OB case

[ethilo]

I have a pretty unique OB case to share with you guys:

28F otherwise healthy G1P0 patient presents in early labor with sudden onset of R-sided abdominal pain. She is on the midwife service with a plan for "unmedicated birth", she is interested in nitrous oxide as her means of pain control with labor.

On exam, she has severe anterior R sided abdominal pain with some swelling and mild crepitus under the skin just R of the umbilicus. Ultrasound exam shows a normal gestation without uterine rupture, no appendicitis, no cholecystitis. Instead, it finds she had a spontaneously ruptured R internal oblique muscle with a free-fluid collection in the capsule of the muscle.

She is admitted to L&D in early labor with plans for SVD, but her anterior abdominal pain is excruciating and distracting her and her husband from the birth experience. I received a page from the RN that said "patient is requesting an epidural."

On my evaluation, she is utterly dismayed and appears defeated. She relays "I was told an epidural is my only option here so I guess that's the way it's gotta be."

So what did we do? (what would you do)

---

Members don't see this ad.

 

[deleted59964]

educate her on the available options, and let her choose

 

[Hoya11]

I have a pretty unique OB case to share with you guys:

28F otherwise healthy G1P0 patient presents in early labor with sudden onset of R-sided abdominal pain. She is on the midwife service with a plan for "unmedicated birth", she is interested in nitrous oxide as her means of pain control with labor.

On exam, she has severe anterior R sided abdominal pain with some swelling and mild crepitus under the skin just R of the umbilicus. Ultrasound exam shows a normal gestation without uterine rupture, no appendicitis, no cholecystitis. Instead, it finds she had a spontaneously ruptured R internal oblique muscle with a free-fluid collection in the capsule of the muscle.

She is admitted to L&D in early labor with plans for SVD, but her anterior abdominal pain is excruciating and distracting her and her husband from the birth experience. I received a page from the RN that said "patient is requesting an epidural."

On my evaluation, she is utterly dismayed and appears defeated. She relays "I was told an epidural is my only option here so I guess that's the way it's gotta be."

So what did we do? (what would you do)

Put in the epidural. She will probably go to section. Its not my problem that she is disappointed that she could not have a natural birth. SH** happens. She should be happy to get through with a healthy baby. She should have a section, not labor and make the muscle injury worse, then after section re-evaluate the muscle/hematoma situation and possibly consult specialists.

 

[Hoya11]

.

 

[pgg]

You could TAP block her. That way she could avoid the pain of the torn abd muscle but still be able to enjoy the pain of childbirth like she wants.

 

[deleted162650]

You could TAP block her. That way she could avoid the pain of the torn abd muscle but still be able to enjoy the pain of childbirth like she wants.

I'm not so sure she has an intact plane to do a TAP with a ruptured internal oblique.

 

[pgg]

I'm not so sure she has an intact plane to do a TAP with a ruptured internal oblique.

You could be right. I'm not really a fan of TAP blocks, but I bet it would work for this better than what people usually use them for.


Pushing through labor with an injured abdominal muscle seems foolish and pointlessly painful to me, but crazy is as crazy does and there's plenty of that in the au naturale OB crowd. Also, it goes without saying that if you're going to symptomatically treat (or ignore) excruciating sudden onset abdominal pain in a term pregnant woman, you better be really, really sure you've got the right diagnosis. Ultrasound isn't exactly the gold standard for ruling out intra-abdominal badness. She ought to get a spinal and a c-section right now, but if she's glum and grudgingly OK with an epidural, good luck getting her to see the wisdom of that path.

 

[narcusprince]

Anybody question why a healthy g1p0 has an abdominal wall hematoma with internal oblique rupture? Connective tissue disease? She has a hematoma what does her labs look like? Platelet count? Agreed the internal oblique rupture could be a uterine rupture. Whats baby heart rate look like on the monitor? If normal platelet count and INR/APTT normal then she should be counseled that her best bet right now is to get the epidural if she says no. Then make sure the OR is ready to go if baby goes into distress. TAP, Snap, and FAP all things I don't like. TAP blocks rarely work and when they do they only take care of the somatic pain.

 

[pgg]

TAP blocks rarely work and when they do they only take care of the somatic pain.

Yeah, that was the idea.

We have a crazy person who wants the visceral pain of childbirth (hence the epidural-free birth plan) but doesn't want the somatic pain of an abdominal wall muscle strain. It's as if a TAP block was invented solely for people like her!

