Questions about OB anesthesia at other institutions

[sifidawkins]

1. Who calls anesthesia to request epidural placements in laboring patients? WHere I'm at it is often the nurses and not the resident/attending/nurse midwife taking care of the patient and this is a big pet peeve of mine. Am I wrong for wanting the pt's doctor and not their nurse to call the anasthesia consult?

2. Do other residents get called in the middle of the night to pull epidurals? Do you pull them in the morning? Do nurses pull them? We get called in the middle of the night even if nothing else is happening and the nurses call again and again even if we tell them we'll pull them in a few hours and it drives me nuts. Just wondering again if I'm being too picky or if things are different elsewhere.

Thanks.

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[pgg]

1. Who calls anesthesia to request epidural placements in laboring patients? WHere I'm at it is often the nurses and not the resident/attending/nurse midwife taking care of the patient and this is a big pet peeve of mine. Am I wrong for wanting the pt's doctor and not their nurse to call the anasthesia consult?

Usually it's the L&D nurse who calls me.

I know lots of anesthesiologists desire or prefer the implied respect from being "consulted" by another physician but it's not important to me personally to get this explicitly reaffirmed with every patient. I know from other interactions with our OBs that they value my contribution and participation in their patients' care. I don't need to hear them say over the phone "Yeah, so Mrs Jones is at 6 cm, and is hurting, and would like an epidural."

2. Do other residents get called in the middle of the night to pull epidurals? Do you pull them in the morning? Do nurses pull them? We get called in the middle of the night even if nothing else is happening and the nurses call again and again even if we tell them we'll pull them in a few hours and it drives me nuts. Just wondering again if I'm being too picky or if things are different elsewhere.

That's a bunch of crap. I pull labor epidurals immediately after c-sections, and I pull epidurals placed for non-OB surgical pain, but I don't think I've ever pulled an epidural after a routine SVD.

Regardless, even if it's your hospitals misguided policy to not allow the L&D nurses to pull catheters, they shouldn't be calling you at 3 AM. That's just ******ed. They can push the off button on the pump and wait until morning.

 

[monchi]

1. Who calls - the nurse. How much the attendings & other residents talk to me directly depends on their personalities. Most of the OB attendings won't even look at me - but I'm a resident, so I don't really care. To my (anes) attending, though, they are much more collegial. It's a similar dynamic with the OB residents - I try to keep the lines of communication open as much as they will let me. Some are more open than others - I think it's a personality thing more than anything else. However, if I have concerns about a pt, I make myself heard, even if that means bordering obnoxiousness. In the end, it's always been appreciated - just about everyone recognizes that I trying to do the best for the pt.

2. 3am wake-up: Yeah, I get those. I think it's b/c they don't want to send the pt to the floor with the catheter in place. There are a limited # of rooms, and on a busy night, once one is delivered, the room is cleared out for the next. Sometimes when it's slow, they'll wait until there are two or three to pull or new pts to see.

 

[rsgillmd]

1. Who calls anesthesia to request epidural placements in laboring patients? WHere I'm at it is often the nurses and not the resident/attending/nurse midwife taking care of the patient and this is a big pet peeve of mine. Am I wrong for wanting the pt's doctor and not their nurse to call the anasthesia consult?

2. Do other residents get called in the middle of the night to pull epidurals? Do you pull them in the morning? Do nurses pull them? We get called in the middle of the night even if nothing else is happening and the nurses call again and again even if we tell them we'll pull them in a few hours and it drives me nuts. Just wondering again if I'm being too picky or if things are different elsewhere.

Thanks.

Where I am now, the nurses are reliable. I've been asked both by residents, attendings, and nurses here, and don't mind. At most there are 2 attendings: service and family practice. Very rare to have a private patient. So I know the attending is always in house and available. The residents here are also given a lot of independence with PGY-4 residents routinely starting C/S without the attending being in the room.

Where I trained, I was burned by nurses asking for an epidural for a private patient, and the service attending who is supposed to cover knew nothing about the patient. We put a stop to that very quickly. I would accept a call from a physician or a midwife. I would not accept a call from a nurse unless I knew I could trust her to have notified a physician. Heck, I ticked off a clerk in my CA-1 year because the nurses would ask the clerk to call. I told him I would not come on his say-so alone. My attendings backed me up. That ended very quickly also.

As for pulling catheters, we pulled them in the middle of the night. It allowed us to document our wastage so it was not a big deal. When things were crazy I occasionally told the nurses to either a) stop calling me and wait, or b) cap the catheter with a syringe and send them to the floor. They usually waited. Pulling a catheter is not an emergency. They can go up to the floor with it and have it pulled later.

