To Epidural or not…That is the question??

Ashley Rigby

Brittney Bunnell

Heather Lee

Erika Highstead

Lumbar Block Overview

Involves injection of a local anesthetic agent into the epidural space

Space between the dura mater and ligamentum flavum

Assessed through lumbar area

Block the Pain

Technique most often is a continuous block

Start of Active Labor through the episiotomy repair

Pain Relief is achieved in 85% of women12% experience partial relief3% no pain relief

Cultural Factors- France

Epidural during labor is suppose to be available to all women

8,233 low risk women were selected2,720

37% decided not to have one43.9% labor occured to quickly3.3% medical contraindications2.8% anesthesiologist not available

Cultural Factors- U.S.

Medicaid Woman of Georgia29,833 Met Criteria15,936 (53.4%) Chose to have

epidural

Cultural Factors- U.S.

Racial and Ethnic ComparisonsAfrican Americans 49.5%Hispanic: 35.5%Asian: 48.1%White (non-hispanic) 59.6%Race/ethnicity a significant predictor of

epidural analgesia

Signs and Symptoms

Some women come into labor with the intention of having a natural labor but the pain can be too much and they can change their mind

The main sign or symptom to give an epidural is pain

Effects of epidural on Laboring mother:

Hypotension: this can cause decreased blood flow to the fetus

Fever over 100.4Decreased mobility, inability to urinateNausea/ vomitingPruritusSedation and Drowsiness3rd and 4th Degree lacerations

Effects of Epidural on Fetus during labor

Fetal MalpositionFetal Heart rate abnormalities

Tachycardia or bradycardia

Late or variable decelerationsMeconium stained fluid

Effects of progress of labor/effects on mode of delivery

Increased use of ptocin

Decreased rate of dilation

Diminished ability to push

Longer labor over all

Reduced chance of spontaneous vaginal delivery

Instrumental vaginal delivery

Effects on maternal postpartum

Urinary retention/incontinenceThe following are rare but serious:

MeningitisPostdural puncture seizuresCardiorespiratory arrestVertigo

Effects on newborn

Increase in hyperbilirubinemiaThere are studies that show there is

a relationship between the success of breastfeeding right after delivery and whether the mother was given an epidural or not.

Toxic affect of Epidural

Toxic effects due to anesthetic overdose primarily effect the Central Nervous System and Cardiovascular System. The nervous system is more susceptible to toxicity; therefore, will be the first to show signs followed by the cardiovascular.

CNS: Tinnitus, Dizziness, Seizures, Abnormal Taste CVS: Bradycardia (no adrenaline in drug), tachycardia

(if there is adrenaline), arrythmias, Bupivacaine is considered to be the most cardiotoxic

Impact on Nursing Care:

Rise in elective C-sections because of "pain free delivery"

Higher risk patient? potential complicationslonger laborFHR

Impact on Nursing Care:

Nurses work load increases slightly: acts as advocate to correct informationmonitoring of V/S and FHR risk for Hypotension----preloadingTemporary changes in bowel elimination and

placement of catheterAdministering single doses, or "topping it off”another site for possible infectionmonitoring for side effects

Impact on nursing care:

Nursing care benefitsMom's in less, or no pain = less call light use

and uncomfortableness makes transitioning through labor and being

able to save energy for the delivery and recovery

Easier to make a connection and help the mom get through labor

Interventions/ Treatment

Pre-Epidural IV FluidsEducationAdvocateVitalsAssess Labor ProgressCheck Lab ValuesAnswer any questions

Interventions/ Treatment

During Epidural insertion:PositioningSupportHelp woman with breathing techniqueAlert anesthesiologist when

contractions occurMonitor maternal and fetal vital signs

Interventions/ Treatment

Post-epiduralAssist patient into positionMonitor maternal blood pressure1:1 nurse- patient careIndwelling catheterMonitor temperatureConstantly communicate

Implications on Nursing Practice

Effects on Breastfeeding?Are the side affects worth it? Pain being “unatural”Effects during labor- injuries?

References

• Durham, J. (2003). Side effect of epidurals: a summary of recent research data.

International Journal of Childbirth Education, 18(3), 11-17.

• Davidson, M.R., London, M.L., Ladewig, P.A. (2008). Maternal-Newborn Nursing and

Women’s Health Across the Lifespan. Pearson Education, Inc. Upper Saddle River, New Jersey.

• Goodfellow, C.F. (1983). Oxytocin in Epidural Analgesia. British Journal of Obstetrics and Gynecology, 90, 214-219.

• Rust G, Nembhard W, Nichols M, et al (2004). Racial and ethnic disparities in the provision of epidural analgesia to Georgia Medicaid beneficiaries during labor and delivery.

American Journal of Obstetrics and Gynecology, 191 (2), 456-462.

• Le Ray C, Goffinet F, Palot M, et al (2008). Factors Associated with the choice of Delivery without Epidural Analgesia in Women at Low Risk in France. Birth, 35(3), 171-178.