Vbac

[IN2B8R]

Well, since Jet is in his "deep thoughts by Jack Handy" mode, I figured that I can contribute and stir the pot a little by throwing this question out there: what are some of the attendings thoughts on epidurals for VBAC patients? Does your group epiduralize these patients and accept the uterine rupture risk, or do you say "call me when you're ready to do a c-section.."? How do you feel about the legal ramifications and potential of a law suit if you have placed an epidural for a VBAC and things went bad? Do you risk stratify VBAC patients differently? The "guidlines/recommendations" have swung both ways several times on this issue.... Just curious what others are doing out there.

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[rsgillmd]

We epiduralize (if that's a word). Ignoring "windows" I have seen one true uterine rupture in a patient with an epidural, and if we had kept our minds open we would have possibly recognized it for what it was. In fact I strongly encourage epidurals to patients that want a VBAC but the surgeon isn't holding out much hope. It allows me a means to proceed to C/S rapidly if needed while potentially avoiding general anesthesia. Before anyone diverts this into a GA vs regional for C/S thread I'll say that while I am not afraid to use GA for C/S, I make all reasonable efforts to avoid it.

My uterine rupture case was a patient who had an epidural for labor and was comfortable. One previous C/S for NRFHR. She had been doing well when she developed recurrent and severe late decels. We loaded the catheter on the way to the OR and as the surgeons prepped. The patient was quite agitated, but other than mild tachycardia, had normal vitals. We seemed to have a good level to alcohol. When she screamed in pain although nobody was touching her, both my attending and I thought this is just a hysterical patient. He gave Ketamine. We only found out about the rupture when the surgeon opened the belly and saw it. We put her to sleep at that point. Both patient and baby did well.

In retrospect we should have kept our differential open and recognized pain out of proportion to stimulus, or even in the absence of stimulus as being a warning sign of uterine rupture. Our perception had been colored by the patient's behavior earlier in the day.

 

[Noyac]

Uterine rupture and FHT's will clue any clueless OB into the game. We do epidurals for these pts.

What legal ramifications and potential of a law suit having placed an epidural for a VBAC and things went bad? OB is a litigation nightmare to begin with. Why are these pts different? (When I ask these questions don't assume I am on the opposite side of the issue)

 

[Planktonmd]

We don't do VBAC's but if we did I wouldn't hesitate to place an epidural in them, as long as the obstetrician agrees and understands that they might not see the sudden excruciating pain they expect from a uterine rupture, and that the patient needs to be monitored closely.

 

[USAnesthesiaDoc]

We routinely place epidurals in VBAC patients if the patient requests. I personally give a "light" dose, ie low concentration bupivacaine (0.125%) and warn the patients that I'm purposefully not making them really numb. I explain to the patient that if they have pain, then everyone needs to know about it so that a uterine rupture is not covered up.

 

[jwk]

Our VBAC patients get epidurals, placed and dosed the same way we do all of them. I think if the rupture, they're still going to have plenty of pain, but of course the FHT's will clue everyone in as well. If they rupture, we can frequently get an adequate surgical level dosing them while rolling down the hall to the OR.

I have seen several ruptures, and I have seen some paper-thin uteri on VBAC's where we ended up doing a C-Section. I'm not a VBAC fan at all, and would never want one for someone in my family.

 

[IN2B8R]

Uterine rupture and FHT's will clue any clueless OB into the game. We do epidurals for these pts.

What legal ramifications and potential of a law suit having placed an epidural for a VBAC and things went bad? OB is a litigation nightmare to begin with. Why are these pts different? (When I ask these questions don't assume I am on the opposite side of the issue)

Yes. I do epidurals on all VBAC's as well.... But that was not always my practice. Not all OB's stay in house for VBAC's: I personally know one who went home (20min drive) on a VBAC. So...who's sectioning in time? OB is a litigation nightmare, no matter what we do, but risk reduction is a habit of mine. To be totally honest with you, I feel perfectly OK doing epidurals for these patients in a supportive, controlled environment. But I have no control (currently) over where the OB doc stays for a VBAC (in house vs. home). That was the purpose of my post and where I was coming from.... Also, if it was not a LTCS in the past (as some countries still do vertical c-sections), then I won't do an epidural: due to the higher risk of rupture. As always...risk vs. benefit.

