epidurals in small hospitals - page 3

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

  1. by   healthyone
    i am a relatively new RN and i dont know much about the care of epidurals. i have tried to find a short course/seminar in my area unsuccessfully. can anyone help re: where to get training for epi's other than the workplace?

    thanx )
  2. by   kmchugh
    What kind of training?

    KM
  3. by   mark_LD_RN
    Originally posted by kmchugh
    Yeah. Us nasty anesthesia people have even got a lot of patients brainwashed into believing that their amputation will go much easier if we do an anesthetic. Of course, before the advent of anesthesia, most other surgery WAS impossible, because the pain and shock would kill the patient.

    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

    Kevin

    I can understand your defense of the epidural,being you are A CRNA after all. it would be terrible to lose the OB buisness and money.

    yes some have a prejudice attitude but not all as you try to suggest. I as well as most of the OB nurses I work with fully support the patients choice. I see just the opposite of you I see the DOCS pushing for the epidural,because they don,t want to hear screamming patients, can do instrumental operative deliveries faster ,(even if not needed), and with epidural in place they can let patient sit their complete till they are ready,more of the delivery on docs schedule bull. I also see nurse who like it for the same reasons.

    I have worked at several hospitals and with lots of docs and midwives and see a much higher rate of operative deliveries and c/s with epidurals. even if current studies may suggest otherwise. as you should well know studies change with time. just look back to studies of scolpomine births yrs ago.

    epidurals are not the savior of childbirth, they do create problems at times and this needs to be kept in mind.

    DO NOT get me wrong I feel the epidural is a good tool when used properly at the right time with the right patients. I have encourage patients to get it for different reasons time to time. like patients who just could not relax at all, ones who would not dilate r/t increased tension stress what ever. it has helped sometimes ,sometimes not.

    I feel patients have been done a great disservive by the promotion of epidurals as the ultimate method of childbirth. pt often are under the misguide opinion that the birth will be pain free and the epiduaral will not cause any problems.sadly this is not the case. and people should use them wisely.

    I encourage all patients to do as me and my wife did, we registered for the epidural just incase she needed it. which she did not the last 2 times.and those 2 births went much better than the first one with the epidural.

    kevin don't get all defensive, i am not tring to be arguememntative.just trying to clear the air some
  4. by   Ms.Hobbes
    Mark_LD_RN I agree with you. Patients need to be educated when it comes to epidurals. I teach childbirth classes and besides exploring and praciticing lots of non-medicated techniques we also go over medications, epidurals etc. People who have taken this learning to heart have a more positive birth experience and if they do choose an epidural they are aware of how it works, S/E, benefits, etc. and there really is no such thing as a completely pain free birth. I have worked in L&D for 8 years and have seen epidurals work well for patients but have also seen significant problems arise with them.
    A friend of mine is a lactation consultant for my hospital and she is doing a study on the use of epidurals and the delay of breasfeeding due to baby being less alert or decreased suck reflex? Have you noticed anything like that? I had an epidural with my second child and didn't really have any problems. Anyway just wondering if you have seen anything like that. Amy
  5. by   mark_LD_RN
    have not really noticed or maybe paid enough attention to its affects on breast feeding.but will from now on just to see
  6. by   bagladyrn
    Originally posted by mark_LD_RN
    Kevin

    I can understand your defense of the epidural,being you are A CRNA after all. it would be terrible to lose the OB buisness and money.

    yes some have a prejudice attitude but not all as you try to suggest. I as well as most of the OB nurses I work with fully support the patients choice. I see just the opposite of you I see the DOCS pushing for the epidural,because they don,t want to hear screamming patients, can do instrumental operative deliveries faster ,(even if not needed), and with epidural in place they can let patient sit their complete till they are ready,more of the delivery on docs schedule bull. I also see nurse who like it for the same reasons.

    I have worked at several hospitals and with lots of docs and midwives and see a much higher rate of operative deliveries and c/s with epidurals. even if current studies may suggest otherwise. as you should well know studies change with time. just look back to studies of scolpomine births yrs ago.

    epidurals are not the savior of childbirth, they do create problems at times and this needs to be kept in mind.

