POLICY

Perinatal Neuraxial BIRTH CENTER

Analgesia and Anesthesia Patient Care
Issued:
Last Approval: August 2020

I. PURPOSE
To provide guidelines for administration and support of perinatal neuraxial analgesia and
anesthesia for patients at The Birth Center.
II. REFERENCES
Chestnut MD, David H.; Wong MD, Cynthia A; Tsen MD, Lawrence C; Ngan Kee BHB MBChB
MD FANZCA FHKCA FHKAM (Anaesthesiology), Warwick D; Beilin MD, Yaakov; Mhyre MD,
Jill. (2014). Chestnut's Obstetric Anesthesia: Principles and Practice. (5th Ed.) Saunders.
Creehan, P. (2008). “Pain Relief and Comfort Measures in Labor,” Ch. 9, pp 443-472, in KR
Simpson & PA Creehan (Eds) AWHONN’s Perinatal Nursing (3rd Ed), Philadelphia:
Lippincott.
Grant, G. (2012). Adverse effects of neuraxial analgesia and anesthesia for obstetrics. Retrieved
from UptoDate on July 11, 2012
Hughes S.C., Levinson, G., & Rosen, M.A. (2003). “Regional Anesthesia for Labor and
Delivery,” Ch. 8, p.123 and “Intraspinal Opiates in Obstetrics,” Ch. 9, p. 149, in Anesthesia for
Obstetrics, 4th Ed. Philadelphia: Lippincott.
American College of Obstetricians and Gynecologists. (2009). ACOG Committee Opinion No.
441. Oral intake during labor Obstet Gynecol ;114:714.
Practice Guidelines for Obstetric Anesthesia: An Updated Report by the American Society of
Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia
and Perinatology. (2016). Anesthesiology. 124(2):270‐300.
Witcher, P.M., & McLendon, K. (2013). “Anesthesia emergencies in the obstetric setting,” Ch.
11, pg. 175-188, in Troiano, N.H, Harvey, C.J., & Flood-Chez, B. (Eds) High Risk & Critical
Care Obstetrics (3rd Ed.), Philadelphia: Lippincott Williams & Wilkins.
Wright, R.G., Shnider, S.M., Levinson, G., Rolbin, S.H., & Parer, J.T. (1981). The effect of
maternal administration of ephedrine on fetal heartrate and variability.

III. DEFINITIONS/ CRITICAL POINTS

Neuraxial anesthesia is a form of labor analgesia available for UCSF obstetrical patients when
contraindications do not exist. This form of analgesia is provided using any of the following
techniques:
• Epidural catheter placement
• Intrathecal (spinal) single dosing
• Combined spinal epidural (CSE) placement
• Dural puncture epidural (DPE) placement
Contraindications of neuraxial labor analgesia include, but are not limited to, the following:
• Maternal Coagulopathy and/or thrombocytopenia
• Anticoagulation therapy
• Infection of overlying injection site

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 POLICY
Perinatal Neuraxial BIRTH CENTER
Analgesia and Anesthesia Patient Care
Issued:
Last Approval: August 2020

• Uncorrected hypovolemia, refractory maternal hypotension, shock

• Increased intracranial pressure by mass lesion
• Patient refusal

IV. CRITICAL POINTS ABOUT LABOR EPIDURALS

A. Labor neuraxial analgesia should not be promised or administered before agreement is
reached among the patient, provider/CNM and anesthesiologist. This may be achieved
by direct discussion, or verbal communication with the labor nurse as an intermediary.
B. Timing of labor neuraxial analgesia administration should be decided on an individual
basis. There is no exact time at which a patient may or may not have neuraxial
(epidural, intrathecal or combined) analgesia. The timing depends on the patient's pain
perception, coping mechanisms, and medical condition. The specific findings of
cervical examination (dilation, etc.) may not be relevant in circumstances of painful
early labor. Likewise, it is never “too late”, per se, to administer neuraxial analgesia.
Even in the second stage, patients may have neuraxial analgesia placed. If the baby is
crowning and the patient desires epidural or other pharmacological interventions at the
time, nitrous oxide or intrathecal (spinal) labor analgesia may be available options. This
should be a consensus decision among the provider/CNM, the patient, and the
anesthesiologist
C. The OB provider should engage the anesthesiologist in deciding if and/or when
additional analgesia or anesthesia is indicated. Some patients will greatly benefit from
enhancement of the labor dose for an operative vaginal delivery and episiotomy repair.
D. Spontaneous vaginal delivery with effective second stage analgesia is possible.
Diaphragmatic pushing is not interrupted by neuraxial analgesia, but sensation and
stimulation to push are diminished or occasionally abolished. Labor support is,
therefore, important.
E. With the increased use of more dilute local anesthetic epidural infusions, the need to
modify the analgesia intensity has diminished. Only the anesthesiologist may modify
epidural infusions, except in the case of the RN stopping the infusion after delivery of
the placenta and any repair is complete.
F. Early labor epidural analgesia or early placement of an epidural catheter is available at
the UCSF Birth Center when desired by a patient and agreed upon by the
provider/CNM and the anesthesiologist. The catheter can be placed without medication
(or 'test dosing') for later use. This can be administered for early labor, or active labor.
However, the patient should be aware that early placement may increase the risk of
epidural failure, the use of opioids alone has a high rate of pruritus and nausea.
Additionally, the patient should be aware that in a true “emergent” cesarean delivery,
the presence of an epidural catheter may not alleviate the need for general anesthesia

