Process Optimization and Digital Quality Improvement to Enhance Timely Initiation of Epidural Infusions and Postoperative Pain Control.

BACKGROUND: Although intraoperative epidural analgesia improves postoperative pain control, a recent quality improvement project demonstrated that only 59% of epidural infusions are started in the operating room before patient arrival in the postanesthesia care unit. We evaluated the combined effect of process and digital quality improvement efforts on provider compliance with starting continuous epidural infusions during surgery. METHODS: In October 2014, we instituted 2 process improvement initiatives: (1) an electronic order queue to assist the operating room pharmacy with infusate preparation; and (2) a designated workspace for the storage of equipment related to epidural catheter placement and drug infusion delivery. In addition, we implemented a digital quality improvement initiative, an Anesthesia Information Management System-mediated clinical decision support, to prompt anesthesia providers to start and document epidural infusions in pertinent patients. We assessed anesthesia provider compliance with epidural infusion initiation in the operating room and postoperative pain-related outcomes before (PRE: October 1, 2012 to September 31, 2014) and after (POST: January 1, 2015 to December 31, 2016) implementation of the quality improvement initiatives. RESULTS: Compliance with starting intraoperative epidural infusions was 59% in the PRE group and 85% in the POST group. After adjustment for confounders and preintervention time trends, segmented regression analysis demonstrated a statistically significant increase in compliance with the intervention in the POST phase (odds ratio, 2.78; 95% confidence interval, 1.73-4.49; P < .001). In the PRE and POST groups, cumulative postoperative intravenous opioid use (geometric mean) was 62 and 34 mg oral morphine equivalents, respectively. A segmented regression analysis did not demonstrate a statistically significant difference (P = .38) after adjustment for preintervention time trends. CONCLUSIONS: Process workflow optimization along with Anesthesia Information Management System-mediated digital quality improvement efforts increased compliance to intraoperative epidural infusion initiation. Adjusted for preintervention time trends, these findings coincided with a statistically insignificant decrease in postoperative opioid use in the postanesthesia care unit during the POST phase.

The Accuracy of a Handheld Ultrasound Device for Neuraxial Depth and Landmark Assessment: A Prospective Cohort Trial.

This study investigated the accuracy of a wireless handheld ultrasound with pattern recognition software that recognizes lumbar spine bony landmarks and measures depth to epidural space (Accuro, Rivanna Medical, Charlottesville, VA) (AU). AU measurements to epidural space were compared to Tuohy needle depth to epidural space (depth to loss of resistance at epidural placement). Data from 47 women requesting labor epidural analgesia were analyzed. The mean difference between depth to epidural space measured by AU versus needle depth was -0.61 cm (95% confidence interval, -0.79 to -0.44), with a standard deviation of 0.58 (95% confidence interval, 0.48-0.73). Using the AU-identified insertion point resulted in successful epidural placement at first attempt in 87% of patients, 78% without redirects.

Nurse Practitioner-Administered Chloroprocaine in Children with Postoperative Pain.

BACKGROUND: Pain is a complex physical and emotional experience. Therefore, assessment of acute pain requires self-report when possible, observations of emotional and behavioral responses and changes in vital signs. Peripheral nerve and epidural catheters often provide postoperative analgesia in children. Administration of chloroprocaine (a short acting local anesthetic) via a peripheral nerve or epidural catheter allows for a comparison of pain scores, observations of emotional and behavioral responses and changes in vital signs to determine catheter function. AIMS: The aims of this study are to describe the use chloroprocaine injections for testing catheters; patient response; and how changes to pain management are guided by the patient response. METHODS: This study describes the use of chloroprocaine injections to manage pain and assess the function of peripheral nerve or epidural catheters in a pediatric population. We examined 128 surgical patients, (0-25 years old), who received chloroprocaine injections for testing peripheral nerve or epidural catheters. Patient outcomes included: blood pressure, respiratory rate, heart rate and pain intensity scores. RESULTS: There were no significant adverse events. The injection guided intervention by determining the function of regional analgesia in the majority (98.5%) of patients. DISCUSSION: Chloroprocaine injections appear to be useful to evaluate functionality of peripheral nerve and epidural catheters after surgery in a pediatric population.

[Recent standards in management of obstetric anesthesia]. / Aktuelle Versorgungskonzepte in der geburtshilflichen Anästhesie.

