Obstetrics

[Noyac]

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I was asked the other night to place an epidural in a laboring pt who was 1cm after being in labor for over 12hrs. She was now uncomfortable and wanted relief. She was a G1P0. Contractions were about 3 minutes apart and she looked uncomfortable.

You gonna place it?

I did.

 

[Planktonmd]

I was asked the other night to place an epidural in a laboring pt who was 1cm after being in labor for over 12hrs. She was now uncomfortable and wanted relief. She was a G1P0. Contractions were about 3 minutes apart and she looked uncomfortable.

You gonna place it?

I did.

I couldn't care less how dilated she is.
If she wants an epidural and her OB agrees to it she will get one.

 

[urge]

Why wouldn't you?

 

[LethalInjection]

It depends on how late in the night it is!😴
J/K. I would place the epidural. If she wants one and OB agrees, I'll put it in. In Wong's study, the median cervical dilation was 2 cm and there was no increased rate of C/S.

 

[Noyac]

Its 3 am and she is a midwife pt.

 

[huktonfonix]

Its 3 am and she is a midwife pt.

midwife patient = epidural at 4 am, followed by a csection 12-24 hours later....... Only anecdotal evidence at this point although I should do a study.

Re: the original question. Yeah I think that NEJM study showed that it doesnt affect the progress of labor much if given early. I went to a conference sorta recently at which the speakers motto was "never too early, never too late". I agree with that sentiment. I feel that low concentrations of local/narcotic epidural or narcotic only CSE affect uterine contraction/cervical dilation minimally and probably help since it decreases pain/circulating catechols which can produce a dysfunctional labor pattern

 

[deleted126335]

.

 

[usnavdoc]

As long as they are committed to delivery, YUP.

Thats the key. She could be in latent labor for days.

 

[Noyac]

Yep and ACOG recently stated that once the pt asks for an epidural it is time to place it.

 

[dfk]

placing it at 1cm only guarentees oncall person top-off throughout the eve/night... tell the G1P0's to suck it up.. or tell them that they won't get the same relief with initial CSE (if that's what's done).

 

[Noyac]

placing it at 1cm only guarentees oncall person top-off throughout the eve/night... tell the G1P0's to suck it up.. or tell them that they won't get the same relief with initial CSE (if that's what's done).

So you are saying you would forgo the recommendations of the ASA and ACOG in this case?

So I guess that since you are a nurse you think you can ignore these to organizations?

"SUCK IT UP", really?

 

[drccw]

placing it at 1cm only guarentees oncall person top-off throughout the eve/night... tell the G1P0's to suck it up.. or tell them that they won't get the same relief with initial CSE (if that's what's done).

I'll put the LEP in...

but I got to tell you that this is why I don't do CSEs...
1. They take more time (not much more but more)
2. They take more effort (got to get more stuff out)
3. It's not the best of both worlds.. it's like the worse of two techniques.
4. Most importantly, it creates falses expectations for the patient. I don't want them to think that I can get them comfortably within 5 mins. I want them to know it'll take 20 mins, and when I get it done in 15 then I'll look more like a hero. If you get them comfy quickly, and they call for a top off- it's not going to be the same....

If a patient is super uncomfy and cant sit still, and far enough along (ie a multip at 8 cms or so) I will pop them with a one shot spinal... I dont do them often and you gotta pick the right patient- but they will deliver on the spinal and it'll be sweet....

PS: why is L&D so hesitant to use narcs. 1 cm for IOL? Gonna take a while pop them with some fentanyl or morphine and let them sleep. By the time the baby delivers (probably the next day) that stuff is all gone.. and if not, just hit the little dude with some naloxone.. that'll get his or her attention.. OBs are so obsessed with the little things and dont see the big picture... APGARS, FHTs, etc...

 

[numbmd]

On the flip side Noyac, a multip that's an ant lip wants one, do you give it?

Numb

 

[seinfeld]

AS a general rule i would place it. but i would have a discussion with the patient that her lack of experience regarding true labor pains may make the epideral appear to be less effective as labor progress and her satisfaction with pain relief may be less.

With the Midwife i would be quite clear that the patient would deliver within the next ~36 hours.

 

[coprolalia]

What do you guys do for back labor? Anything? I've found that, if they're late and in back labor, the CSE is like a magic bullet. But, this is a rare combination.

-copro

 

[dfk]

So you are saying you would forgo the recommendations of the ASA and ACOG in this case?

So I guess that since you are a nurse you think you can ignore these to organizations?

"SUCK IT UP", really?

i wouldn't literally tell them to suck it up, but there are times that you get these patients (typically primi teens) and nothing is ever as good as the initial 'feel good' from the CSE. they're the hardest to please, and you just wanna roll your eyes many times. and no, i don't forgo the recs of the ASA/ACOG.

