Why do epidurals fail?

[knufflebunny]

About a third of all my patients that get epidurals fail at the end. Why? In the beginning, the epidurals work beautifully, and then when it gets close to 8, 9, 10cm, it fails completely like they don't have an epidural at all. I call anasthesia back to try to fix it, but no matter how much they bolus, it doesn't work. Sometimes we try to replace the epidural but most of the time it's too late and they just deliver. Why does this happen?

[klone, MSN, RN]

If one third of your patients are getting epidurals that fail, I would say that it's something wrong on the part of the anesthesiologist.

Are your epidurals given with a PCA?

[nocturnalnurse]

Epidurals can fail for many reasons. Sometimes technique or circumstance causes a poor placement of the catheter. Sometimes patients anatomy can cause problems with how the medication travels in the epidural space. Asymetrical blocks or "patchy" blocks can sometimes result even with best technique. Sometimes a patient's labor is rapid enough the epidural doesn't get time to set up fully.

I think, however, that what you may be refering to as failure of the epidural to "work" is actually not a true epidural failure. The nerves that cause labor pain from contractions are easily blocked by epidural placement for the nerves that travel from T10 to L1 (typically speaking, uterus cervix and perhaps even the upper lady parts). The second stage of labor, as the baby drops lower, causes pain to result from a different set of nerve fibers-namely the sacral nerves (posterior pain and perineal pain, lower lady parts). local anesthesia has a harder time blocking these nerves in general, and with typical placement of an epidural they offten times aren't completely blocked.

Our anesthesia team and nurses do a good job to provide adequate education for our patients that epidural labor is not pain free labor and as labor progresses and the baby moves down, epidurals block low pain less. This may result in pressure type pain sensations during second stage. We reassure the patients that often times this means they are getting close and that this pain will assist in directing pushing efforts. Anesthesia will still come up and evaluate these cases and give boosts when appropriate. alernative pain management options such as position changes,breathing techniques, heat, ice, counterpressure can sometimes help, too.

Next time you have a patient who's epidural "isn't working", try checking their block with ice or alcohol wips. If their block is up to their umbilicus and they are still having pain, chances are their epidurals ARE working, just not for the nerves being stimulated. The most common pain we have trouble blocking at my facility is suprapubic pain and low back labor. It can be frustrating as the nurse, because lets face it, pain free is best if you ask me! But knowing WHAT is going on for you and your patient can help. This also allows you to let your patient know that their epidural IS helping her some. We have one CRNA that jokes "If you don't beleive me, I can turn it off".

[knufflebunny]

Thank you!! Your response not only answered my question but was very educational! Are you a CRNA?

[nocturnalnurse]

not a CRNA, just a nurse who asked "why aren't these epidurals working?!" and found a great anesthesiologist to explain it all. Better educated nurses=better educated patients=happier patients!

[pearlsrwisdom]

It varys by facility sometimes! In my first job our epids were very good all throughout labor.. now where i work almost half really start hurting..both with pumps..funny enough..crnas gave thw better epidurals!