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 POLICY
Perinatal Neuraxial BIRTH CENTER
Analgesia and Anesthesia Patient Care
Issued:
Last Approval: August 2020

V. POLICY
It is the policy of UCSF Benioff Children’s Hospital that a Labor and Delivery nurse familiar
with the indications and side effects of epidural anesthesia can assist the anesthesiologist with
this procedure and care for the patient receiving neuraxial labor analgesia.
The RN and anesthesiologist remain present at all times during injection until the patient is
stable. This applies to the initial injection and subsequent boluses. This practice does not
apply to patient self-administered doses administered via the patient-controlled infusion
pump
Neuraxial anesthesia is used during labor to diminish the sensory innervation of the uterus
(T10, T11, T12, L1) as well as perineum for vaginal delivery (S2, S3, S4). If an epidural is to
be used for cesarean delivery, a different local anesthetic is used for the goal of surgical
anesthesia (rather than labor analgesia) and the block height is typically increased to T4.
Patients in labor do not have to reach an arbitrary cervical dilation such as 4 to 5 cm before
receiving neuraxial labor analgesia. A reasonable approach is to allow the patient in labor to
receive neuraxial analgesia when they desire it, as long as the diagnosis of labor has been
established or a commitment to deliver has been made. Notification of the OB team prior to
epidural placement is desired. It is also reasonable to insert an epidural catheter before pain is
severe, so that analgesics can be injected when the patient begins to experience discomfort.
Prior to anesthetic procedures a “time-out” between the provider and nurse should occur to
confirm procedure and patient comorbidities.
A. Epidural catheter is to be placed under sterile conditions.
B. Anesthesiologist may administer a test dose of local anesthetic containing 3 ml of 2%
lidocaine with 15 mcg epinephrine to rule out inadvertent intravascular or subarachnoid
injection. Lidocaine will provide profound block with motor weakness (intrathecal) as
well as possibly creating ringing in ears and metallic taste (intravascular). The
epinephrine will result in increase in HR (> 15 bpm) and increased BP approximately 30-
60 sec after test dose given if the catheter is intravascular.
C. A typical loading dose is approximately 10 ml of bupivacaine or ropivacaine with or
without adjunctive agents. Maintain uterine displacement off vena cava even during this
initial bolus to reduce risk of significant hypotension.
D. Dosing and rate are initiated by the anesthesiologist after connecting the epidural to the
pump tubing.
E. The patient then self–administers additional medication using a patient-controlled
infusion pump.
F. Anesthesiologist should be called for maternal hypotension, inadequate analgesia or any
significant form of maternal or fetal distress in conjunction with the obstetrician.

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 POLICY
Perinatal Neuraxial BIRTH CENTER
Analgesia and Anesthesia Patient Care
Issued:
Last Approval: August 2020

VI. PROCEDURE
CRITICAL POINT
A. Patients receiving epidural anesthesia are placed on a bed that can be placed in
Trendelenberg position in an area where emergency equipment is readily available.
B. The provider/CNM should be aware of the progress of the labor and electronic fetal
monitoring (EFM) tracing prior to placement of the neuraxial anesthesia.
C. Major risks include:
1. Local anesthetic toxicity - systemic reaction due to accidental vascular injection
with symptoms of:
a. Dizziness
b. Tinnitus
c. Strange taste/sensation in mouth
d. Convulsions
e. Heart block
2. Total ‘high’ spinal - due to inadvertent subarachnoid (intrathecal) injection of local
anesthetic with symptoms of:
a. Rapid onset of widespread anesthesia
b. Profound hypotension
c. Respiratory depression
d. Possible loss of consciousness
D. Other risks/side effects:
1. Post-dural ‘spinal’ puncture headache
2. Hypotension
3. Maternal fever
4. Shivering
5. Pruritus
6. Backache
7. Inadequate pain relief
8. Rare (<1:10,000) risks of epidural or spinal hematoma, infection, and nerve damage
E. At least 10 minutes of EFM/toco monitoring is obtained whenever applicable and
possible prior to catheter placement. During catheter placement the FHR should be
monitored before and after the initial test dose is injected. FHR monitoring and uterine
activity assessment should occur continuously from the time the epidural is dosed until
birth. For patients with a fetal demise or a fetus with a condition incompatible with life,
fetal monitoring may not be warranted.
F. During placement, the patient is positioned preferably in the sitting positioning. Exact
positioning is dependent on numerous factors including medical indications and
anesthesia provider preference.

