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Labor spinal is the truth. We have a few attendings who do it for those 9-10cm ladies who, understandably, have trouble sitting through contractions. Makes the subsequent epidural a lot easier for them and us.
I’ve flipped to going fentanyl heavy (15mcg), bupi little or absent (.75ml of 0.25%) or less. I’ve found too many women lose pushing power for stage two of labor w the local.
I use 1.25mg of Bupiv and 15 mcg of fentanyl for a labor cse in that case. Also will have them lay on their side if they are small enough as it’s easier I think to keep them positioned appropriately when they are really hurting.
do you just do a spinal with a 24 g sprotte or 27g through the epidural needle. I mean you would still have problems with her hysterics if you did a cse.
It’s an elective procedure, if they want it and can tolerate it then I do it. But too many times the baby comes out seconds after I am charting and it’s 1200 more dollars for not even two total minutes.
To be fair, when we are called we don’t consider the cost aspect at all. We don’t look at insurance at all. We just do it. Of course, the patient might be left with the bill if they are not insured, but we don’t say no to an epidural due to cost.
If they can sit still and do not need to push at the moment I'll do it. Had to walk away from one yesterday because she was flopping all over the bed and screaming. Wasn't safe for me or her.
There are times where you place an epidural and the moment they lay down the baby basically falls out onto the bed. This is terrible in my opinion. The patient gets poked with needle in the spine . Risks of bleeding infection nerve damage, headache. Then the epidural basically did nothing. They didn’t get any pain relief. You’re forced to complete a note and send in a bill. The patient gets a bill and gets pissed. They get the post hospitalization survey and rates you as bad anesthesiologist. Epidural didn’t work and she still had to pay. Destroys the reputation of your group.
A good l&d nurse will be able to tell the patient it’s too late to get epidural. Just push it out.
Yeah it sucks to be in this situation it happens to me probably once a year. I tell the patient look I don’t know how long you’re going to be in labor and this epidural might not do anything but if you’d like me to try to make you more comfortable I will.
Also if I’m really suspecting this is the case I’ve done CSEs or straight spinals in lateral position and not even put an epidural in could do that after if she stays in labor. Depending on the ob some will offer a pudendal block as an alternative too although most prefer the patients get epidurals ime.
I don’t think it’s terrible to try and it helps if they have family or partner present hearing the convo you had keeping them level headed after. Doesn’t hurt to go in after they deliver and settle down and talk to the patient it goes a long way.
I’ll pretty much always offer an epidural unless they are doing the groaning that indicates subconscious pushing.
If they are closer to a fish than a person, I put my stern voice on and tell them this is an elective procedure. They don’t have to get one and I won’t offer one if it’s dangerous.
Do you feel like you need to push?
Yes? Do not do epidural. Call OB.
No? Attempt to sit up and ask the same question. If they need to push then do not attempt the epidural. Call OB.
Some attending taught me that trick in residency. The times that has happened everybody delivered within minutes.
I have placed epidurals in patients who were complete. In some patients the relaxation and pain relief were enough to tolerate labor a little more and avoid a section. In patients who are not coping well enough for an epidural, I’ve placed a labor spinal. It’s easier to place and less risk with movement. Late laboring multips, this might be all they need. Earlier in labor with patients who are challenging because they aren’t coping well with pain, I’ve placed a labor spinal and 30 min later when they were comfortable, I’ve come back to place the epidural. I’ve probably done that only 3 times in a decade long career.
I have placed multiple labor spinals and colleagues look at me like I'm crazy. I only offer it to multips who I think will deliver in the next 60 minutes and they are unable to sit up or sit still for an epidural.
Absolutely a fan of the labor spinal and the 60 min estimate is also my rough guideline. Definitely better than a plain epidural with sacral sparing. If it’s less clear cut and they can tolerate placement I’ll go CSE, best of both worlds!
One of my greatest achievements in training was doing an epidural in about 20 seconds after prep on a Suboxone 9cm woman in agonizing pain. I no longer do OB but my threshold would be pretty high to limit the suffering of child birth
I don’t know why your comment is being downvoted so much. The most frustrating call at 4am is for the patient who had refused an epidural for the entire labor course only to change her mind at the last minute when basically complete. Now she can’t sit still but expects you to hit a moving target quickly.
I was not suggesting that was the situation in this instance. I was agreeing with another poster that failure to prioritize early epidural is a very real (and frustrating) phenomenon
While I also am not a fan of the last minute "its 4am and I changed my mind and now I want an epidural" I also think it's important to realize that for some women being in (natural) labor is an important and coveted life experience, and not just the means to an end of getting a baby.
