ANZ college of Anaesthetists statement!

[Denise Hynd]

Locate on NZ COllege of Midwives web site but note it is from AUSTRALIAN NZ COLLEGE OF aNAESTHETISTS dENISE   This policy statement is an important contribution to information for women considering having an epidural. Australian and New Zealand College of Anaesthetists New Zealand Regional Committee Submission to the HFA on Maternity Referral Guidelines From Dr Jennifer Weller, New Zealand National Committee of the Australian and New Zealand College of Anaesthetists The New Zealand National Committee of ANZCA wishes to make the following submission to the HFA in regard to obstetric epidurals. Category: Labour and Birth, First and Second Stage, Code 4015 We propose that the HFA referral guidelines be changed so that epidural anaesthesia requires a Level 2 referral. Category: Services Following Birth We propose that the HFA referral guidelines ensure that referral by the anaesthetist to a neurologist, neurosurgeon, radiologist, psychiatrist or other specialist as required for management of complications of a regional or general anaesthetic is covered under the referral guidelines. We offer the following reasons: Epidural anaesthesia influences the course of labour, prolonging the second stage. There is a strong association with increased instrumental delivery, which will generally involve an obstetrician. The increased analgesia requirements resulting in a request for an epidural may indicate an abnormal labour, which will require intervention An epidural is associated with risk of hypotension, convulsion and total spinal anaesthesia requiring resuscitation and urgent delivery. Assurance that an obstetrician is involved and available is required to expedite delivery in these circumstances and avoid last minute emergency referral. An epidural can cause significant morbidity. Apart from immediately life threatening complications, an epidural frequently causes urinary retention and motor block. Approximately 1% of recipients will get a post dural puncture headache which will restrict them to bed and require further intervention. Damage to nerve roots with resultant paraesthesia or weakness may occur. Paralysis following an epidural is fortunately rare but does occur. This results from spinal cord compression from haematoma or abscess. Immediate diagnosis and surgery can limit neurological deficit. As anaesthetists, our primary concern is safety. Epidural anaesthesia is not a trivial intervention and the benefits of good analgesia should be weighed up against the risks. The rate of epidural analgesia is increasing and it is the experience of some that requests can be inappropriate, and less invasive methods of pain relief may be clinically indicated. The need for referral would emphasise the need for serious consideration for the request for epidural analgesia. In addition, we suggest addition in the referral guidelines of codes for referral to specialists for consultation after possible complications after epidural and general anaesthesia. For instance: Radiologist for MRI for diagnosis of epidural mass Neurosurgeon – for evacuation of spinal haematoma or abscess Neurologist – for management of neuropraxia either related to delivery (lumbar plexus or lateral cutaneous nerve problems) or central axis problems form the epidural Psychiatric/psychological services for awareness under anaesthesia and post traumatic stress disorder. Trying to sort out problems postpartum in the above areas was not adequately covered by the Referral Guidelines in one instance and the mother "fell between the cracks"!! In summary: A request for an epidural should not be trivialised. This is a significant intervention and consultation with an obstetrician as well as an anaesthetist is required to assess the risk versus the benefits of the procedure. Where epidural anaesthesia is of clear benefit, an obstetrician needs to be involved for the following reasons. Immediate delivery may be required due to a complication of the epidural The epidural may alter the course of labour requiring further intervention including urinary catheterisation, augmentation or forceps delivery Request for epidural may indicate that the labour is not normal Delayed complications may occur which may be more rapidly diagnosed by a person with medical training. The guidelines for the conduct of obstetric anaesthesia, written by experts in the field in the United Kingdom, America, Australia and New Zealand require the involvement of an obstetrician in the management of parturients when an epidural is sited. For these reasons we recommend that when a midwife requests an epidural, a referral must be made to an obstetrician. In addition, there is occasionally the need for referral to a specialist for management of complications resulting from general and regional anaesthesia and this should be included in the maternity codes for referral to a specialist.