The following article contains information not only for the clinical working anaesthesiologist, but also for other specialists involved in obstetric affairs. Besides a synopsis of a German translation of the current "Practice Guidelines for Obstetric Anaesthesia 2016" [1], written by the American Society of Anesthesiologists, the authors provide personal information regarding major topics of obstetric anaesthesia including pre-anaesthesia patient evaluation, equipment and staff at the delivery room, use of general anaesthesia, peridural analgesia, spinal anaesthesia, combined spinal-epidural anaesthesia, single shot spinal anaesthesia, and programmed intermittent epidural bolus.

Defining competence in obstetric epidural anaesthesia for inexperienced trainees.

BACKGROUND: Cumulative sum (CUSUM) analysis has been used for assessing competence of trainees learning new technical skills. One of its disadvantages is the required definition of acceptable and unacceptable success rates. We therefore monitored the development of competence amongst trainees new to obstetric epidural anaesthesia in a large public hospital. METHODS: Obstetric epidural data were collected prospectively between January 1996 and December 2011. Success rates for inexperienced trainees were calculated retrospectively for (1) the whole database, (2) for each consecutive attempt and (3) each trainee's individual overall success rate. Acceptable and unacceptable success rates were defined and CUSUM graphs generated for each trainee. Competence was assessed for each trainee and the number of attempts to reach competence recorded. RESULTS: Mean (sd) success rate for all inexperienced trainees was 76.8 (0.1%), range 63-90%. Consecutive attempt success rate produced a learning curve with a mean success rate commencing at 58% on attempt 1. After attempt 10 the attempt number had no effect on subsequent success rates. From these results, the acceptable and unacceptable success rates were set at 65 and 55% respectively. CUSUM graphs demonstrated 76 out of 81 trainees competent after a mean of 46 (22) attempts. CONCLUSIONS: CUSUM is useful for assessing trainee epidural competence. Trainees require approximately 50 attempts, as defined by CUSUM, to reach competence.

[EPIDURAL ANALGESIA FOR INTRAOPERATIVE AND POSTOPERATIVE CARE IN NEWBORNS].

Anesthesia care in newborns has to be complex, balanced and safe. Nowadays epidural analgesia (EA) in neonates during intra- and postoperative period is widely used in Russia. Modern EA techniques imply the installation of a catheter into epidural space at lumbar or thoracic level as well as different approach to local anesthetics dosage. Newborns have special anatomy, physiology and pharmacodynamics which have to be taken in mind when EA is used. At the present moment Ropivacine (2 mg/ml) is approved for peripheral nerve blocks in newborns.

Video-assisted structured teaching to improve aseptic technique during neuraxial block.

BACKGROUND: Teaching epidural catheter insertion tends to focus on developing manual dexterity rather than improving aseptic technique which usually remains poor despite increasing experience. The aim of this study was to compare epidural aseptic technique performance, by novice operators after a targeted teaching intervention, with operators taught aseptic technique before the intervention was initiated. METHODS: Starting July 2008, two groups of second-year anaesthesia residents (pre- and post-teaching intervention) performing their 4-month obstetric anaesthesia rotation in a university affiliated centre were videotaped three to four times while performing epidural procedures. Trained blinded independent examiners reviewed the procedures. The primary outcome was a comparison of aseptic technique performance scores (0-30 points) graded on a scale task-specific checklist. RESULTS: A total of 86 sessions by 29 residents were included in the study analysis. The intraclass correlation coefficient for inter-rater reliability for the aseptic technique was 0.90. The median aseptic technique scores for the rotation period were significantly higher in the post-intervention group [27.58, inter-quartile range (IQR) 22.33-29.50 vs 16.56, IQR 13.33-22.00]. Similar results were demonstrated when scores were analysed for low, moderate, and high levels of experience throughout the rotation. CONCLUSIONS: Procedure-specific aseptic technique teaching, aided by video assessment and video demonstration, helped significantly improve aseptic practice by novice trainees. Future studies should consider looking at retention over longer periods of time in more senior residents.

Epidural catheter connectors: a laboratory-based comparison of the Portex Tuohy-Borst and EpiFuse™ designs.

