Fetal monitoring during epidural placment

RNBelle · Mar 28, 2009

I would love to know the answer to that question too!

RedCell · Mar 28, 2009

Can anyone tell me what awhonn's guidelines are for fetal monitoring during epidural planement? I can find info on fetal monitoring before and after epidural placement, but nothing consistant for during. We all know that during the placement the maternal position makes it difficult. I have been told conflicting things by my manager/educator and my co-workers and I are constantly being told different things by traverlers who come to help us!
Thank you

The Basics:

-baby oxygenation dependant upon placental blood flow

-placental blood flow dependant upon uterine blood flow

-uterine blood flow is not autoregulated in preggos and therefore is a product of cardiac output and vascular resistance

-When mom is placed in a sitting position preload is decreased so cardiac output decreases (not so bad with lateral position though)

-The epidural (if local anesthetic is administered) will create a sympathetectomy which can decrease uterine blood flow

-Bad things can happen with epidural placement: 1)Unintentional intravascular injection 2) Unintentional intrathecal injection 3)Hypotension

-Using a test dose with a little epi is a fairly safe way to verify placement, however it is still enough to cause complications in certain patients.

All of the bad things can result in distress to the baby, that is why fetal monitoring is indicated. Maternal or even fetal comorbidities also play into the mix and should be considered as well.

LM813 · Mar 28, 2009

Thank you for the info, but what I am really looking for is policies and/or recommendations for fetal monitoring specifically during the actual placement. The anesthesiologist at our facitlity have the patients sitting up which makes monitoring the fetus next to impossible as you pick up maternal heart rate prob 99% of time with ext EFM. Some nurses take the monitors off completely during the placement and others doppler with hand held and others just leave them on tracing the maternal HR with a pulse ox on so you can prove the rate is maternal. I am looking for imput regarding awhonn's rec or some of your facilities practices/policies for this.

Thanks again!

babyktchr, BSN, RN · Mar 28, 2009

If you cannot monitor the baby with the fetal monitor because of positioning, you should get a doppler and assume the ausculation of FHT parameter set forth by AWHONN. Since epidural placement only takes a short time, you shouldn't have to listen for extended periods of time. Make sure you have good strip prior, document why you cannot continuously monitor and that auscultation has begun. I usually listen every 2-3 mins for 30 secs. There is no specific guidelines that I know of for FHM during epidural placement, unless it is hiding in the guidelines for anesthesia (which I do not own currently). You can always fall back on the auscultation guidelines though.

lamazeteacher · Mar 29, 2009

Red Cell:

I think the OP was about protocol; and what the organization responsible for setting norms and continuing education of OB nurses thinks is appropriate regarding fetal monitoring during placement of the epidural.

I know how difficult it is to get a good strip during placement of an epidural, so I'd imagine that unless it took an inordinate amount of time to get the thing going, it wouldn't be harmful if it was taken off. However, that said, if there were irregularities in fetal response to contractions (like occasional decels), it would be very important to get it right back on again.

Please don't refer to expectant mothers as "preggos". It smacks of degredation and lacks respect.

Elvish, BSN, DNP, RN, NP · Mar 29, 2009

Really? I read 'preggos' and didn't think twice about it. Guess it depends on where you sit. :)

jrring1019 · Mar 30, 2009

I take it off (during the actual procedure)and listen intermittently if it is taking a long time. I always trace mom if I leave it on and how is that helpful? You are still not getting a strip. I sometimes document "unable to maintain fhr tracing due to maternal position during epidural placement". Our anesthesia people (mostly CRNA's) are really good and have it in very fast. I will continuously monitor while she is sitting until the CRNA is ready, then as soon as the needle is out she sits up a bit while they are taping and I will dopple until I am ready to lay her back down.

NurseNora, BSN, RN · Apr 5, 2009

In active labor you only have to assess FHR q15min, so if everything has been well, the loss of signal for that period of time is not a big deal. Document why you can't record it and if takes longer than 15 min, ask anesthesia to pause while you listen through a contraction or two. If the strip has been showing signs of compromise, I'd want an electrode on before placement or at least another person to hand hold the transducer so you can get a strip during the procedure. It's usually uncomfortable for the patient, but you usually can get a recording if you push on it hard to aim it correctly with the patient leaning foreward.