OB present while placing labor epidural?

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Just wondering what everyone's hospital policy is. We are a small community hospital and take call from home. We currently require the OB (or their midwife) to be in the building when we place a labor epidural. Obviously, the OB department has an issue with this policy and wants it revoked.

Any thoughts? ASA says OB physician has to be readily available, but that is open to interpretation.

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If no
Just wondering what everyone's hospital policy is. We are a small community hospital and take call from home. We currently require the OB (or their midwife) to be in the building when we place a labor epidural. Obviously, the OB department has an issue with this policy and wants it revoked.

Any thoughts? ASA says OB physician has to be readily available, but that is open to interpretation.
If no one is around, who checks the patient to approve them for the epi?
 
If no

If no one is around, who checks the patient to approve them for the epi?
Usually what happens is the OB checks the patient, and leaves, either for office or home. Then the labor nurse checks the patient, calls the OB, and the OB then calls us from wherever they may be that "patient wants an epidural, and I'm available if any issues arise." But they are still at their office or at home.

We are okay with them being in the hospital office, but some private OB's have office 10-15 minutes away. At night, they want to stay home while we come in and do the epidural.
 
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If no

If no one is around, who checks the patient to approve them for the epi?
The nurse!
Look at this as an opportunity to make strong ties with your OB docs. If you are taking call from home then why should they be required to come in for a procedure that another doctor is doing? I'm sure they are within a reasonable distance just as you are if needed. Back off and make friends.
 
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The nurse!
Look at this as an opportunity to make strong ties with your OB docs. If you are taking call from home then why should they be required to come in for a procedure that another doctor is doing? I'm sure they are within a reasonable distance just as you are if needed. Back off and make friends.
Worked at two places that had strict MD to MD communication. One was implemented after an epidural was placed upon nurse request for a patient not in active labor.

Currently work at a place where OB is in house. I have no answer to the situation asked in the OP question but I'd just like to make absolute sure that the patient is approved for epi...

Also, let's be honest. Doesn't happen too often, but no one here has seen an epi cause fetal compromise needing stat section? I've seen it once or twice and that was after position change, ephedrine, terbutaline, etc... Wouldn't want an OB 15 minutes away in that situation. But if ACOG says it's ok, then you should have some legal standing I would think.
 
Worked at two places that had strict MD to MD communication. One was implemented after an epidural was placed upon nurse request for a patient not in active labor.

Currently work at a place where OB is in house. I have no answer to the situation asked in the OP question but I'd just like to make absolute sure that the patient is approved for epi...

Also, let's be honest. Doesn't happen too often, but no one here has seen an epi cause fetal compromise needing stat section? I've seen it once or twice and that was after position change, ephedrine, terbutaline, etc... Wouldn't want an OB 15 minutes away in that situation. But if ACOG says it's ok, then you should have some legal standing I would think.
Yea, we still require MD to MD communication. The OB has to call/text me before I do the epidural. But they just don't want to come in - whether it be leaving their office, or getting out of bed.
 
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Yea, we still require MD to MD communication. The OB has to call/text me before I do the epidural. But they just don't want to come in - whether it be leaving their office, or getting out of bed.
Same here. I don't do anything until another MD requests it. The midwifes are another story and don't get me going on them.
 
All depends on how readily available they are, but if they're taking call from home for OB they must (or should) be pretty close. Personally I'm fine with the labor nurse checking dilation and contraction pattern and relaying this to the OB. Their presence doesn't add a whole lot to the situation if you're doing low risk patients to begin with.
 
The nurse!
Look at this as an opportunity to make strong ties with your OB docs. If you are taking call from home then why should they be required to come in for a procedure that another doctor is doing? I'm sure they are within a reasonable distance just as you are if needed. Back off and make friends.

Listen up here. This is how we forge relationships and back ea. other up.
Physicians need to stick together on the easy stuff and work through the more complicated issues... both dealing on the same side of the table.
Nice post Noy.
 
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Worked at two places that had strict MD to MD communication. One was implemented after an epidural was placed upon nurse request for a patient not in active labor.

Currently work at a place where OB is in house. I have no answer to the situation asked in the OP question but I'd just like to make absolute sure that the patient is approved for epi...

