LOCAL for C/S?????

Ok, just wanted to throw this out there and get some input:

My first pt this morning was a primip, complete, +1 with a bulging bag. Dr comes to AROM; every other time or so we push she has a big fat 70 sec variable down to the 80's. We actually only pushed 4 or 5 times; this doc is one that will not tolerate much on the monitor, so off we went to the back bcuz she was only +2 station and he didn't think he could use a vaccuum. (I wondered if he could've let her labor down, as the baby was FINE unless she was pushing, and then applied a vaccuum? Probably didn't want to wait that long, I guess.)

So anyway, she had had her labor epidural pretty well redosed before we started pushing, but she still had some muscle control and sensation. We got back to the OR, got her onto the table, and they kept injecting meds into her epidural and she just would not get numb completely. I thought for sure they were going to put her to sleep, but then the doctor says, "Can I get some Lidocaine and a control syringe please?" I froze, waiting for him to ask for it again like I had heard him wrong. So we opened it up on the table and he injected local around the incision site and then CUT. My charge nurse was in the OR with me because she had helped me take the pt to the back, so I asked her about it and she said that maybe it was just the incision site that wasn't numb - if that was the case, she said it would have been appropriate for him to use local.

Anyone else have experience with this? Did I fail to advocate for my pt today by opening the local for him? Should I have asked loudly, "So, Dr X, do you think we might have to put her to sleep?" or am I upset for no reason? As a side note, she got epidural narcotics and Fentanyl, Morphine, Astromorph - you name it IV for pain. She sure was not hurting in recovery, but she was sick as a dog. Couldn't get her nausea under control completely, 8mg of Zofran later. The anesthesiologist told her it was the narcotics making her sick; that he could reverse the narcotics to take her nausea away, but then she would be hurting . . .

Just kind of upset about this poor pt today. Feel like I didn't do my job.

Yes, I've seen it, and I was equally (but unnecessarily) horrified. In my patient's case, it was a C/S for FTP, so not a "true" emergency. She had a labor epidural that couldn't be adequately dosed. The OB had been very patient, and wasn't trying to rush anesthesia. After numerous attempts to numb the patient, both docs agreed on a local. The patient was told that if the local wasn't acceptable to her they would put her under general anesthesia, which she didn't want. It worked like a charm. Mom was numb, and was able to be awake for her baby's birth.

As a side note, she was very comfortable afterward. Probably a combination of the local and the numerous epidural meds she had received. But she moved well post-op without any complaints!

At a facility where we do approx 3 C-sections per shift and I have been there over eight years, I've seen the local trick used quite a few times. Don't know why the epidural seems to be numbing everything deeper, but not superficial. SG

I suspect the local option would be more acceptable than what was done to my daughter. After 1 cytotec on a thursday morning, they ended up sectioning her on friday. She had not progressed, after the one cytotec, pit drip, AROM, and epidural for pain. When they decided to do a section, I asked how they were going to anesthetize her, they said it could be done through the current epidural. I waited in the labor room for nearly a half hour before they called me in. They had assured me that they would not bring me in until she was completely numb. The first thing I noticed that my daughter was in shock, unable to talk, the look of a panicked DOG on her face! The team was tugging and pulling the baby out, and my daughter started to scream, and scream again. apparently while they were anesthetizing her, she kept telling them she still felt pain, and they just gave up and started cutting. She said she felt everything. I was so sad for her. I felt as her coach I had let her down as I never suspected they would start cutting before she was properly anesthetized. :stone

I suspect the local option would be more acceptable than what was done to my daughter. After 1 cytotec on a thursday morning, they ended up sectioning her on friday. She had not progressed, after the one cytotec, pit drip, AROM, and epidural for pain. When they decided to do a section, I asked how they were going to anesthetize her, they said it could be done through the current epidural. I waited in the labor room for nearly a half hour before they called me in. They had assured me that they would not bring me in until she was completely numb. The first thing I noticed that my daughter was in shock, unable to talk, the look of a panicked DOG on her face! The team was tugging and pulling the baby out, and my daughter started to scream, and scream again. apparently while they were anesthetizing her, she kept telling them she still felt pain, and they just gave up and started cutting. She said she felt everything. I was so sad for her. I felt as her coach I had let her down as I never suspected they would start cutting before she was properly anesthetized. :stone

That is horrifiying, and I am sorry that she had to go through that - you as well. When the baby is delivered through the incision, there is normally a great deal of pressure,tugging, pulling etc that will be felt. I suspect her experience was NOT normal, and it sounds like she in fact was not adequately anesthetized if she actually felt PAIN. The other sensations are normal, while pain is not. My heart goes out to both of you. How 'bout that baby?! Is he/she just wonderful? SG

At a facility where we do approx 3 C-sections per shift and I have been there over eight years, I've seen the local trick used quite a few times. Don't know why the epidural seems to be numbing everything deeper, but not superficial. SG

Actually, it is pretty common for a spinal or epidural to be inadequate at the skin and fine once the incision is done. Epidurals are more reliant on normal anatomy than spinal anesthesia and they are notorious for patchy unanesthetized spots. Unless the epidural is working absolutely perfectly, we remove it for sections and give patients a spinal which is a much more foolproof anesthetic. Local anesthesia, given to get the surgery going,usually works well.

It's also possible (not fun) to do a C-Section under local (and I mean JUST local), and every OB and hospital that does C-Sections should understand that it is a viable option. If you don't have an epidural in place and you don't have anesthesia in-house, how long are you going to wait to do a truly emergent C-Section?

Anesthesia can put the patient to sleep when they get there - you can get the baby out under local if you have to.

That is horrifiying, and I am sorry that she had to go through that - you as well. When the baby is delivered through the incision, there is normally a great deal of pressure,tugging, pulling etc that will be felt. I suspect her experience was NOT normal, and it sounds like she in fact was not adequately anesthetized if she actually felt PAIN. The other sensations are normal, while pain is not. My heart goes out to both of you. How 'bout that baby?! Is he/she just wonderful? SG

She is wonderful. I got to see her over the holidays, my daughter and son in law live in San Diego, he is a Marine and will be deployed in February. I am flying out in May with my little guy, and the 4 of us (daughter granddaughter and my 3 year old son) are going to take a much needed vacation in the sun and on the beach.

Thank you for the concern. It was not the picture perfect birth that I wanted for her, but as long as we got a good healthy baby, that is all that matters.

Thanks for all your responses. I learn so much every day that I work (and after work, here on the forum!) . . . Just the first time I had seen that.