Role of Midwives in Administration of Epidural Anesthesia - Essay Example

ROLE OF MIDWIVES IN ADMINISTRATION OF EPIDURAL ANESTHESIA By of School and The roles played by midwives in the United Kingdom have continuously expended over time in the healthcare service history, with more responsibilities being introduced in the profession than it used to be in the past decades. As part of the medical team in the hospital setting, there has been need for their involvement in many of the practices, previously performed exclusively by the physicians. Considering their prime role in facilitating childbirth, it has become necessary that the professions become conversant with, and incorporated into the epidural anaesthesia administration, which has gained significant popularity for its effectiveness in providing regional anaesthesia for child delivery. The paper, therefore, seeks to address the variable roles of the midwives in the in epidural anaesthesia administration in the UK, together with the numerous practices involved in the practice. The merits and demerits of the practice are equally highlighted herein, together with the variable conditions required for anaesthesia administration. Epidural analgesia is considered by many practitioners as a gold standard of analgesic during the major surgery-related operations. It ideally has the potential to give suitable patients the complete algesia provided the epidural is maintained for a long time. This technique allows the patient to rest and experience less pain in the process. In addition, the technology aids in creating a positive attitude towards the delivery process. However, epidural administration may lead to partial paralysis, lowered hormonal levels, and unbearable pain among other shortcomings. The procedure is under constant improvement and there is hope for a more advanced epidural delivery technique, free of the many problems currently encountered. Through the procedure, midwives play critical roles among which is assisting anesthetists in preparatory as well as administrative phases of the process. Introduction Epidural anesthesia has gained massive popularity as the most preferred method for pain relief at the time of labour. For instance, more women have been found to have preference of the anesthesia than they do for any other pain reliever (Anin-Somuah, Smyth and Jones, 2011). Epidural anesthesia could be defined as a regional anesthesia which works by blocking pain in a certain body region, with the aim of providing analgesia or relief pain, as opposed to other forms of anesthesia that result in total lack of feelings. Ideally, the epidural anesthesia block nerve impulses from the lower segment of the spine hence reduce sensations within the lower part of the body (Altunkaya, Ozer, Kargi and Babuccu, 2003). This form of medication is categorised into drug class called local anesthesia, and they are often delivered together with narcotics or opioid for the purpose of decreasing the dose needed for local anesthetic. The desired outcomes are thus realised through combined opiod and epidural local anaesthetic. The effectiveness of the epidural technique is realised in provision of dynamic analgesia, where the patient is allowed to mobilise and eventually resume her routine activities without any hindrances due to pains (Varney, Kriebs and Gegor, 2004). Even when performed as a patient-controlled system of delivery, Parenteral opioids cannot effectively offer a similar level of analgesia. As Anin-Somuah, Smyth and Jones (2011) atate, during childbirth, both mopther’s and infant’s lives are are often at risk. As such, there is need for focused methodologies aimed at handling any arising complication that could possibly affect the entire proess of delivery and the health of the newborn and the mother While the process is often expected to occur smoothly with minimal complications, the later do arise in many instances. Such an occurrence necessitates specialised care aimed at ensuring successful delivery (Beattie, Badner and Choi, 2001). Occurence of delivery complications could result in the mother losing energy rapidly, and this compromises the ability to push during delivery. This is particularly observed in prolonged deliveries where the mother becomes highly restless. Epidural anasthesia has thus been discovered as an essential aid in such circumstances. Role of Midwives Midwives are the medical personnel tasked with numerous responsibilities, amongst which is the provision of midwife care in line with the standards specified by the council at a given time to both women and children right from antenatal, intranatal and eventually at the postnatal periods (Yokoyama, Hanazaki, Mizobuchi and Takahashi, 2004). In addition, they are expected to offer informed family planning advice and information as well as prescribing and advising on the necessary examinations at the most safe time for possible diagnosis of any risks at time of pregnancy (Demiraran, Kocaman and Akman, 2005). They have also been known for their roles in providing parenthood preparation programs together with the complete childbirth preparation, which include advice on nutrition and other hygiene-related guidance. Midwives provide assistance and care to mothers in labor as well as monitoring the foetus’ condition in utero by use of preferred clinical and technical means. They carry out spontaneous deliveries that include the time of episiotomy and during urgent cases, breach of delivery.  