Epidural Anesthesia for Obstetric Patients

Transcription

1 Volume 10, Number 1, January/February 1981 Journal of Obstetric, Gynecologic, and Neonatal Nursing Epidural Anesthesia for Obstetric Patients STEPHANIE M. MacLAUGHLIN, RN, MS, and ANN M. TAUBENHEIM, RN, MS The use of epidural anesthesia for the obstetric patient is increasing in many areas of the country. The maternity nurse needs to have a basic understanding ofthe technique used by the physician to initiate this type of anesthesia, and also has a responsibility to know the contraindications, possible complications, and disadvantages and advantages of epidural anesthesia. This information is presented below. Skilled nursing and medical management will reduce the potential risks of epidural anesthesia for both the mother and fetus. The use of epidural anesthesia for the relief of pain during labor and delivery is preferred in some obstetric practices. Some physicians claim it is the perfect method; however, in view of the complexity and invasiveness of the technique and the potential inherent side effects, epidural anesthesia should be used judiciously. Epidural anesthesia is a form of regional anesthesia resulting from the blockage of spinal nerves in the epidural space as they emerge from the dura and pass into the vertebrae foramen. The terms epidural, peridural, extradural, and spinal epidural are synonymous. The anesthetic solution is deposited outside the dura rather than in the subarachnoid space as in spinal anesthesia. The chief targets of the block are the sensory and sympathetic nerves; however, motor fibers may be partially blocked. In 1885, Corning accidentally performed, in a dog, one of the first epidural blocks.' In 1910, Lawen, studying the anatomy of the spinal and epidural area, discovered that injections into the peridural space did not reach the subarachnoid space.' In 1921, Pages used an epidural block clinically for surgery, and in 1931, epidural anesthesia was first used in obstetrics by Aburil.' January/February JOGN Nursing /81/ In 1939, Dogliotti wrote a book on regional anesthesia which discussed epidural anesthesia thoroughly.' Uterine pain is transmitted by the sympathetic nerve fibers which pass through thoracic spinal nerves During the first stage of labor, most of the pain is caused by uterine contractions and cervical dilation. As the fetal head descends into the pelvis, pain is caused by the stretching of structures in the pelvis and the perineum. The sensation of pain there is carried by somatic fibers beginning in sacral roots 2-4. Blockage of these fibers is needed to relieve pain. During delivery it is necessary to block sacral motor nerves, as well as sensory nerves, since perineal relaxation as well as pain relief may be required, especially for a forceps delivery. This may necessitate the administration of more medi~ation.~ (See Figure 1.) The epidural space is between the dura, which encloses the spinal cord and cerebrospinal fluid, and the vertebrae. It extends from the foramen magnum to the sacroccygeal ligament. The nerves within the space pass out of the dura and through the foramen of the vertebrae. By depositing a local anesthetic in the epidural space, conduction of nerve impulses will be delayed. The smaller nerve fibers which transmit sensation can be 9

2 PUDENDAL Figure 1. Site of injection and sensory pathways in obstetric epidural anesthesia. blocked with less anesthetic solution than the larger motor nerves. It is the aim of the obstetric anesthesiologist to block only the fibers which are transmitting pain5 (See Figure 2.) It is essential that the technique be carefully explained to the gravida before the physician begins epidural anesthesia. This can best be accomplished during a prenatal visit, or when the gravida is in early labor. Prior to initiation of the block, an intravenous solution should be started. The patient's physical condition determines the solution to be used. The usual solution is 5% dextrose in water, with or without a salt solution, such as Lactated Ringers.' A loading dose of approximately cc may be given in an attempt to prevent the hypotensive effect which may follow epidural administration.