Also, let's be honest. Doesn't happen too often, but no one here has seen an epi cause fetal compromise needing stat section? I've seen it once or twice and that was after position change, ephedrine, terbutaline, etc... Wouldn't want an OB 15 minutes away in that situation. But if ACOG says it's ok, then you should have some legal standing I would think.

That would be my biggest concern. We use CSE's on a busy labor floor. At least once/month we have this, but I haven't seen it go to section yet but rather resolve with positioning, ephedrine, nitro.

For those doing epidurals w/o OB present, I assume no CSEs?
 
Sometimes I think we engage in too much "schadenfreude" in medicine. This thought of if I am working, you should be too (maybe not quite equivalent to schadenfreude). I think "readily available" is more important than "in hospital" (unless the patient is high risk, of course). However, I do require the patient to have been somehow evaluated by the obstetrician before placing an epidural. I am an anesthesia consultant, so a doctor needs to consult me before I provide my services...not a nurse.

If there is fetal compromise after placing an epidural, usually by the time you try various techniques like positioning and ephedrine, the OB can be in house. That is the "readily available" part. The OB has to be aware and ok with an epidural being placed and readily available if they are needed.
 
That would be my biggest concern. We use CSE's on a busy labor floor. At least once/month we have this, but I haven't seen it go to section yet but rather resolve with positioning, ephedrine, nitro.

For those doing epidurals w/o OB present, I assume no CSEs?
Stopped doing CSE for this reason. Had a couple of patients head to section after cse caused tracing problems. What is the point, so she gets comfortable 5 minutes faster? Not worth it IMO
 
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Stopped doing CSE for this reason. Had a couple of patients head to section after cse caused tracing problems. What is the point, so she gets comfortable 5 minutes faster? Not worth it IMO
How much of a bolus are your pts getting before the CSE? What was in the IT dose, marcaine and fentanyl?
 
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Stopped doing CSE for this reason. Had a couple of patients head to section after cse caused tracing problems. What is the point, so she gets comfortable 5 minutes faster? Not worth it IMO
Same. Though it depends on the OB. Some understand the anesthesia caused the issue and can usually be reversed with some nitro/ephedrine. Many don't though.
 
That would be my biggest concern. We use CSE's on a busy labor floor. At least once/month we have this, but I haven't seen it go to section yet but rather resolve with positioning, ephedrine, nitro.

For those doing epidurals w/o OB present, I assume no CSEs?
I always did CSEs.

As you noted the associated decels, from the abrupt withdrawal of beta agonism, are fixable with the IV drugs you've got. I favor CSEs over straight epidurals for several reasons and for ordinary elective labor epidurals the OB's physical absence or presence nearby doesn't change that.
 
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Stopped doing CSE for this reason. Had a couple of patients head to section after cse caused tracing problems. What is the point, so she gets comfortable 5 minutes faster? Not worth it IMO
I've never once taken a patient who just got a CSE urgently to section because of a CSE-related decel. Maybe I just worked with better OBs though. :)
 
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I've never once taken a patient who just got a CSE urgently to section because of a CSE-related decel. Maybe I just worked with better OBs though. :)
You definitely did. I've worked with OBs who wouldn't let me give nitro...
 
CSE induced fetal brady is self-limited and easily fixable. It's not much of a problem if you keep your IT dosing reasonable (I give 2.5cc of 1/8th Bupi w/ fent 2mcg/mL - the bag solution).

The only ones that proceed to section shortly after CSE are the babies that already had a mediocre strip to begin with, and the OB was just looking for a reason.
 
Wouldn't "let" ?

If my epidural caused transient hemodynamic issues or side effects I fixed them with my drugs.
We were in the back sectioning her before I could crack the vial open...some of the OB's I've worked with in the past were BEYOND.
 
I've never once taken a patient who just got a CSE urgently to section because of a CSE-related decel. Maybe I just worked with better OBs though. :)
Some are just ready to section at the drop of a hat but would love to blame anesthesia . After one particular OB told a patient that her tracing went bad after receiving a "special " epidural, i decided no more.
 
Op this should be a nonissue. Do the epidural so you can both be at home :0
 
Thanks for all the replies. Seems like the consensus is that the patient should be evaluated/examined prior to placing the epidural, and this is good medicine anyway.

