When do you refuse a labor epidural

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GA8314

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So, our current set up isn't super conducive to CSE's. I've traditionally had no problem placing epidural at 8 cm on gals who couldn't get through their birth plan. They changed their mind after experiencing the full intensity of pain etc. I get it. No problem, but I caveat that it may not help that much.

Also, there is the idea that a prime may go to C/S (dependent on her and the OB/GYN)..... And, having an epidural in place to bolus if needed for C/S is fine by me.

However, I've recently been burned by an 8cm dilated woman. Couldn't sit still. Of course it's 2 a.m.
I should have had her checked before even attempting as after I put it in (with some difficulty due to movement which I should not have tolerated but did) she was complete and ready to push. That one was my mistake. I should have managed it better, and of course overnight L&D nurses are notoriously.......

My question is do any of you have a "cut off" whereby you won't do an epidural for an elective vaginal delivery?? There are many points to consider here, but I still think 8 cm as a general rule is a reasonable cut off where risk of procedure is greater than benefit to patient.

Thoughts?
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GA8314 said:
So, our current set up isn't super conducive to CSE's. I've traditionally had no problem placing epidural at 8 cm on gals who couldn't get through their birth plan. They changed their mind after experiencing the full intensity of pain etc. I get it. No problem, but I caveat that it may not help that much.

Also, there is the idea that a prime may go to C/S (dependent on her and the OB/GYN)..... And, having an epidural in place to bolus if needed for C/S is fine by me.

However, I've recently been burned by an 8cm dilated woman. Couldn't sit still. Of course it's 2 a.m.
I should have had her checked before even attempting as after I put it in (with some difficulty due to movement which I should not have tolerated but did) she was complete and ready to push. That one was my mistake. I should have managed it better, and of course overnight L&D nurses are notoriously.......

My question is do any of you have a "cut off" whereby you won't do an epidural for an elective vaginal delivery?? There are many points to consider here, but I still think 8 cm as a general rule is a reasonable cut off where risk of procedure is greater than benefit to patient.

Thoughts?
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If they can't stay still (enough to safely place an epidural), it's too late.
 
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as long as they don't deliver while I'm placing it, fine by me. I've actually started an epidural, had the woman yell "i gotta push" and have the OB note the head delivering and offer to hold it in place while I finish the epidural. Lady ended up having a bad tear requiring repair, so it turned out to be useful.
 
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GA8314 said:
So, our current set up isn't super conducive to CSE's.
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What does this mean? Don't have the equipment..?

Because a CSE solves all of your problems...
 
INR or hostile family. Other than that, whatever, whenever.
 
I did an epidural in residency on a woman who was 8cm. Thread the catheter, pull out the needle, test dose, and she says, "I gotta push!!!" I told her to wait a second. Bolus the cath, slap on some tape, and quickly lay her down. In the process of laying down she GRUNTS and a baby shoots out of her and is only stopped from flying off the end of the bed by the umbilical cord which acts as a bungee cord. Later the nurse tells me I have to sign the delivery record since I was the physician present for delivery!
Long story short, to this day if that can sit up and stay still, and don't say they have to push I'll place the epidural.
 
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I feel like half the epidurals I've placed in the last year since I started as an attending have been in for 5 minutes before the woman pushes the baby out. I think the OBs here don't know how to measure the cervix cause it seems like the women are never more than 6 cms...
 
1. How did you get burned? 2. Why not do a quick spinal? Get her comfortable then place the epidural. 3. No hard fast numbers if they can stay still they get an epidural.
 
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I only refused once and that was because the patient was hostile and cussing at me before I even said "hello." Otherwise, I've done plenty of epidurals on patients who were 8-9cm...so long as they can sit up and sit still for 5 minutes.
 
I'll typically only refuse between the hours of 2300-0600.
 
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No hard line, some people stay at 8cm for a while, esp the first pregnancies. though these days i have less than 0 tolerance of people yelling at me.
 
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At 8cm I just do a spinal and I don't place a catheter afterwards usually. I tell the nurse, she has an hour and a half to deliver. They love it.
 
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If they feel the urge to push, I'm out. Can't hold still when u feel the urge to deliver. Nothing suck more than hearing how your epidural didn't work because they delivered before your bolus set up. I have nurse recheck ob patients all the time. If there a multip and moving fast I'll put in an intrathecal. Faster procedure, smaller needle, 60 seconds to comfort and I'm out the door. Rarely get burned by a 2 hour time limit.


