C-section meds choices with spotty epidural

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

whiteorgo

Full Member
10+ Year Member
Joined
Dec 27, 2008
Messages
61
Reaction score
0
Hey guys, CA1 here. I just wanted to get your thoughts on how you would approach a spotty epidural during C-section?

What I've been doing is obviously re-dose epidural with 2% lido + epi (+/- fentanyl) up to 20cc, then I would go to 3% chloro. From here, I've had attendings do many different things. Most of them start working in some ketamine (10mg a time), some give midaz, rarely give IV fentanyl (until the baby is out).

I was also wondering, is there any specific contraindication to giving ketamine or midaz to the mother before the baby is out? Obviously you wouldn't give IV opioids before the baby's out to avoid any respiratory issues, but is there anything about ketamine/midaz?

Members don't see this ad.
 
Hey guys, CA1 here. I just wanted to get your thoughts on how you would approach a spotty epidural during C-section?

What I've been doing is obviously re-dose epidural with 2% lido + epi (+/- fentanyl) up to 20cc, then I would go to 3% chloro. From here, I've had attendings do many different things. Most of them start working in some ketamine (10mg a time), some give midaz, rarely give IV fentanyl (until the baby is out).

I was also wondering, is there any specific contraindication to giving ketamine or midaz to the mother before the baby is out? Obviously you wouldn't give IV opioids before the baby's out to avoid any respiratory issues, but is there anything about ketamine/midaz?

99% of the time if my epidural is spotty during CS it was spotty during labor. The time to figure this out is BEFORE you take the patient to CS. If you know this, you pull epidural and place SAB. If you have the perfect LEA, you can use it for CS, but it's never as good as SAB for CS. If you run into issues during the case using your LEA, as you wrote above, the correct answer for meds is induce-->intubate. However, you'll find people who use a variety of stuff to limp through depending on myriad factors.

Personally, seeing babies come out struggling with no clear reason, I try to give NOTHING other than my LEA or SAB meds prior to baby. I want my anesthetic as clean as possible. As to your question, I don't think there's a contraindication to ketamine/midaz before baby, but I wouldn't do it. But for the sake of argument, let's say you give low dose ketamine/midaz and the Mom is still hurting/moaning/screaming. Now what? You just muddied the water if you encounter a struggling baby. However you'll certainly find attendings who'll say NO WAY it was the drugs they gave. Crystal clear answers in medicine are often hard to come by. I just find it's easy, and honestly best for Mom and baby, to KISS.
 
  • Like
Reactions: 7 users
Members don't see this ad :)
Southpaw said it all. I’d only add this, if the epidural was used and is spotty before the baby is delivered then I put them to sleep. If the mom makes it through the delivery ok but is uncomfortable for closure of the uterus etc then I will try to limp through with some ketamine and propofol. I don’t use Midaz in c/s. My reasoning is this, they don’t need to forget anything. They need pain control. Ketamine is much better for this. The propofol also allows them to recall the delivery of their child when used in small doses but seems to smooth out the ketamine.
 
  • Like
Reactions: 2 users
One academic dogma that I had to get over in private practice is to avoid GA for cs at all cost. If the epidural has failed and the airway is good and there is any sort of urgency, just do GA.

And sedation is great but at some point on the spectrum what good are you doing snowing the patient with ketamine/versed/whatever and not protecting the airway?
 
  • Like
Reactions: 1 user
In residency, do whatever the attending recommends. They're supposed to be there until the baby comes out anyway. When you hit the real world, that syringe of propofol is your friend and the absolute SAFEST thing to do will be to put the mom to sleep and secure the airway. Sure the OBs may be grumpy and the pops may be upset he can't stay on the room, but I always have to emphasize to the people in that room that SAFETY IS FIRST. They're going to have the rest of their lives (hopefully) to enjoy that baby and I don't want to shorten those odds by dancing around with sedation

Also, i understand people are saying "redo the epidural" or "do a spinal instead" but i would caution that most of the time you're in a C/S after labor for some "urgent" (or emergent) reason. Yes, sometimes it can be pure mom fatigue, but I would caution redoing blocks in people have had decels all day or experiencing some other, again, "urgent" matter.

GA is always a backup to regional for a reason.
 
Hey guys, CA1 here. I just wanted to get your thoughts on how you would approach a spotty epidural during C-section?