So how long before the epidural is this evaluation/examination sufficient? Meaning what if the OB saw the patient in the AM, goes to office, and now at lunchtime calls and says "She wants the epidural, and I evaluated her." What is the timeline? 1 hour, 2 hours, few minutes, all day?

Again, thanks for the replies.
 
Thanks for all the replies. Seems like the consensus is that the patient should be evaluated/examined prior to placing the epidural, and this is good medicine anyway.

So how long before the epidural is this evaluation/examination sufficient? Meaning what if the OB saw the patient in the AM, goes to office, and now at lunchtime calls and says "She wants the epidural, and I evaluated her." What is the timeline? 1 hour, 2 hours, few minutes, all day?

Again, thanks for the replies.
I'm sorry but you are being an obstructionist. You will piss off your colleagues.
I'd be ok if the OB saw the pt in the clinic a few days ago. As long as the OB makes the formal request and the nurse says the pt is ready then I will place the epidural. OB just needs to be available.

Btw, I'm a doctor and I can assess if the pt isn't acting right.
 
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I don't care about the time frame. The OB knows what an epidural is and what it does. If the OB consults me for an epidural, I'm not going to quibble that it's too early.
 
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Thanks for all the replies. Seems like the consensus is that the patient should be evaluated/examined prior to placing the epidural, and this is good medicine anyway.

So how long before the epidural is this evaluation/examination sufficient? Meaning what if the OB saw the patient in the AM, goes to office, and now at lunchtime calls and says "She wants the epidural, and I evaluated her." What is the timeline? 1 hour, 2 hours, few minutes, all day?

Again, thanks for the replies.

Speaking as an OB GYN, what exactly are you looking for from me before the patient can get an epidural?

Not sure why there seems to be a need for so many hoops before placing one...
 
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Speaking as an OB GYN, what exactly are you looking for from me before the patient can get an epidural?

Not sure why there seems to be a need for so many hoops before placing one...
Most of us have been burned, at some point, by an epidural request that came from someone other than the attending OB, which was ultimately either contrary to the OB's plan or the patient's not-actually-in-labor status.

We're just looking for
1) assurance that the OB is aware and actually wants an epidural
2) the courtesy of a physician-to-physician consult for our services

Beyond that, I don't care when the epidural goes in ... with the caveat that an epidural placed super early has a higher risk of failure when the moment of truth comes.
 
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I am happy to place in a patient prior to active labor. Really the only thing I need is for the OB to determine that the patient is not going to be sent home, and will be delivered in a reasonable amount of time.
Example would be ruptured membranes that they are going to start inducing.
To OP, be happy for business, make friends and let them go home. There are strict guidelines for them about availability, just as there are for us.


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Speaking as an OB GYN, what exactly are you looking for from me before the patient can get an epidural?

Not sure why there seems to be a need for so many hoops before placing one...
Personally, I just want to know that you are familiar with the pt and abreast of her progress. If you have any concerns I would like to know what they are and that you are following them closely. I would also like to know the delivery plan if it isn't obvious. I really hate to get called to place an epidural in the middle of the night so that the OB can sleep. Then I get there and the pt isn't sure that they even want one. Do that to me once and I will ask that you see the pt before I place the epidural. Basically, you scratch my back and I'll scratch yours.
 
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Most of us have been burned, at some point, by an epidural request that came from someone other than the attending OB, which was ultimately either contrary to the OB's plan or the patient's not-actually-in-labor status.

We're just looking for
1) assurance that the OB is aware and actually wants an epidural
2) the courtesy of a physician-to-physician consult for our services

Beyond that, I don't care when the epidural goes in ... with the caveat that an epidural placed super early has a higher risk of failure when the moment of truth comes.

All reasonable.

But to the OP, I don't think it's necessary to quibble about timing of previous evaluation.

It's interesting because where I trained, nursing basically called anesthesia when the patient wanted an epidural. Never ran into an issue, although we were in house 24 hours.

Interesting to see the variety out there.
 