Advantages of Epidural Anesthesia The use of epidural anesthesia is associated with numerous advantages that include the ease with which the practice can be performed, despite the fact that it is more involving than spinal anesthesia. On the other hand, this is regarded as a reliable anesthetic since it offers excellent conditions for conducting and operation (DeRossi, Junqueira, Lopes and Beretta, 2005). The practice is popular in most labor wards due to the ability for administration of additional local anesthetics periodically over time. Epidural anesthesia enables the usage of epidural catheter for postoperative analgesia. On the other hand, practitioners have found the anesthesia as being fast in returning the gastrointestinal functioning of the patient following the anesthesia adminstration (DeRossi, Junqueira, Lopes and Beretta, 2005). The practice is also associated with minimal pulmonary complications than it could possibly be expected when other general anesthesia are used. It is also believed to reduce deep vein thrombosis incidences together with formation of pulmonary emboli. Procedures, Requirements and Implications Epidural anesthetic administration is a labor-intensive process that requires critical and technical presence from the initial stages involving storage of the infusion bags, to the later stages. While the anesthetist plays the leading role in the delivery of the medication, the midwife or nurse provides supportive role which is critical for successful procedure (Doherty, Redua, Queiroz-Castro and Rohrbach, 2007). These supportive roles commence in the preparatory phase and move right into the procedure and follow up phases. While the preparatory phase is often underrated, it is a great determinant of the success or failure of the whole procedure (Yokoyama, Hanazaki, Mizobuchi and Takahashi, 2004). Since patient safety is a priority to any medical institution, it is often necessary that medical records of the patient are reviewed prior to epidural injections. This will help in preventing toxication of the patient. For instance, it is not ideal to subject a patient to epidural injections if they have taken heparin and other anticoagulant injection within 8 hours as this could lead to fatal hemorrhage resulting from impaired collagen linkage, hence compromising bloot clotting and wound healing processes (Wheatley, Schug and Watson, 2001). Since epidural injections are often administered through the spinal it is necessary that the patient sits in appropriate position. However, the expectant women are at times too tired to turn around and, therefore, the midwife is often tasked with helping her attain the required posture which ensures maximal access to her back (Burvill, 2002). The midwife also helps the anesthetist to determine critical parameters such as patient blood pressure, prior to commencement of the practice. After the determination of the required parameters and consequent clearance of the patient as fit to attain the epidural treatment, the midwife should is tasked with the determination of the foetus raisks resulting from the procedure (Anin-Somuah, Smyth and Jones, 2011). The electronic scans used determine the response of the infant to changes in its external environment. While the midwife plays little role limited to submitting required epidural equipment and assisting the woman during the procedure, their roles magnify following successful completion of the injection (Demiraran, Kocaman and Akman, 2005). On the assistance part, the midwife is often expected to facilitate the identification of procedural lapse that may compromise the efectiveness of the procedure. The anesthetist may, for instance, forget to properly label the infusion line, an occurrence that may affect follow up injections and top up treatments. During the condition of anesthesia, the patients are often bound to experience pain and other complications that may require specialised attention (Stuart, 2000). As such, it is often necessary that the midwife remains in close proximity to check on the patients condition. In hospital setups, maintenance of hygiene is