Failed Epidural for C section-Now What?

[jetproppilot]

CAmbie,

With all due respect, the academic studies regarding the intubation of Pregnant patients are over-blown. An experienced, competent Anesthesiologist will intubate the airway of 99% pregnant patients with normal anatomy.

I understand your caution in choosing GA as a route. But, when Neuraxial Anesthesia fails the FIRST time it is a reasonable choice. However, I respect your reluctance to choose GA; but in PP EXPEDIENCE is part of the game. So, you better be real quick with re-doing that Neuraxial block.

Heres a FINAL SAY SO on this subject:

In this biz we all make our living by, there is rarely a "right" answer.

By stimulating ourselves thru interaction we all benefit.

Nice, nice thread everyone.

Thank you.

I always learn by interacting here.

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[ProRealDoc]

Has any of you ever heard or been told that the spinous ligaments get 'soft' in pregnancy?

A few times, after engaging the needle, I have felt a false loss of resistance and then think I am not in the right space. Interestingly I have checked to see if I am in the right space by introducing the spinal needle just to realize I am still far from the epidural layer despite having loss of resistance.

I asked around and was told that in pregnancy the ligaments develop laxity and it is expected to not always have the firmness on the plunger even though your needle is fully engaged.

Any truth to this?

 

[dhb]

Has any of you ever heard or been told that the spinous ligaments get 'soft' in pregnancy?

I've heard women get fat during pregnancy.
High levels of progesterone will cause a certain ligamentary laxity but i have never had a different feel for LOR. Probably exiting the ligament if you're slightly off midline.

 

[ProRealDoc]

I've heard women get fat during pregnancy.
High levels of progesterone will cause a certain ligamentary laxity but i have never had a different feel for LOR. Probably exiting the ligament if you're slightly off midline.

I was referring to the ligaments having laxity to the point where applying a bit too much pressure on the syringe plunger would cause saline to be displaced easily and make you think you are in the epidural space.

 

[huktonfonix]

I was referring to the ligaments having laxity to the point where applying a bit too much pressure on the syringe plunger would cause saline to be displaced easily and make you think you are in the epidural space.

Yes, they can get "mushy" from progesterone, but its not gonna cause what youre thinking of. You just need to get a better feel of the ligament. Before I got a better feel for the ligaments I used to wonder about that "false LOR". Looking back, it was just not being able to appreciate the feel of the ligament. Like someone else mentioned, youve probably gone off center into paraspinous. If you dont get a nice firm ,occasionally crunchy flavum feel before the LOR, ya aint there.

 

[jetproppilot]

Yes, they can get "mushy" from progesterone, but its not gonna cause what youre thinking of. You just need to get a better feel of the ligament. Before I got a better feel for the ligaments I used to wonder about that "false LOR". Looking back, it was just not being able to appreciate the feel of the ligament. Like someone else mentioned, youve probably gone off center into paraspinous. If you dont get a nice firm ,occasionally crunchy flavum feel before the LOR, ya aint there.

With all due respect I'm not liking the gist of this conversation.

Mainly, that theres some difference in the ligament (which I disagree with), how it feels, from pregnancy.

I'm not keen on creating or propagating academic dogma.

I haven't appreciated a true difference in a pregnant woman's ligament.

Actually as a general rule I'd say from a tactile point of view it is more noticeable as a general rule.....crunchier....then the epidurals I do in the OR on old people for total joints et al.

I use a dry syringe.

I use the constant pumping technique tm and as a general rule I can feel the ligament as I traverse it....WAIT FOR IT.....WAIT FOR IT.....

POOOOOOOOOSH

Loss of resistance.

May I add that placing an epidural once you are very comfortable with them is a totally tactile skill.

My eyesight is pretty bad....if I don't have my glasses on and I'm on OB for the day, for an epidural placement, initially, my face is like a foot away from dudette's back for initial needle placement laugh then once the Tuohy is lined up I can back up.

I don't need to see what I'm doing anymore.

I can feel it.

 

[jetproppilot]

Has any of you ever heard or been told that the spinous ligaments get 'soft' in pregnancy?

A few times, after engaging the needle, I have felt a false loss of resistance and then think I am not in the right space. Interestingly I have checked to see if I am in the right space by introducing the spinal needle just to realize I am still far from the epidural layer despite having loss of resistance.

