OB Case: What would you do?

[sigrhoillusion]

On call the other night and get a call from OB resident at 2am that there is a patient that was scheduled for a C-section the upcoming day for 7:30am. PAtient had come to OB office that afternoon due to feeling contractions around 4PM. In office patient was found to be 3cm and sent to hospital for observation, ultrasound and cerv exams.

So at 2:30AM patient with increasing contractions and found to be 5cm, so they wanted to go ahead and do the section. When I asked why the patient was having a C-section in the first place, resident said that patient had a prior c-section and wanted a repeat. When I asked why she couldn't just VBAC, resident essentially brought up the risk of rupturing... (thanks Captain Obvious...) but no real other reasons to immediately section the patient. FHT were reassuring.

To add to the issue, the patient had just had eaten at 9PM. I know technically these patients are full stomach already, but I'm not fond on bringing back patients with full stomachs in non-emergent situations. Bigger question is, if they knew this was an issue and they had brought her in the hospital, why didn't they make her NPO if they were planning on doing the section at some point...?

Thing is I'm at a level 1 trauma center, and it would have been nice in the middle of a lull to get this section in and out. The last thing I needed was to wait until NPO status when I'm unlucky enough to have two traumas crash into the regular ORs, have the patient fully dilated and pushing, or have her actually rupture and have a STAT section.......

So what would you guys have done? Full stomach anyway, popped a spinal in her and let the OBs get the baby out. Delay the case since it's not an emergency? Put in an epidural while we wait, and then use that for the section once NPO status is acceptable?

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[dhb]

We put epidurals in laboring patients that are not NPO all the time and some go to c-section while not meeting "NPO criteria" so i think it's a no issue.
If something goes wrong with the delivery you'll be thrown under the bus.

 

[sigrhoillusion]

We do to, the only issue was that when we go to section it's usually not planned. In this case the plan was to go to section regardless, so I was debating with myself do I put in an epidural now and then use it for section, or do I put in a spinal and have like 99% confidence that it will work for the section. I've gone to section with a ton of laboring epidural and they work most of the time, but even the best laboring epidurals sometimes don't cut it (pun intended...) when it comes to a section.

I ended up postponing the case for 1.5 hours so we had about 7 hrs npo since it really wasn't emergent. Spinal went in, patient and baby did well.

I guess i could have done the same thing 1.5 hours earlier, but I just didn't see it as a true emergency that had to be rushed back since she wasn't progressing that quickly and the FHTs were reassuring.

 

[Planktonmd]

Do you really think that NPO for 7 hours is better that 5.5 hours?

 

[sigrhoillusion]

In a pretty much elective case, yea I'm going to go as long as possible. It ended actually being 7.5hrs and i tried to push it back further but they said the baby had some variables so we went back.

Like I said I probably would have been fine just going back right away with the spinal but felt there was no harm in waiting. Everything went fine, but if for sombre reason we had to convert and she aspirated, not sure how is be able to justify it.

 

[Planktonmd]

In a pretty much elective case, yea I'm going to go as long as possible. It ended actually being 7.5hrs and i tried to push it back further but they said the baby had some variables so we went back.

Like I said I probably would have been fine just going back right away with the spinal but felt there was no harm in waiting. Everything went fine, but if for sombre reason we had to convert and she aspirated, not sure how is be able to justify it.

Some people would argue that a patient with a previous C Section, who is contracting, and where VBAC is either not available or not desired, that would not be a "purely elective case"!

 

[Hoya11]

We do to, the only issue was that when we go to section it's usually not planned. In this case the plan was to go to section regardless, so I was debating with myself do I put in an epidural now and then use it for section, or do I put in a spinal and have like 99% confidence that it will work for the section. I've gone to section with a ton of laboring epidural and they work most of the time, but even the best laboring epidurals sometimes don't cut it (pun intended...) when it comes to a section.

I ended up postponing the case for 1.5 hours so we had about 7 hrs npo since it really wasn't emergent. Spinal went in, patient and baby did well.

I guess i could have done the same thing 1.5 hours earlier, but I just didn't see it as a true emergency that had to be rushed back since she wasn't progressing that quickly and the FHTs were reassuring.

I would have put in an epidural as soon as I heard about her, then go back for the section when deemed necessary to section by OB if that time came sooner than the NPO guidelines.

 

[Arch Guillotti]

So what would you guys have done? Full stomach anyway, popped a spinal in her and let the OBs get the baby out.