* If the patient is quite uncomfortable, prernedication with a narcotic may facilitate insertion of the epidural catheter. A baseline determination of maternal blood pressure, pulse, and fetal heart rate should be made prior to inserting the epidural catheter. Continuous fetal monitoring is essential to determine any fetal distress which may result from anesthesia-induced hypotension. When the physician is inserting the epidural catheter, the patient should be positioned in either the sitting position or the lateral position. The lateral position is usually more comfortable for the patient. If there is difficulty in inserting the catheter, the sitting position is necessary because in this position the median furrow of s4 the back coincides with the spine, while in the lateral position the furrow sags due to gravity.' The sitting position allows better flexion of the back if the shoulders drop, the lower limbs are bent, the feet are crossed, and the head is flexed. The patient should be asked to arch her back like a cat. This widens the inter-laminar space. If the lateral position is used, the patient lies in the left lateral position if the physician is right-handed. Shoulders and pelvis are moved toward the edge of the bed and should be parallel to each other and perpendicular to the bed. A pillow placed under the patient's head is used to position the shoulders. The patient is instructed to bring her knees toward her chin and arch her back.2 The nurse should help maintain the patient's position if either the sitting or the lateral position is used, since proper positioning is essential in administering epidural anesthesia properly. Words of encouragement should be offered by the nurse if the patient finds it difficult to maintain the position, especially during contractions. During insertion, full aseptic technique, including the wearing of caps and masks, should be maintained. When the patient is in the proper position, the physician palpates the patient's back (see Figure 3) for landmarks. The L3-L4 interspace is palpated by positioning the index finger on the highest part of the iliac crest and placing the thumb on the third lumbar spine. The patient's back is then prepared with an antiseptic solution, such as povidone iodine. The excess antiseptic solution is removed from the area of injection. The skin and subcutaneous tissue are anesthetized with a local anesthetic. The ligaments of the back are not anesthetized because there is little discomfort unless the needle reaches the periosteum.' The skin is usually punctured with a large bore, blunt gauge need1e.''4'5 A blunt needle is preferred because there is less chance of puncturing the dura. Several disposable epidural trays available supply a sharp borer to puncture the skin prior to inserting the blunt epidural needle. The needle is directed cranially parallel to the spinous processes. Since the veins in the epidural space expand with a contraction, the needle or catheter POSTERIOR Figure 2. Anterior and posterior view of a section of the lumbar spine showing the epidural space with a catheter in it. (Figure distorted to demonstrate epidural space, which is largely a potential space.) 10 January/February 1981 JOCN Nursing

3 Figure 3. Patient positioned in lateral position. Physician palpating the patient s back for the L3-L4 interspace landmarks. should not be advanced during this time due to the possibility of rupturing a vessel5 The needle should be inserted slowly and gradually. To reach the epidural space, the needle must pass through the skin, subcutaneous tissue, the supraspinous ligament, the interspinous ligament, and the ligamentum flavum. There is a slight resistance from the skin and interspinous ligament, then no further resistance is met until the ligamentum flavum is rea~hed.~ The needle is advanced slowly until the loss of resistance is felt upon puncturing the ligamentum flavum and entering the epidural space. Various techniques may be employed to determine if the needle is in the epidural space. These methods take advantage of the potential negative pressure in the epidural space or the loss of resistance when the ligamentum flavum is penetrated. However, in obstetric epidural administration, the negative pressure in the lumbar region becomes positive due to distention of the vertebral veins, rendering the negative pressure methods (e.g., the hanging drop technique) ineffective. Popular methods employing the loss of resistance idea include the syringe technique. This employs the sudden loss of resistance to pressure exerted on the plunger of a syringe as the needle advances through the ligamentum flavum and progresses to the epidural space. Other loss of resistance techniques include the spring-loaded syringe, the balloon technique, and Brook s device. When the needle is thought to be in the epidural space, gentle aspiration is done to rule out the presence of blood or cerebrospinal fluid. When the physician is assured of the needle s placement in the epidural space, the catheter is advanced two to four centimeters. The patient should be kept informed of the sensations she will feel during the procedure, including burning or stinging skin, from local anesthetic, a pressure sensation with the insertion of the needle, and a crazy bone sensation in her leg as the catheter is advanced. A test dose of 2 ml of anesthetic solution is given to ascertain that the dura has