SELF DIRECTED LEARNINGPACKAGE: PAIN

SDLP Pain Module 2: Epidural/Spinal Analgesia of 67 September 2021

GIPPSLAND HEALTH SERVICES CONSORTIUM

SELF DIRECTED LEARNINGPACKAGE: PAIN

MODULE 2: EPIDURAL/SPINAL

ANALGESIA

CPD

5 POINTS: RN 6 POINTS: RM


CONTENTS

Acknowledgments/Copyright/Disclaimer 3

Introduction 4

Anatomy & Physiology 5

Overview of Epidural & Spinal Analgesia 9

Epidural Analgesia 13

Medications used in Epidurals 16

Key Principles of Care 19

Patient Assessment : Observation & Frequency

23

Assessment of Motor & Sensory Block 25

Key Nursing & Midwifery Considerations 29

Management of Adverse Events & Side Effects

36

Checklist of Care : Patient receiving Epidural Analgesia

51

Giving an Epidural Bonus 52

Troubleshooting Table 54

Spinal Analgesia with Intrathecal Opioid 55

Midwifery care of the woman with epidural analgesia: Key Principles of Care

57

Reference List 64


ACKNOWLEDGEMENTS

This Self-Directed Learning Package was adapted from Epidural Management Learning Package & Competency - Goulburn Valley Health and Epidural Management Self-Directed Learning Package – Bass Coast Health Approved by the Gippsland Region Nurse Educators Group July 2009 & updated by Sarah Pearse-Clarke LRH and Robyn Godbold GRNMEC January 2014. Peer review & midwifery component Rosemary Parker LRH. Updated as part of new Pain SDLP 2020- Deb Kennedy perioperative educator LRH, Pain Team LRH & Barbara Dann BCH, WGHG & SGH midwife. COPYRIGHT Wherever possible permission has been obtained for reproduction of materials and images and the compilers acknowledge the rights of the copyright holder in all reproduced materials which are referenced on the page or in the reference notes. DISCLAIMER The information in this learning package is intended to be a guide only and Health Care Professionals should be aware of the policies and procedures of their employing organisation. This learning package consists of current best practice at the time of publication, September 2021 however it should be noted that changes in the medical and nursing field can occur quite rapidly therefore it is up to the individual to ensure they are accessing current information.

NAVIGATION TOOLS & TERMINOLOGY

Critical areas of practice & key points

* Please refer to local guideline while you are working through this section

Escalation Protocol “The protocol that sets out the organisational response required for different levels of abnormal physiological measurements or other observed deterioration.” (ACSQHC, 2017) Rapid Response System The protocol set out by organisation in order to obtain emergency assistance in response to severe deterioration it is included as part of escalation protocol. (ACSQHC, 2017)


INTRODUCTION

This is a learning package only and clinicians should refer to their own organizational policy and procedures to direct their practice. Please ensure you have access to these documents as you undertake this SDLP

Once you have completed the reading of this SDLP you will need to complete the online quiz on your Kineo/ReHSeN e-learning portal. If this does not appear under your learning TAB, please contact your education department so they can get this allocated to you. There is one quiz for midwives and one for nurses. AIM

The purpose of this self-directed learning package is to provide education for Nurse’s & Midwives so that they are able to safely and effectively care for patients receiving Epidural/Spinal Analgesia.

LEARNING OUTCOMES On completion of this package including assessments the learner will be able to:

• Provide comprehensive patient and carer/family education

• Describe the basic anatomy of the spine, spinal nerves and epidural/subarachnoid (spinal) space

• State his/her role in the management of a patient with an epidural/spinal analgesia and or infusion

• Conduct a comprehensive assessment of patient who has an epidural/spinal in progress including sensory and motor block assessment

• Understand assessment and precautions with mobilisation

• Understand adverse reactions, potential complications and initiate the appropriate nursing interventions

• Ability to escalate care/initiate rapid response system according to Hospital protocol in response to adverse reactions/complications

• Outline the care related to an epidural catheter dressing/site

• Outline the procedure for discontinuing infusion and removal of the epidural catheter.

• Have sound knowledge of the drugs commonly used in epidural/spinal analgesia

• Demonstrate operational competence with the epidural infusion pump and the management of epidural infusions.

• For midwives: to understand the implications for practice in the care of a labouring woman

Please Note: Training and competency requirements will be determined by your employee Health Service.


ANATOMY & PHYSIOLOGY Spine

The spine is divided into 5 sections:

1. Cervical C1-C7

2. Thoracic T1-T12

3. Lumbar L1-L5

4. Sacral S1-S5

5. Coccyx

(Martini 2006)

(Exercises for injuries, 2013)


Spinal Cord The spinal cord extends form the foramen magnum to L1and is protected by vertebrae, ligaments, meninges and CSF. The meninges are the 3 layers that run continuously around the spinal cord and brain

• Dura mater: outer layer

• Arachnoid mater: middle attached to dura

• Pia mater: inner layer (Nagelhout, 2017) Dividing the meninges are spaces or potential spaces Epidural: potential space between ligamentum flavum and the dura mater Subdural: potential space between dura and arachnoid mater Spinal/intrathecal/subarachnoid: space between the arachnoid and the pia mater

and contains CSF (Nagelhout, 2017)


Spinal Nerves

The spinal nerves emerge through the intervertebral spaces along the spine. The area of skin innervated by a given spinal nerve is called a dermatome. (Sawhney, 2012) There are 31 paired spinal nerves leaving the spinal column.

After leaving the spine the nerves now form the peripheral nervous system. The peripheral nervous system contains 3 types of nerves

• Autonomic: regulates involuntary body functions, cardiac muscle, smooth muscle and glands

• Sensory: conducts sensory impulses from the periphery, pain temperature pressure touch

• Motor: conducts impulses to muscles (Harris, 2010)


Segmental Dermatomes


Overview of Epidural & Spinal Analgesia/Anaesthesia Epidural and Spinal analgesia is: the administration of drugs (local anaesthetic/opioid/adjuncts) into the epidural or spinal space bathing the spinal nerves and/or cord providing analgesia/anaesthesia depending on drug, doses & volumes used. They are often referred to collectively as neuraxial blockade/analgesia

• Epidural

• Spinal +/- intrathecal narcotic

• Combined Spinal/Epidural (CSE)


Epidural The epidural space is a potential space that lies between the ligamentum flavum and the spinal meninges, specifically the dura mater. It extends from the foramen magnum (base of the skull) to the sacrococcygeal ligament (sacrum), and it contains fatty (adipose) tissue. Blood vessels, lymphatic vessels, and spinal nerves pass through the epidural space. (Sawhney 2012) The epidural needle is inserted between the vertebra into the epidural space without puncturing the dura. A catheter is then inserted down the needle into the epidural space for administration of drugs. The epidural needle is then removed & the catheter is left insitu.

The exact insertion level of the epidural needle is determined by the type of surgery or procedure being performed. It is inserted at a level appropriate for the dermatome which will cover the midpoint of the surgical wound or the uterus (in labour). The epidural drugs will spread to a range of segments above and below the insertion point.


Spinal/Subarachnoid/Intrathecal The sub arachnoid space is located between the arachnoid mater and the pia mater and contains cerebrospinal fluid (CSF). The spinal cord extends from the brain to the level of L1-L2. When anaesthetic drugs +/- opioids are injected into this space it is called a spinal anesthetic. If opioids are used it is referred to as spinal anesthetic with intrathecal opioid (morphine or fentanyl). A finer (diameter) needle is used for insertion of spinal anaesthetic and the dura is punctured. Correct positioning of the needle is determined by the presence of CSF at the hub of the needle. Much smaller doses of drugs are used via this method than are with epidural administration as they spread more easily in the CSF (ANZCA, 2019) Analgesia onset is more rapid, reliable and effective. (Shatil, 2019)

Summary of differences between Spinal and Epidural Anaesthesia

Spinal Epidural

Mechanism of action Nerve roots blocked as they pass through CSF

Nerve roots blocked outside the subarachnoid space (CSF)

Administration site Lower lumbar below termination of spinal cord

Lumbar or thoracic

Dose comparison of drugs Smaller dose & volume Larger dose & volume

Administered via Needle Catheter

Ongoing dosage No Yes

Speed of onset Rapid, intense motor and sensory block more likely to lead to hypotension

Gradual less dense blockade, if hypotension usually more gradual

(Nagelhout, 2017)


Combined Spinal/Epidural (CSE) A combined spinal/epidural (CSE) combines the two methods. An epidural needle is inserted into the epidural space. A finer spinal needle is then inserted down the epidural needle puncturing the dura so the tip of the needle sits in the spinal/subarachnoid space. Drugs are injected into the space and the spinal needle is removed. The epidural catheter is then threaded down the epidural needle into the epidural space for administration of ongoing analgesia. (Up to Date 2020)

Needles for combined spinal/epidural: Spinal needle

Epidural needle


EPIDURAL ANALGESIA

How an epidural works Epidural analgesia is a central neural blockade which is used primarily for surgical anaesthesia, obstetric analgesia and post-operative pain relief. The degree of effect covers a wide range from analgesia with minimal motor block to dense anaesthesia with full motor block. Epidural analgesia is the administration of analgesic drugs into the epidural space via an epidural catheter, providing pain relief by bathing the spinal nerves as they run through the epidural space. It can be placed at thoracic or lumbar level. Effective analgesia is achieved when local anaesthetics and opioids are combined because they work synergistically to provide better pain relief with fewer adverse reactions. (Summers, 2019) The underlying principle is to provide effective analgesia to patients without causing excessive motor block (weakness) or sensory deficit (numbness) during and following various surgical procedures, post-operative or during labour and childbirth. Epidural analgesia may be administered as an

• Intermittent injection: with the epidural drugs being administered as a bolus when required without a background infusion.

• Continuous infusion: where a dose range is delivered continuously, following an initial bolus.

• Patient Controlled Epidural Analgesia PCEA: Where the patient is able to activate a metered dose (small bolus) of epidural medication on demand within set limits via specialized device, following an initial bolus dose. PCEA may sometimes have a low dose background continuous infusion.

Please refer to your local protocols in terms of PCEA. Separate training may be required. You may need to complete local training and clinical competency around this.