Disconnection of an epidural catheter from its connector may result in patient harm and commonly requires resiting of the epidural. Clamp-connector designs such as the novel Portex EpiFuse™ potentially offer an improved safety profile over screw-cap designs such as the Tuohy-Borst, but comparative studies are limited. We therefore compared the tensile strength of EpiFuse and Tuohy-Borst connectors in a laboratory setting. We further sought to establish whether operator modification of the EpiFuse increased its vulnerability to disconnection. The median (IQR [range]) force to induce disconnection was 8.0 (4.1-12.8 [0.0-22.6]) N for Tuohy-Borst connectors and 16.4 (15.2-17.7 [5.7-18.9]) and 15.9 (15.0-16.9 [5.8-18.1]) N for standard and modified EpiFuse connectors, respectively (p<0.0001). The Tuohy-Borst was also less likely to meet British Standard requirements (13/20 sets vs 19/20 and 20/20, p=0.002). Modification of the EpiFuse did not affect lumen patency or connection strength. We conclude that under controlled conditions, EpiFuse connectors are superior to Tuohy-Borst connectors.

Predicting lumbar plexus depth in children and adolescents.

BACKGROUND: Lumbar plexus block provides effective analgesia for hip, thigh, and knee surgery. A simple measurement that accurately predicts lumbar plexus depth would be invaluable for clinicians performing this block in children, in whom plexus depth varies with age. METHODS: Surface anatomy measurements were taken on children having lower extremity surgery and lumbar plexus block. All blocks were placed under general anesthesia using peripheral nerve stimulation. The distance from the posterior superior iliac spine (PSIS) to the intercristal line (ICL), i.e., PSIS-ICL distance, and from midline to the intersection of a perpendicular line drawn from the PSIS and the ICL were measured. Lumbar plexus depth was recorded at the point at which maximum quadriceps stimulation was elicited using the lowest current output. Linear regression was used to explore the least squares line of best fit for each measure. RESULTS: Measurements were made on 350 consecutive patients aged 1 month to 24 years. A very strong linear relationship between lumbar plexus depth and PSIS-ICL distance was noted. The median (interquartile range) absolute difference between observed lumbar plexus depth and that predicted by PSIS-ICL distance was 2 mm (1-5 mm), 95% CI for median = 1.36 to 2.64. Ninety-two percent of patients (95% CI, 88.7%-94.6%) had lumbar plexus depths within ±10 mm of the predicted depth. The strongest correlation to lumbar plexus depth was found with PSIS-ICL distance (R(2) = 0.89, P < 0.0001). Weaker correlations were found for weight, height, body mass index, midline-PSIS line distance, and age. CONCLUSION: PSIS-ICL distance provides an accurate, patient-specific predictor for lumbar plexus depth in children over a wide range of age and body habitus. The strong linear relationship obviates the need for complex calculations. This measurement can be used as a guide for ultrasound location, to choose an appropriate needle length, and may reduce complications associated with this block.

The effect of neuraxial versus general anesthesia techniques on postoperative quality of recovery and analgesia after abdominal hysterectomy: a prospective, randomized, controlled trial.

BACKGROUND: Patients undergoing abdominal hysterectomy often have significant postoperative pain despite the use of concurrent multimodal pain strategies. Neuraxial anesthesia has opioid-sparing effects and may provide better postoperative recovery to patients when compared with general anesthesia. Our main objective in this study was to compare the effects of neuraxial and general anesthesia on postoperative quality of recovery after abdominal hysterectomy. METHODS: The study was a prospective, randomized, controlled clinical trial. Seventy healthy females were recruited and randomized to a general anesthesia or neuraxial technique as their primary anesthetic regimen. The primary outcome was the global quality of recovery-40 questionnaire (QoR-40) at 24 hours after the surgical procedure. Other data collected included postoperative pain scores and opioid consumption. Data were analyzed using the Mann-Whitney U test, Fisher's exact test, and linear regression. A P value <0.05 was considered statistically significant. RESULTS: The median difference (95% confidence interval [CI]) in the global QoR-40 score at 24 hours between the neuraxial and general anesthesia groups was 17 (11 to 21.5) (P < 0.001). Patients in the neuraxial anesthesia group had better quality of recovery scores in all the QoR-40 subcomponents than did the general anesthesia group (all P < 0.005). The median difference in global QoR-40 scores at 48 hours between the neuraxial anesthesia and the general anesthesia groups was 8 (6-10) (P < 0.001). Postoperative opioid consumption and pain scores were higher in the general anesthesia group than in the neuraxial anesthesia group. There was an inverse linear relationship between opioid consumption and postoperative quality of recovery at 24 hours, r(2) = 0.67 (P < 0.0001, 95% CI of 0.77 to 0.51), and at 48 hours, r(2) = 0.58 (P < 0.0001, 95% CI of 0.72 to 0.42). CONCLUSION: Neuraxial anesthesia provides better quality of recovery than does general anesthesia for patients undergoing abdominal hysterectomy. The opioid-sparing effects of neuraxial anesthesia were associated with a better quality of recovery in patients after the surgical procedure. In the absence of contraindications, neuraxial anesthesia seems to be a better anesthetic plan for those patients.

