Learning Objectives
By the end of this section, you will be able to:
- Assist with the education, preparation, insertion, and post care of the person receiving epidural anesthesia during the process of labor and birth
- Educate the person receiving pudendal anesthesia for the discomfort of birth
- Educate the person receiving local anesthesia for the discomfort of birth
- Provide education to the person giving birth on the advantages and disadvantages of spinal anesthesia
- Provide education to the person giving birth on the advantages and disadvantages of general anesthesia
Anesthesia for labor is provided in various forms, such as epidural, pudendal, and local. General anesthesia is used in emergency cesarean births. There are positive and negative aspects of each type of anesthesia. The nurse assesses the laboring person for the desire for anesthesia and risk factors according to the stage and timing of labor, educates the person about the side effects associated with the type of anesthesia, and monitors the safety of the laboring person and the fetus.
Epidural Anesthesia
The regional anesthesia produced by injection and infusion of a local anesthetic (bupivacaine [Marcaine]) and a narcotic (fentanyl) in the epidural space around the spinal nerves to block pain from T10 to S5 during labor is called epidural anesthesia (McDonald et al., 2019). Figure 17.8 shows the insertion of the epidural catheter. The most common side effect of epidural anesthesia is maternal hypotension. Less common side effects include bradycardia, respiratory depression, infection, nerve injury, and paresthesia (McDonald et al., 2019).
When the laboring person requests an epidural, the nurse notifies the health-care provider and receives orders for the epidural. The nurse ensures the person has signed the informed consent after the anesthesia provider has educated the laboring person on the risks and benefits of epidural anesthesia. The epidural is inserted by the anesthesia provider. The nurse assists the laboring person into a sitting or side-lying position based on the anesthesia provider’s preference. For continuous infusion of anesthesia during labor and birth, the anesthesia provider inserts a hollow needle into the epidural space and then threads a small catheter through the needle so that it rests in the epidural space. After the insertion needle is removed, the catheter is attached to an infusion bag and epidural pump. The pump is programmed to administer anesthetic continuously and provide for limited self-administration by the laboring patient if the infusion does not adequately control the pain of labor. While the epidural is in use, the laboring person should have reduction of pain; should have loss of some sensation in the abdomen, perineum, and legs; but should maintain a sense of perineal pressure. If a cesarean birth becomes necessary, the labor epidural is usually dosed to provide deeper anesthesia for surgery. After birth, the epidural catheter is usually removed, and sensation slowly returns to the abdomen, perineum, and legs.
Nursing Actions before Epidural Insertion
Upon the patient’s admission in labor, the nurse assesses the laboring person’s desire for pain control. If the person chooses an epidural for pain control, the nurse obtains the order from the obstetric provider. Once the laboring person has met the health-care provider’s criteria for an epidural, the nurse informs the anesthesia provider, who then educates the person on epidural use, risks, and benefits. The nurse reviews the admission labs and reports the platelet count to the anesthesia provider. If platelets are below normal (less than 150,000 per microliter), there is an increased risk for hemorrhage in the epidural space. The anesthesia provider will inform the nurse if the patient is not eligible for an epidural for labor. People with valvular heart disease, infection, coagulopathy, hypovolemia, and neurologic disease may not be good candidates for epidural anesthesia. The obstetric and anesthesia health-care providers will collaborate to determine the eligibility of each person.
Contraindications to the use of epidural anesthesia for labor and delivery include (Ring et al., 2021):
- coagulopathy,
- hypovolemia,
- allergy to the local anesthetic,
- thrombocytopenia,
- infection,
- aortic or mitral valve stenosis, and
- severe left ventricular outflow obstruction.
Obese and severely obese laboring persons have more complications during pregnancy, labor, and birth. This is especially true when a spinal or epidural anesthetic is being placed. Because of the size of these patients, it can be more difficult for the anesthesia provider to find the correct space for the administration of medication. The anesthesia provider might need a special needle that is longer than normal to penetrate the tissue and enter the epidural space.
The nurse explains to the laboring person the need to continuously monitor their vital signs and the FHR. Table 17.3 explains the nursing actions surrounding epidural anesthesia. An automatic blood pressure cuff, pulse oximeter, and continuous fetal monitor are placed. The well-being of both the laboring person and the fetus is confirmed prior to epidural placement. Because hypotension is a side effect of epidural anesthesia, an IV fluid bolus of 500 to 1,000 mL of lactated Ringer’s or normal saline is started 10 to 60 minutes prior to epidural insertion. Laboratory results are reviewed by the nurse and anesthesia provider to determine eligibility for anesthesia. The anesthesia provider will review the platelet count and determine if the count is high enough to continue with the procedure. Prior to epidural insertion, the nurse evaluates the vital signs, stage of labor, cervical change, contraction pattern, and FHR. The nurse may also assist the person to the bathroom to void prior to insertion of the epidural if needed.