 

[urge]

On exam, she has severe anterior R sided abdominal pain with some swelling and mild crepitus under the skin just R of the umbilicus. Ultrasound exam shows a normal gestation without uterine rupture, no appendicitis, no cholecystitis. Instead, it finds she had a spontaneously ruptured R internal oblique muscle with a free-fluid collection in the capsule of the muscle.
)

How does one tear and abdominal muscle?

Crepitus in soft tissue usually involves air. Why would that be?

Is it a good idea to keep pushing when your abdominal wall is falling apart?

 

[ethilo]

Baby had a category 1 tracing, mom had stable vitals. She clearly had nothing wrong internally and her symptoms strongly pointed to MSK source in our discussion with the OB team (midwives consulted OB for the workup of the abdominal pain). Yeah, you're right, I used the wrong terminology with "crepitus" because this was a little different. It was more "spongy, fluid-filled" than the feeling of crepitus from subQ air.

We counselled her for a while on the options (she wanted nitrous + dula). In terms of an epidural, her biggest grudges about them were 1) medicated removal of labor pain and 2) forced bedrest, unable to walk around.

We decided to place a R-sided TAP catheter. Placement was challenging because the gravid uterus stretched the planes so tightly it was hard to identify and place a needle into it. Nevertheless we were successful after some struggling. We bolused it 25 mL 0.2% ropivacaine and her anterior pain entirely resolved without touching her labor pain. She was not required to be on bed rest or need for additional monitors. The catheter was not hooked to an infusion because it's a volume block and is better suited or intermittent bolusing. She liked that because she wasn't tied to an IV pole. She labored for 48 hours and the catheter allowed us to repeat boluses which we did every 4 hours.

We considered whether or not anesthetizing the plane would exacerbate the ruptured muscle. In all reality it was likely therapeutic by preventing that muscle from contracting on itself when it's injured. I discussed with her that there's a slightly possibility her pushing could be weaker with the TAP catheter in place and she may arrest labor, but we really didn't know HOW or even IF it would affect her ability to push.

After laboring for 48 hours (again, unclear if that was a consequence of the TAP catheter) the labor pain grew excruciating and she was progressing slowly. She then requested an epidural on her own and shortly thereafter was deemed in second stage arrest. We took her to the OR for C-section and had the surgery team prep the TAP catheter into the field so we could use it post-operatively if she needed it. We pulled the epidural at surgery end.

Post-op course, interestingly, was benign. After baby was delivered, the tension on the muscle was relieved and her pain went from severe to tolerable.

She and her husband told us later that the turning point of their experience was the placement of the TAP catheter because they felt like they were heard, respected, and empowered. She decided on her own for the epidural and was happy that we tried to find an alternative strategy before jumping right to it. She didn't use nitrous

 

[sevoflurane]

Baby had a category 1 tracing, mom had stable vitals. She clearly had nothing wrong internally and her symptoms strongly pointed to MSK source in our discussion with the OB team (midwives consulted OB for the workup of the abdominal pain). Yeah, you're right, I used the wrong terminology with "crepitus" because this was a little different. It was more "spongy, fluid-filled" than the feeling of crepitus from subQ air.

We counselled her for a while on the options (she wanted nitrous + dula). In terms of an epidural, her biggest grudges about them were 1) medicated removal of labor pain and 2) forced bedrest, unable to walk around.

We decided to place a R-sided TAP catheter. Placement was challenging because the gravid uterus stretched the planes so tightly it was hard to identify and place a needle into it. Nevertheless we were successful after some struggling. We bolused it 25 mL 0.2% ropivacaine and her anterior pain entirely resolved without touching her labor pain. She was not required to be on bed rest or need for additional monitors. The catheter was not hooked to an infusion because it's a volume block and is better suited or intermittent bolusing. She liked that because she wasn't tied to an IV pole. She labored for 48 hours and the catheter allowed us to repeat boluses which we did every 4 hours.

We considered whether or not anesthetizing the plane would exacerbate the ruptured muscle. In all reality it was likely therapeutic by preventing that muscle from contracting on itself when it's injured. I discussed with her that there's a slightly possibility her pushing could be weaker with the TAP catheter in place and she may arrest labor, but we really didn't know HOW or even IF it would affect her ability to push.

After laboring for 48 hours (again, unclear if that was a consequence of the TAP catheter) the labor pain grew excruciating and she was progressing slowly. She then requested an epidural on her own and shortly thereafter was deemed in second stage arrest. We took her to the OR for C-section and had the surgery team prep the TAP catheter into the field so we could use it post-operatively if she needed it. We pulled the epidural at surgery end.

Post-op course, interestingly, was benign. After baby was delivered, the tension on the muscle was relieved and her pain went from severe to tolerable.