What I've been doing is obviously re-dose epidural with 2% lido + epi (+/- fentanyl) up to 20cc, then I would go to 3% chloro. From here, I've had attendings do many different things. Most of them start working in some ketamine (10mg a time), some give midaz, rarely give IV fentanyl (until the baby is out).

I was also wondering, is there any specific contraindication to giving ketamine or midaz to the mother before the baby is out? Obviously you wouldn't give IV opioids before the baby's out to avoid any respiratory issues, but is there anything about ketamine/midaz?
So you already have a patchy epidural, then give 20cc of 2% lido, and THEN you want to add more local on top of that? If it was patchy before, and you add another 20cc of local, and it's still not good, it's pointless to add anything else.

No fentanyl before the baby is out, and our OBs generally freak with midaz since the mom may lose any memory of their beautiful birthing experience but it still has it's place. You could let them breathe a little 50:50 N2O:O2. Ketamine is God's gift to regional anesthesia. 10-20mg can smooth over many marginal epidurals, then once the baby is out, do whatever you want. I give fentanyl IV post-delivery, and if they're still uncomfortable, then put them to sleep.

It also depends on what stage of the procedure you're developing problems. If you've just made the incision, put them to sleep and be done with it. If it's when they get down deep and about to make the uterine incision, you may be able to get by with just the ketamine. Then again, post delivery, do whatever you like.
 
  • Like
Reactions: 2 users
So you already have a patchy epidural, then give 20cc of 2% lido, and THEN you want to add more local on top of that? If it was patchy before, and you add another 20cc of local, and it's still not good, it's pointless to add anything else.

No fentanyl before the baby is out, and our OBs generally freak with midaz since the mom may lose any memory of their beautiful birthing experience but it still has it's place. You could let them breathe a little 50:50 N2O:O2. Ketamine is God's gift to regional anesthesia. 10-20mg can smooth over many marginal epidurals, then once the baby is out, do whatever you want. I give fentanyl IV post-delivery, and if they're still uncomfortable, then put them to sleep.

It also depends on what stage of the procedure you're developing problems. If you've just made the incision, put them to sleep and be done with it. If it's when they get down deep and about to make the uterine incision, you may be able to get by with just the ketamine. Then again, post delivery, do whatever you like.
The next time I have trouble with an epidural for a c/s I’m gonna stick a blunt needle under my finger nail just so I never forget to pull the f’er next time and do a SAB. Then I’m gonna call JWK to get some guidance. That guy or gal has done more c/s than probably all of us combined, and mostly all under epidural.
 
  • Like
Reactions: 1 user
@jwk speaks from experience with regard to CS w epidural for sure. But just one point to his post, I don’t particularly care about an OBs response to my medications, nor do I volunteer what I’ve given. I’ll say ‘I’ve given some sedation to help Mom out’ or ‘my epidural sucked (of course it did!!) so I had to put her under GA’. I’m not in the business of justifying my choices to anyone, as @Twiggidy said I’m there for Mom’s safety and to get her through surgery safely. If the OB wants to question me, they can do so in an empty room w just me and them, after the case, beyond the ears of staff and patients. That’s just professional and appropriate. FYI, I’ve never had that happen.
 
  • Like
Reactions: 1 users
Members don't see this ad :)
@jwk speaks from experience with regard to CS w epidural for sure. But just one point to his post, I don’t particularly care about an OBs response to my medications, nor do I volunteer what I’ve given. I’ll say ‘I’ve given some sedation to help Mom out’ or ‘my epidural sucked (of course it did!!) so I had to put her under GA’. I’m not in the business of justifying my choices to anyone, as @Twiggidy said I’m there for Mom’s safety and to get her through surgery safely. If the OB wants to question me, they can do so in an empty room w just me and them, after the case, beyond the ears of staff and patients. That’s just professional and appropriate. FYI, I’ve never had that happen.
Midaz for OB use is one of the few areas we'll cut the surgeon a little slack. That being said, I give what I need to give. Actually, I don't find much use for midaz in OB anyway - I can do the same thing with ketamine and fentanyl and my incredibly calming demeanor. (at my age, I can BS and schmooze just about anyone)
 
  • Like
Reactions: 1 user
A "spotty" labor epidural can mean a lot of things but I'd not pull it out until I bolused it with an anesthetic dose of LA. An analgesic concentration of LA for labor not giving complete relief is no guarantee that a slug of real anesthesia can't give the desired conditions for a c-section. I'd at least see I could "fix" it then put her to sleep if need be. All that said, a small window is pretty easily dealt with by ketamine.

