ASA status

[Twiggidy]

Not having to cover OB... priceless.

there’s truth in this......im considering selling my soul to an AMC just to have this

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[dannyboy1]

Non-reassuring fetal tracing is easy. I am talking about cases like "this has been taking too long, she's tired, we can section her now, or wait till midnight when she is NPO according to your guidelines". Guess what? Half of these cases end up taking a long nap, waking up rested hours later and delivering naturally.

Everybody seems to need a C-section at 5-6 pm, when the office hours end, and before primetime and dinner, never earlier. Really?

Are your patients eating during labor? Because the failure to progress patient should have been there for damn close to 8 hours ...

 

[Twiggidy]

But isnt every pregnant lady after 12 weeks considered full stomach or is that old school attending urban legend?

I agree with a little bit of what everyone is saying and it becomes a slippery slope because no one wants a baby witha complication or a mother for that matter.

We can all agree that NPO means nothing when placing an epidural and most of these ladies who go from labor to urgent C/S have one in place so whats stopping you from loading it? Same goes for spinals. The reality is that unless someone had a Whopper, there's usually no reason to delay an urgent section.

 

[deleted162650]

But isnt every pregnant lady after 12 weeks considered full stomach or is that old school attending urban legend?

Nope. See my post above. Pregnancy itself doesn’t alter gastric emptying time. A fasted pregnant patient is just as fasted as anyone else. Obviously you still have to account for other comorbidities.

Labor on the other hand does bring gastric motility to a halt. Once in labor, a patient should always be considered a full stomach.

 

[Twiggidy]

Nope. See my post above. Pregnancy itself doesn’t alter gastric emptying time. A fasted pregnant patient is just as fasted as anyone else. Obviously you still have to account for other comorbidities.

Labor on the other hand does bring gastric motility to a halt. Once in labor, a patient should always be considered a full stomach.

i agree with that.

in training every 12 week d/c was intubated. to me today in my current practice that would be ridiculous

 

[dannyboy1]

i agree with that.

in training every 12 week d/c was intubated. to me today in my current practice that would be ridiculous

20 weeks is the new 12. At least that’s what it says in baby Miller’s

 

[deleted171991]

Wait a minute, so you've got a laboring patient who's been deemed "failure to progress" or whatever term they're using these days, and you're gonna make them wait for NPO status?? While pregnancy itself has essentially no effect on gastric emptying, labor profoundly effects gastric emptying. That laboring patient will be no more NPO at midnight than they are right now. Give 'em shot of bicitra and do the damn section. Waiting in this case is just plain wrong.

Now if you think your OB's are scheduling unnecessary sections out of convenience and you're just trying to teach them a lesson, that is another issue entirely and probably needs to be taken up on a higher level.

Change the guidelines and I'll be happy to oblige.

 

[deleted171991]

But isnt every pregnant lady after 12 weeks considered full stomach or is that old school attending urban legend?

Very urban legend. It's only labor that slows down gastric emptying (but doesn't stop it), which is why the ASA guidelines recommend waiting at least as long as for a non-pregnant patient, if not longer.

@SaltyDog, there is a big difference between considering a patient full stomach and the patient actually being full stomach. Next time I do OB (hopefully never), I'll just start doing gastric ultrasound on them.

 

[deleted171991]

Are your patients eating during labor? Because the failure to progress patient should have been there for damn close to 8 hours ...

You'd be surprised how much "failure to progress" you get to see when the OB wants to be done with his cases and go home for the night.

 

[deleted162650]

You'd be surprised how much "failure to progress" you get to see when the OB wants to be done with his cases and go home for the night.

Personally, I’d also rather do the section at 1800 than 0000, too. We have 24H in house laborists though, and they don’t seem to mind the wee hours sections.

 

[deleted171991]

there’s truth in this......im considering selling my soul to an AMC just to have this

Sell it to the VA, or to one of the many academic centers where OB anesthesia is covered by a dedicated team. Or to an ASC (best use of a critical care fellowship). I'm serious.

