OB related case with failed progression of labor

[anesthesia11230]

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Im covering OB this month.

Got the sign out from the night before as I arrive early morning.
Get signed out that patient has recieved spinal fentanyl along with 1.2cc bupivicaine for labor pain (she is multiparous and about 8 cm dilated) so they figured she was going to deliver shortly.

She ends up having delayed progression of labor and stuck at 8cm. The Ob attending is now considering sectioning her if after 1 hr there is no more progression. In the meantime she is hoping the patient can have an epidural.

My attending didnt want to go back and have to stick her after someone else (night team on call) had already played around with her back.

Question: How many of you guys would have simply placed an epidural in this situation all in efforts to avoid GA.

The patient ended up going for a C section under GA. Baby had an APGAR score of 5 initially due to meconium aspiration. After vigorous suctioning and attempted intubation the baby then had an APGAR of 9

What would be the consensus and standard of care for this lady?
Place an epidural even after the night team had previously performed a spinal or proceed on with RSI ETT GA?

My attending's logic was that he was burnt before in the past and took 2 years to clear his name from "BS"...his choice was obvious...GA

 

[jwk]

Im covering OB this month.

Got the sign out from the night before as I arrive early morning.
Get signed out that patient has recieved spinal fentanyl along with 1.2cc bupivicaine for labor pain (she is multiparous and about 8 cm dilated) so they figured she was going to deliver shortly.

She ends up having delayed progression of labor and stuck at 8cm. The Ob attending is now considering sectioning her if after 1 hr there is no more progression. In the meantime she is hoping the patient can have an epidural.

My attending didnt want to go back and have to stick her after someone else (night team on call) had already played around with her back.

Question: How many of you guys would have simply placed an epidural in this situation all in efforts to avoid GA.

The patient ended up going for a C section under GA. Baby had an APGAR score of 5 initially due to meconium aspiration. After vigorous suctioning and attempted intubation the baby then had an APGAR of 9

What would be the consensus and standard of care for this lady?
Place an epidural even after the night team had previously performed a spinal or proceed on with RSI ETT GA?

My attending's logic was that he was burnt before in the past and took 2 years to clear his name from "BS"...his choice was obvious...GA

We don't do epidurals on top of spinals - or vice versa.

Maybe my perspective is skewed by my own practice, but if you have in-house anesthesia coverage (it appears that you do) why not start with and epidural instead of a spinal? What's the advantage?

 

[VentdependenT]

who the hell does straight spinals for labor. You can wait till spinal wears off then proceed with epidural or go ga now.

 

[Noyac]

Thats ridiculous. Put the epidural in. Don't be lazy.

 

[aged2]

Place the epidural.

 

[VentdependenT]

Thats ridiculous. Put the epidural in. Don't be lazy.

You'd put the epidural in someone who has a complete spinal block? I'm not doing that. Not yet at least. I don't want to cause any nerve damage. What if the epidural doesn't work? Ok so what if it does? You gonna dose it when she starts to have pain during the procedure? Or you gonna prophylactically dose it? Its gonna take 10 minutes to work unless you use chlorprocaine.

Those are my concerns. Rip me a new one. I be ready.

Yeah call me a wuss. Thats the same reason I don't do asleep epidurals in people.

I would never do a strait spinal for labor pain.

 

[Planktonmd]

1.2 cc Bupivacaine with Fenatnyl !
I assume you mean 1.2 cc of .75 % Bupivacaine = 9 mg ! with fentanyl!
This not labor analgesia this is surgical anesthesia and this is exactly why this woman failed to progress!
I don't understand the problem with placing an epidura! Even if she has a working spinal right now this would a perfect opportunity to place the epidural and use it later when she starts having pain or if she needs surgery.
This is why in these situations when I think the delivery is imminent I always do a CSE no matter how confident I am that the baby was about to pop out and I never use more than 3 mg bupivacaine if at all for these spinals.

 

[aged2]

I would at least ploace it, I can dose it later, will it take time for it to work yes, but I at least have one more option.

 

[Jeff05]

NO reason not to place an epidural.

 

[anesthesia11230]

explanation for all the "why" responses

reason why attending overnight did a spinal for labor pain: laziness
reason why attending coming afterwards did not do an epidural: jaded

Jaded as explained before...took him (the attending following the lazy overnight attending) about 2 years to clear his name from a previous lawsuit of a lady complaining having lost sensation during intercouse and was blaming it on the spinal...although totally frivilous...its a reality of our litigacious society.

