Epidural management in labor

  1. Hi, I'm new to this site, but have enjoyed it greatly. Recently at our small hospital(only 3 ob/gyns) we have had some controversy over epidural management. Our manager has told us that we are not allowed to lower or increased the rate of the epidural pumps, but are allowed to turn it off completely, but not back on. The MDs are having "fits" about this. :angryfire They think that if they have given the order, then we are "covered" they seem to have a tendency to start an induction/augmentation and then around 2000 if no results "turn it off and let the pt rest", which drives us all crazy...then in the am want to call and restart it. Anesthesia, seems to ride the fence, depending on who they are talking to...and of course working nights, they don't want to come in to readjust a pump...just wondering what other hospitals do. What about when a pt is pushing and unable to feel anything, and the MD orders it decreased...any comments on how it's done elsewhere?
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  2. 20 Comments

  3. by   nursey_girl
    Our epidurals are totally managed by our anesthesia department which is primarily CRNAs, esp. at night. We do turn them off, we can turn them on, we even pull the caths, etc. Most of us nurses play dumb when it comes to adjusting them, therefore anesthesia manages that.
    I've worked in several hospitals where epidural management was a pain in the @$#. My current facility makes it a breeze to manage, decreased paper work, and a much more satisified patient!
    Do to insurance coverage of the CRNAs, we will no longer be doing VBACs as of next month. I guess for those refusing a repeat section... no epidural for them!
  4. by   Jolie
    Are your patients are having epidurals placed early in the induction process, which then need to be turned off when the induction is put on hold? Seems like they are getting the epidurals too soon. Why not wait until a labor pattern is established before placing the epidural, so the patient isn't exposed to the risks of the epidural needlessly, or sooner than necessary? I am guessing that these patients are then confined to bed rather than being able to walk the hall (which might be effective in helping to establish a contraction pattern), not to mention the increased risk of infection the longer the epidural catheter is left in place.

    Also, if the epidural is turned off, how long can the catheter safely be left in place without a running medication infusion or injection? Do these things clot off over time when left unused?
  5. by   nursey_girl
    I worked in a facility that placed the caths in the Am prior to induction, and then turned the pumps on later in the day. Seemed to work great, but I did notice a definite increase in our section rate if the pump was on prior to 4 cm.
  6. by   Jolie
    Quote from nursey_girl
    I worked in a facility that placed the caths in the Am prior to induction, and then turned the pumps on later in the day. Seemed to work great, but I did notice a definite increase in our section rate if the pump was on prior to 4 cm.

    Wow! I've never heard of this. It seems like there is a good chance of exposing a patient to the risks of epidural placement needlessly, should she decide that her pain is manageable with less invasive means, and forgo the epidural. I also wonder how many patients go along with starting the epidural infusion, just because the "equipment is in place," who otherwise may not have done so.

    Don't get me wrong, I'm all for epidurals, if that is what the patient wants, and what is best for her, but it seems like this system makes it almost a forgone conclusion. I wish I'd had my epidurals placed at about 36 weeks, as both of my (very intense and painful) labors progressed so rapidly that I never had time to get one!
  7. by   Spidey's mom
    The only "management" in epidurals where I work is having the CRNA or doc come back to redose. We don't use pumps.

    steph
  8. by   nursey_girl
    The particular facility primarily catered to VIP patients. That was the idea anyway. I guess having a higher social class bought these special priveledges, but indeed bought a lot of unnecessary procedures, ie. C sections, as well. ( My reasoning for leaving had a lot to do with certain prejudices I sen with the have nots!)
  9. by   SmilingBluEyes
    We, as nurses where I work, are not allowed to adjust rates on epidural pumps---only to turn them off upon the order of the Anesthesiologist or Obstetrician. I would be VERY careful about adjusting rates. You can get into shaky ground here. It's up to the MD's to do that.
  10. by   gypsyatheart
    At every institution I have worked at, the RN can load the bag/cassette and tubing, program the pump(although CRNA confirms this), turn it off, and pull the catheter.
    Anesthesia's role is to confirm programming w/RN,sometimes anesthesia is the one programming the pump, connect tubing, turn it on and do any rate adjustments.
  11. by   gypsyatheart
    Quote from nursey_girl
    I worked in a facility that placed the caths in the Am prior to induction, and then turned the pumps on later in the day. Seemed to work great, but I did notice a definite increase in our section rate if the pump was on prior to 4 cm.

    That's crazy! Does anyone realize that they could actually be doing an injustice to these patients?? Geez! It sounds like they were serving the convienience of the anesthesia staff more than they were catering to the patient.....
  12. by   palesarah
    our state BON allows nurses to program, turn on, turn off, change rates, so at the hospital I worked at, we did it. In fact, the anethesia orders allowed us a lot of leeway to increase/decrease; we could do so within the written parameters without getting an addition order. So we did, in effect, manage the epidurals once they were placed. The hospital employed 1 or 2 CRNAs, but the MDAs did all labor epidurals, and at night they would come in to place and then go home. I brought up several times that we were held not just to our state's nurse practice act, but also to the national standard, and that how we were practicing was not in agreement with AWHONN standards, but no one listened to me...
  13. by   heartICU
    I am a SRNA doing my OB rotation right now, and I have a question about those hospitals that offer OB services without an anesthesia provider in house. What happens if you have a laboring woman with an epidural (or without, for that matter) and she needs to go for a stat section? I am not criticizing - I am truly curious. I have been discussing this with a few L&D RNs at my current facility, and some of them have worked in facilities without a CRNA or MD in house to manage the epidural, and they did not feel it was safe. What do you all think?
  14. by   sdavis56
    I agree with "palesarah", we were doing the same,not adhering to awhonn standards but as of Monday,Oct.17 we WILL be adhering to those standards, it has been a LONG battle. It is not that we can't manage the epidural, but the standards are very clear that an ANESTHESIA CARE PROVIDER should manage starting, restarting,adjusting the rate. We as L&D nurses can stop the infusion, and remove the cath(as a Category II credential).
    We all know the liability in L&D and it is good to know that at least the epidural piece is where it belongs.
    I've been a L&D nurse for 21 yrs and love it as much today as i did my first day! Thanks for listening!

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