I asked around and was told that in pregnancy the ligaments develop laxity and it is expected to not always have the firmness on the plunger even though your needle is fully engaged.

Any truth to this?

No.

 

[huktonfonix]

With all due respect I'm not liking the gist of this conversation.

Mainly, that theres some difference in the ligament (which I disagree with), how it feels, from pregnancy.

I'm not keen on creating or propagating academic dogma.

I haven't appreciated a true difference in a pregnant woman's ligament.

Actually as a general rule I'd say from a tactile point of view it is more noticeable as a general rule.....crunchier....then the epidurals I do in the OR on old people for total joints et al.

I use a dry syringe.

I use the constant pumping technique tm and as a general rule I can feel the ligament as I traverse it....WAIT FOR IT.....WAIT FOR IT.....

POOOOOOOOOSH

Loss of resistance.

May I add that placing an epidural once you are very comfortable with them is a totally tactile skill.

My eyesight is pretty bad....if I don't have my glasses on and I'm on OB for the day, for an epidural placement, initially, my face is like a foot away from dudette's back for initial needle placement laugh then once the Tuohy is lined up I can back up.

I don't need to see what I'm doing anymore.

I can feel it.

It is a purely tactile procedure. Thats all I was saying. I personally dont think the ligament is noticably different in pregnant women, but that is what the books claim. Im just telling the OP that that false LOR isnt caused by the "softer ligament" and that he just needs to get a better feel for the tissue. I personally like the continuous with saline, but as many past threads have stated as long as you know what the ligament feels like, it doesnt matter what technique you use.

 

[jetproppilot]

It is a purely tactile procedure. Thats all I was saying. I personally dont think the ligament is noticably different in pregnant women, but that is what the books claim. Im just telling the OP that that false LOR isnt caused by the "softer ligament" and that he just needs to get a better feel for the tissue. I personally like the continuous with saline, but as many past threads have stated as long as you know what the ligament feels like, it doesnt matter what technique you use.

Apparently the books were written by dudes that havent done thousands of epidurals.

 

[Planktonmd]

Apparently the books were written by dudes that havent done thousands of epidurals.

People who do thousands of epidurals usually don't have time to write books.

 

[dhb]

a nice firm , crunchy flavum feel before the LOR, ya aint there.

This is exactly what it is: when you get the crunch you can lighten the pressure slightly on the plunger LOR will ensue with 0.5ml of saline in the epidural space & voila.

 

[sevoflurane]

Had a new collegue ask me some questions this am about this topic. Oral boards coming up for him.

Spinal after failed epidural... reminded me of this thread... which is a good one.

Just wondering about the MECHANISM of high spinal after epidural.

Dural puncture and LA getting into the intrathecal space? Seems possible, I guess... but the IT space is a place that has higher pressure than the epidural space... but maybe not when there is 15 cc's of LA swiming around the epidural space. Any studies that IMAGE this (I'm guessing not)?

What are people doing nowadays?

1) Still placing spinals after epidruals that have been running @ a constant rate?

2) Still placing spinals after epidrual bolus and patchy block? Or redo epidurals?

3) Bailing out and passing out PVC for a failed epidural presenting for C/S?

 

[jwk]

Had a new collegue ask me some questions this am about this topic. Oral boards coming up for him.

Spinal after failed epidural... reminded me of this thread... which is a good one.

Just wondering about the MECHANISM of high spinal after epidural.

Dural puncture and LA getting into the intrathecal space? Seems possible, I guess... but the IT space is a place that has higher pressure than the epidural space... but maybe not when there is 15 cc's of LA swiming around the epidural space. Any studies that IMAGE this (I'm guessing not)?

What are people doing nowadays?

1) Still placing spinals after epidruals that have been running @ a constant rate?

2) Still placing spinals after epidrual bolus and patchy block? Or redo epidurals?

3) Bailing out and passing out PVC for a failed epidural presenting for C/S?

IMHO.....

1) We dont' do SAB for C/S anyway, BUT, if you have an epidural running already, it is pointless to change to a SAB.

2) Never an SAB after epidural bolus - ever. We'll redo the epidural.

3) Epidural dose >> patchy block >> more local or replace epidural >> GA.

I still stand by my posts on this from 3 years ago - and we do >6000 C-sections a year.

 

[BobBarker]

Why don't you do a SAB for C/S in your practice?