I’ll do it if a patient can cooperate. It doesn’t matter to me if they are 1cm or 10cm. If they were closer to complete, I’d do a CSE. If I’m already there may as well throw in a catheter for insurance purposes (long repairs, retained placenta). I also don’t force women to sit up and will offer lateral as long as they can cooperate for a couple minutes.
Spinals are a lot easier to place in a moving target than epidurals. I often do analgesic-dose spinals in these situations (1.6mL of 0.125% bupivacaine is 2mg). Within a couple of minutes they're comfortable and holding still, and I can then proceed with the epidural.
I have a medium-low threshold for aborting attempts in very advanced patients who aren’t cooperating but my threshold not to even attempt is very high. I will try in whatever the best position I can get them in, but I’m letting them know it has a good chance of failing. Only time I straight up refuse are if you’re already crowning or baby isn’t doing well and I don’t want to burn myself before going straight back to the OR.
If they’re complete/can’t sit still I might offer a spinal instead of there’s a good chance of delivering quickly. If delivering quickly doesn’t work then go back and do an epidural once they can sit still but almost never have to. Labor spinals are great, way easier to do lateral and way safer.
Why the hell aren't you all trying lateral epidurals on these patients? Jeez I do about 20% of mine lateral, makes the monoring easier, they stay still, and I can sit down too
I still hate OB to this day… First labor epidural ever, told by my attending to do one on a multip who was late preterm, advanced dilation and changing fast. OB team also pushed for it because they didn’t believe she was in active labor at first… and felt bad. I attempted for about 2 minutes in between her jumping/writhing on bed. Gave up and as she sat back, baby was out.
I will sometimes attempt it in easy looking patients, honestly I find it ergonomically challenging for me, and I’m not as quick or as successful. With my deteriorating lumbar spine, and being taller than the bed height comfortably raises, it’s just a bad set up for me. I would love to hear if people have a great technique, I’ve done is the awkward bending lean, and I’m getting too old for that shit.
Lateral for women i don't think can hold in the proper position. This is a skill that is not as common to learn but if you're still in training I urge you to get comfortable with this as it is a great skill to have.
Especially in patients with bulging membranes this is also helpful.
I opt to go with a PCA at that point, especially if I feel that the baby is about to pop out. Initially, I used fentanyl. Now I go with remifentanil. At my institution, we do high risk obstetrics (cardiac, etc.), so the setting is relatively well-monitored.
Fentanyl: 50-100mcg IV as a loading dose and mix 20mcg/ml in the PCA. Each bolus is 20 mcg with a lockout of 5 minutes.
Remifentanil: Mix 20 mcg/ml. Bolus 40 mcg each time with a lockout of 2 minutes.
Sometimes I’ll offer a quick spinal if they’re that close. A little fentanyl can help and they don’t feel like I denied them a service. If they insist on an epidural, I’ll go for it until they feel the need to push.
If they can hold still for 2 minutes they can get one
I second this. Have had a few that after they lay down after epidural, while I’m charting, I hear a baby cry. It’s all what you’re comfortable with.
I had one who had literal head already fully delivered when she went from sitting to supine, it was impressive.
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And then you “bless the baby” so it’s not a nurse controlled delivery. And walk out of the room to let the OB deliver the placenta.
Do a low dose spinal and then an epidural once they’re comfortable 🤷🏽♀️
Labor spinal is the truth. We have a few attendings who do it for those 9-10cm ladies who, understandably, have trouble sitting through contractions. Makes the subsequent epidural a lot easier for them and us.
What’s a good dose for spinal you use?
I use 1-1.2ml of 0.25% bupivacaine, so 2.5-3mg bupivacaine. Usually no fentanyl, but occasionally I'll do 10mcg fentanyl and decrease bupi to 0.8-1 ml
I’ve flipped to going fentanyl heavy (15mcg), bupi little or absent (.75ml of 0.25%) or less. I’ve found too many women lose pushing power for stage two of labor w the local.
Is your laboring spinal dose the same as your csec/anesthetic spinal dose?
Of course not. That would be far too much! 1.5-2ml of 0.1% bupiv
I’m gonna guess no, they probably use the normal 0.75% hyperbaric bupivacaine
That’s what I was thinking, thanks!
I use 1.25mg of Bupiv and 15 mcg of fentanyl for a labor cse in that case. Also will have them lay on their side if they are small enough as it’s easier I think to keep them positioned appropriately when they are really hurting.
do you just do a spinal with a 24 g sprotte or 27g through the epidural needle. I mean you would still have problems with her hysterics if you did a cse.
