Second C-Section

[WorriedPT]

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First, I'm the pt, DH is a doc....not my doc, but a doc.

My first c-section was disasterous...my epidural failed, but not due to misplacement, inadequate dose, or anything else other than I'm tolerant of the drug used (didn't know this going into the surgery). Anyway, I was numb and pain-free until the peritoneum (sic) and then it was just full on pain - Dr. DH and anesthesiologist going at each other about what to do to me (DH wants me snowed, anesthesiologist says he's trying, I won't go out and I'm puking so he can't keep trying now)....anyway, it was hell and I felt it all from that moment through close.

So, now here I am, six years later, expecting baby two....due to age and pelvic position, a scheduled c-section is considered my best option.....so I want an anesthesia plan.

Anesthesiologist nurse calls this morning, poo-poohs my concerns and basically implies that my epidural was inadequate, not that it failed because I have a tolerance to marcane....said straight out she'd never ever seen a pt tolerant to any 'caine and I shouldn't worry, they'll do a spinal and I'll be fine.

I explained after the disaster, I had dental work done and spoke with my dentist because for years he'd appeased me thinking I was simply a difficult pt, giving me lots of marcane, the twilight valium drip and nitrious - but after the c-section, he was now curious if I was really tolerant to the stuff and it wasn't in my head! I had the work done with 4....yes 4 shots that should last 12 hours, along with the drip and nitrous....told me to call him when I am no longer numb (the procedure took 1 hour)....and hour later, I'm eating, drinking and talking just fine, can feel my lips, tounge, gums, etc. Dentists says wow, you are tolerant to marcance - I gave you enough to last into tomorrow.....make sure anyone doing anything on you with it KNOWS you metabolize it out way faster than expected and avoid it if you can instead.

So she says I'll be just fine with the spinal.....no need to worry.

Thing is, I am worried - she refused to schedule a consult with the anesthesiologist for me and said it'd be in my chart the plan for the spinal - so I asked, what's the plan if that fails? She said not to worry again!

Oh man I want to slap her!

So now the question is to you all.......

I am NOT seeking medical advice.....but, what would you do with a pt like me walking into you for a consult for an anesthesia plan knowing this pt gets nothing more than surface numbing from marcane/lidocaine/etc? I get the outside numbed, pain-free - nothing at my core nerves though.

 

[Intensivist]

Slap the murse and just seek medical expertise!

 

[Mman]

I am NOT seeking medical advice.....but, what would you do with a pt like me walking into you for a consult for an anesthesia plan knowing this pt gets nothing more than surface numbing from marcane/lidocaine/etc? I get the outside numbed, pain-free - nothing at my core nerves though.

You'll get a spinal and there is a >99% chance it will work perfectly. Sounds like your first epidural did work fine, but the problem with labor epidurals is frequently that they just don't cover sacral nerve roots. Those are the ones transmitting the pain during delivery as the baby's head descends. They work great for contractions transmitted by lumbar and thoracic nerves, but not so much on sacral.

So you essentially had a pretty normal experience with a labor epidural. Now sometimes people do get good sacral coverage, but not everybody.

Your epidural worked as they normally do.

Your spinal should work as they normally do. When your spinal nerves are bathing in a combination of bupivicaine and CSF, they will be "numb".

Your obstetrician will test you to make sure you are numb before they make an incision.

You will be fine.

 

[WorriedPT]

You'll get a spinal and there is a >99% chance it will work perfectly. Sounds like your first epidural did work fine, but the problem with labor epidurals is frequently that they just don't cover sacral nerve roots. Those are the ones transmitting the pain during delivery as the baby's head descends. They work great for contractions transmitted by lumbar and thoracic nerves, but not so much on sacral.

So you essentially had a pretty normal experience with a labor epidural. Now sometimes people do get good sacral coverage, but not everybody.

Your epidural worked as they normally do.

Your spinal should work as they normally do. When your spinal nerves are bathing in a combination of bupivicaine and CSF, they will be "numb".

Your obstetrician will test you to make sure you are numb before they make an incision.

You will be fine.

As I noted, my surgery started fine with the epidural - I was numb on the outside, so the OB checking to see I'm numb (which she did) didn't mean I was numb at my core.

If your pt is tolerant to marcane, what would you use instead? That's what I'm basically trying to find out since I absolutely do not want to go through a full surgery with no anesthesia again.

