Obstetrics Case

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.
L

Lonestar

Senior Member
15+ Year Member
20+ Year Member
Joined
Jul 12, 2002
Messages
446
Reaction score
19
Members don't see this ad.
Had a 28 y/o WF G1P0 at 38 wks come in for labor. pt received a lumbar epidural for pain management during labor. 10 hrs later, C-section was called due to failure to progress. Pt has been comfortable throughout the labor. Anesthesia team bolus the pt with 15 ml of 2% lidocaine with epi and 100 mcg of fentanyl. pt had a T6 sensory level on left and T8 sensory level on the right. Pt receives additional 5 ml of 2% lidocaine with epi. The block was patchy with some sensation in Right upper quadrant of the abdomen. Incision was made and pt felt no pain on incision. As the Obstetrician further explored the peroteneum pt started to have pain. Local was given by the surgeon with the pt having pain in that area. At this point, 60 mg of ketamine was given (incrementally), pt was more comfortable, surgery proceeded and baby was out. Pt started to feel pain once again and received fentanyl (250 mcg) and Nitrous. Surgery finished and no post op issues.

6 wks later, pt threatens the hospital with a lawsuit alleging that she has post-traumatic stress disorder from "feeling every bump and nick" during surgery.

What are your thoughts?
 
once you started giving ketamine, midaz should have been worked in. i would have stuck with the ketamine for the remainder of the procedure, would have given you amnesia.

remember, that nitrous narcotic technique does NOT guarantee amnesia. again, midazolam should have been titrated.
 
Forgot to mention midazolam 2mg was given once baby was out.
 
Lonestar said:
6 wks later, pt threatens the hospital with a lawsuit alleging that she has post-traumatic stress disorder from "feeling every bump and nick" during surgery.

What are your thoughts?
Click to expand...

Probably poor anesthesia pre-op and risk/benefit discussion followed by likely poor post-op follow-up.

-copro
 
This is why when a regional anesthetic fails the next step should be a real GA.
Giving 250mcg Fentanyl + Midazolam + Ketamine + N2O is not regional Anesthesia anymore but not a very good GA either.
Still, this patient might have said that she was traumatized regardless of what you did because this is her winning Lotto ticket.
Unfortunately many of our patients see the possibility of winning a malpractice law suit as a once in a life time opportunity that they will jump on if given the chance, and there is no lack of sleazy lawyers who encourage that trend.
 
Lonestar said:
Had a 28 y/o WF G1P0 at 38 wks come in for labor. pt received a lumbar epidural for pain management during labor. 10 hrs later, C-section was called due to failure to progress. Pt has been comfortable throughout the labor. Anesthesia team bolus the pt with 15 ml of 2% lidocaine with epi and 100 mcg of fentanyl. pt had a T6 sensory level on left and T8 sensory level on the right. Pt receives additional 5 ml of 2% lidocaine with epi. The block was patchy with some sensation in Right upper quadrant of the abdomen. Incision was made and pt felt no pain on incision. As the Obstetrician further explored the peroteneum pt started to have pain. Local was given by the surgeon with the pt having pain in that area. At this point, 60 mg of ketamine was given (incrementally), pt was more comfortable, surgery proceeded and baby was out. Pt started to feel pain once again and received fentanyl (250 mcg) and Nitrous. Surgery finished and no post op issues.

6 wks later, pt threatens the hospital with a lawsuit alleging that she has post-traumatic stress disorder from "feeling every bump and nick" during surgery.

What are your thoughts?
Click to expand...

I tell every c-section patient, no matter how well the spinal or epidural is working, that they should not expect to feel nothing. I also end up reminding them over and over again both before and during the procedure that pressure and tugging can be quite uncomfortable but is to be expected. They need to have realistic expectations going into it and they often need to be reminded of what to expect as "normal."

Did you re-bolus the epidural? Ultimately what level did you end up getting? (Prior to your last bolus you said T6/T8 which is definitely not high enough.)