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1cc 0.25% Bupivicaine 25mcg fentanyl for my single shots. I tell them 2hrs if not delivered I'll consider one repeat. Very rarely need too.


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I always refuse - CRNAs do them.
 
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Don't even need a special kit. Just drop a 25g x 120mm pencil point onto the epidural tray and go.
 
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okayplayer said:
You still have to take extra time to draw up your bupiv/fentanyl for your spinal.

Also does the long 25g Whitacre fit in an 18g Tuohy or only the 17g?
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Well we only have the 17g Arrow kits, but it fits just fine through this 18g needle:
image.jpeg



Why anyone still uses the POS Braun kits is a mystery to me.

If you just use the epidural infusion solution it literally takes no extra time to draw up. In fact, I just squirt 15-20mL of the bag solution into the tray and use it for everything (skin local, LOR fluid, IT dose, and then a few mL through the cath). Doing it this way is even faster than cracking open the vials in the kit.
 
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SaltyDog said:
Well we only have the 17g Arrow kits, but it fits just fine through this 18g needle:
View attachment 221994


Why anyone still uses the POS Braun kits is a mystery to me.

If you just use the epidural infusion solution it literally takes no extra time to draw up. In fact, I just squirt 15-20mL of the bag solution into the tray and use it for everything (skin local, LOR fluid, IT dose, and then a few mL through the cath). Doing it this way is even faster than cracking open the vials in the kit.
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How do you dose the CSE portion? Our usual PCEA solution is 0.125% bupiv + 2mcg/ml fent. 2ml?
 
anbuitachi said:
is it a different catheter that you put in?
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I've intentionally done IT catheters a few times for various reasons, both in L&D and the OR. I used a regular epidural kit, drove the tuohy through dura, then threaded the catheter. Dosing varied, based on why I thought the technique was a good idea.

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psychbender said:
I've intentionally done IT catheters a few times for various reasons, both in L&D and the OR. I used a regular epidural kit, drove the tuohy through dura, then threaded the catheter. Dosing varied, based on why I thought the technique was a good idea.

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I would be incredibly hard pressed to find a reason to place an IT cath in L&D. Do you mind sharing when you'd place such a cath?

BTW, if anyone ever told my wife that they'd plan to place an IT cath, I'd respectfully request another anesthesiologist.
 
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Gaseous Clay said:
I would be incredibly hard pressed to find a reason to place an IT cath in L&D. Do you mind sharing when you'd place such a cath?

BTW, if anyone ever told my wife that they'd plan to place an IT cath, I'd respectfully request another anesthesiologist.
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The L&D one was in residency. 33yoF G1 who had her tetrology of fallot repaired a year ago, with also severe AI. Chief complaint around 32 weeks was "I can't go on like this" when she went from two to six pillow orthopnea. The OBs didn't see a problem, as "she was fixed already." Cards was following her, super nervous, and recommending a passive second stage of labor. Oh, and she had scoliosis and a difficult airway. The OBs admitted her for induction on a night when we only had a CRNA on the labor deck, they ignored our instructions to not induce. The CRNA placed an epidural, it was one sided. She had a lot of pain, high blood pressure, pulmonary edema. Second attempt at epidural was again one sided (the other side). By this time, it was the morning, we were back, and going "WTF, guys?!" our attending decided to just drive through, wet tap, place the catheter, then slowly bolus to achieve adequate block. When it came time to deliver, she was numb, the OBs reached up with forceps, and slid that kid out.

The other IT catheters on L&D were all from wet taps. The staff wanted everyone to thread the catheter if we wet tapped, and manage it as an intrathecal cath, rather than just repeat at a different level. With three new CA1s in rotation on the labor deck for two months, we each ended up placing one or two catheters, and managing the ones from our colleagues.

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Thanks for the great feedback. I used to do anything anytime (aside from feeling need to push). Just recently, I should have had the OB resident RE check the patient. It was 2 a.m. (of course it would be), and the patient was having a hard time sitting still. I was focused on getting the damn thing in, but it took multiple attempts. I did not have CSE or any spinal equipment with me since often in the early a.m. hours I just grab stuff (not cart) and go to room with gear in hand.

I think our nurses such so bad also. Coaching and help is terrible. I do blame myself for not either 1) just doing spinal and 2) fu..cking around for too long on a patient clearly further along than the 6 cm they told me.......