 

[IlDestriero]

1. Who calls anesthesia to request epidural placements in laboring patients? WHere I'm at it is often the nurses and not the resident/attending/nurse midwife taking care of the patient and this is a big pet peeve of mine. Am I wrong for wanting the pt's doctor and not their nurse to call the anasthesia consult?

2. Do other residents get called in the middle of the night to pull epidurals? Do you pull them in the morning? Do nurses pull them? We get called in the middle of the night even if nothing else is happening and the nurses call again and again even if we tell them we'll pull them in a few hours and it drives me nuts. Just wondering again if I'm being too picky or if things are different elsewhere.

Thanks.

I don't have OB residents so we get a call from the OB or midwife directly.
As for pulling the epidural in the middle of the night, they know better than to wake me for that. I get a page to notify me when they deliver. If I'm going home, I go and pull it. I usually just roll back over and get some more zzzs and get it in the morning.

 

[periopdoc]

In residency we were pretty strict about being consulted by another MD so that we could know the plan and address pain control appropriately. In private practice where things are a little more predictable, it is not as much of an issue and it doesn't make sense. It goes something like this.

Patient comes in laboring and gets checked by the nurse who calls to wake the OB for admission.

OB comes and evaluates the patient and outlines the plan of care then goes back to sleep. Plan of care is usually, patient may have an epidural whenever she wants as long as she is 4 cm.

When it comes time for epidural, the OB is asleep and it doesn't make much sense to wake her up to request the epidural so the nurse just calls and tells me that the patient is ready for epidural.

It would really suck if the OB woke me up to run the patient by me before the patient was ready for an epidural and it would really suck for me to insist that the OB wakes up and tells me about the patient later when it is time for the epidural.

Sleep is more important than ego.

If a nurse tells me the patient is ready for epidural and the OB didn't want it, then it is on the nurse. I can easily determine if it is safe and reasonably appropriate to place an epidural, why does the OB need to call me?

If a nurse asked me to pull a catheter in the middle of the night, I would laugh, tell her to give me a wake up page at 7, and go back to sleep. Thankfully, I have never worked in an institution where I was required to pull the catheter or change the epidural infusion when it runs out. The only time I get called to pull an epidural is if they have had problems and think that it is stuck.

- pod

 

[dhb]

In residency we were pretty strict about being consulted by another MD so that we could know the plan and address pain control appropriately. In private practice where things are a little more predictable, it is not as much of an issue and it doesn't make sense. It goes something like this.

Patient comes in laboring and gets checked by the nurse who calls to wake the OB for admission.

OB comes and evaluates the patient and outlines the plan of care then goes back to sleep. Plan of care is usually, patient may have an epidural whenever she wants as long as she is 4 cm.

When it comes time for epidural, the OB is asleep and it doesn't make much sense to wake her up to request the epidural so the nurse just calls and tells me that the patient is ready for epidural.

It would really suck if the OB woke me up to run the patient by me before the patient was ready for an epidural and it would really suck for me to insist that the OB wakes up and tells me about the patient later when it is time for the epidural.

Sleep is more important than ego.

If a nurse tells me the patient is ready for epidural and the OB didn't want it, then it is on the nurse. I can easily determine if it is safe and reasonably appropriate to place an epidural, why does the OB need to call me?

If a nurse asked me to pull a catheter in the middle of the night, I would laugh, tell her to give me a wake up page at 7, and go back to sleep. Thankfully, I have never worked in an institution where I was required to pull the catheter or change the epidural infusion when it runs out. The only time I get called to pull an epidural is if they have had problems and think that it is stuck.

- pod

I agree with everything in your post except the bolded part. The 4cm law has no basis.

 

[sevoflurane]

I don't mind getting paged by nurses for an epidural placement on a laboring paient. I am not offended when OB doc doesn't call me.

Never do I get a call for removal of said epidural in the middle of the night. Epidurals generally get removed once a day. In the am during lightning OB rounds (low volume OB practice so we remove 1-4 in the am and then we are done). If I've placed an epidural and the patient has delivered before I go home I will remove it then. Sometimes the late guy will call up and remove some catheters... but not always.

I've been at places where epidural catheters are actually removed by trained nursing staff. I don't find this to be a big deal as I've never seen a sheared catheter upon removal. If it does happen, then you get notified. Simple. Removing an epidrual catheter is not that difficult.

 

[Jeep23Guy]

I agree with everything in your post except the bolded part. The 4cm law has no basis.

Agreed.

NEJM 2/17/2005.

 

[periopdoc]

I agree with everything in your post except the bolded part. The 4cm law has no basis.

