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.
