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Obstetric Epidural Analgesia Chart EXPLANATORY NOTES 2017

These explanatory notes are to be used in conjunction with the Obstetric Epidural Analgesia Chart education slides.

Target Patient Group

The Obstetric Epidural Analgesia Chart is intended for use in women receiving an epidural during labour

Target Education Group

Anaesthetists who insert an epidural for women during labour

Midwives working in maternity services

Obstetric Epidural Analgesia Management Guidelines (PAGE 1)

Management guidelines are printed on the front page of the Obstetric Epidural Analgesia chart. Users should refer to

their own hospital’s obstetric epidural policy or procedure for detailed information relating to obstetric epidural

prescribing and management.

The Management Guidelines are summarised in point form:

Obstetric Epidural Analgesia Chart: EXPLANATORY NOTES. May 9, 2017

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Managing adverse effects or inadequate analgesia are summarised in point form:

Yellow Zone and Red Zone Clinical Care Instructions (PAGE 1)

Instructions on how to respond to patient clinical observations assessed in the Yellow or Red Zone are consistent

with the ‘Track and Trigger’ principles of the Between the Flags Program 1 which has been established as a ‘safety

net’ in NSW Public Hospitals to reduce the risk of undetected clinical deterioration of patients and ensuring

appropriate responses when needed.

Although the Obstetric Epidural chart incorporates a decision support tool it should not replace clinical judgement.

Clinicians must assess the woman’s condition and escalate to the appropriate level, using the chart as a guide.

For example, if a clinician considers that a woman requires urgent medical attention, based on their clinical

judgement, even though the woman’s observations remain in the Yellow Zone, then he or she should initiate a Rapid

Response call.

YELLOW ZONE OBSERVATIONS AND RESPONSE

The Yellow Zone observations highlight the following observations that require clinical review by the obstetric team

and/or the anaesthetist responsible for the care of a woman receiving an epidural during labour:

o Blood pressure (systolic 140 -170 mmHg, diastolic 80 – 90 mmHg)

o Heart rate (40 – 50 or 120 – 140 beats per minute)

Where a woman has a blood pressure or heart rate in the Yellow Zone the midwife must initiate appropriate clinical

care, repeating and increasing the frequency of observations as indicated by the woman’s condition. The assessing

midwife may need to consult with the MIDWIFE IN CHARGE to determine whether a CLNICAL REVIEW (or other

CERS – Clinical Emergency Response) call should be made.


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RED ZONE OBSERVATIONS AND RESPONSE

The Red Zone highlights the following observations that require an immediate rapid response following the

hospital’s clinical emergency response system (CERS) protocol. The anaesthetist responsible for the care of a

woman with an epidural during labour must also be contacted.

o Blood pressure (systolic greater than 170 mmHg, diastolic less than 80 mmHg)

o Heart rate (less than 40 or greater than 140 beats per minute)


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Prescription component of the Obstetric Epidural Analgesia Chart (PAGE 2)

The prescription section of the Obstetric Epidural Analgesia chart is to be completed by a prescriber (anaesthetist) in

accordance with the NSW Health Policy Directive Medication Handling in NSW Public Health Facilities PD2013_043. 1

The epidural prescription is valid for a maximum of 24 hours unless ceased earlier. If an epidural infusion is

required beyond 24 hours, a new prescription chart must be completed. If an epidural solution (either local

anaesthetic or opioid) is changed, a new Obstetric Epidural Analgesia chart must be commenced.

Patient allergy and adverse drug reaction (ADR) section to be completed by the prescriber in full.

Patient identification details to be either handwritten or a patient label affixed (first prescriber to check patient

label is correct).

Specialist referral: This section to be completed to comply with Medicare requirements for billing private patients.

Each hospital will have their own processes for the review of patients by an anaesthetist for the purpose of

inserting an epidural during labour.

The Obstetric Epidural Solution prescription:

To include the following details: Local anaesthetic, opioid, amount (in microgram), concentration (microgram per

mL), total volume (mL), date, prescriber’s signature, printed name and contact, space for pharmacy annotation.

(Example displayed below).

Obstetric epidural infusion modality: Generally only one of the following will be prescribed.

o Infusion

o Top up bolus for administration by a midwife

o PCEA (patient controlled epidural analgesia) OR


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o PIEB (programmed intermittent epidural bolus) OR

o PIEB + PCEA (programmed intermittent epidural bolus + patient controlled epidural analgesia)

Examples:


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Record of epidural insertion (PAGE 3)

The Record of Epidural Insertion section of the Obstetric Epidural Analgesia chart is to be completed by the

anaesthetist who inserts the epidural. Documentation to include drugs administered to initiate the epidural and

any subsequent drugs that may be needed after the epidural has commenced.

A completed example is displayed below:

Epidural initiation and pain rescue drugs (top up administered) (PAGE 3)


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Epidural initiation drugs administered: name of the drug or combination of drugs administered to initiate the

epidural. Example displayed below.

