epidurals in small hospitals - page 2
We are a small hospital in upper Michigan. We do approximately 350-400 deliveries per year. I would like to know from similar size hospitals if you do epidurals and what your policies are regarding... Read More
Nov 12, '02Brainwashed? OH NO! Experience taught me! Tried natural with the first one, then some inj. drugs. Forget that!!!
An epidural was my friend for all three kids!!!!!
I had two kids in a metro hospital, no problem getting epidural. The other one in a very very rural backwoods hospital, my dr. was new and arranged for an epidural, I was the first woman in the county hospital history to have an epidural. Nurses hated it. I loved it!!!!!!!!!
Guess I started a trend, they are still doing them there, and that was twenty one years ago this month!
Nov 21, '02I work in a hospital that deliveries 400-500/yr. RN's assist in administration. Never bolus or dose patient crna is responsible to dose or bolus pt. We are allowed to d/c catheter after delivery. We have to confirm a blue tip with another RN Hope this helps.
Nov 21, '02we do 600/yr. epid. on demand. no anesthesia in house after hrs. we must get ok for epid. by ob over the phone, then ob and anesthesia must be present for insertion. then they can both go home if pt. plodding along. usually ob stays in house at night post-epid. insertion. we do not pull cath or dose epid. nurses may only turn it off. pharmacy or nursing supv. can dec. the dose, but ob must be present when they do this. (pharmacy goes home too after 2300). we only have ob drs. as providers no cnm's or family dr's. our epid. rate is about 50%.
Nov 21, '02Originally posted by SmilingBluEyes
We are IN NO WAY COVERED to set rates, administer boluses or do ANYTHING w/epidural drips except to turn them off. We DO remove the catheters and assess dermatomes. Anesthesia remains inhouse once the epidural is in til delivery occurs.
on some hospital areas, RNs w/ special training may check epidural placement and bolus for pain relief(duramorph, fentanyl), like the chemo/cancer areas, but not where TWO lives are at stake!
Having seen epi catheters migrate, I would NEVER dose thru the catheter!
The closest I get to "adjusting" an epidural is turning it off if the motor block gets too heavy!
Jan 8, '03We have to have current platelet counts, and the pt has to have had at least a liter of iv fluid....Usually have to be 4 0r 5 cms though some kind docs will allow those with ruptured membranes going on pit to have theirs earlier. We have to give alka gold per anesthesia, and be present during the epidural to assist and monitor. We have no LPNs, unfortunately, in delivery. We monitor BP and o2 sat q 3 min throughout the procedure, and the anesthesiologist is responsible for turning it on, though we set up the pump...They redose, and have to stay in house as long as one is running. They also give the ephedrine if the BP plummets..Although they say it isn't so, we have noticed a lot of pts have what we nurses call, the epidural dip soon after administration. After half and hour of the epidural on board, bps can go to q 15 minutes. We do not have walking epidurals, so of course straight cath every so often prior to delivery.
Jan 8, '03we definitly see the epidural dip here, we don't do the walking epidural either. I wish anesthesia stayed in house here they place it wait 15 min or so then they are gone. we give the ephedra and other drugs as need,
usually insert foley if they are going to labor awhile verse repeated in/out cath
Jan 9, '03I just started working at a small hospital! Have I mentioned that it is brand new and I love it????? (yeah, I think that I have.) Anyway, we have one CRNA that is dedicated to our unit. He is on call pretty much 24-7. We just opened 2 weeks ago and so far we have done 18 deliveries so I can't really give you an accurate number of deliveries per year, but we call him for an epidural and he comes in and places the epidural and then stays in house until she delivers. It is great because he also attends deliveries if we have a bad strip to help with NRP if needed. When he is not on call we have one of the OR CRNA's on call.
Jan 18, '03Hi!!! Student here, I was wondering hoe many of your pts opt for the walking epidural? Do they have an easier birth because they can walk around? Second, if a pt has seriious back problems (Herniated disks) would that be an issue in receiveing an epidural?