I think OB is OK if one is a partner; it can be a huge moneymaker for a group (depending on the population). OB as an employee is for masochists.

 

[dannyboy1]

You'd be surprised how much "failure to progress" you get to see when the OB wants to be done with his cases and go home for the night.

Strictly speaking NPO guidelines should be followed for all sections. That being said the OB’s (at least at my place) have learned to give us some reason, however flimsy, for proceeding. The usual excuse “baby is fine now but there was a decel.. and she is only 2cm.. I typically do not fight with them. To have a problem you would need the rare scenario of a failed neuraxial, followed by the rare scenario of aspiration despite proper RSI. And even if this happens you still have documented something not reassuring about FHR. I would much rather go with that then being perceived as someone who delayed a C/S after OB had expressed a concern. Their malpractice premiums are a lot more then ours for a reason. In practice the only patients we ever delay is if they showed up for their scheduled c/s having eaten breakfast.

 

[GigiBuffon]

Strictly speaking NPO guidelines should be followed for all sections. That being said the OB’s (at least at my place) have learned to give us some reason, however flimsy, for proceeding. The usual excuse “baby is fine now but there was a decel.. and she is only 2cm.. I typically do not fight with them. To have a problem you would need the rare scenario of a failed neuraxial, followed by the rare scenario of aspiration despite proper RSI. And even if this happens you still have documented something not reassuring about FHR. I would much rather go with that then being perceived as someone who delayed a C/S after OB had expressed a concern. Their malpractice premiums are a lot more then ours for a reason. In practice the only patients we ever delay is if they showed up for their scheduled c/s having eaten breakfast.

Couldn't agree more. If the board-certified OB puts their call for a C-section in writing, however flimsy it is, we go whenever they want. If you delayed a section like that, and for whatever freak reason there is a bad baby... you'll have a hard time explaining yourself. Most OBs in my experience are reasonable and are honest about urgent vs emergent, but the ones who aren't... you won't win the argument.

 

[Twiggidy]

Couldn't agree more. If the board-certified OB puts their call for a C-section in writing, however flimsy it is, we go whenever they want. If you delayed a section like that, and for whatever freak reason there is a bad baby... you'll have a hard time explaining yourself. Most OBs in my experience are reasonable and are honest about urgent vs emergent, but the ones who aren't... you won't win the argument.

This is so true. As @narcusprince said, much of the airway hype on OB is overrated, so if I need to I can tube anyone, especially with the Glide sitting right behind me. If the OB says we go to do this, then we got to do this. If they have the hesitancy to ask "when can we do this?" that means it's not a true emergency and I'll follow NPO guidelines.

And they'll still be an "E".....

 

[anbuitachi]

Strictly speaking NPO guidelines should be followed for all sections. That being said the OB’s (at least at my place) have learned to give us some reason, however flimsy, for proceeding. The usual excuse “baby is fine now but there was a decel.. and she is only 2cm.. I typically do not fight with them. To have a problem you would need the rare scenario of a failed neuraxial, followed by the rare scenario of aspiration despite proper RSI. And even if this happens you still have documented something not reassuring about FHR. I would much rather go with that then being perceived as someone who delayed a C/S after OB had expressed a concern. Their malpractice premiums are a lot more then ours for a reason. In practice the only patients we ever delay is if they showed up for their scheduled c/s having eaten breakfast.

True , we pretty much always proceed unless we have no ORs. (we like to save 1 OR open for the real stat C sections).
That being said, I imagine if it goes to court, they have the data on the EMR. Just cause the OB said it shouldn't mean its a slam dunk case. If the baby had one decel to 90 and OB goes STAT C SECTION. And they review the chart and sees theres only 1 decel to not even that low, it shouldn't be that hard to argue that it's not a true stat c section and couldve been delayed