*Please review how epidural analgesia is delivered in your health service


Indications for epidural analgesia

• Anaesthesia for surgery on the chest, abdomen and lower limbs

• Postoperative analgesia after thoracic, abdominal, bowel, spinal or lower limb surgery.

• Pain relief post trauma e.g. # ribs.

• Analgesia for some types of chronic pain.

• Obstetric analgesia – during labour and birth. Contraindications for Epidural Infusion (maybe absolute or relative)

• Client refusal.

• Any documented previous allergic reactions to any of the medications that may be administered.

• Antiplatelet or anticoagulation drugs

• Coagulation disorders

• Therapeutic anticoagulation (relative follow local protocols)

• Uncorrected severe hypovolaemia.

• Actual or anticipated serious maternal haemorrhage

• Significant hypotension.

• Recent head injury or head trauma or CNS disease. Any clinical signs of raised intracranial pressure.

• Neurological disease (relative)

• Stenotic valvular heart disease

• Foetal distress (consider need for urgent caesarean)

• Serious infection: infection at site, sepsis or bacteraemia.

• History of spinal deformity, surgery or disease (relative) (Nagelhout, 2017)

Benefits of Epidural Analgesia

• Patient comfort – a well-managed epidural infusion results in excellent analgesia.

• Patient is mentally more alert (drugs administered locally not systemically)

• Reduces systemic side effects of opioids, such as nausea and vomiting and decreased bowel motility.

• Increased ability to deep breath, cough and mobilise. This is especially pertinent after abdominal or thoracic surgery as it aids rehabilitation and decreases side effects such as chest infections and deep vein thrombosis.

• Post-operative analgesia following bowel surgery with the benefits listed above.

• Decreased stress response to surgery by decreasing pain and consequently sleep disturbances.

• Shorter hospital stays (optimal pain management)

• Lowers BP in pre-eclampsia

• Provides analgesia for instrumental births & multiple pregnancy


Limitations of Epidural Analgesia

• Requires specialist skills: medical & nursing/midwifery

• Takes time to insert epidural catheter

• Epidural analgesia may not be effective when there is pain from multiple sites.

• Adverse side effects, associated with epidural insertion and/or administration of epidural drugs, may limit the effectiveness of epidural analgesia


MEDICATIONS USED IN EPIDURALS

*Before completing this section find out what drugs are commonly used in

your health service for epidural analgesia and how they are prepared & stored for safety i.e. polybag, premix Local Anaesthetics Bupivacaine (Marcain) & Ropivacaine (Naropin) are the local anaesthetics of choice for an epidural infusion and have a longer duration of action (4 to 7 hours) than other local anaesthetic agents. Lignocaine (Xylocaine) may be used in epidural anaesthesia (fast action but shorter duration) Adrenaline may be used in combination with the local anaesthetic to potentiate the action of local anaesthetic drugs. The effect of the local anaesthetic depends on

• Choice of drug

• Volume of drug: larger volume greater spread within the epidural space

• Concentration of drug: rapidity of onset & density of block

• Additives: adrenaline will speed up action Opioids Fentanyl is lipid soluble and has a quick onset (5 to 15 minutes) but a short duration of action (2 to 3 hours). Morphine is hydrophilic and has a longer time to onset (30 to 60 minutes) and duration action (up to 24 hours) (Sawhney, 2012) Hydromorphone is more hydrophilic (water soluble) than fentanyl but more lipophilic than morphine. The onset of action for hydromorphone ranges from 15 to 30 minutes, and duration of action is up to 18 hours. Fentanyl is usually the opioid used in epidurals. It has been chosen because it has high lipid solubility. This gives it several advantages:

• It works rapidly because it penetrates nerve tissue easily. • It has relatively short mode of action because it is rapidly removed from the

systemic circulation and taken up by fat. • When given via the epidural route it is less likely to cause respiratory

depression because it is easily absorbed into the local nerve tissue. Epidural anaesthesia vs. epidural analgesia

While epidural analgesia is used to manage pain, epidural anaesthesia is used to provide anaesthesia for surgical procedures. Epidural anaesthesia includes the loss of sensation and motor function as well as the management of pain, and involves the administration of local anaesthetics and/or opioids into the epidural space at a larger dose than what’s administered to achieve epidural analgesia. (Sawhney, 2012)


How local anaesthetic works in epidurals

Local anaesthetics affect spinal nerve roots by binding to sodium channels and preventing the influx of sodium ions into the nerve cells. This prevents generation of action potentials and interrupts conduction of nerve impulses, so the pain “message” can’t be transmitted along the spinal nerves. (Sawhney, 2012)

• Autonomic - are the smallest and will be blocked first [sympathetic blockade] causing vasodilation, sweating and heat loss. Results in drop in blood pressure (BP), postural hypotension, warm dry periphery, and compensatory vasoconstriction in the upper limbs

• Sensory - In order from small to larger they are pain, temperature, touch, pressure, and proprioception. Pain and temperature nerves are approximately the same size so pain and temperature nerve block will occur simultaneously and therefore can be checked by temperature testing.

• Motor - Results in loss of motor power within the blockade segment if the concentration of LA is high enough. E.g. a thoracic block should only affect the thoracic and abdominal muscles/myotomes innervated by the thoracic nerves. Lumbar epidurals will affect the lower limbs more. This is very important when considering mobilisation. The extent of the motor block can be assessed by use of the Bromage Scale (this will be discussed later in the package)

(Craig, 2012) How opioids work in epidurals Opioids administered into the epidural space work by binding to opioid receptors in the dorsal horn of the spinal cord to block transmission of the pain message to the brain. Opioids have no effect on sympathetic, sensory, or motor nerve fibres. The onset of action depends on the lipid (fat) solubility of the opioid. The more lipid soluble the opioid is, the faster it passes through the epidural space to bind to opioid receptors. (Sawhney, 2012) Fentanyl is considered to be a lipid soluble opioid. As such it is taken up more readily by the neural tissues at the particular epidural level where it is injected.

(Craig, 2012)


KEY PRINCIPLES OF CARE

Refer to your own hospitals Policy & Procedure manual for information on the equipment required, insertion instructions and the roles and responsibilities of all involved. RESPONSIBILITY Refer to your hospital guideline for responsibility of care and management of ongoing epidurals. Generally- The patient should be reviewed at least daily by anaesthetist or the acute pain service. (ANZCA, 2014)

Nurse & Midwife - Who has undertaken an epidural education & competency program. (ANZCA, 2014)

• Checking consent, patient identification and allergies

• Preparation of equipment

• Monitors & maintains surgical aseptic technique during preparation, insertion and all interventions

• Care and management of the patient undergoing epidural anaesthesia, including monitoring of vital signs & escalation of care as required

• Documentation of all monitoring and care given in accordance with protocols.

• Preparation of fluids and medications for administration in accordance with o Hospital policy & Procedure o Scope of practice/competency o Legal & regulatory requirements for drug administration o Maintenance of aseptic technique

(CGHS, 2010) Midwife - Who has undertaken an epidural education & competency program. (ANZCA 2014)

• As above &

• For the care and management of the woman having epidural analgesia in labour ward

• To document all monitoring and care given in accordance with protocols. PROCEDURE & EQUIPMENT Infection prevention & control principles

Insertion of an Epidural requires application of a “surgical aseptic technique” utilising a “critical aseptic field” (utilising full barrier precautions) & strict adherence to the five moments of hand hygiene. (NHMRC, 2019)


Epidural Equipment (refer to your local hospital policy and procedure)

At bedside:

• Oxygen & Suction equipment

• Monitoring equipment

• Air viva or manual ventilation device Drugs: Available & valid order as per epidural chart/record

• Naloxone: Rx of respiratory depression

• Ephedrine: Rx of hypotension

• Metaraminol (aramine): Rx of hypotension Please refer to local administration and monitoring guidelines when these drugs are used. A protocol for the management of hypotension and respiratory depression may be included as part of this.

*Please review the epidural management chart at your health service

Resuscitation Trolley:

Including O² supply, suction equipment, self-inflating bag, face mask, intubation

equipment, defibrillator & supply of intra-lipid readily available for treatment of LA toxicity (Kasson, 2017)

CTG Machine

All labouring women having an epidural require continuous CTG monitoring as per

RANZCOG guidelines (2019) with a consistently good trace i.e. no periods with loss

of contact. If the quality of the trace is questionable a foetal scalp electrode should

be applied if possible. (RANZCOG, 2019)

Instructions: Prior to Epidural Nursing/Midwifery staff responsibilities:

• Consultation in patient selection.

• Informing patient of basic procedural details in conjunction with anaesthetist

• Document baseline observations prior to procedure.

• Preparation of equipment.

• Ensure patient IV access & patency Insertion of Epidural:

• Procedure is undertaken in Operating Suite / Labour Ward

• A Nurse/Midwife must be present throughout the procedure

• If a Syntocinon infusion is in progress, this does not need to be paused during the procedure as long as high quality CTG monitoring can be continued (SCV 2018) *Please refer to local guideline and instructions of treating MO

• Baseline observations should be taken including pulse, blood pressure, respiratory rate and foetal heart rate (if applicable).

• Intravenous line is inserted prior to the epidural insertion and an IV fluid bolus may be given prior to insertion


• Assist patient into anaesthetists preferred position with back curved. Either sitting over heart table or lying on left side.

• Monitor and maintain asepsis during setup, procedure & ongoing management

• Monitor the patient’s responses throughout the insertion procedure

• Assist with preparation of equipment and drugs

• Skin prep is applied and allowed to dry, sterile drapes are applied

” Skin preparation should be conducted in such a manner that agents used for skin preparation are unable to contaminate drugs or equipment used for neural blockade” (ANZCA, 2014 pp2) Alcohol preparations are neurotoxic (alcoholic chlorhexidine & alcoholic betadine skin preparations) If equipment or drugs are contaminated by skin prep, they must be discarded. To prevent contamination separate skin prep from other equipment & drugs used in epidural insertion.

• The doctor will inject local anaesthetic into the skin and subcutaneous tissue and then insert epidural needle through to the epidural space.