| Nursing Actions | Implementation |
|---|---|
| Initiate and verify orders | Orders will be placed by health-care providers |
| Assess maternal fall risk | Standardized fall risk assessment |
| Assess well-being of laboring person and fetus | Apply continuous fetal monitor, BP device, and pulse oximeter |
| Confirm laboratory studies | Ensure platelet count is within normal limits |
| Administer IV fluid bolus | Approximately 1,000 mL IV fluid bolus 30–60 minutes prior to the procedure |
| Assist person to appropriate position | Ensure appropriate position is maintained |
| Assess vital signs during procedure | Vital signs monitored using continuous monitoring for person and fetus |
| Assess for reaction during test dose | Monitor vital signs, metallic taste in mouth, hypotension, difficulty in speaking, sudden-onset headache, and neck pain during test dose |
| Assess for pain relief and side effects of epidural | Monitor pain relief, vital signs per protocol (every 5–15 minutes), respiratory depression, and level of anesthesia |
| Assess for urinary retention | Intermittent urinary catheterization or insertion of indwelling catheter |
Nursing Actions during Epidural Insertion
The nurse educates the person on leg numbness and explains that they will no longer be able to get out of bed. After insertion, fall precaution education will be reinforced, and the bed will be kept low with side rails up. During the epidural insertion, the nurse positions the person most commonly in the sitting or side-lying position with the back in a C-position to open the spaces between the vertebrae (see Figure 17.8). The anesthesia provider inserts the epidural catheter using sterile technique. The nurse or partner assists the patient to maintain the appropriate position; the nurse monitors the vital signs and FHR. After insertion of the epidural catheter, the anesthesia provider injects medication as a test dose. The nurse notes the time and any side effects reported by the laboring person. The catheter is taped into place, and the anesthetic can be set to a continuous infusion with patient-controlled periodic bolus until after birth.
Nursing Actions after Epidural Insertion
After the epidural catheter is inserted and dosed, the nurse assists the person into a supine position with a wedge under one hip to displace the pregnant uterus from the vena cava and aorta, to avoid aortocaval compression syndrome. Vital signs and FHR are monitored every 5 to 15 minutes after insertion. The nurse also assesses the patient for respiratory depression, level of consciousness and paresthesia, and pain control. If the laboring person becomes hypotensive, the nurse will begin another bolus of IV fluid or notify the anesthesia provider. Ephedrine (Akovaz), a vasopressor, can be administered (as ordered) to increase blood pressure if the IV bolus does not help or if increased fluid is contraindicated. During the hypotensive episode, the blood pressure can decrease enough to reduce uteroplacental perfusion, causing late decelerations and bradycardia in the FHR. See Chapter 16 Electronic Fetal and Uterine Contraction Monitoring for more information on nursing actions for fetal bradycardia and decelerations. The nurse monitors for late decelerations while attempting to reverse the hypotension.
Bladder function is affected by anesthesia, and the nurse monitors for urinary retention. Depending on the stage of labor, cervical dilation, and the institutional policy, the nurse will drain the bladder intermittently or insert an indwelling urinary catheter. During the second stage of labor, the nurse will remove the indwelling urinary catheter before the laboring person starts pushing.
Clinical Safety and Procedures (QSEN)
Postepidural Hypotension
The nurse will monitor vital signs every 5 minutes during the first 30 minutes after the epidural is placed and every 15 minutes during the remainder of the process of labor and birth. A common side effect of the epidural is hypotension. If the nurse notices hypotension, the IV fluids will be increased, the anesthesia provider can be called, and ephedrine could be given. If the hypotension continues, perfusion to the placenta will decrease, and uteroplacental insufficiency will occur.
Education of the Person Desiring an Epidural
The nurse educates the laboring person on loss of mobility and feeling in the abdomen, perineum, and legs. The nurse also educates the laboring person that they will no longer be able to ambulate until after delivery and the effects of the anesthesia have worn off. Common side effects are mild itching, nausea, and back pain after birth at the epidural site. The nurse can administer antiemetics and antihistamines to reduce these side effects. Epidural anesthesia has been previously linked to increased risk of oxytocin augmentation, operative and instrumental birth, and increased length of labor; however, research suggests these outcomes are dependent upon the dosing of epidural medication and the practices of the obstetric care provider (Lim et al., 2018). The nurse reviews the procedure and the need for monitoring before, during, and after epidural placement. Informed consent is obtained. Institutional policies outline nursing actions related to administering a new epidural infusion bag, monitoring the infusion, and discontinuing the infusion.
Link to Learning
This video describes how an epidural works, discusses possible side effects, and provides evidence of how epidurals affect labor.
Pudendal Block
A pudendal block is the anesthetizing of the pudendal nerve that provides sensation to the perineum, anus, vulva, and clitoris using local anesthesia (American College of Obstetricians and Gynecologists [ACOG], 2019). The health-care provider can perform a pudendal block before or after the birth. This block is helpful when a third- or fourth-degree laceration repair is required, or the use of forceps or the vacuum extractor is necessary (see Chapter 18 Nursing Care and Interventions During Labor and Birth). The advantage of the pudendal block is the lack of sedation or loss of motor function. The disadvantage is that occasionally the laboring person does not get pain relief from the block. Figure 17.9 demonstrates the placement of a pudendal block. The introducer or trumpet is placed into the vagina, and lidocaine (Xylocaine) is injected between the ischial spine and sacrospinous ligament. This local anesthetic block does not require special monitoring by the nurse. The risks of the pudendal block include damage to the pudendal nerve, organ injury, and puncture of the pudendal artery.
