• Women requesting epidural anaesthesia in labour and /or in special circumstances in latent phase.
• Obstetric indication e.g. multiple pregnancy (to facilitate delivery of second twin) and blood pressure control

Absolute contraindications

• Patient refusal
• Abnormal coagulation
• Platelet count <50x10⁹
  • Bleeding disorders (severe Von Willebrand disease)
  • Prophylactic low molecular weight heparin e.g. Dalteparin given within last 12 hours
  • Therapeutic low molecular weight heparin with last 24 hours
  • Coagulopathy
  • Clopidogrel
    
    
• Allergy to local anaesthetics
• Local sepsis

Relative contraindications

• Systemic sepsis (discuss with Consultant if WCC >25 and wishing to proceed)
• Raised intracranial pressure
• Platelet count <75x10⁹
• Lumbar spinal surgery

Midwives should discuss different forms of analgesia available for labour and birth. Ideally this should occur antenatally, however this can be revisited anytime, particularly when admitted in labour or induction of labour.

If a woman is contemplating regional anaesthesia, talk to her about the risks and benefits, and implications for labour (NICE). This is available to print in multiple languages from www.labourpains.org.

Give unbiased information regarding effects of epidural anaesthesia on labour and delivery to ensure that the woman is able to make an informed decision.

Fetal wellbeing must be assessed and documented prior to commencement of the epidural (at least 15-20 minutes of CTG)

The anaesthetist should plan to attend within 30 minutes of request, although in periods of exceptional workload demand/acuity this may not be possible.

The anaesthetist should explain the procedure and common complaints to the patient to obtain an informed consent, this should be documented on the epidural chart and within Badgernet.

Epidural analgesia should usually only be initiated if the patient is in established labour or with agreement from obstetrician. However, there may be occasions where there is severe pain in the latent phase of labour and epidural analgesia may be appropriate in which case it should not be denied.

It is the responsibility of the midwife to ensure appropriate monitoring of fetal well-being and the responsibility of midwife and anaesthetist to ensure maternal well-being during the procedure.

• The midwife should check maternal blood pressure and pulse every 5 minutes for 15 minutes then every 30 minutes thereafter. After each subsequent bolus if >10ml volume (i.e. this is not required after a programmed bolus or patient controlled bolus as these are both <10ml)

It is important that the midwife conveys any fetal or CTG concerns to the anaesthetist prior to or during the initiation of epidural analgesia so that the procedure can be paused if required.

Maternal and or fetal risk factors present; 15-20 minutes of normal CTG analysis is required before an epidural is inserted.

Assess maternal and fetal parameters (blood pressure, pulse rate, temperature, progress in labour and liquor).

Epidural is not an indication for a fetal scalp electrode.

Do not routinely perform ARM prior to epidural insertion if all aspects of fetal and maternal well-being have been ensured.

If the epidural procedure is not completed within 30 minutes of starting, CTG monitoring should be re-started until normality is confirmed.

• Positioning:
  • The woman should be positioned on the flat portion of the bed with her feet flat on a stool.
  • Adjust the bed height to ensure patient’s knees are slightly higher than her hips.
  • Give a pillow to curl over, aiming to achieve an arched back.
    
    
• Equipment:
  • Intravenous cannula must be in situ.
  • Dedicated epidural pump with lockable anaesthetic bag chamber.
  • Sterile epidural pack
  • NRFit epidural needles, syringes and drawing up needles
  • Epidural trolley
  • Local anaesthetic bag (250ml bag of 0,1% levobupivicaine +2mcg/ml fentanyl) This is kept in CD cupboard and should be dispensed as per local policy.

Placement of the epidural catheter should be completed within approximately 20 minutes or 3 attempts after starting.

If the midwife feels that the anaesthetist has persisted for long enough it is reasonable to suggest seeking assistance.

The anaesthetist should give a test dose, following this dose the midwife should check maternal pulse and blood pressure every 5 minutes for 15 minutes.

The anaesthetist should assess the epidural block fully then proceed with pump set up.

• Use a cold stimulus such as Ethyl Chloride spray (or Coolstick if available)
• Demonstrate cold stimulus on “unblocked area” e.g. arm or shoulder
• Start at the groin and move upwards. Record the upper level.
  • Groin = L1
  • Umbilicus = T10
  • Mid-point between umbilicus and xiphoid = T8
  • Xiphoid = T6
  • Nipple = T4

Block to the level of the umbilicus or a few cm higher is ideal. If the block is higher than T6 you should call the anaesthetist.

This should happen with a degree of flexibility e.g. if a low-risk woman with uncomplicated epidural anaesthesia, with no motor block when assessed at 02.00 hrs is due for next vaginal examination at 03.30 hrs, it would be reasonable to defer the 03.00 hrs test of the block until 03.30 hrs, just before the vaginal examination to allow her to catch up on sleep.

• The midwife should perform continuous cardiotocography throughout use of epidural
• Check maternal pulse and blood pressure every 5 minutes for 15 minutes after clinician delivered bolus
• Inspect pressure care areas every 2 hours and document on Badgernet
• Check pain score every hour
• Test block
• Perform straight leg raise every hour and record on chart and Badgernet
• Any test doses/clinician boluses must be documented on anaesthetic chart

• The woman is uncomfortable
• The woman requires more than one bolus after auto-bolus
• High block
• The woman in unable to perform straight leg raise
• Maternal hypotension
• Pump re-start is required
• LA needs to be changed.
• If the midwife has any concerns

Anaphylaxis

Respiratory depression

Total spinal

Local anaesthetic

Hypotension

Nausea and vomiting

Pruritis

Urinary retention

Accidental Dural puncture

Fever

Management of complications or side effects

Women may sit or lie on their sides but should not lie flat on their back. If a woman needs to lie flat on her back for vaginal examination, ensure the uterus is displaced to the left to avoid auto-caval compression. Encourage regular position changes to minimise pressure area damage. The pressure care risk assessment must be completed on Badgernet.

Women should be encouraged to empty their bladder every 4 hours after epidural insertion. If spontaneous voiding is not possible then an in-out catheter should be used. Bladder distension can cause suprapubic breakthrough pain.

Position patient on her side.

Remove all dressings and pull gently on epidural catheter with constant force.

If there is resistance ask the woman to curl up and try again, if this fails ask the anaesthetist to attend.

Ensure blue tip is intact and visible.

If the blue tip is absent contact the anaesthetist.

The first dose of Dalteparin should be given 4 - 6 hours after removal of an epidural catheter.