Improvement Stories

Prenatal Shared Decision-Making
for Analgesia and Anesthesia in Labor

Tami Michele, DO, FACOOG
Medical Director, Spectrum Health Gerber Memorial OB/GYN and OB Department Chair

What did you set out to change or improve?

Our intention was to provide our OB patients with the knowledge needed to make appropriate decisions for epidural use during labor. We educate our patients on the risks, effects on the obstetrical care, and alternatives for pain management during labor.

How did you change it? What new policy, process, or practice did you put in place?
One prenatal visit is devoted to discussing epidural anesthesia at about 32-36 wks in the pregnancy. Our childbirth educator who teaches the hospital childbirth education also covers this; however not all women take the class. Even if the woman has attended the classes, it is important for the physician or midwife to address this topic.

We have an in-depth education form (recently changed from a consent form), that is reviewed during prenatal care. Many women thank us for discussing this sheet, and state they appreciate having time to think about their options available, and to consider the risks/benefits. Many women are receiving advice from friends or family that have had an epidural during their own births, but they may not have been given any alternative comfort technique options to consider

Additionally, we have created a birth plan for our patients with every option we have available for labor and delivery. The birth plan has the alternatives to an epidural listed so all patients are aware of these comfort measures.

Who was involved in making the change and what was each person’s role?

  • Childbirth Educator: Created a file of handouts in each clinician’s exam room, with educational information appropriate for each prenatal visit with the physician or midwife. The file is arranged by gestational weeks in the pregnancy and corresponds to the prenatal visits.
  • Medical Assistant: Responsible for giving the handout to the patient at each prenatal visit when she places the patient in the exam room. The patient can read this while she is waiting for her visit with the OB provider.
  • Physician or midwife: Reviews the informational topic predetermined as appropriate for each visit with the patient. Epidural use in labor is one of those topics.
  • Anesthesia Provider: Obtains informed consent for the procedure at the time the epidural is administered using a generalized anesthesia procedure form.

How did you determine if the change worked? What data did you collect? How did you define “success”? How did you ensure your change didn’t have any unintended negative consequences?
The statistics collected for the OB department include percent of patients who have an epidural, which varies by month from 18-30%. As compared to other area hospitals which have about a 90% epidural usage, we find that when women are given alternatives for comfort in labor the epidural rate is lower. Success is defined by whether every woman who plans to get an epidural as noted in their birth plan, receives a timely epidural. We have found that although some women are disappointed with their birth experience after requesting an unintended epidural, equally there are women who are unhappy with their birth experience when an intended epidural was not received because of a fast labor. The nurses read the patient’s birth plan that was filled out and submitted during her prenatal care, and make every effort to provide the experience desired by the patient.

What was the biggest barrier to making the change? How did you overcome that barrier?
There was some discussion between the anesthesia providers and maternity care providers regarding whose responsibility it was to obtain informed consent for the epidural. We agreed that the maternity care provider is responsible for discussing the risk to the mother and baby as it relates to the effect on obstetrical care.

The anesthesia provider is responsible for obtaining consent for the procedure, reaction to the anesthetic agent, managing maternal adverse effects, and spinal headache treatment.

If you had one piece of advice for someone who wanted to make a similar change in their setting, what would you advise?
Do not wait until the woman is in labor to provide education and discuss informed consent. The OB provider should not expect the anesthesia provider to have sole responsibility for obtaining consent. While the risk of this anesthetic procedure to the women may be small, the implications of this intervention on the obstetrical outcome must also be addressed. It is worth the effort to educate women on epidural anesthesia in providing quality patient-centered care and improving patient satisfaction. When collaboration occurs, everyone benefits.


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