Local Anesthesia
Local anesthesia is used prior to performing an episiotomy or during repair of an episiotomy and lacerations (see Chapter 18 Nursing Care and Interventions During Labor and Birth). This can also be used for persons without an epidural or with an epidural that is not sufficient to relieve perineal pain. The health-care provider uses a local anesthetic such as lidocaine or bupivacaine (Marcaine) to numb the area. The vaginal or perineal repair is then performed. The nurse’s role is to have the supplies ready and open for the provider to administer the anesthetic. The advantage of local anesthesia is the longer-lasting pain relief at the specific area of pain. The disadvantage is the stinging pain during the infiltration and the occasional lack of pain relief from the injection.
Spinal Block
A spinal block is the injection of a local anesthetic and narcotic into the cerebrospinal fluid to cause complete pain control, loss of sensation, and loss of motor control. The injection is a single injection through the third, fourth, or fifth lumbar space into the subarachnoid space. No catheter is inserted for further medication to be infused. The effect is almost immediate. The spinal block is most commonly used for cesarean birth. One advantage of the spinal block is the ability of the anesthesia provider to inject a narcotic, usually morphine, with the local anesthetic to provide pain relief for approximately the first 24 hours postpartum. Another advantage is the rapid onset of spinal anesthesia; this allows for use of a spinal block instead of general anesthesia in some emergency cesarean births. A third advantage is the lack of sedation or drowsiness so that the birthing person can be alert during the birth of their baby. The risks of spinal anesthesia are explained to the birthing person by the anesthesiologist and include hypotension, respiratory depression, and nausea.
Pharmacology Connections
Bupivacaine
Bupivacaine is used in spinal and epidural anesthesia.
- Generic Name: bupivacaine
- Trade Name: Marcaine, Sensor Caine
- Class/Action: anesthetic
- Route/Dosage: epidural or spinal
- High Alert/Black Box Warning: contraindicated for paracervical block
- Indications: anesthetic for spinal or epidural
- Mechanism of Action: blocks the conduction of nerve impulses by increasing the threshold for electrical excitation in the nerve
- Contraindications: hypersensitivity to the drug, injection site infection, hepatic impairment
- Adverse Reactions/Side Effects: heart block, respiratory arrest, ventricular arrhythmia
- Nursing Implications: Witness consent. Review patient education with the family.
- Parent/Family Education: The nurse reminds the person not to try to get out of bed, explains the side effect of itching and that an antihistamine can be given, and explains the side effect of nausea and that an antiemetic can be given.
(Papadakis et al., 2022)
General Anesthesia
General anesthesia is a systemic anesthesia in which a loss of consciousness occurs. The advantage of general anesthesia is its immediate onset. Typically, general anesthesia in childbirth is used only in extreme emergencies or when regional anesthesia is contraindicated. Because of the safety risk to the birthing person and newborn and the rapid onset of spinal anesthesia, general anesthesia is used less frequently than it used to be. The disadvantage to the neonate is that respiratory depression can occur at birth due to the sedating effect of general anesthesia. The disadvantage of general anesthesia for the birthing person is its relationship to anesthesia complications, aspiration, surgical wound infections, venous thrombosis, postpartum depression, increased perinatal mortality, and failed intubation (Ring et al., 2021). A failed intubation, defined as a difficult airway with lack of success on more than two attempts, occurs more often in pregnant persons because of physiologic changes in pregnancy (Ring et al., 2021). Nurses who circulate surgeries using general anesthesia are trained in the application of cricoid pressure, which is applied before intubation to block the esophagus and prevent aspiration should the birthing person vomit or regurgitate.
Medications used for general anesthesia cross the placenta into fetal circulation; therefore, the health-care provider will make the cesarean incision quickly and deliver the fetus as soon as possible to reduce the risk of respiratory distress. Fetal risk factors related to general anesthesia include lower Apgar scores, increased assisted ventilation use, and increased admissions to the neonatal intensive care unit. Breast-feeding after general anesthesia can be more difficult to initiate, and breast-feeding success at 6 months postpartum has been shown to be lower (Ring et al., 2021). Table 17.4 presents a comparison of epidural, spinal, and general anesthesia.
| Epidural | Spinal | General | |
|---|---|---|---|
| Placement | Epidural space | Cerebrospinal fluid of spinal cord | Systemic |
| Area of anesthesia | Abdomen, pelvis, legs | Abdomen, pelvis, legs | General |
| Level of pain management | Pain relief with sensation | Complete pain relief | Unconscious pain relief |
| Movement | Some muscle control | No muscle control | No muscle control |
| Use in surgery | Yes, when dosage is increased beyond labor strength | Yes | Yes |
| Onset | 10–20 minutes | Immediate | Immediate |
| Duration | Long lasting with continuous infusion | Approximately 2 hours | Controlled by anesthesia provider; duration of surgery |