CSE....oops there goes the babys HR, through the floor!

[joncmarkley]

Hi all

I have done maybe 12 CSE's in OB in my short little career...usually 1/2 cc .25 bupi with 12.5 fentanyl for labor. On three occasions I have had a decel for the baby within 3-5 minutes of finishing. There has always been a relative decrease in BP from lets say 130's to 110 systolic but no major drops.

I usually treat those numbers even though they are not really that low because I figure it may be relative hypotension and I don't know what else to do!!!!

I am hesitating to keep doing these because our OB's have around a 40% section rate. Do this represent decrease in moms catecholamine's or placental hypoperfusion? Are they harmless for the baby? Should it be a part of informed consent that they may get a section? Any references would be great


Thanks

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[jwk]

Hi all

I have done maybe 12 CSE's in OB in my short little career...usually 1/2 cc .25 bupi with 12.5 fentanyl for labor. On three occasions I have had a decel for the baby within 3-5 minutes of finishing. There has always been a relative decrease in BP from lets say 130's to 110 systolic but no major drops.

I usually treat those numbers even though they are not really that low because I figure it may be relative hypotension and I don't know what else to do!!!!

I am hesitating to keep doing these because our OB's have super low section threshold (i.e. 48% section rate). Do this represent decrease in moms catecholamine’s or placental hypoperfusion? Are they harmless for the baby? Should it be a part of informed consent that they may get a section? Any references would be great


Thanks

I think it's coincidence. Twelve is not exactly a big series. And a 48% C/S rate by anyone's standard is woefully excessive. Maybe your OB's have a different concept of decels than the rest of the country.

 

[Planktonmd]

Hi all

I have done maybe 12 CSE's in OB in my short little career...usually 1/2 cc .25 bupi with 12.5 fentanyl for labor. On three occasions I have had a decel for the baby within 3-5 minutes of finishing. There has always been a relative decrease in BP from lets say 130's to 110 systolic but no major drops.

I usually treat those numbers even though they are not really that low because I figure it may be relative hypotension and I don't know what else to do!!!!

I am hesitating to keep doing these because our OB's have super low section threshold (i.e. 48% section rate). Do this represent decrease in moms catecholamine’s or placental hypoperfusion? Are they harmless for the baby? Should it be a part of informed consent that they may get a section? Any references would be great


Thanks

Skip the Fentanyl.

This has been discussed before on this forum.

 

[epidural man]

Skip the Fentanyl.

This has been discussed before on this forum.

Link?

A conversation with OB's go a long way to prevent a C/S for this transient decrease in HR.

 

[drrosenrosen]

My attendings have said that the sudden drop in sympathetic outflow can lead to hypoperfusion and decel not from maternal hypotension but from increased uterine tone. sure enough, two of three times that I've seen the decels after cse, there was a big tonic contraction showing on the toco, too. They recommend treating this with one or two cc's of double-diluted ntg, and chasing it with neo if needed to maintain maternal bp. anyone else ever heard of this, or is it just the theory of one crazy ob anesthesia guy?

 

[Noyac]

My attendings have said that the sudden drop in sympathetic outflow can lead to hypoperfusion and decel not from maternal hypotension but from increased uterine tone. sure enough, two of three times that I've seen the decels after cse, there was a big tonic contraction showing on the toco, too. They recommend treating this with one or two cc's of double-diluted ntg, and chasing it with neo if needed to maintain maternal bp. anyone else ever heard of this, or is it just the theory of one crazy ob anesthesia guy?

It is most likely the sudden drop in sympathetic outflow. I make sure that mom has a very liberal bolus b/4 placing the CSE. I like at least 750ml. I just trat it with ephedrine and it seems to work but I haven't had one in quite some time. We were doing a study at UNM were we gave fent/ bupiv, fent only and bupiv only. I seem to remember the fent only cse's caused this more often but not sure. The study was never completed b/c we felt that the fent/ bupiv combo was far superior after doing so many that we just stopped and the resident heading up the study also had something to do with the study not getting completed.

 

[johankriek]

dont do cse

 

[jwk]

dont do cse

 

[Laurel123]

I remember in residency seeing a tonic uterine contraction after a fent/bupiv CSE a few times. It was always when we used the CSe for woman that was crazy and writhing in pain and then got instant relief. Then the decels and then the CSection. I remember looking this up but right now I am drawing a blank. Then on a different Ob rotation, we had an attending who showed me these articles about how doing CSE for patients is early labor like 3 cm, would speed along labor so we started doing CSE for early labor and I never saw the tonic contractions.

 

[USAnesthesiaDoc]

The previous posters and your ob anesthesia attendings are correct. The patients pre-CSE are experiencing a high sympathetic outflow secondary to pain (increased epinephrine circulating peripherally). Beta agonism inhibits smooth muscle uterine contraction. Therefore, when you give a woman instant pain relief, there is a sudden drop in these epinephrine levels, and all of a sudden there is nothing counteracting the uterine contractions. You get a tonic uterine contraction, no blood flow to the baby, big fetal bradycardia. The key to preventing this with CSEs is to administer ephedrine PROPHYLACTICALLY as soon as you complete the CSE. Literally, while I am threading my epidural catheter, I will have the RN administer 10-15 mg of ephedrine iv. Works really well because the ephedrine is replacing the beta agonism of the rapidly decreasing epinephrine levels and will prevent that hypertonic uterus. This was what I learned as a resident.