• In the labouring woman, it is important that the needle and catheter are inserted in between contractions. During contractions the epidural veins become distended and an inadvertent bloody tap may occur. It is important to instruct the patient that they must alert the anaesthetist to the onset and easing of contractions.

• Anaesthetist will confirm loss of resistance (this confirms placement in the epidural space) as the needle passes through the ligamentum flavum into the epidural space.

• Patient must be kept as still as possible during this time to minimise the risk of inadvertent dural puncture or serious injury to spinal nerves

• The needle is then aspirated to detect any blood/CSF. If negative, the epidural catheter can be introduced.

• Once the catheter is inserted, the needle is removed and a filter is attached to the distal end of the catheter. Attach securement device appropriate to the size of epidural catheter at the site of insertion. The insertion site is dressed with clear occlusive dressing and the edges of the dressing secured with sleek or fixamul. The rest of the catheter is then secured up the patient’s back to their shoulder with sleek or fixamul. Secure to shoulder on opposite side to the IV cannula (safety & to facilitate line reconciliation).


The dressing should allow for easy visibility of insertion site and catheter. (Faculty of Pain Medicine, 2010)

• A test dose of local anaesthetic is given by the anaesthetist whilst assessing for any sensory or motor changes. Correct placement of the catheter in the epidural space is indicated by no noticeable effects of the test dose.

• If after 5 minutes there are no complications from the test dose the full dose is given.

• The pregnant woman should then be positioned on her left or right side, either flat or in a semi – reclining position (still on her side), all other patients are positioned supine. All patients have their head elevated on at least one pillow. Change of position may be necessary to assist spread of the anaesthetic agent. Follow anaesthetist direction in relation to positioning.

• Patient observations are recorded and any problems recorded and reported.

Post Insertion The Nurse/Midwife must remain with the patient for the next 30 minutes at least, whilst the block becomes effective. (ANZCA 2014)

• Vigilant patient assessment according to Hospital guidelines (this will be covered later in SDLP)

• After 30 minutes the effectiveness of the block and the upper limit of the block should be tested with ice (or a cold pack) and the level noted and recorded. (Procedure described in subsequent section of the SDLP)

• The patient can then be placed in any favoured position, avoiding the supine position in pregnant women.

• If the epidural catheter is inserted and infusion commenced in the operating suite the patient must be stabilised prior to transfer to the ward.


Epidural insertion equipment Epidural catheter Epidural filter Loss of resistance syringe Epidural needle

PATIENT ASSESSMENT - OBSERVATIONS & FREQUENCY

Close observation and timely and appropriate interventions in response to abnormal or concerning findings is critical area of patient safety when caring for someone who has an epidural insitu.

*Please refer to local guideline while you are working through this section, the

following information is a guide only, follow your local observation regimen.

*Please review the epidural management chart at your health service, noting

parameters for escalation of care

Initial observations

• Pulse, respiration, blood pressure, foetal heart rate (continuous CTG), level of pain & level of sedation are recorded frequently (generally 5 minutely) in the initial period following insertion or bolus doses (or until stable) (ANZCA, 2014). ANZCA recommend this for 30 minutes Motor and sensory function (will be discussed in more detail on subsequent pages) should be measured during this initial period (at 30 minutes). These observations are documented on an epidural infusion chart. (ANZCA, 2014)

• Monitoring of patient’s temperature should also be carried out as per hospital guidelines (at least 4 hourly)

• Pulse oximeter and ECG monitoring should be available. (ANZCA, 2014)


This frequency of observations is repeated following bolus doses or increases in infusion rates or change of drug concentration/dosage.

Ongoing observations

• Observations then continue at frequent intervals according to local protocol, observation frequency may need to alter in response to abnormal findings. An example of monitoring requirements is tabled on the next page.

• Obstetric patients’ in labour will continue to have observations at half hourly intervals for duration of labour & continuous foetal monitoring. (RANZCOG 2019)

• Level of anaesthesia dermatome level & motor block should be checked 4-6 hourly or more frequently if changes to rate or bolus doses or if clinically indicated.

• After epidural infusion is discontinued observations shall be done at least four hourly and IV access shall be maintained for a minimum of four hours

• If epidural morphine has been used observation regimen should continue for 24 hours.

• Monitor urine output. In most cases, an indwelling catheter will be insitu, if not encourage patient to empty bladder at least 2-hourly

Reportable parameters are also noted on an epidural infusion chart and anaesthetist should be contacted immediately of changes in vital signs outside these parameters. Follow you Hospitals Escalation Protocol in response to this The following table is a guide only observation frequency will depend on local guideline; observation frequency needs to be responsive to abnormal findings Baseline observations should be obtained prior to commencement of procedure

• Pulse, BP, respirations, temp, pain & sedation score

Observation Initial observation

Ongoing observation Labouring Woman

Post Epidural

Pulse 5 min for 1/2 hr ½ hourly for 4 hours ½ hourly 4 hourly

BP 5 min for 1/2 hr ½ hourly for 4 hours ½ hourly 4 hourly

Resp 5 min for 1/2 hr ½ hourly for 4 hours ½ hourly 4 hourly

Temp 4 hourly 4 hourly 4 hourly 4 hourly

FHR Continuous Continuous Continuous

Pain 5 minutely ½ hourly for 4 hours ½ hourly 4 hourly

Sedation 5 minutely ½ hourly for 4 hours ½ hourly 4 hourly

Motor at 20-30 mins ½ hourly till block established then 4-6 hourly

½ hourly till block established then 4-6 hourly

Till normal motor function returns

Sensory at 20-30 mins ½ hourly till block established then 4-6 hourly

½ hourly till block established then 4-6 hourly

Till normal motor function returns

SpO2 continuous Intermittent ½ hourly for 2 hours

Intermittent ½ hourly

4 hourly

ECG If indicated If indicated If indicated If indicated


PAIN ASSESSMENT

Comprehensive assessment of pain is a critical component of ongoing patient assessment & will determine ongoing management Level of pain is monitored to determine efficacy of analgesia but may also be a key indicator in the development of complications. MEASURING SEDATION

Sedation scoring is used primarily to assess the effect of opioid analgesia. The level of a patient’s sedation is measured according to their level of wakefulness and their ability to respond to verbal commands. (ACSQHC, 2017)

There will be a sedation score guideline on your epidural infusion observation record. Please refer to this and to the appropriate reporting parameters.

ASSESSMENT OF MOTOR & SENSORY BLOCK

In relation to epidural the dermatome levels and the Bromage scale assess two distinct aspects of the analgesia. The dermatome levels are used to assess sensory block whilst the Bromage scale assesses the motor block. They are part of the initial and ongoing assessment of the patient with an epidural. SENSORY BLOCK ASSESSMENT Performed to map the epidural sensory block upper & lower level (Barwon Health, 2016) What is a dermatome? An area on the surface of the body innervated from a single spinal nerve root. Key dermatome landmarks C3 Neck C5 Clavicles T4 Nipples T7 Xiphoid T10 Navel L1 Groin L4 Knee L5 Dorsum of foot S1 Lateral ankles (Cross, 2006) C5-T1: perform dermatome assessment on arms Why assess dermatome levels? Assessment of dermatome levels enable caregivers to assess the extent of sensory block associated with epidural analgesia.


The local anaesthetic blocks the conduction of impulses into and out of the nerves. When lower concentrations of local anaesthetic are used, there will be a sensory block with minimal or no motor block. Pain and temperature nerves are blocked at the same time. Nurses/Midwives can therefore use a piece of ice to detect which nerve roots at the spinal level are covered with local anaesthetic. Thus, loss of temperature sensation to COLD is used to determine analgesic block height (sensory block height). Key indicators of dermatome levels T4 Mid sternum (nipple line).

Sensory blocks above this level represent a high or extensive block. This level of block has the potential for cardiovascular and respiratory instability. This may signal excessive local anaesthetic and sympathetic block, indicating a need for reducing or stopping the epidural infusion. When to access dermatome levels

• Initially following commencement of epidural (according to local protocols) & frequently till block established

• Usually 4-6 hourly once epidural established & at shift handover

• If patient shows signs of other complications: e.g. difficulty breathing, arm weakness tingling fingers

• If the patient develops significant hypotension

• If patient has severe pain

• Prior to changes in infusion rate

• Prior to bolus and following bolus (@ 30 minutes’ post bolus) (Monash Health 2016)


SEGMENTAL DERMATOMES

High Sensory Block If the sensory block level exceeds the acceptable height charted on the epidural infusion chart by the Anaesthetist

• Escalate care and cease infusion if indicated

• Increase your vital sign recordings. Low sensory block If the block is below the level of the wound or desired area

• Increase the epidural infusion rate (within the parameters prescribed) and notify the anaesthetist.

• The patient will usually need to have a “top up” bolus dose administered.


Patchy” Sensory Block If the blocked area is becoming poorly defined or “patchy”

• Notify the anaesthetist and increase the epidural infusion rate (within the parameters prescribed).

• “Patchy” blocks are usually an early sign that the patient is going to lose their dermatome block levels altogether and a bolus dose is required.

Unilateral Block When only one side has sensory loss, this is called a unilateral block. This is usually caused by the epidural catheter moving off to one side and there are some strategies we can employ to try and compensate for this.

• Obviously if the side that is well blocked is also the location of the surgical procedure and the patient has no pain then the fact the block is unilateral is of no real concern, however this won’t always be the case.

• Turn the patient onto their painful side (the side that is not being blocked); gravity can sometimes help spread the local anaesthetic across. The patient will probably also need a bolus dose to be administered. (Craig, 2012)

Steps to carry out a dermatome assessment:

1. Patient Explanation – inform the patient that you would like them to tell you when they feel a change in temperature and/or sensation as the ice is moved along their body.

2. Ice Test – using ice, in a thin glove, touch the patient’s chest or face. This effectively shows the patient what is ‘baseline’ cold.

3. Utilising a Dermatome chart for reference points – systematically advance the ice over the dermatomes of each side of the patient’s body on either side of the midline Determine where the patient can feel ‘nothing’, touch only’ or ‘cold’. Start at the patient’s feet and move the ice upward in three to four cm increments at a time

4. The dermatome below where the patient feels the cold sensation is the upper level of the block.

5. Changes in sensation – document the upper and lower level of the block for each side of the body using the dermatome chart as a map.