Epidural pain rescue (top up) drugs administered: the documentation of additional drugs administered by an

anaesthetist for the occasion where an epidural is not functioning adequately or where a dense block is required.

Epidural record of drug administration and volume of drug discarded (PAGE 3)This section is for the documentation of the epidural solution prescribed on page 2 administered and discarded by a

midwife. In the space provided document: date, time and 2 signatures for the record of infusion bag volume or top

up total volume and the record of volume discarded. Example below for ropivacaine + fentanyl solution mix of

100mL (taken from drug cupboard) and portion discarded at cessation of epidural infusion:

Removal of epidural catheter (PAGE 3)

This section is for the documentation of the removal of the epidural catheter. Only gentle traction is needed to

remove an epidural catheter. Various patient positions of lumbar flexion or extension may be required to assist in

catheter removal. In the event of a difficult catheter removal, the procedure should be stopped and an anaesthetist

contacted to review. Complications associated with difficult catheter removal are rare.


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Epidural catheter breakage is a rare occurrence with only isolated reports. During the past few decades, a number

of innovations in the design and manufacture of epidural catheters have been made with materials evolving to

improve the flexibility and reduce complications associated with catheters. 1 Events involved with this complication

have not been studied systematically. In most cases, the catheter broke during a difficult removal with increased

resistance. Resistance during removal might occur due to coiling of the catheter, a knot of the catheter, or

entrapment of the catheter by the supraspinous or interspinous ligaments. Vertebral arches and processes, the

lumbar fascia, the yellow ligament, posterior vertebral joints, and lumbar nerve roots have been implicated as sites

of catheter entrapment. 2

Epidural during labour observations (PAGES 4 – 8)

The observations component of the Obstetric Epidural Analgesia chart has been developed in consultation with the

Clinical Excellence Commission (CEC) to incorporate the ‘Track and Trigger’ principles of the Between the Flags Program2

to promote the early recognition of the deteriorating patient. The observations of blood pressure and heart rate are

included in the Obstetric Epidural Analgesia chart due to the potential complications and the need for increased

frequency of these vital signs following the administration of local anaesthetic +/- an opioid via the epidural route.

The Obstetric Epidural Analgesia chart is intended for concurrent use with a Partogram or Record of Labour.

Some facilities may use the Standardised Maternity General Observation chart (SMOC) chart for a woman during labour.

It is recognized that documenting vital signs (blood pressure and heart rate) in two places is onerous, however until the

NSW Record of Labour chart is complete, blood pressure and heart rate are to be documented on both charts.

Two pages are provided for the recording of maternal observations.

Pages 4 and 6: top up dose given, blood pressure, heart rate, motor block assessment, dermatome assessment.

o Altered Calling Criteria: For the extreme rare occasion where a medical officer determines that Altered calling

Criteria is indicated for blood pressure or heart rate, this must be documented on the SMOC.

o Blood pressure and heart rate is graphically recorded.


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o Frequency of blood pressure and heart rate observations 5 minutely blood pressure and heart rate are

required after epidural insertion, top up or bolus, then hourly for the duration of the epidural.

o Motor block assessment: To be commenced AFTER the 5 minutely blood pressure and heart rate and then

every 2 hours. Assess bilateral motor function and document ‘L’ for left leg and ‘R’ for right leg.

o Dermatome level check: the assessment of dermatome level varies between facilities. Refer to your local

obstetric epidural procedure or policy for instructions on the requirement of this observation.


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Pages 5 and 7: Documentation of epidural infusion delivery.

o Epidural infusion delivery: the documentation of epidural infusion delivery will be determined on the modality

prescribed on page 2. The completed example below is for a continuous epidural infusion running at initially

8mL per hour and increased to 10 mL per hour.

o Infused total or Volume remaining: Either of these observations can be documented determined on the brand

of epidural pump used. There are some epidural pumps that display ‘volume remaining’ on the main screen,

other pump brands may display the ‘infused total’.

o Epidural program checked: every 8 hours to ensure that the epidural pump is delivering what has been

prescribed on page 2.

o Comments: for free text which may include information about block inadequacy, unilateral block or epidural site

check.


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Back page – Visual motor block assessment and dermatome figure


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Relevant Policy Directives and References

1. NSW Health. Recognition and Management of the Patient who is Clinically Deteriorating PD 2010_026.

2. NSW Health. Medication Handling in NSW Public Health Facilities PD2013_043.

3. Roulhac, D. et al. (2014) Epidural catheter design. History, innovations, and clinical implications. Anaesthesiology 121(1) 9-17.

4. Hobaika, A.B. (2008) Breakage of epidural catheters: etiology, prevention, and management. Revista Brasilerira de Anestesiologia 58(3) 227-233.


For further information regarding implementation of the Obstetric Epidural chart go to the ACI website https://www.aci.health.nsw.gov.au/resources/pain-management/acute-sub-acute-pain/acute-pain-formsor you can contact:

Your birthing unit midwifery educator Obstetric anaesthetist

https://www.aci.health.nsw.gov.au/resources/pain-management/acute-sub-acute-pain/acute-pain-forms

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