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[Walter Petorski]

Does anybody change their epidural technique for woman having a trial of VBAC? I ask because recentlyI had an episode of uterine rupture in a woman who I had previously placed an epidural and using my usual epidural solution and dosing (0.125% bupivacaine with 5mcg/mL fentanyl on a 5mL PCEA). The rupture was picked up quickly because of a worsening CTG and an ultrasound on standby.

[George Miklos]

I don't alter anything I do. Our hospitals have a policy of CTG monitoring for ALL patients with epidurals. The ultrasound on standby is only useful if there is somebody around who knows how to use it.

[Bucky]

We have a large OB practice comprising many TOLAC (the term used until successfully delivered vaginally) patients.  We do not alter anything that we do, epidurally.

[Ahmad Menari]

Likewise, standard epidural, CTG monitoring.

However, the hospital where I work has put in a new policy that any time there is a VBAC patient, the anesthetist should be on standby within the hospital, epidural or not. This DESPITE the fact that they do not require the obstetrician to be within the hospital. Naturally we have raised the issue of the fault in logic with administration but so far they have failed to yeild.

[jetproppilot]

I don't alter my technique. My partners and I started doing combined spinal-epidurals (CSE) for labor analgesia several years ago and have never looked back. Arrow makes what I think is the best CSE kit. To the epidural space with the Tuohy, pop intrthecally with the 26 gauge spinal needle, inject ropivicaine 2mg and sufentanil 5 mcg, pull out the spinal needle, thread the catheter, and you're done! Just hook up the infusion. We use ropivicaine .2% with sufentanil .5 mcg/ml and run it at 12 ml/hr for just about every lady. Our redose rate is very, very low, unlike the bupivicaine/fentanyl stuff we used before.

Many advantages in my humble opinion. One does not have to dose the catheter which saves time, and is safer since there is virtually no chance of a high block. The intrathecal dose given isn't enough to give a high block, or at least I've never seen one in the 3 or 4 years I've been doing it. Redose rate is VERY low, yet another advantage for the busy practitioner. I've had one post-dural puncture headache in the last eight months and our delivery unit does between 175-200 deliveries a month.
Not to mention the superior safety profile of ropivicaine. One disadvantage is the women itch for about thirty minutes after the procedure from the sufentanil, but usually resolves on it's own. The delivery nurses love it and so do the patients. The CRNAs love it too because at my facility we have an OB CRNA who does the redosing. Drastically reduces their workload.
 

[Thomas Porter]

I work in a 110 bed community hospital where the OBs(5 of them) wanted to do VBACs.  We have one anesthesia provider on-call and a fairly active overnight Main OR schedule.  The OBs would only do a VBAC IF the patient agreed to epidural analgesia, effectively keeping the anesthesia in-house.  However, we declined to do this UNLESS the OB was also in house and the anesthesia provider had no Main OR responsibilities.  The hospital offerred to reimburse if another anesthesia provider had to come in but the OBs wanted to continue with the "30 minute" rule when applied to themselves.  I pointed out the hospital's legal liability in this and also pointed out that the hospitals small blood bank support (we do not do any trauma).  I also did an extensive literature search and documented the latest opinions in the general medical literature (NEJM) and well as the anesthesia and obstetrical literature.  After 6 months of rangling over this, the hospital administration sided with the Anesthesia Department.  Our OB Service is not busy enough to justify having 24-7 dedicated OB Anesthesia coverage.

The moral to the story is, do your homework, stand on firm medical grounds, and don't let yourself be bullied into doing something you know is wrong.

[moises]

:-*can you share your to us the medications you use in spinal for labor pains?

[yogenbhatt1]

You asked for drugs used intrathecally for labour analgesia.
We here in India use it when we know that patient will deliver in a very short while. Specially when called at 7-8 cm dilatation and patient suddenly becomes roudy. At this time it is not easy or needed to give an epidural.
We inject 0.2 ml of Buivacain Heavy and 25 microgram of Fentanyl.