6. Take appropriate action – if the block level is too low or too high.

7. Assessment should be done bilaterally, one side at a time. (Loader, 2011)


MOTOR BLOCK ASSESSMENT Motor block assessment using the Bromage scale assesses the patient’s ability to move their lower limbs. During an operation it is desirable for patients to have a motor block, postoperative or in labour it is not. The patient is asked to move their legs and the result is graded according to the table below. (Faculty of Pain Medicine, 2010) Bromage scale

An increase in the degree of block (motor weakness) may be indicative of excessive drug administration but could also indicate the development of more serious complications

• Migration of catheter

• Epidural haematoma

• Epidural abscess (Faculty of Pain Medicine, 2010)


KEY NURSING/MIDWIFERY CONSIDERATIONS

Infusion pumps & lines

LINE RECONCILIATION - Where all tubes and catheters are traced from patient to infusion source. Should be done at the change of each shift, at handover to different departments, prior to a bolus and when changing lines or poly bag/infusion syringe.

• The use of a single chamber infusion pump is mandatory for epidural infusion. (ANZCA, 2014)

• Key pad to infusion pump must be locked once dose entered.

• The epidural catheter should be taped to the opposite shoulder to the arm the IV line is in

• The infusion pump should be situated and managed from the opposite side to the intravenous infusion.

• Only yellow coloured epidural lines with no injection ports for accidental access are to be used. (ANZCA, 2014)

• Burettes must not be added to infusion line

• These lines are generally available in the Operating Suite and Labour Ward.

• Dosing must be set hourly i.e. if the rate is 10mls per hour, the volume to be infused is set at 10mls.

Labelling

• Some hospitals require a label above the patients bed (check your hospitals policy). All epidural infusion labelling must be routinely checked each shift

• Dedicated epidural infusion labels must be attached and clearly visible on

• The infusion bag/syringe

• The line above the infusion pump if polybag used

• The line below the infusion pump close to the filter

• The infusion pump itself (ANZCA, 2014) Labelling must comply with ACSQHC (2015) “National standard for user applied labelling of injectable medicines fluid and lines”. https://www.safetyandquality.gov.au/

https://www.safetyandquality.gov.au/


Yellow epidural line (no injection ports)

Observation of epidural catheter & site

• Epidural catheter line and filter should be observed regularly for integrity.

• Epidural site checked at least once per shift or when there are any issues with the epidural. Any redness, ooze, swelling or pain is noted and reported to the anaesthetist & vital signs should be checked including temperature. If leaking is observed DO NOT remove the dressing, cover with sterile dressing and notify the anaesthetist.

• Epidural catheters have markings on them to indicate their length from tip of the catheter. o It is good practice to check the catheter level mark at the insertion site

when doing epidural site checks or when catheter migration is suspected. o Each mark represents one centimetre. Two marks close together

represent ten centimetres. Three marks close together indicate fifteen centimetres and so on.

o Check the marking at the insertion site and document. o This measurement can be compared to the length documented on

insertion by the anaesthetist. Urinary output Insertion of an indwelling catheter is usually required for the duration of the epidural (Monash Health, 2019) If urinary catheter is not insitu, monitor urinary output and encourage regular voiding: fluid balance chart Infection Control Principles

• Strict adherence to five moments of hand hygiene (ACSQHC, 2019)

• Insertion of an epidural should adhere to surgical aseptic technique using a critical aseptic field (NHMRC, 2019)

• Standard aseptic technique should be adhered to when changing poly bags/syringe, setting up infusion or administering bolus injections. (NHMRC, 2019)


• Bags must be renewed every 24 hours in accordance with Infection Prevention & Control guidelines.

• Injections or infusions must always be administered through bacterial filter, which is attached between the epidural catheter and the infusion tubing.

• In the event of accidental disconnection of line, cover with sterile dressing and contact Anaesthetist in charge of epidural.

Other safety considerations

• A peripheral intravenous cannula must be insitu during the epidural catheterisation and for at least four hours post removal (Monash Health, 2016) Longer if epidural Morphine is used (see local guideline)

• Intake and output is to be monitored for 24 hours to assess adequate bladder function, urinary retention is a complication of both epidural narcotic and local anaesthesia.

• Care with systemic opioid analgesia. o If required - This must be under direction of anaesthetist caring

for patient and vigilant observation for side-effects of opioid analgesia must be undertaken.

o Post epidural requirements around timing of ongoing opioids may differ depending on whether epidural morphine or fentanyl was used.

• Drugs ordered in conjunction with epidural infusions should only be ordered by the Anaesthetist caring for patient.

• Naloxone and administrative equipment should be available at all times. At some hospitals this is at the patient’s bedside please check your hospitals policy on this.

• Resuscitation equipment should be readily available

• Pruritus may occur and a STAT order for Naloxone is often ordered. A small dose of Naloxone may reverse side effects without reducing analgesia. Other measures may be used check your local guideline.

• Heat packs should not be used (risk of burns due to altered sensation)

• Pressure injury assessment and care due to reduced sensation and mobilisation

Escalation of care according to individual hospital escalation protocol when observations vary from desired parameters.

A Nurse or Midwife (in Labour Ward) must be in continuous attendance for the first 30 minutes after insertion and any untoward occurrence or change in vital signs is noted and reported to the Anaesthetist immediately. (ANZCA, 2014)


Checking of pump settings, drugs and documentation

Infusion pump settings must be checked by two Nurses/Midwives (current competency in epidural care) when:

• Setting up

• Poly bag/syringe changes

• Bolus dose administration

• Infusion rate is altered

• Change of shift

• Infusion ceased and contents of poly bag discarded

• At handover on discharge from PACU. These checks should be noted on the observation chart and signed by both Nurses/Midwives.

• Record infusion rate/mgs/hr and volume infused as per guidelines. Mobilisation of patient & falls prevention The effects of an epidural infusion relating to mobilisation are

• The degree of motor block: A thoracic epidural affecting only the thoracic segments should not cause significant weakness in the legs. A lumbar epidural may affect the lower limbs more.

• The sympathetic block will cause vasodilation below the block so postural hypotension will occur.

• Some patients while having full motor power to their legs may experience block of proprioception when mobilising. This is an inability to ascertain where their feet are in relation to the ground caused by altered sensation and lack of position sense which leads to unsteadiness. (Some patients describe the sensation as similar to trying to walk on water). It is important to assist these patients with mobilising.

• Patients therefore have an increased risk of falls (update falls risk assessment to align with this)

(Women’s and Newborn Health, 2018) Prior to ambulation the Medical Officer shall be consulted and an assessment made regarding the patient's ability to walk (Bromage scale) Walking will require the assistance of two nurses/midwives initially Blood pressure should be checked prior to ambulation and the patient ambulated slowly as they are still susceptible to hypotension from the sympathetic block. (Women’s and Newborn Health, 2018)


Documentation “Contemporaneous records must be kept of events throughout the period of epidural analgesia”. (Faculty of Pain Medicine, 2010 pp. 10) The following elements must be documented

• Informed consent as per hospital protocol

• Insertion on the epidural infusion order chart (labour ward) or anaesthetic record (theatre)

• Allergies on the epidural infusion chart

• Prescription of the infusion on the epidural infusion chart

• Rate of the infusion on the epidural infusion chart including rate ranges

• Bolus dose on the epidural infusion chart

• PCEA dose & lockout

• Catheter insertion site and level at skin on the epidural infusion chart

• Reportable levels of observations on the epidural infusion chart

• Discontinuation of the epidural on the epidural infusion chart

• Removal of epidural catheter in the patient notes

• Name, signature and contact number or prescribing anaesthetist on the epidural infusion chart. Record of nurse/midwife who made up infusion medications if not using pre prepared polybags or syringes.

• Antidote & protocol for respiratory depression and low blood pressure or decreased conscious state on the epidural infusion chart

• Use of controlled substances in the DD book

• Observations as per hospital policy on the epidural infusion chart

• Administration of bolus doses or rate changes on the epidural infusion chart

• Any reportable events, patient activity, side effects or adverse reactions in the patient notes

• Patient involvement and education on the care plan (as appropriate) and in the patient notes

Removal of epidural catheter

• Must be ordered by the anaesthetist and documented on the epidural order chart for post op epidurals, follow local guideline in relation to labour epidurals following vaginal delivery (generally the midwife can cease these unless otherwise specified)

• “A protocol for catheter removal that relates timing of removal to the timing of administration of anticoagulant medication, or in the presence of a coagulopathy should be available” (ANZCA, 2014)

o Follow your local hospital protocol/guideline which will clearly outline timing of removal in relation to administration of anticoagulant medication.

o Ensure instructions for the timing of removal correspond to this & are clearly written on epidural infusion chart


• Place patient in left lateral or sitting position, with legs drawn up and back curved in a bent forward position.

• After removing dressing, gently pull on catheter, if any resistance is felt, get the patient to bend further forward, if the catheter will still not come or patient experiences any pain, referred pain or sensation, cease pulling on catheter and contact the Anaesthetist.

• Following removal cover site with clear occlusive dressing

• The tip of catheter should be examined by 2 Nurses/Midwives to verify completeness – same should be noted on Epidural Chart. Notify Anaesthetist if not complete. (ANZCA, 2014)

• Catheter site should be observed for redness and swelling after removal and once per shift. Temperature should also be attended 4/24, for 24 hours.

Post epidural removal observations

• Observations as per Epidural Chart should continue at least four hourly (see local guideline).