not been punctured. If the catheter is in the subarachnoid space, the test dose should cause analgesia, loss of motor power in the legs, and complete perineal anesthesia within five minutes. The patient is asked to report any abnormal sensations. The catheter is then secured to the skin with adhesive tape. In administering the initial dose, the aim is to give the proper amount to block the pain without causing muscular paralysis. The smaller nerve fibers, which transmit pain, can be blocked with a lower dosage of anesthetic than is needed to block the larger motor nerves. The injection should be given between contractions since the veins dilate during contractions and the anesthetic solution may diffuse further than desired. The solution diffuses by gravity, so to block uterine pain effectively the patient should be supine. After excluding a subarachnoid or intravascular position of the catheter, an appropriate anesthetic solution is injected. Two popular anesthetics used for epidural anesthesia are chloroprocaine and bupivacaine. A concentration of 2% chloroprocaine is usually used for the laboring patient. Chloroprocaine s duration of action is usually minutes in doses of 6-10 ml. For the cesarean section patient, a 3% concentration of chloroprocaine may be used in doses of ml. Bupivacaine, 0.25% in doses of 6-10 ml, may also be used for the laboring patient. Its usual duration of action is one to two hours. Bupivacaine, 0.75% in doses of ml, is used for the cesarean section patient. Aspiration is often done before and after the injection to reaffirm the position of the catheter. The refill doses of anesthetic should be administered according to patient need, since the duration of action is variable from patient to patient. Repeat injections should be performed when the patient feels uncomfortable. It is the nurse s responsibility to alert the physician when the patient is in need for more analgesia. Nursing Care After each injection of medication is administered via catheter, the blood pressure should be checked every five minutes for the first 15 minutes and every 15 minutes thereafter. Any significant drop in blood pressure should be immediately treated by a position change, a bolus of intravenous fluid, or vasopressors if necessary. Beta stimulants such as ephedrine or mephentermine are the preferred vasopressors since they do not affect blood flow to the uterus. January/February 1981 JOGNNursing 11

4 Since most sensation in the pelvic area is lost, many women are unaware of a full bladder. Therefore, before epidural anesthesia is begun, the woman should be encouraged to empty her bladder. Frequent observations of bladder status by the nurse are essential during epidural administration. If the woman is unable to void and her bladder is becoming distended, catheterization is indicated. Because hypertonic contractions cannot be felt by the patient receiving an epidural, the intensity of the contractions should be carefully observed by the nurse, especially if any oxytocic is used. During the pushing stage, the woman must be coached vigorously since she will not feel the urge to bear down. The quality of coaching by the nursing staff may be a factor in the use of outlet forceps by the physician. If delivery is anticipated shortly, a concentration of 0.5% bupivacaine or 3% chloroprocaine in a dose of 6-10 ml may be given with the patient in a sitting position to enhance perineal anesthesia. After delivery, the catheter is removed and a small dressing is applied to the epidural site. The effects of the anesthesia may last up to four hours after the last dose was given. Since the woman may not feel any urge to void, the bladder must continue to be observed. In the immediate postpartum a full bladder may predispose a new mother to postpartal hemorrhage. After epidural administration, the normal uncontrollable shaking of the legs or chilling that many newly delivered mothers experience may be exaggerated due to the epidural-induced increased vasodilation and subsequent loss of body heat. The patient should be assured that this is a normal physiological response. Care should be taken when the mother stands for the first time, since there may be residual muscle weakness. Contraindications or Epidural Anesthesia Contraindications for epidural anesthesia in the obstetric patient are usually classified as absolute or relative. It is imperative for the nurse to be aware of these contraindications when assessing the early labor patient and to collaborate with the obstetrician and anesthesiologist for the purpose of determining the type of anesthesia that may be employed during active labor. Absolute contraindications for epidural anesthesia in the obstetric patient include the following: 1. Anticoagulant therapy or bleeding diathesis. An epidural block attempted with a patient who is receiving anticoagulants may result in the formation of a hematoma following inadvertent injury to a blood vessel. It is possible for a hematoma to compress the spinal cord with subsequent paralysis occurring. 