Practices doing both CSE and Epidurals for labor

wait til you get pregnant, youll feel differently. as for me, the answer to your question is simple: because I don't like to see people in pain. all those other guys who do the checking in, giving fluids, drawing labs blah blah blah are not in the vocation of pain relief. I am.

 

It's not completely for the pt. It's so that I can get out of there sooner.

 

Imagine you are in the worst pain of your life. Someone walks in and says "I can take all your pain away right now, or 15 mins from now. Which would would you like?"

 

It's more like, "I can take your pain away in 10-12 minutes. I can spend slightly longer setting up my kit and taking out narcotics but wait slightly less time for the meds to kick in once given (cse), or I can spend less time getting ready and more time waiting for the meds to work (cle). Either way you'll be comfortable in about 10-12 minutes."

 

My CSE set-up time is identical to CLE set-up time, and doesn't involve checking out or drawing up any additional meds. I've posted the technique a few times in the past, so I don't wanna do it again. I wish I could say I invented it, but I stole it from the guys at one of the busiest OB hospitals in the state. They came up with it specifically because it's fast both to set up and to kick in. It's the RonCo of labor analgesia techniques.

 

How do you maintain sterility? I dont personally like using other than filtered needles for anything going into the CSF. And also only from glass vials so the drawing up needle doesnt pass through any membranes. How do you get around that?

 

That's a little excessive. It's unnecessary. How do you draw up PF morphine or Bupiv 0.5%. Ours requires drawing through rubber stoppers.

 

What @nimbus said. Although I do wear an ortho space helmet.

 

I can't really answer that as I've never worked in a place that didn't have some easy means of getting around those stoppers.

Personally I don't really care but I do remember some staff being picky about that

 

I remember scrubbing for a spinal one day for a 90 year old broken hip in residency. When I emerged from the scrub room minutes later my staff had everything for the spinal drawn up and laid out with his bare hands laughing at me.

I'm new to North America so maybe not yet

 

those HA aint from the spinal part of the cse; your partners are doing something wrong (or misdiagnosing pdph). I do 25G spinals routinely - and I would guess most people here too - and have probly seen one pdph (and even that I'm still not convinced was from the spinal) in years of practice. and you've seen "quite a few in a few weeks"???

 

We're all pretty experienced and trust me, it's from the spinal needle. I exclusively do epidurals (no CSE), and tried a dural puncture epi to see what the fuss was all about (with a 25 g spinal), and my patient got a PDPH the next day.

I'm not saying it's common, and it's CERTAINLY not severe and we just treat conservatively, but if you think putting a 25g needle in someone's dura is risk free, you're wrong. With a 25g pencil-point needle, your risk could be as high as 5% (see article below). We've certainly had some patients with spinal for C-Section get HA's as well. It's not a zero risk.

Do pencil-point spinal needles decrease the incidence of postdural puncture headache in reality? A comparative study between pencil-point 25G Whitacre and cutting-beveled 25G Quincke spinal needles in 320 obstetric patients

 

This is very interesting to me. At least half of my group does CSE and I can not remember the a single PDPH from one. Our needle is a 27g but local practice is for c/s is to remove any epidural catheter and place a spinal in most cases. This is with a 25g and I still can not recall a single PDPH. Obviously, I am not there everyday and therefore some may have occurred but if the incidence was truly as some here claim then you would think I would have seen one. So I wonder if something else is going on?

 

IMHO, the majority of headaches after a 25G non cutting needle for a SAB are very mild not requiring a blood patch. I do think the PDPH runs around 5% after a 25G Sprotte or Whitacre puncture but the vast majority of these do not require any follow-up or patches and resolve in 48-72 hours on their own. That's why most of us doing a lot of OB using 25G non cutting needles rarely (less than 1 percent) need to do a blood patch on these patients.

CSE is a good technique but the dura is still being punctured resulting in a small chance of a very mild headache for a few days. This technique is well tolerated by patients and the need for a blood patch secondary to the dural puncture is very rare.

 

Agree with all of this, and I think that the headache might be so mild that it might depend on patient population on whether your finding out about it. Our patients are very "vocal" and tell is about it, but it really is mild and we don't patch them.

 

Ironic that the CSE was developed in NYC to deal with the "high maintenance" patients.

 

Someone should do a study to see what percentage of new mothers have a mild headache in the first few days after delivering a baby.

 

Was the Cse was developed in new York?

 

A quick pubmed seems to show a lot of the early work was done by RE Collis et al in the UK. We all know the stoic British aren't complaining of PDPH. Lol

 

They certainly didn't have one 9 months prior.

 

Fairly sure that 100% wasnt true, same as most things in North America lol