A Technique to Reduce Pain During Labor: The Midwife's in the Administration of Epidural Anesthesia - Essay Example

The Midwifes in the Administration of Epidural Anesthesia Introduction Epidermal analgesia is a technique or procedure that is widely used to reduce pain during labour (Newton 2009). The pain that is experienced during labour is as a result of contraction of the uterus and the birth canal. The injection is given in a region that is close to the nervous system. The anaesthetic dose that is given works by preventing or limiting the movement of the painful stimuli during the labour contractions. Different doses of the anaesthetic are used depending on the condition of the pregnancy (Newton 2009). According Aveline and Bonnet (2004), the concentration of the anaesthetic that is used to prevent or block the propagation of the stimuli from the uterus and birth canal vary from one case to the other.Higher doses are used when the mobility of the stimuli is to be fully blocked. Despite the advantages of this technique that has been commonly used during labour, it is also associated with some problems. Some of the known problems include shivering, fever, cardiovascular depression as well as retention of urine in the patients’ bladder. The anaesthetic can be administered through a bolus, continuous infusion or through PCP.PCP refers to the use of a patent controlled pump. Overview of the Role of Midwife in the Procedure According to Benfield (2002), the last ten years, about 24 % of women have used epidural analgesia during labour in the United Kingdom. In addition to this, about 60 % of those women who underwent assistive delivery also used this technique. Midwives do play an important role during the administration of epidural analgesia. Most of the roles are focused on monitoring the women to ensure their overall well being. The NICE guidelines lay out the duties and responsibilities of the midwives during the administration of epidural analgesia. The midwives work in collaboration with obstetricians and anaesthetist in the maternity clinics. All these three professionals have their specific duties that are concisely and clearly laid down in the NNC guidelines (Nursing & Midwifery Council 2014). The midwife, just like the other professionals always follows these guidelines when caring for the pregnant women in labour who are being given epidural analgesia as a way of relieving the pain that result from the contraction of the birth canal and the uterus. The midwife, working with the obstetrician and anaesthetist may consider epidural analgesia for the expectant women for several reasons. Some of the reasons why this can be done include maternal request, prolonged and painful labour, multiple pregnancy and anticipated instrumental delivery. Apart from the above reasons, this technique for relieving pain can also be used in cases of vaginal bleech delivery, trial vaginal birth after caesarean section and in cases where the woman is experiencing premature labour (Wunsch 2003). Cases of pre eclapsia, diabetes, cardiac and respiratory disease as well as uncontrollable urge to push may also require epidural analgesia. The decision is made by all the three, obstetricians, midwife and anaesthetists working together because they are the people involved. Precautions To Be Taken Before a midwife takes part in the administration of epidural analgesia, they are required by the NNC guidelines to be cautious about some issues that are associated with epidural analgesia (Nursing & Midwifery Council 2014). The midwives are required to be cautious about central nervous system disorder, spinal deformity and gross obesity, systemic sepsis and potential severe haemorrhage. In addition to this the midwives should be cautious about fetal distress and cardiac pathology. These are the requirements of the NNC Guidelines that every midwife needs to follow during their duty in the administration of epidural analgesia. The midwife who is looking after a woman who requires epidural analgesia for pain relief in a case of uncomplicated labour needs to immediately contact the anaesthetists who is on duty and explain the situation to him or her. The midwife needs to have all the relevant information about the patient. The midwife needs to perform the vaginal examination on the patient in accordance to the midwifery guidelines and protocols within four hours of the request for epidural analgesia. It is the duty of the midwife to obtain the relevant blood results that are required before the commencement of the epidural process (Van der Vyver and Halpern 2004). The midwife should ensure that the platelet count is done within six hours of the epidural request. In addition to contacting the anaesthetists, the midwife is also supposed to contact the obstetricians if he or she was involved in the case. The midwife should alert the obstetrician about the woman’s request for an epidural. Apart from contacting the anaesthetists and the obstetricians, the midwife is supposed to discuss with the anaesthetists the kind of process that will be suitable for the patient. In addition to this, the midwife is required to have a discussion with the obstetrician and the anaesthetists on the advantages of the process. The midwife should also discuss with patients the potential side effects of the process that are normally listed in the anaesthetic charts (Wunsch, 2003). The role of the midwife during the whole process of administering epidural can be better explained and analysed by dividing them into three. The first category is the roles that they perform prior to the epidural. The second category involves those roles that are done during the epidural catheterization. The other category involves those done during the insertion. Finally, some roles can be considered to be those that take place after the completion of the whole process but are related to the epidural procedure. Prior to Epidural As indicated earlier, before the epidural process is started, the midwife is required to have all the necessary information about the patient who is going to be given the epidural. Regardless of whether the epidural is as a result