Obstetric Consent for the Use of Epidural Anesthesia

Sharon Lopez
Apollo College
Obstetrics
Professor Scherer
October 8, 2009
Nurse Perspective

Epidural anesthesia is a procedure utilized frequently, for pain relief, by woman enduring the labor process. There are many considerations that the nurse is responsible for prior to, during, and after the procedure is performed. Knowing what these assessments, provisions, interventions, and evaluations are will prevent harm of the patient and ensure suitable pain relief measures are successful. According to Wong, epidural is the most effective pain relief measure used for labor (Wong, Perry, Hockenberry, & Deitra Leonard Lowdermilk, 2006).

Epidural by Definition

Epidural anesthesia involves the process of placing a needle fed catheter into the epidural space of the spinal column in between the L4 and L5 lumbar vertebrae. The purpose of this placement during labor is to block the T10 to S5 required for pain relief of all body areas involved in labor without suppressing organ function and decreasing LOC (Wong, Perry, Hockenberry, & Deitra Leonard Lowdermilk, 2006). The quantity and type of medication used determines the inhibitory effects on motor function and activity. This is a consented procedure which requires adequate education.

Assessment

Upon admission to the labor and delivery unit, the nurse should be attentive to any surgical history, allergies, obstetrics history, current medications, renal function, last meal eaten and at what time, contraction pattern, progression status of labor, and current maternal and fetal vital signs. The nurse knows that these are all significant factors in the administration of epidural medication.

Surgical history involves the use of general anesthesia and gives the nurse clues as to the patient’s physiological reaction and recovery process. This is also an assessment tool to ascertain if the spinal region has been affected by any past surgical procedures. In the event that this patient has a spinal surgical history, or an adverse response to past anesthesia administration, epidural is contraindicated. Other pain relief measures will need to be considered for these patients (Ignatavicius, 2006).

Other conditions that exist during pregnancy such as preeclampsia could complicate the use of spinal anesthesia. Preeclampsia is a condition involving an increase in blood pressure that is associated with pregnancy. Medication may have been prescribed to control blood pressure throughout pregnancy. Anesthesia could have adverse effects on blood pressure as well as loss of sensation of edematous fluid retention in the peripheral extremities, as is frequently found as a sign connected with preeclampsia (Wong, Perry, Hockenberry, & Deitra Leonard Lowdermilk, 2006). As labor progresses, preeclampsia, and fluid retention becomes a constant concern and the nurse needs to be aware.

The nurse should also be made aware of anti-coagulation therapy the patient had been receiving prior to onset of labor. These medications reduce the time it takes blood to clot and may interfere with the catheter patency post-procedure and clotting factor once the needle or catheter is removed. Another consideration is a vein could be struck by the needle when the anesthesiologist is making the attempt to place the catheter. Should this happen in the presence of a slow clotting factor, blood loss could potentiate a dramatic decrease in BP. A thorough lab evaluation may be necessary to record PTT and INR times before the procedure is performed. Before any anesthesia is administered, a meal status should be assessed. Eating a large meal too close to the anesthesia use could result in episodes of vomiting and aspiration becomes a concern. Even small amounts of fluids such as juices or carbonated beverages could increase the risk for emesis. The nurse knows that at least 8 hours of NPO status should be achieved before epidural administration (“StayWell,” 11-30-2004). NPO status does apply to epidural anesthesia as it is the medication used, not necessarily the general application, which produces the physiologic emesis.

Nursing Goals

Pain relief is an expected outcome, but not the only matter for the nurse to consider. Safety is absolutely important in all situations. It is valuable for the nurse to set goals such as; patient will comprehend the procedure before signing consent. Verbal explanation with the use of pamphlets or handouts may be utilized to help the patient understand the concept of the experience she may have during the procedure. This is a great time to answer questions or address concerns the patient has about pain relief, risk vs. benefit, and to assure her that the nurse will remain present throughout the procedure for support.

Planning

Epidural anesthesia is a consented procedure that requires a witnessed signature from the patient (Wong, Perry, Hockenberry, & Deitra Leonard Lowdermilk, 2006). The education, along with risk and benefits, fall to the anesthesiologist. However, the instructions and patient placement, in addition to preparation, and witness to consent fall to the nurse. The nurse will flush the IV with at least 5 Ml of NS to confirm patency, place the patient in a modified Sims position with legs dangling off bedside, arched back to expose vertebrae, take a baseline BP, secure the oxometer on a finger to get a reading, check temperature, track fetal heart tones throughout the procedure, bolster patient with pillows, encourage a slumped shoulder posture, support the patient from the front to prevent falls, and secure the patients safety at all times. Dad may decide if he would like to sit throughout the procedure or leave the room (Lui, Carptenter, & Neal, 1995). Explaining to the patient the importance of all these interventions will improve her confidence and assurance in the nurse. Some woman may not have ever received spinal epidural anesthesia and it is important for the nurse to address any concerns or questions she may have. Educating the patient of what she may experience, how the procedure will progress, what the anesthesiologist may ask her to do, and providing emotional support are nursing responsibilities. She should also be informed that a Foley catheter will be necessary post procedure as she will lose the ability to control GU function. Consent for the Foley insertion is separate and should be obtained along with the epidural consent. Once she understands the procedure in its entirety she can sign the consent form in the presence of a nurse.

