Kosher or not Kosher? standard practice, OB THREAD

Started by turnupthevapor
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turnupthevapor

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Wondering if any of you young padawans or jedi masters have any insight for me:

In a community hospital does and obstetrician need to be IN THE BUILDING during the introduction and maintance of a laboring epidural? Our facility only has in-house OB from 8pm-8am. I am looking for ACOG or ASA practice guideline type suggestion. Evidence based answers should be out there I don't think we are the first facility to deal with this question and I would like to have our policy match standard practice.

Thanks!!!!!!😀😛👍
 
turnupthevapor said:
Wondering if any of you young padawans or jedi masters have any insight for me:

In a community hospital does and obstetrician need to be IN THE BUILDING during the introduction and maintance of a laboring epidural? Our facility only has in-house OB from 8pm-8am. I am looking for ACOG or ASA practice guideline type suggestion. Evidence based answers should be out there I don't think we are the first facility to deal with this question and I would like to have our policy match standard practice.

Thanks!!!!!!😀😛👍
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Whatever answer you get is likely to be controversial. If you want something semi-authoritative, try asking someone at SOAP (http://soap.org/ask.php). The question will be answered by a SOAP board member so it will be their opinion only, but a board member is probably more likely to know if any guidelines exist (I don't think they do).
 
In my experience during residency we would be willing to initiate and maintain an epidural for the patient of a private obstetrician, but they would have to talk to the service (in-house) OB to get them to cover their patient in the event of the need for an emergency C/S.

We also tended not to insert new epidurals if both OB ORs were being used, even if we had someone available to insert the epidural, out of concern that there would be free OR to perform a C/S if needed. Obviously this didn't affect maintenance of existing epidurals.

But this was a community hospital in Brooklyn. The situation would obviously be different in a more rural setting.
 
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It depends on your pt population. At my community hospital OBs are not in house and neither are we. We need to be w/in 15 minutes of the hospital at all times to respond and we are usually there before the OB arrives in house for a section. We don't do any high risk OB though and only ~150 deliveries/month
 
I'm interested in hearing opinions on this too.

We have no written policy regarding the OB's presence in the hospital while an epidural is running, but they've always been here.

We just got a new OB who wants to go home (~20 minute drive) after we put in an epidural. It's freaking some people out.

I personally think it's an awful ballsy move to trust the RNs to recognize good vs bad fetal strips in a laboring patient. Our department flatly said "no epidural if OB's not in house" but I'm not so sure I agree that it's our place to dictate the OB's proximity to the patient.



ssmallz said:
It depends on your pt population. At my community hospital OBs are not in house and neither are we. We need to be w/in 15 minutes of the hospital at all times to respond and we are usually there before the OB arrives in house for a section. We don't do any high risk OB though and only ~150 deliveries/month
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That's the same setup here (except our policy is 30 min). Question is, after the OB has come in to see the G1 patient at 3 cm, consulted you for an epidural, and you've placed the epidural - should he go home for a couple hours? And should your placement of that epidural depend on whether or not he stays or goes?
 
When I was at my little community hospital, the OB physician was only in house if on call or called in by the midwife or FM provider covering the unit. If there was a person in labor, someone (midwife, FM MD, or OB) was there the whole time. We used the 30 min decision to incision guideline from ACOG. I would get called in and usually place a CSE and go home for a few hours. Eventually they would call me back to start the epidural. Depending on the time of night, I might just go straight epidural and go to bed there. The OBs were all 5-10 min away.
I think it's nuts to have the OB go home when someone is in labor, unless a FP trained guy or midwife are present to keep an eye on things. You'd do well to try to avoid getting involved in that lunacy. What happens if the nurse calls him at 2am and says there's a "terminal" decel, or worsening decells with loss of variability. Are you supposed to dose her up for a crash c/s w/o him ever seeing what is really going on? And if you wait until he/she arrives, thats 20 minutes lost and maybe an avoidable bad outcome? Of course we had the same thing when FM/midwife were on call, but at least they knew (should know) how to read a strip properly, and they were less than 10 min from bed to OR door.
 
pgg said:
That's the same setup here (except our policy is 30 min). Question is, after the OB has come in to see the G1 patient at 3 cm, consulted you for an epidural, and you've placed the epidural - should he go home for a couple hours? And should your placement of that epidural depend on whether or not he stays or goes?
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I don't see any reason for OB to stay in house just b/c there's an epidural in place. I feel it's up to the OB and their comfort level w/the patient to figure out whether or not they want to stay in house. I don't alter my placement of an epidural if the OB is in house vs not in house b/c that's just the way it is at this hospital.
 