of maternal request or from any pregnancy complication, the midwife is supposed to have all the needed information prior to the procedure. Therefore, several tests and examinations need to be performed by the midwife. One of the initial tests that he or she is required to carry out is the pulse rate checking. The midwife is supposed to take and record the maternal blood pressure and FHR within four hours of the epidural request by the patient (NICE 2014). The other test that needs to be performed by the midwife prior to the process is vaginal examination. The essence of performing the vaginal examination is to assess the progress of labour. The midwife should ensure that the examination is carried out in accordance to the midwifery guidance and protocols. Failing to follow the protocol will amount to breach of professional code of conduct. The third duty of the midwife prior to the administration of the epidural is ensuring that there is enough or sufficient intravenous access. The midwife should assist the patient to wear the required clothing. It is the sole duty of the midwife to ensure that either 14G or 16G IV cannula is sited prior to the administration. All relevant results and instruments should be available. Another role of the midwife prior to the procedure is to ensure that the woman’s bladder is empty prior to the procedure. For the process to be effective and successful the bladder is required to be empty at the time of carrying out the procedure. Therefore, the midwife is supposed to ensure that the bladder is emptied just before the process begins. According Tramer, McQuay, Nye and Moore (2010), it is also the duty of the midwife to ensure that epidural trolley is stocked and is available in the room. All the requirements and equipment should be available in the trolley and those that require labeling should be well marked to avoid any form of confusion during the epidural procedure. The midwife is supposed to discuss the use of PCEA or any other technique that is to be used with the anaesthetist. They should also discuss the benefits as well as the most appropriate delivery method for delivering the analgesia with the anaesthetist so as to ensure that the best method that will be beneficial is used. When choosing the best deliver method, the midwife is supposed to share the necessary information about the woman and the condition of the pregnancy with the anaesthetist so that the best method of delivery is chosen (Leeman, Fontaine, King, Klein and Ratcliffe 2003). This will go a long way in ensuring that the procedure is effective, efficient and beneficial to the patient. If the midwife and the anaesthetist agree that the continuous epidural infusion of the PCEA is to be the method of delivery to be used, the midwife is supposed to prepare the low epidural doses. The low dose mixture consists of 0.1% bupivacaine 0.1% and fentanyl 2 micrograms per two hundred and fifty millilitres. Another option that can be used for the low dose in place of this is 0.15% bupivacaine and fentanyl 2 micrograms per two hundred and fifty milliliters. When preparing these mixtures, the midwife should ensure that they are taken under sterile conditions from each of the solution bags. According to Habib and Gan (2006), the drugs that are used to prepare this mixture are controlled drugs. Due to this, it is normally a requirement that they are checked and signed out by the midwife from the controlled drugs cupboard (NICE, 2014). Role Of The Midwife During The Catheterization During the procedure, the midwife has three main important roles. The first role during the process is assisting the anaesthetist. Apart from assembling the epidural trolley and preparing the mixtures or the dose that is to be used, the midwife is expected to offer assistance to the anaesthetists during the whole process. This is after the method of delivery has been decided on. The midwife is expected to open the epidural packs and supply the equipment and drugs required for the process as requested by the anaesthetist During the whole process the midwife is also expected to ensure that the pack, equipment and drugs remain free from any form of contamination. This will help in ensuring that no further complications are caused.The second role of the midwife during the actual administration process is checking the fetal well being. According Halpern (2005) the midwife should ensure that he or she constantly checks the fetal will be using the routine methods. The midwife should begin continuous fetal monitoring immediately the process starts. Electronic monitoring is normally used to ensure that nothing goes wrong. The reason why this is done is due to the fact that the use of epidural dose is known to at times have effects on the baby. The dose can result in the increase of the baby’s heartbeat.This can be detected by the midwife on the CTG monitor (Bucklin, Chestnut and Hawkins 2002). This fast heart rate, normally referred to as fetal tachycardia, in most cases is a sign of distress.Heart beat, blood pressure and temperature are some of the issues that the midwife is supposed to check when carrying out the fetal monitoring. The midwife is supposed to alert the anaesthetist on any fetal abnormality that is witnessed as the epidural dose is being administered. This is done so as to ensure the safety of both the baby and the mother. It is worth noting that the monitoring process should also be done in accordance to the midwifery guidelines and protocols. The midwife is also expected to use his or her personal judgment to ensure that nothing goes wrong with the mother or the baby during the administration process. The other duty of the midwife during the administration or catheterization stage is helping position the patient. The midwife is supposed to help the patient be in the position that the anaesthetist requires her to be in. He or she should help the woman be in a comfortable position with left or right tilt using the pillow. When positioning has been done, the anaesthetist will then secure the catheter to the woman’s back. The midwife should help the anaesthetist in doing this. The catheter and the epidural