Labor Epidural "Hypotension"

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pirate_doc

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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...
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dabears505 said:
To be honest, I'd almost always rather place an epidural late than earlier. It's getting so annoying having to do epidurals that stay in for 18 hrs because maternal request to place one is indication enough to place one
Click to expand...
Also, the patients that get an epidural before they have any pain tend to be less appreciative of it. So they will complain about a pain 2/10 and want a bolus..
 
fascinating how i recommend a phenylephrine infusion, and the OB nurses say they aren't trained to administer vasopressors cause of "cardiac" side effects, yet half the patients are on Mag. Same deer in headlight look when I remind them of Magnesium effects on cardiac conduction.
 
It’s endless with these fools. Unfortunately we’re not going to win. Only option is to stop doing OB but it’s a nice little salary bump for pretty easy (yet annoying) work.

Favorite example though: last job a nurse called a code blue TWICE on a patient that fell asleep after I placed an epidural. Vitals perfectly normal and patient completely normal when awoken. Nurse documented in epic “patient unresponsive” and “anesthesiologist refusing to treat.”

I got the same deer in the headlights look when trying to explain to the nurse that the patient was comfortable and sleeping. I had to get in an entire chart war and felt like I was taking crazy pills.
 
AppTrail said:
fascinating how i recommend a phenylephrine infusion, and the OB nurses say they aren't trained to administer vasopressors cause of "cardiac" side effects, yet half the patients are on Mag. Same deer in headlight look when I remind them of Magnesium effects on cardiac conduction.
Click to expand...

I mean, come on, magnesium isn't a titratable vasopressor. I certainly don't think L&D nurses should be titrating a phenylephrine infusion. Yeah, that stuff is painfully easy for us, but we do it every day. Despite what this board routinely says, a good L&D nurse is worth their weight in gold, can make or break a patient's entire birthing experience, and has a ton of responsibility. Though, I understand some of OPs gripes with treating hypotension after placing a labor epidural -- particularly in preE patients . Sometimes it is directly related to maternal comorbidity and ok to watch. But sometimes, it actually is an anesthesia problem with significant impacts on fetal tracing.
 
As long as people are being respectful, I don't expect them to understand things we specialize in like vasopressors and hemodynamics as well as we do so I patiently answer their questions and explain when I don't agree. I wouldn't like it if somebody acted condescending when I asked them about something in their specialty I didn't know.

This situation doesn't seem that hard. A MAP of 70 is mildly hypotensive, even though we generally consider it acceptable enough to maintain perfusion to everything in the OR under anesthesia. Can it affect the fetus? I don't know although I suspect it's not likely. That said, a trial push dose of phenylephrine to somebody with a MAP of 70 is pretty low risk and should be comfortably manageable for any competent anesthesiologist, even with preeclampsia.

In short, their distress seems annoying, but it also sounds like you're being a bit difficult about it.
 
Tbh: some part of this depends on us too.

Personally I don't like OB but have colleagues who do it 80-90% of the time and not just for the reimbursement. The best places are busy with a lean anesthesia staff, it forces the anesthesia department to be involved in decision making and education.

The OPs comment is a reflection of lack of education. One place I did OB MD only, second highest volume in the state, up to 4 sections a day and up to 15 epidurals...and this was with one person on, OR backup was there but was rarely called in, it was a training camp for being swift. The part I realized was the best was the people who did a lot of OB in the group did education for the nurses: what to call for, what not to call for, how to have the room set up, how to treat xyz and we had it put in all the order sets. Compare this to a place I worked where it was 1-2 sections and 4-6 epidurals a day at max but you changed every epidural bag, answered asinine calls, come in the room and clean off the chick-fil-a bags from the procedure table... it was more work than the other place.

I started timing myself and I was in the door and out in less than 15 min per epidural: you have to have a spiel ready, set expectations and know what you're doing, have plan A/B/C ie easy epidual/difficult/wet tap. I actually don't mind OB at all, I just find the staffing at most places to be less than stellar. The one place I worked at that did anesthesia education was stellar, nurses have a meeting every month for BS things they don't care about, get involved.

@pirate_doc is your group PP/AMC/hospital? What have they done to educate the OB staff. When I saw anesthesia being involved in nurse education it was amazing just in terms of the daily frustration that burns people out, the places where I was changing epidural bags was ridiculous and I'm not going back. Most healthcare staff just want to help their patients, don't let it burn you, educate or find a way to change it

Edit: and this goes for OR too, if you're still rushing around putting on monitors while your circulator stands around, change the culture, I've seen it both ways, one place went to MD only to supervision and one of the positives was the crnas told the circulators to get in line and start helping out before induction and start rolling the patients back, it was nursing infighting but once it rolled out it was interesting to see, MDs need to start standing up
 
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zizzer said:
As long as people are being respectful, I don't expect them to understand things we specialize in like vasopressors and hemodynamics as well as we do so I patiently answer their questions and explain when I don't agree. I wouldn't like it if somebody acted condescending when I asked them about something in their specialty I didn't know.

This situation doesn't seem that hard. A MAP of 70 is mildly hypotensive, even though we generally consider it acceptable enough to maintain perfusion to everything in the OR under anesthesia. Can it affect the fetus? I don't know although I suspect it's not likely. That said, a trial push dose of phenylephrine to somebody with a MAP of 70 is pretty low risk and should be comfortably manageable for any competent anesthesiologist, even with preeclampsia.

In short, their distress seems annoying, but it also sounds like you're being a bit difficult about it.
Click to expand...
How is a MAP of 70 "mildly hypotensive" in a parturient? Do you have published data or evidence to support that assertion?

