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NOW AVAILABLE AT https://inmoprofessional.ie Use of epidurals in labour
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10/05/2018 16:45:46
It is vital that midwives stay abreast of the latest professional standards regarding pain relief in women in labour
Epidurals are used as a form of labour analgesia by approximately 25-30% of women during childbirth. Midwives have a responsibility to be educated on types of epidural, the advantages and disadvan- tages of their use, and the impact they may have on the women who choose them. This i-learn module on epidural use for labour aims to develop midwives’ knowl- edge and understanding of epidurals to improve their confidence in safely caring for women who choose to give birth using epidural analgesia, in line with the profes- sional standards. Learning outcomes On completion of this module (study time: 60 minutes) you will understand: • The intended and unintended effects of labour epidural • Which types of epidural are commonly available and how they work • When each epidural type is appropriate and the indications and contraindications for their use • The role of the midwife in caring for the labouring woman before, during and after epidural administration, including informed consent, drug safety and mon- itoring of both the woman and foetus • The range of epidural effects, from common side effects to major complica- tions, and how to identify these and take safe, appropriate actions • The midwife’s role in the wider multidisci- Pharmacological methods to control pain and discomfort during childbirth have been used across human history and have included agents that have been inhaled, swallowed, injected and topically applied. Mention of opiate use can be found in early Chinese writing, references to wine consumption can be found in Persian liter- ature, and the use of beer or brandy across Europe can be found in literature from throughout the Middle Ages. During the 1930s and 40s, women in plinary team during epidural care. History of pain relief for labour
Indications
Contraindications
• Maternal request for pain relief during labour • Intubation risk or family history of general anaesthetic problems • Cardiac/respiratory disease • Blood pressure control in hypertension • Post-operative analgesia after CS (rare)
• Declines epidural/no consent • Some neurological disorders • Thrombocytopaenia: platelet count < 100 • Bleeding disorders, eg. haemophilia • Coagulopathy • Clopidogrel (for managing stroke risk/heart disease in < seven days • 1:1 midwifery care not available • Anticoagulants/thromboprophylaxis within 12-24 hours, depending on dose • Allergy to medications used
• A needle is inserted into the lumbar spine intervertebral spaces – these are usually selected because the spine can be readily identified as lying between the highest point of the iliac crests • The nerve fibres responsible for transmit- ting pain during labour include T10 to S4 • After inserting a Tuohy needle into the lumbar intervertebral space, a fine cath- eter is threaded through and secured in place through which the analgesia is administered • Nerve fibres also transmit sensations such as temperature – this is why temper- ature sensation (eg. ice cold) changes can be used to assess the level of the epidural block. Indications and contraindications Women may choose epidural for labour for a number of reasons and sometimes an epidural may be advocated or indicated for medical or obstetric reasons, eg. car- diac disease or a perceived high risk labour where urgent transfer to operative delivery is envisaged. It is important for healthcare professionals and their patients to be fully informed about possible contraindica- tions (see Table) . Some practices may vary between anaesthetists and trusts. RCM i-learn access for INMO midwife members If you are interested in completing the module, visit www.ilearn.rcm.org.uk Free access is available to all midwife members of the INMO. www.inmoprofessional.ie/RCMAccess
labour were often injected with high doses of morphine and scopolamine, which was sometimes supplemented with inhaled analgesia with chloroform, nitrous oxide or trichloroethylene. These doses would often cause the woman to lose consciousness, leading to maternal and neonatal compli- cations. Women found this approach to be unacceptable and there was a demand to find a more effective method of pain control. Today, regional analgesia has emerged as a widely used approach to pain relief in obstetrics. Epidural analgesia is very effec- tive and is the method of choice for many women where pain relief is concerned. What is epidural regional analgesia? A suitably trained, competent anaes- thetist is required for epidural regional analgesia. The procedure involves placing an epidural catheter into the epidural space around the spinal column of the lower back for injection of local anaesthetic such as bupivacaine, often with an opioid analgesic such as fentanyl, through a bacterial filter. The analgesia is able to cross the dura and arachnoid membrane and act on the nerve roots (local anaesthetics) or the receptors in the spinal cord (opioids). This blocks the passage of pain impulses and cuts off sen- sory innervations to the region, preventing transmission of pain pathways in labour. How epidural analgesia works • Epidural analgesia affects motor, sensory and autonomic nerves
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