Failed Induction of Labor

[PainDrain]

So I am constantly amazed at the OBs where I practice. They clearly have no understanding of what we do, but the fact they know so little or care so little about their patients really bothers me.

We have several OBs who bring patients in for "induction" with little to no chance of achieving a vaginal delivery. We are talking morbidly obese, short women who are 38 weeks with a long closed cervix. They start them on pit, get an epidural and if they don't progress fast enough it's off to section. Seriously? I can't understand this, it boggles my mind.

Where I trained no one got an epidural unless they were in active labor (3cm or greater and contracting regularly). I have been asked to put epidurals in patients 1cm. Is it our place to call bull**** on this?

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[deleted171991]

So I am constantly amazed at the OBs where I practice. They clearly have no understanding of what we do, but the fact they know so little or care so little about their patients really bothers me.

We have several OBs who bring patients in for "induction" with little to no chance of achieving a vaginal delivery. We are talking morbidly obese, short women who are 38 weeks with a long closed cervix. They start them on pit, get an epidural and if they don't progress fast enough it's off to section. Seriously? I can't understand this, it boggles my mind.

Where I trained no one got an epidural unless they were in active labor (3cm or greater and contracting regularly). I have been asked to put epidurals in patients 1cm. Is it our place to call bull**** on this?

Obviously it's your place. You are not a tech. You are a physician and if, in your professional judgment, the patient does not qualify, then the patient does not get an epidural.

 

[drmwvr]

ACOG and the ASA do not have your back on this.

https://www.acog.org/Resources-And-...n-Obstetric-Practice/Pain-Relief-During-Labor

The OB's where I am (mercifully, I am no longer in their service) have claimed this opinion since it was published.

Surprise! You're the bad guy. The labor and delivery culture is a curse and when I left I never looked back... although I must confess a certain Schadenfreude whenever I see posts like this.

 

[deleted171991]

ACOG and the ASA do not have your back on this.

https://www.acog.org/Resources-And-...n-Obstetric-Practice/Pain-Relief-During-Labor

The OB's where I am (mercifully, I am no longer in their service) have claimed this opinion since it was published.

Surprise! You're the bad guy. The labor and delivery culture is a curse and when I left I never looked back... although I must confess a certain Schadenfreude whenever I see posts like this.

Actually, that does not contradict @PainDrain. Anesthesiologists don't insert epidurals for Braxton-Hicks either.

 

[deleted171991]

http://www.huffingtonpost.com/2014/10/08/timing-epidural_n_5952826.html

"For years, OB-GYNs and anesthesiologists have grappled with the right time to give a laboring woman an epidural to help with the pain of childbirth.

A new Cochrane review offers a clear answer: When she asks for it.

The review, published Wednesday, includes nine studies, each looking at the timing of epidurals and birth outcomes. There has been some concern that early epidurals, or those administered before a woman’s cervix is dilated at least 4 centimeters to 5 centimeters, prolong labor and increase her chance of a Cesarean section — a continued worry given that the C-section rate in the United States hovers just below 33 percent.

However, the reviewers concluded that was not the case.

Taken together, the nine studies showed no clinically significant differences in the risk of having a C-section in women who got early versus later epidurals. Nor did the studies show any meaningful differences in the risk of needing an assisted birth using forceps or suction.

Furthermore, the researchers found no major differences in the duration of the second stage of labor — the period between when a woman is fully dilated and when she delivers her baby."

That's what contradicts @PainDrain.

I am too lazy to look up the review now.

 

[GravelRider]

So I am constantly amazed at the OBs where I practice. They clearly have no understanding of what we do, but the fact they know so little or care so little about their patients really bothers me.

We have several OBs who bring patients in for "induction" with little to no chance of achieving a vaginal delivery. We are talking morbidly obese, short women who are 38 weeks with a long closed cervix. They start them on pit, get an epidural and if they don't progress fast enough it's off to section. Seriously? I can't understand this, it boggles my mind.

Alot of what happens on the OB floor boggles my mind. Logic doesn't always win out there.

 

[deleted171991]

Alot of what happens on the OB floor boggles my mind. Logic doesn't always win out there.

Agree. And the liability makes it not worth it. Unless partners, I advise new grads to look for jobs with no OB. The CRNAs can have it.

 

[WholeLottaGame7]

The short, fat ones are the ones I'd rather put an epidural in at 1cm than get called for a neuraxial when they're 9cm.

 

[IlDestriero]

When I was at my small community hospital type gig we said 4cm. We had one person on call for OB and the OR. They were welcome to administer IV pain medication. We even gave them guidelines. 10 of morphine and some phenergan did a great job of getting them quiet and a nice nap. If they were dying, we'd put one in, but if you're in 12/10 pain in early labor your chance of a SVD is pretty poor.


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Il Destriero

 

[PainDrain]

The Cochrane review is related to an epidural prolonging labor or increasing the chance of c-section. And it does put us in a bad position where we must do whatever the OB or woman wants.