• If morphine has been used, continue observation regimen for 24 hours. PATIENT AND CARER/FAMILY INVOLVEMENT AND EDUCATION Patients’ and their carers/family are more relaxed and feel more confident in their care if they understand what is occurring, are encouraged to report changes in their condition and understand what to report to the nursing/midwifery staff It is the responsibility of the anaesthetist to obtain consent for the insertion of an epidural, but it is a nursing/midwifery responsibility to provide ongoing education and reassurance to promote quality and safe nursing care. Patients’ should be encouraged to report

• Any increases in their pain or when the pain is becoming uncomfortable

• A cold, numb, heavy, weak or tingling feeling in any area of their body which could indicate their epidural block is too high

• f they have breathing difficulties or tightness in chest

• Any pain or irritation around the insertion site

• If the dressing is coming away

• If they want to ambulate

• If they feel ‘unwell’ so that assessments can be made

• If they can’t move or experience a heavy, numb feeling in parts of their body

• Itchiness from opioid irritation

• Inability to feel when their bladder is full or incontinence (if no IDC in place)

• If they feel drowsy or dopey

• If they feel dizzy or light headed

• If they feel their heart is racing


Patients’ and their carers/family should be advised

• Escalate care if they have any concerns, all health services have information on how family or carers can initiate this process formally

• That the patient should seek assistance when ambulating due to the possibility of dizziness and unsteadiness and the risk of dislodgement

• Of the assessments the nurse is undertaking to ensure the pain relief is adequate and side effects are minimal

• An IDC may be required because the medication stops the patient being able to feel when they need to void and may lead to retention or incontinence

• The basic way in which an epidural works and what the patient can expect as far as analgesia, monitoring and how the nurse will ensure quality care

• That the epidural is not designed to completely remove the pain but to make the pain manageable

• If the pain relief is not adequate, then the patient needs to let the nurse know

• Not to touch the insertion site as it can cause dislodgement or infection

• Not to touch the infusion pump

• It is very important to report if the patient becomes drowsy or difficult to rouse

• The medication can cause side effects such as drowsiness, nausea & vomiting, etc. but these can be managed if reported to staff

• The process of discontinuing and removal of the epidural catheter

Epidural Infusion Analgesia Patient Education for Adults Each health service should provide language and culturally appropriate written and verbal information to all patients who may require epidural analgesia.

*Please review how this is managed at your health service for both midwifery

and perioperative patients.


MANAGENT OF ADVERSE EVENTS & SIDE EFFECTS

Epidural analgesia/anaesthesia can cause serious and potentially life threatening complications. Safe & effective management requires a co-ordinated multi-disciplinary approach (Faculty of Pain Medicine, 2010)

RELATED TO EPIDURAL CATHETER & INSERTION DURAL PUNCTURE This situation may arise during epidural catheter insertion. The needle or catheter punctures the dura passing into the subarachnoid space. This causes cerebrospinal fluid to leak out of the subarachnoid space.

Clinical features

This manifests as a severe “postural” headache (‘post dural puncture headache’), usually more severe whilst sitting and standing than when lying down.

• Headache

• neck pain,

• nausea and vomiting,

• photophobia, diplopia

Management

Treatment is centred on

• Timely notification to the anaesthetist/medical officer

• Nursing/midwifery interventions aimed at relieving symptoms

• Lie the patient down in a quiet, darkened room – bed rest

• Administration of PRN medications to relieve headache (e.g. paracetamol) If the headache still persists after this time, or is severe an appropriately skilled medical practitioner may perform an epidural blood patch: a sterile sample of the patients’ blood is obtained and injected into the epidural space under strict aseptic conditions at the same level as the epidural insertion site. This stops the leak of CSF thus relieving symptoms. (Craig, 2012) CATHETER MIGRATION The epidural catheter may migrate as a consequence of ordinary movement and activity that the patient undergoes. There are three main ways in which the catheter may migrate and it is important to understand these, along with associative clinical manifestations, so that prompt diagnosis and early treatment may ensue.

• Migration into the subarachnoid space

• Migration into an epidural blood vessel

• Migration out of the epidural space - falls out


a) Migration into the subarachnoid space.

Drugs will now enter into the cerebrospinal fluid and will rapidly cause an extensive block, possibly a TOTAL SPINAL BLOCK. This is an emergency situation as cardiovascular collapse; respiratory arrest and loss of consciousness may follow. (Faculty of Pain Medicine, 2010)

Clinical features

• Immediate pain relief and motor block in legs, rapidly evident

• Rapid fall in blood pressure

• Bradycardia

• Patient may complain of tingling in arms

• Patient may complain of being unable to move their arms or fingers

• Patient may complain of breathing difficulty

• Patient may become unconscious

Management

• Stop epidural infusion

• Initiate Escalation Protocol/Rapid Response System in response to clinical deterioration

• In the pregnant woman lay her on her side or in a left lateral tilt, all other patient’s position supine with feet raised, and head slightly elevated.

• Maintain airway and administer 100% oxygen as clinically indicated

• If respiratory arrest occurs ventilate and prepare to intubate

• Give an IV fluid bolus to treat hypotension per local protocol

• Administer emergency drug to treat hypotension as per local protocol

• If bradycardic Rx as per protocol

• If intrapartum continue to manage in line with this b) Migration into an epidural blood vessel

In this situation, epidural drugs are now being infused directly into a blood vessel and thus directly into the systemic circulation. This may lead to a systemic toxic reaction to local anaesthetic. Local anaesthetic drugs can produce a systemic reaction that may involve the central nervous system (CNS) and/or the cardiovascular system. CNS signs and symptoms will appear before cardiovascular collapse. However, adverse effects involving the cardiovascular system are more serious and more difficult to treat. (Faculty of Pain Medicine, 2010)

See section on Local Anaesthetic Toxicity (page 45)

c) Migration out of the epidural space - falls out

This results in inadequate analgesic cover. Re-insertion of the epidural catheter may be necessary or alternative analgesia sought.


EPIDURAL HAEMATOMA

This is a haematoma forming within the epidural space that may compress the spinal nerves or cord, causing ischemia and irreversible damage with associative loss of function below the site. This diagnosis must be considered if excessive motor block does not resolve rapidly after stopping the epidural infusion. (Faculty of Pain Medicine, 2010)

A rare (less than 1 in 150,000) but serious complication, which can occur at insertion/removal of catheter or at any time during the epidural infusion. (Craig, 2012) May be related to anticoagulated patients if insertion and/or removal timing is not followed in relation to the administration of anti-coagulant medication. Follow your local guideline. Knowing the coagulation status of your patient is another important preventative measure.

Clinical features

• Severe localized back pain

• Persistent or increasing motor block (following cessation of infusion)

• Lower limb paresis

• Loss of sphincter tone (urinary and faecal)

• Frank paralysis. Confirmation of the diagnosis is by CT or MRI scanning

Management

• Stop the infusion

• Notify anaesthetist urgently & escalate care according to Hospital Escalation protocol/Rapid response

• Treatment involves surgical decompression of the spine

• If intrapartum continue to manage in line with this

EPIDURAL INFECTION

Epidural infection or abscess is an uncommon complication of epidural catheter insertion. It can, however, hold the same catastrophic results as an epidural haematoma.

Clinical features

• Pyrexia

• Severe localised back pain

• Inflammation around the epidural site, on the patient’s back

• Lower limb weakness

• Loss of sphincter control

• Paralysis is a late sign and often irreversible. (Craig, 2012)

The threat of epidural haematoma is the most important reason for following the coagulation guidelines. (ANZCA, 2013)


Management


• Notify anaesthetist urgently & escalate care according to Hospital Escalation protocol


• Usual treatment involves antibiotic therapy and/or surgical decompression of the spine.

The symptoms are similar to an epidural haematoma and the investigation and urgency is the same.

An epidural haematoma or abscess leads to pressure being placed upon the spinal cord. This can cause irreversible neurological damage; therefore, it is paramount that there is no delay in reporting any of the above symptoms to the anaesthetist. (follow escalation protocol) It is a neurological emergency and quick action may save the patient from serious and permanent impairment. (Faculty of Pain Medicine, 2010)


RELATED TO EPIDURAL DRUGS

HYPERSENSITIVITY REACTIONS/ANAPHYLAXIS

A rare complication which usually occurs after first injection of drugs

Clinical Features

• Hypotension

• Tachycardia

• Wheezing

• Itchy skin rash

• Rapid swelling of the face and extremities

• GI SYMPTOMS (University of Pittsburgh, 2013)

Management

• Follow anaphylaxis protocol if severe reaction, administer IM adrenaline 0.5mg

https://www.bettersafercare.vic.gov.au/resources/clinical-guidance/emergency-

care/anaphylaxis-adults

• Stop infusion/trigger



OPIOIDS These include Morphine and Fentanyl. Fentanyl is the opioid of choice used in epidurals at many Health Services in the Gippsland Region. There are a number of side effects associated with the use of opioids. SEDATION Sedation is often the most sensitive indication of opioid-induced respiratory depression. (Faculty of Pain Medicine, 2010) Usually dose related or can be due to the patient receiving concurrent opioid analgesia via another route, may be due to inadvertent subarachnoid injection (e.g. catheter migration). Epidural opioids do not usually cause sedation. Over sedation differs from normal sleep in that patients are easily roused with normal sleep. (Loader, 2011) Clinical Features

• Patients may become very drowsy and unrousable. It is important to regularly assess their level of sedation as part of your observation regimen as outlined previously

https://www.bettersafercare.vic.gov.au/resources/clinical-guidance/emergency-care/anaphylaxis-adults

https://www.bettersafercare.vic.gov.au/resources/clinical-guidance/emergency-care/anaphylaxis-adults


Management

• Follow the instructions on your epidural observation form re the reportable parameters for sedation and escalate care

If associated with respiratory depression, follow protocol for this RESPIRATORY DEPRESSION This is usually associated with high doses of opioids however it is possible with any dose of opioids. The risk of respiratory depression is increased if sedatives and other drugs that affect the conscious level are used in conjunction with opioids. This also applies to the period of four hours post epidural catheter removal. If epidural morphine is used, respiratory depression may occur for up to 24 hours post last dose. (Faculty of Pain Medicine, 2010) Clinical features

• Excessive sedation as above

• A respiratory rate of < 10/min is reportable.

• Low or normal respiratory rate but decreased tidal volume.

• Pin point pupils

• Possible hypotension Management

• Stop infusion


• Administer oxygen via mask and maintain airway and ventilation as clinically indicated

• Administer Naloxone 0.1mg (100micrograms) intravenously and repeat every 2-3 minutes. (orders may vary so follow local protocols)


• Maintain more frequent observations until stable - observe for re-occurrence of respiratory depression, arrhythmias and pain due to reversal following administration of Naloxone

(Monash Health 2019) GIT DISTURBANCES Nausea & Vomiting This may be due to other factors particularly in the post op surgical patient. Nausea and vomiting is a serious post-operative complication. It reduces the patient’s speed of recovery and it is a major complaint of post-operative patients. All patients receiving epidural should have a minimum of one anti-emetic prescribed on the prn side of the drug chart. (Loader, 2011)

• Nausea and Vomiting – occurs more frequently when opioid analgesia is used. Treat with anti-emetics. If this is ineffective consult anaesthetist.