Yeah... there is def. differences in how people practice.
I work in a high volume OB center and I rarely if ever get a call from the OB for my epidurals. It's almost always a nurse and I don't mind that one bit.
Never been burned on this.
If I get a call from an OB, it's usually for something serious like consultation for a percreta that will require the services of urology, interventional radiology and a general surgery...or a patient with some zebra diagnosis or questions regarding an analgesic plan for a patient that may not be a neuraxial candidate.
I really don't need a call from my OB colleagues every time I need to place an epidural when we are doing 300-400 deliveries a month.
They are plenty busy as it is and are bouncing between rooms dealing with OB patients all night long.
I get a call from the nurse. Go to their room. The patient is already in sitting position. I interview them like that and then proceed with neruaxial. Once done, I give my PCEA order and I'm back to the call room trying to get some sleep before the next call.
Just a different approach.
 
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We just have hospital wide policy that any consult is carried out physician to physician. At least when this happens I know that the OB is aware of the pt getting an epidural. I like for them to know.
 
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Great replies. For the record, I personally have no issue doing an epidural as long as the OB calls me. They don't have to be physically present, but should be aware and readily available. Obviously, if they have called me, they are aware, and that is sufficient. However, my group asked me to pose this question on the forums simply because some of them can be obstructionists.

We have a great relationship with administration, and the last thing we need is the OB department complaining that we are being difficult. That is bad for business. There is definitely something to be said about having a good relationship with your physician colleagues as well. In the world of private practice (and hospital subsidies), you need to pick your battles.

The replies on this topic were what I expected, and I absolutely love this venue for hearing what other hospitals/practices do. Now I can simply relay this discussion to my partners!
 
Great replies. For the record, I personally have no issue doing an epidural as long as the OB calls me. They don't have to be physically present, but should be aware and readily available. Obviously, if they have called me, they are aware, and that is sufficient. However, my group asked me to pose this question on the forums simply because some of them can be obstructionists.

We have a great relationship with administration, and the last thing we need is the OB department complaining that we are being difficult. That is bad for business. There is definitely something to be said about having a good relationship with your physician colleagues as well. In the world of private practice (and hospital subsidies), you need to pick your battles.

The replies on this topic were what I expected, and I absolutely love this venue for hearing what other hospitals/practices do. Now I can simply relay this discussion to my partners!
Sounds good but I have another comment, not that that surprises anyone one here.
i understand the anxiety of being under the thumb of administration. But it will only make you crazy if you make every decision based on other services complaining about your group to administration. And that's no way to practice either.
I recommend your group practice the best and safest medicine you are capable of and let the cards fall where they may. That may seem like a cliche' but it's the only way I know how to survive in this current environment.
So if you and your group are consistent in your management of pts and politics then other groups will respect this and they will support you. But don't think they won't carry on if you are dismissed either. So don't expect security from any of this. Its just my way of getting thru this day to day chaos. And I can stand by it. Don't be obstructionist. Don't go behind your partners backs doing cases they cancelled. Have a secure forum for discussing cases that you may not have agreed on and to help bring others in the group along. Basically, function as a stable consistent group were there are no surprises. Not a bunch of individuals.
I say all of this because I've heard the similar rumblings like yours above (concerns of other groups complaining to admin) and I only no of one way to squash it.
 
The nurse!
Look at this as an opportunity to make strong ties with your OB docs. If you are taking call from home then why should they be required to come in for a procedure that another doctor is doing? I'm sure they are within a reasonable distance just as you are if needed. Back off and make friends.
I tried to do that at my last job as I didn't really see the need, but I got in trouble from the partners. As in, I got a talking to, and told, no OB, no epidural. So each time, I would have the OB park outside and wait in their car. Just in case.
 
I tried to do that at my last job as I didn't really see the need, but I got in trouble from the partners. As in, I got a talking to, and told, no OB, no epidural. So each time, I would have the OB park outside and wait in their car. Just in case.
My post may have been a bit misleading.
The nurse calls when the pt is ready (and the nurse is ready) after the OB has consulted you.
I don't mean to give the impression that the nurse decides if the pt gets an epidural and when.
 
My post may have been a bit misleading.
The nurse calls when the pt is ready (and the nurse is ready) after the OB has consulted you.
I don't mean to give the impression that the nurse decides if the pt gets an epidural and when.
Misunderstanding. I meant putting in the epidural without the OB being around. I was told by the partners that once the OB consults and calls you, they can't leave until after the epidural has been placed.
 