Do you remember the discomfort looking like the normal tugging-and-pressure of c-section or do you remember this looking like a true failed regional?
 
jennyboo said:
I tell every c-section patient, no matter how well the spinal or epidural is working, that they should not expect to feel nothing. I also end up reminding them over and over again both before and during the procedure that pressure and tugging can be quite uncomfortable but is to be expected. They need to have realistic expectations going into it and they often need to be reminded of what to expect as "normal."

Did you re-bolus the epidural? Ultimately what level did you end up getting? (Prior to your last bolus you said T6/T8 which is definitely not high enough.)

Do you remember the discomfort looking like the normal tugging-and-pressure of c-section or do you remember this looking like a true failed regional?
Click to expand...

All excellent points.

Also, in an FTP C/S, unless they've already made the uterine incision, there's no harm in stopping and waiting a few minutes while you dose the epidural some more (20cc may not have been enough), then starting again.
 
jwk said:
All excellent points.

Also, in an FTP C/S, unless they've already made the uterine incision, there's no harm in stopping and waiting a few minutes while you dose the epidural some more (20cc may not have been enough), then starting again.
Click to expand...

I agree with Jen and JWK. You need a T2-3 level. Im not 100% sure how you dosed your epidural or if she truely had a hot or patchy spot. When I am called for C/S on a Pt with a working Labor epidural she gets 20cc before I leave the labor room. Then after arrival to the OR 100Mcg Fentanyl followed by another 5-10cc. So depending on height she will have 20-30cc of 2% lido with epi or .50% bupiv. Then redosing at appropriate intervals depending on medication.
 
pt was told about normal discomfort with the epidural (pushing, tugging especially during extraction of baby). intially 20 ml of 3% lidocaine with epi plus 100 mcg of fentanyl were dosed. epidural was also dosed with 3% cholroprocaine afterwards and level was T6 on left and T8 on the right with some patchiness. At that point, ketamine was administered and pts comfort level improved. The surgery proceeded, the baby was out, and pt was moderately sedated on ketamine. Afterwards, pt felt some more pain and midazolam and 250 mcg fentanyl were titrated in. Nitrous gas was also administered at this point. 5 ml of lidocaine with epi was titrated in also. pt was comfortable once again and comfort lasted until the surgery was almost over. When the surgical techs started to wipe the chloroprep off pts belly she felt the pain.
 
usnavdoc said:
I agree with Jen and JWK. You need a T2-3 level. Im not 100% sure how you dosed your epidural or if she truely had a hot or patchy spot. When I am called for C/S on a Pt with a working Labor epidural she gets 20cc before I leave the labor room. Then after arrival to the OR 100Mcg Fentanyl followed by another 5-10cc. So depending on height she will have 20-30cc of 2% lido with epi or .50% bupiv. Then redosing at appropriate intervals depending on medication.
Click to expand...

really? seems like a dense T4 would be adequate enough.
 
A patient threatening to sue is not the same thing as having a winnable case. I doubt a lawyer would take this case, except to try to extract a settlement. I'd make sure she's clear you plan on fighting the case and not settling, and I hope your documentation is solid.
 
usnavdoc said:
I agree with Jen and JWK. You need a T2-3 level. Im not 100% sure how you dosed your epidural or if she truely had a hot or patchy spot. When I am called for C/S on a Pt with a working Labor epidural she gets 20cc before I leave the labor room. Then after arrival to the OR 100Mcg Fentanyl followed by another 5-10cc. So depending on height she will have 20-30cc of 2% lido with epi or .50% bupiv. Then redosing at appropriate intervals depending on medication.
Click to expand...

T2-T3? 30 ml via Epidural? Sounds like overkill to me. As discussed in another thread, my practice is similar to numbmd's. If epidural is working well, 10 ml bolus via Epidural + Fentanyl. This will generally get you a T6 level at a minimum, usually a T4. If it's T6 b/l I'll let the surgeons start, and work in some more volume. In my opinion, you don't need more than a T4 level at most.
 