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IlDestriero said:
What happens if the nurse calls him at 2am and says there's a "terminal" decel, or worsening decells with loss of variability. Are you supposed to dose her up for a crash c/s w/o him ever seeing what is really going on? And if you wait until he/she arrives, thats 20 minutes lost and maybe an avoidable bad outcome? Of course we had the same thing when FM/midwife were on call, but at least they knew (should know) how to read a strip properly, and they were less than 10 min from bed to OR door.
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I won't dose a pt up until I get in go ahead that this pt is definitively going to section. As long as if the pt is still in the labor room and not the OR, I've got more than enough time to dose the pts epidural up and be ready by the time the OB is ready to cut. If not, there's always prop/sux/tube.
 
Idiopathic said:
i understand political posturing, etc. but i cant see any legitimate reason for this
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ssmallz said:
I don't see any reason for OB to stay in house just b/c there's an epidural in place. I feel it's up to the OB and their comfort level w/the patient to figure out whether or not they want to stay in house. I don't alter my placement of an epidural if the OB is in house vs not in house b/c that's just the way it is at this hospital.
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I couldn't really come up with a reason to really object either, but the decision was made above me.


IlDestriero said:
I think it's nuts to have the OB go home when someone is in labor, unless a FP trained guy or midwife are present to keep an eye on things. You'd do well to try to avoid getting involved in that lunacy. What happens if the nurse calls him at 2am and says there's a "terminal" decel, or worsening decells with loss of variability.
Click to expand...

There's that ... but even if the OB was in house the OR crew is still up to 30 min away. I guess the question is whether the OB can (is willing to) call a crash section from home based on a strip read from an RN.
 
Just skip the issue - don't place an epidural.

Remifentanil PCA works (maybe not as well - but works just fine).

Or how about intrathecal shots? Give a shot - go home for a while. If they need more, come give another.

I think a Navy Hospital (Bremerton?) used to train the FP residents how to do the intrathecal morphine or fenanyl for this reason.

I would consider using intrathecal demerol with it's local anesthetic properties. Apparently, you can do a c-section with just intrathecal demerol (read about it...never actually heard of it being done.)
 
epidural man said:
Or how about intrathecal shots? Give a shot - go home for a while. If they need more, come give another.
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Never. No way would I ever want to do that b/c 1) increased risk of complications b/c you are poking patients w/needles multiple times 2) no way I want to come back and do 2 procedures when I can just do it right the first time. I hate getting called back and 3) What happens if you need to go to c-section quickly? gotta do another spinal or GA just not options I want to go through when I could have just placed an epidural and been done w/it.

I just don't see any benefit to giving a single shot spinal. If the pt needs an epidural that badly and you can't do one b/c the OB is not in house you shouldn't do a spinal. Tell the OB to get their but in the hospital and let you do your epidural per hospital policy.
 
I never do single shot labor spinals any more. Been burned one too many times by labor RNs who are certain the patient is 20 minutes from delivery, and all she needs is an intrathecal.

For the time it takes me to do a spinal + perhaps 2 or 3 minutes, she can get a CSE and have a catheter in and taped to her back. Funny how many of those about-to-deliver patients suddenly go 2 or 4 or 6 more hours after that needle goes in.

I end up doing plenty of CSEs where the catheter is probably not needed, but it beats going back to stick someone twice.

I also wouldn't go home while I had an anesthetic of any kind in effect for an ongoing procedure / labor. I know some places the labor analgesia of choice is a long labor spinal (5+ mg of bupiv + morphine for hours of relief) and she gets what she gets and the anesthesia provider goes home, but I think that's kind of half-ass. Seems like that's usually driven by uninsured self-pay no-pay economics, not best practice. (Not that I'm knocking the $.)