2. Hemorrhage and shock. For any patient with a history of antepartal, intrapartal, or postpartal hemorrhage, epidural anesthesia is never ventured. In the state of acute hypovolemia, compensatory mechanisms include vasoconstriction and an increased tone of the sympathetic nervous system. Administration of epidural anesthesia, which would block the sympathetic nerve fibers, could cause severe hypotension, endangering the lives of the mother and baby. Epidural anesthesis is con- traindicated when a patient is in a state of shock because it may lead to a cardiac arrest. 3. Infection. A local infection at the site of injection, or any systemic infection such as septicemia, contraindicates the use of epidural anesthesia. With either type of infection there is a danger of abscess formation or meningitis occurring from the introduction of the epidural needle. 4. Tumor. A tumor at the site of epidural insertion predisposes the patient to the danger of introducing tumor cells into the epidural space with the insertion of the needle or catheter. 5. Increased intracranial pressure. Epidural anesthesia is contraindicated in a patient with increased intracranial pressure because there is a possibility of causing a further increase in pressure or injuring the dura.' Relative contraindications for epidural anesthesia include: 1. Previous cesarean section ($or trial labor). A controversy exists among physicians regarding the use of epidural anesthesia for a patient in labor who had a previous cesarean section. Some physicians feel that it is safe to use an epidural block if the patient is closely monitored, while others feel that the danger of an unrecognized rupture of the uterus is too great. 2. Patient refusal of epidural anesthesia. 3. Inexperience of the physician. Epidural anesthesia is contraindicated when a physician is inexperienced in the technique of initiating this type of anesthesia, or when the physician lacks experience in monitoring a patient with this type of anesthesia. 4. Active central nervous system disease. 5. Backache, or a patient who is obsessed with her back. 6. Previous laminectomy. In this condition, the landmarks for epidural injection are more difficult to feel and there is an increased chance of dural puncture. 7. Technical dttficulties. Conditions such as marked scoliosis, lordosis, or obesity would make insertion of the epidural catheter more diffi~ult.',~ Complications Related to Epidural Anesthesia The disadvantages of epidural anesthesia for obstetrical use include maternal-fetal side effects. The most common complication of epidural anesthesia is maternal hypotension. A slight degree of hypotension may be anticipated since the drugs used in epidural anesthesia block sympathetic nerve fibers resulting in peripheral vasodilation and a decrease in blood pressure. The concentration of a drug influences the occurrence of hypotension. For example, there is an increase in incidence and degree of hypotension with the use of a 0.75% bupivacaine as opposed to 0.25% bupivacaine. The nurse needs to monitor carefully the patient's blood pressure throughout the entire period of epidural anesthesia. Any significant drop in maternal blood pressure causes a decrease in uterine blood flow which may result in fetal hypoxia. Maternal hypotension most often occurs within minutes after an injection of epidural medication. How- 12 January/February 1981 JOGN Nursing

5 ever, hypotension can occur up to 20 minutes following the injection of medication and may result from suddenly shifting the position of the ~atient.~ A decrease in uterine activity resulting in prolongation of labor may occur with the use of epidural anesthesia. The results of one study showed that a significant depression of uterine activity occurred after injection of lidocaine. During the ten-minute period following the injection of medication, uterine activity dropped markedly and remained below preinjection levels for 30 minutes7 Another researcher observed transitory decreases in uterine activity after epidural injection of lidocaine. This decrease in uterine activity was more greatly pronounced in instances when epinephrine was used with the lidocaine for injection.8 Therefore, epinephrine should not be used in local anesthetics for epidurals because of its depressing effect on uterine contractions. In a study of 1,035 patients' who had received epidural blocks a marked prolongation of the second stage of labor was observed in primigravidae. Fifty percent of these primigravidae remained in the second stage of labor