The instances I am specifically referring to are women with no chance of a successful induction because their body habitus, pelvis, and cervix are not inducible. Bishop score less than 6 = no chance of induction.

 

[deleted171991]

The Cochrane review is related to an epidural prolonging labor or increasing the chance of c-section. And it does put us in a bad position where we must do whatever the OB or woman wants.

The instances I am specifically referring to are women with no chance of a successful induction because their body habitus, pelvis, and cervix are not inducible. Bishop score less than 6 = no chance of induction.

That sounds like bad medicine, something you should bring up with the hospital management. Also one more reason to get an early epidural in these patients, before any fetal distress.

 

[Noyac]

When I was at my small community hospital type gig we said 4cm. We had one person on call for OB and the OR. They were welcome to administer IV pain medication. We even gave them guidelines. 10 of morphine and some phenergan did a great job of getting them quiet and a nice nap. If they were dying, we'd put one in, but if you're in 12/10 pain in early labor your chance of a SVD is pretty poor.


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Il Destriero

Well this is all a double edged sword IMO. If you mandate a cutoff for placement then you are guaranteed more middle of the night calls. I hate middle of the night calls. I'd rather place one a 1cm at 5pm then at 4 cm at 3am.

So I would approach this with my OB Colleagues this way. Hey guys, you decide when the pt needs an epidural. However, we are a smaller hospital with limited resources so if after (some determined time like 10pm) they are not at 3-4cm and in severe pain let's say we wait till the morning and everyone gets some well needed sleep. Capeesh?

 

[Ezekiel2517]

Where I trained no one got an epidural unless they were in active labor (3cm or greater and contracting regularly). I have been asked to put epidurals in patients 1cm. Is it our place to call bull**** on this?

You can call bullsh!it on this but I know I wouldn't be able to where I practice. When I'm on OB, if they tell me to jump, I jump. I may not like it but OB can be quite lucrative for me so I just shut up.

 

[Planktonmd]

So I am constantly amazed at the OBs where I practice. They clearly have no understanding of what we do, but the fact they know so little or care so little about their patients really bothers me.

We have several OBs who bring patients in for "induction" with little to no chance of achieving a vaginal delivery. We are talking morbidly obese, short women who are 38 weeks with a long closed cervix. They start them on pit, get an epidural and if they don't progress fast enough it's off to section. Seriously? I can't understand this, it boggles my mind.

Where I trained no one got an epidural unless they were in active labor (3cm or greater and contracting regularly). I have been asked to put epidurals in patients 1cm. Is it our place to call bull**** on this?

Why do you want to wait until they start hurting and become a moving target to place your epidural??? You actually should be happy that your OBs want it early.
Placing an epidural does not necessarily mean you need to start the infusion if the patient is still comfortable.

 

[deleted126335]

As long as the OB and the patient are committed to delivery I am willing to place the epidural whenever they want. Earlier is better imo.


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[pgg]

I don't see a problem with early epidurals.

I don't much care if they call the section now vs later, or if I put in an epidural now vs later.

Some people just hate OB, I guess.

 

[anes121508]

Why do you want to wait until they start hurting and become a moving target to place your epidural??? You actually should be happy that your OBs want it early.
Placing an epidural does not necessarily mean you need to start the infusion if the patient is still comfortable.

this is the general sentiment where I am training....some attendings prefer i run saline 1ml/hr some just tell me to cap it and leave it...ever have clot off or stop functioning if you place it and don't run it?

 

[ZzzPlz]

Seems like a lot of the time when they come down the next morning for a tubal, I dose up the epidural and it doesn't work well or at all, even if the catheter hasn't migrated out of the skin. I know it's not clotted since I can bolus through it easily.

Anyone have ideas why they stop working?

 

[sigrhoillusion]

Seems like a lot of the time when they come down the next morning for a tubal, I dose up the epidural and it doesn't work well or at all, even if the catheter hasn't migrated out of the skin. I know it's not clotted since I can bolus through it easily.

Anyone have ideas why they stop working?

Some people think patient's develop tachyphylaxis...

 

[PainDrain]

Some people think patient's develop tachyphylaxis...

Tachyphylaxis is legit, most common with lidocaine.

 

[Phyrst]

Anecdotally, it seems the larger BMI folks fail inductions on L&D. If the OBs are going to continue to push trial of labor in these folks, I'd rather place an early epidural to avoid problems on my end when things take a turn for the worse.

 

[deleted171991]

Some people just hate OB, I guess.

Some employees are paid peanuts to do OB, while the partners get the coconut. At the employee level of liability and stress, it's just not worth it for some people. I can understand that. I'd rather do critical care myself.

Now when one makes many thousands per OB shift, one will keep the clients happy, won't one?

 

[Ignatius J]

I don't do OB much anymore and I don't miss it one bit. You think you may lose skills with neuraxial, until you have to do one again and you realize a monkey can do it if you trained them.