Implementation

The nurse will remain at bedside with the patient throughout the test dose administration. BP is taken immediately following the administration of this dose as it can cause an acute unsafe drop in BP effecting perfusion to the neonate. Should this happen, the nurse will report the BP to the anesthesiologist who will then administer a dose of epinephrine into the IV lower port to revive pressure and rate, hence the patency of IV plays a major role in patient safety (Kee, Hayes, & McCuistion, 2009). The nurse will continue to reassess the patient taking BP every 5 minutes for the first fifteen minutes, and every fifteen minutes until after delivery. Fetal monitoring is important to assess as mom has lost feeling of neonate movement. Edema can result from the limb immobility and the nurse should watch for signs of fluid retention. Once the effects of the epidural have taken full effect, the Foley can be inserted and output can be accurately monitored. Maintaining accurate I&O is important while mom is NPO, receiving IV fluids, and has Foley evacuation for the duration of her labor.

Evaluation

Continuous reassessment and evaluation of the patient ensures safety and effectiveness of pain relief, hydration status, VS stabilization, progression of labor, and neonatal health. The level of pain should be reassessed post procedure to ensure that epidural pain relief is effective. Hydration status is monitored with calculation of I&O. Vital signs are monitored frequently and consistently throughout labor. External monitoring should indicate the continuation of contraction strength and duration throughout labor post procedure. External fetal monitoring should indicate variability WNL, regular HR in the 130-160’s, and the absence of D-cells until late transition phase of labor. Cervical changes should also be regularly assessed to determine the progression of labor and establish the end of transition phase into the delivery phase of labor.

The Nurse Should Know

Approximately 95% of all laboring women consent to an epidural to ease pain during labor (Wolf, 2009). There are associated risks such as: HA, N/V, adverse reaction, movement is restricted, dizziness, sedation, orthostatic hypotension, tinnitus, paresthesia, injection into blood vessel resulting in convulsions, subarachnoid injection resulting in respiratory arrest, temperature regulatory issues (Wong, Perry, Hockenberry, & Deitra Leonard Lowdermilk, 2006). Conversely, there are numerous benefits to using epidural anesthesia during labor and include: decrease in fetal complications, medication volume and administration can be modified for more or less sensation, and mom remains alert and is able to rest and participate. Which ever method mom uses to relieve pain during the laboring process, it is the nurse’s primary responsibility to educate, instruct, advocate, and protect the patient’s safety and rights (Wong, et al.). There are numerous materials available to the nursing and anesthesia staff in a hospital setting that will allow the patient access to informed consent. Safety is such an important consideration for the well being of patients and many of the educational materials are focused on how the hospital staff intends to provide a safe environment. Helping patients understand the role they play in their own safety is of vital importance as well. The patient should be made aware of what all of these interventions are, which of these the nurse, anesthesiologist, delivery doctor, or herself, will be responsible for.

References

Ignatavicius, W. (2006). Medical-Surgical Nursing: Critical Thinking for Collaborative Care (fifth ed.). Missouri: Elsevier Saunders.
Kee, Hayes, & McCuistion. (2009). Pharmacology: A Nursing Process Approach (sixth ed.). Missouri: Saunders Elsevier.
Lui, S., Carptenter, R., & Neal, J. (1995). Running head: SPINAL VERSUS EPIDURAL ANESTHESIA. Anesthesiology, 83(4), 757-765.
StayWell. (11-30-2004). Retrieved from Healthline Web site: http://Retrieved from http://www.healthline.com/sw/kbr-epidural-anesthesia-relieving-pain-during-labor-and-delivery
Stoelting, R. K., & Miller, R. D. (2007). Basics of anesthesia (5th ed.). Philadelphia: Churchill Livingstone.
Wolf, J. H. (2009). Deliver me from pain: Anesthesia and birth in America. Baltimore: Johns Hopkins University Press.
Wong, D., Perry, S., Hockenberry, M., & Deitra Leonard Lowdermilk. (2006). Maternal Child Nursing Care (third ed.). Missouri: Mosby, Elsevier.