Lonestar said:
pt was told about normal discomfort with the epidural (pushing, tugging especially during extraction of baby).
Click to expand...

Kudos, that's good. I also find that when they evert the uterus after the baby's out there's still quite a lot of discomfort, and (our OBs are friggin' slow especially with residents assisting) it takes a loooooooooooong time for them to close.

level was T6 on left and T8 on the right with some patchiness. At that point, ketamine was administered and pts comfort level improved.
Click to expand...

Again... T8 is too low.

If there was time (if this was not an emergent section such as cord prolapse, uterine rupture, etc) I would've told the OB to wait until the epidural reached a satisfactory level after pushing more drug through it. I would not let them start cutting until they have at least a bilateral T6 as rsgill said (which is only JUST enough and needs re-bolusing if your OBs are as slow as ours are). T4 is my ideal level.

Couple more questions:
- How was the "pain" described?
- Why did you administer ketamine when the level was only T6/T8 instead of re-bolusing the epidural? Were you out of time?

If it's a true emergency and the baby needs to come out now-now-now, then it's tough luck and you're out of time and conversion to GA would be the appropriate thing to do. However, if you have time, you can re-bolus the epidural or (if you have all day) even pull it out and replace it. It is still not clear to me whether you have a true failed regional or whether you could've gotten a better block and a higher level by simply re-bolusing and waiting.

Either way, don't be too hard on yourself. The fact that you're looking back and asking these questions shows you're thinking earnestly about your practice, the things you do well and the things you can improve on. It takes an unusual and possibly nutty person to take the time away from the craziness of a new baby to file a lawsuit.
 
I did rebolus the epidural with chloroprocaine as I said. That did help some, pt confused about her actual level. At times she could not feel the alcohol swab to her chest bilaterally. At this point, I decided to give ketamine and she weirded out with lateral nystagmus, but comfortable at this point. So we decided to proceed. Gave 10 mg of ketamine at a time for a total of 60 mg before the baby was out. Once the baby was out, gave 2mg midaz, 250 mcg fent and nitrous later on.

My documentation of all the sensory levels (after each of the epidural boluses) and patient pain level may not be noted.

You are right about over analyzing and being overly critical.

I have learned one thing. If a pt complains about "sharp" pain more than once, they are going to sleep! End of story.
 
it ain't worth my time to try to dork through a case with a crappy regional... especially a c-section.... if you are having to give ketamine before the baby is out then the answer ain't ketamine...

pentothal sux tube...

if my regional sucks (and it has before) then I ask them once if they want to go off to sleep- if they refuse i document it... if they still complain i pretty much stop everything and tell the patient that they are going to sleep....

i think that inadequate anesthesia is a pretty high on the list of things that'll get you sued.... put em off to sleep...
 
rsgillmd said:
T2-T3? 30 ml via Epidural? Sounds like overkill to me. As discussed in another thread, my practice is similar to numbmd's. If epidural is working well, 10 ml bolus via Epidural + Fentanyl. This will generally get you a T6 level at a minimum, usually a T4. If it's T6 b/l I'll let the surgeons start, and work in some more volume. In my opinion, you don't need more than a T4 level at most.
Click to expand...

Sorry I actually meant t3-4 level. Regardless, yeah I use 20-30cc as an initial dosing with a working epidural.
 
Noyac said:
Can you remind us all what nerves are involved in c/s? And how does T4 come into play?
Click to expand...

T4 is an adequate level for a C/S. what's so hard to understand?
 
dfk said:
T4 is an adequate level for a C/S. what's so hard to understand?
Click to expand...

Dude, I didn't ask you what was adequate for a c/s. I asked what nerves or dermatomes (if you know what that is) are involved in a c/s.
 
