Pt. positioning with epidural

ImaStork · Dec 19, 2003

Our anesthesia dept. has us keep our patients off their backs after epidural, we do left side and left lateral tilt then semi-fowlers. We never use stirrups to push we have the patient set up. We have a birthing ball if you put the foot piece down and place the ball in front of the epidural patient where they can still be sitting up but lean over the ball it supposed to help with rotating the baby from the OP presentation. Not many of our patients want to use the ball yet.

gypsyatheart · Dec 19, 2003

Wow, pushing on your back w/stirrups?!? Sounds like the dark ages to me...LOL! We let moms push in whatever position is comfortable to them...semi-fowlers w/mom pulling on her own legs/behind the knees works very well, but so does using a squat bar in a variety of ways... We have birthing balls, not many utilize them though.

SmilingBluEyes · Dec 19, 2003

it's mighty fargin hard to push with an epidural..so yes, often stirrups are needed. I don't know about you, but holding some of these HUGE ---(many of these gals exceed 200-250 lb)--- legs for 2 hours takes a toll on my back....I am not sacrificing my back for that; I got a lot of working years ahead of me.

squat bars and birth balls are wonderful but useless if a woman has no leg power. I am only one person, after all, and they often push in excess of 2 hours.

those w/o epidurals can push in any position they choose, squat, sit, on the toilet, I don't care. ....when there is no block to stop them, they can decide how it will work best for them.

Dayray, RN · Dec 19, 2003

What a great idea for a thread!! I want to hear how you guys push and position. Here's mine

Although I see epidural as wonderful (in some cases), I find it a little frustrating when it comes to positioning.

Immediately after placement of an epidural I usually have the bed down nearly flat and turn from side to side q 10 - 15 min using a hip wedge. Epidural meds follow gravity, turning side to side with the head lowered has worked well for me in getting pain relife on both sides. Of course its different for each patient and sometimes I throw all that out the window.

As for pushing, I lean towards semi fowler with the legs opened. Usually I have the husband hold one and I support the other on my shoulder while sitting on the bed, the patient pulls back on there legs behind the knee. Most of my patients have epidurals so until they get the hang of it I use my fingers to show them the point to focus pushing. I turn the Head of the bed up and down trying to match the angle the head is coming at so that it has the most space to slip under the pelvic bone. 90% of patient do really well with that method so I use it unless it isn't working. if things aren't progressing with that position I try different things, side-lying, knees bent and patient pulls on knees I have had some strange positions work even when I couldn't explain why they did.

Other then that if a patient has a feeling that a certain position will work for them I let them try it a while and suggest modification if it isn't working but leave them alone if it is.

I've only used squatting a few times because most of my patients have epidural and cant squat. When I have had the opportunity to let the patient squat it works pretty well and seems to give the patent a sort of satisfaction with pushing. I have them stand at the side of the bed with there arms hung over the edge and put it up high so that they only squat a little. I then lower the bed as the patient gets more accustom to the position.

The toilet is also a good place for early pushing. At first its great and real progress comes fast but as the baby gets lower the patients worry about having the baby in the toilet (so do I honestly) and we move back to the bed.

I'd love to hear more about what others do, I'm still new at this and any tricks or tips would be great.

SmilingBluEyes · Dec 19, 2003

I might add, I can use a squat bar/ padded, to help a lady push on her side...in the right position, the squat bar holds the upper leg up for ya. Also, sometimes I will sit on the bed, the leg on my shoulder, and let her push, while I guard my back.

Side-lying pushing is terrific, esp if you change sides frequently, to aid with a stubborn OP or other difficult presentation.

It also relieves deep variable/late decels by taking all the pressure off the vena cava and/or umbilical cord. I use this quite often with success. Whatever position used:

It is critical we guard our backs in nursing, folks, and OB is no different. Trust me after 6 years of holding legs, people, etc, this does a number on your back and if you don't have your back, you have no career. I advise whatever you do to help a laboring patient push, you keep in mind the status/position of your back. YOu will regret it if you don't.

