Post-partum tubals

[Monty Python]

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I searched SDN before posting this and it yielded no previous thread.

What is the general consensus of post-partum tubal ligations after a vag delivery with functioning epidural?

What is the consensus if epidural is absent and pt refuses a spinal. Would you perform GETA for this? Would you make them wait X number of days/weeks?

 

[Laryngospasm]

Epidural present- use it
No epidural- spinal
Refused spinal- try and talk them into it
Still refuses- GETA- NOT LMA
JMHO

 

[Noyac]

I don't get it. Whats the risk of GETA here?

All kidding aside, I would do GETA (your right, I wouldn't use a LMA) a tubal takes 15-30 minutes and I usually do them GETA or spinal but we don't do them very often. We are a catholic hosp and they need special circumstances to get a tubal. I think Jet has made this point over and over, it may be stressed in residency but a controlled RSI (if you feel necessary) is safe even in pregnancy/post partum. I think the majority of you will find that in practice you will see that some of the dogmatic styles of your attendings are safe but not always necessary.

 

[davvid2700]

Epidural present- use it
No epidural- spinal
Refused spinal- try and talk them into it
Still refuses- GETA- NOT LMA
JMHO

well ******* i n g said.. thats it.

 

[UTSouthwestern]

Versed + ketamine.

 

[Laryngospasm]

Versed + ketamine.

I love that combination of drugs, how often do you use it for BTL's? Im just not sure that I would know how to explain it to the patient, what do you say to them? used if for retained placenta etc. Just curious.

 

[UTSouthwestern]

I love that combination of drugs, how often do you use it for BTL's? Im just not sure that I would know how to explain it to the patient, what do you say to them? used if for retained placenta etc. Just curious.

Don't use it much now, but in training, it was certainly a viable option. Definitely effective when a first year OB resident was completing the 3+ hour C section under spinal.

I would explain to the patient that this is an alternative method of anesthesia that they could consider with a full explanation of the possible adverse side effects. With even the slowest tubal OB/GYN doc, it was usually more than enough to give the patient 2 mg of Versed and 5 mg increments of Ketamine titrated to comfort during a pinch test with a surgical instrument (I usually gave 10-15 mg right off the bat).

I only had one patient complain of vivid dreaming postoperatively and she was already a bit "off kilter" to start with. Still, she said she would have done it again the same way if she had to do it again.

 

[Laryngospasm]

Don't use it much now, but in training, it was certainly a viable option. Definitely effective when a first year OB resident was completing the 3+ hour C section under spinal.

I would explain to the patient that this is an alternative method of anesthesia that they could consider with a full explanation of the possible adverse side effects. With even the slowest tubal OB/GYN doc, it was usually more than enough to give the patient 2 mg of Versed and 5 mg increments of Ketamine titrated to comfort during a pinch test with a surgical instrument (I usually gave 10-15 mg right off the bat).

I only had one patient complain of vivid dreaming postoperatively and she was already a bit "off kilter" to start with. Still, she said she would have done it again the same way if she had to do it again.

Thanks, good info. Yeah, Ive noticed that ketamine+slightly off patient=crazy patient.

 

[Noyac]

Yeah, versed and ketamine. A favorite of mine. I do the same 2mg versed and 10-20 mg ketamine then keep hitting them with 5 mg ketamine till the case is over. I had one pt have dreams that she couldn't really explain in the 5+ yrs of using it. She said that the dreams were not bothersome however.
But I don't use it for retained products cause it can cause some uterine contraction and then you need sevo, nitro or amylnitrate(?) for relaxation in order to retreive the products.

 

[UTSouthwestern]

Yeah, versed and ketamine. A favorite of mine. I do the same 2mg versed and 10-20 mg ketamine then keep hitting them with 5 mg ketamine till the case is over. I had one pt have dreams that she couldn't really explain in the 5+ yrs of using it. She said that the dreams were not bothersome however.
But I don't use it for retained products cause it can cause some uterine contraction and then you need sevo, nitro or amylnitrate(?) for relaxation in order to retreive the products.

You could still use ketamine for retained products if you hit the patient with about 20-40 mcg of nitroglycerin along with neo to counteract the afterload reduction. 20 is usually more than enough to induce uterine muscle relaxation.

Funniest dream I had a patient tell me of was of them skiing down a snowy mountain and crashing into a phone booth, yes on the ski slope, with Micky Mouse in it making a call. Yes, she took out Micky.

 

[heartICU]

I searched SDN before posting this and it yielded no previous thread.

What is the general consensus of post-partum tubal ligations after a vag delivery with functioning epidural?

What is the consensus if epidural is absent and pt refuses a spinal. Would you perform GETA for this? Would you make them wait X number of days/weeks?

I just finished my OB rotation, and our policy at that hospital was that if they wanted the tubal done after a vag delivery before they went home, they had to have it under regional. If they refused a spinal or epidural and demanded a general, they were told that since it was an elective procedure, they had to come back in 6 weeks. Most of the time, they agreed to a spinal, but had one woman with 3 kids who delivered all three of hers without an epidural because she was afraid of needles. She agreed to come back in 6 weeks. Incidentally, she also had a nose ring and three tattoos, so I am not sure where this needle fear came from.

 

[Lizard1]

If they refused a spinal or epidural and demanded a general, they were told that since it was an elective procedure, they had to come back in 6 weeks.

We have the same policy. If pt has an epidural for delivery, we'll leave it running at a reduced rate and do the PPTL 1 hr after delivery to allow for any hemodynamic changes that may occur during autotransfusion from a shrinking uterus. We'll leave it runnning mostly to ensure that the pt doesn't get up and move around alot - possibly allowing the catheter to "migrate" out of the epidural space.

If no epidural, then we'lll only do the PPTL under a SAB. If they refuse regional, it's an elective procedure so they are scheduled for a general in the main OR 4-6wks later.

Interestingly, I don't know if it's medicaid or what, but Hispanics (mostly) cannot get authorized(i.e. no payment ot the hospital) for a PPTL unless it's done during their hospital stay for their delivery. So if they refuse regional, they usually don't get a PPTL.

 

[The_Sensei]

I just finished my OB rotation, and our policy at that hospital was that if they wanted the tubal done after a vag delivery before they went home, they had to have it under regional. If they refused a spinal or epidural and demanded a general, they were told that since it was an elective procedure, they had to come back in 6 weeks. Most of the time, they agreed to a spinal, but had one woman with 3 kids who delivered all three of hers without an epidural because she was afraid of needles. She agreed to come back in 6 weeks. Incidentally, she also had a nose ring and three tattoos, so I am not sure where this needle fear came from.

Blah, blah, academic-blah.......where I work the tubals are done in about 10 minutes skin to skin.....I know all about the post-gravid "full stomach" theoretics so spare me the lecture.....anyway, since it often takes longer to do the spinal and wait for an adequate level, we do the majority of our PPTLs under GA - LMA, mask, ETT.....NEVER had an aspiration and don't expect one.

Private practice is a different animal, kids.

 

[militarymd]

Blah, blah, academic-blah.......where I work the tubals are done in about 10 minutes skin to skin.....I know all about the post-gravid "full stomach" theoretics so spare me the lecture.....anyway, since it often takes longer to do the spinal and wait for an adequate level, we do the majority of our PPTLs under GA - LMA, mask, ETT.....NEVER had an aspiration and don't expect one.

Private practice is a different animal, kids.

We put all of our PPTL to sleep. The only reason I intubate is because our OBs ask for paralysis, and I don't like using the Vent with a LMA.

 

[Noyac]

and I don't like using the Vent with a LMA.

Ditto