 

[pgg]

Why don't you do a SAB for C/S in your practice?

I assume he means for patients with existing labor epidurals.


Not doing SABs for scheduled c-sections is just nuts, and jwk isn't nuts ...

 

[sevoflurane]

IMHO.....

1) We dont' do SAB for C/S anyway, BUT, if you have an epidural running already, it is pointless to change to a SAB.

2) Never an SAB after epidural bolus - ever. We'll redo the epidural.

3) Epidural dose >> patchy block >> more local or replace epidural >> GA.

I still stand by my posts on this from 3 years ago - and we do >6000 C-sections a year.

1) I should be clear... running epidural that is patchy. If it's working, abosolutely no reason to do a spinal.

2) So you are in the "never spinal after epidrual camp"... bolus or no bolus. If bolus and patchy... redo epidural and bolus again...? (Could get a high epidural this way... but maybe not as drastic as a high spinal).

3) Local or replace epidural?- I've asked the surgeon to infiltrate with LA on more than one occasion (patient already with monitors, prepped, that suddenly has a small spot that is not covered when testing before inscision). Works very well, especially with a little nitrous mixed in.

>6000 C/S

Whoa. That is a shait ton of C/S's.

i don't even want to know how many deliveries per year is in that practice. I worked at a place that did about 4k deliveries/year = busy nights.

Agree with pgg, unless his practice is placing them for post-op pain for a couple of hours (never really done them this way, altough it may be a lucrative way of billing... + you can add some duramorph before pulling it).

 

[deleted162650]

We have one attending with the following approach:

If epidural is sketchy, he will bolus 5-10cc of 2% Lido. If the response is unfavorable (still patchy, unilateral, level fails to rise appropriately), he will then proceed with spinal. He uses a standard spinal dose (not reduced). He will inject slowly, over a full 30 seconds. He then leaves the pt sitting for an additional full 30s before lying them down. After lying down the pts have a T4 level pretty much immediately. He says he's never had a high spinal with this technique though I'm not sure what his n is.

He will not do this if the epidural has been bolused w/ more than 10cc.

 

[Consigliere]

IMHO.....

1) We dont' do SAB for C/S anyway, BUT, if you have an epidural running already, it is pointless to change to a SAB.

2) Never an SAB after epidural bolus - ever. We'll redo the epidural.

3) Epidural dose >> patchy block >> more local or replace epidural >> GA.

I still stand by my posts on this from 3 years ago - and we do >6000 C-sections a year.

Assuming a 25% C-section rate, that's 24,000 deliveries a year. I'm not sure I believe that.

 

[pgg]

Assuming a 25% C-section rate, that's 24,000 deliveries a year. I'm not sure I believe that.

65 deliveries / day isn't impossible for a big group covering multiple hospitals in an urban area. That's what, maybe ~3-4 fairly busy hospitals?

 

[BLADEMDA]

We have one attending with the following approach:

If epidural is sketchy, he will bolus 5-10cc of 2% Lido. If the response is unfavorable (still patchy, unilateral, level fails to rise appropriately), he will then proceed with spinal. He uses a standard spinal dose (not reduced). He will inject slowly, over a full 30 seconds. He then leaves the pt sitting for an additional full 30s before lying them down. After lying down the pts have a T4 level pretty much immediately. He says he's never had a high spinal with this technique though I'm not sure what his n is.

He will not do this if the epidural has been bolused w/ more than 10cc.

Well since his technique is slow anyway why not just redo the epidural with the patient sitting up? I can redo the epidural and be ready to cut as fast as the described technique by your attending.

 

[cincincyreds]

Well since his technique is slow anyway why not just redo the epidural with the patient sitting up? I can redo the epidural and be ready to cut as fast as the described technique by your attending.

Blade, thanks for the case. I think maybe in the last 3 years I had one failed labor epidural when used for C-section. That patient I put to sleep because of "late decels per the OBGYN".

I think if one has enought time, re-doing the epidural is the most reasonable and safe choice. You decrease the risk of aspiration from GA and decrease the risk of high spinal with the spinal choice. Also, you can titrate to effect versus the one time spinal shot. Lastly the epidural can be used for postop pain if needed.

Again, good case for review.

 

[jwk]

Assuming a 25% C-section rate, that's 24,000 deliveries a year. I'm not sure I believe that.