 

[Noyac]

Yes. I do epidurals on all VBAC's as well.... But that was not always my practice. Not all OB's stay in house for VBAC's: I personally know one who went home (20min drive) on a VBAC. So...who's sectioning in time? OB is a litigation nightmare, no matter what we do, but risk reduction is a habit of mine. To be totally honest with you, I feel perfectly OK doing epidurals for these patients in a supportive, controlled environment. But I have no control (currently) over where the OB doc stays for a VBAC (in house vs. home). That was the purpose of my post and where I was coming from.... Also, if it was not a LTCS in the past (as some countries still do vertical c-sections), then I won't do an epidural: due to the higher risk of rupture. As always...risk vs. benefit.

I agree, if the OB is not in-house than I won't get involved with the pts care. That means no epidural.

 

[IN2B8R]

Our VBAC patients get epidurals, placed and dosed the same way we do all of them. I think if the rupture, they're still going to have plenty of pain, but of course the FHT's will clue everyone in as well. If they rupture, we can frequently get an adequate surgical level dosing them while rolling down the hall to the OR.

I have seen several ruptures, and I have seen some paper-thin uteri on VBAC's where we ended up doing a C-Section. I'm not a VBAC fan at all, and would never want one for someone in my family.

Depends on degree of rupture and where the blood is tracking, my friend. An epidural may give you a T4 level and even a higher sensory level and the patient may experience no discomfort (or may actually experience little discomfort from phrenic irritation, but how do definitively distinguish that from the usual moans and groans of OB patients--other than my shoulder hurts a little, blah, blah, blah..) and you could be fooled. FHT's will take a nose dive, but remember that unless you have a fetal scalp electrode (which is not very often), the external monitors are sometimes altogether off the patient, as the patient is moving around or getting repositined by the room RN: so your best external monitor (FHT's) is sometimes off the patient and the following picture is present (happpened to one of our partners): a slightly uncomfortable patient and ongoing slow fetal demise that no one is picking up.... Seconds count in this scenario, so OB presence and continous monitoring is of the essence on ALL VBAC's. Being sharp and expecting the worst--just like everything else we do.

 

[IN2B8R]

Our VBAC patients get epidurals, placed and dosed the same way we do all of them. I think if the rupture, they're still going to have plenty of pain, but of course the FHT's will clue everyone in as well. If they rupture, we can frequently get an adequate surgical level dosing them while rolling down the hall to the OR.

I have seen several ruptures, and I have seen some paper-thin uteri on VBAC's where we ended up doing a C-Section. I'm not a VBAC fan at all, and would never want one for someone in my family.

I'm never the one to tell other specialists what to do, but in these patients I would not mind have a fetal scalp electrode, since it is a continous monitor that won't (easily) come off the patient with movement/repositioning....

 

[pgg]

We offer epidurals to all VBACs. OB & OR crew in house on standby until they deliver. 1:1 nursing with FHR monitoring.

 

[2win]

We offer epidurals to all VBACs. OB & OR crew in house on standby until they deliver. 1:1 nursing with FHR monitoring.

The same. I have to tell you that I hate this stuff???
We tried to negotiate out of it but the hospital didn't let us. Wasting money and boring.
P.S. _ we tried to get out of OB generally but we couldn't. The black hole in out budget.

 

[IN2B8R]

The same. I have to tell you that I hate this stuff???
We tried to negotiate out of it but the hospital didn't let us. Wasting money and boring.
P.S. _ we tried to get out of OB generally but we couldn't. The black hole in out budget.

