Epidural vs. Spinal Block: Anesthesia for Pain Relief During Labor and Delivery (Nursing)

00:01 Now, let's talk about a category of pain relief options called anesthesia.

00:05 We just finished talking about analgesics.

00:08 Remember, analgesics have sedative effects and pain relief effects.

00:13 Anesthesia is all pain relief. We have two options we're going to talk about first.

00:19 The epidural and the spinal. Let's talk about the epidural.

00:23 So, an epidural is very much like a peripheral IV, except, it goes into the back.

00:29 It goes in around somewhere between L2 and L5 an there's a catheter that's placed that allows for continuous flow of pain medication, okay? The spinal on the other hand is more like a shot.

00:43 So, it's also given in the back but this time, it goes into the subarachnoid space.

00:48 So, this is a one and done kind of deal.

00:51 The injection goes into the subarachnoid space, the needle is pulled out and that's it.

00:56 We can also do a combination of an epidural and a spinal and we'll talk in just a second about why that might be an ideal option.

01:05 So, I want you to take a look at this graphic to get a better idea of the placement of the epidural versus the spinal.

01:11 You'll see in the left graphic, we have the spinal column here and the epidural is the needle that's a little higher up.

01:18 You see that that needle enters into the epidural space.

01:23 The catheter will stay in place and again, this allows for continuous infusion of pain medication.

01:29 The spinal on the other hand is just the needle that's introduced into the subarachnoid space and pulled out.

01:36 So, you can see the same description on the graphic on the right, just a different view.

01:42 Epidural goes in epidural space, spinal goes into the subarachnoid space.

01:47 When we think about advantages for epidural anesthesia, remember, it doesn't cause sedation.

01:55 So, we don't get the issue with drowsiness or change in cognition.

01:58 So, that can be a plus during labor.

02:01 It definitely does decrease the pain during labor and during birth and potentially, during a repair, so, that's a positive.

02:09 Also, very little of the medication if any reaches the fetus.

02:14 So, remember when we talked about the analgesics and the potential for the medication to cross-over the placenta and also affect the baby, that is not the case with epidurals, so, this is a really great method if that's a concern.

02:27 Another advantage of the epidural is it causes massive vasodilation of the vessels.

02:32 So, it helps to relax to pelvic floor.

02:35 So, when you think about situations where it may be beneficial to relax the pelvic floor like when Cletus the Fetus needs to come through the pelvic floor, then, this is going to be a positive.

02:46 Some clients actually may change their dilation pretty soon after getting an epidural because of the vasodilation. So, that's also a plus.

02:55 Now, there are also some contraindications for an epidural.

02:58 So, let's say a client says, "I don't want one." That's a perfect reason for them not to have one.

03:05 Some clients really want to have an unmedicated birth or maybe they don't want an epidural and even though they have made that decision and they voiced that decision, sometimes, we may try to talk them into getting an epidural but we really have to be careful and make sure that the decision that's being made is exactly the one the client wants.

03:24 Also, think about where that needle is going. It's going into the spinal column.

03:29 So, if we have a client that has any sort of clotting disorder, that would be something that would make it contraindicative for us to place an epidural or a spinal.

03:39 If there's an infection at the site of placement.

03:42 So, imagine if there's some sort of septic event going on and we introduce that infectious process or that bacteria into the spinal column.

03:51 That would be the exact opposite of what we want to do.

03:54 So, whoever's placing that epidural is going to do a good job of inspecting the back and make sure there's no signs of infection.

04:01 Also, if we have a client that has raised intracranial pressure.

04:05 Again, thinking about where that needle is going to be going, we don't want to introduce a needle into that space if we have increased intracranial pressure.

04:13 Another absolute contraindication is a birthing person who's presenting with Hypovolemia.

04:19 One of the things we're going to talk about in just a second is the importance of making sure that clients are adequately hydrated before the epidural is placed.

04:27 Hypovolemia can lead to Hypotension which we all know can have major effects on the fetus and lead to decelerations.

04:37 Now, let's talk about relative contraindications.

04:41 These are not absolutes.

04:43 So, if we have a client that's uncooperative and when we say uncooperative, we mean maybe they're having a little difficulty maintaining proper positioning for the epidural placement, then, this may not be the best option for them.

04:55 Also, clients with neurologic disorders.

04:58 Depending on what they are, this may not be the best option for them either.

05:03 Also, fixed cardiac output states.

05:06 Again, when we get into issues with mass vasodilation that can have pretty big effects on blood pressure, so, we want to be careful.

05:13 And finally, any sort of anatomical abnormalities.

05:17 So, thinking of someone who's had some sort of injury or maybe a motor vehicle accident or a fall and there's something that is different about their anatomy concerning their spine.

05:27 That may create some challenges around placing an epidural or a spinal.

05:32 When we think about the responsibilities of the nurse.

05:36 What do they need to do? Clearly unless you're a nurse anesthetist, you're not going to be placing the epidural but the nurse has a pretty big job when it comes to making sure that everything is set-up and prepared for this client.

05:48 They're going to need to make sure that an assessment has been performed both by them and also by whomever is going to place the epidural.

05:55 It will be the responsibility of the nurse not to sign the consent but to make sure that the consent form for the procedure has been signed.

06:03 And remember, as advocates, we want to talk to the client and make sure they understand all the risks and benefits of the procedure.

06:10 We want to prepare the client and that has to do with physical positioning but also, mental positioning.

06:16 They need to know that likely, they will not be able to get up and move around and go to the restroom after the epidural.

06:22 That's not something they need to find out after the epidural has been placed.

06:26 Remember the whole thing about hydration.

06:29 It's very important that the client is well-hydrated before that epidural or spinal is placed.

06:36 If we have mass vasodilation, we could then have hypotension which leads to poor profusion to the fetus.

06:43 So, a 500 mL bolus of fluid may be what's ordered prior to.

06:47 Now, I say that with one small caveat.

06:50 If you have a client who has an issue potentially with fluid overload, then, a 500 mL bolus of fluid may not be what is recommended.

07:00 So make sure you use your critical thinking skills to decide whether you should do 250 or 500.

07:06 Again, thinking about the client and the position, I'll show you a graphic of what that looks like in just a minute.

07:13 We need vitals, so, remember, as a side effect, we might experience some hypotension.

07:17 It'd be a good idea to have a baseline before we get started.

07:21 Also, the anesthesiologist or the CRNA may ask the nurse to watch the pulse because depending on potential allergies to medication or other side effects, the pulse may increase as the test dose of the medication is placed.

07:37 So, a pulse ox is usually placed on the client's finger as a way to monitor that.

07:41 We want to monitor the fetus for any signs of any complications.

07:45 So, if the blood pressure begins to drop, you may notice late decelerations on the fetal monitor.

07:51 So, we want to pay attention to that as well.

07:53 And finally, it's really important to make sure that we monitor the bladder.

07:59 Now, just because someone has an epidural, doesn't mean they can't void on their own.

08:03 They actually can try to void on a bedpan but if they're not able to empty their bladder that way, an indwelling catheter or an in and out catheter or a straight cath would be a really helpful option.

08:15 Remember when we talked about labor.

08:17 A full bladder will make it impossible for the fetus to descend in the pelvis.

08:22 So, keeping the bladder empty is very important.