If Carefully Selected, Patients in Labor Can Ambulate Safely—The Key is the Use of Low-Dose Epidural Analgesia

If Carefully Selected, Patients in Labor Can Ambulate Safely—The Key is the Use of Low-Dose Epidural Analgesia

Christopher M. Colville MD

Christopher E. Swide MD

Effective analgesia for women in labor has become a reality since the 1950s. Labor suites have progressed from the time of sedated mothers and babies to modern central neuraxial techniques managed by professional anesthesia providers. Women can now enjoy a comfortable labor with safe, effective pain control. Many women and their obstetric providers believe that walking during labor can speed progress and provide comfort to the parturient. We can now provide effective pain control while preserving motor function, so the question becomes “does ambulation play a role for those patients with labor epidurals?”

What does ambulation do for mothers? The medical literature is unclear as to whether ambulation truly helps with the outcome of labor despite the common wisdom that this is true. Ambulation for the laboring patient theoretically can result in fairly substantive benefits. Faster labors, fewer instrumental and operative deliveries, and better maternal and infant outcomes are some of the alleged advantages to having the parturient walking early and often. Decreases of up to 2 hours in the first stage of labor, decreased requests for analgesia, lower rates for instrumental deliveries, and improved Apgar scores have all been reported in patients who walked after placement of the labor epidural. However, other studies have not found statistically significant changes in length of labor (from epidural insertion), Apgar scores, or cesarean delivery rate for these walking patients. The current literature has not revealed evidence of harm to the mother or baby if ambulation is allowed in the properly selected laboring patient. Patient satisfaction seems markedly improved because the majority of women who did ambulate in labor with analgesia reported that they would do so again for future pregnancies. Implicit in this satisfaction may be the decreased motor block that allows ambulation in the first place. With increased lower extremity mobility, parturients seem to feel greater independence from the labor bed. The low-dose epidural dosing studied (and used in many centers) also allows patients to void with greater autonomy. Patients have reported a somewhat greater satisfaction of the entire laboring experience when being allowed to walk, even if that ambulation is of short duration (e.g., walking across the room
to the toilet). What is clear is that women like to walk in labor, and they particularly like to walk with adequate pain control, so patient satisfaction can be improved even if we cannot prove any medical benefits of ambulation.

Is it safe for laboring patients with epidural analgesia to ambulate? Safety concerns can be separated into two main classes: maternal safety and fetal safety. Maternal safety depends on having a protocol in place that addresses the main safety concerns in ambulatory epidurals, which are patient falls and hemodynamic stability. Patients who are allowed to ambulate with neuraxial labor analgesia need to be carefully selected and approved by the attending obstetrician or midwife and anesthesia provider after careful review of the patient’s medical and obstetric history. In addition, this “freedom from the bed” should only be permitted with close ambulation supervision and with appropriate equipment (e.g., portable pumps, easily mobile intravenous [IV] stands). If medically dictated, at the discretion of the attending obstetrician or midwife, fetal heart rate monitoring will need to be portable, with mechanisms in place for remote monitoring units. Also, having a “rest” area at the nurses’ station where the mom can have her blood pressure, heart rate, and fetal heart rate measured every 15 minutes facilitates nursing efficiency. A standard protocol is waiting 30 to 45 minutes after initial dosing, and then having the anesthesia provider examine the patient for signs of motor weakness and hemodynamic instability. A simple test is the modified Bromage score. If the patient can flex the leg at the hip and resist the examiners hand, then she is given a score of 5, and if she can stand from the bed with minimal assistance (deep knee bend), then she is given a score of 6 and is cleared to ambulate. To test hemodynamics, the patient is asked to stand, and both systolic blood pressure and fetal heart rate are measured to look for significant changes. Ambulation is then allowed using the patient’s support person or designated helper to walk with her for assistance. The use of appropriate IV poles can help facilitate walking. Fetal safety depends on maintaining adequate perfusion of the placenta by ensuring maternal safety. For properly selected patients, there is no evidence in the literature of fetal/maternal harm from walking in labor.

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Jul 1, 2016 | Posted by in ANESTHESIA | Comments Off on If Carefully Selected, Patients in Labor Can Ambulate Safely—The Key is the Use of Low-Dose Epidural Analgesia
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