Yeah....Unless you get a hospital subsidy for OB coverage, the units generated are not exactly a cash cow. Just a fuggin' coverage pain in da arse issue, biting the rear of every unsupported group....🙁

 

[IN2B8R]

We epiduralize (if that's a word). Ignoring "windows" I have seen one true uterine rupture in a patient with an epidural, and if we had kept our minds open we would have possibly recognized it for what it was. In fact I strongly encourage epidurals to patients that want a VBAC but the surgeon isn't holding out much hope. It allows me a means to proceed to C/S rapidly if needed while potentially avoiding general anesthesia. Before anyone diverts this into a GA vs regional for C/S thread I'll say that while I am not afraid to use GA for C/S, I make all reasonable efforts to avoid it.

My uterine rupture case was a patient who had an epidural for labor and was comfortable. One previous C/S for NRFHR. She had been doing well when she developed recurrent and severe late decels. We loaded the catheter on the way to the OR and as the surgeons prepped. The patient was quite agitated, but other than mild tachycardia, had normal vitals. We seemed to have a good level to alcohol. When she screamed in pain although nobody was touching her, both my attending and I thought this is just a hysterical patient. He gave Ketamine. We only found out about the rupture when the surgeon opened the belly and saw it. We put her to sleep at that point. Both patient and baby did well.

In retrospect we should have kept our differential open and recognized pain out of proportion to stimulus, or even in the absence of stimulus as being a warning sign of uterine rupture. Our perception had been colored by the patient's behavior earlier in the day.

Excellent case, bro'👍. Thanks for posting. Hope you learned from it, because it is more common than we think it is. You had a good outcome, that's always a good thing. I hope that jwk reads this post, as it is a good presentation of what is seemingly, at first, non-specific symptoms....

 

[rsgillmd]

Yes. I do epidurals on all VBAC's as well.... But that was not always my practice. Not all OB's stay in house for VBAC's: I personally know one who went home (20min drive) on a VBAC. So...who's sectioning in time? OB is a litigation nightmare, no matter what we do, but risk reduction is a habit of mine. To be totally honest with you, I feel perfectly OK doing epidurals for these patients in a supportive, controlled environment. But I have no control (currently) over where the OB doc stays for a VBAC (in house vs. home). That was the purpose of my post and where I was coming from.... Also, if it was not a LTCS in the past (as some countries still do vertical c-sections), then I won't do an epidural: due to the higher risk of rupture. As always...risk vs. benefit.

Do the OBs that go home have someone in house to cover for them? Although no private attending I know of went home with a VBAC in labor, I do know where I trained some private attendings asked the service attending to cover them in the event of an emergency C/S, while a midwife covered the patient for everything else.

Where I am now it is extremely rare to see a private patient. 99.9% of the time the patient is covered by the service OB or by the family practice doc (they do their own C/S and now have an OB as part of the group for high risk patients so they don't have to transfer the patient to the OB service).

Both where I trained and where I am now, if it is an unknown scar or a known vertical incision on the uterus, the patient is not even offered a VBAC. Exception was an essentially fully dilated previous C/S x 1 (unknown scar) multip during residency -- the OB decided to do a VBAC because he felt by the time we got the patient to the room and he started, the baby would be out vaginally.

 

[jwk]

Not all OB's stay in house for VBAC's: I personally know one who went home (20min drive) on a VBAC. But I have no control (currently) over where the OB doc stays for a VBAC (in house vs. home). That was the purpose of my post and where I was coming from.... Also, if it was not a LTCS in the past (as some countries still do vertical c-sections), then I won't do an epidural: due to the higher risk of rupture. As always...risk vs. benefit.

Your OB isn't in house for VBAC's? Isn't that a solid requirement of ACOG to be doing VBAC's? Do you put epidurals in these patients as well?

Depends on degree of rupture and where the blood is tracking, my friend. An epidural may give you a T4 level and even a higher sensory level and the patient may experience no discomfort (or may actually experience little discomfort from phrenic irritation, but how do definitively distinguish that from the usual moans and groans of OB patients--other than my shoulder hurts a little, blah, blah, blah..) and you could be fooled. FHT's will take a nose dive, but remember that unless you have a fetal scalp electrode (which is not very often), the external monitors are sometimes altogether off the patient, as the patient is moving around or getting repositined by the room RN: so your best external monitor (FHT's) is sometimes off the patient and the following picture is present (happpened to one of our partners): a slightly uncomfortable patient and ongoing slow fetal demise that no one is picking up.... Seconds count in this scenario, so OB presence and continous monitoring is of the essence on ALL VBAC's. Being sharp and expecting the worst--just like everything else we do.

