Spinal for Caesarean Section question

Phosphate · Jul 20, 2006

For labour delivery a spinal block is extened to the T10 level. For Caesarean Section the level or the block is extended to T4 due to peritoneal manipulation?

My question is: What part or the peritoneum is manipulated, and what part of the peritoneum is innervated by a segments T4, T5, T6,T7 etc?

Thanks

jetproppilot · Jul 20, 2006

Phosphate said:
For labour delivery a spinal block is extened to the T10 level. For Caesarean Section the level or the block is extended to T4 due to peritoneal manipulation?

My question is: What part or the peritoneum is manipulated, and what part of the peritoneum is innervated by a segments T4, T5, T6,T7 etc?

Thanks

see UTs post.

Phosphate · Jul 20, 2006

Ok, thanks for your reply.

Please forgive my ingnorance I am 2nd year. Just thought I would ask a group with good understanding.

Anyway, what I was trying to find out is why spinal blockade is extended to T4 for CS. I could not think of any structures that would see the knife or be manipulated by the surgical team, that receives innervation from T4.

And I found out the answer.

Cheers.

jetproppilot said:
Sorry, bro,

your post makes no sense.

First of all,

a spinal for "labour delivery" is a bad choice unless delivery is imminent and you are trying ANYTHING within seconds to provide parturient analgesia.

Secondly,

peritoneal manipulation has nothing to do with the penetrance-level obtained by spinal analgesia.

Your goal with labor analgesia is to provide the parturient pain relief whilst concominantly providing her the ability to push when necessary.

Your goal with Caesarean analgesia is to provide dense analgesia AND muscle relaxation to the T4 level, which will 1) enable the obstetrician to do their job 2)keep the mom comfortable during the C section.

with all due respect, most of your post is clinically insignificant jibberish.

Read the above guidelines for clinically significant pointers.

UTSouthwestern · Jul 20, 2006

Phosphate said:
Ok, thanks for your reply.

Please forgive my ingnorance I am 2nd year. Just thought I would ask a group with good understanding.

Anyway, what I was trying to find out is why spinal blockade is extended to T4 for CS. I could not think of any structures that would see the knife or be manipulated by the surgical team, that receives innervation from T4.

And I found out the answer.

Cheers.

The spinal is allowed to extend up to T4 because the obstetricians may have to do a significant amount of pushing and manipulation of the upper abdominal reqion to help expel the baby from the uterus after incision of the uterus. Incomplete relaxation of that region extending up to the xiphoid makes it extremely difficult for them to do so.

Also understand that as time progresses over one to three hours depending on what drug you used, the block will start to decrease in intensity and level so if you start with analgesia only to T8 or T10, aside from making your patient extremely uncomfortable during manipulation, the block may wear off before completion of the procedure at the level of the incision. Not good for repeat business. Good reason to have a touch of ketamine available.

fval28 · Jul 20, 2006

Have a related question(s)...

What local/ narcotic mixes are you guys using for labor epidurals? what rates are you running for maintenance? And how successful are you converting from a labor to a surgical epidural in the event of a c-section.

We currently use 1mg/cc bupivicaine mixed with 1 mcg/cc fentanyl at 8-12 cc/hr with good results during labor but in the event of a c-section, our conversion rate sucks-- usually wind up having to do a spinal to get an adequate surgical block and some of the ones I have done with 12.5-15 mg heavy marcaine have gotten a little higher than I feel comfortable with. Thanks for any info.

seattledoc · Jul 20, 2006

what are you using to convert your labor epidural into a csection epidural? Lidocaine? The BF mix?

fval28 · Jul 20, 2006

seattledoc said:
what are you using to convert your labor epidural into a csection epidural? Lidocaine? The BF mix?

usually 2% PF lido or Nesacaine- volume roughly determined by patient height

seattledoc · Jul 20, 2006

you could try adding 100mcg fentanyl to the mix. And the IV ketamine as a back up.
dunno why it's not working...

seattledoc · Jul 20, 2006

Forgot to ask, what's the typical volume of lido?

fval28 · Jul 20, 2006

seattledoc said:
Forgot to ask, what's the typical volume of lido?

