intra-op N/v OB

[sweetalkr]

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I am CA-1 in my 2nd month on OB, 1st month running the show alone.
I am having what it seems like is a 30-40% rate of intra-op n/v with my pts.
I am keeping up on the BP's, with sbps> 110, but I end up giving zofran by the end of the case to keep these human puke machines under control .
any advice/prophylactic meds/intraop measures/pearls for OB pts undergoing spinal csxn?
i use bupivicaine 12mg/fentanyl 20mcg/morphine .15mg
sometimes reglan post op

 

[Planktonmd]

I am CA-1 in my 2nd month on OB, 1st month running the show alone.
I am having what it seems like is a 30-40% rate of intra-op n/v with my pts.
I am keeping up on the BP's, with sbps> 110, but I end up giving zofran by the end of the case to keep these human puke machines under control .
any advice/prophylactic meds/intraop measures/pearls for OB pts undergoing spinal csxn?
i use bupivicaine 12mg/fentanyl 20mcg/morphine .15mg
sometimes reglan post op

It might be the effect of exteriorizing the uterus combined with the effect of pitocin.
Try adding some glycopyrrolate.

 

[bostonblaz]

some people i work with like to use 20-30 mg propofol. i have used it and it does work but i feel like persuading rthe oob's to put the utuerus back in the pt's bosy seems to help the most

 

[Trisomy13]

sometimes reglan post op

although the evidence for Reglan's antiemetic effect outside of the realm of chemotherapy is weak, I use it occasionally as well in OB, but I give it about 15 min prior to the start of the case, rather than post-op. this is one scenario where i have experimented with the 10-20 mg bolus of Propofol as an antiemetic, with fairly positive results. i also try to explain to the patient that she can expect some nausea during externalization/internalization of the uterus and warn her before it happens. Zofran sometimes towards the end if she had some nausea that wasn't easily explained by hypotension / didn't respond to fluid bolusing. I only had a handful of pukers during my month on OB.

 

[jetproppilot]

I am CA-1 in my 2nd month on OB, 1st month running the show alone.
I am having what it seems like is a 30-40% rate of intra-op n/v with my pts.
I am keeping up on the BP's, with sbps> 110, but I end up giving zofran by the end of the case to keep these human puke machines under control .
any advice/prophylactic meds/intraop measures/pearls for OB pts undergoing spinal csxn?
i use bupivicaine 12mg/fentanyl 20mcg/morphine .15mg
sometimes reglan post op

I've found being more aggressive with pressors has anecdotally reduced the N/V I see.

I used to wait after doing a spinal until I saw a low BP, lady said she was nauseated, etc.

I dont wait anymore no matter what their BP is. I hittem with 10-15 mg ephedrine as soon as I lay her down.

 

[Laurel123]

I've found being more aggressive with pressors has anecdotally reduced the N/V I see.

I used to wait after doing a spinal until I saw a low BP, lady said she was nauseated, etc.

I dont wait anymore no matter what their BP is. I hittem with 10-15 mg ephedrine as soon as I lay her down.

I also have found that helps with that time period before the OB's pop the uterus out. I pretty give everyone a 10 mg of ephedrine, unless they are already very tachycardic.

 

[IlDestriero]

When I was a resident I also seemed plagued by frequent intraoperative N/V.
As an attending I gave everyone 10 mg reglan 30 min prior to going to the OR (or ASAP in the case of an urgent section). I also preload everyone with 1 L of LR immediately prior to going to the OR on a pressure bag (yes even if they had preeclampsia, as long as there were no signs of pulmonary edema).
After the spinal (almost always 10.5 mg hyperbaric bupiv with 25 mcg fent with 100 mcg duramorph, unless the patient was <4'10" or >6'2") and a bit of trendelenberg I continued to load the patient with LR. I gave 10 mg of Ephedrine at the first sign of dropping BP, which is usually increasing HR. Over the course of the case I usually give 2-3 L of LR. I also ask the patient if they are nauseated at incision and again when closing the uterus. Occasionally a patient will admit to some mild nausea if asked that they would not otherwise report to you. Since changing my routine, I had an intraop N/V rate close to zero. 4 of zofran and continued 02 seemed to help the rare ones who admitted to some nausea.
YMMV.
Having said that I think that the real reason that my N/V rates dropped is that during residency all the c/s took more than an hour and as an attending all my c/s were less than an hour.👍
Thank god I don't do OB anymore!
Regards.

 

[jwk]

I'm with Jet - nausea=pressors at C/S time - although now I use a lot more phenylephrine and a lot less ephedrine.

 

[militarymd]

Ever go and just watch labor...and then vaginal delivery.....the whole process....

Do you know how many of them get nause and vomiting?

a LOT....EVEN without the C-sectin...

Nature of the beast....

 

[Trisomy13]

Ever go and just watch labor...and then vaginal delivery.....the whole process....

Do you know how many of them get nause and vomiting?

a LOT....EVEN without the C-sectin...

Nature of the beast....

i get a little N/V just thinking about it.

 

[Planktonmd]

Nausea and vomiting caused by uterine or peritoneal manipulation is mainly a vagal response even in the absence of the typical bradycardia and an anticholinergic agent (Glycopyrrolate, Scopolamine or even atropine) should take care of it.

 

[militarymd]

so allow me to sum it up:

Nause and vomiting is just a part of labor.