Does not have to be a big deal.
 
A "spotty" labor epidural can mean a lot of things but I'd not pull it out until I bolused it with an anesthetic dose of LA. An analgesic concentration of LA for labor not giving complete relief is no guarantee that a slug of real anesthesia can't give the desired conditions for a c-section. I'd at least see I could "fix" it then put her to sleep if need be. All that said, a small window is pretty easily dealt with by ketamine.

Does not have to be a big deal.

If you have time to do a spinal (at my place, the OB's often give their blessing for us to do so in urgent situations), I'd pull the epidural. If there's any window, its not worth bolusing and handcuffing yourself to GA assuming you have time for a spinal. That being said, if it's a TRUE emergency (no time for spinal), I'd agree with at least bolusing the epidural and attempting to move forward with it before going the GA route.
 
If you have a patchy epidural that isn't keeping the patient comfortable in labor, it's a terrible idea to bolus it and expect it to do any better for a section. In the literature, biggest risk factor for failed epidural during section is poorly functioning epidural in labor. Not exactly a shock.

Take it out and place a spinal. If you already bolused a ton of local, best bet is an epidural. I trained at a place that didn't believe it was safe to take out the epidural and place a spinal. Trust me, it is. There's a lot of evidence for that.

If you bolused epidural and it was working well for section until it wasn't (we've all been there), ketamine with a little versed is a fantastic, very underutilized choice. Don't need much, maybe 30-50mg to start, 10 a time from there, but usually not necessary.
 
  • Like
Reactions: 2 users
If you have a patchy epidural that isn't keeping the patient comfortable in labor, it's a terrible idea to bolus it and expect it to do any better for a section. In the literature, biggest risk factor for failed epidural during section is poorly functioning epidural in labor. Not exactly a shock.

Using that logic, no one would ever top up a catheter and just pull it out and re do it with a patient having break through pain. No one does that.

Ideally, a genuinely problematic catheter would be identified within an hour of initial placement, most usually (not always) in plenty of time for an urgent or failure to progress section to be called. Very little excuse to be caught with a lousy labor epidural going back to the OR. It should definitely be unexpected if that does occur.
 
Using that logic, no one would ever top up a catheter and just pull it out and re do it with a patient having break through pain. No one does that.

Ideally, a genuinely problematic catheter would be identified within an hour of initial placement, most usually (not always) in plenty of time for an urgent or failure to progress section to be called. Very little excuse to be caught with a lousy labor epidural going back to the OR. It should definitely be unexpected if that does occur.
Say what?

Huge difference if the patient needs a top-up once or twice and responds well to it vs. needs many top-ups and no matter what you give they're never quite comfortable.

First pt, load the epi and proceed. Patient two, don't waste your time. Pull it and place a spinal.

You're right that in an ideal world every epidural works and if it doesn't, you've replaced it and it's perfect. If that's the way things go where you practice, that's great, but it's not like that at the three gigs I've been at.
 
Say what?

....needs many top-ups and no matter what you give they're never quite comfortable.

this is my point. that should never happen. one top up and pull the catheter
 
this is my point. that should never happen. one top up and pull the catheter
You've never walked into a labor room to take a patient to section and asked how the catheters been working, and they tell you it's pretty good except for a certain spot? You would then bolus that patient for section?

And my point remains, if the epidural is marginal, just pull it and put in a spinal.
 
.
If you bolused epidural and it was working well for section until it wasn't (we've all been there), ketamine with a little versed is a fantastic, very underutilized choice. Don't need much, maybe 30-50mg to start, 10 a time from there, but usually not necessary.
Wow, you say that they don’t need much but that’s a big a$$ dose in my book. If I can’t get bye with 10 mg here or there then they bought a tube. 50mg is like a hammer.
 
  • Like
Reactions: 1 users
Wow, you say that they don’t need much but that’s a big a$$ dose in my book. If I can’t get bye with 10 mg here or there then they bought a tube. 50mg is like a hammer.
Sedation dose of ketamine is usually quoted at 0.5-1mg/kg. 50 is not a crazy dose IMO.

I use ketamine for my 90 year old broken hip spinals and even most of them require at least 20-30mg. 10mg in a young healthy patient is spitting in the wind if you ask me.
 