 

[Noyac]

On the flip side Noyac, a multip that's an ant lip wants one, do you give it?

Numb

The OB's don't ask us to place one for these pts but the FP's and midwives do on occassion. So for those I do the one shot spinal technique.

 

[coprolalia]

When I have the initial discussion about labor epidurals with the patient (pre-consent), among the first words out of my mouth are that it is an elective procedure.

-copro

 

[Noyac]

i wouldn't literally tell them to suck it up, but there are times that you get these patients (typically primi teens) and nothing is ever as good as the initial 'feel good' from the CSE. they're the hardest to please, and you just wanna roll your eyes many times. and no, i don't forgo the recs of the ASA/ACOG.

YOur contradicting yourself. You say you will tell the G1P0's to 'suck it up". But you say that you don't ignore the ASA or the ACOG rec's.

You don't literally tell them to "suck it up" but you are advising us to do this! Is that what you are saying.

 

[Noyac]

When I have the initial discussion about labor epidurals with the patient (pre-consent), among the first words out of my mouth are that it is an elective procedure.

-copro

Do you discuss the risk of c/s with them?

Would you if you were placing an epidural at 1 cm?

 

[dfk]

YOur contradicting yourself. You say you will tell the G1P0's to 'suck it up". But you say that you don't ignore the ASA or the ACOG rec's.

You don't literally tell them to "suck it up" but you are advising us to do this! Is that what you are saying.

yea noy, that's what i'm saying. ...never mind.

 

[periopdoc]

In my book if the patient wants it and OB/FP/midwife agree, the patient gets it. I don't spend a lot of time arguing on the labor deck unless I feel that fulfilling the request I receive is likely to result in harm to the patients.

I would likely have a discussion with the OB/FP/midwife and the patient about whether a little opiate and some sleep might be better at this stage.

I don't understand the idea of having to be "committed" to delivery before the epidural is placed. Is the risk/ benefit ratio of LEP analgesia really that high?


- pod

 

[Gern Blansten]

I don't understand the idea of having to be "committed" to delivery before the epidural is placed. Is the risk/ benefit ratio of LEP analgesia really that high?


- pod

I think the point is, it would be pretty foolish to place an epidural only to have the OB, FP, midwife say two hours later that she is not in active labor. Then you need to remove the epidural and discharge the patient. I have never seen this occur, but to me, that was what was meant by "committed" to delivery. Thus my interpretation was that the poster was saying, if she is in labor and committed to imminent delivery by some route, then it is not too early.
I apologize if I misunderstood your point.

 

[coprolalia]

Do you discuss the risk of c/s with them?

Of course!

Would you if you were placing an epidural at 1 cm?

I'm not sure I follow... LOR at 1cm? Leaving the catheter at 1cm? Or, -2 station, 1cm dilated, and 30% effaced? If it's the latter, Stadol, baby, Stadol.

-copro

 

[zippy2u]

Zip's timeline: 1 week out of residency at the new job, I would have paid the lady $100 to put in an epidural at 3AM. 1 year post residency, I would have done it for free. 5 years out, I'd want $500. Now, I'd want $2000 to put it in. Oh yeah, I ain't picky; the CNA or janitor can call me at 3AM to put it in. ACOG, BCOG, TCOG guidelines--- just a bunch o' noise for the academic "white coats" to blabber about around the cherry desks. Regards, -----Zip

 

[Noyac]

Of course!



I'm not sure I follow... LOR at 1cm? Leaving the catheter at 1cm? Or, -2 station, 1cm dilated, and 30% effaced? If it's the latter, Stadol, baby, Stadol.

-copro

Sorry, 1 cm dilation.

 

[Noyac]

Zip's timeline: 1 week out of residency at the new job, I would have paid the lady $100 to put in an epidural at 3AM. 1 year post residency, I would have done it for free. 5 years out, I'd want $500. Now, I'd want $2000 to put it in. Oh yeah, I ain't picky; the CNA or janitor can call me at 3AM to put it in. ACOG, BCOG, TCOG guidelines--- just a bunch o' noise for the academic "white coats" to blabber about around the cherry desks. Regards, -----Zip

What if they aren't paying you $200?

 

[coprolalia]

Sorry, 1 cm dilation.

STADOL, baby, STADOL! 😀

-copro

 

[zippy2u]

Actually, the 3AM epidural call is reason #296 to find yourself an ASC job and eliminate this HA from your life. ASC job just north of 300 coins and many, many HAs are eliminated; sorry Pops, it doesn't pay to be a hero anymore. Regards, -----Zippy

 

[Planktonmd]

STADOL, baby, STADOL! 😀

-copro

Is this connected to "Drill baby Drill"???