Trust Guideline for the Management of Epidural Analgesia in Labour A clinical guideline recommended for use In:

Delivery suite

By:

Anaesthetists, Midwives

For:

Women in labour requiring epidural analgesia

Key words:

Epidural analgesia, Labour

Written by:

Dr Lindsay Barker Consultant Anaesthetist Dr Jeremy Corfe Consultant Anaesthetist Dr Stuart Brown Consultant Anaesthetist

Supported by:

Dr John Harrad Consultant Anaesthetist Janet Edwards Midwifery Manager Rosie Goodsell Practice Development Midwife

Approved by:

Chair’s action agreed 12 January 2015 Reported Clinical Guidelines Assessment Panel (CGAP) 21 January 2015

Approval Reported to

Clinical Standards Group Effectiveness Sub-board

Date of approval

January 2015

To be reviewed before: January 2018 To be reviewed by:

Dr Lindsay Barker

Guideline supersedes: CA4054 V2 Guideline Reg. No:

CA4054 V3

Author: Dr L Barker Valid until: 12 January 2018 Document: Management of Epidural Analgesia in Labour Copy of complete document available from: Trust Intranet

Date of issue: 12 January 2015 Guideline Ref No: CA4054 V3 Page 1 of 8

Trust Guideline for the Management of Epidural Analgesia in Labour Quick reference guideline/s Analgesia must be established with 10-25 mLs of low-dose levobupivicaine /fentanyl mixture by anaesthetist initially. The epidural pump can be primed by a midwife or an anaesthetist. The infusion should be connected to the epidural filter by a midwife and an anaesthetist together. The pump will be set to deliver boluses via a handset as follows: 

Levo-bupivacaine 0.1% plus fentanyl 2micrograms/mL



10 mL boluses 10 minute lock out period



Pump setting: Maximum 20 mL/hr

Fetal heart rate monitoring 

During insertion of epidural and for 20 minutes after establishment of block.



Every 15 minutes thereafter (unless there is a medical reason for monitoring the foetus continuously).

Blood pressure 

Every 5 minutes for 20 minutes after the establishment of the block and for 15 minutes after any 10 mL bolus.



Otherwise every 60 minutes for the duration of the labour.

Bromage scores (Appendix 1) should be recorded hourly and recorded in the notes. The times of bladder emptying must be recorded.

Author: Dr L Barker Valid until: 12 January 2018 Document: Management of Epidural Analgesia in Labour Copy of complete document available from: Trust Intranet

Date of issue: 12 January 2015 Guideline Ref No: CA4054 V3 Page 2 of 8

Trust Guideline for the Management of Epidural Analgesia in Labour Rationale Midwives currently administer boluses of local anaesthetic/fentanyl mixture from a premixed bag. This system no longer conforms with infection control guidance and a closed system for delivering epidural analgesia is preferable. Our aim is to provide safe, effective epidural analgesia via a closed system using McKinley epidural pumps. These pumps can be programmed for the midwife to deliver boluses through the pump via a handset or for the patient to administer bolus doses herself (Patient Controlled Epidural Analgesia-PCEA). The advantages of this method are: 1) 2) 3) 4)

Reduced risk of drug error. Reduced risk of infection. Enhanced maternal autonomy (if choosing to use the Patient Controlled mode). Less labour intensive for the midwife (no need to find second midwife for checking top-up doses in accordance with Trust medicines policy etc).

