Ambulatory epidural analgesia
Correspondence and reprint requests to: Dr. M. Joanne Douglas, Division of Obstetric Anaesthesia, British Columbia Women's Hospital and Health Centre, 4490 Oak St., Vancouver BC V6H 3V5
Can J Rural Med 1996; 1(1): 7-8
The difficulty of providing obstetric analgesia and anesthesia to rural areas is not unique to Canada. Surveys have demonstrated similar problems in many countries.[1-10] Generally speaking, obstetric epidural anesthesia services are available in large centres with a base of specialist anesthetists but are less available in small and moderate-sized units, generally in rural areas. Closure of smaller units has occurred in the United States and United Kingdom because of insufficient obstetric expertise (pediatric, obstetric and anesthetic), and although this is occurring in Canada (regionalization), smaller units will survive, because geography and weather are limiting factors.
If we agree that there is a need for obstetric epidural analgesia, irrespective of location, then the issue becomes one of who should provide it and what skills and expertise are necessary. Currently there are inadequate numbers of specialist anesthetists and inadequate workloads to sustain specialist anesthetic services in most rural communities. Family physicians with anesthetic skills provide anesthesia in many of these communities but often limit their involvement to the operating room. They may not have the necessary skills nor desire to provide obstetric epidurals. Part of this may have been owing to the previous guidelines, which required a physician to be physically present in the hospital once an epidural was started. Current guidelines to the practice of anesthesia (detailed in Dr. Iglesias's article) allow for initiation of an epidural (continuous infusion) following which the anesthetist only needs to be available for advice and direction. This change imposes the need for specific protocols to detect complications and places added responsibility on the nursing staff to follow those protocols. Some provincial sections of anesthesia have produced specific guidelines, which set out requirements for obstetric epidurals and infusions. The Ontario guidelines specify that "it is not necessary for the responsible physician to remain physically present or immediately available during maintenance of continuous infusion epidural analgesia, provided appropriate protocols for the management of these epidurals and complications thereof are in place, and the responsible physician or another anesthetist to whom this task is delegated can be contacted for the purpose of advice and direction."[11] In my opinion, this does not mean a decrease in the anesthetist's responsibility or vigilance. In the UK the recommended minimum standards for obstetric anesthesia services specifically state that "attending the woman only when called by the midwife is not sufficient."[12] Whenever an epidural is functioning, there is an obligation to review periodically the patient's progress, her level of analgesia and to address any issues that may arise.
What about the acquisition and maintenance of skills? Dr. Iglesias suggests an initial training period of 2 to 4 weeks for physicians who are already qualified to provide anesthesia. I would suggest that physicians who have not previously done epidurals require a minimum of 4 weeks' training. It is not only the technical skills that are required; there are nuances to the practice that are only obtained with time. Obstetric epidural analgesia is more an art than a science.
What about maintenance of skills in centres where there are few opportunities to practise them? Many hospitals in rural Canada have 100 to 200 deliveries per year and of that number 20% to 30% of women might require or wish epidural analgesia. In that situation, the number of epidurals inserted per year would be 20 to 50 and they may be divided among two or three physicians. This is an inadequate number to maintain skill and could result in an increase in complications. A possible solution would be for the anesthetists to have their skills upgraded every 1 to 2 years in a centre where a large volume of epidurals is used.
Who should have this update and who should reimburse the physician for the time away from his or her practice? To date, most physicians who have refreshed their skills have done so because they have recognized a need and wish to be adept in performing epidurals. I would suggest that it is beneficial for any anesthetist who does less than 50 epidurals per year to take a "refresher," and that governments should be prepared to finance it appropriately.
Another issue involves the transfer of function to allow nurses to assume greater responsibilities in the management of epidurals, such as "top-ups." Initiation of this practice would depend on circumstances in the community and the pattern of practice in the particular province. In a hospital where few epidurals are given this may not be practical, and a more traditional approach, without a transfer of function, may be more appropriate. In a larger centre with a greater volume of deliveries and epidurals it may be possible to increase the nurse's role.
Should a family physician with anesthetic skills administer an epidural to one of his or her own obstetric patients? In other words, should the physician function as anesthetist and obstetrician? In some countries, obstetricians have managed epidurals, but I feel that this should be discouraged because the single physician cannot care for both mother and fetus if complications develop.
As for the technique, Dr. Iglesias makes a plea for the use of a combined spinal epidural (CSE) technique. Although this technique is excellent and is gaining widespread acceptance it is not without its share of complications. Some are common to all epidurals and spinals, namely, post-dural puncture headache, hypotension, unilateral and failed blocks. Rare, but now being reported with the CSE, are cases of meningitis.[13,14] It is thought that breeching of the dura combined with insertion of an indwelling catheter make this complication more likely than with a regular epidural. For these reasons strict asepsis is mandatory. Intrathecal narcotics are associated with several side effects, most of them minor, such as pruritus, but severe respiratory depression may occur.[15,16] In a darkened labour room with a patient who is sleeping this complication may go unrecognized. It is imperative that there be adequate monitoring protocols and that the nursing staff be alert to this possibility. Other complications of intrathecal narcotics include hypotension and fetal bradycardia (without maternal hypotension, possibly associated with uterine hypertonus). Dr. Iglesias has listed steps to ensure that the patient has adequate motor power prior to ambulation. In addition, I test for postural hypotension and for sensation in the feet. Lack of lower limb proprioception or sensation could result in injury if the patient inadvertently "stubs her toe." Initially, the patient should be accompanied by two people (partner and nurse) when ambulating. If the patient requires top-ups, then the same steps must be taken each time prior to ambulation (check motor power, sensation and blood pressure).
Epidural analgesia and its variations, such as CSE analgesia, provide effective pain relief, which is greater than that provided by any other modality, including narcotics. Narcotic analgesia (intramuscularly or intravenously) enables the parturient to cope with the pain of labour but rarely completely abolishes it. Severe pain, which is well handled by an epidural, may imply a labour problem, such as dystocia or an abnormal presentation, which could require a cesarean section. For this reason I would not recommend epidurals in centres that are unable to do a cesarean section. Transferring a patient with an epidural in-situ may be difficult and the very rare complication of a high block or inadvertent spinal anesthetic may require emergent cesarean section in order to resuscitate the patient.
There is a definite need for obstetric epidural anesthetic services in rural communities. Adequately trained rural physicians with anesthetic qualifications and epidural experience will help to fulfil this need. What needs to be addressed are the length of training required to acquire the skills, a program for ongoing maintenance of those skills and the funding of that training. As well, individual hospitals have to establish minimum monitoring protocols and have an ongoing continuing education program for physicians and nurses to highlight the possible complications that may occur and to ensure their appropriate management. With a low delivery rate these education activities must be repeated regularly to ensure that the staff are aware of the protocol. Our major focus must always be the patient . . . to provide the best possible care and to ensure her comfort and safety.
References