Hmmm, a T4 block for a labor epidural? That's a C-section level. Why would you get them that high for labor? That level would certainly mask any pain from a rupture, but we don't dose to a level anywhere near that high, nor that dense with fentanyl/ropivicaine infusions. Fetal monitoring is the OB's call, not ours.

I hope that jwk reads this post, as it is a good presentation of what is seemingly, at first, non-specific symptoms....

As I indicated previously, I hate VBAC's, but I'm not nearly as cavalier as you apparently think I am. We have 24/7 anesthesia and OB coverage and do about 5,000 C-Sections a year, many of them repeat C-Sections since a lot of our OB's will not do VBAC's 👍👍👍 . We can make the incision for the section in a minute or less after they hit the OR with the patient if need be, and most of the time get an adequate surgical level by dosing the epidural running down the hall with the bed. If they hit the OR before we get dosed, it's an RSI and off we go. If the patient's OB is tied up with another delivery or section, ANY OB will do the section for a crash.

 

[IN2B8R]

Your OB isn't in house for VBAC's? Isn't that a solid requirement of ACOG to be doing VBAC's? Do you put epidurals in these patients as well?

I personally cannot enforce the whereabout of an OB doc, ACOG or no ACOG. I stated above in my previous post that it does happen. And I do not place epidurals for absentee services.


Hmmm, a T4 block for a labor epidural? That's a C-section level. Why would you get them that high for labor? That level would certainly mask any pain from a rupture, but we don't dose to a level anywhere near that high, nor that dense with fentanyl/ropivicaine infusions. Fetal monitoring is the OB's call, not ours.

Yes, that is a c-section level. Some of our partners dose the **** out of epidurals (talking about a 14ml bolus, then run it about 10-12 mL/hr with 1/8% bupiv and 2mcg/ml fent). That can easily attain you a T4 level, if not higher. Fetal monitoring is OB's call, but we as physicians need to pay attention to what the hell it's telling us, especially in VBAC patients.



As I indicated previously, I hate VBAC's, but I'm not nearly as cavalier as you apparently think I am. We have 24/7 anesthesia and OB coverage and do about 5,000 C-Sections a year, many of them repeat C-Sections since a lot of our OB's will not do VBAC's 👍👍👍 . We can make the incision for the section in a minute or less after they hit the OR with the patient if need be, and most of the time get an adequate surgical level by dosing the epidural running down the hall with the bed. If they hit the OR before we get dosed, it's an RSI and off we go. If the patient's OB is tied up with another delivery or section, ANY OB will do the section for a crash.

Seems like you have the best of all setups there.... We do not have OBs on demand like you, but that sure would be a nice thing to have 👍.

 

[Noyac]

Seems like you have the best of all setups there.... We do not have OBs on demand like you, but that sure would be a nice thing to have 👍.

How in the world can your hospital allow VBAC's and not have OB's in-house?

This is a blatant lack of understanding and lack of patient care.

 

[IN2B8R]

How in the world can your hospital allow VBAC's and not have OB's in-house?

This is a blatant lack of understanding and lack of patient care.

Simple: the head of OB is married to the hospital CEO; yeah, like everything else, fuggin politics trump patient care, which has literaly pissed off every anesthesiologist in our dept. The fortunate thing is that we only do about 2100 OB cases/year....which is still enough to keep you busy... They supposedly all live within 20min from hospital, as if that is sufficient time. If we don't get our subsidy this year, we will drop in house Ob coverage 😀

 

[Noyac]

Simple: the head of OB is married to the hospital CEO; yeah, like everything else, fuggin politics trump patient care, which has literaly pissed off every anesthesiologist in our dept. The fortunate thing is that we only do about 2100 OB cases/year....which is still enough to keep you busy... They supposedly all live within 20min from hospital, as if that is sufficient time. If we don't get our subsidy this year, we will drop in house Ob coverage 😀

That is worthy of a call to a local journalist.