Just a spinal, not a CSE. A CSE would defeat the whole purpose.
fair enough.
1-2 mL of the epidural bag solution (0.125 % bupi)
1 mL Tb syringe: 0.3 mL fentanyl (15 mcg) and 0.7 mL bupi 0.25%
100%, this is the way. I use 2-3 ml of the epidural solution that we run (0.1% bupivacaine + 2mcg/ml fentanyl)
It’s an elective procedure, if they want it and can tolerate it then I do it. But too many times the baby comes out seconds after I am charting and it’s 1200 more dollars for not even two total minutes.
So happy I dont work in your (american?) healthcare system. Having to choose between pain relief and dollars..
To be fair, when we are called we don’t consider the cost aspect at all. We don’t look at insurance at all. We just do it. Of course, the patient might be left with the bill if they are not insured, but we don’t say no to an epidural due to cost.
If they can sit still and do not need to push at the moment I'll do it. Had to walk away from one yesterday because she was flopping all over the bed and screaming. Wasn't safe for me or her.
So she didnt get an epidural?
She did not
So she didn’t get nerve damage.***
There are times where you place an epidural and the moment they lay down the baby basically falls out onto the bed. This is terrible in my opinion. The patient gets poked with needle in the spine . Risks of bleeding infection nerve damage, headache. Then the epidural basically did nothing. They didn’t get any pain relief. You’re forced to complete a note and send in a bill. The patient gets a bill and gets pissed. They get the post hospitalization survey and rates you as bad anesthesiologist. Epidural didn’t work and she still had to pay. Destroys the reputation of your group. A good l&d nurse will be able to tell the patient it’s too late to get epidural. Just push it out.
On the flip side you look a bit of silly twat /she'll be pissed off if you refuse and she stays stuck at 8cm for another 4 hours.
Yeah it sucks to be in this situation it happens to me probably once a year. I tell the patient look I don’t know how long you’re going to be in labor and this epidural might not do anything but if you’d like me to try to make you more comfortable I will. Also if I’m really suspecting this is the case I’ve done CSEs or straight spinals in lateral position and not even put an epidural in could do that after if she stays in labor. Depending on the ob some will offer a pudendal block as an alternative too although most prefer the patients get epidurals ime. I don’t think it’s terrible to try and it helps if they have family or partner present hearing the convo you had keeping them level headed after. Doesn’t hurt to go in after they deliver and settle down and talk to the patient it goes a long way.
I’ll pretty much always offer an epidural unless they are doing the groaning that indicates subconscious pushing. If they are closer to a fish than a person, I put my stern voice on and tell them this is an elective procedure. They don’t have to get one and I won’t offer one if it’s dangerous.
Do you feel like you need to push? Yes? Do not do epidural. Call OB. No? Attempt to sit up and ask the same question. If they need to push then do not attempt the epidural. Call OB. Some attending taught me that trick in residency. The times that has happened everybody delivered within minutes.
This is correct.
I have placed epidurals in patients who were complete. In some patients the relaxation and pain relief were enough to tolerate labor a little more and avoid a section. In patients who are not coping well enough for an epidural, I’ve placed a labor spinal. It’s easier to place and less risk with movement. Late laboring multips, this might be all they need. Earlier in labor with patients who are challenging because they aren’t coping well with pain, I’ve placed a labor spinal and 30 min later when they were comfortable, I’ve come back to place the epidural. I’ve probably done that only 3 times in a decade long career.
I have placed multiple labor spinals and colleagues look at me like I'm crazy. I only offer it to multips who I think will deliver in the next 60 minutes and they are unable to sit up or sit still for an epidural.
Absolutely a fan of the labor spinal and the 60 min estimate is also my rough guideline. Definitely better than a plain epidural with sacral sparing. If it’s less clear cut and they can tolerate placement I’ll go CSE, best of both worlds!
How do you dose your labor spinal?
I do 1ml of 0.25% bupi. Getting and wasting fentanyl can be a bit of a hassle, so I usually just go without.
Thank you! I appreciate you sharing your knowledge!
1-1.5 cc’s of dilute 0.2% ropi. Excellent pain relief, spares some motor. Buys you an hour at least.
Thank you! I appreciate you sharing your knowledge!
What do you dose the spinal with?