Yes.

 

[jwk]

Pointless to wait. SAB or epidural and have at it. We get scheduled repeats show up in labor all the time. We do them as soon as the OB wants to do it.

 

[Noyac]

You were being an obstructionist.

 

[deleted162650]

When I asked why she couldn't just VBAC

Are you F'in serious??

 

[Orin]

VBAC/TOLACed a bit at our academic hospital but we had OB anesthesia coverage 24/7 and folks ready for the risks.

In that scenario, if they document an indication and a need that justifies urgency, I'd proceed with a single shot spinal and be ready for a GETA if needed. They should be able to document that this patient is at ~X% risk of rupture with a Y% risk of successful vaginal delivery. As far as I know, we can't accurately quantify her risk vs time for aspiration, but as she is increased due to her PO intake and has risk of morbidity from aspiration, you would proceed with precautions since the risk for fetal demise with rupture is ~6% and the risk for maternal hysterectomy is ~15-30%.

Either way, root cause of the problem is poor planning/communication about what the plan was for her if she was eating at 9 PM and being sectioned. When was shift change?

 

[risnwb]

Asking someone who is not interested in taking the risk, to TOLAC, is not acceptable in my opinion. When these patients go into labor spontaneously, and the obstetrician and patient decide to proceed with a section, it is no longer purely elective. If patient were to have a complication (rupture) after stating a desire NOT to TOLAC, then you are going to take a lot of heat (and in my opinion liability) by waiting.


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[dannyboy1]

previous c/s and contracting is an indication for proceeding without waiting for NPO (at least this is how we do it at my residency). In fact some of the OB's have figured this out and will always say their patient is "contracting". as long as they document it we are good to go.

 

[urge]

Spinal.

Give her a yankauer hooked to suction and tell her to pretend it is a pacifier.

 

[pjl]

Some even show their patients how to fake contractions on the monitor (or at least that is what it feels like).
This is a case to do immediately, no questions. Thirty minutes later you will be ready for trauma. Delaying only increases the risk of a trauma coming in and making the situation worse for staffing.


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[teeva]

No delay. Spinal whenever OB wants to do case. You don't just randomly bring up VBAC unless it's already planned and staffing/policy/procedures are in place.

 

[Noyac]

Asking the OB why she can't just TOLAC or VBAC as you stated probably was met with eye rolling.

Let me put this in perspective. How would you like it if the OB told you to just put the pt to sleep?

 

[Arch Guillotti]

When I asked why she couldn't just VBAC, resident essentially brought up the risk of rupturing... (thanks Captain Obvious...)

It is probably just as obvious to the OB resident that the section needs to be done.

What did your attending want to do and what was his/her role in the whole scenario?

 

[sigrhoillusion]

I've never been in this situation before. That's why I asked. At my residency we had a ton of VBACs with the knowledge of the risks and prepared for them, as is the case where I work now.

Again, the OB wasn't willing to state it was an emergency, so I didn't feel like it was an emergency to rush her back at the time. If she said it was urgent I would have gone back and done the spinal. I was jsut getting a concensus of what others would have done.

The thing that pissed me off the most is that this patient had gone to the OBs office that afternoon and had been sent to the hospital. Knowing the plan was to do an elective section the next day, I'm not sure why they waited until 2 in the morning to inform me about teh patient, or why they allowed her to eat at 9pm... When they first called me I was ready to go in and get the baby out, but the way they had initially put it was more of a "we don't want to wait, might as well get it done now" situation, which I was thinking whatever, but when I found out about the food, I became hesitant. Again, never been in that situation, cause every elective C-section that had ever eaten we have always delayed. Granted this wasn't "purely" elective, but again with the reassuring FHTs, slow progression and OB's not writing that it was an emergency I felt that it was ok to wait a little while. The OB didn't seem to think I was bein unreasonable.

Just getting an idea what others thought, cause again, I felt a little stuck at the time. I think from now on I'm just going to do the spinal and move on. I'm usually very gung ho in getting stuff done when I can.

 

[pjl]

If you do make them sit for some reason in that situation, at least put in an epidural.


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[sigrhoillusion]

If you do make them sit for some reason in that situation, at least put in an epidural.