 

[huktonfonix]

terbutaline or IV NTG may help to decrease the tonic contraction. Alternatively you could just use fentanyl in the intrathecal space and skip the local. This seems to decrease the incidence of tonic contraction with CSE.

 

[Planktonmd]

terbutaline or IV NTG may help to decrease the tonic contraction. Alternatively you could just use fentanyl in the intrathecal space and skip the local. This seems to decrease the incidence of tonic contraction with CSE.

Actually it's the opposite, if you don't want that uterine tetany you need to skip the Fentanyl and make sure you are using hyperbaric Bupivacaine so you don't get that high sympathetic block.
The best solution: Don't do CSE.

 

[GeddyLee]

I've now done close to 40-50 CSE's for both labor and c-section, mostly with 20mcg fentanyl in the spinal, some with 1cc .25% bupiv and 20mcg fentanyl....only seen one FHR decel which went to section. Be ready to treat uterine tetanic contractions with some NTG. To those who say don't do CSE, I would like to know their experience with the technique. It seems quite safe in my experience and is a very nice technique...almost instant relief for the patient and low rate of failure of the epidural limb of the technique.

 

[Planktonmd]

I've now done close to 40-50 CSE's for both labor and c-section, mostly with 20mcg fentanyl in the spinal, some with 1cc .25% bupiv and 20mcg fentanyl....only seen one FHR decel which went to section. Be ready to treat uterine tetanic contractions with some NTG. To those who say don't do CSE, I would like to know their experience with the technique. It seems quite safe in my experience and is a very nice technique...almost instant relief for the patient and low rate of failure of the epidural limb of the technique.

Ok,
For labor: You do a CSE, the patient gets relief but you never know if your Epidural catheter is going to work later when you need it because you can't do a proper test after the spinal. If you do the CSE late in labor using Fenatnyl as you described you also have to add the risk of uterine tetany.

For a C Section: Why not do a real spinal using Hyperbaric Bupivacaine and fentanyl? What's so special about doing a weak hypobaric spinal and then trying to supplement it with an Epidural?

 

[GeddyLee]

Ok,
For labor: You do a CSE, the patient gets relief but you never know if your Epidural catheter is going to work later when you need it because you can't do a proper test after the spinal. If you do the CSE late in labor using Fenatnyl as you described you also have to add the risk of uterine tetany.

For a C Section: Why not do a real spinal using Hyperbaric Bupivacaine and fentanyl? What's so special about doing a weak hypobaric spinal and then trying to supplement it with an Epidural?

In my limited experience, I've seen no failed epidurals after a successful CSE in labor. It seems if your epidural needle is in good enough position to be successful with the spinal limb, your know where your epidural catheter is going. With regards to uterine tetany, yes it can happen, but it can happen with LA in the spinal limb as well and i don't think it is something that only happens with fentanyl. The benefit, I think, is that you aren't having to bolus dose an epidural to get relief so it's quicker (if you're the one having to dose the epidural) and in theory lower risk of LA toxicity. I still test dose the epidural.

For a c-section i have not had to supplement the spinal limb by dosing the epidural unless the section runs longer than 1.5-2 hours. Advantage is that you do have a way to prolong your block if the c-section becomes complicated. You can also dose the epidural with depodur if you're so inclined. We use 0.75% bupiv in the spinal limb of the cse for c-section with 10mcg fentanyl...never had a problem with block density using the technique.

 

[Planktonmd]

In my limited experience, I've seen no failed epidurals after a successful CSE in labor. It seems if your epidural needle is in good enough position to be successful with the spinal limb, your know where your epidural catheter is going. With regards to uterine tetany, yes it can happen, but it can happen with LA in the spinal limb as well and i don't think it is something that only happens with fentanyl. The benefit, I think, is that you aren't having to bolus dose an epidural to get relief so it's quicker (if you're the one having to dose the epidural) and in theory lower risk of LA toxicity. I still test dose the epidural.

For a c-section i have not had to supplement the spinal limb by dosing the epidural unless the section runs longer than 1.5-2 hours. Advantage is that you do have a way to prolong your block if the c-section becomes complicated. You can also dose the epidural with depodur if you're so inclined. We use 0.75% bupiv in the spinal limb of the cse for c-section with 10mcg fentanyl...never had a problem with block density using the technique.

Well,
The reason why you get more Uterine Tetany when you use intrathecal hypobaric Bupivacaine (0.25% comes hypobaric unless you add Glucose) is because your block travels up so you get more sympathetic block and that upward migration is worse with Fentanyl.
About not seeing failed epidural catheters in CSE, wait, you will see them.
And about needing an epidural in case the C section outlasts your spinal: This happens only in residency