Epidural Analgesia

Epidural Analgesia for Labor & Delivery

Indications:

Patient request for analgesia
Discoordinate labor pattern
Improved utero-placental perfusion in PIH patients
Improved obstetric management (e.g. twin delivery)

Contraindications:

Patient refusal
Hypovolemia
Coagulopathies
Back problems (infection, hardware, neurologic)
Sepsis (epidural may be used if patient on antibiotic therapy prior to epidural placement)
Primary HSV infection
Heart Disease (?)

*Typical sequence of events:*	*Notes:*
Request for analgesia from patient, nurse, or obstetric provider.	Prior to initiating block you must discuss obstetric management plan with obstetrician.
Pre-block evaluation, informed consent, and discussion with attending.	Fill out pre-anesthetic evaluation form, including basic OB history.
Place IV. Prehydrate with 500-1000 ml LR. Place monitors (EKG, BP, SpO2). Place oxygen is necessary.	All patients will be monitored when block is initiated. Nurse can help with placement of leads, BP cuff, IV placement, etc.
Check: emergency equipment on block cart, suction, and oxygen setup.	(It's your M&M conference if you don't have it when you need it)
Position patient (lateral or sitting).	Put significant other on opposite side: he or she can help patient and be out of your way. Consider asking other spectators to wait outside.
Prepare block tray.
Prep and drape.	Consider tucking towel under patient prior to betadine spray: this makes for a cleaner bed and happier nurse.
Place epidural.	(with as much style and grace as you can muster)
Inject test dose & anesthetic medications.	Place patient semi-supine, with left uterine displacement. Monitor for 20-30'; fill out anesthetic record. Usual sensory level T9-11 to L1-3.
For intermittent technique repeat doses every 1-2 hours as needed.
For continuous infusion technique use infusion device starting at 10-12 ml/hr.	Plug pump into wall power, check alarms, adust settings. It is necessary to check these patients every 1-2 hours for comfort, vital signs, and block level. You are responsible for the anesthetic administration, not the nurse or obstetrician.
Analgesia for delivery Check perineal analgesia	You will be called when patient is near delivery. If adeqate analgesia, monitor patient and assist with infant resuscitation if necessary.
If inadequate perineal analgesia, place patient in semi-recumbent position and give delivery dose.	Patients on continuous infusions often have adequate analgesia for delivery. If not, try to time delivery dose approx. 10 minutes prior to delivery. Earlier dosing may interfere with patients' ability/urge to expel infant.