Epidurals overnight for IOL

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LaryngoSpazz

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Our OBs have a tendency to bring in their non-urgent inductions of labor during the evening and start pitocin overnight. I think they prefer this as it sets them up for a morning delivery. However, this practice often has us being called to place a labor epidural in the middle of the night unnecessarily which really drives me crazy. For reference this is not a busy OB service and the anesthesiologist on call would otherwise likely be sleeping.

Is this happening everywhere or have some of you been successful at restricting this practice?
 
LaryngoSpazz said:
Our OBs have a tendency to bring in their non-urgent inductions of labor during the evening and start pitocin overnight. I think they prefer this as it sets them up for a morning delivery. However, this practice often has us being called to place a labor epidural in the middle of the night unnecessarily which really drives me crazy. For reference this is not a busy OB service and the anesthesiologist on call would otherwise likely be sleeping.

Is this happening everywhere or have some of you been successful at restricting this practice?
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So you are being asked to place an epidural during a call shift that youre being paid to take?

I dont see the issue here. You cant really expect to have your cake and eat it too. If you're getting paid for call, you should be expected to work during that time.

That said, I wouldn't call placing an epidural for a laboring patient unnecessary. You're helping a patient who is in pain.
 
Maybe coordinate these minor concerns with the OB staff if you have good camaraderie so they start pit sooner - can do epidurals on all those starting to feel it in the late evening and then have an easier night.
 
GandalfTheWhite said:
So you are being asked to place an epidural during a call shift that youre being paid to take?

I dont see the issue here. You cant really expect to have your cake and eat it too. If you're getting paid for call, you should be expected to work during that time.

That said, I wouldn't call placing an epidural for a laboring patient unnecessary. You're helping a patient who is in pain.
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To clarify, I’m asking only about non urgent inductions of labor. For example, patient is an induction for dates, she is scheduled to arrive on OB floor at say 6pm, pitocin started at 10pm, request for epidural at 1am.
 
Evening inductions for G1s actually make a lot of sense, and often times they just chill the first night for cervical ripening or whatever and then ask for their epidural during daytime the next day. Agree that this does not make much sense for multigravida, but doubt you can really push back.
 
Standard practice. Better/safer to time it for them to deliver during daylight hours the next day with more staff around. Emphasis should be on a safe delivery plan, not a convenient epidural plan. As much as I hate the inconvenience of the 1am epidural, I hate the 1am PPH infinitely more.
 
Standard everywhere I've worked.

The only thing that sort of annoys me is the flurry of epidural calls between 6 and 7 AM, just as the overnight shift is ending. The L&D RNs do this because they know we get busy around 7 and the epidural might not get placed inside of 10 minutes if they call after the ORs start for the day. Getting called in the last 30 min of a 12 or 24 hour shift to do a timed-for-nursing-convenience procedure doesn't fill me with joy.
 
LaryngoSpazz said:
Our OBs have a tendency to bring in their non-urgent inductions of labor during the evening and start pitocin overnight. I think they prefer this as it sets them up for a morning delivery. However, this practice often has us being called to place a labor epidural in the middle of the night unnecessarily which really drives me crazy. For reference this is not a busy OB service and the anesthesiologist on call would otherwise likely be sleeping.

Is this happening everywhere or have some of you been successful at restricting this practice?
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I would say if you are looking to exert some control over your daily schedule, Anesthesiology may have been the wrong choice. We are a service line. Within the parameters of our scheduled shift, the surgeons control when things happen, for the most part.
 
6pm is too early. We had 10pm, midnight 2am and 5 am inductions. They called around 7-8 am for epidural. At 4-5 cm.
 
We had a relationship with our OB's like lions have with honey badgers. We had a small ob unit, 300 deliveries a year, so no volume of cases to justify a dedicated person for L &D. Requests for induction epidurals were sure to come at the most inconvenient time. What would grind my gears would be the sat Elective induction when the medical reason from the OB was.".I'm on call this weekend." So when the call for the epidural comes in, there I am with the call team doing a thoracic aneurysm and an acute abdomen with my 2nd call like 30 min away. Only to have the OB screaming on the phone that this is not the 20 min response they expect. I came to understand that OB and Anesthesia are natural enemies.
 
I agree we are a service line and have limited control. However if you don’t ever ask questions or attempt to push back you have absolutely no control. I would suggest radiologists have done a better job of this than us as a profession. For example do you see them doing epidural blood patches under flouro after hours or on weekends? I have seen anesthesiologists do these all the time and I’m not taking about on patients where we caused the Pdph.