  • Like
Reactions: 1 users
Sedation dose of ketamine is usually quoted at 0.5-1mg/kg. 50 is not a crazy dose IMO.

I use ketamine for my 90 year old broken hip spinals and even most of them require at least 20-30mg. 10mg in a young healthy patient is spitting in the wind if you ask me.
Not in my book.
 
  • Like
Reactions: 1 user
You've never walked into a labor room to take a patient to section and asked how the catheters been working, and they tell you it's pretty good except for a certain spot? You would then bolus that patient for section?

I would and I have. If I thought a bolus of 8 or 10cc .2% ropivicaine would help in that situation if we weren't going to section, why wouldn't I think 15 to 20 mls of 2% lidocaine was a reasonable thing to do? By the time the prep and drape were done and the Allis test was done, I'd have a very good idea if GA were next or some ketamine would do.

And I wouldn't follow a "pretty good" epidural with an SAB. Too unpredictable, IME, and you're as likely to have to give some sedation for a panicky mother with a numb chest as for an occasional hot spot during the section.

But, by all means, do what you do. I will too.
 
And I wouldn't follow a "pretty good" epidural with an SAB. Too unpredictable, IME, and you're as likely to have to give some sedation for a panicky mother with a numb chest as for an occasional hot spot during the section.

But, by all means, do what you do. I will too.
There is nothing unpredictable about a spinal after epidural. The evidence if you pubmed it, and in my and my partners experience, is that you'll be just fine and no level higher than anticipated. Never had a panicky mother because of this either. More panic when the epidural fails and I have to sedate or go to GA.

With that being said, we can agree that we'll both do what we think is best.
 
Hey guys, CA1 here. I just wanted to get your thoughts on how you would approach a spotty epidural during C-section?

What I've been doing is obviously re-dose epidural with 2% lido + epi (+/- fentanyl) up to 20cc, then I would go to 3% chloro. From here, I've had attendings do many different things. Most of them start working in some ketamine (10mg a time), some give midaz, rarely give IV fentanyl (until the baby is out).

I was also wondering, is there any specific contraindication to giving ketamine or midaz to the mother before the baby is out? Obviously you wouldn't give IV opioids before the baby's out to avoid any respiratory issues, but is there anything about ketamine/midaz?
GETA always works (if you know how)
 
What dose spinal are people giving after a failed/unreliable topped up epidural?
I cut the local down to 7.5-10mg (usual dose is 13mg). I add 20mcg for fentanyl. I don’t use fentanyl routinely in c/s spinals or total joints for that matter because they will occasionally begin to itch before the case is over and all that moving bugs me.
 
It is unpredicatable if you fully dose the epidural, pull it and then give a normal spinal dose.
Sure. That's why I don't load it up if it hasn't been working well during labor. I would not place a spinal if I gave 20ml of local and the patient didn't have a level.
 
  • Like
Reactions: 1 user
Southpaw said it all. I’d only add this, if the epidural was used and is spotty before the baby is delivered then I put them to sleep. If the mom makes it through the delivery ok but is uncomfortable for closure of the uterus etc then I will try to limp through with some ketamine and propofol. I don’t use Midaz in c/s. My reasoning is this, they don’t need to forget anything. They need pain control. Ketamine is much better for this. The propofol also allows them to recall the delivery of their child when used in small doses but seems to smooth out the ketamine.

why propofol? why not ketamine and fentanyl? baby is out so no respiratory depression, and pt is having pain.
 
It's interesting all these people are giving midaz, fent, ketamine to a pregnant lady. We do the same at our place for c-sections. But heaven forbid they come in while pregnant for a procedure that needs sedation. In that case, absolute no midaz/fent/ketamine/propofol because of aspiration risk. They end up with neuraxial or GETA.
 
It's interesting all these people are giving midaz, fent, ketamine to a pregnant lady. We do the same at our place for c-sections. But heaven forbid they come in while pregnant for a procedure that needs sedation. In that case, absolute no midaz/fent/ketamine/propofol because of aspiration risk. They end up with neuraxial or GETA.

Well, there's a difference between plan A ... and plan B, executed in the midst of a plan A failure.

midaz/fent/ketamine isn't plan A for these patients.
 
How often are you guys experiencing the need to top off epidurals? And you're saying any epidural that needs even a single redose gets pulled?
Also what do you guys do about the complicated patient who seems to be in labor pain no matter what. It's like if they feel movement they are flipping out, even though you're 99% sure the epidural is working no matter how much you try to explain to them what to expect. These seem like the patients you least want to deal with in a section.

