How do I chart during Epidural procedure?

suzanne4, RN · Jul 28, 2005

What is your hospital's protocol? That is the one that you need to follow.

Most procedures of any type require q 5 minute vital signs. :)

SmilingBluEyes · Jul 28, 2005

follow protocol regarding vital signs/Sat monitoring/EKG readings.

In the narrative area, chart how the patient tolerates the procedure, fetal heart tones before, during and afterward, vital sign stability of mom, and comfort levels (using 1-10 scale) before, during and after the epidural is in place. Check in frequently to make sure the epidural is still effective in controlling her pain---and chart this. Chart increased or unrelieved discomfort and what you are doing to address these. Also, ensure if you use PCA, that you chart this and that patient verbalizes understanding of its use.

SmilingBluEyes · Jul 28, 2005

During procedure for us, vital signs are q3 min x5, q5 min x5 then q 15 min until epidural is D/C'd. O2 Sat monitoring is continuous until vital signs are stable.

RNnL&D · Jul 28, 2005

I agree with Suzanne. Follow your hospital's protocol.

Our policy does not require O2 sat monitoring (although some of the anesthesiologists ask for it with the test dose), nor continuos EFM during insertion. We do get fht before and immediately following, (and during if the US will stay on Mom's belly in that position). Our BP protocol is similar to what SBE said, except q15 x 2 hours, then q 30 min.

USA987, MSN, RN, NP · Jul 28, 2005

Our P&P states: Mom's BP/Pulse/SaO2 q5x4 (or until stable) then q15x1 then q30 & PRN while epidural remains in place. RN must remain in the room for 30 mins. after the insertion.

NEVER become complacent with it. We had to code a pt. when she received a high epidural...stopped breathing completely!!!!!!!!!!

PegRNBSN · Jul 28, 2005

Our policy is q2 min vitals for 10 minutes after test and first dose then q5 minutes x 30 minutes then q 15 minutes for 1 hour then q 30 minutes for the rest of the time. One of the most important things to be aware of is that the biggest drop in BP usually comes between 20 and 30 minutes after initial dosing.

BTW we researched extensivesly and found no researched based recommendations for vitals with labor epidurals. If anyone has any would love to see it!

SmilingBluEyes · Jul 28, 2005

I agree with Suzanne. Follow your hospital's protocol.
Our policy does not require O2 sat monitoring (although some of the anesthesiologists ask for it with the test dose), nor continuos EFM during insertion. We do get fht before and immediately following, (and during if the US will stay on Mom's belly in that position). Our BP protocol is similar to what SBE said, except q15 x 2 hours, then q 30 min.

US wont' stay on, but you can "spot check" the FHT and chart them during the procedure, which is what I always try to do. Esp if the procedure takes longer than about 10-15 minutes to complete.

And I agree, do NOT be complacent. The level can rise----and blood pressure drop well after the procedure is completed!!!!

RNnL&D · Jul 30, 2005

US wont' stay on, but you can "spot check" the FHT and chart them during the procedure, which is what I always try to do.

Sometimes, but not always. When Mom sits up, leans forward, and rounds out, if baby is pretty low, I'd have to have her lean back to get her belly off her thighs to hear fht's.

SmilingBluEyes · Jul 30, 2005

I hear you. But I do always worry about that "gap" where no FHT are being monitored and it's defensibility in court. It's the litigious nature of what we do that gets to me. I often wind up crawling under the overbed table she is leaning on, to auscultate FHT--it's a pain, but I feel I have to try.

Editorial Team / Admin · Jul 30, 2005

I hear you. But I do always worry about that "gap" where no FHT are being monitored and it's defensibility in court. It's the litigious nature of what we do that gets to me. I often wind up crawling under the overbed table she is leaning on, to auscultate FHT--it's a pain, but I feel I have to try.

Excellent observation and action!! Keep up the good work, SmilingBlueyes.

I just reviewed a case for merit where there was approximately 15 minutes of absent monitoring strips for FHR checks during epidural placement. Without going into detail, this (absence of strips) will be used to strengthen the plaintiffs case.

NurseNora, BSN, RN · Jul 30, 2005

Yes, check in your P&P manual for what is your hospital's requirement. Your preceptor should have had you do that. Ours is BP, P, O2 Sat or Resp q2m X5, Q5m X2, then Q15m until delivery. After reading these posts, I may start talking to members of our anesthesia department about q30m after We don't have to have the pulse ox on, but anesthesia prefers it. It allows us to be sure that that baseline rate of 80's that shows up on the EFM as soon as the woman leans foreward is truly the maternal pulse. Anesthesia also wants to know if there is a sudden change in maternal HR after the initial dose (epinephrine in that initial dose would cause a significant increase if there were an inadvertent intravascular injection). Anesthesia also wants O2 on our epidural patients, but we live at a very high elevation and there isn't enough oxygen in the air up here anyway. We usually need O2 to keep the sats >95.

If I lose the FHR on the monitor (all our patients who get epidurals are on the monitor), I document in our notes (we don't do computer charting) that the signal was lost when pt was positioned for the epidural. AWHONN standards only require FH to be assessed q15m in active labor and most epidurals don't take that long to insert. If it does take longer, there is opportunity to catch it when anesthesia is readjusting and getting ready to try again.

One evaluation I didn't see anyone mention was bladder distention. Many women can't feel a full bladder with an epidural and you've probably been giving them lots of IV fluids. Some women can void with an epidural, many can't. One of my docs orders a foley cath for all his patients with epidurals, the rest don't, so I ask for a "cath prn" order (I work nights, they prefer that I wake them as little as possible).