Sounds like the IOL schedule I’m taking about is standard practice everywhere. However I’d push back on the idea that this is best practice for the patient as the patient is up most of the night getting induced and the complications we want to avoid overnight can still come up the next night as some of these G1s end up as failure to progress 18-24 hours later.
 
It's safer to have them induce at midnight to be ready to deliver during the day when there is a full staff of obestetricians for emergencies. You need to suck it up and do the epidural during overnight hours. The overnight induction and during the day delivery is common practice. You part in this process as an epiduralist takes 15 minutes. They have to watch the laboring patient all day. They want an awake and alert obstetrician.
 
Our OB's bring primips in at 8 for 3 rounds of cytotec then start pit early morning. Multigravids or those with some dilation already get brought in at 6am and go straight to pit. Usually this means we're getting called shortly after 7 or mid-morning. The unit isn't busy enough to have a dedicated anesthesiologist during the day but usually we can get over there fairly quickly. I'm not sure why anyone anywhere should think having an epidural in within 20 minutes after the phone call is a reasonable rule.
 
LaryngoSpazz said:
To clarify, I’m asking only about non urgent inductions of labor. For example, patient is an induction for dates, she is scheduled to arrive on OB floor at say 6pm, pitocin started at 10pm, request for epidural at 1am.
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U are in-house right? If u are going to put in labor epidurals I don't think this is a huge stretch to do these epidurals too
 
DocMcCoy said:
I haven’t done OB in a long time. Can’t you just place an epidural when they show up? Why do you have to wait till they start laboring for placement? Orders to “turn it on/up” as they start hurting.
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Catheters that are placed but not running are more likely to not work when you start/restart them. I don’t have the specific citation, but the study involved epidurals placed for labor that were turned off then re-activated the next day for a tubal ligation. They didn’t work in a significant number of patients. Probably a small number though.
 
LaryngoSpazz said:
To clarify, I’m asking only about non urgent inductions of labor. For example, patient is an induction for dates, she is scheduled to arrive on OB floor at say 6pm, pitocin started at 10pm, request for epidural at 1am.
Click to expand...
Again, you are paid to provide call coverage during your call shift. Whether its urgent or non-urgent. Its also not your call to make. Your job on call is to provide anesthesia services to whomever is asking for it, and that includes OB when they ask for an epidural. Have you considered asking the patient for a preemptive epidural placement? That might help move the epidurals before nap time.

pgg said:
Standard everywhere I've worked.

The only thing that sort of annoys me is the flurry of epidural calls between 6 and 7 AM, just as the overnight shift is ending. The L&D RNs do this because they know we get busy around 7 and the epidural might not get placed inside of 10 minutes if they call after the ORs start for the day. Getting called in the last 30 min of a 12 or 24 hour shift to do a timed-for-nursing-convenience procedure doesn't fill me with joy.
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Same thing happened at my old place. I loved it since i was on production. Wake up at 6, place 3-4 epidurals, collect the units and go home to sleep.

LaryngoSpazz said:
I agree we are a service line and have limited control. However if you don’t ever ask questions or attempt to push back you have absolutely no control. I would suggest radiologists have done a better job of this than us as a profession. For example do you see them doing epidural blood patches under flouro after hours or on weekends? I have seen anesthesiologists do these all the time and I’m not taking about on patients where we caused the Pdph.

Sounds like the IOL schedule I’m taking about is standard practice everywhere. However I’d push back on the idea that this is best practice for the patient as the patient is up most of the night getting induced and the complications we want to avoid overnight can still come up the next night as some of these G1s end up as failure to progress 18-24 hours later.
Click to expand...

It isnt about control. Its about what is best for the patient. Radiologists may not be doing blood patches after hours, but you bet they're coming in to do those embolectomies. They're also doing all those CT reads and plain films in the night not because they're urgent, but because they're paid to work that shift. I dont see where the issue is coming from. Using your example, a patient who comes in on the weekend for PDPH is in pain and need your help. Why are you complaining about doing something that will help that patient?

Regarding the IOL schedule. It IS whats is best for the patients SAFETY. The patient is up most of the night because theyre in pain... something you can help them get through. Most of my IOLs sleep through the night. Most inductions that usually fail to progress will get called after 24 hours. Youre right about that, but then again, you are being paid to be on call to do those cases.
 
pgg said:
Standard everywhere I've worked.

The only thing that sort of annoys me is the flurry of epidural calls between 6 and 7 AM, just as the overnight shift is ending. The L&D RNs do this because they know we get busy around 7 and the epidural might not get placed inside of 10 minutes if they call after the ORs start for the day. Getting called in the last 30 min of a 12 or 24 hour shift to do a timed-for-nursing-convenience procedure doesn't fill me with joy.
Click to expand...