Constipation

• Monitor & treat as required. PRURITUS, URTICARIA Pruritus = itchiness Can be caused by the opioid in epidural infusion solution which may be mild or severe (Craig, 2012)

• Pruritus is indicated by patient complaints of itchiness which is not usual for them or patient observed to be frequently scratching

Management

• Assess the skin for signs of a rash or other inflammatory problem

• Check if the patient has had similar reactions to opioids previously

• Provide nursing measures to relieve irritation

• Consider if a medication may need to be prescribed to relieve the pruritus

• This may be treated with low doses of Naloxone or an antihistamine as per local protocol.

URINARY RETENTION This may be caused by the effect of the opioid at the spinal level. It may also be the effect of the local anaesthetic on the nerves supplying the bladder muscle (detrusor nerve). (Loader, 2011) For this reason, a urinary catheter may be kept in place until the epidural therapy is discontinued. (Monash Health, 2019) Urinary retention is indicated by low urine output, bladder discomfort and abdominal distension if there is not a urinary catheter insitu Management

• Maintain accurate fluid balance chart. (All patients receiving epidural analgesia should be placed on a FBC)

• Observe and report any signs of urinary retention. Be aware that the patient may not experience any discomfort from the distended bladder due to the epidural anaesthetic

• Palpate gently for bladder distension as the reason for any abdominal-pelvic pain.

• Encourage micturition by use of position, ambulation and warm compresses.

• If the patient is having difficulty passing urine notify a medical practitioner, an IDC may be required.

• Small dose of Naloxone may be ordered.

• Observe for occlusion of urinary catheter if applicable.

Antihistamines can cause sedation and should only be used if specified by the Anaesthetist


LOCAL ANAESTHETIC DRUGS These drugs include Bupivacaine (Marcaine), Ropivacaine (Naropin) and Lignocaine (Xylocaine). Bupivacaine and Ropivacaine are used at most Health Services in the Gippsland region. HYPOTENSION Hypotension is a common complication of epidural anaesthesia due to sympathetic nerve blockade.

• Sympathetic nerves, B fibres, supply the arteries and veins of the trunk and legs.

• Sympathetic activity dictates the degree of vasoconstriction of these vessels.

• Small concentrations of local anaesthetic drugs, used in epidurals, block sympathetic nerves thereby inhibiting vasoconstriction of vessels. (Loader, 2011)

• This reduces cardiac output The implications are that the patient is unable to vasoconstrict in order to increase their blood pressure if they are hypovolaemic (very common postoperatively) or when they sit or stand up from lying/supine. In the case of the pregnant woman aortocaval compression (from lying/supine) can pre-empt hypotension.

Even a mild drop in blood pressure is significant in high risk patients such as the elderly and those with underlying organ dysfunction in whom the auto-regulatory mechanism may be abnormal.

This is why Anaesthetist usually orders an IV fluid bolus prior to the insertion of an epidural. (ANZCA 2014)

A drop in systolic BP of >30% from baseline or below 90mmHg is considered to be hypotension. (Goel et al, 2009) It is normal for a patients BP to drop by 10 -20% after an epidural block is established. When hypotension occurs after surgery, other common causes should be considered and excluded, e.g. bleeding, myocardial insufficiency, sepsis, pulmonary embolus, dehydration. (Faculty of Pain Medicine, 2010) Check your local protocol/epidural order chart

• An IV fluid bolus may ordered if the patient becomes hypotensive or has a decrease in conscious state

Clinical features

• Nausea & vomiting

• Feeling faint/light headed

• BP below 90mmHg systolic or more than 30 mmHg from the baseline BP.

• Foetal distress demonstrated on the CTG in the pregnant woman.


Management

• Give an IV fluid bolus as ordered on the epidural chart (N/Saline/Hartmans) 250-500mls as per local protocol

• Consider : Stop epidural infusion for severe hypotension in line with parameters on chart. If mild drop in BP continue with fluid bolus and review


• Pregnant woman – lay her down on her side if possible or with a left lateral tilt, raise the legs and have the head in a neutral or slightly lowered position.

• Other patients position on their back with their legs elevated and head neutral

• Administer oxygen via a face mask if clinically indicated

• Administer drug to treat hypotension in line with local protocols

• If intrapartum continue to manage in line with this (Monash Health, 2019)

EXCESSIVE SENSORY BLOCK/HIGH BLOCK Sensory nerve blockage is expected with epidural drug infusions. The area of the patient’s body is numb, with little or no sensations to pain or cold stimuli is described as being blocked/covered by the epidural. This block should ideally cover the level of the operative/trauma site, providing pain relief where it is needed.

This level of block is maintained by the rate of the infusion and gravity. The level of block should not continue to rise up beyond the T4 dermatome (nipple line), on the patient.

However, this sensory block can become excessive and potentially dangerous. Any Sensory block involving dermatomes of T4 (nipple line) or above should be reported immediately.

Never tip the patients bed head down if they are receiving an epidural infusion, as the direction of gravity will make the epidural block rise up the patient’s body. (Loader, 2011)

Immediate action is required with Sensory Block > or = T4 or a BP<90mmHg (systolic)


• Notify anaesthetist urgently & escalate care according to hospital escalation protocol

• Administer oxygen via face mask if clinically indicated

• Stay with the patient and continue to monitor

• Treat hypotension with IV fluids & drugs according to local protocol


• If BP stable sit patient as upright as possible


MOTOR BLOCK/SPINAL CORD COMPRESSION A motor block occurs when the local anaesthetics bind with sodium channels on the motor nerve roots, which transverse the epidural space, blocking them. Blocking motor nerves produces weakness. An ideal epidural infusion will cause sensory block without motor block, however this isn’t always the case. Motor weakness could also be a sign of epidural haematoma or abscess. Clinical features

• A grade III or higher motor block according to the Bromage Scale

Management This particular side effect has implications for clients, particularly midwifery, as it may affect their ability to mobilise. If a client is unable to flex their knees or is having difficulty flexing their feet, the nurse should report this to the Anaesthetist immediately. This situation represents an almost complete motor block (66%). Escalate care according to local protocol (Monash Health 2019) LOCAL ANAESTHETIC TOXICITY Caused by high dose of epidural or when the epidural catheter migrates into a blood vessel in the epidural space, causing the medications to be delivered systemically into the general circulation. Clinical Features Local anaesthetic toxicity signs often emerge progressively and are indicated by: Early signs

• Perioral numbness & tingling

• Light-headedness

• Bradycardia

• Hypotension

• Tinnitus

• Muscle twitching

• Visual disturbances

• Slurring speech

• Disorientation & drowsiness Late signs

• Convulsions

• Decreased level of consciousness

• Cardiac Arrest (Loader, 2011)


These signs and symptoms occur rapidly and this is why a patient should not be left unattended when receiving boluses of local anaesthetic agents. The nurse must stay with any patient, who has received an epidural bolus and do five minutely observations for thirty minutes. (ANZCA, 2014) Management

• Stop the infusion • Notify anaesthetist urgently & escalate care according to Hospital

Escalation protocol • Stay with the patient and increase regularity of observations • Support and resuscitative measures as required. • If intrapartum continue to manage in line with this

Management of severe Local Anaesthetic Toxicity Your Hospital should have a kit for treating local anaesthetic toxicity. Please check where it is located & familiarise with the protocol. (It may be called LA toxicity kit or Lipid rescue kit) For further information and to view guideline: AAGBI Safety Guideline Management of Severe Local Anaesthetic Toxicity 2010

http://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf

Please review the guideline on the next page.

http://www.aagbi.org/sites/default/files/la_toxicity_2010_0.pdf


OTHER COMPLICATIONS

INADEQUATE ANALGAESIA

Usually caused by insufficient rate of infusion but can be caused by epidural failure, line kinking, blockage, dislodgement or pump failure

Inadequate analgesia is indicated where reported pain levels and perceived patient discomfort is greater than tolerable for that patient despite bolus administration and increasing the rate

Management

• Determine/record adequacy of pain relief according to patient response

• Check all connections, line and pump functions to ensure correct flow

• If the observations are stable, administer bolus and or adjust dose within prescribed parameters

• Re-assess level of pain and level of block

• Notify medical officer if pain relief remains inadequate despite dose adjustment - alternate analgesia may be required. (LRH Policy, 2013)

UNILATERAL BLOCK

Epidural medication is directed within the epidural space by gravity. Therefore, it can be affected by the patient’s position. Clinical features A unilateral block is indicated by patient’s complaints of pain in a specific area that was previously blocked, uneven dermatome findings when checked bilaterally Management

• Turn the patient to the unaffected side and secure position with pillows.

• Assess degree of pain and level of block, monitor vital signs

• Administer bolus and or increase rate of infusion within prescribed parameters.

• Remain with the patient.

• Monitor the response to increased rate as per protocol

• Notify anaesthetist and escalate care.


PRESSURE INJURIES May develop if patient is unable to move independently and can develop within a short period of time. If the epidural is working effectively the patient may be unaware that a sore is developing as little or no discomfort will be felt. (Women’s and Newborn Health, 2018)

Clinical Features

The development of pressure injuries is indicated by patient complaints of soreness in back, sacrum or heels and reddened and non-blanching areas to heels and sacrum

Management

• Ensure the Braden Scale is completed and up to date, consider increasing the risk rating due to the increased risk posed by the epidural

• Ensure all appropriate interventions are in place – air mattress, chair cushion, heel elevators, foam dressings to heels and sacrum, etc.