Appreciate your insight Maverikk. It was PP, now AMC (I was there for both), so definitely not better on that front, although OB less effected than main OR. We have tried to do some education, but even trying to get the nurses to change the epidural bags has been pretty much a non starter.
 
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Published data or evidence? Hypotension is a definition, lower-than-normal MAP, which is usually more in the mid-80s.
 
zizzer said:
Published data or evidence? Hypotension is a definition, lower-than-normal MAP, which is usually more in the mid-80s.
Click to expand...
Even MINS prevention isn't that aggressive being that the conventionally held threshold for harm is a MAP < 65 mmHg or a systolic pressure < 90 mmHg maintained for about 15 min. I can cite the source if you're interested.
 
Hypotension is a definition, and there is no definition produced by any org/journal article/textbook that says a MAP of 70 is hypotension. We are of course talking in generalities ignoring patient factors (89 year old CEA patient), but nonetheless, calling a MAP of 70 hypotension in isolation is factually incorrect. Tons of tiny parturients with baseline BPs 90s/60s. Just because the bell curve bulges at a MAP in the mid 80s doesn't mean standard deviations either way are abnormal or harmful, which is why there are normal ranges.
 
pirate_doc said:
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...
Click to expand...


If it's any consolation, I had a very dry, BMI 60 severe pre-eclamptic with a difficult airway coming for an elective section recently. BP 180s/95. OB ordered 50mg of IV labetalol push as I was around. Asked them to hold off and re-evaluate post spinal and that we can manage the pressures. Ignored me as if I was speaking Chinese to her. Sent her resident to hand push the labetalol.

Their training stresses that nothing bad happens on OB and if it does, anesthesia must have screwed up. Somehow, this lady's BP wasn't in the toilet during the case.

Arguing with OB nurses is an exercise in futility. It's like talking to your tv. Nothing good comes of it.

I worked at a shop with 14+ MD only anesthesiologists, purely production. Like 3 of them ever agreed to cover OB. Rest avoided it like the plague.
 
TheLoneWolf said:
If it's any consolation, I had a very dry, BMI 60 severe pre-eclamptic with a difficult airway coming for an elective section recently. BP 180s/95. OB ordered 50mg of IV labetalol push as I was around. Asked them to hold off and re-evaluate post spinal and that we can manage the pressures. Ignored me as if I was speaking Chinese to her. Sent her resident to hand push the labetalol.

Their training stresses that nothing bad happens on OB and if it does, anesthesia must have screwed up. Somehow, this lady's BP wasn't in the toilet during the case.

Arguing with OB nurses is an exercise in futility. It's like talking to your tv. Nothing good comes of it.

I worked at a shop with 14+ MD only anesthesiologists, purely production. Like 3 of them ever agreed to cover OB. Rest avoided it like the plague.
Click to expand...
Why no CSE?
 
TheLoneWolf said:
If it's any consolation, I had a very dry, BMI 60 severe pre-eclamptic with a difficult airway coming for an elective section recently. BP 180s/95. OB ordered 50mg of IV labetalol push as I was around. Asked them to hold off and re-evaluate post spinal and that we can manage the pressures. Ignored me as if I was speaking Chinese to her. Sent her resident to hand push the labetalol.

Their training stresses that nothing bad happens on OB and if it does, anesthesia must have screwed up. Somehow, this lady's BP wasn't in the toilet during the case.

Arguing with OB nurses is an exercise in futility. It's like talking to your tv. Nothing good comes of it.

I worked at a shop with 14+ MD only anesthesiologists, purely production. Like 3 of them ever agreed to cover OB. Rest avoided it like the plague.
Click to expand...
Jeez, I don’t think I’ve ever given that much labetalol all at once.

OB doesn’t even know their own specialty. Most of em still think lowering the BP will prevent progression to eclampsia
 
I guess I’m fortunate to work in a place with good OB culture. My dept gets along very well with all the OBs. They’d certainly defer to us for any management of HTN in preE, but we do have a protocol they generally follow. No one would give labetalol 50mg IV at once. Seems silly.

I love my L&D nurses generally speaking. We’ve had lots of locums nurses since Covid and some of them haven’t been as knowledgeable but they’re fine. My ability to sleep on a night of OB call is generally speaking largely dependent on the nursing staff. We do CSEs almost 100% of the time. Our regular nurses know what to expect of the epidurals and can help the patients along the way. They call us when we’re needed but I’m not called for every tiny bit of breakthrough pain or pressure, generally speaking.

If they call me for hypotension I’ll come and listen and make changes if needed. I wouldn’t ask them to start a phenylephrine gtt - that’s just not normal on the OB floor and not something I should expect out of a L&D nurse.
 
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Hypotension is all relative.

Do a c-section and the first NIBP before the spinal is 100/60, they'll probably tolerate 90/50 without getting nauseous and yakking everywhere.

First value is 155/100, they'll often puke if they slip below the 120s.

Nausea seems to be correlated with decels.
 
pgg said:
Hypotension is all relative.

Do a c-section and the first NIBP before the spinal is 100/60, they'll probably tolerate 90/50 without getting nauseous and yakking everywhere.

First value is 155/100, they'll often puke if they slip below the 120s.

Nausea seems to be correlated with decels.
Click to expand...
Don’t you know that nausea is 100% always our fault, and not due to the OB’s playing basketball with the uterus during the section?
 
Trying to rationalize with anyone on an OB floor is a fool's errand. Might as well be at a chiropractor or naturopath's office.
 
pirate_doc said:
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...
Click to expand...
Sigh. I am only involved in OB because of keeping job opportunities open in the future. Their whole practice seems just like “feelings” and not based on an algorithm. I have no idea what they learn about physiology in residency or midwives schooling.
 
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