Comparison of Ultrasonography and Conventional Fluoroscopy Guided Caudal Epidural Injection in Chronic Low Back Pain.

AIM: To compare the efficacies of fluoroscopy- and ultrasound (US)-guided caudal epidural steroid injections (CESIs) in patients with chronic low back pain (LBP). MATERIAL AND METHODS: This study included patients with chronic LBP who underwent US- (Group U; n = 90) or fluoroscopyguided (Group F; n = 90) CESI. The procedure time, successful injection rate on the first attempt, complication rate, Oswestry Disability Index (ODI) score, and Numeric Rating Scale (NRS) score before CESI and after 3 weeks and 3 months of CESI were analyzed. RESULTS: NRS and ODI scores improved at 3 weeks (p < 0.001) and 3 months (p < 0.001) after CESIs. No significant differences were noted between the two groups for the NRS (p=0.22 and p=0.47) and ODI (p=0.58, p=0.22) scores. Moreover, the CESI procedure time was significantly shorter (p < 0.001) and the successful injection rate on the first attempt was significantly higher (p=0.002) in Group U than in Group F. The complication rate difference was statistically insignificant between the two groups (p > 0.05). CONCLUSION: Outcomes of US-guided CESI were superior than those of fluoroscopy-guided CESI considering the successful injection rate on the first attempt and procedure time. In addition, US-guided CESI was as effective as fluoroscopy-guided CESI and did not expose patients and practitioners to radiation.

Effectiveness of Superior Hypogastric Plexus Block for Pain Control Compared to Epidural Anesthesia in Women Requiring Uterine Artery Embolization for the Treatment of Uterine Fibroids - A Retrospective Evaluation.

PURPOSE: To assess the effectiveness of pain management with superior hypogastric plexus block (SHPB) compared to epidural anesthesia (EDA) in women requiring uterine artery embolization (UAE). MATERIALS AND METHODS: In this retrospective, single-center, non-randomized trial we included 79 women with symptomatic uterine fibroids who were scheduled for percutaneous, transcatheter UAE. According to their informed decision, the women were assigned to two different approaches of pain management including either SHPB or EDA. The effectiveness outcome measure was patient reported pain using a numeric rating scale ranging from 1 to 10. The pain score was assessed at UAE, 2 hours thereafter, and at subsequent intervals of 6 hours up to 36 hours after intervention. RESULTS: Treatment groups did not differ significantly regarding age, pain score for regular menstrual cramps, uterine fibroid size, location, and symptoms of uterine fibroids. During UAE and up to 6 hours thereafter, women who received SHPB experienced stronger pain than those who received EDA (mean pain score during UAE: 3.3 vs. 1.5, p < 0.001; at 2 hours: 4.4 vs. 2.8, p = 0.012; at 6 hours: 4.4 vs. 2.6, p = 0.021). The maximum pain level was 5.8 ±â€Š2.9 with SHPB and 4.5 ±â€Š2.9 with EDA (p = 0.086). Women with a history of severe menorrhagia tended to experience worse pain than those without (regression coefficient 2.5 [95 % confidence interval -0.3 to 5.3], p = 0.076). CONCLUSION: Among women who underwent UAE, pain management including SHPB resulted in stronger pain during and after the procedure than pain treatment including EDA. KEY POINTS: · Pain control with superior hypogastric plexus block was worse than epidural anesthesia.. · Peak of pain was at 12 hours after uterine artery embolization.. · Maximum pain was independent from uterine fibroid size or location.. CITATION FORMAT: · Malouhi A, Aschenbach R, Erbe A et al. Effectiveness of Superior Hypogastric Plexus Block for Pain Control Compared to Epidural Anesthesia in Women Requiring Uterine Artery Embolization for the Treatment of Uterine Fibroids - A Retrospective Evaluation. Fortschr Röntgenstr 2021; 193: 289 - 297.

Counterbalancing clinical supervision and independent practice: case studies in learning thoracic epidural catheter insertion.