• Promote and facilitate regular mobility

• Encourage regular position changes

• Provide education to the patient regarding minimising their risk of developing pressure injures

DISCONNECTION This occurs when the epidural connection becomes loose, is snapped or has been tampered with by the patient or someone else Management

• Stop infusion. Do not reconnect catheter

• Cover end with sterile dressing

• Notify the Anaesthetist. INADVERTENT INCORRECT INJECTION INTO EPIDURAL CATHETER or INJECTION OF EPIDURAL MEDICATION INTRAVENOUSLY

This may occur when the incorrect infusion or the wrong drug is connected to the epidural catheter. It also can occur when epidural medication is inadvertently connected to intravenous line. The risk of this is reduced by

• Line reconciliation by 2 nurses/midwives (as described on page 24)

• Yellow lines with no injection ports being used for epidurals

• Epidural medications being clearly marked as for epidural use only


• Labelling of all lines with different coloured stickers to clearly identify type of line

Management

• Stop infusion.


• Support and resuscitative measures as required.

• Complete a Riskman report. LEAKAGE AT EPIDURAL SITE The main problem with leakage at the epidural site is that it tends to lift the epidural site dressing. If patency of dressing becomes a real issue the epidural may have to be removed. Leakage can also be an early sign of epidural failure. (Craig, 2012)

Clinical Features

Leakage at site is indicated by clear liquid observed within the window of the epidural dressing or oozing from under the dressing or wetness observed on the bedding below the epidural site

Management

• Do not remove the dressing

• Reinforce the dressing by putting an occlusive dressing over the top of the existing dressing

• Notify the anaesthetist


CHECKLIST OF CARE OF THE PATIENT RECEIVING EPIDURAL ANAESTHESIA/ANALGESIA Equipment Checks All components of the infusion must be checked by two Nurses/Midwives on return to the ward, at the commencement of each shift or any other time when handover of care occurs. One of the Nurses/Midwives must have completed an epidural education/competency program. Insertion is conducted in theatre or delivery suite. Anaesthetist must give the test & first therapeutic dose of epidural medication.

• Line reconciliation

• Epidural poly bag drug mix/syringe and dose against orders and in line with drug administration framework

• Protocol and drug orders available for the treatment of respiratory depression and hypotension including IV fluid bolus

• Epidural tubing, filter and connections o (Yellow port less tubing)

• Epidural catheter site and dressing (dressing must be clear & occlusive and allow for visualization of insertion site)

• Epidural yellow stickers labeling line “epidural use only”

• Single channel infusion pump

• Key panel must be locked when unattended by nursing staff

• “Volume to be infused” (VTBI) must be set hourly. This ensures only 1 hour’s dose can be delivered if there is a pump malfunction

• Emergency equipment including oxygen, suction, self- inflating bag & resuscitation trolley must be readily available

Patient checks

• Hx drug allergies/sensitivities

• Epidural medication chart with legible drug orders and reportable parameters

• Baseline & ongoing observations respiratory rate/depth, heart rate, blood pressure

• Oxygen saturation levels

• Pain score

• Sedation levels

• Motor function – assess for appropriate movement of limbs: bromage scale

• Sensory block level assessment: dermatome levels

• Dressing and insertion site at least once per shift or when indicated

• CTG if intrapartum

• Epidural insertion details and catheter length and insertion markings

• Epidural catheter taped over patients shoulder opposite side to IV access

• The patient must have patent IV access during the epidural infusion and for at least four hours after catheter removal


GIVING AN EPIDURAL BOLUS DOSE

WHO MAY GIVE A BOLUS DOSE?

• A Nurse/Midwife who has current epidural competency.

• All bolus doses must be given in the presence of two Nurses/Midwives, one of who must hold epidural competency.

• An anaesthetist order must be appropriately written enabling such a dose. Verbal Orders may be obtained however two Nurses/Midwives must hear this order and document the same.

• An infusion pump must be used to deliver this bolus. IMPORTANT CHECKS PRIOR TO GIVING THE BOLUS DOSE Individual Hospital guidelines will determine who is allowed to administer bolus doses via epidural infusion pump

• Anaesthetist has given test and initial therapeutic dose

• Drug administration in line with all regulatory guidelines

• Observations within acceptable parameters

• Dermatome levels & bromage scale within parameters

• IV cannula is insitu and patent.

• Ensure bladder empty if IDC not insitu Also

• Ensure emergency equipment available including emergency protocol & drugs to treat hypotension & respiratory depression.

• Line reconciliation with 2 nurses/midwives prior to infusion of bolus (Monash Health, 2019)

• Check all line connections, insertion site, connections & filters (no leakage).

• A thorough patient assessment must be completed, and documented, prior to any epidural bolus being given.

• Note the patients’ response to previous epidural boluses. (Monash Health, 2019)

• Observe patient carefully during administration of bolus, whilst maintaining verbal contact

• Cease administration if signs of complications & escalate care

Follow observation regimen as per local hospital guideline following bolus dose.


BOLUS RATES The epidural bolus must be given slowly as the epidural space is fat lined, and if given too quickly very little of the solution will be absorbed. Infusing a bolus at a slow rate ensures that the medication is more efficiently absorbed by the patient.

Check your local protocol for instructions on calculation of bolus rate.

CHANGING THE INFUSION RATE Infusion rate may have to be altered within the parameters on epidural order chart. The objective is to control pain ideally without motor block. All the above checks are applicable when checking prior to increasing rate and following increase in rate.

Follow observation regimen as per local guideline


TROUBLESHOOTING

If the epidural does not provide adequate analgesia despite administration of a bolus consider the following:

Start with the basics • Is the infusion pump running?

• Is the infusion connected to the patient?

• Is the giving set patent and not kinked?

• Is the epidural catheter insitu?

• Is there leakage round the site?

The patients position may be affecting the spread of the block

• Check dermatome levels to determine where the block is working

• A unilateral block may be due to the patient lying on one side. Try turning the patient onto the other side to encourage dispersion of fluid into that area

Depth of catheter • The length of catheter inserted into the epidural space can affect the efficacy of the block.

• Check the level of the catheter by looking at the marking at the level of insertion. Compare this to the length recorded on the epidural order form. Each mark represents one cm. Two marks close together represent ten cm. Three marks close together indicate fifteen cm and so on. If the catheter is in too far, the block may be unilateral.

• At times the catheter may need to be withdrawn in order to improve analgesia. This is a medical decision and the anaesthetist performs this procedure.

Repeating bolus doses.

• Usually two boluses may be given, thirty minutes apart (refer to your bolus order to ensure this is allowed)

• If two boluses and/or an increase in rate (in line with current orders on chart) have not achieved pain relief contact the anaesthetist.


SPINAL ANALGESIA WITH INTRATHECAL OPIOID A spinal anaesthetic is used for surgical procedures including caesarean section. Intrathecal opioids are often administered in conjunction with the local anaesthetic to provide post-operative analgesia. In obstetrics it may also be used for instrumental birth, retained placenta or perineal repair. It is generally the preferred method for caesarean section as it provides a quicker effective block for surgical procedures. Intrathecal opioids are inserted at the time of spinal anaesthetic (when LA is injected)

*Please refer to local guideline while you are working through this section

*Please refer to your observation chart for spinal and intrathecal opioid

Post spinal care Follow local guideline regarding observation regimen post spinal anaesthetic. The type of opioid used will determine the length of the ongoing observation period, after the initial post-operative period. Care with

• Monitor level of sedation and for signs of respiratory depression

• Mobilisation,

• Falls risk management and assessment,

• Pressure area assessment and prevention

• Bladder care as per epidural till motor and sensory block have worn off. Spinal Drugs Spinal Marcain (Heavy) is the local anaesthetic used for spinals +/- an opioid. Intrathecal opioids A lower dose of opioids is required to deliver an analgesic effect via the intrathecal route, the opioids attach to the opiate receptors in the spinal cord as well as circulating in the CSF. Cautions and relative contraindications

• Patients age

• Respiratory disease

• Obstructive sleep apnoea

• Opioid tolerant patients

• Known sensitivity Risks and side effects of intrathecal opioid

• Respiratory depression

• Sedation

• Nausea and vomiting

• Pruritus (ondansetron given early may prevent/minimise this

• Inadequate pain relief


Observations Observation regimen may differ depending on the opioid used and needs to be continued for up to 24 hours if morphine used.

• Sedation score, respiratory rate, SpO2 & pain scores hourly for 24 hours with morphine and for 4 hours with fentanyl.

• Care with systemic opioid analgesia & should only be given under direction of the anaesthetist.

Observation regimen will be inclusive of all other requirements related to surgical procedure and patients clinical condition. Intrathecal Fentanyl

• Rapid onset

• Duration short

• Short term post-operative pain management

Intrathecal morphine

• Onset of analgesia 45-60 minutes

• Duration of analgesia 4-24 hours generally at least 12 hours therefore closer post-operative monitoring required in a higher acuity setting

• Delayed respiratory depression may occur, although rare monitoring regimen should allow for this

• SpO2 monitoring

• I/N oxygen for 24 hours (check local guideline)

• IDC may be indicated for 24 hours

• Maintain IV access for at least 24 hours

Precautions

• Signage stickers and documentation identifying patient has received intrathecal opioids

• Care with other opioids

• Protocol for management of respiratory depression/sedation

• Protocol for management of pruritus

• IDC or careful monitoring of bladder function and urinary output

Adjuvant analgesia

• Paracetamol

• NSAID’s

• Tramadol If analgesia inadequate contact anaesthetist

Please complete the quiz (for nurses) allocated to on your e-learning platform. Midwives please complete the next section of the SDLP then the quiz for Midwives on your e-learning platform.


MIDWIFERY CARE OF THE WOMAN WITH EPIDURAL ANALGESIA:

KEY PRINCIPLES OF CARE Analgesia administered via an epidural is today a safe and effective option for pain relief in labour. Once the epidural is insitu the drugs, concentrations and volumes can be adapted to the changing requirements of both labour and delivery. Using low concentrations of local anaesthetic combined with opioid allow for good analgesia with minimal motor block. It also helps minimise side effects and complications. If a denser block is required for e.g. for operative delivery changes can be made to facilitate this. (Kasson, 2017) Epidural analgesia in obstetrics can potentially affect the normal physiological processes of labour & delivery (ANZCA, 2014) therefore:

• Skilled staff & monitoring equipment must be available to care for the labouring woman with an epidural.

