Name: D.O.B: Hospital no: Ward: AFFIX PATIENT STICKER Obstetric Epidural Analgesia Record Date: Time: Section 1: To be completed by ANAESTHETIST Anaesthetist 1: Anaesthetist 2: Has mother recieved Pethidine?: Y / N Time: Following discussed (tick as appropriate): Hypotension Backache Itch Headache Unilateral Block Failed Block Nerve Damage Urinary catheter Pre-existing problem: None High BMI PIH/PET Cardiovascular DM Neurological Other Technique Position: Left Lateral / Right Lateral / Sitting Depth to epidural space: cm Interspace used: L2/3 L3/4 L4/5 Length of catheter in space: cm Loss of resistance: Saline / Air No. of attempts: Pre-loading fluid: N/Saline / Hartmans / Gelatin Reason for resiting: First Dose: Drug: Levobupivacain Conc: 0.1% Vol: 15ml Op: Fentanyl 2mcg/ml Time given: Sign: Other: Drug: Conc: % Vol: ml Op: Time given: Sign: Constant Infusion Instructions Start pump at: : hrs (use 24 hr clock) Test Dose: Infusion drug(s): Ring prescription AND delete alternatives 250ml 0.1% Plain Levobupivacaine with fentanyl 2.0 mcg/ml Use readymade bag and Gemstar pump Background infusion rate 0 ml/hr or ml/hr PCEA to up to volume 8 ml or ml Lockout between top ups 20 mins OR 50ml 0.1% plain Levobupivacaine Draw up 1 x 10ml ampoule of 0.5% plain Levobupivacaine into a 60ml syringe. Make up to 50ml with 40ml 0.9% Saline. ml Anaesthetist s signature: Please discuss UHL default mobile epidural and confirm with midwife that catheterisation is NOT mandatory
1. Please record BP every 5 minutes for 20 min after loading or top-up and record in maternal notes 2. Please record all observations below hourly 3. Please call anaesthetist for pain, complications and instrumental deliveries Section 2: To be completed by Midwife Time Infusion rate ml/h BP Block height (see over) R L R Leg weakness none (0) mild (M) severe (S) L R Pain none (0) mild (M) severe (S) L Perineal (P) P R Feet warm/dry/cold/wet L Epidural catheter removed complete: Y / N Signature: Epidural Information leaflet given to the patient: Y / N NB: Please ensure mother passes urine within 6 hours of delivery Sensory dermatones overlap T10 centres on umbilicus T12 and L1 overlap in inguinal region Aims of Epidural Infusion Analgesia To provide adequate pain relief the upper level of block should be maintained at T9 - T10. The Anaesthetist will check the block during the first hour after the epidural. Thereafter the midwife should assess and record the block at hourly intervals If Block rises above T9 or falls below T11 call anaesthetists Name: Unit number:
Obstetric Anaesthetic Sheet Ward Checklist Pre-operative Assessment NBM from: Consent: Gravida: Parity Gestation (Weeks) Booking weight (kg): X-match: (units) Height: BMI: Pre-op BP: Airway assessment/teeth: Allergies: Translator Required Y / N Risk Assessment Y / N Premedication Risks discussed with patient: Hypotension Backache study Itch Urinary catheter Headache Unilateral Block Failed Block Others Drug Dose Route Time Na Citrate Ranitidine Metaclopramide Consent for PR medication: Y / N Patient signature: Lab results: Hb Na+ WBC K+ Plat Ur Sickle Cr Coag Glu INR LFTs Operation performed: Date: Anaesthetist(s): Grade: Surgeon(s): Grade: LSCS: Degree of Urgency 1. Immediate threat to life of woman or foetus Time Anaesthetist informed: 2. No immediate threat to life of woman or foetus Time Anaesthesia starts for surgery: KTS: 3. Requires early delivery Time of delivery: 4. At a time to suit the woman and maternity services Decision to delivery time: Name: Unit number:
Monitors Patient Safety Drugs Route Units ECG Equipment check NIBP TED stockings Pulse oximeter Flowtron boots Capnometer Eyes protected 2 0 analyser Pressure points Ventilator alarm Forced air warmer P.N. stimulator Inline iv fluid warmer Temperature Invasive BP Position Maintenance agent/etaa% Regional Anaesthesia: Epidural / Intrathecal / CSE / Epidural in situ / Other: Sterile technique: Hat / Mask / Gown / Gloves T E M P ºC 40 35 250 200 Skin preparation: Position: Needle(s): 30 150 Interspace: Midline / Paramedian Local infiltration: Loss of resistance: Saline / Air No. of attempts: 100 Depth to space (cm): Length of catheter in space (cm): Upper level of block: Right: Left: 75 Lower level of block: Right: Left: BP (mmhg) Method of Testing: 50 Technical problems: 25 Insertion difficulties: needle / catheter More than one space attempted Paraesthesia: needle / catheter Blood tap: needle / catheter Insp 0 2 % Dural tap: needle / catheter Space Failure of block General: Indication for GA: Anaesthetic Technique: Induction: Airway: LMA: ETT: SpO 2 % ETAA ETCO 2 Tidal Vol. I.E Respiratory Rate Blood Loss: Laryngoscopy Grade: Breathing System: Ventilator: Mode: Warming blanket Urine Output Fluids Name: Unit number:
Prescribed PCA Opioids Anti-emetics NSAIDS Oral Analgesics Epidural Regime Fluids Anti-thrombotic Antibiotics Anaesthetic Alert Details Uneventful Y / N* (*Please give details below) Anaesthetic Alert N / Y* Clinical Incident Report N / Y* No: Signed/Name Cannula\e HD PPE SkPr AT StDr SD 1 2 3 4 5 Special Remarks / Postoperative Instructions Observations Oxygen Other HD hand decontamination SkPp Skin prep % chlorhexidine StDr Sterile Dressing PPE appropriate personal protective equipment AT aseptic technique SD sharps disposal N & V SCORE PAIN SCORE SEDATION SCORE Vomiting 3 Severe 3 Unconcious/Difficult to wake 3 Retching 2 Moderate 2 Mostly Sleeping 2 Nausea 1 Mild 1 Dozing intermittently 1 No Nausea 0 No Pain 0 Wide Awake 0 SPO2 O2l/min / % Sedation Score Pain Score Nausea/ Vomiting Wound Drain Urine Output Medications Block Level IV Infusion Lochia Time Temp BP HR RR 40 240 39 230 38 220 37 210 36 200 35 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 15 10 5 0-5 240 40 230 39 220 38 210 37 200 36 190 35 180 170 160 150 140 130 120 110 100 90 80 70 60 50 40 30 20 15 10 5 0-5
Other notes:
Obstetric Analgesia Audit UHL Name: D.O.B: Hospital no: Ward: AFFIX PATIENT STICKER Date: Pre-existing problem: none Parity: Multip Primip obesity PIH / PET Gastrointestinal Age: /40 cardiovascular respiratory EDD: DM neurological ASA: other Labour Analgesia Epidural Time: Time Called: Onset of Labour: Spontaneous Induced Augmented Anaesthetist 1: Indication: Maternal request Obstetric indication Anaesthetist 2: Cx dilation: <3 3-5 6-8 9-10 Prior Analgesia: Nil Entonox Opiod TENS Technique: top ups constant infusion PCEA CSE+infusion CSE+top ups CSE+PCEA spinal Insertion Problems Analgesia problems Critical incidents None None None Multiple attempts Inadequate block Total spinal Parasthesia - needle Unilateral block Convulsions Parasthesia - catheter Action taken - analgesia: Intravascular injection Pain on insertion Bolus of infusion solution Severe hypotension Bloody tap - needle Concentrated LA top up Hypersensitivity reaction Bloody tap - catheter Positional top up cardiac arrest Dural tap - needle Fentanyl added to top up Equipment failure Dural tap - catheter Catheter withdrawn Other Epidural resited Comments $ Put partially completed form in folder in Obstetric Office and Post-follow up completed form in Audit box in Anaesthetic room PTO
Delivery Anaesthesia / Operative Procedure Date: Time: Operation: Urgency: LSCS / Instrumental delivery / MROP / ERPC / Suturing of tear / Cx suture / Hysterectomy / IUD / Other Emergency / Urgent / Scheduled / Elective Anaesthetist 1: Anaesthetist 2: Anaesthetic: Spinal / Epidural / CSE / Top up Epidural / GA / PCA Indication for GA: Failed regional / Regional abandoned / Feotal distress / Regional contr-indicated / Pt. Request / Obstetrician request / Other Insertion Problems Analgesia problems Critical incidents None None None Multiple attempts Inadequate block Total spinal Parasthesia - needle Unilateral block Convulsions Parasthesia - catheter Action taken - analgesia: Intravascular injection Pain on insertion Bolus of infusion solution Severe hypotension Bloody tap - needle Concentrated LA top up Hypersensitivity reaction Bloody tap - catheter Positional top up cardiac arrest Dural tap - needle Fentanyl added to top up Equipment failure Dural tap - catheter Catheter withdrawn Other Epidural resited Follow up visit Yes / No follow up / Gone home Follow up Anaesthetist: Date: Mode of Delivery: Analgesia: Stage 1 Stage 2 Intra-op Post-op SVD Excellent Ventouse Good Forceps Moderate LSCS Poor Mobility in Labour: Adverse Effects: ITU / HDU Admission Immobile Nausea/Vomiting Yes Mobile in bed Pruritus No Sat out PDP Headache Stood out Neurological Walked Bladder dysfunction Would you have an epidural again? GA: Were you satisfied with our service? Yes No problems Very Satisfied No Awareness Satisfied Maybe Other Dissastisfied Further followup required: No discharge (sheet in to audit box) Yes (sheet back in folder) Day 2: discharge Day 3: discharge Comment: Comment: Comments