Our peak year about 3-4 years ago, before we added OB services at a new hospital in our system, was 18,000 deliveries at a single community hospital. We have the largest non-academic OB practice in the country. A few years ago we added a second hospital (same system) doing OB, and now have a third. For the three hospitals, we're now probably at 20-21k total. At the biggest hospital, I was guessing the C/S rate at about 33% - we do a TON of repeat C-Sections and a minimum of VBAC's, even with in-house OB and anesthesia.

As you might imagine, the logistics are crazy sometimes, particularly at our main hospital which has 5 C/S OR's. There are 3 MD's and 4-5 anesthetists that do nothing but OB on weekdays, and 24/7 MD and anesthetist coverage at all three hospitals with additional backup on call. Our OB anesthetists do only sections and manage labor epidurals when assigned to OB - they have no surgical OR responsibilities. The anesthesiologists place all the epidurals. On a busy day, an anesthesiologist might put in 20 epidurals. I think our single day-record at one hospital is near 80 deliveries. That hospital has about 75 labor rooms. BTW, our group is approaching 150 docs, AA's, and CRNA's.

 

[deleted162650]

Blade,

Would you not bolus the in situ epidural first to see if you could achieve an adequate level? If you're omitting that part from the equation, then I could see how your technique may be faster. If not though, I don't believe you can place an epidural start to finish and have it bolused to a surgical block in less than the 60s it takes to do the technique I described. If you can, I would love to hear your technique. I'm always looking to get better/faster.

 

[BLADEMDA]

Blade,

Would you not bolus the in situ epidural first to see if you could achieve an adequate level? If you're omitting that part from the equation, then I could see how your technique may be faster. If not though, I don't believe you can place an epidural start to finish and have it bolused to a surgical block in less than the 60s it takes to do the technique I described. If you can, I would love to hear your technique. I'm always looking to get better/faster.

I can do an Epidural pretty darn fast and since I know the corners to cut my hunch is that my patient would be ready to cut within 5-6 min flat.

As for spotty epidurals I'd rather just do an SAB in the O.R. from the get-go then deal with the failed Epidural scenario. I only like to BOLUS good, working epidurals for Sections otherwise the GA scenario is looking like 50/50 at least.

I've got not qualms or issues about converting to GA quickly and efficiently when an Epidural is inadequate.

 

[Consigliere]

Our peak year about 3-4 years ago, before we added OB services at a new hospital in our system, was 18,000 deliveries at a single community hospital. We have the largest non-academic OB practice in the country. A few years ago we added a second hospital (same system) doing OB, and now have a third. For the three hospitals, we're now probably at 20-21k total. At the biggest hospital, I was guessing the C/S rate at about 33% - we do a TON of repeat C-Sections and a minimum of VBAC's, even with in-house OB and anesthesia.

As you might imagine, the logistics are crazy sometimes, particularly at our main hospital which has 5 C/S OR's. There are 3 MD's and 4-5 anesthetists that do nothing but OB on weekdays, and 24/7 MD and anesthetist coverage at all three hospitals with additional backup on call. Our OB anesthetists do only sections and manage labor epidurals when assigned to OB - they have no surgical OR responsibilities. The anesthesiologists place all the epidurals. On a busy day, an anesthesiologist might put in 20 epidurals. I think our single day-record at one hospital is near 80 deliveries. That hospital has about 75 labor rooms. BTW, our group is approaching 150 docs, AA's, and CRNA's.

Well sir, you have just described what hell must be like. Thank you for painting such a vivid picture.

 

[Mman]

If a patient has an epidural and is coming for c-section, I first test the epidural. Ask how well the patient feels it's been working and check levels to temp sensation. If everything seems like it's been working fine and they have good levels, I'll bolus it and proceed with c-section. If it's a little iffy at all, I'll put it and place a spinal. I have little desire to deal with a failed epidural in the middle of a c-section.

Since the patient already has a documented good level before I bolused, I'm pretty sure we will be passing the "alice test". At that point it's either we are getting through the procedure with the epidural or we are converting to GA. Patient's choice. I'll work with them and give them things like nitrous or ketamine or fentanyl or versed, but if they can't handle it we go to sleep.

