How midwives manage rapid pre-loading of fluid in women prior to low dose epidurals: A retrospective chart review

Abstract

Aim: To describe contemporary routine practice regarding rapid pre-loading of intravenous fluid management prior to epidural analgesia during labour and birth. Background: Midwives are the key health professionals providing care for women before, during and after an epidural in labour. Part of this management involves maternal hydration; however, how midwives assess and manage maternal hydration and fluid management is not well understood. Prior to the administration of a low dose epidural for pain relief a rapid intravenous pre-loading of between 500-1000 mls of crystalloid fluids is administered to the pregnant women. Currently, there is limited evidence available to assess if intravenous pre-loading reduces maternal hypotension and foetal bradycardia. Anecdotal evidence suggests that wide variation in clinical practice in relation to volume of fluid administered, fluid status assessment and clinical documentation occurs. Design: A retrospective medical health record review, in a regional Australian maternity hospital. Methods: A retrospective medical health record review chart review from women who received an epidural for pain relief during labour and birth (June–September 2015). Results: Data from 293 charts were collected, including: maternal factors; blood pressure distributions; maternal fluid status; types, concentration and timing of analgesia loading doses; IV fluid loading volumes; maternal hypotension, foetal outcomes and documentation of fluid balance charts. Wide variation in clinical practice was evident with midwives administering pre-loading fluid volumes ranging from 250-1000 ml. Midwifery assessment, documentation and practice pertaining to hydration was inconsistent and lacking. Conclusion: Management of intravenous fluids during labour is fragmented. Although fluid balance charts are used internationally to assess maternal hydration, documentation of fluid balance status was poor. Multi-professional collaboration between obstetrics, anaesthetics and midwifery is required to address this wide variation and reach consensus on best practice based on what evidence is currently available.