longer than minutes. Fifty percent of the multigravidae who received epidural blocks also experienced a marked prolongation of the second stage of labor. The drug used was bupivacaine 0.25% with a somewhat indiscriminate use of epinephrine for some patients. No clear information concerning fetal outcome and well being was repoited. Insertion of the epidural needle and catheter predisposes the patient to the danger of accidental dural puncture which may result in total spinal anesthesia. This hazard is more pronounced in the obstetric patient as she may become restless and uncooperative during contractions while the physician is attempting to insert the epidural needle or catheter. The incidence of accidental dural puncture ranges from 0.5% to 3%.2 Total spinal anesthesia is caused by unrecognized dural puncture with the injection of a large volume of anesthetic solution intended for the epidural block.' The nurse must carefully monitor the patient receiving an epidural block, watching for indications of total spinal anesthesia. If total spinal anesthesia occurs, there is a great danger of respiratory depression, circulatory collapse with hypotension, and a decreased uterine blood flow. Therefore, the nurse should have emergency resuscitation equipment ready for instant use. Another complication is the possibility that a patient may have a seizure following injection of the epidural anesthetic. This may occur from an accidental injection of the medication into the venous system, toxic blood levels of the medication, and total spinal anesthesia." There appears to be a greater use of forceps for patients receiving epidural anesthesia. The woman who receives this type of anesthesia does not have the urge to bear down and is unable to push effectively. A one-year period study of 739 patients receiving epidural blocks with mepivacaine showed that an unusually high number of deliveries were aided by forceps. Among 367 primigravidae, 63.3% had low-forceps deliveries and 23.7% required mid-forceps deliveries. The incidence of low forceps for multigravidae was 56.9% and midforceps 9.5%." In another study, of 1,025 women who had received epidural anesthesia, forceps were necessary in 54.8% of the primigravidas and in 3 1% of multigra~idas.~ There are several other maternal complications and disadvantages related to the use of epidural anesthesia. There is the possibility that the mother may have a toxic reaction to the drug used. Nausea and vomiting may occur after an injection of the medication, and bladder dysfunctions, such as inability to void and retention of urine, may occur because the mother loses her sensation to void. Problems with the epidural catheter may occur. The catheter may introduce a foreign body into the epidural space, break off, or slip out of place. A patient whose labor is being augmented by oxytocin is endangered by the possibility of a painless uterine rupture. The position that a mother must assume while the epidural catheter is being inserted is uncomfortable during contractions and it is difficult for her not to move. Psychological disadvantages of epidural anesthesia also exist, especially for the woman who believes that, ideally, the childbirth experience should be as natural as possible. Initiating and maintaining epidural anesthesia requires several medical interventions and the woman's relinquishing of control of some bodily functions and sensations to the physician. Some women may feel they are cheated and are not in control of their own bodies when they cannot experience the urge to bear down or push effectively on their own. Rather, the woman may feel that the changes and events she wishes to experience, which are natural occurrences of labor and delivery, are being controlled by the medical personnel. Husbands may feel a lack of participation and may feel left out of the labor and delivery experience. It may not be necessary for a husband to provide as much support, coaching, or help with contractions if his wife receives epidural anesthesia. With epidural anesthesia, the fetus may be at risk due to the possibility of bradycardia, lack of variability of the heart rate, and late decelerations resulting from maternal hypotension and decreased uterine blood flow. One study showed that out of 41 fetuses, 23 experienced an increase in the number of late decelerations after the mother received an injection of epidural medication. The greatest incidence of late decelerations was noted when the epidural anesthesia was combined with the use of oxytocin to augment labor.12 The effects of epidural anesthesia on the fetus and newborn need to be further studied. The traditional use of Apgar scoring to assess the effects of maternal anesthesia on the newborn needs to be examined closely since this method of assessment may not entirely reflect the effects of anesthesia on the newborn. Scanlon, et al." used a neurological test to examine the newborn's state of wakefulness, various reflexes, responses to various stimuli, and decrement behavior. Decrement behavior is defined as the ability of the newborn to modify behavior in response to repetitive stimuli. This examination was performed on two groups of infants who had Apgar scores of seven or more at twohour intervals during the first eight hours of life. The experimental group consisted of newborns whose mothers had received low spinal or local anesthesia with either January/February JOGN Nursing 13

