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Tips and hints for IVs in L&D

Posted Jan 07 2009 3:05pm
This is for you Pammie!!

Helpful hints and handy tips for IVs in Labor and Delivery:

Finding a site is probably the hardest part of starting an IV, in my opinion. So, to help you with choosing a site, remember your basic anatomy of the hand and arm.

Just ignore that foot there, because unless you work in peds or NICU, you won't be starting an IV in a foot.

Best sites for IV starts: top of the hand, in the wrist (also known as the med student vein - because it's usually huge and easy to find), or in the antecubital space. A good key to remember is that you can always work your way up from the hand when starting IVs or drawing blood, but you cannot work your way down from the upper arm. This is because if you have previous sites used or attempted that is higher on the arm, your fluids can potentially meet up with the other sites used/attempted, and fluids can leak out around that site.

Also, take into consideration: is the patient right or left handed? I prefer to use the non-dominant arm, so she can have freedom of movement of the dominant hand and arm. After all, how would YOU like to have an IV in your dominant hand/arm and try to wipe yourself after using the bathroom? Or holding/touching your newborn baby?

In labor and delivery, you are going to find that most of your patients have nice, fat, juicy veins. Think about it: most pregnant women are healthy, drinking plenty of liquids, and have about a 50% increase in blood volume at term gestation. That means big, huge veins! Usually. Sometimes you have a very large person or an edematous pregnant woman with deep veins. Or you have a dehydrated, sick pregnant woman with itty bitty or non-existant veins. Let's just stick with the normal, healthy women for now, when discussing IV starts.

Use a tourniquet (or two of them, or a blood pressue cuff inflated for harder to find veins), about 3-4 inches above the intended site. Start at the hand. You'll look and feel for a bouncy, spongy type of feel. You may not always see the vein with your eyes! Veins do not have a pulsating feel to them - if you feel pulsating, you've found an artery. If you don't find anything that looks usable in the hand, readjust your tourniquet to a higher part of the arm, and look at the wrist. Look at the outer/posterior/top of the arm. Look at the inner arm. Last, but not least, look at the antecubital space. The AC space is mostly where you will find your really big veins. So, if all else fails, use what you have!

If you still can't feel any veins, try the other hand/arm.

Veins have valves in them. You will see these on big, ropey veins, and on men. You'll see little knots along the vein. Avoid these knots when finding a site. The valves may occlude the blood return you will look for when starting an IV.

Make sure you choose a site where the vein is not twisting and turning. You usually need about an inch (or more) of straight vein to get an IV started.

Veins may also move around a lot, especially when you try to start the IV. A good way to keep the vein from moving is to use your non-dominant hand (I use my left thumb) to stabilize the veins, by putting downward pressure on the skin and vein, below where I plan on starting the IV.

Now that you're ready to actually start the IV, make sure your supplies are all at hand. You'll probably want to set up everything before you even look for a vein. Everyone has their "routine", so play around with your set up. There is no right or wrong way. Personally, I like having all of my supplies set up on the overbed table, along with the IV start box right there, just in case I need to grab extra supplies during the IV insertion. I like my tape all ready to go. I also like to put a towel under the hand/arm, to catch runaway blood, should it be a messy IV start. (Don't worry about making a mess - it takes tons of practice to be a very clean IV starter. After 7+ years, I still make a mess sometimes.)

Make sure the bevel side is up - in other words, the opening is seen on the top portion of the needle. This allows you to puncture the vein and get a good blood return to assure you that you are in the vein.

Most people will say to insert the angiocatheter at a 45 degree angle for the initial "stick", then lowering the angiocath to a 15-20 degree angle for the rest of the insertion. Sometimes, I do a 15-20 degree insertion if the vein seems like it's small. This prevents me from puncturing through the other side of the vein and blowing it. The following picture shows a 45 degree angle initial "stick".

Depending on what angiocaths your hospital provides, you may have different ways of advancing the plastic sheath. Some angios have a little nub at the top to help advance that catheter over the needle. Just remember this: once you get a good blood return, try not to advance the entire needle - just the catheter - or you may puncture the other side of the vein, thus blowing the vein.

Advance the catheter slowly over the needle. If you come across resistance, you may need to pull back on the catheter, and use the needle to guide again - you could be hitting a valve, and must push past that valve in order to get the catheter in a good spot in the vein.

Try not to do too much digging with the needle - it hurts!

You may need to float the catheter into the vein. To do this, I have a syringe of flush solution at the ready. Just detach the needle, and attach the syringe with the flush solution to the hub of the catheter, and slowly inject the fluid as you advance the catheter. Look for signs of the vein being infiltrated - fluid will puff up the IV site, and make it edematous. The patient will probably complain of pain at the site as well. If this happens, discontinue the site and cover it with a pressure dressing.

Once you've found a good site, prepped your site, gotten a good flash of blood, and inserted the IV catheter, go ahead and remove your needle (after you utilize the needle locking/retracting mechanism on your angiocath). Put pressure on the vein above where the IV site is, to keep blood from pouring out of the open angiocath. Don't worry if you can't get a good firm grip on the vein: if it's a big vein you will probably end up with blood coming out anyway. Just do your best. This is why I like a towel under the hand/arm. Great way to catch the blood leaking out.

Hook up your IPID cap, or your IV fluids, and you're done. Make sure that you don't have signs of infiltration when you start your IV fluids (edema or pain at the IV site, or moving up the hand/arm). If you have infiltration, follow your hospital policy of d/c'ing the site.

A good rule of thumb: you get two tries to get the IV started. If you can't after two attempts, ask someone else to try, or utilize your IV team nurse, if you have one in the hospital.

On L&D, you will more than likely be using 18 or 20 gauge needles for IV starts. See your hospital policy for more details. Where I work, 18's are the preferred size, due to the need for IV fluid boluses for epidural placement, fetal distress, or for a c-section. 20 gauge IVs are ok too, but the fluids will infuse slower.

Practice, practice, practice. Do as many IV starts as you can to get more experience. Do IV starts for other nurses. Do as many admissions as you can. This is what I tell new nurses that I precept. The more you do, the more confident you will become, and the more you will be exposed to different veins - yes, even those hard to stick veins!

Good luck Pammie on your transition to L&D. You'll love it there!!

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