She and her husband told us later that the turning point of their experience was the placement of the TAP catheter because they felt like they were heard, respected, and empowered. She decided on her own for the epidural and was happy that we tried to find an alternative strategy before jumping right to it. She didn't use nitrous

Nice work.

 

[Hoya11]

Baby had a category 1 tracing, mom had stable vitals. She clearly had nothing wrong internally and her symptoms strongly pointed to MSK source in our discussion with the OB team (midwives consulted OB for the workup of the abdominal pain). Yeah, you're right, I used the wrong terminology with "crepitus" because this was a little different. It was more "spongy, fluid-filled" than the feeling of crepitus from subQ air.

We counselled her for a while on the options (she wanted nitrous + dula). In terms of an epidural, her biggest grudges about them were 1) medicated removal of labor pain and 2) forced bedrest, unable to walk around.

We decided to place a R-sided TAP catheter. Placement was challenging because the gravid uterus stretched the planes so tightly it was hard to identify and place a needle into it. Nevertheless we were successful after some struggling. We bolused it 25 mL 0.2% ropivacaine and her anterior pain entirely resolved without touching her labor pain. She was not required to be on bed rest or need for additional monitors. The catheter was not hooked to an infusion because it's a volume block and is better suited or intermittent bolusing. She liked that because she wasn't tied to an IV pole. She labored for 48 hours and the catheter allowed us to repeat boluses which we did every 4 hours.

We considered whether or not anesthetizing the plane would exacerbate the ruptured muscle. In all reality it was likely therapeutic by preventing that muscle from contracting on itself when it's injured. I discussed with her that there's a slightly possibility her pushing could be weaker with the TAP catheter in place and she may arrest labor, but we really didn't know HOW or even IF it would affect her ability to push.

After laboring for 48 hours (again, unclear if that was a consequence of the TAP catheter) the labor pain grew excruciating and she was progressing slowly. She then requested an epidural on her own and shortly thereafter was deemed in second stage arrest. We took her to the OR for C-section and had the surgery team prep the TAP catheter into the field so we could use it post-operatively if she needed it. We pulled the epidural at surgery end.

Post-op course, interestingly, was benign. After baby was delivered, the tension on the muscle was relieved and her pain went from severe to tolerable.

She and her husband told us later that the turning point of their experience was the placement of the TAP catheter because they felt like they were heard, respected, and empowered. She decided on her own for the epidural and was happy that we tried to find an alternative strategy before jumping right to it. She didn't use nitrous

I personally would never TAP block a pregnant patient. Your needle could slip and cause damage to mom or the baby due to altered anatomy. Caudal blocks are not even recommended for the same reason. Too close to the baby with a large needle... You could have also pulled the TAP catheter and not bothered with prepping and maintaining it during CS, and instead left the epidural catheter in for post op analgesia. What if the mom developed a post op abd wall hematoma/infection? or the baby developed cardiac arrythmia? think they would not blame your TAP catheter/ropivicaine?

This is someone that wanted LESS anesthesia. TAP block wouldnt have crossed my mind. She ended up getting a TAP AND an epidural..

 

[urge]

Baby had a category 1 tracing, mom had stable vitals. She clearly had nothing wrong internally and her symptoms strongly pointed to MSK source in our discussion with the OB team (midwives consulted OB for the workup of the abdominal pain). Yeah, you're right, I used the wrong terminology with "crepitus" because this was a little different. It was more "spongy, fluid-filled" than the feeling of crepitus from subQ air.

We counselled her for a while on the options (she wanted nitrous + dula). In terms of an epidural, her biggest grudges about them were 1) medicated removal of labor pain and 2) forced bedrest, unable to walk around.

We decided to place a R-sided TAP catheter. Placement was challenging because the gravid uterus stretched the planes so tightly it was hard to identify and place a needle into it. Nevertheless we were successful after some struggling. We bolused it 25 mL 0.2% ropivacaine and her anterior pain entirely resolved without touching her labor pain. She was not required to be on bed rest or need for additional monitors. The catheter was not hooked to an infusion because it's a volume block and is better suited or intermittent bolusing. She liked that because she wasn't tied to an IV pole. She labored for 48 hours and the catheter allowed us to repeat boluses which we did every 4 hours.

We considered whether or not anesthetizing the plane would exacerbate the ruptured muscle. In all reality it was likely therapeutic by preventing that muscle from contracting on itself when it's injured. I discussed with her that there's a slightly possibility her pushing could be weaker with the TAP catheter in place and she may arrest labor, but we really didn't know HOW or even IF it would affect her ability to push.