Broad recommendations The Delivery Suite provides epidural analgesia using a pre-prepared low-dose levo bupivacaine solution combined with fentanyl. In comparison to using 0.25% levo bupivacaine for epidural analgesia, using the 'low-dose' epidural solution reduces the risk of instrumental assisted vaginal deliveries whilst maintaining satisfactory analgesia. Intravenous access must be instituted prior to insertion of the epidural and an infusion of Hartmans solution must be commenced. The midwife may prime the pump with the mixture using the designated giving set. The anaesthetist will determine the rate of infusion. The IV access must stay in place until the end of the labour. The pre-mixed infusion bags should be checked by two midwives in accordance with the Trust Medicines policy. The anaesthetist will administer an initial test dose using either levobupivicaine 25% or a 0.1% levobupivicaine plus fentanyl 2 micrograms/mL mixture. The low-dose epidural analgesia can be established by the anaesthetist as follows: 1) Incremental epidural injections using 0.1% levo-bupivacaine with 2 micrograms/mL fentanyl (Standard Epidural) through the pump. This is the preferred method. 2) Manually administered incremental injections of 0.1% levo-bupivicaine with 2 micrograms/mL fentanyl. A 10 mL pre-prepared ampoule can be used. Do not puncture the 100 mL bag of pre-mix 0.1% levobupivicaine plus fentanyl that is intended for use through the pump. These bags do not contain preservative and there is a risk of infection if subjected to multiple punctures. If the 10 mL Author: Dr L Barker Valid until: 12 January 2018 Document: Management of Epidural Analgesia in Labour Copy of complete document available from: Trust Intranet

Date of issue: 12 January 2015 Guideline Ref No: CA4054 V3 Page 3 of 8

Trust Guideline for the Management of Epidural Analgesia in Labour ampoules are unobtainable a new, separate 100 mL pre-mix bag should be used and then discarded. 3) A levobupivicaine ± fentanyl mixture which they have drawn up themselves in a sterile fashion. 4) In some cases where pain is intense or labour is advanced the anaesthetist may chose to perform an intrathecal injection of 1-1.25 mL 0.25% plain levobupivacaine mixed with fentanyl 25 micrograms OR 3 mLs of the 0.1% levobupivacaine with 2 micrograms/mL fentanyl (Combined Spinal Epidural, CSE) Management of Midwife Controlled or Patient Controlled Epidural Analgesia Satisfactory analgesia must be established by the anaesthetist initially   

The anaesthetist and midwife will connect the pump and check the settings. The pump can give EITHER midwife controlled boluses OR patient controlled boluses The bolus will be administered by using the Remote Dose Cord.

Pump Setting Midwife administered boluses or patient controlled boluses    

Levo-bupivacaine 0.1% plus fentanyl 2 micrograms/mL 10 mL boluses with a 10 minute lock out period Maximum 20 mL/hr All boluses should be administered with the woman sitting on the bed.

Observations Fetal heart rate monitoring – during insertion of epidural and for 20 minutes after establishment of block. Every 15 minutes thereafter (unless there is a medical reason for monitoring the foetus continuously). Blood pressure - this should be recorded every 5 minutes for 20 minutes after the establishment of the block and for 15 minutes after any 10 mL bolus. Otherwise every 60 minutes for the duration of the labour. The woman should be observed during and after each bolus and verbal contact maintained. If the woman feels unwell after a bolus or exhibits signs of maternal hypotension (faintness, nausea, dizziness) or develops sudden marked motor weakness of the legs (unable to straight leg raise either leg) then no further boluses should be given. The woman should be put into the left lateral position. The IV fluid infusion should be increased to give a fluid bolus of 250 mLs. The anaesthetist should be called to attend. Maternal blood pressure should be measured and recorded. Author: Dr L Barker Valid until: 12 January 2018 Document: Management of Epidural Analgesia in Labour Copy of complete document available from: Trust Intranet