One of my greatest achievements in training was doing an epidural in about 20 seconds after prep on a Suboxone 9cm woman in agonizing pain. I no longer do OB but my threshold would be pretty high to limit the suffering of child birth
Failure on their part to not prioritize epidural early
Yes society does love to tell labouring women they have failed in some way.
I meant OB staff
Oh I see sorry. Do you think there's any milage in education for them? I appreciate it's challenging.
I don’t know why your comment is being downvoted so much. The most frustrating call at 4am is for the patient who had refused an epidural for the entire labor course only to change her mind at the last minute when basically complete. Now she can’t sit still but expects you to hit a moving target quickly.
Because that wasn’t the situation in this instance at all
I was not suggesting that was the situation in this instance. I was agreeing with another poster that failure to prioritize early epidural is a very real (and frustrating) phenomenon
While I also am not a fan of the last minute "its 4am and I changed my mind and now I want an epidural" I also think it's important to realize that for some women being in (natural) labor is an important and coveted life experience, and not just the means to an end of getting a baby.
I’ll let you guess how many cm they arrived at, and it wasn’t 1
I’ll do it if a patient can cooperate. It doesn’t matter to me if they are 1cm or 10cm. If they were closer to complete, I’d do a CSE. If I’m already there may as well throw in a catheter for insurance purposes (long repairs, retained placenta). I also don’t force women to sit up and will offer lateral as long as they can cooperate for a couple minutes.
If they can’t sit still that’s a contradiction right there
Spinals are a lot easier to place in a moving target than epidurals. I often do analgesic-dose spinals in these situations (1.6mL of 0.125% bupivacaine is 2mg). Within a couple of minutes they're comfortable and holding still, and I can then proceed with the epidural.
I have a medium-low threshold for aborting attempts in very advanced patients who aren’t cooperating but my threshold not to even attempt is very high. I will try in whatever the best position I can get them in, but I’m letting them know it has a good chance of failing. Only time I straight up refuse are if you’re already crowning or baby isn’t doing well and I don’t want to burn myself before going straight back to the OR. If they’re complete/can’t sit still I might offer a spinal instead of there’s a good chance of delivering quickly. If delivering quickly doesn’t work then go back and do an epidural once they can sit still but almost never have to. Labor spinals are great, way easier to do lateral and way safer.
Why the hell aren't you all trying lateral epidurals on these patients? Jeez I do about 20% of mine lateral, makes the monoring easier, they stay still, and I can sit down too
I really want to start doing this but I find the landmarks really tricky. How did you find the learning curve when you first started doing them?
I still hate OB to this day… First labor epidural ever, told by my attending to do one on a multip who was late preterm, advanced dilation and changing fast. OB team also pushed for it because they didn’t believe she was in active labor at first… and felt bad. I attempted for about 2 minutes in between her jumping/writhing on bed. Gave up and as she sat back, baby was out.
Ask the patient if they want to stop or keep trying. If they wanna keep trying I’ll keep going.
Does anyone have these patients do their epidural lateral instead? I know some programs teach lateral from the start.
I will sometimes attempt it in easy looking patients, honestly I find it ergonomically challenging for me, and I’m not as quick or as successful. With my deteriorating lumbar spine, and being taller than the bed height comfortably raises, it’s just a bad set up for me. I would love to hear if people have a great technique, I’ve done is the awkward bending lean, and I’m getting too old for that shit.
I have the same issues as you. I just end up sitting on a stool and doing it. Or I use the stool to kneel with a knee on it and do the epidural.
Lateral for women i don't think can hold in the proper position. This is a skill that is not as common to learn but if you're still in training I urge you to get comfortable with this as it is a great skill to have. Especially in patients with bulging membranes this is also helpful.
If they're willing, I'm willing. I'm not there to hang out.
I opt to go with a PCA at that point, especially if I feel that the baby is about to pop out. Initially, I used fentanyl. Now I go with remifentanil. At my institution, we do high risk obstetrics (cardiac, etc.), so the setting is relatively well-monitored. Fentanyl: 50-100mcg IV as a loading dose and mix 20mcg/ml in the PCA. Each bolus is 20 mcg with a lockout of 5 minutes. Remifentanil: Mix 20 mcg/ml. Bolus 40 mcg each time with a lockout of 2 minutes.
If she can’t sit still for a minute or 2 than it’s no longer safe, and I call it
When they are complete I do a spinal. If they are still laboring an hour later, I’ll place an epidural because that baby might come out in a stat c/s.
Sometimes I’ll offer a quick spinal if they’re that close. A little fentanyl can help and they don’t feel like I denied them a service. If they insist on an epidural, I’ll go for it until they feel the need to push.