I hope they are paying you guys top dollar.

 

[IN2B8R]

That is worthy of a call to a local journalist.

I hope they are paying you guys top dollar.

2 mil annual subsidy--no chump change....

 

[Noyac]

2 mil annual subsidy--no chump change....

Well if there are only 4 of you then that is good. Any more than that, not so good. How many are you?

 

[jetproppilot]

I'm fortunate in that the OBs I work with apparently don't like VBACs since I havent placed a labor epidural for VBAC in three years. They all go to C section.

I'm surprised from all the posts reflecting many OBs out there still VBACing, what with all the fairly recent literature defining how risky it really is.

 

[IN2B8R]

Well if there are only 4 of you then that is good. Any more than that, not so good. How many are you?

Four? No, no, bro', this is a 20+ MD group, with 4 hired crna's (pretty much a fee for service model). The 2 mil subsidy is only for OB coverage. It ain't much, but then our OB volume is not that much either (2100 cases, hit or miss). We are seeking to go from a 2 mil to a 4 mil subsidy (this is a contract year for us), if they still want us to remain in house for OB coverage. Frankly, I think that it is a joke for any of us to stay in house, with such little volume and, often, with some Ob docs covering from home.... But money and politics dictate things in all hospitals. If they don't give us what we want, then we'll shaft the in-house Ob coverage.

 

[jetproppilot]

.

 

[IN2B8R]

I'm fortunate in that the OBs I work with apparently don't like VBACs since I havent placed a labor epidural for VBAC in three years. They all go to C section.

I'm surprised from all the posts reflecting many OBs out there still VBACing, what with all the fairly recent literature defining how risky it really is.

Yep, that was the case with my prior group, Jet.

 

[InductionAgent]

Well, since Jet is in his "deep thoughts by Jack Handy" mode, I figured that I can contribute and stir the pot a little by throwing this question out there: what are some of the attendings thoughts on epidurals for VBAC patients? Does your group epiduralize these patients and accept the uterine rupture risk, or do you say "call me when you're ready to do a c-section.."? How do you feel about the legal ramifications and potential of a law suit if you have placed an epidural for a VBAC and things went bad? Do you risk stratify VBAC patients differently? The "guidlines/recommendations" have swung both ways several times on this issue.... Just curious what others are doing out there.

My anesthesia group (at a community hospital) refuses to do VBACs, so they are not performed at our institution.

 

[Coastie]

Well, since Jet is in his "deep thoughts by Jack Handy" mode, I figured that I can contribute and stir the pot a little by throwing this question out there: what are some of the attendings thoughts on epidurals for VBAC patients? Does your group epiduralize these patients and accept the uterine rupture risk, or do you say "call me when you're ready to do a c-section.."? How do you feel about the legal ramifications and potential of a law suit if you have placed an epidural for a VBAC and things went bad? Do you risk stratify VBAC patients differently? The "guidlines/recommendations" have swung both ways several times on this issue.... Just curious what others are doing out there.

Most common sign of uterine rupture is non reassuring FHT, so, yeah, I wouldn't mind placing an epidural for analgesia.

 

[Noyac]

Four? No, no, bro', this is a 20+ MD group, with 4 hired crna's (pretty much a fee for service model). The 2 mil subsidy is only for OB coverage. It ain't much, but then our OB volume is not that much either (2100 cases, hit or miss). We are seeking to go from a 2 mil to a 4 mil subsidy (this is a contract year for us), if they still want us to remain in house for OB coverage. Frankly, I think that it is a joke for any of us to stay in house, with such little volume and, often, with some Ob docs covering from home.... But money and politics dictate things in all hospitals. If they don't give us what we want, then we'll shaft the in-house Ob coverage.

Good Luck👍