BACKGROUND: Thoracic epidural catheter placement is an example of a demanding and high-risk clinical skill that junior anaesthetists need to learn by experience and under the supervision of consultants. This learning is known to present challenges that require further study. METHODS: Ten consultant and 10 trainee anaesthetists in a teaching hospital were interviewed about teaching and learning this skill in the operating theatre, and a phenomenological analysis of their experience was performed. RESULTS: Trainee participation was limited by time pressure, lack of familiarity with consultants, and consultants' own need for clinical experience. There was a particular tension between safe and effective consultant practice and permitting trainees' independence. Three distinct stages of participation and assistance were identified from reports of ideal practice: early (part-task or basic procedure, consultant always present giving instruction and feedback), middle (independent practice with straightforward cases without further instruction), and late (skill extension and transfer). Learning assistance provided by consultants varied, but it was often not matched to the trainees' stages of learning. Negotiation of participation and assistance was recognized as being useful, but it did not happen routinely. CONCLUSIONS: There are many obstacles to trainees' participation in thoracic epidural catheter insertion, and learning assistance is not matched to need. A more explicit understanding of stages of learning is required to benefit the learning of this and other advanced clinical skills.

Nordic guidelines for neuraxial blocks in disturbed haemostasis from the Scandinavian Society of Anaesthesiology and Intensive Care Medicine.

BACKGROUND: Central neuraxial blocks (CNBs) for surgery and analgesia are an important part of anaesthesia practice in the Nordic countries. More active thromboprophylaxis with potent antihaemostatic drugs has increased the risk of bleeding into the spinal canal. National guidelines for minimizing this risk in patients who benefit from such blocks vary in their recommendations for safe practice. METHODS: The Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) appointed a task force of experts to establish a Nordic consensus on recommendations for best clinical practice in providing effective and safe CNBs in patients with an increased risk of bleeding. We performed a literature search and expert evaluation of evidence for (1) the possible benefits of CNBs on the outcome of anaesthesia and surgery, for (2) risks of spinal bleeding from hereditary and acquired bleeding disorders and antihaemostatic drugs used in surgical patients for thromboprophylaxis, for (3) risk evaluation in published case reports, and for (4) recommendations in published national guidelines. Proposals from the taskforce were available for feedback on the SSAI web-page during the summer of 2008. RESULTS: Neuraxial blocks can improve comfort and reduce morbidity (strong evidence) and mortality (moderate evidence) after surgical procedures. Haemostatic disorders, antihaemostatic drugs, anatomical abnormalities of the spine and spinal blood vessels, elderly patients, and renal and hepatic impairment are risk factors for spinal bleeding (strong evidence). Published national guidelines are mainly based on experts' opinions (weak evidence). The task force reached a consensus on Nordic guidelines, mainly based on our experts' opinions, but we acknowledge different practices in heparinization during vascular surgery and peri-operative administration of non-steroidal anti-inflammatory drugs during neuraxial blocks. CONCLUSIONS: Experts from the five Nordic countries offer consensus recommendations for safe clinical practice of neuraxial blocks and how to minimize the risks of serious complications from spinal bleeding. A brief version of the recommendations is available on http://www.ssai.info.

Does the Technique for Assessing Loss of Resistance Alter the Magnitude of Epidural Needle Tip Overshoot?

INTRODUCTION: Postdural puncture headache due to accidental dural puncture is a consequence of excessive needle tip overshoot distance after entering the epidural space via a loss of resistance (LOR) technique. We are not aware of any quantitative comparison of the magnitude of needle tip overshoot (distance traveled by the needle tip beyond the point where LOR can be discerned) for the various LOR assessment techniques that are taught. Such a comparison may provide insight into contributing factors of accidental dural puncture and associated postdural puncture headache. METHODS: A custom-built simulator was used to evaluate the following 3 LOR assessment techniques: incremental needle advancement, intermittent LOR assessment (II); continuous needle advancement, high-frequency intermittent LOR assessment (CI); and continuous needle advancement, continuous LOR assessment (CC). RESULTS: There were significant mean differences in maximum overshoot past a virtual LOR plane due to technique (F(2,124) = 79.31, P < 0.001) (Fig. 2). Specifically, maximum overshoot was greater with technique II [mean = 3.8 mm, 95% confidence interval (CI) = 3.4-4.3] versus either CC (mean = 1.9 mm, 95% CI = 1.5-1.8, P < 0.001) or CI (mean = 1.4 mm, 95% CI = 0.9-2.3, P < 0.001). Differences in maximum overshoot between CC and CI were not statistically different (P = 0.996). Maximum overshoot was greater at 4 cm (mean = 3.0 mm, 95% CI = 2.6-3.4) compared with 5 cm (mean = 2.3 mm, 95% CI = 2.0-2.5, P = 0.044), 6 cm (mean = 2.0 mm, 95% CI = 1.9-2.2, P = 0.054), 7 cm (mean = 1.9 mm, 95% CI = 1.7-2.1, P = 0.002), and 8 cm (mean = 1.8 mm, 95% CI = 1.6-2.1, P = 0.001). In addition, maximum overshoot at 5 cm was greater than that at 7 cm (P = 0.020) and 8 cm (P = 0.037). The other LOR depths were not statistically significantly different from each other. Depth did not have a significant interaction with technique (P = 0.517). Technique preference had neither a significant relationship to maximum overshoot (P = 0.588) nor a significant interaction with LOR assessment technique (P = 0.689). DISCUSSION: Technique II LOR assessment produced the greatest needle overshoot past the simulated LOR plane after obtaining LOR. This was consistent across all LOR depths. In this bench study, the II technique resulted in the deepest needle tip maximum overshoot. We are in the process of designing a clinical study to collect similar data in patients.