***NOTE: The nurse should never leave the bedside during epidural placement.
G. RNs are responsible for changing epidural infusion bags.

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 POLICY
Perinatal Neuraxial BIRTH CENTER
Analgesia and Anesthesia Patient Care
Issued:
Last Approval: August 2020

H. Reinforce to the patient that there may be a loss of sensation and decreased lower
extremity strength and movement with regional anesthesia.
I. Maintain uterine displacement off vena cava and turn patient q 1 to 2 hours. Protect legs
from falling off bed when changing position.
J. Clear liquids are appropriate unless patient condition suggests otherwise. Particulate-
containing fluids and solid food should be avoided. (ACOG Practice Bulletin #441, 2009)
K. If patient is placed in stirrups for delivery, legs must be placed and removed
simultaneously. Avoid flexing hips past 90° for significant period during pushing as
patient cannot perceive nerve stretch or compression well and could lead to increased risk
of nerve damage.
L. Check for a palpable bladder every 2 hours and offer a bedpan when the bladder is full. If
the patient is unable to void, follow unit voiding protocol.
***Routine placement of indwelling catheters in patients with an epidural is not
indicated. Refer to Bladder Care in OB Patients for additional information.
M. RNs do not change the rate of the epidural infusion. Epidural infusion rate is not charted
by the RN. Should the patient's condition warrant a change in the infusion, the RN should
call the anesthesiologist for a bedside consultation. The RN may discontinue the infusion
after the birth of the baby, placenta is out, and repair of any laceration or episiotomy is
complete.
N. After the epidural infusion is discontinued, do not allow the patient to ambulate until full
motor and sensory functions are returned and BP is maintained sitting and standing.
Refer to Falls Prevention Program in the 15 Long Policy/Procedure Files for ambulation
after epidurals.
O. RNs may remove the epidural catheter per protocol.
P. The epidural infusion solution should be wasted with all bag changes and after the
epidural is removed.

STEP-BY-STEP PROCEDURE (PARTS I – IV)) PART I: PREPARATION FOR

INITIATION OF NEURAXIAL LABOR ANALGESIA
A. If patient or provider/CNM requests labor neuraxial analgesia, notify the anesthesiologist.
B. Obtain at least a 10-minute FHR monitor tracing and full set of vital signs.
C. Make available in room for anesthesiologist:
1. 1 to 2 liters Lactated Ringers or Normal Saline (not dextrose)
2. Standard emergency equipment set up and functioning correctly:
a. O2 flow meter with and Ambu bag (Jackson-Reese) with mask attached
b. Suction with tonsil tip
3. Consent form for the patient and witness to sign

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 POLICY
Perinatal Neuraxial BIRTH CENTER
Analgesia and Anesthesia Patient Care
Issued:
Last Approval: August 2020

D. Infuse an IV bolus (at least 500ml) per anesthesiologist's order just prior to procedure. It
is NOT required that the bolus be completed prior to epidural placement unless requested
by the anesthesiologist. In a fluid restricted patient, discuss with anesthesia and
provider/CNM the appropriate bolus amount or potential use of other solution such as a
reduced volume of a synthetic colloid.
E. RN to remain in room during the procedure to assist the anesthesiologist and remain with
the patient for at least 20 minutes after any anesthesia administered manual bolus dose to
monitor BP and FHR. Patient self-administered doses via the patient-controlled pump are
very small, and do not require monitoring above what is indicated for a stable epidural
infusion.
F. Position the patient as described earlier either on her side or sitting up per preference of
the anesthesiologist and as patient and fetal condition permit. Remain facing patient to
assist with positioning and support throughout the procedure.
G. We support a family centered labor policy; however, it is important for patient safety that
the practitioner’s sterile technique and concentration not be impaired during placement of
neuraxial analgesia. Minimize family and support persons in room for placement of
neuraxial analgesia and any support person must be seated during the duration of the
procedure.
H. Adjust EFM belts to allow for the patient’s back to be prepped. Apply BP cuff and pulse
oximeter.
I. Everyone in the room during the epidural placement procedure must wear a face mask.