After laboring for 48 hours (again, unclear if that was a consequence of the TAP catheter) the labor pain grew excruciating and she was progressing slowly. She then requested an epidural on her own and shortly thereafter was deemed in second stage arrest. We took her to the OR for C-section and had the surgery team prep the TAP catheter into the field so we could use it post-operatively if she needed it. We pulled the epidural at surgery end.

Post-op course, interestingly, was benign. After baby was delivered, the tension on the muscle was relieved and her pain went from severe to tolerable.

She and her husband told us later that the turning point of their experience was the placement of the TAP catheter because they felt like they were heard, respected, and empowered. She decided on her own for the epidural and was happy that we tried to find an alternative strategy before jumping right to it. She didn't use nitrous

Impressive.

 

[narcusprince]

Not impressed. You wasted resources placing a Tap catheter into a hostile environment unresolved oblique rupture. The conversation should have been directed at placing the epidural( analgesia away from the site of injury). If her abdominal wall ruptures again or does not heal. Would they blame the catheter?

 

[GravelRider]

I personally would never TAP block a pregnant patient. Your needle could slip and cause damage to mom or the baby due to altered anatomy. Caudal blocks are not even recommended for the same reason. Too close to the baby with a large needle... You could have also pulled the TAP catheter and not bothered with prepping and maintaining it during CS, and instead left the epidural catheter in for post op analgesia. What if the mom developed a post op abd wall hematoma/infection? or the baby developed cardiac arrythmia? think they would not blame your TAP catheter/ropivicaine?

This is someone that wanted LESS anesthesia. TAP block wouldnt have crossed my mind. She ended up getting a TAP AND an epidural..

I agree here. This lady needs more counseling about her anesthetic options. It doesn't make sense to me that she would prefer a systemic anesthetic, like nitrous, over having an epidural placed. Often times these doulas give women misinformation about anesthetic techniques and what to expect during labor. An epidural placed in the first place would have been the simplest and probably safest option.

 

[Orin]

You can do it, but should you...

It worked this time so that's great, but I wouldn't think this makes sense for 99% of cases.

On a safety side, do you think local anesthetics help or hurt a healing muscle?
What's the systemic absorption of local anesthetic around a hematoma?

On a billing side, as you aren't treating her obstetric pain at all, what're you coding this as since you aren't really delivering OB Anesthesia services?

I love thinking outside the box, but just because you can, doesn't mean you should.

 

[pgg]

Let's not get carried away overblowing the risk of a TAP block.

And absolutely everything we do for labor analgesia is totally elective. Sure, ACOG and ASA have some touchy-feely statements on how epidurals are a human right that shan't be denied. It's still an elective procedure we do to get the pain of her birth experience in line with her desires.

I don't think an ultrasound guided TAP block in a motivated, cooperative patient is at any real risk of needle slippage and baby skewerage. I don't think a compartment block at 1/4 or less of the max allowable dose is a significant LAST risk. This patient and her doula were one step away from delivering at home in a bathtub. I mean, she went 48 hours before throwing in the towel.

I don't much care about the resources used or the billing. The patient had pain from a non-OB injury and got directed analgesia for it. Nice job OP.

 

[OB1🤙]

I think this was a good case with good, conscientious management. Well played, OP. Haters gonna hate.

 

[teeva]

So instead of inserting an epidural at the beginning which would have been used for the predicted c/s, you do a block that requires manual bolus q4h for 48h, and then put in an epidural anyway, and then go to c/s anyway? Seems like a lot of work.

 

[ethilo]

The attending that I was on with was a regional anesthesia specialist. I proposed the procedure to her after I had a long discussion with the patient about what it looks like etc. etc. Sure, this seemed like a fairly invasive procedure, especially for someone interested in unmedicated birth. But If you look at what her perspective is, someone interested in unmedicated birth is often trying to say "I don't want to be snockered by a bunch of drugs" and "I don't want stuff to effect my baby." It was far better than IV fentanyl or nitrous for her because it wasn't mind-altering and no significant effects on baby.

We weren't too concerned about needle puncture to fetus. It was ultrasound-guided and we were far posterolateral to better engage where the plexus first emerges in the TA plane . What made it difficult was not a concern about doing further harm. What made it difficult was actually getting the hydrodissection and catheter into the appropriate plane instead of the transverse abdominus or the internal oblique muscle.

As a resident billing hadn't crossed my mind.

Sure it was a lot of work but it was what SHE needed and it made all the difference to her.

 

[dhb]

This is all fine and dandy at an academic hospital. In the real world who is going to bolus a cath q4h?? That's crazy. She felt empowered and heared? big deal you catered to her craziness: 48h of labor wtf?
Maybe i would have done a tap with dexamethasone but no more.