Determining competence in performing obstetric combined spinal-epidural procedures in junior anesthesiology residents: results from a cumulative sum analysis.

BACKGROUND: The epidural anesthesia technique is a challenging skill to master. The Accreditation Council for Graduate Medical Education (ACGME) stipulates that anesthesiology residents must complete 40 epidural procedures by the end of junior residency. The rationale is unknown. The aim of this prospective study was to determine the minimum case experience required to demonstrate competence in performing obstetric combined spinal-epidural procedures among junior residents, using an objective statistical tool, the cumulative sum (CUSUM) analysis. METHODS: Twenty-four residents, with no prior experience performing epidurals, sequentially recorded all obstetric combined spinal-epidural procedures as a 'success' or 'failure', based on study criteria. Individual CUSUM graphs were plotted, with acceptable and unacceptable failure rates set at 20% and 35%, respectively. The number of procedural attempts necessary to demonstrate competence was determined. RESULTS: Twenty-four residents (mean (SD) age 29 (2) years) participated in the study. Median (IQR) number of procedures was 78 (66-85), with a median (IQR) success rate of 86% (82-89%). Nineteen of 24 residents required a median (IQR) of 40 (33-50) attempts to demonstrate competence. Five did not achieve procedural competence in the training period. The CUSUM graphs highlighted performance trends that required intervention. CONCLUSION: Competence was achieved by 19/24 residents after the ACGME-required case experience of 40 combined spinal-epidural procedures, based on a predefined acceptable failure rate of 20%. In our experience, CUSUM analysis is useful in monitoring technical performance over time and should be included as an adjunct assessment method for determining procedural competence.

How are decisions made to access a planned epidural in labour? Midwife-woman interactions in antenatal consultations.

OBJECTIVE: The purpose of this study was to examine the ways in the decision to access a planned epidural in labour was topicalised and negotiated between pregnant women and midwives. DESIGN: This article uses conversation analysis to examine how decision-making unfolds in antenatal consultations in a large metropolitan hospital in South Australia. Data were sampled from naturally-occurring interactions between women and midwives in routine antenatal consultations. Analysis focused on talk about planning to access (or, avoid) an epidural during an upcoming labour. FINDINGS: This paper illustrates that in the context of woman-centred care, women are held unilaterally responsible for the decision to accept or reject a planned epidural in labour with little or no input from the midwife. Midwives take a step back from involvement in the discussion beyond the solicitation of a decision from the woman. Women wanting a planned epidural took a strong, assertive stance in the interaction and drew on their previous birthing experience, limiting opportunity for the midwife to engage in meaningful discussion about the risks and benefits. On the other hand, women rejecting a planned epidural were less assertive and engaged in more complex interactional work to account for their decision. KEY CONCLUSIONS: The lack of involvement by midwives may be linked to the non-directive ethos that prevails in maternity care. It is argued that, in this dataset, the institutional imperative for women to know and decide on pain relief while pregnant in order to allocate to a model of care is prioritised over women's aspirations and expectations of childbirth. IMPLICATIONS FOR PRACTICE: By analysing the ways in which midwives and women interact at the point in time at which decisions were made to plan access to an epidural we can continue to reveal underlying forces that drive the rising rates of medical interventions in childbirth. This paper also contributes to research evidence on how midwives manage the potentially contradictory dialect between supporting women's childbirth preferences while also managing institutional requirements and evidence-based practice.