Date of issue: 12 January 2015 Guideline Ref No: CA4054 V3 Page 4 of 8

Trust Guideline for the Management of Epidural Analgesia in Labour If maternal analgesia remains unsatisfactory after two consecutive bolus doses (or if a woman is not pain free 30 minutes after any bolus) then the anaesthetist should be contacted and the epidural reviewed. Patient Controlled Epidural Analgesia (PCEA) Patient Controlled Epidural Analgesia can be used if this mode of analgesia is acceptable to the woman, midwife and anaesthetist. The correct and safe use of this mode of analgesia will require cooperation from the woman. Patient Controlled Epidural Analgesia should only be instituted when satisfactory epidural analgesia has been established and maternal observations and the fetal heart rate are satisfactory. Satisfactory maternal observations include absence of symptomatic maternal hypotension and ability to straight leg raise both legs. The woman needs to be instructed in how to use the Remote Dose Cord and when to administer a bolus dose. The midwife should supervise the woman administer the first two doses. The woman should only administer a bolus dose when she is sitting or lying down on her side. The woman should be asked to tell her midwife when she has administered a bolus dose. The woman should be instructed to inform the midwife of any light-headedness, nausea, dizziness, breathlessness or marked weakness of the legs. If the woman has any of these symptoms, the midwife should remove the Remote Dosing Cord from the woman and lay the woman on her left lateral position. The IV infusion rate should be increased to give a fluid bolus of 250 mLs. The anaesthetist should be called to attend. Maternal blood pressure and block height should be recorded and maternal leg weakness assessed. If analgesia is inadequate after two consecutive bolus doses, the anaesthetist should be informed and asked to review the epidural. Fetal heart rate monitoring should be performed at 15 minute intervals throughout the duration of the epidural. Caesarean sections and assisted deliveries in theatre. When a decision is made for a patient to go to theatre, the pump should be disconnected and should not accompany the patient to theatre. The anaesthetists will then administer their own top-ups manually.

Author: Dr L Barker Valid until: 12 January 2018 Document: Management of Epidural Analgesia in Labour Copy of complete document available from: Trust Intranet

Date of issue: 12 January 2015 Guideline Ref No: CA4054 V3 Page 5 of 8

Trust Guideline for the Management of Epidural Analgesia in Labour Mobilisation The patient may mobilise if:  

The midwife and the partner are available in the room to assist. The patient’s Bromage score has been assessed by the midwife (Appendix 1) and is deemed to be 0 or 1 in both legs. This should be assessed prior to mobilisation and is recorded by the midwife in the notes.

If the mother wishes and feels able to do so she should be encouraged to adopt upright positions. The epidural is continued until after the third stage of labour and may be continued for suturing. Care of the pumps When an epidural pump is in use, the number of the pump must be clearly marked next to the patients name on the delivery suite board. When the pump is no longer in use it should be cleaned with 2.1% sodium chlorite solution (Trade name TRISTEL). After cleaning it should be returned to the equipment cupboard and plugged in to recharge. Disposal of the remaining solution should be made by two midwives and documented on the epidural chart and in the records.

Clinical audit standards An audit of patient satisfaction, midwife satisfaction, analgesic consumption and obstetric outcome will be conducted for the first 3 months following its introduction.

Summary of development and consultation process undertaken before registration and dissemination During its development, the guideline has been circulated for comments to all anaesthetists, midwives and pharmacy.

Distribution list/ dissemination method Anaesthetists, midwives, display of quick reference guideline in the obstetric anaesthetic office/delivery suite and intranet.

Author: Dr L Barker Valid until: 12 January 2018 Document: Management of Epidural Analgesia in Labour Copy of complete document available from: Trust Intranet

Date of issue: 12 January 2015 Guideline Ref No: CA4054 V3 Page 6 of 8

Trust Guideline for the Management of Epidural Analgesia in Labour References/ source documents The Royal College of Anaesthetists. The Pain Society. Pain Management servicesGood Practice May 2003 Royal College of Anaesthetists, Royal College of Nursing, Association of Anaesthetists of great Britain and Northern Ireland, British Pain Society, European Society of Regional Anaesthesia. Good practice in the management of continuous epidural in the hospital setting. (2004) NPSA. Alert 21. Safer practice with epidural injections and infusions. 2007. March 28

Author: Dr L Barker Valid until: 12 January 2018 Document: Management of Epidural Analgesia in Labour Copy of complete document available from: Trust Intranet

Date of issue: 12 January 2015 Guideline Ref No: CA4054 V3 Page 7 of 8

Trust Guideline for the Management of Epidural Analgesia in Labour Appendix 1 Bromage score 0: No motor block: full extension of knee and foot 1: Inability to raise extended leg. Just able to move knee 2: Inability to flex knee. Able to move foot only 3: Inability to flex ankle joint. Unable to move foot or knee

Author: Dr L Barker Valid until: 12 January 2018 Document: Management of Epidural Analgesia in Labour Copy of complete document available from: Trust Intranet

Date of issue: 12 January 2015 Guideline Ref No: CA4054 V3 Page 8 of 8