Epidural Drug Choice and Failure to Progress/Descend

[heartICU]

Hey guys,

I am a SRNA currently doign my OB rotation, and have noticed something over the past few call shifts. Just wanted to see if any of you see the same thing.

Depending on the staff for the day, I use either ropivacaine or bupivacaine. If I use marcaine, I usually load them first with ten cc of either 0.25% marcaine with 50mcg of fentanyl or 25mcg of sufentanil (depending on staff) and then start an infusion of 0.0875% marcaine with 5mcg/ml fentanyl.

If I use ropivacaine, I load them with 10cc of 0.2% ropivacaine with 1mcg/ml sufentanil, and then start an infusion of the same solution.

Here is my observation...it seems like I end up doing a lot more C/S for FTP when I use the ropivacaine. Seems like even though they feel the contractions, their pushing ability is not the same as with marcaine. What do you think? Do you see an increased rate of FTP depending on which epidural drug is used?

[SmilingBluEyes]

Where I work, All of our MDAs use bupivicaine or lidocaine these days. I remember CRNA's giving ropivicaine where I used to work and never noticed an increase in FTP cases at all. But then a lot of people there got intrathecals, versus epidurals. It was a different environment altogether.

[heartICU]

Where I work, All of our MDAs use bupivicaine or lidocaine these days. I remember CRNA's giving ropivicaine where I used to work and never noticed an increase in FTP cases at all. But then a lot of people there got intrathecals, versus epidurals. It was a different environment altogether.

My observation may be purely anecdotal with no evidence behind it. Just checking to see if it is a trend that others have noticed, or if I am crazy:rotfl:

[PegRNBSN]

We have noticed stronger motor blocks with ropivicaine, which the anesthesiologists have used more and more without narcotics because they didn't want to sign the narcotic waste sheet at the end of the epidural!

We have no research based data but we need to move these patients more, their pushing seems less effective, and we are turning the epis down more to enable them to push (but they end up going from no pain to alot of pain and I think this is cruel). We have also had three significant back/neck injuries to nurses, one possibly career ending. We are pushing to have them return to Marcaine with narcotics.

[SmilingBluEyes]

Great input, Peg. That was enlightening. As I said, I have not seen Ropivicaine used for about 6 or 7 years now---so I am not too terribly qualified to judge. Anecdotally, I have noticed WHEN the epidural takes place seems to be of importance. In the absence of active labor, where cervical change is occurring, there has seemed (just to me) to be a problem----more so than which drugs the MDA has chosen to use. Also, like I said, ours are using Bupiv/Lido and Fentanyl---(we sign the Fentanyl out and open it for the MDA when ready--- and they use the whole 5ml in the bag, so no wastage to sign). It seems to work really well, most women are very comfortable, yet able to detect their contractions as pressure and fully participate in pushing. Another key is letting women "labor down"----SO VERY IMPORTANT in the success and fatigue factors. Also, moving a lady from side to side and varying positions (High Fowler's for gravity benefit, if tolerated) is also a key in succeeding in baby descending down.

I let them labor down til baby is VERY low before even discussing pushing. I think that is just as important, if not more so, than almost anything else.

One question HeartICU, are you discussing Primips here?

[JaneyW]

Anectdotally (sp?), I worked at a place a few years ago that used premixed ropivicaine/fentanyl and I was seeing more motor block as Peg said. These women were pretty much paralyzed from the waist down and had I think more c/s for FTP. Again, no real evidence to back that up. I have since worked where they use Marcaine or lidocaine and the women can still move and feel pressure and don't seem to have the high c/s rate.

I will say that I also think that station has a lot to do with FTP. I am now at a teaching hospital and there seems to be a real urgency to get them pushing when they are complete regardless of station. Maybe they are being told that they shouldn't be complete very long? I have to play games to keep people from puching too early. Not fond of that, but it works.

[oneRNprn]

My hospital uses a fent/ropi mixture. I agree with SmilingBluEyes that the the most important determinant of a c/s for FTP is the patient's cervical dilation at the time of receiving the epidural. Also, the rate of infusion seems to make a difference. My best trick for moms who absolutely "need" an epidural at 2 cm is using a birthing peanut to help with fetal head descent.