PCEA – Putting Patients in Control

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Sara Muir is in the last stages of her labour, and yet she looks calm and comfortable.

One wouldn’t really know she’s on the verge of giving birth except for the telltale sign of her enlarged belly. Her concentration on Hollywood Squares is interrupted for a moment as a labour pain hits. But with one swift press of her thumb, Sara zaps the pain away and gets back to her show.

Sara is among the first group of pregnant women at Barrie’s Royal Victoria Hospital, who this year have access to a Patient Controlled Epidural Analgesia (PCEA).

“The PCEA was awesome. When I had my last child, I had a regular epidural. I really didn’t feel as if I had good pain relief. This time, just knowing that I could push a button and not wait for anyone, made me relax and stay calm – even before the medication got to me,” said Sara Muir, 22.

While many metropolitan hospitals have offered this method of pain control for a while, RVH is one of the first community hospitals (outside the GTA) to put the program in place. Since October 2002, 320 of the approximately 500 women who had epidurals, used the PCEA technique.

“The theory behind PCEA is to have patients hover themselves around their own personal pain threshold. As labour progresses they can give themselves pain medication without a time delay,” says Dr. Susan Goheen, an RVH anesthesiologist.

“This system makes medication more available to the patient at their time of need, and allows her to maintain a sense of control.”

The plan, says Goheen, is to establish a walking program, (if only to the bathroom), for women on PCEA. Currently, pregnant patients with epidurals in place are still required to stay in bed, but with the lower concentration of anesthestic that is used in the PCEA, they are able to move around more freely in bed.

The introduction of PCEA, also came on the heels of a restructuring of the Anesthesia Department’s approach to pain control for women in labour. Prior to Goheen’s arrival at RVH, each of the department’s anesthesiologist had their own drug mixture for epidurals. Goheen believes there were at least 10 different prescriptions the birthing unit nurses had to prepare. All of the nurses, anesthesiologists, and members of the pharmacy department have worked hard together to come up with a safer, more effective way.

Today, RVH has two epidural mixes, color-coded for easy recognition of the concentration of local anesthetic in the solution. “Pink” is for a continuous infusion epidural only while “green” can be used either for continuous infusion or for the patient controlled epidural. These solutions are now pre-mixed by the hospital’s pharmacy department, which takes a load off the already busy birthing unit nurses, and adds safety to the program.

Goheen is excited about these advancements at RVH. She believes it is in the best interest of patient care.

“With PCEA the patient can simply push a button to deliver themselves a predetermined amount of pain medication,” says Goheen. “Now instead of lying there feeling like a ‘beached whale’ and having the anesthesiologist in control, labouring women are now the ones with the control. In most cases, they are also able to maintain control over their bladder and bowel functions as well as leg strength and mobility.”

With the PCEA, patients control the amount of medication they receive instead of an anesthesiologist arbitrarily delivering a certain amount of medication, which in many cases may be too much, says Goheen.

“As before, a continuous infusion of medicine goes through the tube in the patient’s back, but at a lower rate. The nurse programs the pump, as ordered by the anesthesiologist, to deliver the appropriate amount of baseline infusion, “boost”, and lock-out period. This is an excellent way to get epidural medication because it allows the mother to stay in “control”, and prevents giving too much medication early in labour when pain may not be so severe,” she says.

The solution of medication that RVH uses with the PCEA technique has a lower concentration of local anesthetic in it. The pain sensation goes away, but the patient’s legs, ability to move in bed, urine control, and ability to push should remain strong.

The PCEA is equipped with a safety mechanism, which allows a patient to medicate themselves on 10-minute intervals. They could push the button 20 times in a one-minute span, but would still only get one dose until the 10-minute lock-out time period had passed.

That was just fine for Muir, who delivered a healthy baby girl – Tiana Lee VanDorsselaer.

“This type of epidural made me feel very comfortable. I could barely feel the contractions, which I was told were very strong,” said Muir.”It was really great.”

The birth experience was a pleasant one for this Barrie mother, and that is the ultimate goal of Royal Victoria Hospital. So, mission accomplished, thanks to PCEA.