LisaRN2B · Dec 19, 2003

Originally posted by SmilingBluEyes
it's mighty fargin hard to push with an epidural..so yes, often stirrups are needed. I don't know about you, but holding some of these HUGE ---(many of these gals exceed 200-250 lb)--- legs for 2 hours takes a toll on my back....I am not sacrificing my back for that; I got a lot of working years ahead of me.

squat bars and birth balls are wonderful but useless if a woman has no leg power. I am only one person, after all, and they often push in excess of 2 hours.

those w/o epidurals can push in any position they choose, squat, sit, on the toilet, I don't care. ....when there is no block to stop them, they can decide how it will work best for them.

I had an epidural with all three of my l/d's. No one ever turned me (except w/my 2nd...in distress) and there was NO way I could have done the ball or anything else. I couldn't move my legs or do anything like squat!

Having had experience with others in labor in a non-nursing capacity has let me observe that those w/o an epidural do much better if they are able to choose which position they want to be in to push and deliver (if they are allowed!). Give me the epidural...I don't mind the stirrups...just let me get that baby OUTTA there!

Look forward to reading everyone's replies to this thread!

Nursz-R-Awsm · Dec 20, 2003

This is a great thread. Haven't been on here in a long time.

Once in awhile I have had pts squat w/epidurals, however it depends on the CRNA that places it. Some get the pts so numb they can't move a thing, others can. Also great care needs to be taken not to disturb the cath site/dressing. I put the bed up high, feet lowered and pull up the handles on the sides. The pt can 'scoot' her butt off into a squat on the lower part of the bed and scoot back for rest between pushes/ctx.

Also, I have had pt grab her ankles (with legs in 'frog' like position and soles of feet together). Not everyone can do this position, but I just try to find what works best for that mom.

I will have to try out more side lying and squat bar pushing!

:)

LisaRN2B · Dec 20, 2003

Originally posted by Nursz-R-Awsm
T...Also great care needs to be taken not to disturb the cath site/dressing...

Oh yeah! That's for sure. Cath came out, first labor, had to be reinserted.

There is nothing like the feeling of all of a sudden rousing to a late labor contraction, pit augmented... :eek:

I wish I had had an epidural where I could have moved my legs. I was glad for the relief of the epidural, but did not like the helplessness of it. My leg started to fall off the bed, my body started to follow...I told the nurse I was falling, please help! She said, "Well, put your leg back up!" :rolleyes: I really wasn't being lazy, I couldn't lift my own leg!

So if any of you out there want to know...please be careful when you reposition, and if one of the mothers in labor says we can't move our legs, please believe us! :)

Sorry if this isn't exactly on-topic...

BRANDY LPN · Dec 20, 2003

This is completely off the subject off epidurals but when I had my last baby two years ago I spent the whoe pregnancy sitting on the birthing ball when I was at work, I absolutely loved it made my lower back discomfort sooo much better so I planned on using it in labor but..... after three ctx on that horrible torture device I have a whole nother perspective. I felt like my pelvis was about to split with contractions.

Anyone else out there use one while laboring? How was it?

Dayray, RN · Dec 20, 2003

I use the birthing ball allot. Its good for patients who don't have an epidural yet but are on pit. I put the ball on the floor lower the bed and let them hang there arms over the bed while sitting on the ball with there feet on the ground as far apart as is comfortable. The patient can then rotate there hips which loosens the pelvic ligaments and encourages decent. I put the Significant other behind the on a chair and show them how to do counter pressure on the patients back. Its great. monitoring is a little harder but doable with allot of adjustment. I'm not sure it makes a difference but I always put a bath blanket as a wedge behind the ball to prevent it from rolling out from under them.

I had one patient that really enjoyed the ball in a hand knee position. I put a blanket under her knees she hung her arms over the ball and rolled back and forth. It was her idea but it seemed to help her so much I'm going to try it again some time.

If a patient isn't on pit they usually prefer to walk or jacuzzi but sometimes I let them try the ball to see if they like it.

BETSRN · Dec 20, 2003

We put our patients supine with a roll under one hip for a few minutes after the epidural is placed. Then we put them however they want to go. I try and get my patients to sit right up to let nature help the process. most people are fine with sitting up. The last position they should be in for the rest of the labor is supine. We need to do all we can to help the baby rotate into an optimal position for birth. As far as pushing positios, we rarely use stirrups at all. We have people pusing in a semi squat, full squat, on their side, etc. We often use the squat bar as a footrest with a towel tied on the bar to hold on to. It's a wonderful way to push! otherwise we use the footplates.