Epidural therapy





Definition

An epidural is a local (regional) anesthetic delivered through a catheter (small tube) into a vacant space outside the spinal cord called the epidural space.

The drugs commonly used in epidural anesthesia are bupivicaine (Marcaine, Sensorcaine); chloroprocaine (Nesacaine); and lidocaine (Xylocaine). The solutions of anesthetic should be preservative-free.


Purpose

The anesthetic agents that are infused through the small catheter block spinal nerve roots in the epidural space and the sympathetic nerve fibers adjacent to them. Epidural anesthesia can block most of the pain of labor and birth for vaginal and surgical deliveries. Epidural analgesia is also used after cesarean sections to help control postoperative pain.


Precautions

The primary problem associated with receiving epidural anesthesia is low blood pressure, otherwise known as hypotension, because of the blocking of sympathetic fibers in the epidural space. The decreased peripheral resistance that results in the circulatory system causes dilation of peripheral blood vessels. Fluid collects in the peripheral vasculature (vessels), simulating a condition that the body interprets as low fluid volume. A simple measure that prevents most hypotension is the infusion of 500–1000 cc of fluid intravenously into the patient prior to the procedure. Ringer's lactate is preferable to a solution containing dextrose, because the elevated maternal glucose that accompanies the rapid infusion of solutions containing dextrose can result in hyperglycemia in the newborn with rebound hypoglycemia.

It is important not to place a woman flat on her back after she has an epidural because the supine position can bring on hypotension. If a woman's blood pressure does drop, then the proper treatment is to turn her on her side, administer oxygen, increase the flow of intravenous fluids, and possibly administer ephedrine if the hypotension is severe. Very rarely, convulsions can result from severe reactions. Seizure activity would be treated with short-acting barbiturates or diazepam (Valium).


Description

Epidural anesthesia, because it virtually blocks all pain of labor and birth, is particularly helpful to women with such underlying medical problems as pregnancyinduced hypertension, heart disease, and pulmonary disease. Epidural anesthesia for labor is usually initiated at the woman's request, provided that the labor is progressing well, or if the mother feels severe pain during early labor.


Diagnosis/Preparation

To prepare for the administration of epidural anesthesia, the woman should have the procedure explained fully and sign consent forms if required. An intravenous line is inserted, if not already in place. She is positioned on her side or in a sitting position and connected to a blood pressure monitoring device. The nurse/assistant has the following equipment available: oxygen, epidural insertion equipment, fetal monitor, and additional intravenous fluid.

The health-care provider cleans the area with an antiseptic solution, injects a local anesthetic to create a small wheal at the L 3–4 area (between the third and fourth lumbar vertebrae), and inserts a needle into the epidural space. Once it is ascertained that the needle is in the correct place, a polyethylene catheter is threaded through the needle. The needle is removed and a test dose of the anesthetic agent is administered. The catheter is taped in place along the patient's back with the end over her shoulder for easy retrieval when further doses are required.

If the patient responds well to the test dose, a complete dose is administered. Pain relief should come up to the level of the umbilicus. The epidural anesthesia lasts approximately 40 minutes to two hours, or longer as required. If necessary, additional doses of anesthetic, or top-up, are injected through the catheter or by continuous infusion on a special pump.

Epidural anesthesia can be given in labor in a "segmented" manner. In this instance, the laboring woman receives a small dose of anesthesia so that the perineal muscles do not fully relax. The baby's head is more apt to undergo internal rotation when the perineal muscles are not too loose, thus facilitating delivery. At the time of delivery, an additional dose can be administered for perineal relief.

Women who have cesarean deliveries may have additional medication injected into the epidural space to control intra-operative pain. Medications generally used are such narcotics as fentanyl or morphine (Duramorph). Side effects include severe itching, nausea, and vomiting. Treatment of these side effects with the appropriate medication can be helpful. Despite these problems, epidural analgesia is an effective method to relieve pain after cesarean delivery, allowing the woman to move easily and speed recovery.

Local anesthetics are generally safe when administered by the epidural route. There is a low frequency of allergic reaction to the drug. Most often the drug causes a mild skin reaction, but in more severe cases can cause breathing difficulty and an asthma-like reaction. A burning sensation at the site of injection may occur, sometimes with swelling and skin irritation. Other adverse reactions may occur if the epidural anesthetic is not properly administered.


Aftercare

It is important to carefully monitor vital signs after the administration of epidural anesthesia. Hypotension can result in fetal death and can also have grave consequences for the mother. The nurse should monitor the patient constantly and use a continuous blood pressure machine to obtain regular blood pressure readings for 20–30 minutes after each administration of anesthesia. The systolic blood pressure should not fall below 100 mm Hg or be 20 mm Hg less than a baseline systolic blood pressure for a hypertensive patient.