That would be my biggest concern. We use CSE's on a busy labor floor. At least once/month we have this, but I haven't seen it go to section yet but rather resolve with positioning, ephedrine, nitro.

For those doing epidurals w/o OB present, I assume no CSEs?
Why cse?

I almost never get a.call from ob. Always madwife. But ob is always in house.
 
Why cse?

I almost never get a.call from ob. Always madwife. But ob is always in house.

Are you asking why we use them?

I've got another year left of training and it's more than anything, a cultural thing here. The best argument IMO is it let's everyone (attending included) know that the epidural is in the correct position. Our CD rate is >50% of laboring patients. As such, we're frequently running back to the OR and it's nice knowing a catheter will work
 
Are you asking why we use them?

I've got another year left of training and it's more than anything, a cultural thing here. The best argument IMO is it let's everyone (attending included) know that the epidural is in the correct position. Our CD rate is >50% of laboring patients. As such, we're frequently running back to the OR and it's nice knowing a catheter will work
I would argue that's the opposite reasoning. Assume your patient gets comfortable right away from cse. You start the epi. An hour later, you get called for section. You really don't know at all if your epi is working... Analgesia to this point is from the cse. Not common, but I have seen patients with a good csev with poor epidural analgesia and then you're up a creek...

You put the epi from the beginning and either it works or it doesn't, but at least you know from the start.

Another technique I've seen discussed is dural puncture without med given. Confirms placement and there is literature to suggest people get comfortable a little quicker and require fewer top ups down the road.
 
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Are you asking why we use them?

I've got another year left of training and it's more than anything, a cultural thing here. The best argument IMO is it let's everyone (attending included) know that the epidural is in the correct position. Our CD rate is >50% of laboring patients. As such, we're frequently running back to the OR and it's nice knowing a catheter will work

The best argument is actually that it leads to better analgesia during labor (see below). Once you get past training and do a couple thousand epidurals, you can usually tell whether the epidural will be in the correct position or if something was funny and there is a chance it may not fly. Of course we all get get surprised every now and again, but by and large you can usually predict based on the ease of placement, tactile feel, etc.

A randomized controlled comparison of epidural analgesia and combined spinal-epidural analgesia in a private practice setting: pain scores during fir... - PubMed - NCBI
 
I would argue that's the opposite reasoning. Assume your patient gets comfortable right away from cse. You start the epi. An hour later, you get called for section. You really don't know at all if your epi is working... Analgesia to this point is from the cse. Not common, but I have seen patients with a good csev with poor epidural analgesia and then you're up a creek...

You put the epi from the beginning and either it works or it doesn't, but at least you know from the start.

Another technique I've seen discussed is dural puncture without med given. Confirms placement and there is literature to suggest people get comfortable a little quicker and require fewer top ups down the road.

I see what you're saying. If you're getting CSF back though, at some point the Tuohy was in the epidural space. There could be any number of reasons why the catheter subsequently ends up not working, but that catheter should be in the epidural space with CSF return.

I personally like the idea of not given the ITE meds, but that's not currently my decision. I recently learned that many of our patients attend a hospital-sponsored, pre-labor class detailing what to expect. Long story short, the teacher (a breast feeding specialist) tells everyone that epidurals provide complete pain relief. This leads to false expectations on the labor floor and subsequent "pain evals" over and over. By not giving the IT meds, maybe expectations could be better set?

Do most people just do straight epidurals in PP?
 
I see what you're saying. If you're getting CSF back though, at some point the Tuohy was in the epidural space. There could be any number of reasons why the catheter subsequently ends up not working, but that catheter should be in the epidural space with CSF return.

I personally like the idea of not given the ITE meds, but that's not currently my decision. I recently learned that many of our patients attend a hospital-sponsored, pre-labor class detailing what to expect. Long story short, the teacher (a breast feeding specialist) tells everyone that epidurals provide complete pain relief. This leads to false expectations on the labor floor and subsequent "pain evals" over and over. By not giving the IT meds, maybe expectations could be better set?

Do most people just do straight epidurals in PP?

I did straight epidurals in residency and that is what I do now. You know pretty quickly if an epidural is working or not. If it's patchy or one-sided, I usually just replace it if it isn't corrected quickly with a top-up bolus rather than futzing around too much with pulling back the catheter, etc...

