OB NPO status

[Planktonmd]

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I am trying to find out what other people are doing on this one:
Term pregnant with a history of previous C section, in early labor, had a couple of donuts 1 hour ago, hospital does not allow VBAC, OB does not want to wait but won't consider it an emergency.
What would you do?

 

[urgewrx]

Well, if she had some donuts being in labor she is probably fat. You'll be digging under 4 inches of panus to find a 0.5cm space. After the 10th attempt you'll be pissed and want to do GA. Induction goes well but when you take a look you cannot see anything beacause she is too fat. You pop an LMA when the sat is 44%. Surgery goes well but she aspirates after the ob pushes on the belly to get the baby out. In the end the ob looks like he did a good job. Not so much you.

Dude, tell that OB to gorw up.

 

[Noyac]

I am trying to find out what other people are doing on this one:
Term pregnant with a history of previous C section, in early labor, had a couple of donuts 1 hour ago, hospital does not allow VBAC, OB does not want to wait but won't consider it an emergency.
What would you do?

Gotta wait.

 

[The_Sensei]

I am trying to find out what other people are doing on this one:
Term pregnant with a history of previous C section, in early labor, had a couple of donuts 1 hour ago, hospital does not allow VBAC, OB does not want to wait but won't consider it an emergency.
What would you do?

Wait 7 more hours - do the case under spinal. Tell the OB tough shi*.

Easy one.......

 

[mille125]

Wait 7 more hours - do the case under spinal. Tell the OB tough shi*.

Easy one.......

i agree...this is not a tough decision

 

[militarymd]

Well, if she had some donuts being in labor she is probably fat. You'll be digging under 4 inches of panus to find a 0.5cm space. After the 10th attempt you'll be pissed and want to do GA. Induction goes well but when you take a look you cannot see anything beacause she is too fat. You pop an LMA when the sat is 44%. Surgery goes well but she aspirates after the ob pushes on the belly to get the baby out. In the end the ob looks like he did a good job. Not so much you.

Dude, tell that OB to gorw up.

In 7 hours, those dounts will still be in the stomach...except they are now a slurry, and easier to slide into the lungs.

So the above will STILL happen .except now its happening at 3 AM when no one is around to help you.

 

[Planktonmd]

In 7 hours, those dounts will still be in the stomach...except they are now a slurry, and easier to slide into the lungs.

So the above will STILL happen .except now its happening at 3 AM when no one is around to help you.

Good point!

 

[Laurel123]

I am trying to find out what other people are doing on this one:
Term pregnant with a history of previous C section, in early labor, had a couple of donuts 1 hour ago, hospital does not allow VBAC, OB does not want to wait but won't consider it an emergency.
What would you do?

She is 9 months pregnant and in labor. No matter how long you wait, she will still be a full stomach and aspiration risk.

If the hospital doesn't allow VBAC - then she has to have a C-section. If you wait 7 hours and she is multip, she could very well be in active labor and be well on her road to a VBAC. Then it becomes all emergent and stressful because her cervix is dilating quickly and she needs to be rushed to the OR and there is no time for a spinal....

I don't think it is a clear decision, but if she is really in labor, I would just do it while the patient is still not in active painful labor and writhing and wiggling. We have all seen multips go from 3 cm to popping out a baby in just a few hours.

 

[Noyac]

She is 9 months pregnant and in labor. No matter how long you wait, she will still be a full stomach and aspiration risk.

If the hospital doesn't allow VBAC - then she has to have a C-section. If you wait 7 hours and she is multip, she could very well be in active labor and be well on her road to a VBAC. Then it becomes all emergent and stressful because her cervix is dilating quickly and she needs to be rushed to the OR and there is no time for a spinal....

I don't think it is a clear decision, but if she is really in labor, I would just do it while the patient is still not in active painful labor and writhing and wiggling. We have all seen multips go from 3 cm to popping out a baby in just a few hours.