It is important to remind the woman to empty her bladder at least every two hours. With epidural anesthesia, there is loss of sensation of the need to void. Sometimes, an overfull bladder can block the descent of the baby's head. A catheter can be inserted into the bladder to drain the urine. The nurse needs to closely monitor intake and output and assess the bladder for signs of distension.


Risks

Side effects and complications are rare, but sometimes the patient will experience a "spinal headache" due to leakage of cerebrospinal fluid (CSF).

When a woman receives epidural anesthesia for labor pains, at times the labor can be prolonged because of excessive relaxation of the muscles. Also, the baby's head may not rotate—especially if it is in the occiput-posterior position (the back of the head is facing toward the woman's back). The woman may not have the sensation that results in the desire to push during contractions when she is fully dilated. These complications may result in an increased incidence of births with the use of vacuum extraction, forceps, or even cesarean deliveries. Administering a Pitocin (oxytocin) drip intravenously can counter this problem. Pitocin is a medication that causes the uterus to contract. Allowing the epidural to wear off in the second stage of labor when the woman is pushing may avoid this problem, but the return of the labor pains may be overwhelming to the woman.

Occasionally, slow absorption of the medication from the epidural space into the circulation can result in toxic reactions evident by decreased level of consciousness, slurred speech, loss of coordination, drowsiness, nervousness, and anxiety. The health-care provider should look out for these signs, and also report any elevation in temperature before a top-up dose is administered.


Normal results

Epidural anesthesia is a safe and effective method of giving pain relief to women during labor and delivery. It also can be used for cesarean births. It is believed that very little of the anesthetic is absorbed throughout the body (systemically), therefore epidural anesthesia is ideal because it does not pass the medication into the baby's circulation.


Resources

BOOKS

Pillitteri, Adele. Maternal & Child Health Nursing, 3rd edition. Philadelphia: Lippincott, 1999.

ORGANIZATIONS

American Association of Nurse Anesthetists (AANA). 222 S. Prospect Avenue, Park Ridge, IL 60068. (847) 692-7050. http://www.aana.com .

OTHER

Anesthesia Options for Labor and Delivery: What Every Expectant Mother Should Know. AANA, 2001. http://www.aana.com/patients/options.asp .


Nadine M. Jacobson, RN Samuel D. Uretsky, PharmD

User Contributions:

agila
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Nov 23, 2007 @ 10:10 am
hi!!! i want more details regarding epidural.since im goin to give birth within 3 months.i dono whether i can take epidural injections.but people says the intake of epidural wll results in certain side effects....
agila
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Nov 23, 2007 @ 10:10 am
hi!!! i want more details regarding epidural.since im goin to deliver a baby within 3 months.i dono whether i can take epidural injections.but people says the intake of epidural wll results in certain side effects....is it true or not
D Robinson
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Sep 5, 2008 @ 8:08 am
I received an epidural while in labor with my daugter in September of 2007. The Anesthetist tried five times to adminster the epidural. He stated that he missed and hit a blood vessel. It is now a year later and I am still experiencing headaches, feeling faint, it feels as if my heart flutters and I would have to gasp for breath, my legs still swells and I am experienceing nausea. I have been to the obgyn twice, in which this doctor stated that I needed to reduce my caffine intake and chocolate intake,also wait until the baby fats comes off. I am not an caffine drinking nor do I eat an excessive amounts of chocolate. I have been to my family doctor two times as well, which she stated that I am not retaining fluid and that my lab results from my six week check up stated that I was a high risk for blood clots. I was told by this doctor to lose more weight and walk more. Here it is a year later and the doctors now do not undersatnding where these symptoms are coming from. My supervisor came to me and ask why was I going to the doctors more often. I told her the situation of each doctors visit and then explain to her that the symptoms are getting worse and the swelling and pain in my legs reminds me of the experience I have when I received the epidural while in the hospital after I gave birth. She then suggested that it maybe an reation to the epidural and to lookup some information on line, and behold, every symptom I was experiencing was related to a reation to the epidural. I never had any problems with headaches, nausea, dizzeness, difficult breathing. I was very shock to see that another symptoms was BLOOD CLOTTING. Why was this not related to the epidural? Since my six week checkup I have not had any lab work drawn. Help! What treatments are out there and how do I get these doctors to research to see if this is a reaction to the epidural. This toxic has been in my system for a year, will I have any complications?
Anne-Marie
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Sep 7, 2008 @ 8:20 pm
I had recently had the epidural the doctor missed and hit a blood vessil leaving me with headaches. I had tohave another operation after having it called the blood patch. I have difficulties breathing now. Headaches are starting to go away breathing is really hard though i went to 3 different hospital. All doctors say breathing is fine. Symptoms persist. I like to know how long this will last for... As breathing is hard.
susan
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Mar 25, 2009 @ 7:07 am
I had 3 cervical epidurals in a 6wk. pd. Been to cardiologist and am going for a stress test. My heart jumps,skips and races 24/7.
Sunni
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Jul 13, 2009 @ 11:23 pm
I gave birth Oct. 2008. I was given an epidural but was never told I had to push the button until it beeped. Naturally I kept complaining I felt know relief they began giving me bolaces(injecting) doses one after another. I complained I could not feel myself breathe and that I had numbness up to my neck. They could not detect baby's heart so they tried to insert internal heart monitor but did it incorrectly. Result being I have pelvic floor prolapse & perineal descent. I nerve damage in part of my colon, a bowel obstruction, when they remove my obstruction I will more than likely have bowel incontinence it's very possible I will end up with a colostomy at 20 years old. I have a beautiful healthy son that I am thankful for but I will never assume that the doctors or nurses caring for me are knowledgeable in all areas ever again. Always research any & all problems that can occur regarding your medical care.
Becky
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Sep 15, 2009 @ 8:20 pm
I had an Epidural daone with my middle daughter and I wish I never did. She will be 12 in March or 2010. Ever since I have had this done my back and neck have not been right. I use to be able to do alot of thing and now I can not do to much before my back neck and legs start to hurt. I also have migrains. All of the Drs. i have been to all say they do not know what is wrong with me and when I tell them about the epidural they say no that could not have happened to you. I have had x-rays and MRIs done on my back but they show nothing. It will start to hurt so back I feel like I am going to get sick and I can not move at all. I sleep with a heating pad at night so I can lay on my back but most of the time that does not work. If some one knows how I can prove that this is from the epidural or even HELP me with my pain PLEASE email me.
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Feb 9, 2010 @ 1:13 pm
i HAD RECIEVED AN EPPY 2.5 YEARS AGO. WHERE THEY GAVE IT TO ME AT... THE BUMP IS VERY BIG AND IT LOOKS LIKE A MOLE THAT HAS SOMETHING WRONG WITH IT. IT CONSTANTLY ITCHES AND I DON'T KNOW IF THIS IS NORMAL?
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May 17, 2010 @ 12:12 pm
where can I get more info about epidural cases? are there lawsuits? i can't live with this pain! Can't sleep, can't sit, have to take strong painkillers ! Th most imoprtanlty is there a procedure that can reduce pain? Please help
Tyler maxwell
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Aug 20, 2011 @ 3:03 am
What is the most common treatment for heart fluttering and shortness of breath after giving birth? It's been a week and my wife is still having these problems. And will it go away on it's own or require treatment?
Jenny
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Dec 30, 2011 @ 3:15 pm
I had a c section almost 2 weeks ago & they missed the 1st time attempting to put in epidural, said he hit a blood vessel & had to re-do it. Ever since I left the hospital I haven't been right at all. I have severe bck pain that radiates to my left side of my chest & it hurts so bad a vomit. I had to go to the er the night because of severe abdominal pain & back pain but they only did a cat scan on my stomach & nothing about my back. I hurt so much & was wondering if this was related to them missing the epidural placement the first time. Will this pain ever go away?
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Dec 10, 2012 @ 4:04 am
I had a c-section in feb2012 using epidural, 3 months down the line I started having back pain,swollen legs, loss of breath weakness,chest pains, numbess, tingling feeling in my legs and my legs started to turn black at the back. Someone please help.
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Feb 7, 2013 @ 6:18 pm
I had an epidural with my 3rd child where the doc missed twice. The third time he Finally got it right(so he said). He put 3 doses in and it never worked and now I have severe burning and possibly arthritis/ sacroiliitis in my lower back. I had an epidural with my first born and I was fine afterward. I just wish there was something we could do to prevent these doctors from doing it again.
Jessica
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Feb 7, 2013 @ 6:18 pm
I had an epidural with my 3rd child where the doc missed twice. The third time he Finally got it right(so he said). He put 3 doses in and it never worked and now I have severe burning and possibly arthritis/ sacroiliitis in my lower back. I had an epidural with my first born and I was fine afterward. I just wish there was something we could do to prevent these doctors from doing it again. I also had HIGH blood pressure right after they missed. It was 220/170 and my daughter's heart rate dropped and wouldn't go back up. I almost had a c-sec but my daughter was out within 10 mins.

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