On a side note, I had great board scenario case last night.
32 week di-di twins with a bleeding placenta previa that was hypotensive being rushed back from triage for a section. Aaaaannndddd she was a Jehovah's witness. I was like... cmon!!! Saving grace was she wasn't morbidly obese and had a decent airway. And she was OK with albumin which she agreed to right before prop-sux-tube. Extra IVs, A-line, 2 liters EBL later and a final Hgb of 4, all is well...
 
There is nothing unpredictable about a spinal after epidural.

It is unpredicatable if you fully dose the epidural, pull it and then give a normal spinal dose.

Sure. That's why I don't load it up if it hasn't been working well during labor. I would not place a spinal if I gave 20ml of local and the patient didn't have a level.

You are contradicting yourself.

Is a spinal after epidural, whether topped up or not, always predictable?
 
While we are on the subject, what do you guys use to raise a labor epidural for c section? I typically give 20cc 2% lidocaine and 100mcg fentanyl then add on some 0.5% bupivicaine
 
Is a spinal after epidural, whether topped up or not, always predictable?

If you pull the epi before dosing, and place a spinal, it's perfectly predictable that you can give a regular dose spinal without a problem (well documented in the literature). I would not dose a spinal after loading an epidural. And I would not load an epidural if a patient told me the epidural wasn't keeping them comfortable during labor.

Really not sure what the controversy is.
 
  • Like
Reactions: 3 users
While we are on the subject, what do you guys use to raise a labor epidural for c section? I typically give 20cc 2% lidocaine and 100mcg fentanyl then add on some 0.5% bupivicaine
10-15ml of 2% lido with 1:200,000 epi works well. Rarely do I need to give any further volume. Never give fent for an epi c-section (yes for a spinal c-section), but I do give morphine at the end of the case for post-partum pain control.
 
  • Like
Reactions: 1 user
While we are on the subject, what do you guys use to raise a labor epidural for c section? I typically give 20cc 2% lidocaine and 100mcg fentanyl then add on some 0.5% bupivicaine
Why would you add bupivacaine?

20 mL of 2% lido is reasonable, but possibly more than most patients need.

Some will argue that the fentanyl should be held until after delivery. That said, I give it and morphine up front if the c-section is a routine failure to progress without any concern for fetal wellbeing.

For c-sections that are being done for fetal distress, the textbook answer is probably chloroprocaine instead of lidocaine, because chloroprocaine is metabolized so quickly there's no chance of any local anesthetic reaching the baby. The major downside to chloroprocaine of course is that subsequent epidural opiates are less effective.
 
why propofol? why not ketamine and fentanyl? baby is out so no respiratory depression, and pt is having pain.
The pts seem to like propofol better. I’m not trying to knock them out. I’m just trying to calm them down some and get them through it. If it’s discomfort then they do fine with some sedation. If it’s really painful then they are going off to sleep for me.
 
A lot of people getting defensive about their personal preferences. I would comment but I have never had a spotty epidural!!! lolololol

I had a partner that gave 0.5% Bupivacaine for epidural CS's and it worked great without the additional boluses that you sometimes need with 2%Lidocaine. I have used it several times and it seems to be equivocal.

20 mg of Ketamine works great with additional 10 mg boluses. It has been a while since I have had to (knocks on wood). I find that being chatty helps out tremendously. I hated the idea of skin to skin, but have found it helps those types of patients be preoccupied on other stuff.
 
I had a partner that gave 0.5% Bupivacaine for epidural CS's and it worked great without the additional boluses that you sometimes need with 2%Lidocaine. I have used it several times and it seems to be equivocal.
Are you guys using the bupi for crash c/s? My attendings have let me use it a few times for non-emergent c/s just so I'd appreciate the difference in density & time to setup for 0.5% bupi VS. 2% lido+epi / 3% chloroprocaine. The bupi definitely created a longer acting surgical block but it also took a lot longer to setup.
 