15-20cc's - I have used up to 25 cc's for 5" 9" woman with very stable hemodynamics- pushed the 25 cc's over about 15 or so minutes.

seattledoc · Jul 20, 2006

Well, I don't know, that same drug plus fentanyl works for me. Maybe add in the IV ketamine and throw in the soooooooothing voice of Barry White singing in the background. 😀

jwk · Jul 20, 2006

fval28 said:
15-20cc's - I have used up to 25 cc's for 5" 9" woman with very stable hemodynamics- pushed the 25 cc's over about 15 or so minutes.

2% Lido with epi with 1cc of Neut (bicarb) for each 10cc. +/- Fentanyl, but that's not going to help your level.

Try injecting faster - 15 minutes is a long time. Assuming you've already got a labor epidural in, check a level before you start, just in case you have one. Most of the time it's pretty low, if it's even detectable. After pushing in 5cc for a test dose, add another 15cc, aspirating after each 5cc. Wait 5 minutes, check a level. If it's good but not great (T6 or lower) you can add another 5cc. Unless they're under 5'2", 20cc is not a problem - I rarely give less than 20 unless they've recently been redosed. 30cc isn't that unusual for us - the key is checking your level as you go once you get in the first 20cc. If you have a lousy or no level after the first 20cc, consider replacing the epidural using a decreased amount of local. If the block is one sided, try pulling back the catheter 1cm before adding any more local.

It's a good 100 yards from our furthest labor room to the OR. It's not unusual for us to dose on the run for a true stat C/S and have an adequate level by the time we cut.

pmichaelmd · Jul 22, 2006

fval28 said:
Have a related question(s)...

What local/ narcotic mixes are you guys using for labor epidurals? what rates are you running for maintenance? And how successful are you converting from a labor to a surgical epidural in the event of a c-section.

We currently use 1mg/cc bupivicaine mixed with 1 mcg/cc fentanyl at 8-12 cc/hr with good results during labor but in the event of a c-section, our conversion rate sucks-- usually wind up having to do a spinal to get an adequate surgical block and some of the ones I have done with 12.5-15 mg heavy marcaine have gotten a little higher than I feel comfortable with. Thanks for any info.

We use a CSE technique in which we give 5 mcg of sufentanil via spinal and then mix the remaining 45 mcg sufentanil in a 100-ml 0.9NS bag with 25-ml 0.5% ropivacaine. This works out to be about 0.36 mcg/ml of sufentanil and 1 mg/ml ropivacaine. I typically run a continuous infusion at 8-ml/hr with a PCEA bolus of 6-ml q20min, max 26-ml/hr. If labor fails and we're heading to section, I bolus 5-ml 2% lidocaine with or without epi and check a level once we hit the OR doors. If low (which it usually will be), I give another 5-ml 2% lido bolus and recheck. I just titrate it in from that point on. If the solution has epi, I add bicarb (1 ml for each 10 ml lidocaine). Seems to work well and I haven't seen any failures that have necessitated SAB or GA.

Cheers,
PMMD

deleted697535 · Jan 12, 2018

Phosphate said:
For labour delivery a spinal block is extened to the T10 level. For Caesarean Section the level or the block is extended to T4 due to peritoneal manipulation?

My question is: What part or the peritoneum is manipulated, and what part of the peritoneum is innervated by a segments T4, T5, T6,T7 etc?

Thanks

Really old thread apologies!
Someone asked me this today and im not sure the answer...
Why do we have to get to T4 block for CS?