infusion lines require to be labelled (Fogarty 2008). This is normally the duty of the anaesthetist. However, the midwife is supposed to ensure that the catheter and the epidural infusion lines are properly and clearly labelled in accordance with the aesthetic guidelines. The role of the Midwife after the Insertion Has Been Done The anaesthetist, after securing and labeling the infusions, will make sure that they are working accordingly. When this is done, he or she will then write the required prescriptions. This information will then be handed over to the midwife who is in charge of the process. The woman who has had the epidural should not be left unattended to when the epidural is on her back. This is not the duty of the anaesthetist but rather that of the midwife. This is because it is a requirement of the NICE guidelines that the blood pressure of the woman be recorded after every five minutes once the epidural is insitu (Nursing & Midwifery Council 2014). This is expected to occur in the first twenty minutes, meaning that the midwife should record the pulse four times in an interval of five minutes. This is should then be followed by maternal pulse recording after every 30 minutes. This is done to ensure maternal well being and to allow the midwife to detect any drop in blood pressure level. When a drop is detected, the midwife is expected to treat it accordingly. The maternal blood pressure can either be recorded on a print out from the pressure monitoring device or manually recorded as per the guidelines for recording the blood pressure in programs. If the midwife feels that the condition requires more monitoring, then he or she should carry out the blood pressure recording more frequently as deemed necessary so as to ensure maternal and fetal well being. After the anaesthetist has commenced the epidural dose at the prescribed rate the midwife is also expected to check the sensory block once every thirty minutes. This can be done using ice. The effectiveness of the epidural should also be checked by the midwife and any deviation from the normal or expected trend should be immediately reported to the anaesthetist. Van de Velde (2009) says that this should be reported immediately as it may have a huge impact on the maternal and fetal well being. The level of the sensory block that is checked using ice should also be recorded on the monitoring form by the midwife on duty. After the insertion, it is also necessary to carry out bladder care on the woman. This is the role of the midwife. According to Cyna, McAuliffe and Andrew (2004), the bladder care can be done by the midwife inserting a size twelve Foley using the appropriate aseptic technique as per the midwifery guidelines. It is important for the midwife performing the insertion to ensure that damage is not caused. Moreover, he or she should ensure that the epidural infusion amount are carefully observed and recorded so as to ensure that the correct amount of prescribed drug is being delivered by the pump. Any deviation should be immediately corrected or reported to the anaesthetist on duty (Zhang, 2009). The woman’s pressure should need to be monitored and her position changed on an hourly basis. All the positional changes should also be duly recorded as per the requirements. The anaesthetist is expected to complete all the necessary documentation in accordance with the recordkeeping guideline and then hand over the records to the midwife who is going to take charge of the patient after it is ensured that epidural procedure is going on as required. If the pain recurs as the epidural is being used, a top up may be required. Before giving the top up, it is required that the epidural block level is checked. The level should always remain almost equal. If the pain persists, the midwife is expected to carry out a midwife initiated bolus. This is supposed to be given using the pump. The midwife should connect the bolus control and then press the button to give the bolus. After the bolus is administered it is important to increase the monitoring. It is recommended that this is done after every five minutes. Roles When the Infusion is No Longer Needed After it has been deemed that the epidural is no longer required by the woman, the delivery pump should be turned off by the midwife. The midwife is then expected to wash his or her hands and then proceed to remove the dressing from the site of insertion taking care not to case any injury or harm to the woman (Capogna and Camorcia 2004). The next duty that the midwife is expected to perform is to carefully remove the catheter tip from the site of insertion. When this is done, it should be recorded in the case notes as per the record keeping guidelines. In the case notes, this should be recorded as a completed task or procedure. The midwife should then go ahead to dispose off the remaining solutions from the process together with the catheter in the infusion bag. One important step that should not be forgotten is the recording of the amount of solution that has been disposed. This is because the solutions that have been used in the procedure fall under the umbrella of controlled drugs. Therefore the disposed amounts should be clearly recorded in the register for controlled drugs and in the patient notes register or book. The Trust Policy requires that the disposed drugs from the procedure are undersigned. The midwife is therefore required to find an appropriate processional to countersign the disposed solutions (Serrano, Corral and Valle S 2009). It is additionally the duty of the midwife to ensure that intravenous access is maintained until there is the return of maternal sensory power. The sensory power must fully return in the patient’s limps and she should be mobile or be able to move. In addition to that, the midwife is expected to maintain the urinary catheter as it was for a period of twelve hours after the last dose of the top up was given. 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(2009) ‘Epidural analgesia in association with duration of labor and mode of delivery: a quantitative review’, American Journal of Obstetrics and Gynecology 180(4):970-7. Read More