I have no desire to have a recently bolused epidural and then proceed with another neuraxial procedure. Spinal would risk a high spinal and even repeating epidural, how much local can you give? Because if I bolused it I probably already gave up to 400 mg of Lidocaine. I'd be reluctant to give another 400 ml of lidocaine through another epidural 10 minutes later.

 

[deleted162650]

For those who opt to place a spinal if the epidural does not seem reliable enough for C/S, do you reduce your dose or just give your standard dose. What intrathecal dose are you guys using out there in the real world where a C/S doesn't take 1-2H like here in academia?

 

[saratoga733]

For those not in the know, it's called an "Allis" test (as in Allis clamp). Was glad someone pointed it out to me, thought I'd return the favor. My anesthesia record makes more sense now...

 

[IlDestriero]

For those who opt to place a spinal if the epidural does not seem reliable enough for C/S, do you reduce your dose or just give your standard dose. What intrathecal dose are you guys using out there in the real world where a C/S doesn't take 1-2H like here in academia?

If I've got an epidural that sounds shady, I don't bolus, just pull and do a spinal. Full dose. I don't think there's much risk of a high spinal from a running epidural that you don't test with a bolus. If it's urgent, there's no time to mess with a bolus, hope for the best and end up with a general. I'm not afraid of a general, and have done many, but I don't want mom and dad to miss the birth. If there's time I guess you could replace the epidural, but the spinal works 999 times out of 1000, and the new epidural might be just as shady.
Our surgeons are reasonably quick and I usually use 10.5-12mg heavy bupiv with epi, 20 mcg fentanyl and 150mcg duramorph. A third timer, etc would get an extra 1.5 mg. If they need more time than that, something is seriously wrong and the spinal wearing off is the least of our problems.

 

[fakin' the funk]

If I've got an epidural that sounds shady, I don't bolus, just pull and do a spinal. Full dose. I don't think there's much risk of a high spinal from a running epidural that you don't test with a bolus.

Amen, brother.

The problem with the situation in Blade's original post was that the patient was bolused w/ 20ml 2% lidocaine before a problem was detected. Talk about being painted into a corner.

 

[fakin' the funk]

I'm just gonna throw in my 2 cents on the original posting...

The #1 thing you can do to improve outcomes for parturients is avoid GA. I know Blade and Jet will tell you they can intubate a gravid fire ant, and maybe they can, but statistically and population-ally speaking, avoid GA and the risks of lost airway or aspiration are the best things anesthesiologists can do.

The risk of lost airway or aspiration, whether it's 1% or 0.1%, is still WAY WAY higher than hemorrhagic complications from neuraxial block. And if you're doing 6,000 C-sections a year like JWK you're talking about 60 or 6 such events a year.

So, for me, the plan is neuraxial at (nearly) any cost, unless time or physiology or coagulation status contraindicate it.

Of all the options discussed, I like pulling the epidural and using a 60-75% spinal dose (8-10mg bupiv), having been placed with a 25g or 27g spinal needle. Hell, you could even use the epidural Tuohy as an introducer if the 27g is too floppy. (My n for such a technique is admittedly zero)

 

[Mman]

I'm just gonna throw in my 2 cents on the original posting...

The #1 thing you can do to improve outcomes for parturients is avoid GA.

No, that isn't the #1 thing you can do. That's where you are wrong. The #1 thing you can do is avoid having to convert to GA in the middle of the case. That's where something bad is FAR more likely to happen.

A nice smooth induction where you can take your time, get the patient properly positioned, well preoxygenated, etc. is a controlled situation. Dealing with a failed epidural in the middle of the case with the patient's uterus exteriorized and having to convert to GA at that point is the worst thing you can do. Plus, if they have a bad airway it's far better to deal with at the start of the case. Hell, that's an oral boards topic on to itself and one that many people will get on the real boards.

 

[deleted162650]

"Hell, you could even use the epidural Tuohy as an introducer if the 27g is too floppy. (My n for such a technique is admittedly zero)" [/QUOTE]

Ive done this a few times and it works really well

 

[Arch Guillotti]

I assume he means for patients with existing labor epidurals.


Not doing SABs for scheduled c-sections is just nuts, and jwk isn't nuts ...

i think they do epidurals on all comers.

 

[jwk]

I assume he means for patients with existing labor epidurals.

Not doing SABs for scheduled c-sections is just nuts, and jwk isn't nuts ...