PART II: REGIONAL ADMINISTRATION OF AGENTS:

A. Local Anesthetics
1. Set electronic blood pressure monitoring device to take BP q 2 min if a test dose is
administered.
2. Until level of anesthesia is established and patient is stable, BP is taken via electronic
BP monitor or BP cuff q 15 minutes or more frequently if requested by
anesthesiologist. Once stable, the monitoring is Q 15 minutes x 1 hour then q 30
minutes until delivery, or as patient condition warrants.
3. If BP is less than 90 systolic and/or less than patient's range of normal by 20%:
a. Notify anesthesiologist.
b. Increase IV fluid to 200 mL/hr.
c. Turn patient off her back (on either her right or left side)
d. Recheck BP.
e. If anesthesiologist gives ephedrine to treat maternal BP, there may be potential
for an increase in FHR variability and baseline after the injection for up to 4
hours.
f. In addition, if fetal bradycardia results from maternal hypotension, also:

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 POLICY
Perinatal Neuraxial BIRTH CENTER
Analgesia and Anesthesia Patient Care
Issued:
Last Approval: August 2020

1) Notify OB emergency team

2) Prepare to move patient to OR if bradycardia persists.
3) Attempt conservative measures as long as doing so does not delay
preparations for delivery.
B. Opioids
1. Opioids may be administered in the intrathecal or epidural space alone or
concomitantly with local anesthetics. When opioids are administered with local
anesthetics, follow procedure for monitoring after local anesthetic administration.
2. When opioids alone are administered:
a. Record time of dose.
b. Obtain and document BP & P q 1 hr.
c. Hypotension, though rare, can occur with opioids alone. Follow steps in Part II
above
d. When opioids are given alone, the patient may ambulate 10-15 minutes after the
dose is administered.

PART III: EPIDURAL INFUSION

A. The anesthesiologist will connect the infusion and be responsible for administering and
maintaining the infusion.
B. Change patient position q 1-2 hours to promote even distribution of the regional block.
C. Monitor motor block by checking patient's ability to lift legs every 30 to 60 minutes and
notify the anesthesiologist if patient is unable to do so.
D. The labor nurse will change the infusion bag when it becomes empty.

PART IV: RECOVERY

A. For vaginal deliveries: once the placenta has been delivered, the bleeding is stable, and
the repair of any lacerations is complete, the epidural infusion may be turned off by the
RN or provider.
B. Obtain and document vital signs per 4th stage of labor guidelines
C. Observe for return of sensation and ability to move lower extremities
D. If vital signs are stable, after 1- 1/2 hours obtain BP in sitting position prior to getting the
patient out of bed. If the patient has suspected hypovolemia and/or dizziness, modified
orthostatic BPs should be checked prior to getting the patient out of bed with a BP and
HR done in the supine position and then in semi-fowlers position. When the patient is
stable, there should be no significant drop in BP when patient is in semi-Fowler's position
E. If BP is less than 90 systolic or falls more than 20 points from baseline, place patient on
her side and take BP every 5 minutes x 4, then every 15 minutes x 2, then every 30

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 POLICY
Perinatal Neuraxial BIRTH CENTER
Analgesia and Anesthesia Patient Care
Issued:
Last Approval: August 2020

minutes until stable. Notify anesthesiologist and provider as this could represent
undetected hemorrhage.
F. The epidural catheter should be removed before transfer to postpartum unless
contraindications exist and with an order from the anesthesiologist. Contraindications or
considerations for the RN prior to removing the catheter include but are not limited to:
1. Known or suspected coagulopathy
2. Thrombocytopenia (platelet count less than 100,000)
3. Excessive bleeding
4. If the catheter had been purposefully placed in the intrathecal space rather than the
epidural space.
5. Planned use of the same epidural for an additional procedure, such as tubal ligation.
Consideration for postpartum analgesia for 3rd/4th degree perineal injury or episiotomy.
***If any contraindications are suspected or present, check with the anesthesiologist
prior to removing the catheter.
G. When removing the catheter:
1. Remove the tape and apply gentle traction to the catheter to remove it.
2. If any resistance is met, stop traction and immediately call the anesthesiologist
3. Ensure the catheter was removed intact by identifying the blue or black tip on the end
of the catheter
4. Call the anesthesiologist if the tip is not intact and save the catheter
5. Document that the catheter was removed and the tip condition (i.e. blue tip intact).
H. Consult the anesthesiologist if the patient does not meet recovery discharge criteria within
three hours.
VI. RESPONSIBILITY
For questions regarding this policy, contact The Birth Center Clinical Nurse Specialist.
VII. HISTORY OF THE POLICY
Author: S. Thomas, RN
Issue Date:
Revised by: M. Killion, CNS, M. Rollins, MD, April 2014
Last Revision/Review: A. Britton, MD; J. Markley, MD; M. Duck, CNS; R. George, MD,
August 2020

VIII. APPENDIX
None

This guideline is intended for use by UCSF Medical Center staff and personnel and no representations or
warranties are made for outside use. Not for outside production or publication without permission. Direct
inquiries to the Office of Origin or Medical Center Administration at (415) 353-2733.

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