paramount. It not only helps to eradicate possible spread of infections, but also plays a role in ensuring patient comfort. Like any other hospitalised condition, delivery process and hence epidural anesthesia administration and monitory process can be marred with hygiene concerns (Demiraran, Kocaman and Akman, 2005). Therefore, the midwife ensures cleanliness is maintained. Since medical confusion and errors are a likely occurrence in hospital settings, factors that may predispose such occurrences should be eliminated at all costs. Also, the medical field requires timely administration of medical procedures and drugs. To prevent possible procedural lapses, midwives always ensure the success of follow up procedures in a wider variety of ways (Lieberman and O’Donoghue, 2002). First, they must replace empty epidural bags immediately to ensure continuity in medication. Besides, they must keenly study the patient response to medication and report any adverse observation to the doctor in charge so as to initiate appropriate follow-up procedures (Torrance, Thomas and Grindey, 2003). For example, if the patient experiences renewed bouts of pain, the doctor may opt to administer a top up anesthesia. Aseptic Technique Hand washing practice remains the major method through which the spread of pathogens during the epidural anesthesia administration and delivery practices. Hands have been identified as the most common means by which transmission of micro-organisms occurs thus, hand washing is regarded an essential practice for cross-infection prevention (Varney, Kriebs and Gegor, 2004). During the washing of hands, soap and water have been found to move bacteria but failed to kill organisms. The use of anticeptic solutions that contain alcohol components is preferred in hand washing. On the other hand, it is believed that healthcare workers with artificial finger nails harbor high gram-positive bacteria concentrations on their fingertips and hands prior to and after washing their hands (Lieberman, Davidson, Lee-Parritz and Shearer, 2005). In this respect, therefore, the midwives are discouraged from keeping nails to minimise the risk of harboring and transmitting pathogens. During their practice, there is need to avoid the use of jewelries by the midwives and other medical care practitioners in the labor ward. Wrist watches, bangles and rings among other jewels could increase the harbor of pathogens (Prakash, Tyagi, Gogia and Singh, 2006). Surgical masks are equally important during the regional techniques like administration of epidural anesthesia. The masks have been identified as important in prevention of pathogen transmission in the healthcare setting, which eventually reduces the risk of infecting the patients or the midwives professionals with bacterial pathogens from other individuals (DeRossi, Junqueira, Lopes and Beretta, 2005). Midwives Knowledge of Epidural Analgesia To effectively accomplish duties, it is necessary that one fully understands the underlying theoretical principles behind proposed actions. It is hence necessary that the practising midwives be well equipped with pharmacological knowledge that enables them to have comprehensive knowledge on the appropriate methods of responding to different situations that may arise (Guedes, Natalini, Robinson and Oliveira, 2005). Studies indicate that despite the continuous use of the epidural analgesic procedure, midwives have minimal knowledge of the technique. In some instance, it has been observed that most midwives remain lack basic knowledge of the mode of action of the analgesic drug administered. Indeed, Burvill (2002) points out that epidural injections act through partial paralysis of nervous response structure, preventing transmission of nervous impulses to the central nervous system. The article points out that increased popularity of the analgesic procedure should translate into proportional knowledge about it to ensure proper care for the patients. On the contrary, midwives have in many occasions been involved in wrong pain diagnosis due to lack of appropriate knowledge required (Tracy, Sullivan, Wang, 2007). In some instances midwives are unable to identify and differentiate different drugs. Such drug confusion may lead to wrong medication and toxication of patients. Indeed, it has been established that most nurses and midwives prefer to learn more through long term experience and assumptions (Varney, Kriebs and Gegor, 2004). As a result, their practical performance far out ways their theoretical knowledge about the procedures involved. These trial and error techniques are dangerous encounters that should hardly be tolerated. Therefore, it would be appropriate to subject midwives and other medical practitioners to epidural educational programs to facilitate delivery of better