Epidural management in labor

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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":rolleyes: 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?

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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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?

We always have a doc in the house - our ER doc.

We also have to call in the surgery crew for a stat cesarean. So it isn't just the CRNA who is at home. We are a small rural hospital - no way to stay fully staffed 24/7.

steph

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We always have a doc in the house - our ER doc.

We also have to call in the surgery crew for a stat cesarean. So it isn't just the CRNA who is at home. We are a small rural hospital - no way to stay fully staffed 24/7.

steph

How frequently do you end up with someone who needs a stat C/S? How long does it take your surgical team to get into the hospital? When you say surgical team, do you mean the OB/PA, or does that include the nurses as well? The L&D units I have been exposed to (only two, so very limited experience), all the RNs were educated on how to scrub as well. If you need an emergent cesarean, does the ER doc come and help? What is his/her role? It is very interesting to see how other facilities manage their units.Thanks for responding!

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Sarah is right; we are held to AWHONN standards. There were a few of us refusing to alter epidural rates based on this that got the attention of our manager and caused policy to be clearly stated and adhered to by all staff. The MD's and Anesthesia staff understand this is something we cannot/won't do.

Regarding stat section, the need for a stat section brings everyone running, including Anesthesia. By the time we assemble the dr, and shuffle the patient back, the on-call anesthetist is in-house and ready to go. We operate much like Steph's hospital does. No one is further than minutes out when a section is needed/called.

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How frequently do you end up with someone who needs a stat C/S? How long does it take your surgical team to get into the hospital? When you say surgical team, do you mean the OB/PA, or does that include the nurses as well? The L&D units I have been exposed to (only two, so very limited experience), all the RNs were educated on how to scrub as well. If you need an emergent cesarean, does the ER doc come and help? What is his/her role? It is very interesting to see how other facilities manage their units.Thanks for responding!

Everyone has 20 minutes to respond. Our ER doc is usually involved, especially if he is also the OB doc of the woman needing surgery. Our regular floor nurses and OB nurses are not trained in scrubbing - the OB nurses are trained as the baby nurse. Our CRNA lives about 4 miles from the hospital - we only have one.

We don't have emergency cesareans often at all - I'd have to look up the stats but I think maybe one or two a year.

steph

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We too are a small hospital, so it has been interesting hearing how others handle it. We are allowed to stop and pull out epidural caths, but not restart or alter the rate. Our anesthesia is within 15 minutes of the hospital, so when we had a stat section, recently d/t a baby crashing, we had all the calls made, in the OR, scrubbed and baby out in 14 minutes. We do have night nurses that scrub, which makes it much better. she also ended up assisting the MD as the other OB/MD was 15 minutes out and would not have made it in time. Unfortunately the newborn had to be bagged and intubated, we ended up transferring to Dallas... Our big fight has been AWOHNN vs. MD. I'm new with AWOHNN policies, is it just a "strong guideline" to go by, or policy?

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:confused: 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.....:uhoh3:

I couldn't agree more. They state it is for the pt to be able to rest, but who wants to rest after 10+ hours of laboring, I would just want to get it over with. We all remark it sounds more like the MD wants to sleep and not get up and come to a night delivery. They will stop the pit and turn off the epidurals... very crazy:uhoh3:

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OOOHHHHH!! This is currently a hot topic at our hospital. Supposedly the our state BON is ambiguous on the issue. Nearby states do not allow nurses to adjust epidural pump infusion rates. Our hospital policy is that if nurses have taken an anesthesia class provided by our hospital, they may increase the ml/hr, or give a bolus.

Personally, I don't feel comfortable doing such, but then again, I'm new and everything scares me.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.
We too are a small hospital, so it has been interesting hearing how others handle it. We are allowed to stop and pull out epidural caths, but not restart or alter the rate. Our anesthesia is within 15 minutes of the hospital, so when we had a stat section, recently d/t a baby crashing, we had all the calls made, in the OR, scrubbed and baby out in 14 minutes. We do have night nurses that scrub, which makes it much better. she also ended up assisting the MD as the other OB/MD was 15 minutes out and would not have made it in time. Unfortunately the newborn had to be bagged and intubated, we ended up transferring to Dallas... Our big fight has been AWOHNN vs. MD. I'm new with AWOHNN policies, is it just a "strong guideline" to go by, or policy?

http://www.awhonn.org

I feel strongly anyone practicing in L/D, GYN, Newborn or PP nursing would benefit from membership. As ACOG sets the standard of practice for physicians, AWHONN is our standard-setting body. WE are held to their standards, no matter what State we practice in.

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