Chestnut says:
"However, because afferent nerves innervating abdominal and pelvic organs accompany sympathetic
fbers that ascend and descend in the sympathetic trunk (T5 to L1), a sensory block that extends rostrally from the sacral dermatomes to T4 should be the goal for cesarean delivery anesthesia. "

Thats not a great explanation is it? Anyone care to elaborate?

Work · Jan 12, 2018

When the OB-GYN "surgeons" exteriorize the uterus to repair it and place large metal retractors to displace the skin/soft tissues, they tug on everything. Some of the pelvic nerves run with the sympathetic fibers to reach the spinal cord up to about T4, and the intraabdominal structures/viscera also carry sensory afferents and can enter the spinal cord at higher levels as well. My patients almost never fail to dry heave whenever the intern/PGY-2 callously flips the uterus out of the body to admire the damage they did to it.

deleted697535 · Jan 13, 2018

Work said:
When the OB-GYN "surgeons" exteriorize the uterus to repair it and place large metal retractors to displace the skin/soft tissues, they tug on everything. Some of the pelvic nerves run with the sympathetic fibers to reach the spinal cord up to about T4, and the intraabdominal structures/viscera also carry sensory afferents and can enter the spinal cord at higher levels as well. My patients almost never fail to dry heave whenever the intern/PGY-2 callously flips the uterus out of the body to admire the damage they did to it.

Thanks. Doesnt 100% explain it though.
What if they dont exterioise? They shouldnt, even the OB guidelines say that.
And why dont we need to get to T1 if the pelvic nerves run with the sympathetic chain? Im not talking about CVS stability now, just pain

anonperson · Jan 13, 2018

Work said:
When the OB-GYN "surgeons" exteriorize the uterus to repair it and place large metal retractors to displace the skin/soft tissues, they tug on everything. Some of the pelvic nerves run with the sympathetic fibers to reach the spinal cord up to about T4, and the intraabdominal structures/viscera also carry sensory afferents and can enter the spinal cord at higher levels as well. My patients almost never fail to dry heave whenever the intern/PGY-2 callously flips the uterus out of the body to admire the damage they did to it.

Way to sound like a douche.

Newtwo said:
Thanks. Doesnt 100% explain it though.
What if they dont exterioise? They shouldnt, even the OB guidelines say that.
And why dont we need to get to T1 if the pelvic nerves run with the sympathetic chain? Im not talking about CVS stability now, just pain

What OB guidelines.
There's literature to suggest decreased nausea with leaving the uterus in situ but definitely no consensus statement.

abolt18 · Jan 13, 2018

Newtwo said:
Thanks. Doesnt 100% explain it though.
What if they dont exterioise? They shouldnt, even the OB guidelines say that.
And why dont we need to get to T1 if the pelvic nerves run with the sympathetic chain? Im not talking about CVS stability now, just pain

That does explain it. While the sympathetic chain goes as high as T1. The highest sympathetic contribution to the abdominal viscera starts at T4/T5.

deleted697535 · Jan 13, 2018

anonperson said:
Way to sound like a douche.

What OB guidelines.
There's literature to suggest decreased nausea with leaving the uterus in situ but definitely no consensus statement.

Thank you!
Im UK originally so NICE/RCOG both say it shouldnt happen...
"Exteriorisation of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes such as haemorrhage and infection."

anonperson · Jan 13, 2018

Newtwo said:
Thank you!
Im UK originally so NICE/RCOG both say it shouldnt happen...
"Exteriorisation of the uterus is not recommended because it is associated with more pain and does not improve operative outcomes such as haemorrhage and infection."

Interesting but no consensus statement exists in the United States.

This is off topic but exteriorizing the uterus is not meant to prevent infection etc. I solely do it so i can get better visualization of what Im repairing. In these situations, i prefer not to spend precious minutes struggling when the vast majority of times patients have minimal nausea and discomfort with their spinal in place.

Spinal for Caesarean Section question

Phosphate

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jetproppilot

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Phosphate

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UTSouthwestern

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fval28

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seattledoc

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