patient care. Such a program can enhance patient satisfaction in services delivered, minimise hospitalization time and also lower the economic burden of healthcare (McLeod, Davies, Bannister and Macrae, 2002). Epidural Anesthesia enhances comfort allowing the woman to enjoy the birth process, ensuring the patient remains alert and active during the birth process. The continuous evolution of the technology has also ensured that the modern procedure is less harmful like the earlier variants (Chalk, 2004). Epidural administration of the pain relievers also aids in imposing selective analgesia. As a result, all other body organs remain normally functional with minimal impact on their nervous system. In addition, the technique prevents sympathetic blockade that could lead to paralysis. In addition, the treatment ensures easier control on the amount of analgesia through programmed spinal administration (Guedes, Natalini, Robinson and Oliveira, 2005). Problems of Epidural Anesthesia Administration The procedure is associated with certain shortcomings, posing great health risk not only to the mother, but to the newborn child as well. The technique leads to unbearable pain on the back of the patient, and at times leads to formation of large wounds (DeRossi, Junqueira, Lopes and Beretta, 2005). The severity of the wound is further enhanced in obese patients, with multiparity, adverse health history, cervical dilation, and regular use of the technique being some of the predisposing factors that enhance the severity of the pain and wound. Several adverse effects have been cited to result from the procedure. the mother is likely to become less mobile thus hampering her ability to perform routine duties of life (Doherty, Redua, Queiroz-Castro,. and Rohrbach, 2007). Moreover, her hormonal levels, specifically the oxytocin and adrenalin levels are likely to drop. Consequently, her ability to produce milk for breastfeeding is greatly reduced. In some instances, she is likely to develop Fentanyl itch that is persistent for up to 2 days. This may be accompanied by lethal migraines persistent for 7 days following delivery and persistent backaches lasting for months (Gunes, Gunduz, Ozalevli and Ozcengiz, 2004). In addition, the procedure may make the mother paraplegic throughout her future life. Consequently, she is likely to develop pessimistic approach of life hampering her personal development and productivity. To the newborn, the detrimental effects posed by the medical procedure can be life threatening. These effects, however, are often caused by secondary effects resulting from changes in maternal body functioning directly imposed by the medical tool (DeRossi, Junqueira, Lopes and Beretta, 2005). For instance, when blood pressure of the mother reduces, the rate of nutrient and oxygen supply to the fetus is impaired. Consequently, the fetus or newborn is likely to experience anoxic conditions that are at times coupled with neonatal seizures. During the delivery process, the process may prompt vacuum delivery that could lead to bruising of the baby (DeRossi, Junqueira, Lopes and Beretta, 2005). Moreover, the delivery process may enhance the perineal damage, at times necessitating cesarean delivery. Such a process lowers oxytocin level further risking the life of the baby. Sadly, the technique could hamper cesarean delivery, which at times is the only option for successful delivery. According to Chalk (2004), epidural anesthesia administration has, in few occasions, resulted in adrenalin overload. This affects dilation process and as a result prevents surgical delivery. While the process is credited for its pain relieving property, research actually indicates that epidural treatments postpone pain allowing it to magnify and present itself later in a more deadly form (Checketts and Wildsmith, 2004). In fact, the woman is forced to use more energy to compensate the hormonal low levels caused by the treatment. Also, the low catecholamine levels resulting from the treatment leads to prolonged labor in instances where delivery would have been remarkably fast. The chances of vaginal delivery are also lowered creating higher chances of complicated cesarean delivery (Demiraran, Kocaman and Akman, 2005). Therefore, while the process is rapidly gaining popularity, it is not an appropriate venture considering the negative implications associated with it. It is also important for citizens to make personalised medical decisions guided by insights of medical professionals rather than hearsays from friends and colleagues (DeRossi, Junqueira, Lopes and Beretta, 2005). Conclusion While the technique has many merits such as pain relief and enhancing comfort during birth, most users do not understand the possible detrimental effects of the medical process. In fact, the