 

[ethilo]

I'm noticing there's been a few people who are demonstrating a disinterest in listening to what this patient's desires and wishes are. To me, if we had gone straight away and placed the epidural it would have reinforced her dissatisfaction with the medical system. A bit like "I know what's best for you." In the big picture, I think we can be better than that.

I feel our actions are upholding autonomy, beneficence, and justice. If it were me in her shoes sure, I would have gone for the epidural right away. But I'm not her and have different values. It's my duty to uphold the needs of the patient and separate out my self-interest.

 

[deleted59964]

if you're worried about skewering a baby with a TAP block - you're doing them wrong

 

[pgg]

big deal you catered to her craziness: 48h of labor wtf?

What are you gonna do, drag her to the operating room against her will?

 

[Planktonmd]

I am not sure that placing a catheter in a sterile hematoma is the brightest idea from infection point of view... but since it allowed her to experience the spirituality of painful child birth she wanted I guess it's OK!

 

[Psai]

I'm noticing there's been a few people who are demonstrating a disinterest in listening to what this patient's desires and wishes are. To me, if we had gone straight away and placed the epidural it would have reinforced her dissatisfaction with the medical system. A bit like "I know what's best for you." In the big picture, I think we can be better than that.

I feel our actions are upholding autonomy, beneficence, and justice. If it were me in her shoes sure, I would have gone for the epidural right away. But I'm not her and have different values. It's my duty to uphold the needs of the patient and separate out my self-interest.

Yeah let's throw away time and money for no reason just so an unreasonable patient can feel empowered. Awesome op.

 

[narcusprince]

Yeah let's throw away time and money for no reason just so an unreasonable patient can feel empowered. Awesome op.

Totally agree. If this patient develops an infection or complication from the internal oblique rupture they will blame the block or at least try to. We all have this fantasy that informed consent protects us from being sued should a complication arise. It doesn't. Situational awareness this is a malignant environment to place a TAP catheter. I would have offereed an epidural. Or she can labor with nitrous.

 

[caligas]

The reason they were so happy is because they got special treatment, not the tap block per se.

Next time offer a "special" epidural cocktail and add a little sufentanil or something.

 

[dhb]

What are you gonna do, drag her to the operating room against her will?

No, but i'm not going to bolus a cath q4h that's for sure.
Best plan would have been a spinal for a section.
What was done in this case would have been plan Z and is only possible in an academic environment.
Can you imagine your partner giving you the call beeper in the morning and on his way out :
"Oh btw there is this crazy b...h that's been in labor for 24h you just have to bolus her Tap cath every 4h and wait for the c section to come your way have a good one!"

 

[sigrhoillusion]

I'm amazed they let this woman labor for 48 hours... let alone 48 minutes after they realized her abdominal wall had ruptured. I mean who knows what actually caused the rupture, but if I had any concerns it was from the labor, I would have gotten the baby out ASAP! Sorry lady I know you want to spiritually bond with your baby and gobble down her placenta afterwards, but more than likely she's getting a spinal and a section.

And this story would be all warm and fuzzy if you did the TAPI was on callcatheter and she delightfully pushed the baby out in all her agony, but then she ended up caving anyways and getting the epidural, and then failed to get the baby out anyways and went to section. PErhaps the ruptuired abdominal muscle contributed with her inability to push?? I'm just amazed the OBs let her go that long.

I was on call this Saturday and got an OB rapid response to the hospital lobby... always scary... get ther with one of my residents and found a woman on a stretcher shivering with an umbillical cord hanging out of her gown. Had delivered the baby in the parking lot of the hospital. The baby was in a blanket with the NICU team on their way to the ED. Mother and baby did fine. No epidural. No calls for reboluses. No STAT section 4 hours later. Allowed me to catch a few ZZZs...

 

[pgg]

Man, to read this thread you'd think that regional anesthesia was never used for musculoskeletal injuries and that elective analgesic procedures were never done for women in labor.

So much handwringing ... and from the non-academics, for a change!

 

[dhb]

Unreasonable demands met by unreasonable management that's all there is to it.

 

[IlDestriero]

All's well that ends well.
I wouldn't have done the block.
Epidural if she wants, or let the midwife come up with a better plan, with input from the doula, of course.


--
Il Destriero

 

[sigrhoillusion]

All's well that ends well.
I wouldn't have done the block.
Epidural if she wants, or let the midwife come up with a better plan, with input from the doula, of course.


--
Il Destriero

What about the shaman?