Jan 20, '03You need to get a copy of the AWHONN guidelines on epidural anesthesia PRONTO!!!! Nurses should NOT be rebolusing and injecting epidurals on laboring pts, bolusing and rate increases can be done POSTPARTUM. The guidelines from the Anesthesia organization also say they should be managed by anesthesist or CRNA. We only D/C and removed the catheters. We used to increase the rates and bolus on labor patients but after getting the guidelines, we refused to do it anymore. We do 400.yr.
Apr 21, '03Check your Awhonn guidelines on epidurals! The only time a nurse should redose an epidural is postpartum, NEVER on a laboring patient. Those standards are very clear. I am in a small hospital and we had this fight with anesthesia and we refused to do it when they didn't want to acknowledge the nurses standard of care.
Apr 21, '03Our Family Birthing Unit does 400-600 births/year currently and epidurals are offered and anesthesia applies and RNs assist but we do not adjust rates, give boluses, etc. We do remove catheters once finished and turn them off when ordered to. I wish anesthesia would be in house until delivery but there are here on days and o/c at night with less than 10 mins. away time.
I wish I had the choice when I had my children ( first three are in their mid 20's). Giving these women the "choice" is what's important, in my opinion!
Apr 21, '03The small rural hospital I used to work at, utilized epidurals when a patient requested. We have a CRNA on call 24/7 but at times a patient could have to wait 30 minutes to an hour depending on where the CRNA was at the time. The RN assists with the placement...VS Q3" till completed then Q 15" till delivery. We never rebolused the Epidural and once one was placed the Doctor or the CRNA were close by if we needed them for any complications. We could D/C epidurals as long as no resistance was met upon removal. I would definitely question your scope of practice about rebolusing the epidurals though.
Apr 21, '03Originally posted by bagladyrn
I've worked in hospitals where epidurals were not offered. The women there were not necessarily "tougher". I think the difference was that they had not been brainwashed into believing that childbirth was impossible without an epidural. Maybe it's because the t.v. out on the res. doesn't carry "A Baby Story".(Can you tell I HATE that show?) The emphasis on epidurals is a relatively recent development, and I think overused as a result.
There is a point to what I am saying. Yes, women can deliver without epidurals, and have done so for hundreds of thousands of years. But, with the advent of the epidural, done correctly, has made child birth easier, and many women appreciate it because after delivery, they are not as worn out and are better able to bond with baby. I'm tired of the "natural" OB's (both nurses and physicians) who look down on the "weaklings" who want epidurals for childbirth. No, I don't push them on anyone, but neither do I discourage them. Rest assured, your prejudiced attitude shines through, and you are doing your patients a real disservice. There will be those who want epidurals, but won't have them for fear of "dissapointing" you. To me, that just seems cruel, not to mention controlling.
I work at a small hospital, and we do anywhere from about 200 to 300 deliveries per year. We offer epidurals to all patients who want them. One of the big selling points to me for coming here was specifically that when we have an epidural in a patient who is in labor, we stay in house. I went to school to learn anesthesia, and I don't think its fair to dump the responsibility for that on the OB nurses. They can make changes in the pump rate (with appropriate orders), but anesthesia does all boluses, etc. We stay in house (though we may sleep in the call room) and are readily available to our patients and the OB nurses for assistance.
Teaching points: Epidurals, particularly when bolused, will cause a drop in blood pressure. This is due to a loss of vascular tone below the level of the anesthetic. Bigger intervascular space with the same volume, lower blood pressure. Ephedrine is the drug of choice to treat low BP in laboring women because it does not cause the alpha mediated vasoconstriction that other pressors can cause. Hence, blood flow to the uterus is not diminished by the administration of the pressor. The best treatment, though, is to treat the pressure BEFORE administration of the epidural with volume increases through administration of about a liter of crystalloid.
I have also recently found that I can prevent the loss of pressure by doing a combined spinal epidural (CSE). I administer about 10 mcg of sufenta intrathecally, then insert the epidural (all done through one stick), and start the infusion without the epidural bolus. Since there is no big bolus, there is less lowering of BP. There is good pain control with the spinal narcotic. The only down side is that the sufenta can cause pretty significant pruritis. But, the patients who got the sufenta were happy to trade pain for some itching.
Kevin McHugh, CRNA