• Systems and protocols must be in place to detect and manage complications as they arise.

(ANZCA, 2014)

• Education & information on epidural should be given to all pregnant woman in the antenatal period: this needs to be culturally and linguistically appropriate.

References to the obstetric patient have been made throughout the package this section will again highlight and expand on these. This section needs to be completed by midwives only.

*Please refer to local guideline while you are working through this section

*Please refer to your epidural management chart while working through this

section INDICATIONS SPECIFIC TO THE LABOURING WOMAN These are not absolute indications but considerations

• Analgesia for labour & delivery

• Maternal request

• Hypertensive disorders e.g. Pre eclampsia

• Multiple pregnancy

• Breech presentation

• Instrumental birth

• Premature labour

• Potential for caesarean section

• High risk woman with medical conditions such as cardiac, respiratory neuromuscular or neurological

(Kasson, 2017)


CONTRA-INDICATIONS (may be absolute or relative)

• Client refusal.

• Any documented previous allergic reactions to any of the medications that may be administered.

• Coagulation disorders

• Therapeutic anticoagulation (relative)

• Uncorrected severe hypovolaemia.

• Actual or anticipated serious maternal haemorrhage

• Significant hypotension.

• Recent head injury or head trauma or CNS disease. Any clinical signs of raised intracranial pressure.

• Neurological disease (relative)

• Stenotic valvular heart disease

• Foetal distress (consider need for urgent caesarean)

• Serious infection: infection at site, sepsis or bacteraemia.

• History of spinal deformity, surgery or disease (relative) (Nagelhout, 2017) Foetal & Neonatal benefit

• Decreases risk of neonatal respiratory depression compared to IV/IM opioids

• Assist with controlled birth in o Premature o Breech o Multiple pregnancy (Women and Newborn Health Service, 2018)

Maternal benefit

• Excellent analgesia for first & second stages of labour

• In conjunction with antihypertensive therapy to assist in stabilising blood pressure in severe pre-eclampsia

• Woman who have risk factors for general anaesthesia o Difficult airway o Morbid obesity

• For high risk woman with medical conditions such as cardiac, respiratory neuromuscular or neurological where effective pain control can contribute to maternal safety.

(Women and Newborn Health Service, 2018)

• Anaesthesia for instrumental birth

• Doses can be varied between low doses of local anaesthetic to provide minimal motor and sensory block to allow for mobilisation to higher doses which provide more extensive block suitable for caesarean section

• Allows extension of anaesthesia for caesarean delivery

• Facilitates patient cooperation for labour & delivery (Kasson, 2017) Early initiation of epidural analgesia may be considered for woman at risk of anaesthetic or obstetric complications. If commenced early in labour, there is often better cooperation with positioning and insertion. (Kasson, 2017)


MIDWIVES RESPONSIBILITYS

• Inform and educate woman (& birth partner) about epidural

• Baseline assessment o Vital signs o Pain & effectiveness of current therapy o Progress of labour-contractions, abdominal palpation, vaginal

examination & liquor o Foetal wellbeing-continuous CTG monitoring, consider foetal scalp

electrode where applicable o Risk factors

• Obtain or ensure patency & adequacy of intravenous access o Consider using rapid infusion line

• Prepare IV fluid for fluid bolus, give preload bolus as per protocol

• Prepare equipment for insertion of epidural

• Observation and care of mother during insertion & post insertion including monitoring of progress of labour and foetal well-being (ANZCA, 2014)

• Encourage & assist woman to move from side to side to promote even distribution of drug. Ensure mother is not positioned supine

• Commencement & maintenance of fluid balance chart

• Insertion of indwelling urinary catheter

• Documentation

• Maintenance of infusion/bolus dose

• FBE advised for women with pre-eclampsia, hypertension or thrombocytopaenia (Women’s and Newborn Health, 2018)

PROCEDURE & EQUIPMENT For general setup & procedure refer to local guideline

• In the labouring woman, it is important that the needle and catheter are inserted in between contractions. During contractions the epidural veins become distended and an inadvertent bloody tap may occur. It is important to instruct the patient that they must alert the anaesthetist to the onset and easing of contractions.

• If a Syntocinon infusion is in progress, this does not need to be paused during the procedure as long as high quality CTG monitoring can be continued (SCV 2018). Refer to local guideline & guidance from MO responsible for obstetric care

• Encourage mother to empty bladder prior to insertion, generally a urinary catheter is recommended: inserted prior to and remains insitu for the duration of the epidural (Monash Health, 2019)

• Positioning of mother will be directed by anaesthetist (lateral or sitting)

• Clear & concise instruction & reassurance to mother during insertion

• Will require 2nd midwife to assist with procedure as if mother in active labour insertion will have to be timed between contractions

• Continuous CTG during insertion (commenced at decision to insert epidural) (RANZCOG, 2019) Utilise FSE when appropriate

• Avoid supine position post insertion


CTG Machine

“Following a decision to insert an epidural block a CTG should be commenced to

establish baseline features prior to blocks insertion” (RANZCOG 2019 pp8)

All labouring women having an epidural require continuous CTG monitoring as per

RANZCOG guidelines (2019) with a consistently good trace i.e. no periods with loss

of contact. If the quality of the trace is questionable a foetal scalp electrode should

be applied if possible. (RANZCOG, 2019)

OBSERVATIONS & FREQUENCY

• CTG on throughout procedure (RANZCOG, 2019)

Check your local protocol/guideline for observation regimen use below information as a guide only

Initial observations

• Pulse, respiratory assessment, blood pressure, foetal heart rate (CTG), level of pain, level of sedation recorded frequently for thirty minutes (ANZCA, 2014). Motor and sensory function checked @ 30 minutes. (Monash Health, 2019)

• Observations are documented on an epidural infusion chart. (ANZCA, 2014)

This frequency of observations is repeated following bolus doses or increases in infusion rates or change of drug.

Ongoing observations & care

Obstetric patients’ in labour will continue to have observations at half hourly intervals for duration of labour & continuous foetal monitoring. (RANZCOG 2019)

• Reportable parameters are also noted on an epidural infusion chart and anaesthetist should be contacted immediately of changes in vital signs outside these parameters.

Follow you Hospitals Escalation Protocol in response to this


Other Observations & Care

• Progress of labour, contractions, PV loss, abdominal palpation & vaginal examination

• Manual palpation of contractions particularly in 2nd stage of labour (assist woman to know when to push to facilitate birth).

• CTG report as per hospital protocol

• Avoid manual administration of bolus dose during contraction

• Nausea

• Urinary output, a catheter is generally recommended– assess urinary output 2/24

• Position of mother o Position as directed by anaesthetist in initial monitoring period o ½ hourly or frequent position changes will help to ensure even bilateral

spread of medication in the epidural space (Barwon Health, 2016) o If observations within normal limits then position of comfort for mother o 2nd stage of labour position mother side to side rather than upright

• If mobilising: supervise at all times and only allow if meeting criteria in terms of motor and sensory block

• Remain vigilant for signs of foetal distress and decrease in contraction pattern

All principles of care as described earlier apply to care of a labouring woman with an epidural.

Epidural analgesia should be continued till birth and under certain circumstances into the early puerperium

• Management of the epidural in the second stage of labour will be determined by obstetrician. Women should be given opportunity to continue pain relief in second stage of labour. (Women and Newborn Health Service, 2018)

• Indications for epidural to be left in post birth o Third or fourth degree tears o Significant perineal or labial swelling o High risk of surgical intervention i.e. retained placenta (Women and

Newborn Health Service, 2018) Removal post vaginal birth

• A protocol for removal by midwifery staff may be followed

• Continue observation regimen as per local guideline

• Care with mobilisation

• Monitor urine output

• Monitor for side effects and escalate care

• Maintain IV access for at least 4 hours, 24 hours if epidural morphine used


PROBLEMS & POTENTIAL COMPLICATIONS These have been detailed in an earlier section of the SDLP Related to pregnancy

• Hypotension with particular consideration to the effect on maternal & foetal wellbeing: FHR abnormalities

• Maternal pyrexia

• Nausea

• FHR abnormalities: decreased variability, prolonged decelerations or bradycardia

• Prolonged labour & second stage

• Slowing of contractions: may need augmentation with syntocinon

• Instrumental birth

• Increased risk of third & fourth degree tears (Satpathy & Macario, 2013)

Potential for pulmonary oedema following large volumes of crystalloid has been noted as a complication of epidurals in pregnant women (Satpathy & Macario, 2013)

• Monitoring of fluid balance

• Respiratory assessment Are critical interventions to detect this complication. Effect on foetus and possible changes on CTG Local anaesthetic drugs in some cases may reduce variability on the CTG trace. (RANZCOG, 2019) Maternal hypotension may lead to fetal bradycardia. Decreased cardiac output in the mother reduces uterine oxygen delivery & can lead to fetal hypoxia with a resultant fetal bradycardia. (RANZCOG, 2019) Fetal bradycardia often resolves quickly as maternal hypotension is corrected. (RANZCOG, 2014) This illustrates the importance of monitoring maternal vital signs following epidural insertion and prompt correction of maternal hypotension if it occurs.

• IV fluid bolus

• Maternal positioning, left lateral & elevate legs

• Oxygen administration if clinically indicated

• Escalation of care & rapid response

• Administration of medications as per local protocol to correct hypotension if severe

(Monash Health, 2019)


Management of complications in labouring woman. (General principles)

Interventions will be determined by problem arising and maternal & foetal wellbeing

• Stop epidural infusion if indicated

• Oxygen via face mask 8lpm when clinically indicated

• Initiate Escalation Protocol/Rapid Response System in response to clinical deterioration

• Notify Anaesthetist, Obstetrician/GP OBs & paediatrician where applicable

• Position mother in left lateral or tilt to left

• Give an IV fluid bolus per protocol if hypotensive

• Administer emergency drug to treat hypotension as per local protocol

• Continue to monitor fetal wellbeing

• Prepare for delivery

• Documentation (Monash Health, 2019) Fetal Bradycardia

• Reposition the woman: left lateral or tilt to the left

• Treat hypotension, fluid management and drugs as per local protocol

• Escalate care

Please complete the quiz (for midwives) allocated to on your e-learning platform


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