We don't have a VBAC program either but we deliver VBAC's from time to time. The theory is that you can't force a pt into having a surgery against her will. Therefore, we tell them that we don't have all the necessary pieces to the puzzle to labor VBAC's but we can't force them to have a c/s and it is their decision. This policy really sucks. In general it is safe to have a VBAC unless the previous c/s was for CPD or something like that.

 

[urgewrx]

How come nobody has said to give 1 or 2 doses of reglan and do it a few hours later?

 

[urgewrx]

If you wait 7 hours and she is multip, she could very well be in active labor and be well on her road to a VBAC. Then it becomes all emergent and stressful because her cervix is dilating quickly and she needs to be rushed to the OR and there is no time for a spinal....

A shot of terbutaline takes care of this emergency.

 

[urgewrx]

In 7 hours, those dounts will still be in the stomach...except they are now a slurry, and easier to slide into the lungs.

So the above will STILL happen .except now its happening at 3 AM when no one is around to help you.

Yes, it is likely. But, I think you have some ground to stand in if things go wrong.

 

[TIVA]

A pregnant patient at term is a full stomach, even if she hasn't had anything PO in 24 hours.

A/P: Do the spinal. If it works, she's still protecting her own airway. If it doesn't, proceed to GA with ETT. Whether ETT is placed awake via FOB or under RSI is up to you.

 

[TIVA]

One more thing:

Who cares if OB doesn't want to consider it an emergency? On my anesthetic record, I'm gonna mark her as an emergency and provide the following reason:

Full term patient presenting in labor, prior C-section, VBAC not option per OB/hospital policy, proceeding to OR with surgeons.

 

[zippy2u]

Sounds like that OB clown is off the scale on your trusty priick-o-meter. If ya don't write it in chart that the case is an emergency, we don't cut in this case. Oh, ya still want to cut?-- throw the clown a bottle of 1% lidocaine and a 60cc syringe and tell em to go to town. Anesthesia doesn't declare cases "emergency" - only surgeons. Now I'll compromise and take her back if he verbalizes to the pt. and at least one OB nurse that (without writing it down) "this is an emergency and we have to do the C-section now". Regards, ----Zip

 

[Noyac]

Sounds like that OB clown is off the scale on your trusty priick-o-meter. If ya don't write it in chart that the case is an emergency, we don't cut in this case. Oh, ya still want to cut?-- throw the clown a bottle of 1% lidocaine and a 60cc syringe and tell em to go to town. Anesthesia doesn't declare cases "emergency" - only surgeons. Now I'll compromise and take her back if he verbalizes to the pt. and at least one OB nurse that (without writing it down) "this is an emergency and we have to do the C-section now". Regards, ----Zip

Absolutely. And thats the whole reason I say we wait. More than likely you are going to do this case now. Reglan won't help now or in 2 hours. You just need this Idiot OB to play the game. I would rather do it now. In 6 yrs of practice I have never not been able to get a spinal in a OB pt. So she will get a spinal no problem.
Mil is also right, you don't want to do this at 3am mostly b/c in sucks to do anything at 3am, not b/c nobody is around to help. The only time you are going to need help in this case is if she labors and ruptures her uterus. Then you are going to need help, if not for the mom, for the blue baby.
Basically, the OB needs to get on board.

 

[Laurel123]

So is this OB refusing to call this an emergency?

I think that a patient that is in a hospital that refuses to do VBAC that has a history of C/S and is in labor is an emergency. It's just like breech and in labor. It's an emergency. I don't understand why he won't call it emergent.

 

[EtherMD]

At my institution the same case would be phrased "she had donuts one hour ago so when would YOU Like to do the case? If at all possible could we not operate in the middle of the night, but what ever you decide is fine with me."

Now, what is your answer? I can tell you the real world answer is anywhere from 30 minutes (non emergent time to get ready for a c-section) to 6-8 hours depending on the experience of the Anesthesiologist. The older and the more experience the Anesthesiologist has the less likely he is to do any OB C-section in the middle of the night if it can be avoided. Thus, give pre-meds, wait 1-2 hours and then do the spinal anesthetic. That said, I respect the traditional, conservative answer of wait 7 hours and do the case as usual.