procedure can greatly affect child development due to impaired ability of the mother to properly suckle their young ones, an occurrence which results from lowered hormonal levels caused by the treatment. In addition, the technique enhances chances of cesarean birth . Therefore, it is necessary to establish health educational programs aimed at enlightening women on the repercussions of adopting the child delivery technology. This procedure is often administered by the anesthetists closely assisted by midwives and nurses. While the anesthetists are well knowledgeable and fully understand the pharmacologic principles behind the procedures, their assistants often lack adequate knowledge. As such, the rate of response in cases of emergency requirements is often slow thus putting patient lives at great risks. Sadly, it is the nurses and midwives who spend most time with patients. The roles played by midwives towards patient safety during epidural analgesia administration cannot be under-rated. Therefore, special educational programs should be established for nurses and other medical practitioners to familiarise then with the basic requirements for their job environments. References Altunkaya, H., Ozer, Y., Kargi, E. and Babuccu, O., 2003 Comparison of local anaesthetic effects of tramadol with prilocaine for minor surgical procedures. British Journal of Anaesthesia, 90,pp. 320–322. Anin-Somuah, M., Smyth, RMD. and Jones, L., 2011. Epidural versus non-epidural or no analgesia for pain relief in labour. Cochrane Database of Systematic Reviews, Issue 12. Chichester: John Wiley & Sons Beattie, W, S., Badner, N,H. and Choi, P., 2001. Epidural analgesia reduces postoperative myocardial infarction: a meta-analysis. Anesth Analg, 93, pp. 853–8 Burvill, S., 2002. Midwifery diagnosis of labour onset. British Journal of Midwifery, 10 (10), pp. 600-605. Chalk, A., 2004. Limits on second stage pushing and time. British Journal of Midwifery, 12 (9),pp. 568 – 572 Checketts, M,R. and Wildsmith J., 2004. Regional block and DVT prophylaxis. Cont Educ Anaesth Crit Care Pain, 4, pp. 48–51 Demiraran, Y., Kocaman, B. and Akman, R.Y., 2005. A comparison of the postoperative analgesic efficacy of single-dose epidural tramadol versus morphine in children. British Journal of Anaesthesia, 95,pp. 510–513. DeRossi, R., Junqueira, A.L., Lopes, R.A. and Beretta, M.P., 2005. Use of ketamine or lidocaine or in combination for subarachnoid analgesia in goats. Small Ruminant Research, 59, pp. 95–101. Doherty, T., Redua, M.A., Queiroz-Castro, P., Egger, C., Cox, S.K. and Rohrbach, B.W., 2007. Effect of intravenous lidocaine and ketamine on the minimum alveolar concentration of isoflurane in goats. Veterinary Anaesthesia and Analgesia, 34, pp. 125–131 Guedes, A.G.P., Natalini, C.C., Robinson, E.P., Alves, S.D.L. and Oliveira, S.T., 2005. Epidural administration of tramadol as an analgesic technique in dogs submitted to Stifle Surgery. Journal of Applied Research in Veterinary Medicine, 3, pp. 351–359 Gunes, Y., Gunduz, M., Unlugenc, H., Ozalevli, M. and Ozcengiz, D., 2004. Comparison of caudal vs intravenous tramadol administered either preoperatively or postoperatively for pain relief in boys. Paediatric Anaesthesia, 14, pp. 324–328. Lieberman, E. and O’Donoghue, C., (2002) Unintended effects of epidural analgesia during labour: a systematic review. American Journal of Obstetrics and Gynecology 186(5), pp. S31-S68 Lieberman, E., Davidson, K., Lee-Parritz, A. and Shearer, A., 2005. Changes in fetal position during labour and their association with epidural analgesia. Obstetrics and Gynecology 105(5), pp. 974-982 McLeod, G., Davies, H., Munnoch, N., Bannister, J. And Macrae, W., 2002.Postoperative pain relief using thoracic epidural analgesia: outstanding success and disappointing failures. Anaesthesia, 56, pp. 75–81 Prakash, S., Tyagi, R., Gogia, A.R. and Singh, R., 2006. Efficacy of three doses of tramadol with bupivacaine for caudal analgesia in paediatric inguinal herniotomy. British Journal of Anaesthesia, 97, pp. 385. Stuart, C., 2000. Invasive actions in labour, where have the ‘old tricks’ gone? The Practising Midwife, 3 (8),pp. 30-33 Torrance, E., Thomas, J. and Grindey, J., 2003. Outcomes of pethidine or diamorphine administration. British Journal of Midwifery, 11(4),pp. 243-247 Varney, H., Kriebs, J. and Gegor, C., 2004. Varney’s Midwifery (4th ed). Boston: Jones and Bartlett Publishers. Wheatley, R,G., Schug S,A. and Watson, D., 2001. Safety and efficacy of postoperative epidural analgesia. Br J Anaesth, 87, pp. 47–61 Yokoyama, M., Hanazaki, M., Fujii, H., Mizobuchi, S., Nakatsuka, H. and Takahashi T., 2004. Correlation between the distribution of contrast medium and the extent of blockade during epidural anesthesia. 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