So, my near term tolerance went way down after that. I'll be reexamining my practice however, the one aspect of actually getting the epidural in place is in case of a C/S (our rates can be high depending on attending OB). CSE takes time and I see how just a few minutes more with 0.25% 8ml with 100 mcg via epidural can almost achieve the same result (as Blade suggests). Spinal only takes away safety of an epidural for a STAT C/S, and we all know how that stuff goes......

Anyway, I think I'll just go back to what I used to do which is either CSE or more likely carrying some 0.25% bupiv with fentanyl for epidural bolus dose in such cases when they are very far along and in a great deal of discomfort....

The other reason I'm not sure I like the spinal only technique is that I don't really want a call back at 4 a.m. after being up at 2 a.m. I know that's a shi..tty was of looking at it but it is what it is. Murphy's law is that OB nurse is calling you back in 2 hours when "the patient is uncomfortable again"......

Great responses and thank you for that.
 
Left lateral epidurals anyone?
They can be as jumpy as they want then, doesnt matter, they're still pinned to the bed... Easy as pie even at 8cm dilatation

CSE/Spinals whatever, anything that goes into the CSF for me should be done in a monitored environment (I dont really think the L&D floor is monitored). Ive had one case of profound fetal brady from massive uterine contraction after one such jaunt and i dont ever want that again!

Well loaded epidural is equivalent to spinal at 15 mins, so thats that.
Almost everyone that requests an epidural gets one from me, bar coagulopathy or a small number of other reasons.

No CSEs or spinals outside of theatre



Re - IT catheters on LD floor - That is the worst disaster that can ever happen! And should almost never be done. Use Ultrasound, paramedian approach, go up or down many levels, get a colleague. do anything. Just avoid this! Not only will it ruin your night, it will ruin your next day, i wouldnt be able to leave the hospital until that damn thing is out! It is a very dangerous weapon, and uncommon to the point of being rare. Anything untoward that happens that mother/baby will be blamed on you/it. Just my 2c
 
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okayplayer said:
You still have to take extra time to draw up your bupiv/fentanyl for your spinal.

Also does the long 25g Whitacre fit in an 18g Tuohy or only the 17g?
Click to expand...

25g and 24g fit through the Braun 18g Tuohy also.

Do like Salty said -- drop the spinal needle and a couple cc's of 0.25% bupi on the tray and you're good.
 
nimbus said:
:thinking:Apparently you don't do lumbar drains for TEVAR.
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Totally different situation, population, consent etc

There are spinal catheter needles that are smaller. And I really think you need consent to do something like that.

Just for ****s and giggles is absolutely not ok. Mind me asking why you did that to a laboring woman?
 
okayplayer said:
How do you dose the CSE portion? Our usual PCEA solution is 0.125% bupiv + 2mcg/ml fent. 2ml?
Click to expand...

We use the same mix (1/8th Bupi + fent 2/mL). My IT dose is 2.5mL. It seems light but it works really well.
 
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Gaseous Clay said:
I would be incredibly hard pressed to find a reason to place an IT cath in L&D. Do you mind sharing when you'd place such a cath?

BTW, if anyone ever told my wife that they'd plan to place an IT cath, I'd respectfully request another anesthesiologist.
Click to expand...

How about a patient that has had had back surgery that left her epidural space absent or very scarred but with no neurologic defects now. I think a spinal catheter would be reasonable. (Think no-to-little epidural space from L1-L5.)
Or as mentioned below (though unplanned), if you're having difficulty finding the epidural space after multiple attempts (not everyone on this board is a jedi, myself included) and you wet-tap. Option 1) Try again for another undetermined length of time with potential for a second wet-tap. Option 2) Give up. Option 3) Spinal catheter (you could argue for single-shot, but if they outlast it, you're no longer their hero). Option 3 is reasonable.
I had a resident a couple years ahead of me that went to a OB anesthesia fellowship. Later as a fellow, she had a patient with aortic stenosis coming in for a cesarean delivery. (I can't remember the degree, but it was enough to make the other attendings there nervous - Emory, so they see their share of sick patients.) She decided to place an IT catheter and dose up slowly, able to treat/pretreat BP/vasodilation accordingly. Also reasonable.
That took all of 10 seconds to think of three reasons for an IT catheter.
 
Gaseous Clay said:
I would be incredibly hard pressed to find a reason to place an IT cath in L&D. Do you mind sharing when you'd place such a cath?
Click to expand...