As a side note, I consider 6 hours sufficient "NPO" for the healthy ASA 1 patient. I use this time frame often as do most of my colleagues.

 

[The_Sensei]

As a side note, I consider 6 hours sufficient "NPO" for the healthy ASA 1 patient. I use this time frame often as do most of my colleagues.

As do I.....the only downside to this is if the patient aspirates, God forbid. Some shyster-lawyer will pull the ASA NPO guidelines and wonder why you didn't wait the requisite 8 hours (as if that's going to make a difference).🙄

 

[VentdependenT]

mmmmmmmmm.....donut slurry......

I gotta go with sensei on this his elucidation of the litigious nature of the NPO guidelines....that is IF the OB won't declare this an emergency.

 

[Planktonmd]

It continues to amaze me how variable the points of view could be on something as simple as NPO status.
This is another example of how our daily practice can never be governed by protocols written in stone.
Here is what happened:
I got the OB to write that the case needs to be done as soon as the OR is ready, she still refused to use the word "emergency" because, I guess, she still wanted to be able to blame me if anything goes wrong, but I am used to it.
Since I had a bad feeling about the case and a worse feeling about the surgeon's abilities I chose to do a CSE that went well.
Sure enough after the baby was out she had trouble controlling the bleeding and we lost 2500 cc of blood, the patient vomited a few times when they externalized the uterus and we got to see the donuts that she ate.
I was very happy to have my epidural catheter in place when the surgery took more than 2 hours and the spinal started to wear off.
At the end of the day no one got hurt, but I went home feeling a bit older but not necessarily smarter.

 

[The_Sensei]

Good move.

 

[Laurel123]

It continues to amaze me how variable the points of view could be on something as simple as NPO status.
This is another example of how our daily practice can never be governed by protocols written in stone.
Here is what happened:
I got the OB to write that the case needs to be done as soon as the OR is ready, she still refused to use the word "emergency" because, I guess, she still wanted to be able to blame me if anything goes wrong, but I am used to it.
Since I had a bad feeling about the case and a worse feeling about the surgeon's abilities I chose to do a CSE that went well.
Sure enough after the baby was out she had trouble controlling the bleeding and we lost 2500 cc of blood, the patient vomited a few times when they externalized the uterus and we got to see the donuts that she ate.
I was very happy to have my epidural catheter in place when the surgery took more than 2 hours and the spinal started to wear off.
At the end of the day no one got hurt, but I went home feeling a bit older but not necessarily smarter.

Yikes! That just shows the importance of trust in your colleagues as well. First she refuses to call it an emergency. Then there are all sorts of issues during the surgery.

I remember in the academic setting, we were really stringent on the NPO guidelines. So unless there was a prolapsed cord sticking out the vagina, we waited eight hours. With residents doing surgery, a two hour C-section with some pretty rough uterine yanking was expected.

Now in the private world, our surgeons take about 15 minutes. The suction canister at the end just has mostly amniotic fluid with a little blood and they are done by the time the mom and dad have gotten together for that first awkward family picture.

So I would do it. But then again, our guys would call it an emergency.

Now, the guys in the private sector

 

[urgewrx]

As a side note, I consider 6 hours sufficient "NPO" for the healthy ASA 1 patient. I use this time frame often as do most of my colleagues.

As do I.....the only downside to this is if the patient aspirates, God forbid. Some shyster-lawyer will pull the ASA NPO guidelines and wonder why you didn't wait the requisite 8 hours (as if that's going to make a difference).

6 hours, huh? That sounds bold. But wait, I have seen that somewhere. Oh, I remember now. It's on the current ASA guidelines. Not up to date, again. What a surprise!

Oh boy, oh boy!! Why, why, why? Then I'm the smart @ss for teaching you guys something.

http://www.asahq.org/publicationsAndServices/NPO.pdf

 

[militarymd]

6 hours, huh? That sounds bold. But wait, I have seen that somewhere. Oh, I remember now. It's on the current ASA guidelines. Not up to date, again. What a surprise!