Well, yes and no. We definitely don't do them on patients with existing epidurals. However, we really only rarely do an SAB for a C/S in any circumstance. We're probably on the order on 98% epidural, 1.9% GA, and 0.1% spinal/CSE. Pretty much all our C/S patients get an epidural, which stays in about 24hrs post-op for use with a PCEA pump. We have an active acute pain management service, which is financially feasible given our patient volume.

Our practice built their name on OB anesthesia when we were the first in the city (40 years ago) to offer 24/7 in-house anesthesia OB services. We are fiercely protective of that part of our practice, and every single person in the practice participates in OB so that there is never a time where there is an inexperienced or "rarely in OB" anesthetist and MD on duty. If you don't/can't do OB in our practice, you don't work here.

 

[pgg]

i think they do epidurals on all comers.

Why do an epidural for a scheduled c-section?

I'm genuinely asking, I don't see the point, but I do see some disadvantages. Time, reliability, and cost chief among them. What am I missing?


Edit, just saw jwk's post:

Pretty much all our C/S patients get an epidural, which stays in about 24hrs post-op for use with a PCEA pump.

What do you put in the PCEA? Do you let them ambulate in that first 24hrs? Why does your group favor epidural infusions x24h vs intrathecal morphine?

 

[Arch Guillotti]

Why do an epidural for a scheduled c-section?

I'm genuinely asking, I don't see the point, but I do see some disadvantages. Time, reliability, and cost chief among them. What am I missing?


Edit, just saw jwk's post:



What do you put in the PCEA? Do you let them ambulate in that first 24hrs? Why does your group favor epidural infusions x24h vs intrathecal morphine?

I don't get it either.

 

[sevoflurane]

I totally get it....

 

[pgg]

I totally get it....

OK, besides billing for more $, what's the up side?

 

[sevoflurane]

Ummm... patient satisfaction scores...?

A well run OB group is where it's @ in anesthesia. No doubt.

If you are the big boy in town, you can negotiate some pretty good contracts with diff. insurance companies.

I'm gonna guess, the epidurals go in early and are rounded on @ least once an hour with documentation in the chart...

 

[pgg]

Ummm... patient satisfaction scores...?

Really - being stuck in bed x24 hours after a section is more satisfying than a ~ 0.2 mg of intrathecal morphine + Percocet + ketorolac and walking?


Someone posted here a couple years ago that their group left in epidurals after deliveries and c-sections for 48 hours, but just dosed them with morphine. He said patients loved it and I believe it.

I am still curious what jwk's group puts in the PCEA and if those patients get out of bed.

The section I did this morning with a spinal + 0.2 mg morphine is out of bed right now and feels good.

I'm gonna guess, the epidurals go in early and are rounded on @ least once an hour with documentation in the chart...

Hourly rounds on a postop epidural?

How early do you put in epidurals for scheduled c-sections?

 

[sevoflurane]

The place that I worked @ that had 4k deliveries/yr was also very lucrative. Epidurals early and CRNAs we're expected to round on them q15 minutes. Again... nights were busy, busy, busy...

I'm sure JWK has a sweet gig considering a staff of 150.

 

[sevoflurane]

Really - being stuck in bed x24 hours after a section is more satisfying than a ~ 0.2 mg of intrathecal morphine + Percocet + ketorolac and walking?


The section I did this morning with a spinal + 0.2 mg morphine is out of bed right now and feels good.

I don't know if you caught my sarcasm...

Oh and don't forget the foley!

 

[pgg]

The place that I worked @ that had 4k deliveries/yr was also very lucrative. Epidurals early and CRNAs we're expected to round on them q15 minutes. Again... nights were busy, busy, busy...

I'm sure JWK has a sweet gig considering a staff of 150.

I guess I'm just skeptical that the average patient really prefers being anchored to a bed with numb legs and a tube in her back for 24 hours, vs ambulating with a heplocked IV and intrathecal narcotics.

I'm one of those rare guys who likes doing OB, and although my patients are pretty consistently satisfied, I'm always looking for ways to make their experience better. I'm trying to convince myself to give this 24 hr post-c-section epidural thing a shot, but I don't see it.

 

[sevoflurane]

Hourly rounds on a postop epidural?

How early do you put in epidurals for scheduled c-sections?