@jwk speaks from experience with regard to CS w epidural for sure. But just one point to his post, I don’t particularly care about an OBs response to my medications, nor do I volunteer what I’ve given. I’ll say ‘I’ve given some sedation to help Mom out’ or ‘my epidural sucked (of course it did!!) so I had to put her under GA’. I’m not in the business of justifying my choices to anyone, as @Twiggidy said I’m there for Mom’s safety and to get her through surgery safely. If the OB wants to question me, they can do so in an empty room w just me and them, after the case, beyond the ears of staff and patients. That’s just professional and appropriate. FYI, I’ve never had that happen.
Let me begin here by saying you can do whatever you want to do. BUT, your approach to doing whatever you want to do is basically what determines how you are perceived as an anesthesiologist and doctor. If you take the approach that you just laid out then you will be viewed as dogmatic and unapproachable. You will soon find that your colleagues prefer not to work with you even if you are the best of the best. But the best of the best don’t act this way.

When it comes to what you give pts with regards to your anesthetic, just remember that that pt visits the surgeon again and not you. When they complain it is to the surgeon. I doubt you would want to field complaints from pts about how your colleagues did their job all the time. I sure you would get tied of defending that person and you would start to want to cease working with that person. It’s a two way street. So check your ego at the door. It’s not a turf war. We are all trying to do what is best for the pt. If you are so he’ll bent on giving something then at least give them the courtesy of explaining why they are against it. And this should happen long before you are in the presence of staff and pts.
You have been here a long time and you and I go way back. I’m saying this mostly for others because I know 5his isn’t your style. Cheers!
And for the record, I don’t give OB pts midaz. The entire reason we are doing regional for these cases is so mom can experience the birth of their child. You can claim that it is safer and that this is why but that’s BS. this s also why I don’t dick around with an epidural that “might” work. Sure I get burned just like everyone else. Nobody is 100%.
 
Last edited:
A "spotty" labor epidural can mean a lot of things but I'd not pull it out until I bolused it with an anesthetic dose of LA. An analgesic concentration of LA for labor not giving complete relief is no guarantee that a slug of real anesthesia can't give the desired conditions for a c-section. I'd at least see I could "fix" it then put her to sleep if need be. All that said, a small window is pretty easily dealt with by ketamine.

Does not have to be a big deal.
Well that’s not how I see things but it’s a fair approach.
What if the pt had a horrendous airway?
 
Are you guys using the bupi for crash c/s? My attendings have let me use it a few times for non-emergent c/s just so I'd appreciate the difference in density & time to setup for 0.5% bupi VS. 2% lido+epi / 3% chloroprocaine. The bupi definitely created a longer acting surgical block but it also took a lot longer to setup.
I remember using 0.25% bupivicaine in residency. I have no idea how that worked but it did.
 
Let me begin here by saying you can do whatever you want to do. BUT, your approach to doing whatever you want to do is basically what determines how you are perceived as an anesthesiologist and doctor. If you take the approach that you just laid out then you will be viewed as dogmatic and unapproachable. You will soon find that your colleagues prefer not to work with you even if you are the best of the best. But the best of the best don’t act this way.

When it comes to what you give pts with regards to your anesthetic, just remember that that pt visits the surgeon again and not you. When they complain it is to the surgeon. I doubt you would want to field complaints from pts about how your colleagues did their job all the time. I sure you would get tied of defending that person and you would start to want to cease working with that person. It’s a two way street. So check your ego at the door. It’s not a turf war. We are all trying to do what is best for the pt. If you are so he’ll bent on giving something then at least give them the courtesy of explaining why they are against it. And this should happen long before you are in the presence of staff and pts.
You have been here a long time and you and I go way back. I’m saying this mostly for others because I know 5his isn’t your style. Cheers!
And for the record, I don’t give OB pts midaz. The entire reason we are doing regional for these cases is so mom can experience the birth of their child. You can claim that it is safer and that this is why but that’s BS. this s also why I don’t dick around with an epidural that “might” work. Sure I get burned just like everyone else. Nobody is 100%.

Wait the entire reason we are doing section under epidural is so mom can experience it?? I dont know if i agree with that. Kind of like how i do my hips/knees under spinal not because of patient wants to experience it
 
Well that’s not how I see things but it’s a fair approach.
What if the pt had a horrendous airway?

I'm of the school where there are no crash emergencies with patients who are super morbidly obese or who have "horrendous" airways. Where I am currently (community hospital without a lot of back up, etc). I would agitate strongly for a scheduled section. Unclaimed, 2 AM presentation to L and D, same deal. CSE or awake intubation. Bottom line, for any out lier patient you can think of, for me, is that this patient would not be allowed to labor.
 
Top