Oh boy, oh boy!! Why, why, why? Then I'm the smart @ss for teaching you guys something.

http://www.asahq.org/publicationsAndServices/NPO.pdf

Solids.​

​

[FONT=Times New Roman,Times New Roman]A specific fasting time for solids that is predictive of maternal anesthetic complications has not been determined. There is insufficient published evidence to address the safety of .[FONT=Times New Roman,Times New Roman]any .[FONT=Times New Roman,Times New Roman]particular fasting period for solids in obstetric patients. The consultants and ASA members both agree that the oral intake of solids during labor increases maternal complications. They both strongly agree that patients undergoing either elective cesarean delivery or postpartum tubal ligation should undergo a fasting period of 6 to 8 hours depending on the type of food ingested (.[FONT=Times New Roman,Times New Roman]e.g..[FONT=Times New Roman,Times New Roman], fat content).4 .
[FONT=Times New Roman,Times New Roman]​

.


From the OB anesthesia guidelines published/revised in 2006. Not only are you not up to date....You are looking in the wrong guidelines.

You're teaching no one anything.

These guidelines are NOT helpful in the care of the patients....they are mere medical legal documents which bind our hands in providing care.

If you're going to cite them, please cite them accurately and in a relevant fashion.

 

[The_Sensei]

.

 

[The_Sensei]

6 hours, huh? That sounds bold. But wait, I have seen that somewhere. Oh, I remember now. It's on the current ASA guidelines. Not up to date, again. What a surprise!

Oh boy, oh boy!! Why, why, why? Then I'm the smart @ss for teaching you guys something.

http://www.asahq.org/publicationsAndServices/NPO.pdf

You've taught me nothing other than the fact that you are an idiot. See Mil's post and kindly remove your head from your ass, little man.😴

 

[urgewrx]

Solids.​

[FONT=Times New Roman,Times New Roman]A specific fasting time for solids that is predictive of maternal anesthetic complications has not been determined. There is insufficient published evidence to address the safety of .[FONT=Times New Roman,Times New Roman]any .[FONT=Times New Roman,Times New Roman]particular fasting period for solids in obstetric patients. The consultants and ASA members both agree that the oral intake of solids during labor increases maternal complications. They both strongly agree that patients undergoing either elective cesarean delivery or postpartum tubal ligation should undergo a fasting period of 6 to 8 hours depending on the type of food ingested (.[FONT=Times New Roman,Times New Roman]e.g..[FONT=Times New Roman,Times New Roman], fat content).4 .
​

[FONT=Times New Roman,Times New Roman]
.


From the OB anesthesia guidelines published/revised in 2006. Not only are you not up to date....You are looking in the wrong guidelines.

You're teaching no one anything.

These guidelines are NOT helpful in the care of the patients....they are mere medical legal documents which bind our hands in providing care.

If you're going to cite them, please cite them accurately and in a relevant fashion.

I'm glad you learned something by reading the link. If you read the whole thing, you'll see that 6 hours is for a light meal. Fatty meals should be more. As in Ether's case -healthy ASA1 pt- 6hrs is in the guideline. Pregnant pt are full stomach no matter what, so it's hard to say what's adequate.

 

[urgewrx]

The_Sensei,
Trying to save face now? Too late. You 2 were talking about a healthy ASA1 pt. Not a pregnant one.
Ether said:

As a side note, I consider 6 hours sufficient "NPO" for the healthy ASA 1 patient. I use this time frame often as do most of my colleagues.

You replied:

As do I...

as if you guys were so good that 8 hrs don't apply to you.
It's not hard to see from your tone that you 2 were not aware of the current NPO guidelines.

 

[The_Sensei]

The_Sensei,
Trying to save face now? Too late. You 2 were talking about a healthy ASA1 pt. Not a pregnant one.
Ether said:

You replied:

as if you guys were so good that 8 hrs don't apply to you.
It's not hard to see from your tone that you 2 were not aware of the current NPO guidelines.