Noyac said:
Dude, I didn't ask you what was adequate for a c/s. I asked what nerves or dermatomes (if you know what that is) are involved in a c/s.
Click to expand...

well, without looking, manipulation of uterus can extend well into T6-5 at minimum.. i guess i'm missing what you want to hear. my point to navdoc's post was that you don't need T2-3, and he acknowledged that. why am i the bad dude here?
 
dfk said:
well, without looking, manipulation of uterus can extend well into T6-5 at minimum.. i guess i'm missing what you want to hear. my point to navdoc's post was that you don't need T2-3, and he acknowledged that. why am i the bad dude here?
Click to expand...

How does manipulation of the uterus reach into the T5-6? Uterine innervation is only up to T 10.
 
Noyac said:
How does manipulation of the uterus reach into the T5-6? Uterine innervation is only up to T 10.
Click to expand...

show me any literature that promotes T10 anesthesia for C/S and i'll shut up. otherwise, give it a rest. my point was that you don't need T2-3, and that T4 is way more than adequate. what's your point of innervation at this point? T4 bro!
 
C- section for a failure to progress...? I am stuck on that one. What a dumb reason for a c-section.
 
dfk said:
show me any literature that promotes T10 anesthesia for C/S and i'll shut up. otherwise, give it a rest. my point was that you don't need T2-3, and that T4 is way more than adequate. what's your point of innervation at this point? T4 bro!
Click to expand...

You said that "manipulating the uterus" requires T4 anesthesia, Noyac told you that this is not true and that for "manipulating the uterus" a T10 level is enough.
This is not a debatable theory, it is simple anatomy.
A T4 level will definitely provide good anesthesia and the patient will not even feel the pressure on the epigastric area when they push the baby out, but this will also produce a more extensive sympathetic block and hypotension.
I never heard of anyone trying intentionally to achieve T4 anesthesia for a C Section, it happens but we don't specifically aim for it.
Is that clear enough?
 
Planktonmd said:
Why do you think it's dumb??
What do you suggest doing if the baby doesn't want to come out??
Click to expand...

I think 10 hours is a pretty short time frame to assume that the baby doesn't want to come out. To help reposition a baby that is head down but not in a position to slide easily through the uterus (not in LOA), I would have the woman walk around for a while and allow her change in body position coupled with gravity assist the baby's descent. I would do this before subjecting her to possibly unnecessary surgery. I know that sounds so boring and unmedical - why try such a kooky thing when we could just make things faster and cut through her abdomen?

Oh, and Bertelman, just because it has a medical acronym doesn't make it make any more sense. How did birthing get so out of hand in the States?
 
TopDocChick said:
C- section for a failure to progress...? I am stuck on that one. What a dumb reason for a c-section.
Click to expand...


that's the most common reason I take patients back for c-sections....usually around 5 pm.

You must be a nurse midwife.
 
TopDocChick said:
I think 10 hours is a pretty short time frame to assume that the baby doesn't want to come out. To help reposition a baby that is head down but not in a position to slide easily through the uterus (not in LOA), I would have the woman walk around for a while and allow her change in body position coupled with gravity assist the baby's descent.
Click to expand...

What are you going to do if the pt has been complete and pushing for 8 of those 10 hrs? 6hrs? or even 2 hrs? You gonna ask her to walk around?
 
dfk said:
show me any literature that promotes T10 anesthesia for C/S and i'll shut up. otherwise, give it a rest. my point was that you don't need T2-3, and that T4 is way more than adequate. what's your point of innervation at this point? T4 bro!
Click to expand...

Alright, just like a nurse when you don't know the answer you continue to argue the point.
My problem with you is that this is a physicians forum and while you are welcome here, you frequently post information that is wrong. All while others not familiar with your background may take your posts as accurate information. I could simply correct you but that does no good.

But I guess another way of looking at your posts is that it is always a great opportunity to educate others since I frequently need to correct your posts.
 
militarymd said:
that's the most common reason I take patients back for c-sections....usually around 5 pm.