Seems like most people's reply are appropriate...put the epidural in
Spinal had already worn off so Vent's senario is no longer valid

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[Arch Guillotti]

Putting a spinal in for labor is pretty dumb. Sometimes pts. tell me that they have had this done before but it usually means it was at a podunk hospital and was most likely just intrathecal narcotics. I think that this is typically done at small places that don't have anesthesia in-house round the clock.

Placing an epidural really shouldn't take much longer than a spinal so long as the pt. is at least a little bit cooperative and not humongous. Of course w/a spinal most of the time you can just pop through to CSF in a single shot but if you are quick the epidural shouldn't take but a minute longer.

I always do a CSE in this instance. If the pt. is about to lose her cookies very ocasionally I will add a cc of .25% bupi to the normal CSE dose. Should the pt. fail to progress or need a section for any other reason just dose the cath w/chloroprocaine.

We replace catheters not infrequently. Sometimes they are just crappy to begin with, other times they are crappy when we dose them for section. Sometimes they will have a motor block but will obviously fail the Allis test. I have no problem w/replacing a cath even in a pt. who has some pretty big sensory or motor impairment. If theres no rush then replace the cath. If there is a rush then what I do is based on how well the cath is working. Sometimes you can gimp through with nitrous, versed, fentanyl, ketamine but I really think it is just easier to replace the catheter.

In the case of this pt. repeating the spinal is an option so long as the previous one has worn off. Most high spinals come from repeats and/or SAB after failed epidural.

So you are saying tha this attendind doesn't do spinals anymore.

 

[dhb]

would anybody go for a second spinal if the first one is wearing off?

 

[Noyac]

You'd put the epidural in someone who has a complete spinal block?

This lady didn't have a complete spinal block even when it was placed b/c nobody in there right mind would give a laboring woman a complete spinal unless they are having a c/s. She got 1.2cc of .25% bupiv. That isn't gonna give her a complete spinal. So yes I would place the epidural.

I also don't really blame the guy for just placing the spinal. I would have thought it would have been enough as well. I think the follow up attending was just pissed that an epidural wasn't placed in the first place and was being passive aggressive. AND LAZY.

 

[VentdependenT]

If it was .25 then id do the epidural fo sho. But thats still a bit too much aint it?

 

[Planktonmd]

This lady didn't have a complete spinal block even when it was placed b/c nobody in there right mind would give a laboring woman a complete spinal unless they are having a c/s. She got 1.2cc of .25% bupiv. That isn't gonna give her a complete spinal. So yes I would place the epidural.

I also don't really blame the guy for just placing the spinal. I would have thought it would have been enough as well. I think the follow up attending was just pissed that an epidural wasn't placed in the first place and was being passive aggressive. AND LAZY.

I didn't read 0.25% anywhere, I actually understood that they gave her 1.2cc of the 0.75% Bupivacaine with Fentanyl which means they gave her surgical anesthesia for labor pain and contributed to (if not caused) her having a C section later.

 

[Noyac]

I didn't read 0.25% anywhere, I actually understood that they gave her 1.2cc of the 0.75% Bupivacaine with Fentanyl which means they gave her surgical anesthesia for labor pain and contributed to (if not caused) her having a C section later.

Your right, the actual concentration of the Bupiv was not mentioned. But I figure it must have been .25 since it was a labor epidural. If they used .75 then they are responsible for her failure to progress.

 

[coprolalia]

Find the insertion point, go one level higher, put the epidural in. Done.

-copro

 

[nchhabra]

If it was .25 then id do the epidural fo sho. But thats still a bit too much aint it?

seems reasonable. we typically use 2.5-3 mg bupi for a cse or a labor spinal. what are you guys using?

 

[Arch Guillotti]

seems reasonable. we typically use 2.5-3 mg bupi for a cse or a labor spinal. what are you guys using?

When do you do labor spinals?

 

[nchhabra]

When do you do labor spinals?

probably not the correct term. but if someone is 9 cm and i do not think i will get an epidural dosed in time, and sometimes it is b/c the attending says we have to do it, we will place a sab. 2-3 mg bupivicaine with 5-10 mcg of fentanyl. i have been burned by it wearing off and then having to go back and place in epidural, but it also has worked very nicely as well.