I am well aware of the current guidelines; I was responding in the context of the current discussion (i.e. a pregnant patient). You have overwhelmingly proven your inferiority, thus I shall end any further interactions with you and place you on "ignore".

 

[VentdependenT]

Its 6-8 hours per the new ASA newsletter I received on Obstetrics in the mail bout a month ago. Its to allow some room for clinical judgement.

 

[militarymd]

I'm glad you learned something by reading the link. If you read the whole thing, you'll see that 6 hours is for a light meal. Fatty meals should be more. As in Ether's case -healthy ASA1 pt- 6hrs is in the guideline. Pregnant pt are full stomach no matter what, so it's hard to say what's adequate.

I didn't read your link. I quoted the current OB guidelines which is applicable to the current discussion.

The link you cited DOES NOT apply to the current discussion.

Confusing patient populations (healthy patients vs parturients) is a common mistake that junior physicians make when interpreting the literature.

 

[Noyac]

6 hours, huh? That sounds bold. But wait, I have seen that somewhere. Oh, I remember now. It's on the current ASA guidelines. Not up to date, again. What a surprise!

Oh boy, oh boy!! Why, why, why? Then I'm the smart @ss for teaching you guys something.

http://www.asahq.org/publicationsAndServices/NPO.pdf

Who are you teaching?

 

[Intubate]

Just yesterday I had a patient G1 at 36 weeks, ruptured, breech. The OB said, lets go to the OR. So I interview the patient and she ate a plain biscuit on the way to the hospital (an American biscuit, not a cracker). So I go tell the OB, see you in 6 hours. He says, lets do it now, she's in labor. I say, she's 3 cm and not contracting-- she's not in labor, but if its emergency, lets do it. We waited, everyone was fine.
1. The OB is not your friend.
2. An emergency is an emergency.
3. A non-emergency can become an emergency.
4. Six hours, eight hours, if you think there's a difference in a parturient, you're fooling yourself. The ASA realizes this, and doesn't include parturients in their guidelines.

 

[Planktonmd]

Just yesterday I had a patient G1 at 36 weeks, ruptured, breech. The OB said, lets go to the OR. So I interview the patient and she ate a plain biscuit on the way to the hospital (an American biscuit, not a cracker). So I go tell the OB, see you in 6 hours. He says, lets do it now, she's in labor. I say, she's 3 cm and not contracting-- she's not in labor, but if its emergency, lets do it. We waited, everyone was fine.
1. The OB is not your friend.
2. An emergency is an emergency.
3. A non-emergency can become an emergency.
4. Six hours, eight hours, if you think there's a difference in a parturient, you're fooling yourself. The ASA realizes this, and doesn't include parturients in their guidelines.

The new guidelines, published in this month's volume of Anesthesiology, are for OB anesthesia.

 

[mille125]

At my institution the same case would be phrased "she had donuts one hour ago so when would YOU Like to do the case? If at all possible could we not operate in the middle of the night, but what ever you decide is fine with me."

Now, what is your answer? I can tell you the real world answer is anywhere from 30 minutes (non emergent time to get ready for a c-section) to 6-8 hours depending on the experience of the Anesthesiologist. The older and the more experience the Anesthesiologist has the less likely he is to do any OB C-section in the middle of the night if it can be avoided. Thus, give pre-meds, wait 1-2 hours and then do the spinal anesthetic. That said, I respect the traditional, conservative answer of wait 7 hours and do the case as usual.

As a side note, I consider 6 hours sufficient "NPO" for the healthy ASA 1 patient. I use this time frame often as do most of my colleagues.

i would argue that a pregnant patient is not an ASA 1 patient...I know that this is up for debate....To me the pregnant state does not constitute ASA 1 status...........

 

[mille125]

6 hours, huh? That sounds bold. But wait, I have seen that somewhere. Oh, I remember now. It's on the current ASA guidelines. Not up to date, again. What a surprise!

Oh boy, oh boy!! Why, why, why? Then I'm the smart @ss for teaching you guys something.

http://www.asahq.org/publicationsAndServices/NPO.pdf

this proves that some people do not think when they post.......