Epidural Anesthesia…
Use of Epidural Anesthesia in labor
“Epidural Anesthesia: Restrictions and Unintended Medical Intervention with Use”
“Epidural Anesthesia: Restrictions and Unintended Medical Intervention with Use”
The utilization of epidural anesthesia during labor has increased exponentially over the last 30 years. The practice offers individuals increased comfort and reduced pain during delivery and is a very popular option for women and for the doctors and nurses who aide in their deliveries. “In the United States, epidural anesthesia has become the most commonly employed tool to manage the pain of labor. Indeed, 71% of a representative sample of women in America who used pain medication during their vaginal birth labors reported having had an epidural” (De Sevo, M. & Semeraro, 2010, p. 11). Epidural anesthesia is recommended to nearly every pregnant woman, impending delivery unless such treatment is primarily contraindicated by some other medical condition. For many the use of epidural anesthesia is a medical breakthrough that allows women to almost completely avoid the pain of labor with very limited risk to herself or the child. While conversely there is much evidence that epidural anesthesia has a long list of potential and real complications that once administered require additional medical intervention and seriously impede movement outside the short list of passive positioning sitting, semi-sitting and side lying in bed.
Unintended Medical Intervention and Restrictions Correlate to Epidural Anesthesia
Optimal positioning or walking during labor may be limited for many reasons associated with epidural anesthesia, which is associated with increased use of IV oxytocin, poor fetal progression and rotation down the birth canal, prolonged late stage labor, lower apgar scores for baby and increased use of continual fetal heart rate monitoring, continual urinary catheterization and increased use of mechanical labor interventions such as vacuum suction and forceps, (De Sevo, M. & Semeraro, 2010, p. 11) (Stremler, Halpern, Weston, Yee & Hodnett, 2009, pp. 391-392). Nursing and cultural expectations also play a role in limiting movement during labor “….because of caregiver reluctance to allow women to ambulate, because some women prefer to labor in bed… and because cultural expectation may be to lie in bed for labor (Stremler, Halpern, Weston, Yee & Hodnett, 2009, p. 391).
More and more research as well as anecdotal knowledge of the increased use of epidural anesthesia has surrounded the fact that the practice often creates unintended side effects and may limit the ability of the laboring woman to achieve optimal labor, i.e. smooth labor and delivery, with positioning comfort being offered as well as limited fetal disturbances due to the limitation of the laboring woman to both reposition, to achieve a better progression of delivery, avoid catheterization and most importantly avoid medical and mechanical intervention. Many of these unintended consequences have been over time directly related to the use of epidural anesthesia. This is not to exclude a short but important list of far more serious side effects associated with epidural anesthesia including short or long-term femoral neuropathy (Peirce, O’brien & O’Herlihy, 2010, pp. 203-204), infection and contamination at the site or in the spinal fluid (Welliver, Welliver, Carrol, & James, 2010, p. 197), potential risk of severe “spinal” headache and the previous list of potential labor complications already discussed.
Several researchers also discuss the issue from the nursing perspective, associating the expectations of nurses and the ease of nursing care associated with epidural anesthesia as well as some of the measures that accompany it as mandatory, such as only passive positioning and continual urinary catheterization. (Stremler, Halpern, Weston, Yee & Hodnett, 2009, p. 391). (De Sevo, M. & Semeraro, 2010, p. 11) the implications being that the overmedicalization of the labor and delivery process has been well intrenchend in nursing culture and may influence increased rather than decreased medical intervention use for women, even when they would not necessarily have needed it. The challenge to nursing is then to begin to support a reduction in the use of epidural anesthesia as a result of the fact that this comfort measure has been over utilized despite its long list of known complications, some minor and short lived and some very serious. One of the issues that needs serious address in the nursing context with regard to the use of epidural anesthesia is the procedural policies associated with additional medical intervention required with epidural placement. Nurses need to be advocates for changing some of these mandatory intervention implementation care plans. Some examples important examples are mandatory urinary catheterization, and severe limitations of movement, and other less medical comfort measures during labor once an epidural is placed. In a great example of this need for advocacy is offered by Stremler, Halpern, Weston, Yee & Hodnett,
Given the potential beneifits of hands-and-knees positioning, it may be especially important to examine its use for women laboring with an epidural given that use of epidural is associated with persistent malrotation, longer second stage, use of oxytocin, and instrumental delivery & #8230;Because these deleterious outcomes may be related to pelvic floor laxity and less efficient descent and rotation through the birth canal, increasing mobility and optimizing relationships between the maternal pelvis and fetal head through the use of hands-and-knees may be beneficial (2009, p. 391).
These researchers contend that movement restrictions and other mandatory medical interventions used concurrently with epidural anesthesia should be challenged. Increasing the options available to those who chose epidural anesthesia that might mitigate some of its shortfalls would go far in melding the practice into safer and more comfortable labor for thousands of women.
Conclusion
Reducing the ideation of the epidural as the “standard practice” regarding labor and delivery in the modern era will likely go far in reducing the medical intervention stresses of the labor and delivery area. Nurses must become advocates of utilizing epidural anesthesia as a helpful but potentially risky aspect of labor and delivery as well as challenging some of the mandatory medical restrictions and interventions as a result of its use. Epidural anesthesia practice has improved substantially over the last 30 years to mitigate some unintended consequences of its use. Regardless it has also correlated to increased unintended complications for many women and increased need for alternative medical interventions, instrument use, prolonged labor and reduced fetal health, that may not have been the case at all had epidural anesthesia not been introduced in the first place.
Resources
De Sevo, M.R., & Semeraro, P. (2010). Urinary Catheterization During Epidural Anesthesia. Nursing for Women’s Health, 14(1), 11-13. doi:10.1111/j.1751-486X.2010.01502.x
Peirce, C.C., O’brien, C.C., & O’Herlihy, C.C. (2010). Postpartum femoral neuropathy following spontaneous vaginal delivery. Journal of Obstetrics & Gynaecology, 30(2), 203-204. doi:10.3109/01443610903477531
Stremler, R., Halpern, S., Weston, J., Yee, J., & Hodnett, E. (2009). Hands-and-Knees Positioning During Labor With Epidural Analgesia. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 38(4), 391-398. doi:10.1111/j.1552-6909.2009.01038.x
Welliver, D., Welliver, M., Carroll, T., & James, P. (2010). Lumbar Epidural Catheter Placement in the Presence of Low Back Tattoos: A Review of the Safety Concerns. AANA Journal, 78(3), 197-201. Retrieved from EBSCOhost.
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