 

[deleted171991]

I'm noticing there's been a few people who are demonstrating a disinterest in listening to what this patient's desires and wishes are. To me, if we had gone straight away and placed the epidural it would have reinforced her dissatisfaction with the medical system. A bit like "I know what's best for you." In the big picture, I think we can be better than that.

I feel our actions are upholding autonomy, beneficence, and justice. If it were me in her shoes sure, I would have gone for the epidural right away. But I'm not her and have different values. It's my duty to uphold the needs of the patient and separate out my self-interest.

With all due respect to patient autonomy, she was very lucky to find this anesthesiologist. Most of us would have gone for an epidural in the best case.

You have to realize the risks of everything you offer a patient, not just the benefits. You got lucky this time. The reason we go to medical school is exactly so that we can know better what's good for the patient. I don't believe in a paternalistic approach, but I don't believe in the spoiled approach either. I have a very simple standard of care, that I explain to all my patients: "if you were a dear family member, this is what I would (not) recommend...". Also, sometimes there are limited resources available, especially in PP; one cannot just babysit every patient, even if it's more convenient for the patient. It doesn't mean those doctors don't care, just that the system doesn't allow it. (That's also "justice" by the way, but for the doctor's other patients.) Last, but not the least, one should have a bit of self-preservation instinct: in this malpractice environment, always keep in mind your own family's risks and benefits.

 

[WholeLottaGame7]

With all due respect to patient autonomy, she was very lucky to find this anesthesiologist. Most of us would have gone for an epidural in the best case.

You have to realize the risks of everything you offer a patient, not just the benefits. You got lucky this time. The reason we go to medical school is exactly so that we can know better what's good for the patient. I don't believe in a paternalistic approach, but I don't believe in the spoiled approach either. I have a very simple standard of care, that I explain to all my patients: "if you were a dear family member, this is what I would (not) recommend...". Also, sometimes there are limited resources available, especially in PP; one cannot just babysit every patient, even if it's more convenient for the patient. It doesn't mean those doctors don't care, just that the system doesn't allow it. (That's also "justice" by the way, but for the doctor's other patients.) Last, but not the least, one should have a bit of self-preservation instinct: in this malpractice environment, always keep in mind your own family's risks and benefits.

I also would not have gone the TAP route, but people are WAAAY overstating the risks in this case. Do you all seriously worry about your family's financial well-being every time you do a TAP block? If so, as someone else said, you're doing it wrong. If you can't do it because there aren't enough resources to (time or people or both) to bolus it, or you think it will just not work, those are entirely different and reasonable concerns.

I think you're more at risk for a lawsuit if you pressure this woman into getting an epidural against her will and there is a complication related to that. It sounds like the OP had an in-depth conversation with the patient, heard her concerns, and came up with a (for academics) reasonable plan for pain control and adjusted it according to circumstances, and it worked. I say good job, and you should write it up. Especially since it might not work so well next time... ;-)

 

[deleted171991]

I am not an expert in oblique muscle rupture (or TAP blocks), but I wouldn't put a catheter in that area. One can argue that even an epidural could seriously worsen the muscle rupture (and cause who knows what complications), by permitting her to continue laboring naturally. Things do happen, and American patients love blaming anybody else but themselves, even if they have been well-informed about the risks and have accepted them.

So, yes, I tend to do everything I can by the book, or not far from it. It's just not worth it for me, whether I do a serious favor to a patient, a surgeon, or my employer. They all have short memory. All the risks, minimal benefits? No, thanks.

 

[pgg]

If the nerves to the muscle are blocked, how's it going to contract to make the injury worse? The TAP block might even be protective. We make fun of orthopods who ask for more muscle relaxant in a patient with a nerve block. I don't know what to make of anesthesiologists who think a blocked muscle is going to contract its way to further injury.

It seems the objections fall into a few categories:
1) a TAP block in this patient is dangerous
2) it's too much effort
3) crazy people shouldn't be catered to, because

I don't buy #1 at all.

Yes, it would take effort. I wouldn't look down on anyone who didn't offer to do it because they thought it was more trouble than it was worth.

This patient is about a 5 on the OB crazy scale. She gets 4 of those points just for having a doula. The name of the labor analgesia game is catering to the whims and desires of laboring women. It's all elective. It's all to bring her experience in line with her imagined ideal. This is just another flavor of regional anesthesia for labor, which is the cornerstone of OB anesthesia.

I don't do TAP blocks (or even OB any more) but this struck me as a totally reasonable, if labor intensive, solution to an unusual problem.

 

[Orin]

I love the idea of it, but practically speaking it just makes very little sense.

