- Joined
- Jul 12, 2022
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We all know the struggles of working on L&D but I'm curious what others' experiences are with dealing with supposed "hypotension" with a labor epidural and OB trying to blame you. Most often it's a preeclampsia patient who comes in, BP 140s-160s etc, they delay doing epidural because they think it will slow labor so they give nitrous and long acting IV hypertensive meds before finally calling for an epidural at 10pm (CMV epidurals should be first line treatment for preeclampsia HTN in laboring patients, not IV meds - epidural treats both the physiological HTN, the HTN 2/2 to pain, AND improves placental blood flow while IV htn meds only do one), . BPs consequently are lower than "baseline" but still MAPs above 70. These patients will have decels prior to epidural placement, as well as after, but OB (usually midwives not the OB hospitalist cause they are least know some physiology) will call at 0200 and say the patient is "hypotensive" and having a deceleration. You get there and the patient is not hypotensive (MAP in the mid 70s), and the deceleration recovers. I will say ok the patient is not hypotensive, what exactly is your goal MAP if you want me to raise it I need a MAP range and will have to start a pressor. They stare at me like deer in headlights and then stutter something about 120s systolic, and I try to explain to them I don't care about systolic and neither does the fetus. They will say ok well can you just give something just in case, it's a low risk intervention (funny how they deem giving pressers to a preeclamptic patient "low risk" but will absolutely not give a hemorrhaging out c/s with preeclampsia methergine because its "contraindicated"). Make it make sense.
They have no evidence for their assertion or their desire for supranormal BPs other than mom who has a diseased placenta is having decels and they don't know what to do. I'll give 25mg IM ephedrine, BP goes up, strip is still ****ty and still inevitably goes to c/s. In the OR surprise the placenta looks like a piece of ****. Baby is almost always fine. It just irks me when they write in their note something like "mom BPs periodically below 20% of baseline" (ignoring MAPs always above 70, and where is the evidence for 20% of "baseline" for laboring pre-eclamptic patients?), with "baseline" being what she had coming in to the unit in labor pain and untreated preeclampsia. So if a preeclamptic patient came in with a BP of 210/100, per acog guidelines you treat that to below 160 systolic, but won't that end up with the patient below 20% of their baseline? Crickets. Nevermind the rampant belief among many midwives that epidural hypotension leads to c sections. I've tried to explain to them that isn't a thing and I have never heard of a patient going to a c/s for epidural hypotension (I mean I guess if you negligently bolused them enough to give a high epidural/spinal) but alas...
They have no evidence for their assertion or their desire for supranormal BPs other than mom who has a diseased placenta is having decels and they don't know what to do. I'll give 25mg IM ephedrine, BP goes up, strip is still ****ty and still inevitably goes to c/s. In the OR surprise the placenta looks like a piece of ****. Baby is almost always fine. It just irks me when they write in their note something like "mom BPs periodically below 20% of baseline" (ignoring MAPs always above 70, and where is the evidence for 20% of "baseline" for laboring pre-eclamptic patients?), with "baseline" being what she had coming in to the unit in labor pain and untreated preeclampsia. So if a preeclamptic patient came in with a BP of 210/100, per acog guidelines you treat that to below 160 systolic, but won't that end up with the patient below 20% of their baseline? Crickets. Nevermind the rampant belief among many midwives that epidural hypotension leads to c sections. I've tried to explain to them that isn't a thing and I have never heard of a patient going to a c/s for epidural hypotension (I mean I guess if you negligently bolused them enough to give a high epidural/spinal) but alas...
