Clinical thread: Postpartum tubals

[Laurel123]

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Anyone having the labor nurses keep labor epidurals in for PPTL's? All the nurses will leave the epidurals in, sometimes for like 12 hours or more to use in the pptl's, but in my experience, they never work for pptl's. I have been just telling them to take it out and I just do general. Anyone use labor epidurals for PPTL's and have them work?

I have some partners that are concerned about the aspiration risk in postpartum patients, but I don't think that is much of a concern if they are NPO? Thoughts?

 

[Skip2myLou]

I'd rather have them in. They work fine.

Now only if we can get away from the 3 am STAT BTL's

 

[cchoukal]

HAving done 1 month of OB as a resident, it seems like the epidurals work about half the time if the TL is the next day. When it fails I either sat them up for a spinal or augmented a patchy block w/ N2O, ketamine, narcs. I think the oral boards/Miller answer is that the elevated aspiration risk remains post-partum for several days.

 

[Intubate]

Studies show a very high failure rate for PPBTL with the labor epidural-- some as high as 60%. This is not acceptable. Take it out and do a spinal or GA. The aspiration risk is probably not back to baseline, but probably nowhere near as high as the parturient.

I encourage patients to get a spinal, but say that its probably just as safe to go to sleep. I try to tell them that they'll be more awake to take care of/ feed their baby and that the risk of PONV is lower with the spinal. I also tell them that if my wife was having a PPBTL, I would encourage her to have a spinal as well.

They almost all want to go to sleep.

 

[Planktonmd]

Anyone having the labor nurses keep labor epidurals in for PPTL's? All the nurses will leave the epidurals in, sometimes for like 12 hours or more to use in the pptl's, but in my experience, they never work for pptl's. I have been just telling them to take it out and I just do general. Anyone use labor epidurals for PPTL's and have them work?

I have some partners that are concerned about the aspiration risk in postpartum patients, but I don't think that is much of a concern if they are NPO? Thoughts?

Laurel, Thank you for trying to keep things moving on this forum 🙂

I do most of these cases under GA but if a patient has a horrible airway and was not the easiest epidural stick I tell them to keep it in, make sure it is taped correctly, run Normal saline through it overnight, and use it next day for the tubal.
They usually work for me.

 

[johankriek]

I think the oral boards/Miller answer is that the elevated aspiration risk remains post-partum for several days.

thirty, i believe.

 

[Noyac]

My oral board answer would be to pull it and do a spinal.

My actual practice answer is spinal or GA. I don't like to use epidurals that are 1 day old.

 

[Laurel123]

Thanks, just trying to balance out the 'please read my PS' threads with some clinical discussun too.

Anyways, I usually do general endotracheal, as long as they are NPO. Actually I wouldnt do it if they were not NPO. Spinals do reduce the risk of nausea and aspiration, but the surgeons take about five minutes to do a tubal. So by the time the spinal gets up to about T8, they are done. And then the patient sits in the PACU for three hours wishing she could see her baby. So I just tell the patients ahead of time about the risk of aspiration, sore throat and nausea vs the long PACU time andgoing through another spinal and like Noyac said almost all of the choose GA.

I do think that is a good point that if it was a difficult epidural which oftn coincides with fat and possible difficult airway it would be good to keep the epidural in and run saline.

By the way, those that use spinals, what and how much do you use?

 

[Noyac]

In residency I used mepivicaine 75mg (1cc) with 1cc D10. It was great. Lasted about 1 hr and they could move their legs somewhat which kept the uncomfortable feeling of being paralyzed away. I did cystos and turps with it as well. Haven't used it since mostly b/c we don't have PF mepivicaine (I think but haven't checked in a while).

If I did a spinal now I'd probably use 6-8 mg bupiv with fent 20 mcg.

I just put them to sleep though.