What you're saying is essentially what the nurse implied - that I am not tolerant to the medication used (when I know full well I am).....that my experience was "normal" in that epidurals fail to provide enough relief sometimes - mine failed from the moment she cut my peritonieum (sic) until close....it wasn't a bit of pain, it was fire-ice pain because I had nothing relieving any pain --- trust me on this, the hosipital I had the c-section at did everything in their power for damage control (I never intended to sue....I got over it.....but going in again for another, I need to know my options other than "don't worry about it")

And I apologize if that sounds snarky....it's just if you haven't gone through a surgery without any anesthesia, you may not fully "get" it is a pain you'll never ever want to relive again.

 

[Bertelman]

If your spinal fails, you'll go to sleep. Incidentally, do you happen to have red hair?

Having said that, this thread which was once walking the fine line of improper medical advice has now begun to fall, hands waving all about, flat into thew medical advice category.

I suggest a literature search for "failed spinal" or "failed epidural" for cesarean section. With google these days, you don't need to be a doctor to find some pretty straight-forward answers. If you've found this forum, I'm sure you can find a journal article or two describing management of the failed spinal during cesarean section. That may require access to a library at a local college, nursing or medical school.

 

[WorriedPT]

If your spinal fails, you'll go to sleep. Incidentally, do you happen to have red hair?

Nope

Having said that, this thread which was once walking the fine line of improper medical advice has now begun to fall, hands waving all about, flat into thew medical advice category.

I'm attempting to learn my options to discus with the anesthesiologist when DH gets my appointment made since the anesthesiologist nurse didn't think I needed the appointment, but DH and my OB both want him to have a consult with me way before the c-section date arrives.

I suggest a literature search for "failed spinal" or "failed epidural" for cesarean section. With google these days, you don't need to be a doctor to find some pretty straight-forward answers. If you've found this forum, I'm sure you can find a journal article or two describing management of the failed spinal during cesarean section. That may require access to a library at a local college, nursing or medical school.

I have and keep hitting the problems being placement, under-dosing, over-dosing, etc. -- it's in hindsight I know now I'm tolerant to marcaine, have been for forever (first experience with it, three shots to remove a wisdom tooth, wait the obligatory 5-minutes for it to take effect, dentist goes to pull tooth out, I'm up and outta the chair in pain.....it never got better than that until last dentist - now dentist for last 10 years - just thought he'd appease me and go with twilight and nitrous in addition to the marcaine shots.....tolerable, but can still feel the work being done and it's not just "pressure" - pain, but tolerable with the twilight).

Anyway - I want to know my options and figured the best way to do that is to ask you all since it's what you do day to day.....

 

[cchoukal]

This is an interesting discussion and, although it does border on "medical advice," there might be something to be learned here (and it's maybe an interesting oral boards scenario).

Patient claims bupivicaine doesn't work on her. You assume she's crazy because there's no described syndrome that we know of that includes tolerance to or lack of effect from a local anesthetic. But then she provides this interesting dental data which seems to back up her story, although I'm sure we could conjure a handful of reasons why the dental block didn't last as long as it might have.

What's your plan, Dr.?

It sounds like the patient's concerns could fall into the "refuses regional/neuraxial" category. Are there convincing contraindications to a GA for her? Is she fat or have a bad airway? Is a planned GA from the get-go better than a rescue-GA after a failed spinal?

I still think there's a chance that the "tolerant to Marcaine" business is bunk (not that she's making it up, just that there's something else at the root of this), but, at the end of the day, if she refuses a spinal (for whatever reason), a GA for c/s is a perfectly reasonable option, in general.

 

[WorriedPT]

This is an interesting discussion and, although it does border on "medical advice," there might be something to be learned here (and it's maybe an interesting oral boards scenario).

I'll do my best to keep to hypothetical as you are below!

Patient claims bupivicaine doesn't work on her. You assume she's crazy because there's no described syndrome that we know of that includes tolerance to or lack of effect from a local anesthetic. But then she provides this interesting dental data which seems to back up her story, although I'm sure we could conjure a handful of reasons why the dental block didn't last as long as it might have.

In searching through google and pubmed, I've come across two papers which I'm waiting on DH to pulll from online in full-text -- one is a compilation of six cases where tolerance to the anesthetic was considered bunk, yet no other explaination for failed spinal was found....the other is a review of cases where spinal blocks failed to examine potential for resistance to local anesthetic used on some patients.

What's your plan, Dr.?

Inquiring minds want to know!