 

[coprolalia]

probably not the correct term. but if someone is 9 cm and i do not think i will get an epidural dosed in time, and sometimes it is b/c the attending says we have to do it, we will place a sab. 2-3 mg bupivicaine with 5-10 mcg of fentanyl. i have been burned by it wearing off and then having to go back and place in epidural, but it also has worked very nicely as well.

You should be doing a CSE.

-copro

 

[pd4emergence]

Pt is 8cm, why not put in a catheter? I think the spinal was a good idea but not threading a catheter was a bad idea. Pt complete or very close i can see just doing the spinal. However, alot of time can pass for that last 2 cm of dilation. It usually doesn't but there are those times that it does.

 

[nchhabra]

You should be doing a CSE.

-copro

most of the time i agree, but sometimes u gotta do what the attending says.

 

[pd4emergence]

I think the biggest mistake that the night resident made in this case was calling the attending too early. In residency we had a few attendings that were a little too involved and wanted to be called for everything. If it was a simple straightforward epidural I would usually call them about the time my junior resident had lost resistance. By the time they got they there the epidural was taped and the paperwork was ready to sign.

 

[anesthesia11230]

the 2nd attending following up was being passive aggressive along with alil stubborn...although not lazy.
epidural would have been placed without any additional effort on his part since i would have been the one placing an epidural without him being taxed any ATP even to put on sterile gloves.

the concentration of bupivicaine was .25%

for combined spinal epidural we usually use 2.5mg bupivicaine along with 25 ug of fentanyl
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[Arch Guillotti]

I think the biggest mistake that the night resident made in this case was calling the attending too early. In residency we had a few attendings that were a little too involved and wanted to be called for everything. If it was a simple straightforward epidural I would usually call them about the time my junior resident had lost resistance. By the time they got they there the epidural was taped and the paperwork was ready to sign.

Thats sure sounds like a lot of oversight. Rarely do I see an attending overnight. Usually just if there is a section.

 

[Jeff05]

Combined spinal epidural is nice, no doubt. I usually give 25mcg of fent - NO motor block is good. lots of pruritis. some add half ml of 0.25% bupi, ok too. some just give 1ml of 0.25%.

however, i find that if i give 5-10mL NS through catheter. then, test dose, wait for 3 min, and give lido 2% 5mL x2 (separated by 3-5 min), they are comfortable within 5 min. so, i don't think there is ever such a thing as not enough time to load an epidural.

 

[VentdependenT]

Combined spinal epidural is nice, no doubt. I usually give 25mcg of fent - NO motor block is good. lots of pruritis. some add half ml of 0.25% bupi, ok too. some just give 1ml of 0.25%.

however, i find that if i give 5-10mL NS through catheter. then, test dose, wait for 3 min, and give lido 2% 5mL x2 (separated by 3-5 min), they are comfortable within 5 min. so, i don't think there is ever such a thing as not enough time to load an epidural.

Unless its patchy or one sided.

 

[drccw]

1.2 cc of 0.25% bupiv intrathecally?
there is no reason to do a GA for this lady.....
hell if patient comes in and I cant seem to get her to sit still... I tell the nurse to get her hooked up, prep her real quick and dart her with a 24 G spinal needle and 1 cc of 0.25% bupiv at L4-5. takes me 60-90 secs usually and normally i am waiting for the BP to finish cycling... Get her comfy and slide the epidural in at L2-3 after 6-7 mins..... Sure I could do a CSE but that means grabbing and setting up more crap.

i never put fentanyl into my intrathecals, mainly because I am lazy and it's a pain in the *** to draw up, document, and waste where I work

 

[Noyac]

hell if patient comes in and I cant seem to get her to sit still... I tell the nurse to get her hooked up, prep her real quick and dart her with a 24 G spinal needle and 1 cc of 0.25% bupiv at L4-5. takes me 60-90 secs usually and normally i am waiting for the BP to finish cycling... Get her comfy and slide the epidural in at L2-3 after 6-7 mins..... Sure I could do a CSE but that means grabbing and setting up more crap.

I do the same when the pt can't sit still or is one of those hysterical pts. But my nurses can't prep (are talking about crna's doing the prep?). They can barely manage to get the vitals b/4 I'm done placing the epidural.