6 lidocaine or mepivacaine. The results of the study showed that the epidural block infants scored lower than non-epidural block infants on all neurological tests at various time periods. The most striking results were that the infants in the experimental group showed less head control when pulled to a sitting position, their rooting behavior was less vigorous, and there was a decrease in the strength of their arm recoil. For the infants in the experimental group, a diminished vigor of the Moro reflex was noted at four, six, and eight hours of age. There was also a greater incidence of absent decremental response to repeated stimuli in these infants at two and six hours of age. The researchers stressed that medical personnel should not rely solely upon Apgar scores as the criterion for neonatal well being. In a more recent study, Scanlon and colleague^'^ again evaluated the neurobehavioral status of 20 newborn infants following epidural anesthesia during labor and delivery. The research was carried out in a manner similar to the previous study. However, the drug used for the lumbar epidural anesthesia was bupivacaine instead of lidocaine or mepivacaine. The results of the study showed that all 20 newborns were either normal or superior in the neurobehavioral examination carried out when these infants were between two and four hours of age. The newborns muscle tone was normal as well their ability to alter their responses to repeated stimuli (decrement behavior). l4 Advantages of Epidural Anesthesia On the whole, the use of epidural anesthesia for the obstetric patient is considered to provide good anesthesia. McDonald feels that there is no other technique which provides more versatility or greater margin of safety for the mother and the fetus-neonate than lumbar epidural anesthesia when safety precautions are instituted. Epidural anesthesia may be the ideal choice for the woman who chooses anesthesia during labor and delivery. When a woman s comfort is increased during labor and delivery, she may remain more calm and relaxed. The patient may also feel that she is able to keep herself in control and enjoy her labor experience. After the epidural catheter has been placed, medication may be given with ease to the patient throughout labor. It is reported that central nervous system depression does not occur with epidural anesthesia. Also, spinal headache is almost nonexistent following the use of this type of anesthesia. One study focused on maternal oxygen consumption during labor. The researchers pointed out that painful labor is associated with hyperventilation, hypocapnea, an increase in oxygen consumption, a decrease in ph, and an increase in lactic acidosis contributing to maternal metabolic acidosis during labor. The use of epidural anesthesia provided good analgesia and decreased maternal oxygen consumption, thereby preventing metabolic acidosis in the mother. For the woman undergoing a cesarean section, the use of epidural anesthesia may help in promoting a positive childbirth experience. When the mother remains conscious, she may see the baby immediately after delivery and ask questions about the baby s condition. In some hospitals, the father is allowed to be present during the cesarean section when epidural anesthetic is used. This father may function as a significant support person for his wife and he may feel more involved in the childbirth experience. The opportunity for early parent-infant bonding will also exist. Another factor to consider is that the drugs used for general anesthesia (particularly intravenous drugs) reach fetal circulation very quickly, thus fetal narcosis and respiratory depression at birth are major concerns. Epidural anesthesia is considered safe for the fetus if no major maternal complications occur. Conclusion The choice of anesthesia during the intrapartum period should reflect the combined input of the patient and her physician. A well-informed woman should be allowed to weigh the many advantages and disadvantages of available anesthesia and base her decision on the type of childbirth experience she desires. Some women will choose epidural anesthesia for the purpose of a