You must be a nurse midwife.
Click to expand...


haha, not a nurse midwife - just a med student who is interested in going into obgyn and has done enough research to see the problems in obstetric care in America.

I am sure you are performing those c-sections in the best interests of your patients.
 
Noyac said:
What are you going to do if the pt has been complete and pushing for 8 of those 10 hrs? 6hrs? or even 2 hrs? You gonna ask her to walk around?
Click to expand...

We are talking about the OPs original case. I never said that c-sections are not justified ever - just that failure to progress is a stupid reason to perform one. As far as a women stuck in the pushing stage - I would certainly try to reposition her to help get the baby out - perhaps to squatting or on all fours - before cutting her open. I have seen two shoulder dystocias delivered vaginally simply by repositioning.
 
TopDocChick said:
haha, not a nurse midwife - just a med student who is interested in going into obgyn and has done enough research to see the problems in obstetric care in America.

I am sure you are performing those c-sections in the best interests of your patients.
Click to expand...


When time comes for you...and it will....you'll be doing those C-sections at 5 pm just like everyone else.

You can have all the ideals you want, but when time comes to pay bills and have family obligations....you'll be singing a different tune.....just like EVERYONE else....

you know how I know.....I was a 2nd year medical student once a long, long time ago....along with every other doctor who is practicing today.
 
TopDocChick said:
We are talking about the OPs original case. I never said that c-sections are not justified ever - just that failure to progress is a stupid reason to perform one. As far as a women stuck in the pushing stage - I would certainly try to reposition her to help get the baby out - perhaps to squatting or on all fours - before cutting her open. I have seen two shoulder dystocias delivered vaginally simply by repositioning.
Click to expand...

sounds like you should just skip the rest of medical school AND residency....just take out a loan and start your practice...

Obviously the rest of your education will just be time wasted and preventing you from saving lives.
 
Planktonmd said:
You said that "manipulating the uterus" requires T4 anesthesia, Noyac told you that this is not true and that for "manipulating the uterus" a T10 level is enough.
This is not a debatable theory, it is simple anatomy.
A T4 level will definitely provide good anesthesia and the patient will not even feel the pressure on the epigastric area when they push the baby out, but this will also produce a more extensive sympathetic block and hypotension.
I never heard of anyone trying intentionally to achieve T4 anesthesia for a C Section, it happens but we don't specifically aim for it.
Is that clear enough?
Click to expand...

When I was a resident (and it wasn't that long ago), all of the attendings were preaching T4 T4 T4 for a c-section. Some would even push a CSE for a c-section. 8 mg of Bupivicaine and check check check the levels. If no T4, don't let the OBs cut... Bolus the LEP to get the level to ride up... So yeah, the c-sections in academia took forever, but the anesthesia time also took forever.... Now it's blast the spinal in, lay the patient back, and rock and roll... Door to door 30 mins...
 
TopDocChick said:
We are talking about the OPs original case. I never said that c-sections are not justified ever - just that failure to progress is a stupid reason to perform one. As far as a women stuck in the pushing stage - I would certainly try to reposition her to help get the baby out - perhaps to squatting or on all fours - before cutting her open. I have seen two shoulder dystocias delivered vaginally simply by repositioning.
Click to expand...

You know why there is too many C Sections in America?
2 reasons:
1- Because there are too many lawyers in America!
2- OBGYN Docs like to go home sometimes.

You might find these reasons not compatible with your idealistic view but you will grow up and understand eventually.
And by the time you become an OBGYN doctor you will do what you need to do to survive the system.
 
Yes, there is absolutely no doubt that uterine innervation is T10-L1 and sacral is S2-S4. We all learned this in anatomy class. The "T4 level" is to help cover discomfort from peritoneal manipulation. Its not like they magically pluck the uterus out of the abdomen, there are certain layers they gotta go through.
 
TopDocChick said:
haha, not a nurse midwife - just a med student who is interested in going into obgyn and has done enough research to see the problems in obstetric care in America.