 

[Noyac]

Anecdotally, it seems the larger BMI folks fail inductions on L&D. If the OBs are going to continue to push trial of labor in these folks, I'd rather place an early epidural to avoid problems on my end when things take a turn for the worse.

Actually they don't "fail" induction more if given adequate time. A recent report came out showing that the obese progress through labor more slowly. The issue is that we don't give them adequate time.

 

[Doctor4Life1769]

Seems like a lot of the time when they come down the next morning for a tubal, I dose up the epidural and it doesn't work well or at all, even if the catheter hasn't migrated out of the skin. I know it's not clotted since I can bolus through it easily.

Anyone have ideas why they stop working?

Perhaps movement of the catheter?

 

[fakin' the funk]

The short, fat ones are the ones I'd rather put an epidural in at 1cm than get called for a neuraxial when they're 9cm.

False dichotomy, bro.

 

[fakin' the funk]

We have several OBs who bring patients in for "induction" with little to no chance of achieving a vaginal delivery. We are talking morbidly obese, short women who are 38 weeks with a long closed cervix. They start them on pit, get an epidural and if they don't progress fast enough it's off to section. Seriously? I can't understand this, it boggles my mind.

Where I trained no one got an epidural unless they were in active labor (3cm or greater and contracting regularly). I have been asked to put epidurals in patients 1cm. Is it our place to call bull**** on this?

I agree with you on a few things. Yes, I'm as confused as you are why a 38 weeker with unfavorable cervix is getting induced. And yes, I take issue with the paranoia amongst OB's (which drives a lot of the decision making) about the patient not "sticking to the schedule," especially when that patient is not "normal" -- in your case, obese.

I too have been asked to put an epidural in a patient who was 1cm dilated. Usually these are post-dates inductions whose cervix was ready, or, at worst, "social" inductions in 39-40 week range, so maybe they're not hurting that bad now, but they're gonna be in like 45 minutes.

If the patient's NOT in labor, you don't "have" to do the epidural. It's not a lot more complicated than that to me. Call bull**** if you want. But if the agreed-upon OB plan is to induce labor and you don't wanna do it at 1cm, then yeah you're probably gonna have to do it at 3, 4, 5cm on a wiggly fatty, and that may well be at 3, 4, 5 AM. If you believe that that's in the best interest of the patient (the data don't bear that out in terms of 2nd stage duration, C-section rate etc), then go ahead and delay.

 

[deleted59964]

if the patient has approximately no chance of a vaginal delivery I would much rather they just do the section and I'll do a spinal.

much better quality anaesthetic

 

[pgg]

if the patient has approximately no chance of a vaginal delivery I would much rather they just do the section and I'll do a spinal.

much better quality anaesthetic

That is true, and lots of us routinely pull epidurals and do spinals for sections after labor, for exactly that quality reason.

I think we'd all prefer that the OBs make good plans instead of bad plans. But the OB is the one making the plan. If it's cranking up the pit on a patient with a 12% chance of vaginal delivery ... she's getting an epidural.

I'm not sure there's much to discuss in terms of our technique or our decision making here ...

 

[WholeLottaGame7]

False dichotomy, bro.

Is this your first time coming across hyperbole, bro? You're pretty deep into your career to not have seen it before.

I can take it out if it makes you feel better: I would rather know in advance about a patient that I think will fail IOL and need a C-section and that will potentially be challenging to do either a neuraxial or intubation (even though they usually aren't), than to find out at the last second.

I agree with pgg, not sure what we're discussing here.

Is it the decision to induce? We're not OBs, we don't decide who and when to induce patients (even if we have opinions). Just like any of the other surgical procedure threads on here, we can voice our concerns and provide input, but ultimately it's not our decision.

Is it when to place an epidural? Because the guidelines are pretty clear on that. What's the point of arguing 2cm vs 4cm? You're pushing it off by an hour or two? If you're not busy, great, bang it out, get paid, make friends. If you're busy, also great, you still have time to do it later and they can wait.

 

[deleted126335]

More than once I have seen a patient who I "knew" would need a C-section pop the baby out from below. So I tend not to second guess this decision to let these patients labor awhile. What does drive me crazy is the OB who decides that the proper time to declare need for a Section is right after office hours or right before their shift ends.

 

[VA Hopeful Dr]

I obviously can't comment on the anesthesia end of this, but it might be worthwhile to consider the OB's point of view here.

There is a big movement by insurance companies away from c-sections. Its possible that the OBs know these women need to be sectioned but are required to do a trial of labor otherwise they won't get paid for the section. In the cases from the OP, those women could be getting induced for pre-eclampsia or LGA babies due to diabetes (since those need induction but don't automatically need to be sectioned).

I bet if you asked the OB, they'd say something like "Yeah I don't think this induction will work either, but I have to play by Blue Cross/Cigna/Medicaid's rules"