Don’t forget 7am shift change. RNs are busy signing out to next shift at 6:45. Can’t interrupt sacred sign out time for an epidural.
 
GandalfTheWhite said:
Again, you are paid to provide call coverage during your call shift. Whether its urgent or non-urgent. Its also not your call to make. Your job on call is to provide anesthesia services to whomever is asking for it, and that includes OB when they ask for an epidural. Have you considered asking the patient for a preemptive epidural placement? That might help move the epidurals before nap time.


Same thing happened at my old place. I loved it since i was on production. Wake up at 6, place 3-4 epidurals, collect the units and go home to sleep.



It isnt about control. Its about what is best for the patient. Radiologists may not be doing blood patches after hours, but you bet they're coming in to do those embolectomies. They're also doing all those CT reads and plain films in the night not because they're urgent, but because they're paid to work that shift. I dont see where the issue is coming from. Using your example, a patient who comes in on the weekend for PDPH is in pain and need your help. Why are you complaining about doing something that will help that patient?

Regarding the IOL schedule. It IS whats is best for the patients SAFETY. The patient is up most of the night because theyre in pain... something you can help them get through. Most of my IOLs sleep through the night. Most inductions that usually fail to progress will get called after 24 hours. Youre right about that, but then again, you are being paid to be on call to do those cases.
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Some decisions are patient care neutral and have to do with personal preference. Sometimes decisions are made as to what's in the best interest of the people taking care of them. How many laboring patients who were impending C-sections allowed to labor all day while the OB was in office hours suddenly become urgent as soon as office hours are done? How many C-sections are called at 5:15 am because the OB is going off shift @ 07:00 and wants to get the baby delivered by the end of their shift? How many epidurals are scheduled around L & D nurses work flow/breaks, etc.?
 
Dr. Rude said:
Some decisions are patient care neutral and have to do with personal preference. Sometimes decisions are made as to what's in the best interest of the people taking care of them. How many laboring patients who were impending C-sections allowed to labor all day while the OB was in office hours suddenly become urgent as soon as office hours are done? How many C-sections are called at 5:15 am because the OB is going off shift @ 07:00 and wants to get the baby delivered by the end of their shift? How many epidurals are scheduled around L & D nurses work flow/breaks, etc.?
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We do a lot of toe amputations at 5pm.
 
My group also had the contract at a tiny community hospital. That's the culture. Surgeons were mostly solo, so the appy that shows up in the ER gets done after office hours, 5-6 pm. Makes for a long, but generally laid back day. My gripe were the Elective inductions on Sat and Sunday when it was just me and the call team. Better done during the week when reg staff was available.
 
Dr. Rude said:
Some decisions are patient care neutral and have to do with personal preference. Sometimes decisions are made as to what's in the best interest of the people taking care of them. How many laboring patients who were impending C-sections allowed to labor all day while the OB was in office hours suddenly become urgent as soon as office hours are done? How many C-sections are called at 5:15 am because the OB is going off shift @ 07:00 and wants to get the baby delivered by the end of their shift? How many epidurals are scheduled around L & D nurses work flow/breaks, etc.?
Click to expand...
I get your point, but let me counter... If I am paid for a 24 hour call shift, I am able and available to do the C-section during office hours, or immediately after office hours... because I am getting paid for making my services available during that time to the surgeon. Would I like it to be done earlier? Of course. But am I going to complain about it if it gets done at 7PM? No.
 
GandalfTheWhite said:
I get your point, but let me counter... If I am paid for a 24 hour call shift, I am able and available to do the C-section during office hours, or immediately after office hours... because I am getting paid for making my services available during that time to the surgeon. Would I like it to be done earlier? Of course. But am I going to complain about it if it gets done at 7PM? No.
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I don’t disagree with this post. My objection was the implication in the previous post that every discretionary decision about timing of inductions, requests for epidural anesthesia, timing of C-sections, etc. by OB staff was motivated by what’s “best for the patient”
 
medicine2wallstreet said:
It's safer to have them induce at midnight to be ready to deliver during the day when there is a full staff of obestetricians for emergencies. You need to suck it up and do the epidural during overnight hours. The overnight induction and during the day delivery is common practice. You part in this process as an epiduralist takes 15 minutes. They have to watch the laboring patient all day. They want an awake and alert obstetrician.
Click to expand...
I'm glad we have a resident's expert opinion on how OB anesthesia should be run.
 