Remifentanil PCAs are 100x more painful to set up and get tuned in than an epidural. I can't ever see myself doing one in a patient who doesn't have a compelling contraindication to neuraxial anesthesia.
 
pgg said:
I never do single shot labor spinals any more. Been burned one too many times by labor RNs who are certain the patient is 20 minutes from delivery, and all she needs is an intrathecal.

For the time it takes me to do a spinal + perhaps 2 or 3 minutes, she can get a CSE and have a catheter in and taped to her back. Funny how many of those about-to-deliver patients suddenly go 2 or 4 or 6 more hours after that needle goes in.

I end up doing plenty of CSEs where the catheter is probably not needed, but it beats going back to stick someone twice.

I also wouldn't go home while I had an anesthetic of any kind in effect for an ongoing procedure / labor. I know some places the labor analgesia of choice is a long labor spinal (5+ mg of bupiv + morphine for hours of relief) and she gets what she gets and the anesthesia provider goes home, but I think that's kind of half-ass. Seems like that's usually driven by uninsured self-pay no-pay economics, not best practice. (Not that I'm knocking the $.)


Remifentanil PCAs are 100x more painful to set up and get tuned in than an epidural. I can't ever see myself doing one in a patient who doesn't have a compelling contraindication to neuraxial anesthesia.
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Clearly an epidural is the creme de la creme for labor pains. But the point and question is (I thought...) what can be done so I (the anesthesiologist) and the OB can leave the hospital?

I didn't make the point (but you did) and I agree that an epidural shouldn't be left in without me (the anesthesiologist) around. But, I know people do single shots so they can leave - and remifentanil PCA's can work well. And they may be hard to set up, but perhaps if done a lot by the nursing staff, they would become easy. Setting up epidurals are probably a huge pain in the ass for a system that has never seen or used them. I think it is a matter of training and experience.

When we have used remifenatnil PCA's, SOMETIMES they really work well. But the same can be said about epidurals, SOMETIMES they hardly work at all.
 
pd4emergence said:
For those of you using remi for labor, what settings and doses are you using? What have you found that works?
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I have't written for one in a while, but I started wth

demand 0.2 mcg/kg
basal 0.02 mcg/kg/min
lockout 1 minute

Tweaked from there. I've found that you really need to have the IV Y-tubing right at the IV catheter, with IV fluids going in on a pump through one and the PCA plugged into the other. Otherwise, it just takes too long for a bolus to get in and be felt.

Once it's tuned it works nicely, but they were very labor intensive. Maybe someone out there has a good protocol for the nurses to follow in adjusting the pump settings.
 
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Epidural Man: It is funny you mention Bremerton Naval Hospital. We were indeed (FP residents) taught to due Intrathecal narcotics for labor while I was there. I got pretty good at them too. For the most part, they worked if the woman was close to delivering....the anesthesiologist or CRNA would place epidural if ITN wore off.

Now I am an Anesthesiologist. Wouldnt use them now.

PTG
 
pd4emergence said:
For those of you using remi for labor, what settings and doses are you using? What have you found that works?
Click to expand...

This is our order set copy and pasted.

Medication instructions:
  • Remifentanil Loading Dose: ____mcg
Comment: Suggest: .25mcg/kg (0 to 0.5mcg/kg patient specific)

  • Remifentanil Demand Dose: ____mg
Comment: Suggest 0.4 mcg/kg (0.4 to 0.8mcg/kg patient specific; increase in .2mcg increments)

  • Remifentanil Basal Rate: _____mcg/min
Comment: Suggest 0.05 mcg/kg/min for mild contractions (0.1 – 0.2mg/kg/min patient specific)

  • Remifentanil Lockout: _____min
Comment: Suggest 3 min (3-5 minutes patient specific; equipment limit is 3min or greater)

Discontinue all Narcotics/Sedatives… (As listed for the other PCA order sets).
 
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