–point out baby

movements•Attend to other discomforts •Prepare her for pushing.

Woman almost “forgets” she is in labor—

– focuses on other discomforts– challenging later, when it is time to push her baby out.

How to reduce the effect

Possible associated effect of an epidural

Reducing the Side-Effects of an EpiduralHow to reduce the effect

Possible associated effect of an epidural

• Prior warning in class• Summon help• Speak calmly

– Acknowledge her feeling that she is not breathing

– Reassure her that she can breathe

• Coach her through each breath.

High anesthesia level; woman feels frightened, as if she can’t breathe

Reducing the Side-Effects of an EpiduralHow to reduce the effects

Possible associated effects of an epidural

•Apply cool washcloths– where body is numb?– where body is not numb?

•Warm blankets?•Lower room temperature?

Fever (prevention and treatment).

•Look for bulge above pubic bone;

•Keep track of voiding; draw attention to it.

Full bladder, esp. w. IV fluids -- can slow labor.

How to reduce the effectsPossible associated effects of epidural

• Change mother’s position• Delay pushing until UTP or

head is on perineum• Let epidural wear off?• Use monitor for biofeedback

as she bears down:- Call out toco numbers

-“Go for 80, 90, 120! Great!”- “Now, breathe for the

baby”- Repeat

Persistent malposition, asynclitism

Ineffective pushing

Reducing the Side-Effects of an Epidural

“Trial-pushing”“Hold breath, strain 5-7 sec” x 3

If/when head is visible:directed pushing

(contraction monitor for feedback?)

↓ EpiduralSleep or rest up to 1 to 2 hours

(assess FHT for early decels and observe for perineal bulging)

Instructions for Delayed Pushing with an EpiduralWith an Epidural

Complete Dilation

Mother feels pressure

Reducing the Side-Effects of an EpiduralHow to reduce the effects

Possible associated effects of an epidural

• Prevent joint strain by ALWAYS respecting the limits of her joints; don’t strain, jerk, or twist her trunk or limbs.

• Support numb limbs, when assisting with position changes or with pushing.

• Protect your back & joints

Long-term postpartum backache, other joint pain

Emotional Reactions When Laboring with an Epidural

• Does absence of pain equal absence of distress?– Research findings– Personal observations

Distress from pain shifts to concerns over other things

-- Length of labor– Numbness, other discomforts– Feeling of helplessness, passivity– Baby’s well-being– Difficulty pushing– Tension in room (with drop in BP, fever,

slow progress) (Wuitchik, et al. Pain 41:125, 1990)

Graph of Labor Emotions with an Epiduralby Penny Simkin

Descent

1st stage Time (2-24 hr)

2nd stage 3rd stage

+4

+3

+2

+1

-1

Focus on other discomforts

Increased T°, ↑ FHT

No fluids?Rest & Wait

Getting Epidural

Decision

Dilation

Reluctance/inability to push

No feedback“I can’t!”

Passive descent? or “purple pushing”

Rectal pain

Instrumental deliveryIt’s Over!

123456789

10

“Where is everyone?”Pain Relief!!!

0

The Wait

Breakthrough pain( dosage)

Men and Epidurals

Chapman LL. Expectant Fathers and Epidurals. MCN Am J Matern Child Nurs2000;25:133-138

• Qualitative research study of 17 fathers’ experiences during labors in which their partners received an epidural

Two major concepts

1. “Losing her”— period before the woman receives the epidural

– Woman becomes• Progressively less communicative• Exhausted• In greater pain

Two major concepts (cont.)

– Father feels increasingly•Anxious•Frustrated •Helpless

Two major concepts (cont.)

2. “She’s back” – period after the woman’s pain is relieved

– Woman becomes “herself” again behaving in her usual way

– Father feels • Relieved• Less worried• Can enjoy labor

Chapman’s Conclusions

• Childbirth education should describe women’s responses to advancing labor to reduce the father’s negative feelings

• Labor nurses should remain in the room and explain what is happening and how to help

Conclusion

• Care of the woman with an epidural

should include

– Reduction of undesirable side effects

– Attention to her psychosocial needs

©P Simkin 2002