Dr. Rude said:
Some decisions are patient care neutral and have to do with personal preference. Sometimes decisions are made as to what's in the best interest of the people taking care of them. How many laboring patients who were impending C-sections allowed to labor all day while the OB was in office hours suddenly become urgent as soon as office hours are done? How many C-sections are called at 5:15 am because the OB is going off shift @ 07:00 and wants to get the baby delivered by the end of their shift? How many epidurals are scheduled around L & D nurses work flow/breaks, etc.?
Click to expand...
Exactly.

They should not be starting pit at midnight. It's more common to do a few doses of miso overnight and start pit first thing in the morning. Starting pit is not an innocuous thing.
 
You might see this kind of thing to be more balanced for the anesthesiologist and ob doc. It's getting harder and harder at some places to get overnight coverage. The best thing for them would be to have regular call, but use them only for necessary things. So maybe admit patient for induction at 7 pm, don't start the induction stuff til midnight, then epidural at 7-8 am. Still deliver in daylight hours.
 
Maz777 said:
I'm glad we have a resident's expert opinion on how OB anesthesia should be run.
Click to expand...
why discount his/her opinion? Should it not count? Theres nothing false in the statement he/she made, except the part where it takes 15 minutes to do an epidural. Im just not sure what the point is of putting that poster down
 
GandalfTheWhite said:
why discount his/her opinion? Should it not count? Theres nothing false in the statement he/she made, except the part where it takes 15 minutes to do an epidural. Im just not sure what the point is of putting that poster down
Click to expand...
Referring to anesthesiologists as epidural technicians is not my idea of something that is good for our profession nor an opinion I would want any of my residents to espouse.
 
coffeebythelake said:
U are in-house right? If u are going to put in labor epidurals I don't think this is a huge stretch to do these epidurals too
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Heck yeah, now you’re thinking like an administrator. Since he’s in house we’ll call coffee for that difficult IV at 2am and he can do wall to wall elective cases on a Saturday since he’s here already.
 
GandalfTheWhite said:
Again, you are paid to provide call coverage during your call shift. Whether it’s urgent or non-urgent. It’s also not your call to make. Your job on call is to provide anesthesia services to whomever is asking for it, and that includes OB when they ask for an epidural. Have you considered asking the patient for a preemptive epidural placement? That might help move the epidurals before nap time.
Click to expand...
Actually it could be my call to make. There are limited resources available off hours. I’m paid to be on call to cover urgent OR, trauma and OB emergencies. If people are asking me to provide non-urgent services during an overnight shift it is my call to ensure I’m available for emergencies.
 
GandalfTheWhite said:
why discount his/her opinion? Should it not count? Theres nothing false in the statement he/she made, except the part where it takes 15 minutes to do an epidural. Im just not sure what the point is of putting that poster down
Click to expand...
How long does an epidural take?
 
GandalfTheWhite said:
I get your point, but let me counter... If I am paid for a 24 hour call shift, I am able and available to do the C-section during office hours, or immediately after office hours... because I am getting paid for making my services available during that time to the surgeon. Would I like it to be done earlier? Of course. But am I going to complain about it if it gets done at 7PM? No.
Click to expand...
What if the hospital isn't paying you a stipend to do in house call and you are only getting paid for the service?
 
LaryngoSpazz said:
Heck yeah, now you’re thinking like an administrator. Since he’s in house we’ll call coffee for that difficult IV at 2am and he can do wall to wall elective cases on a Saturday since he’s here already.
Click to expand...
Hire these people for the C-suite immediately. Just run all ORs and procedural areas 24/7/365. $. When an emergent mesenteric ischemia exlap gets booked (on a Medicaid patient) at 2am, put the patient on comfort care since you’re busy doing an elective lap chole. Just not cost effective to do the exlap.
 
I think there’s a lot of unpack here.

I just want to say there are many ways these epidurals are/were compensated.

For a good part of the last three decades, epidurals were soooo lucrative, at one practice, only senior partners were allow to take OB calls. In an affluent area, where 10-15 inductions per day. All relative healthy woman in their 20-40s with paying insurance, wouldn’t you want to keep billing for these sometimes 20+ hours epidural running time? I don’t think anyone complained to be woken up for an epidural, because that was expected and also how them earned a living. (Some better than the other… )

Now we’ve enter a world that we are being paid and/or subsidized by time. Of course OP wouldn’t want to do more than what can reasonably be done.

Someone recently told me they were getting $250/epidural. I almost cried. I told her straight up, you guys either need a new billing company or ain’t doing it right.