positive childbirth experience. Other women may choose an alternate method of anesthesia or decide to experience labor without any type of anesthesia. Each woman s choice should be supported by medical and nursing personnel unless the choice would be harmful to the mother or fetus. The use of epidural anesthesia for the obstetric patient requires the skills of several different health professionals. Nurses, as well as physicians, have a responsibility to understand the initiation and maintenance of this type of anesthesia for the laboring patient. References 1. Collins VJ: Principles of Anesthesiology. Philadelphia, Lea & Febiger, 1976, pp Abouleish E: Pain Control in Obstetrics. Philadelphia, JB Lippincott, 1977, pp Dogliotti AM: A new method of block anesthesia: Segmental peridural spinal anesthesia. Am J Surg 20:107, Dripps R, Eckenhoff J, Vandum L: Introduction to Anesthesia. Philadelphia, WB Saunders, 1977, Holdcroft A: Obstetric epidural analgesia. Nurs Mirror, Nov 6, 1975, pp Editorial: Persistent orthostatic hypotension after epidural analgesia. Bri Med J 1: , Lowensohn R, Paul R, Fales S, Yeh BS, Hon E: Intrapartum epidural anesthesia: An evaluation of effects on uterine activity. Omtet Gynecol 44: , Zador G, Nilson BA: Low dose intermittent epidural anesthesia with lidocaine for vaginal delivery. ACTA Obstet Gynecol Scand Suppl 34 17, Crawford JS: The second thousand epidural blocks in an obstetric hospital practice. Br J Anaesthesiol 44: , Ralston DH, Shnider SM: The fetal and neonatal effects 14 January/February JOGN Nursing

7 of regional anesthesia in obstetrics. Anesthesiology 48:34-64, Romine JC, Clark RB, Brown WE: Lumbar epidural anaesthesia in labour and delivery: One year s experience. J Obstet Gynaecol Br Commonw 77: , McDonald JS, Bjorkman LL, Reed EC: Epidural analgesia for obstetrics. Am J Obstet Gynecol 00: , Scanlon JW, Brown W, Wess JB, Alper M: Neurobehavioral responses of newborn infants after maternal epidural anesthesia. Anesthesiology 40: , Scanlon JW, et al: Neurobehavioral responses and drug concentrations in newborns after maternal epidural anesthesia with bupivacaine. Anesthesiology 45: , McDonald JS: Current Reflections on Obstetric Anesthesia. Perinatal Press, Sept 1977, pp Sangoul F, Fox GS, Houle GL: Effect of regional analgesia on maternal oxygen communication during the first stage of labor. Am J Obstet Gynecol pp , 1975 Address for correspondence: Ann Taubenheim, RN, School of Nursing, The University of Wisconsin, PO Box 413, Milwaukee, WI Stephanie M. MacLaughlin graduated from the University of Wisconsin (BSN) in Oshkosh and the University of Wisconsin (MS) in Milwaukee, where she is currently an assistant professor in maternal-child nursing. She has previously worked part-time in newborn nursery, postpartum, and labor and delivey. Ms. MacLaughlin is a member of the Oreat Plains Association for Perinataf Care and Phi Kappa Phi. Ann M. Taubenheim is an assistant professor in maternal-child nursing at the University of Wisconsin in Milwaukee and has experience as a postpartum staff nurse. She holds a BS degree in nursing from the University of Wisconsin in Milwaukee and an MS from the Medical College of Virginia in Richmond. Ms. Taubenheim is a member of NAACOG and Sigma Theta Tau. A NAACOG FIRST! Nurses in the specialty will have another opportunity to earn continuing education credit from the Nurses Association of the American College of Obstetricians and Gynecologists (NAACOG) with the introduction of the first HOME STUDY PROGRAM in mid The first offering, Pregnancy-Induced Hypertension, is now being developed by Linder Wheeler, CNM, EdD, and Mary Brewer Jones, RN, BA, for publication injogn Nursing. The home study concept was developed in response to NAACOG s recent needs assessment and a desire to provide educational opportunities to a greater number of NAACOG members and other interested nurses. PREGNANCY-INDUCED HYPERTENSION was selected as the first topic because of the paucity of nursing literature on the topic and great interest expressed by NAACOG s constituents. Dr. Wheeler, associate professor at the University of Tennessee, has done considerable work on this topic, including other modules. Ms. Jones has had considerable clinical experience caring for women with PIH in all stages of pregnancy and has published numerous articles on the subject. She is currently a doctoral candidate at the University of Texas Health Science Center. WATCH FOR IT! Instructions for completing the program and applying for NAACOG continuing education credit will be published in the program itself. NAACOG is accredited as a provider of continuing education in nursing by the American Nurses Association/Regional Accrediting Committee and by the states of Florida and California. January/February JOGN Nursing 15