I am sure you are performing those c-sections in the best interests of your patients.
Click to expand...


You will learn in the next couple years that the umbrella of evidence based medicine develops a lot of holes on the labor and delivery floor, especially with regards to C-sections. I mean I would love to see a study where we just hook up TOCO to a group of normal, healthy pregnant women with no threat of C-section and see what happens. OMG LOOK a decel!!!! I some times wonder if we are doing all these C-sections for the equivalent of a rare PVC on the cards floor.(obvious exceptions apply)
But, then again, OB's gotta cover their asses, try to get home at night, and pay the bills. ( just like all of us)
 
OBs have the twitchest fingers around... if a funny smell comes from the room then they will take the gal to section... it comes from having friends and colleagues who get hammered with a big decision.... it's a tough life, crappy hours and the ever present spector of litigation... even if you dot your Ts and cross your Is, if the baby has a problem then it's the OBs fault- and the juries will tend to agree... forget about the 2x daily crack cocaine or 12 pack of beer a day about the patient... it's about responsibility.. and it's not on the patient
 
huktonfonix said:
Yes, there is absolutely no doubt that uterine innervation is T10-L1 and sacral is S2-S4. We all learned this in anatomy class. The "T4 level" is to help cover discomfort from peritoneal manipulation. Its not like they magically pluck the uterus out of the abdomen, there are certain layers they gotta go through.
Click to expand...

Absolutely.

Funny how dfk couldn't come up with that. This was a very easy question on my part for dfk. But he still failed.

I shoot for a T6 level personally but as we all know it is variable. It is the visceral traction from uterine traction that I am attempting to cover.
 
militarymd said:
When time comes for you...and it will....you'll be doing those C-sections at 5 pm just like everyone else.

You can have all the ideals you want, but when time comes to pay bills and have family obligations....you'll be singing a different tune.....just like EVERYONE else....

you know how I know.....I was a 2nd year medical student once a long, long time ago....along with every other doctor who is practicing today.
Click to expand...

I fear that you are right but I hope to God that you are wrong.
 
Planktonmd said:
You know why there is too many C Sections in America?
2 reasons:
1- Because there are too many lawyers in America!
2- OBGYN Docs like to go home sometimes.

You might find these reasons not compatible with your idealistic view but you will grow up and understand eventually.
And by the time you become an OBGYN doctor you will do what you need to do to survive the system.
Click to expand...

It is so sad, I agree. I just wonder, how is it that the nurse midwives rarely get sued when comparing a similar patient population? (women with no risk factors, etc).
 
TopDocChick said:
It is so sad, I agree. I just wonder, how is it that the nurse midwives rarely get sued when comparing a similar patient population? (women with no risk factors, etc).
Click to expand...

because people dont see that KACHING! when going after a CNM.
 
Noyac said:
Alright, just like a nurse when you don't know the answer you continue to argue the point.
My problem with you is that this is a physicians forum and while you are welcome here, you frequently post information that is wrong. All while others not familiar with your background may take your posts as accurate information. I could simply correct you but that does no good.

But I guess another way of looking at your posts is that it is always a great opportunity to educate others since I frequently need to correct your posts.
Click to expand...

MSIV here and I really enjoy your posts as they're stock full of knowledge and you give great insight into your thought process. Thanks.

I kinda like dfk's posts sometimes though b/c they illustrate the vast differences b/t the mindset of a CRNA and the thoughts of a physician.
 
You must log in or register to reply here.

Similar threads

woopedazz
Obstetric case
2
Replies
64
Views
4K
narcusprince
narcusprince
W
Case discussion: why acidosis?
Replies
46
Views
3K
narcotics999
N
M
Case logs
Replies
7
Views
2K
Ashers
Ashers
V
CRNA introduced herself as “anesthesiologist” before case
Replies
23
Views
4K
coffeebythelake
coffeebythelake
S
Interesting case
2 3
Replies
114
Views
6K
woopedazz
woopedazz
Top