Say she had slipped and broke her ankle, but wanted an unmedicated birth. Would you drop a pop/fem and then move to the epidural later? Or would you counsel her that your epidural could cover the pain from both and save her some interventional risk?

To me this has very little to do with the pregnancy itself, but more risk/benefit. At the end of the day, that's her life, so if she wants the risks, my job and training is to handle it. In this case, I wonder if a lidoderm patch or an ice pack would've gotten the same bang/buck.

I'm not crazy about our conversation about the 'crazy' of the patient. I don't agree with it, but yeah, her life/her decision. If I can dose a NMB per surgeon request or avoid drug X or technique Y for rare zebra Z, and all that jazz, I can probably accommodate most patient requests.

 

[Gastrapathy]

All's well that ends well.
I wouldn't have done the block.
Epidural if she wants, or let the midwife come up with a better plan, with input from the doula, of course.


--
Il Destriero

No business in this thread but it caught my interest after fat fingering it accidentally. Then I spent 5 minutes trying to decide if this was a poem.

 

[Planktonmd]

If the nerves to the muscle are blocked, how's it going to contract to make the injury worse? The TAP block might even be protective. We make fun of orthopods who ask for more muscle relaxant in a patient with a nerve block. I don't know what to make of anesthesiologists who think a blocked muscle is going to contract its way to further injury.

It seems the objections fall into a few categories:
1) a TAP block in this patient is dangerous
2) it's too much effort
3) crazy people shouldn't be catered to, because

I don't buy #1 at all.

Yes, it would take effort. I wouldn't look down on anyone who didn't offer to do it because they thought it was more trouble than it was worth.

This patient is about a 5 on the OB crazy scale. She gets 4 of those points just for having a doula. The name of the labor analgesia game is catering to the whims and desires of laboring women. It's all elective. It's all to bring her experience in line with her imagined ideal. This is just another flavor of regional anesthesia for labor, which is the cornerstone of OB anesthesia.

I don't do TAP blocks (or even OB any more) but this struck me as a totally reasonable, if labor intensive, solution to an unusual problem.

It's not reasonable to put a catheter in a sterile hematoma and turn it into an abscess by introducing more bacteria every 4 hours!
And as a physician your job and your duty is actually to know what's better for the patient and to prevent craziness from reaching a dangerous level.

 

[sigrhoillusion]

If the nerves to the muscle are blocked, how's it going to contract to make the injury worse? The TAP block might even be protective. We make fun of orthopods who ask for more muscle relaxant in a patient with a nerve block. I don't know what to make of anesthesiologists who think a blocked muscle is going to contract its way to further injury.

It seems the objections fall into a few categories:
1) a TAP block in this patient is dangerous
2) it's too much effort
3) crazy people shouldn't be catered to, because

I don't buy #1 at all.

Yes, it would take effort. I wouldn't look down on anyone who didn't offer to do it because they thought it was more trouble than it was worth.

This patient is about a 5 on the OB crazy scale. She gets 4 of those points just for having a doula. The name of the labor analgesia game is catering to the whims and desires of laboring women. It's all elective. It's all to bring her experience in line with her imagined ideal. This is just another flavor of regional anesthesia for labor, which is the cornerstone of OB anesthesia.

I don't do TAP blocks (or even OB any more) but this struck me as a totally reasonable, if labor intensive, solution to an unusual problem.

I guess what I'm saying is is be concerned about what caused the abdominal injury in the first place. Was it her pushing/ contracting? Did she need that muscle to help push? If it's damaged at this point whether it's blocked or not will she be able to get the baby out naturally with or without a block/epidural/doula/spiritual advisor...

From our n=1 example it appears the answer is no. Granted she might have ended up in section for a million reasons why parents end up at section. But a spontaneous abdominal wall muscle rupture might add to it.

 

[Hoya11]

She relays "I was told an epidural is my only option here so I guess that's the way it's gotta be."

What is she really saying?? This is like a jehovas witness inevitably accepting a blood tansfusion. Shes saying, "I want you to tell me I absolutely need the epidural and that its not my fault and I did everything I could not to have one but I NEED one" I applaud your attitude of respecting patients autonomy. But i think you just misread this situation. She has already made the decision in her mind, she just wants you to reaffirm that an epidural is OK and safe and that SHE has special / unique need for one unlike the regular "wimps" who cant tolerate labor, SHE has a medical need for one so its different. This is because I KNOW epidural analgesia is whats right for her and if this is what I have to tell her to get that to happen then thats what I do. I dont want to waste time skirting the issue and increasing risk with other procedures that SHE feels obligated to get to continue to avoid the evil epidural.