The situation that comes to mind is the morbidly obese full stomach known crazy difficult airway for a crash "Baby's gonna dieeeee!!!!" section.
 
Newtwo said:
Mate seriously!?!
That is assault
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After two "failed" epidurals that at best didn't help the "pain, high blood pressure, pulmonary edema," and at worst worsened the "pain, high blood pressure, pulmonary edema?" To me, that seems less like assault and more like making her comfortable and safe.
 
Newtwo said:
Totally different situation, population, consent etc

There are spinal catheter needles that are smaller. And I really think you need consent to do something like that.

Just for ****s and giggles is absolutely not ok. Mind me asking why you did that to a laboring woman?
Click to expand...

I'm just saying it's a routine procedure and not "assault". It's a 20g silicone drain thru a 14g tuohy. We tell the patients about it but there's no special separate consent. Never did one on a pregnant patient, but if one came in with an aortic dissection that could be stented she'd get one.
 
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twoliter said:
How about a patient that has had had back surgery that left her epidural space absent or very scarred but with no neurologic defects now. I think a spinal catheter would be reasonable. (Think no-to-little epidural space from L1-L5.)
Or as mentioned below (though unplanned), if you're having difficulty finding the epidural space after multiple attempts (not everyone on this board is a jedi, myself included) and you wet-tap. Option 1) Try again for another undetermined length of time with potential for a second wet-tap. Option 2) Give up. Option 3) Spinal catheter (you could argue for single-shot, but if they outlast it, you're no longer their hero). Option 3 is reasonable.
I had a resident a couple years ahead of me that went to a OB anesthesia fellowship. Later as a fellow, she had a patient with aortic stenosis coming in for a cesarean delivery. (I can't remember the degree, but it was enough to make the other attendings there nervous - Emory, so they see their share of sick patients.) She decided to place an IT catheter and dose up slowly, able to treat/pretreat BP/vasodilation accordingly. Also reasonable.
That took all of 10 seconds to think of three reasons for an IT catheter.
Click to expand...

Why not just go higher? Thoracic epidurals are done all the time in the general ORs
Why would she put in a IT catheter for a patient w aortic stenosis???
 
anbuitachi said:
Why not just go higher? Thoracic epidurals are done all the time in the general ORs
Why would she put in a IT catheter for a patient w aortic stenosis???
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Thinking about it further, she may have actually just dosed up an epidural. (Not thoracic, though, it wasn't a back surgery patient.) But an IT catheter isn't completely irrational. Dose it up slowly and it's not considerably different than dosing an epidural for a section. The point remains that it's not completely unreasonable to place an IT catheter in certain situations.
 
Speaking of IT catheters.... Once I did an epidural on a preg lady, LOR w/ saline good, then proceeded to threading the catheter. After catheter was in (braun stiff one) and I pulled back to my desired length I noticed a nice surprise. Upon aspiration I found CSF :0 No wet tap from tuoy! The patient was already like 7 or 8cm I believe so I just left it in and did .25% bupivacaine. I pulled it after 24 hrs :0 No problems..... I really do hate those stiff catheters. I feel like they should be banned!!!
 
Scotty_G said:
Speaking of IT catheters.... Once I did an epidural on a preg lady, LOR w/ saline good, then proceeded to threading the catheter. After catheter was in (braun stiff one) and I pulled back to my desired length I noticed a nice surprise. Upon aspiration I found CSF :0 No wet tap from tuoy! The patient was already like 7 or 8cm I believe so I just left it in and did .25% bupivacaine. I pulled it after 24 hrs :0 No problems..... I really do hate those stiff catheters. I feel like they should be banned!!!
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I would call that a partial wet tap at least.
 
anbuitachi said:
do you guys tell your patients if you get a wet tap?
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I do. Just so they're not completely surprised by a headache which may require a patch after they go home. That way they, at my practice anyway, they can often times skip the ER and come straight back to the labor unit for the patch. Also a heads up about caffeine, fluids, what to expect, etc. isn't a bad idea either.
 
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anbuitachi said:
do you guys tell your patients if you get a wet tap?
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Not telling them is malpractice in my opinion. They need to know what to look for, and you should clearly document so the next provider knows how good the headache story is.
 
On a side note, is anyone leaving in IT catheters for 24hrs? Supposedly far lower headache risk, down to about 10%.
 
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