On a similar note, what are people's feelings about doing a spinal for a c-section (e.g. failure to progress, etc..) if an epidural placed for labor is patchy or one-sided? I was taught that this is a pretty hard "no" in residency due to the potential for a high spinal and that is how I practice now. However, I have heard people argue that you can do a spinal in these situations so long as you reduce the dose (by how much?). Thoughts?
 
On a similar note, what are people's feelings about doing a spinal for a c-section (e.g. failure to progress, etc..) if an epidural placed for labor is patchy or one-sided? I was taught that this is a pretty hard "no" in residency due to the potential for a high spinal and that is how I practice now. However, I have heard people argue that you can do a spinal in these situations so long as you reduce the dose (by how much?). Thoughts?
I was taught the same I'm residency but I did a review of the topic for a presentation and there's actually a fair amount of data that it's safe.

With that being said, I would personally only do it if I had a failed epidural / not working perfectly and I had yet to load the patient. Once the load goes in, I wouldn't do the spinal.

Believe it or not, there are actually institutions where it's standard to pull the epi and place the spinal as first line.
 
I see what you're saying. If you're getting CSF back though, at some point the Tuohy was in the epidural space. There could be any number of reasons why the catheter subsequently ends up not working, but that catheter should be in the epidural space with CSF return.

I personally like the idea of not given the ITE meds, but that's not currently my decision. I recently learned that many of our patients attend a hospital-sponsored, pre-labor class detailing what to expect. Long story short, the teacher (a breast feeding specialist) tells everyone that epidurals provide complete pain relief. This leads to false expectations on the labor floor and subsequent "pain evals" over and over. By not giving the IT meds, maybe expectations could be better set?

Do most people just do straight epidurals in PP?
Expectations are very important and I stress that with patients before I leave the room.

Personally I do straight epidural with about 15 ml of 0.08 bupi. Works well and patients are comfortable about 3-5 minutes after bolus usually. But I do have partners who do CSE frequently. To each their own.
 
I was taught the same I'm residency but I did a review of the topic for a presentation and there's actually a fair amount of data that it's safe.

With that being said, I would personally only do it if I had a failed epidural / not working perfectly and I had yet to load the patient. Once the load goes in, I wouldn't do the spinal.

Believe it or not, there are actually institutions where it's standard to pull the epi and place the spinal as first line.
I pull almost every epidural and place a spinal for c/s. My usual dose for c/s is 1.3 cc marcaine with 200mch duramorph. If an epidural was in place I give .8-1.0 cc marcaine with 20mcg fent and 200mcg duramorph. Haven't had a high spinal in 15 yrs of doing it this way.
 
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I pull almost every epidural and place a spinal for c/s. My usual dose for c/s is 1.3 cc marcaine with 200mch duramorph. If an epidural was in place I give .8-1.0 cc marcaine with 20mcg fent and 200mcg duramorph. Haven't had a high spinal in 15 yrs of doing it this way.
Do you do this even if you had first loaded the epi? Is the dose the same regardless of the load?
 
I pull almost every epidural and place a spinal for c/s. My usual dose for c/s is 1.3 cc marcaine with 200mch duramorph. If an epidural was in place I give .8-1.0 cc marcaine with 20mcg fent and 200mcg duramorph. Haven't had a high spinal in 15 yrs of doing it this way.
Why do you pull a working epidural?

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Only an hour ago had similar case. Personally sited epidural. Feeling loads of pressure but couldn't feel cold. Face presentation.

Whipped out epi and gave sitting spinal. 2mls heavy with 15f 150m. No probs


If any doubt re epi when it comes to section time whip it out. I've even given full dose 2.4 mls post epi. Never had high spinal... Just hypotension. And I can fix that...

I never give cse on labor ward...
 
Why do you pull a working epidural?

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Epidural topup is a million miles away in terms of analgesic effect compared to 2.4 heavy with f&m I'm

I know an obs anaestheist who had never give an epidural topup for section. Maybe a few times in his training. Spinal for everyone

I wouldn't do it... But I def prefer easy spinal to epi topup. Problem is of course, is it going to be easy?
 
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