    DO NOT get me wrong I feel the epidural is a good tool when used properly at the right time with the right patients. I have encourage patients to get it for different reasons time to time. like patients who just could not relax at all, ones who would not dilate r/t increased tension stress what ever. it has helped sometimes ,sometimes not.

    I feel patients have been done a great disservive by the promotion of epidurals as the ultimate method of childbirth. pt often are under the misguide opinion that the birth will be pain free and the epiduaral will not cause any problems.sadly this is not the case. and people should use them wisely.

    I encourage all patients to do as me and my wife did, we registered for the epidural just incase she needed it. which she did not the last 2 times.and those 2 births went much better than the first one with the epidural.

    kevin don't get all defensive, i am not tring to be arguememntative.just trying to clear the air some
    Thanks for putting this so well, Mark. You stated what I feel better than I could have.
    I work very hard to support women in their decisions, and firmly believe that no one way is right for everyone, whether that applies to methods of childbirth, breastfeeding or any other issue.
  7. by   kmchugh
    Mark et al:

    Yes, I see your points, and I too believe there are too many anesthesia providers, as well as OB's and OB nurses who push epidurals for one reason or another. I believe that to be equally wrong. On the part of the anesthesia providers, the reasoning is obvious; more epidurals means more billing. I think you all touched on the reason that epidurals are pushed by others: quieter moms. Like any anesthetic procedure, epidurals are pretty safe, but not entirely risk free. The risks are negligible, but they do exist. And, as at least one poster pointed out, there are techniques that laboring women can follow that might make the laboring process easier, and eliminate the need for an epidural. Its important to point out, though, that these techniques are not perfect, and they do not work for all women.

    The things that bothered me in this thread are things I have seen occur in hospitals. There are some in healthcare who believe in nothing but "natural" childbirth. I have actually had an OB nurse tell me (and the patient) "real women don't need epidurals! Thats just a ploy by you CRNA's and docs to make more money." Some of the folks I have worked with in the past quietly referred to these nurses as the "OB Nazis." The problem is that this attitude is obvious, and can be felt by the woman in labor. I see this as nothing more than controlling. I saw more than one mom in labor who obviously wanted an epidural, but was afraid to ask for it for fear of "upsetting" her OB nurse. How can this kind of attitude be justified?

    Let me tell you how I approach it, and I think you will find that I am more on your side than you think. (Of course some women have their minds made up one way or the other before I ever show up. Unless a medical necessity dictates how things must go, I never even try to change these women's minds.) With an undecided or uninformed mom, I will tell them what I can do, as well as both the risks and benefits of the epidural. Then, I let them tell me what they want. If they opt not to take the epidural, I let them know that's fine. I also let them know that I am no more than about 15 minutes away, should they change their mind. I place them under NO pressure either way. But, in any event, I feel that in each case, the mom can make an informed decision.

    Of course, there are some cases where I cannot be quite so flexible. For example, I have had one or two moms with a history of extensive lumbar surgery, and in these cases, the epidural may not be safe, or even possible. I won't do the much riskier thoracic epidural for a laboring patient, though I have heard of some MD's who will. Also, I recently had a mom needing a scheduled C-section who wanted to a general anesthetic for the procedure. I explained that I don't usually do generals for elective C-sections, because the risks to the baby were much higher. We talked, and she agreed to try a spinal, which worked beautifully. The next day she even expressed appreciation for the anesthetic, and was glad she was awake for the birth of her little girl.

    So, yes, I see your points. The only point I want to make you aware of is that there are some OB nurses whose attitudes affect their care of the patient. That's not fair, and its not good nursing practice. The bottom line is that for most moms, the birth of a baby is one of the most joyous days of thier lives. Everything we do will impact that, and none of us have the right to allow our attitudes to affect that day. Mom's wishes, within reason, must be paramount, and free of clouds causes by our attitudes.

    Kevin McHugh

    Edited to add: Yes, I am also aware the "OB Nazis" are in the minority. Most OB nurses I know are outstanding professionals, who work in a collegial, team atmosphere. Thats a big part of the reason I love OB anesthesia.
    Last edit by kmchugh on Apr 26, '03

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