 

[vector2]

Based on the n=1 case report I found, oblique rupture is exceedingly rare and is usually due to torsional muscle injury, but one of the causes can be epigastric artery or iliac branch artery that's ruptured. Would've just sectioned her to avoid any further damage caused by straining from labor.

 

[pjl]

What is she really saying?? This is like a jehovas witness inevitably accepting a blood tansfusion. Shes saying, "I want you to tell me I absolutely need the epidural and that its not my fault and I did everything I could not to have one but I NEED one" I applaud your attitude of respecting patients autonomy. But i think you just misread this situation. She has already made the decision in her mind, she just wants you to reaffirm that an epidural is OK and safe and that SHE has special / unique need for one unlike the regular "wimps" who cant tolerate labor, SHE has a medical need for one so its different. This is because I KNOW epidural analgesia is whats right for her and if this is what I have to tell her to get that to happen then thats what I do. I dont want to waste time skirting the issue and increasing risk with other procedures that SHE feels obligated to get to continue to avoid the evil epidural.

Absolutely standard practice to talk up all the reasons one patients labor is worse than the rest when they fail the planned "natural childbirth." They need to hear it most of the time. My favorite was a planned hypno-birth complete with hypnotist, who told him off after getting an epidural.

This is interesting management of the situation.
I would not have done it because there is no chance my partners would continue bolusing the catheter. I would think a single shot should last long enough for a standard labor though, for those worried about repeat injections.

Also, after quick poll of a few OBs, she would have been sectioned almost immediately after diagnosis at my hospital. Good for her she gets to be at such a loving hospital.


Sent from my iPhone using SDN mobile app

 

[GravelRider]

Based on the n=1 case report I found, oblique rupture is exceedingly rare and is usually due to torsional muscle injury, but one of the causes can be epigastric artery or iliac branch artery that's ruptured. Would've just sectioned her to avoid any further damage caused by straining from labor.

This is what perplexes me so much about this case. We bring patients to c-section for a lot less. Why let her labor for days?

I also think the OP asked for opinions on management. Epidural and appropriate patient counseling seems like the best and simplest approach. The OP chose a non-standard solution, so I actually think it is appropriate to question it and think about the potential downsides. A lot of the downsides brought up have to do with resource utilization and I think it is our duty as physicians to take that into consideration.

 

[dhb]

It seems the objections fall into a few categories:
1) a TAP block in this patient is dangerous
2) it's too much effort
3) crazy people shouldn't be catered to, because

No, i would do a single shot TAP if she were very nice.
I wouldn't put a cath because a) i've never done one nor have i found a situation that would require it b) i'm not a automated pump c) i don't think it's the right management.

What's funny is you say you don't do TAPs but you're fine with the case, while i'll do a TAP anytime i can but don't see this as a reasonable way to go.

 

[Noyac]

I have come to this discussion late so if anyone has already mentioned this then just ignore my post.

I would not recommend aTAP block in this or any other pregnant pt. Save it for the academic places that want to do the work looking at it and proving its safety. We don't know the blood levels of the local after a TAP block especially when there is a hematoma. The fetus is extremely sensitive to these local agents. This is why paracervical blocks are looked down on. The incidence of fetal Bradycardia after a paracervical block approaches 50%. The fetus also had a much higher incidence of acidosis after PCB. And that is usually with lidocaine. You most certainly used something much more toxic (ropivicaince) which can take up to 9hrs for the fetus to metabolize. And the reason caudals fell out of favor was not because of the risk of trauma with needle placement as someone mentioned earlier but because of fetal local anesthestic toxicity.

This pt had a doola. I would have told OB to let her doola deal with her or get rid of the doola so I can place an epidural ( which I know is safe).

 

[sigrhoillusion]

I have come to this discussion late so if anyone has already mentioned this then just ignore my post.

I would not recommend aTAP block in this or any other pregnant pt. Save it for the academic places that want to do the work looking at it and proving its safety. We don't know the blood levels of the local after a TAP block especially when there is a hematoma. The fetus is extremely sensitive to these local agents. This is why paracervical blocks are looked down on. The incidence of fetal Bradycardia after a paracervical block approaches 50%. The fetus also had a much higher incidence of acidosis after PCB. And that is usually with lidocaine. You most certainly used something much more toxic (ropivicaince) which can take up to 9hrs for the fetus to metabolize. And the reason caudals fell out of favor was not because of the risk of trauma with needle placement as someone mentioned earlier but because of fetal local anesthestic toxicity.

This pt had a doola. I would have told OB to let her doola deal with her or get rid of the doola so I can place an epidural ( which I know is safe).

Don't want to upset the doula. They might cast some voodoo spell on you.