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Yea. To make it a little more confusing, i explained everything to patient. She was OK with waiting for the spinal and said the contractions weren't that bad (maybe that's how she was able to go from 3 to 5 over almost 10 hours while the OBs twiddle their thumbs and let her eat all day despite planning a section... )

It almost seemed like she was oblivious to why she "needed" a repeat section. It almost felt like the OBs when she initially saw her pushed for a section without giving her tree pros and cons of VBAC since she didn't seem all that aware of it. But like others said, can't change to VBAC now (despite my hopes... haha)

In summary. Offered epidural. Patient preferred mild contractions and waiting for spinal. Probably could have/should have just done spinal and gotten it over with. Hate OB...

 

[sigrhoillusion]

Yea. To make it a little more confusing, i explained everything to patient. She was OK with waiting for the spinal and said the contractions weren't that bad (maybe that's how she was able to go from 3 to 5 over almost 10 hours while the OBs twiddle their thumbs and let her eat all day despite planning a section... )

It almost seemed like she was oblivious to why she "needed" a repeat section. It almost felt like the OBs when she initially saw her pushed for a section without giving her tree pros and cons of VBAC since she didn't seem all that aware of it. But like others said, can't change to VBAC now (despite my hopes... haha)

In summary. Offered epidural. Patient preferred mild contractions and waiting for spinal. Probably could have/should have just done spinal and gotten it over with. Hate OB...

Oh and checked records. Prior section was low transverse, so risk of rupture wasn't SOOO much higher that the patient couldn't have reasonably chosen VBACing if proper informed consent was obtained. But to be fair I wasnt in the original office meeting at start of pregnancy, and my views on what could have been planned may just be off based off my interactions that night.

 

[jwk]

Oh and checked records. Prior section was low transverse, so risk of rupture wasn't SOOO much higher that the patient couldn't have reasonably chosen VBACing if proper informed consent was obtained. But to be fair I wasnt in the original office meeting at start of pregnancy, and my views on what could have been planned may just be off based off my interactions that night.

Many OBs simply won't do VBACs due to the medicolegal risk. It's not anesthesia's call to decide what is an appropriate method of delivery, or to decide what constitutes urgent or emergent sections. Could the OBs have handled it better? Sure. But if they decide they want to do a section now, we do it now.

 

[sigrhoillusion]

I know that. But they do VBACs here all the time. the OB didn't seem so concerned and she was willing to delay and didn't push to section right away. And again, it was just the whole timing of everything and the initial delay in just going to section right from the office and then allowing her to sit for 8 hours and eat dinner...

It's whatever at this point. Everything went well, but from now on I'll just do the section but make sure OB writes in the chart. Lesson learned. Thanks for the replies.

 

[sigrhoillusion]

I know that. But they do VBACs here all the time. the OB didn't seem so concerned and she was willing to delay and didn't push to section right away. And again, it was just the whole timing of everything and the initial delay in just going to section right from the office and then allowing her to sit for 8 hours and eat dinner...

It's whatever at this point. Everything went well, but from now on I'll just do the section but make sure OB writes in the chart. Lesson learned. Thanks for the replies.

I'm just amazed this situation never popped up in all my calls during residency. Also, where i did residency it seemed that the OBs were very pro-VBAC, so perhaps i just had a limited sample size. That being said, we did have plenty of VBACs end up going to section due to other reasons.

This is why I like these forums. Seems like I've learned and tailored my practices more from other people's experiences and my hands on experience then i ever did reading...

 

[IlDestriero]

Asking someone who is not interested in taking the risk, to TOLAC, is not acceptable in my opinion. When these patients go into labor spontaneously, and the obstetrician and patient decide to proceed with a section, it is no longer purely elective. If patient were to have a complication (rupture) after stating a desire NOT to TOLAC, then you are going to take a lot of heat (and in my opinion liability) by waiting.


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I agree with this 100%.
She was admitted to r/o labor. Then she was found to be in labor with a changing cervix. Time for C/S. It doesn't matter if she just had a stop at the all you can eat buffet. She is in labor, doesn't want to VBAC, and the longer you wait, the more risk of bad complications. That's liability that the OBs will dump squarely onto your lap.
Spinal and done. I'd trust my spinal over an epidural all day, every day, and twice on Sunday. If she needs a GA, so be it. We do RSIs on patients with full stomachs all the time and don't get our panties in a bunch. This is not an elective case.


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Il Destriero

 

[Noyac]

If you do make them sit for some reason in that situation, at least put in an epidural.


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Why?