It sounds like the patient's concerns could fall into the "refuses regional/neuraxial" category. Are there convincing contraindications to a GA for her? Is she fat or have a bad airway? Is a planned GA from the get-go better than a rescue-GA after a failed spinal?

Patient in this case absolutely refuses to consider general anesthesia as first line option - the risk to the fetus is too high in her opinion and despite the horrible experience of the previous c-section, she also remembers the moments after her baby arrived and that's why she says she was able to get over the procedure itself. So she wants to be awake and alert, but wants to know if she has options other than marcaine that will provide a pain-free birth by CS.

ETA: pre-pregnancy BMI was 26, slightly overweight - expected weight gain will maintain patient in overweight category but not expected to become obese by BMI. No health issues; no otc or prescribed medications; no GD; no hypertention (usual BP is 110/70, even in pregnancy).

ETA: VBAC isn't a good option - patient has a very narrow pelvic area and did not progress past 8 in first pregnancy, c-section was done after 44-hours of labor; given age now in second pregnancy (44) VBAC also increases risk for uterine rupture beyond the patients risk tolerance; in previous c-section BP crashed twice, once to 54/30 and second time to 60/40....pt remembers this as she could see her monitors and her current OB verified with a record request from hospital that did her first c-section. Notes in the chart indicate patient isn't making up the pain - she was restrained by 4 persons in the room (residents and nurses) to keep her on the table while the c-section was done, her pain was real and evident, it was not simply pressure - she constantly, throughout the surgery, attempted to remove herself from the table, screamiing in pain. Maybe those details help a bit?

I still think there's a chance that the "tolerant to Marcaine" business is bunk (not that she's making it up, just that there's something else at the root of this), but, at the end of the day, if she refuses a spinal (for whatever reason), a GA for c/s is a perfectly reasonable option, in general.

What other reasons may be at the root of this? Is there any way to test prior to actually doing the spinal before it can fail in the real world and she's already cut?

 

[bostonblaz]

1) pt is clearly in need of some TLC.
2)Never really heard of hypermetabolism/resdistrabution of marcaine
3) would not go to that dentist again
4) dentist usually use lidocane and I am leary of a guy who is injecting a hyper vascular place like a mouth with marciane
5)wasn't at the last c/s but I would have put her to sleep then or k'ed her out
6)this go around I would make sure she is npo over night and give her bicitra before we roll back
7)I would giver her the option to try a spinal and go from there however I think she is going to complain during the case any way and if the surgeon is slow it could be a total nightmare. If she really had a problen with amides I would use tetracaine and tell her she will be numb for 6 hrs or so. Spinal is still worth doing cause she can get duramorph
8) I find the squemish need a little some thing and I would give her 25 of iv bendryl and hope she would just fall asleep before we really got under way.
I wish this person luck and would let them knwo that they dont have to be upitty when they talk to people and you may just have as you describe but lets just say it is rare to say the least and dont get upset when people brush it off until they see it with there own eyes.blaz

 

[cchoukal]

Patient in this case absolutely refuses to consider general anesthesia as first line option - the risk to the fetus is too high in her opinion and despite the horrible experience of the previous c-section, she also remembers the moments after her baby arrived and that's why she says she was able to get over the procedure itself. So she wants to be awake and alert, but wants to know if she has options other than marcaine that will provide a pain-free birth by CS.

For what it's worth, the best evidence to date, a Cochrane review, showed no difference in terms of mortality and apgars between GA and neuraxial for c/s.

As Blaz reported, there ARE other local anesthetics that can be used in the intrathecal space. Tetracaine is a fine option, although, as he pointed out, you'll be on your back for most of the day.

 

[dhb]

in previous c-section BP crashed twice, once to 54/30 and second time to 60/40....pt remembers this as she could see her monitors. Notes in the chart indicate patient isn't making up the pain

Something ain't right 🙄

 

[periopdoc]

This has clearly and completely crossed the line into soliciting medical advice. The "hypothetical" b.s. is just that.


You need to speak with your anesthesiologist. This can be done on the day of surgery and there is no need to speak with him/ her any earlier than that. If there is no anesthesiologist where you will be delivering, you need to select a different place to have your c-section.


I would recommend that you do not try to tie his or her hands from doing what is best for you and your baby, be open to a discussion of the risks and benefits of all options for your case.

- pod

 

[pgg]

This has clearly and completely crossed the line into soliciting medical advice. The "hypothetical" b.s. is just that.

Agreed, there are a couple interesting lines of discussion here but this thread is headed for ClosedVille.

 

[Arch Guillotti]

agree, closing.