That’s why personally, I think we need to incentivize more work to be done, rather than more time to be spent at work. I also don’t think deserves as much push back as shown here.
 
LaryngoSpazz said:
Heck yeah, now you’re thinking like an administrator. Since he’s in house we’ll call coffee for that difficult IV at 2am and he can do wall to wall elective cases on a Saturday since he’s here already.
Click to expand...

When u signed up for these shifts was this responsibility outlined to you? Does it fall within your work description? Doing early morning epidurals for IOL is a common thing in many birthing centers.
 
Maz777 said:
Hire these people for the C-suite immediately. Just run all ORs and procedural areas 24/7/365. $. When an emergent mesenteric ischemia exlap gets booked (on a Medicaid patient) at 2am, put the patient on comfort care since you’re busy doing an elective lap chole. Just not cost effective to do the exlap.
Click to expand...

Ok dude. This is not what anyone said... the gears jn your head need a little oiling. there is a huge disconnect between what is written and your interpretation of it.
 
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Beeftenderloin said:
Standard practice. Better/safer to time it for them to deliver during daylight hours the next day with more staff around. Emphasis should be on a safe delivery plan, not a convenient epidural plan. As much as I hate the inconvenience of the 1am epidural, I hate the 1am PPH infinitely more.
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That’s false. They could start pit at 5 in the morning and the epidural AND delivery would be in the day. There’s no safety involved it is 100% the OB F’ing your night up for their convenience.

Yes, you are on call to be available for urgent/emergent cases, but the epidural is only necessary in the night because the OB is allowed to schedule an anesthetic in the night. No other case can be scheduled in the night for doctor preference. You don’t routinely do elective rotator cuffs at 1am because they aren’t allowed to schedule anesthetics that late, and neither should OBs!

Sure if a lady comes in in labor and needs an epidural I’ll be there with bells on my toes, but it shouldn’t be scheduled that way for inductions on purpose!

F those F’ing OBs! They should have to be there and awake while you do the epidural for patient safety just in case.
 
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coffeebythelake said:
Ok dude. This is not what anyone said... the gears jn your head need a little oiling. there is a huge disconnect between what is written and your interpretation of it.
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You previously posted that since you’re already there in the middle of the night just do it and don’t ask questions. That was your logic. It’s not a stretch to then say if a surgeon wants to do a 5am trigger finger release since they have clinic in the morning, you might as well do it since you’re in house.
 
triggermaster said:
That’s false. They could start pit at 5 in the morning and the epidural AND delivery would be in the day. There’s no safety involved it is 100% the OB F’ing your night up for their convenience.

Yes, you are on call to be available for urgent/emergent cases, but the epidural is only necessary in the night because the OB is allowed to schedule an anesthetic in the night. No other case can be scheduled in the night for doctor preference. You don’t routinely do elective rotator cuffs at 1am because they aren’t allowed to schedule anesthetics that late, and neither should OBs!

Sure if a lady comes in in labor and needs an epidural I’ll be there with bells on my toes, but it shouldn’t be scheduled that way for inductions on purpose!

F those F’ing OBs! They should have to be there and awake while you do the epidural for patient safety just in case.
Click to expand...

Evening induction for our OBs means starting a cervical ripening agent around 7-9pm then pit whenever cervix is favorable. Often that’s not til next morning, sometimes that’s at 1am, but with the plan being to ideally deliver next day during business hours. Our group has a dedicated doc covering L&D in house 24/7. Overnight doc comes in at 5pm and is getting paid well for it. All seems reasonable in that context. But you’re welcome to disagree.
 
Some models don't reward overnight epidurals it seems but a lot do. I don't do it often as I'm mostly cardiac or icu but from what I understand our OB guys make a Killing from these epidurals.
 
I was in the same boat at my prior job. We had one OB who would bring them in at 10 PM, right at midnight when she hit 39 weeks he would break her water, start pit, and the epidural call would come between 1-2 AM. I'd say > 50% of them would deliver by the time I was packing up to leave at 7 AM. I never understood this. If that is the recipe that works, why not bring them in at 4 PM, break their water at 6 PM after your clinic, then deliver before 10 PM so you can at least sleep for the night. I would always "joke" with him and he would always say, "Ahh, I have busy clinic and then tennis afterwards."

The thing that really "irked" me were the weekend inductions. Covering 2 to 3 rooms including trauma and cardiac only to get calls for multiple epidurals throughout the day was definitely getting unsafe in my opinion.

Anyways, I signed up for it, I knew what to expect, and even though I disliked it, I did it without otherwise complaining. If this really bothers you, then you either need a new job or a new profession.
 
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