Not my rule, this is the OB's rule and I have to play by it. It makes informed consent a little harder, but not as hard as in patients who come in with a birth plan.

I suspect that the 4 cm rule is still pretty prevalent across the country. Not because of the c-section risk, but because OB's and anesthesiologists want to be sure the patient is active and is committed to delivery before placing an epidural.

My rules for epidural - mom wants it and OB says mom is here for more than a quick labor check. I am not even a strict "mom must be committed to delivery one way or another before the epidural."


- pod

 

[Mman]

We do not have a "4 cm rule". However, we have a rule that states that the nurse has to check with the OB to see if they want them to have an epidural before they can call us to request it.

I don't like that.

At my previous location, the only rule was that any patient in active labor could have an epidural if they wanted one. But they at least had to be in active labor.

 

[periopdoc]

At my previous location, the only rule was that any patient in active labor could have an epidural if they wanted one. But they at least had to be in active labor.

Active labor is defined as 4cm dilation.

-pod

 

[Jay K]

In residency, the OB residents would call to request epidurals. If an RN called me, then I'd tell them the resident has to tell me - they'd call the OB resident and have them contact me.

We did not pull post-SVD epidurals; RN's were inserviced and performed this task.

Post-c/s epidurals were pulled in the OR after the case by ourselves.

I was actually more annoyed with having to "sign out" post-c/s patients to go the floor.

Currently in PP my group does not perform labor epidurals. That is all handled by CRNA's. One of the hospitals we cover, we medically direct c-sections. In another hospital we are not involved with c-sections unless the patient has extenuating circumstances. Needless to say, I don't pull post-SVD epidurals at my current practice either.

As an aside, we don't often pull post-op epidurals on the floor for other surgeries either; The RN's are inserviced and follow a protocol for the timing and removal of epidurals, though we round and write orders to do so.

 

[Jeff05]

Active labor is defined as 4cm dilation.

-pod

4 cm is antiquated nonsense.


NEURAXIAL analgesia is the most effective treatment available for pain control during labor and delivery, and it is a preferable method because it can provide more effective pain relief compared with nonneuraxial pharmacological analgesia.1 However, optimal timing of epidural analgesia (EA) has been a controversial issue and how early in the latent phase of labor can women benefit from epidural is still debated. Before 2002, clinical guidelines recommended that the administration of EA in nulliparous women should be delayed until the cervical dilation reaches at least 4.0 to 5.0 cm and that other forms of analgesia should be used until that time.2 In 2005, Wong et al. published a paper clarifying that pain relief early in labor with neuraxial analgesia at the cervix dilated 2.0 cm or more does not increase the risk of Cesarean delivery3; this combined with Ohel's report4 contributed to the change in recommendation on EA in labor pain control from the American College of Obstetricians and Gynecologists in June 2006.5The current best available evidence in nulliparous women at term with singleton fetus in vertex presentation supports that EA is safe in laboring women with cervix dilated 2 cm or more,3,4 and systematic reviews on this topic suggest improved definition of dystocia and nonreassuring fetal status diagnoses with precise and repeatable criteria.1,6,7 The National Institute for Health and Clinical Excellence guidelines8,9 suggest that women in labor who desire regional analgesia should not be denied it, including women in severe pain in the latent first stage of labor - a period of time begins from painful contractions and some cervical change, including cervical effacement and dilation up to 4 cm. However, data in its finding-review section do not address the indication when cervical dilation is less than 2.0 cm.The current randomized controlled trial was designed to test the hypothesis that patient-controlled epidural analgesia in women requesting and receiving early labor analgesia in the latent phase of labor (at least 1.0 cm cervical dilation) do not have an increased risk of prolonged labor or Cesarean section (CS) compared to women who are assigned to wait for a cervical dilation of at least 4.0 cm.

Conclusions: Epidural analgesia in the latent phase of labor at cervical dilation of 1.0 cm or more does not prolong the progression of labor and does not increase the rate of Cesarean in nulliparous women compared with the delayed analgesia at the cervical dilation of 4.0 cm or more.


http://journals.lww.com/anesthesiol...nalgesia_in_the_Latent_Phase_of_Labor.31.aspx

 

[Mman]

Active labor is defined as 4cm dilation.

-pod

Depends on who you ask. We put in plenty of epidurals in women at 2-3 cm who were having regular contractions and who's cervical exam was changing. I can't recall what the exact ACOG definition is but 4 cm isn't a hard cutoff.

