Labor epidural with ??? vital signs

[Monty Python]

This was posted on a different forum:

==> Maternal VS good except temp = 102.2f
....WBC 19.9, ...... In the end I didn't give her the epidural.

==> Do you agree?

My reply was:

Yes. First, do no harm.

Taking the conservative safe approach here was the best thing. A
labor epidural is not an anesthesia emergency. With all due respect to
the ladies here, women have been giving birth for thousands of years without benefit of epidural.

Had ANYTHING happened (even with the baby, not just with mom) a
really sharp plaintiff attorney would try to make a connection between your
epidural and her potential underlying septic state. The epidural was not
needed to save the pt's life, just make her more comfortable, and therefore it could be argued that it was an unncessary risk.

Do you agree?

Also see:

http://www.msnbc.msn.com/id/9818616/

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[Noyac]

This was posted on a different forum:

==> Maternal VS good except temp = 102.2f
....WBC 19.9, ...... In the end I didn't give her the epidural.

==> Do you agree?

My reply was:

Yes. First, do no harm.

Taking the conservative safe approach here was the best thing. A
labor epidural is not an anesthesia emergency. With all due respect to
the ladies here, women have been giving birth for thousands of years without benefit of epidural.

Had ANYTHING happened (even with the baby, not just with mom) a
really sharp plaintiff attorney would try to make a connection between your
epidural and her potential underlying septic state. The epidural was not
needed to save the pt's life, just make her more comfortable, and therefore it could be argued that it was an unncessary risk.

Do you agree?

Also see:

http://www.msnbc.msn.com/id/9818616/

Can you give me the particulars as to why you didn't give her the epidural? I am having a meeting with our midwives b/c I was called to put an epidural into a lady with a tooth abscess and after finding out that she wasn't covered with antibiotics I called an obstetrician (not the midwife) to voice my concerns. The OB gave her a dose of antibx and the pt decided not to have the epi. Now I am having to defend myself.

That article is awful. I think the menengitis came from the epidural. Possible during the disconnect. Whenever an epidural comes disconnected I pull it. No if's an's or but's.

 

[bubalus]

The ASA web site has an article by Michael Mulroy that includes contraindications to regional anesthesia

Regional anesthesia

It states: "Active infection at the site of needle insertion is a contraindication for regional techniques because of the risk of spreading or seeding infection. The presence of systemic infeciton and sepsis has been regarded as a contraindication to spinal anesthesia, but this is not a risk if systemic antibiotic therapy has been instituted."

A woman with a temp of 102 and a white count doesn't get an epidural in my book. The tooth abscess may seem a little softer call, but tooth abscesses can cause epidural abscesses by themselves. Sticking a needle and then an indwelling catheter into that space is going to increase the risk of abscess. I took care of a woman who was a quad because she had an unknown, asymptomatic (according to her) epidural abscess that ruptured. It's just not worth it. When we're on OB, we're not just some trained monkey epidural-putter-inner. Regardless of where we are, a big part of our job is to know when and when not to do something.

 

[militarymd]

All good posts, but the bottom line is that we have no good data on what the actual risks are for developing an epidural abscess.

Without good data, the decisions we make are judgement calls which gets evaluated by a 3rd party AFTER the fact.

Without good data, we wind up in a lose/lose situation.

1) put it in....you get an abscess....why did you do it?

2) don't put it in....patient complains about pain.....why didn't you do it?

Either way, in my opinion, is acceptable....as long as "proper" antimicrobials have been started.

 

[Monty Python]

Can you give me the particulars as to why you didn't give her the epidural? ...... Now I am having to defend myself.

.

Sorry I don't have any other particulars available. I didn't write the original post, only copied it onto SDN from another forum where I originally read it.

You are only having to defend yourself from other people's stupidity who have no business Monday-morning quarterbacking you. You did what you did with the pt's best interest in mind with safety as a paramount concern.

Oh, I forgot, we just provide a "service" at the pt's beck and call. Damned if you do, damned if you don't.

 

[md2k]

The ASA web site has an article by Michael Mulroy that includes contraindications to regional anesthesia

Regional anesthesia

It states: "Active infection at the site of needle insertion is a contraindication for regional techniques because of the risk of spreading or seeding infection. The presence of systemic infeciton and sepsis has been regarded as a contraindication to spinal anesthesia, but this is not a risk if systemic antibiotic therapy has been instituted."

A woman with a temp of 102 and a white count doesn't get an epidural in my book. The tooth abscess may seem a little softer call, but tooth abscesses can cause epidural abscesses by themselves. Sticking a needle and then an indwelling catheter into that space is going to increase the risk of abscess. I took care of a woman who was a quad because she had an unknown, asymptomatic (according to her) epidural abscess that ruptured. It's just not worth it. When we're on OB, we're not just some trained monkey epidural-putter-inner. Regardless of where we are, a big part of our job is to know when and when not to do something.

It si not uncommon to have pregnant women to have an increase white count secondary to demargination. It is also not uncommon to see increase temperature during labor. This is worrisome but not uncommon. You mention that the patient had a tooth abscess? This to me is more worrisome than the the white count and temp. You now have a source of infection that can be casuing the sx's you describe. I agree, no epidural. Not d/t temp and white count but d/t potential source. Seeding can occur, especially with a tooth abscess. We typically do not perform any pain procedures on pts with any tooth abscesses at our pain clinic.