Post-op rounds... I don't remember how those were billed. But you can get 4u/hr (1u/15min.) for vag delivery x 8 hr. for laboring x 20 rooms... it works out to be pretty good.

In a huge busy OB group, I can see an epidural team placing them pre-op then a handover to an OR team.

On a different note, we are FINALLY getting paid for standby VBACS (pain in my arse).

 

[pgg]

I don't know if you caught my sarcasm...

Oh and don't forget the foley!

Ah, detector failing today.

Everybody loves a foley. We've got one L&D nurse who likes to put them in before the patient gets her labor epidural or c-section spinal, just to get ahead on charting or something.

 

[pgg]

Post-op rounds... I don't remember how those were billed. But you can get 4u/hr (1u/15min.) for vag delivery x 8 hr. for laboring x 20 rooms... it works out to be pretty good.

In a huge busy OB group, I can see an epidural team placing them pre-op then a handover to an the OR team.

On a different note, we are FINALLY getting paid for standby VBACS (pain in my arse).

There's a growing trend 'round these parts to cover OB services with 100% CRNA care, with no anesthesiologists in house or on call as backup. They say there's no money in it because no one has insurance here. Instead of epidurals, the patients are offered single shot 'long acting' labor spinals. They wait until the OB guesses they're within a couple hours of delivery, and they get their one shot, and hopefully it lasts long enough. I think that sucks.

VBACs at my day job aren't so bad. They all want epidurals anyway, so I'm stuck in the hospital regardless. It's the OR crew that gets shafted, sitting around waiting for a section that might not happen.

 

[sevoflurane]

I guess I'm just skeptical that the average patient really prefers being anchored to a bed with numb legs and a tube in her back for 24 hours, vs ambulating with a heplocked IV and intrathecal narcotics.

I'm one of those rare guys who likes doing OB, and although my patients are pretty consistently satisfied, I'm always looking for ways to make their experience better. I'm trying to convince myself to give this 24 hr post-c-section epidural thing a shot, but I don't see it.

C/S get spinals from us. We don't have the time or man power to provide post-op epidurals.

I can see it being used as a "walking epidural"

Most patients are exhausted after a C/S and take a little nappy-poo once they get back to their room. Turning down the rate and concentration may allow them a pain free period extending into the am of the next day...

Just another way.

I think it's alright if your patients are liking it, are monitored and are enjoying their new little ones.

 

[sevoflurane]

There's a growing trend 'round these parts to cover OB services with 100% CRNA care, with no anesthesiologists in house or on call as backup. They say there's no money in it because no one has insurance here. Instead of epidurals, the patients are offered single shot 'long acting' labor spinals. They wait until the OB guesses they're within a couple hours of delivery, and they get their one shot, and hopefully it lasts long enough. I think that sucks.

VBACs at my day job aren't so bad. They all want epidurals anyway, so I'm stuck in the hospital regardless. It's the OR crew that gets shafted, sitting around waiting for a section that might not happen.

I've never heard of a "long acting labor spinal". They better be there monitoring the patients... that sounds like a disaster waiting to happen if they are using more than 1cc of .25% marcaine... which as you know, doesn't last 2 hours.

You need to have good contracts with the insurance companies in order to get paid. If you are 80% medicare you are hosed.

 

[sevoflurane]

They all want epidurals anyway, so I'm stuck in the hospital regardless. It's the OR crew that gets shafted, sitting around waiting for a section that might not happen.

Just because you have an epidural running doesn't mean you need to be stuck in the hospital.

If it's a low volume hospital (<600-700 deliveries), all the groups that I have intimate knowledge of don't stay in house if there is an epidural running.

We've done it this way for the last 30 years.

When I got out of residency I thought that was crazy. Now I know better.

We allow our (experienced) nurses to give pressors under strict preset orders. We also allow them to give a small bolus over 10 minutes (on pump of course). Everyone is happy. Patient, doc, nurse.

Zero adverse events. Zero.

Sleeping in your own bed is very nice when you are 1st call....

VBACs are another story. We need to be there.

I just don't get VBACs anyways. That is one procedure that doesn't make sense to me.

Get a spinal, use the same scar and be done with it.... Done in 45 minutes.

VS.

Laboring for 8 hours, experiencing some degree of discomfort and 50% of times... you get to go to the OR @ 3:00am for non-reassuring FHR, failure to progress, etc, etc..