 

[periopdoc]

Mman if you can't recall the exact definition, or be bothered to Google it, then why bother posting? This is basic third year medical school stuff. There are somewhat arbitrarily selected, but agreed upon, definitive cutoffs. First stage of labor is divided into 3 phases. Early or latent labor is 0-3 cm. Active labor is 4cm-8cm. Transition is 8-10 cm. Some people only use two phases for the first stage early or latent labor 0-3 cm and active labor 4-10 cm.

Jeff05, your article reinforces my point. Look how they use the definition of latent (and by extension active) labor.

including women in severe pain in the latent first stage of labor - a period of time begins from painful contractions and some cervical change, including cervical effacement and dilation up to 4 cm.

Conclusions: Epidural analgesia in the latent phase of labor at cervical dilation of 1.0 cm or more does not prolong the progression of labor and does not increase the rate of Cesarean in nulliparous women compared with the delayed analgesia at the cervical dilation of 4.0 cm or more.

As I stated earlier in the thread, I have no problem with placing epidurals in latent labor, although my OBs do. Just don't call it active labor. It makes it look like you don't know what you are talking about.

And now back to the slopes

-pod

 

[Consigliere]

Where I previously worked, the nurses would often call for epidurals to be pulled after hours. I refused but they would continually call until either: a) I did it or b) my shift ended and my night was ruined. Our group president didn't care since he didn't take call and the situation was never addressed. So I left. Now I don't do OB epidurals and LOVE IT!

 

[seinfeld]

Mman if you can't recall the exact definition, or be bothered to Google it, then why bother posting? This is basic third year medical school stuff. There are somewhat arbitrarily selected, but agreed upon, definitive cutoffs. First stage of labor is divided into 3 phases. Early or latent labor is 0-3 cm. Active labor is 4cm-8cm. Transition is 8-10 cm. Some people only use two phases for the first stage early or latent labor 0-3 cm and active labor 4-10 cm.

Jeff05, your article reinforces my point. Look how they use the definition of latent (and by extension active) labor.





As I stated earlier in the thread, I have no problem with placing epidurals in latent labor, although my OBs do. Just don't call it active labor. It makes it look like you don't know what you are talking about.

And now back to the slopes

-pod

I hate semantics. Pt in Pain and expected to deliver in next 5 days (longest i would leave epidural in) then place the darn thing. Stupidest thing i did was allow my wife to get IV pain meds, start vomiting and then see felt nauseous on top of being in intense pain.

 

[DRJ37]

We automatically consult and consent every pt that makes it past triage, whether they want an epidural or not. The nurse calls us when the pt is ready for the epidural. The nurses pull all of the catheters s/p SVD; we pull any after C/S before we leave the OR.

 

[Mman]

Mman if you can't recall the exact definition, or be bothered to Google it, then why bother posting? This is basic third year medical school stuff. There are somewhat arbitrarily selected, but agreed upon, definitive cutoffs. First stage of labor is divided into 3 phases. Early or latent labor is 0-3 cm. Active labor is 4cm-8cm. Transition is 8-10 cm. Some people only use two phases for the first stage early or latent labor 0-3 cm and active labor 4-10 cm.



-pod

Correct me if I'm wrong, but as I recall learning the "basic 3rd year medical school stuff", the definitions are in question and debate amongst obstetricians. I searched the ACOG website, which I consider far more useful than a google search of ******ed articles written by janitors and midwives, and couldn't find anything useful.

Our obstetricians at a world renowned academic medical center (top 10 by US News whatever that means) did not use a 4 cm cutoff as their definition.

 

[RabbMD]

So by this definition a patient who has been 4cm for 2 weeks is automatically in active labor if they start having any contractions? From what I remember of third year medical school, to truely define "active labor" you needed contractions, cervical change, and a true labor curve to look and rate of change inflection points. Now, no one really does this anymore, and 4cm is usually the point someone gets to when that inflection point hits, but it is more complex than just 4cm = active labor.

 

[periopdoc]

The first Google search result for "Stages of Labor" is from the Mayo Clinic. If ACOG had comments on something like this, you would not be able to find it unless you are an ACOG member. They keep policy statements, practice guidelines and things like that inside the members section. When I was a member, I never used the public portion of the site because I was never able to find much useful information outside of the members only section.

Rabb, either you are being ridiculous, or facetious. Clearly one must first be in labor (regular uterine contractions leading to cervical change) before she can be said to be in a specific phase of labor such as active labor. The question of what to call someone who dilates to 4 cm without being in labor is problematic. Advanced cervical dilatation? Incompetent cervix?

- pod

 

[Gimlet]

LOL guys, don't forget that POD came to anesthesiology from OB-Gyn. Do you really want to put in the effort to try and stump him on this one?

 

[IlDestriero]

If only we engaged in this kind of debate on interesting anesthesia topics and not irrelevant trivia.