UCSF OB Anesthesia Meeting

Specialties CRNA

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Just returned on Sunday from the UCSF OB anesthesia meeting, held annually in San Francisco, and I can say that I really enjoyed the conference. It was very informative, interesting, and San Fran's a great city to have a conference in. However, I saw the real estate section in the paper, which reaffirmed my decision not to live out there. A pearl or two from the conference:

There has been a study done on the effect of epidurals on the duration of labor. Now, for a long time, common wisdom has held that epidurals, while great for a mother in pain, can significantly slow the progress of labor. Many OB's and anesthesia providers have also felt that putting in epidurals too early (4 cm dilation seems to be the magic cut off) can even put a temporary halt to labor. The data of this study suggests something many of us have long suspected. Neither of these common wisdom assumptions are borne out by the data. In fact, the timing of the epidural has little or nothing to do with the progress of labor, and epidurals may actually shorten the duration of phase I of labor. The information was presented by one of the study's investigators, and his words were the only reason he could see to delay putting the epidural in a patient who desired it was because you wanted the patient to experience the pain associated with labor. (Said with smirk on face.)

Post epidural infections were also discussed. There are a lot of us (myself included, I must confess) who learned that it was not necessary to wear a surgical mask when doing a neuraxial anesthetic. There is a case of a parturient who died about 24 hours after epidural from bacterial meningitis. When the bacterial culprit was cultured, it was found to be an exact DNA match for bacteria cultured from the anesthesiologist's nose. (Not at all a slam on the provider. There are a LOT of us who don't wear masks when placing epidurals. I will from now on, however.) Interestingly, a confidential survey of anesthesiologists in Australia found that something like 1% felt that sterile gloves were unnecessary for epidural placement. So maybe not wearing the mask isn't the worst thing you could be doing.

We were also addressed by a CNM who provided data on other methods of labor pain management. Like most midwives, this woman appeared to have a definite bias against epidural pain management for labor, but did provide some very interesting data reported by women after delivery. Various modalities were tested and patients were surveyed about what they found most effective for helping cope with labor pain. The methods that are most often used, breathing and position changes, were rated the least effective. Use of a warm bath or warm shower for labor (not to be confused with water birth) were the most efficacious of the non-epidural pain management techniques. In fact, 49% of women found that immersion in a tub was very helpful in dealing with labor pain, and 32% found that a shower was very helpful. (Interestingly, a point mentioned, but downplayed, found that 78% of women rated the epidural very helpful. The survey also failed to ask women how they felt about using a tub used by 250 other laboring women.)

Anyway, I met several people at the conference who make it a point to attend the UCSF conference annually. I don't know that I'll do that, but I will go back.

Kevin McHugh

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Thanks for the synopsis Kevin. I was wondering if you remembered the name of the study dealing with epidural's and length of labor ... I'd love to read about it.

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thanks! As an OB nurse, your report on the conference was an interesting read. I saw a mention of that early labor epidural study somewhere, and have really been wanting to read it. Was it mentioned/do you happen to remember if the study considered women who needed pitocin augmentation post-epidural and those who didn't?

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I am pretty sure the study you refer to was done here at Northwestern I believe it is is the new england journal of Med. Cynthia Wong MD was the P.I.

thanks! As an OB nurse, your report on the conference was an interesting read. I saw a mention of that early labor epidural study somewhere, and have really been wanting to read it. Was it mentioned/do you happen to remember if the study considered women who needed pitocin augmentation post-epidural and those who didn't?
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nevermind I just re-read the first post~!

I am pretty sure the study you refer to was done here at Northwestern I believe it is is the new england journal of Med. Cynthia Wong MD was the P.I.
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Actually, you are correct. Cynthia Wong was the presenter. I typed his earlier. Either my sexism or simply a lack of sleep coming though again.

KM

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Some of the information from Dr Wong:

-Analysis of c-section and instrument assisted delivery rates before and after introduction of epidural pain management for labor demonstrated that neither rose in numbers after the introduction of labor epidurals. Also, epidurals introduced early on don't prolong stage one labor.

http://news.bbc.co.uk/2/hi/health/4268419.stm

On the other hand, epidural analgesia may slightly prolong stage 2 of labor. However, the shortening of stage one of labor seemed (to me) to be significantly more pronounced than the prolongation of stage two. The prolongation of stage two had no impact on neonatal outcomes.

http://www.medicinenet.com/script/main/art.asp?articlekey=43543

When compared to opioids, epidurals were generally found to shorten the overall length of labor:

"The average time between the administration of any pain relief to complete dilation was 295 minutes for women receiving early epidurals compared to 385 minutes for the opioid group. Overall length of labor was shorter for the early epidural group as well -- 398 minutes versus 479 minutes for the opioid group."

Additionally, babies of moms who got epidurals fared somewhat better in the short term over moms who got opioid analgesia:

"Babies born to mothers given an opioid analgesic were significantly more likely to have a one-minute Apgar score of less than seven -- 24 percent versus 16.7 percent for the early epidural group, according to the study."

Kevin McHugh

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Specializes in Anesthesia.
.......

Additionally, babies of moms who got epidurals fared somewhat better in the short term over moms who got opioid analgesia: .........

Kevin, are they referencing IV opioids, intrathecal opioids, or both?

?

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Kevin, are they referencing IV opioids, intrathecal opioids, or both?

?

IV opioids. I don't have the reference materials at hand, but I think they were looking at epidurals with opioid infusions.

KM

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Post epidural infections were also discussed. There are a lot of us (myself included, I must confess) who learned that it was not necessary to wear a surgical mask when doing a neuraxial anesthetic. There is a case of a parturient who died about 24 hours after epidural from bacterial meningitis. When the bacterial culprit was cultured, it was found to be an exact DNA match for bacteria cultured from the anesthesiologist's nose. (Not at all a slam on the provider. There are a LOT of us who don't wear masks when placing epidurals. I will from now on, however.) Interestingly, a confidential survey of anesthesiologists in Australia found that something like 1% felt that sterile gloves were unnecessary for epidural placement. So maybe not wearing the mask isn't the worst thing you could be doing.

Kevin, did they reference any specific study regarding this? I would be interested in reading it if they did. Maybe half of our MDA's wear masks when placing OB epidurals.

Sprout :nurse:

BTW I'm doing better with my epidural placement now at the end of my 3rd week of my OB rotation!

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Sprout

Here are a few references: (All straight from the UCSF course syllabus)

Baer ET. Iatrogenic meningitis. The case for face masks. Clin Infect Dis 2000; 31:519-21

Brown, IM, Birnbach DJ. "Unmasked Mischief" Anesth Analg 2001;92:277-8

Panikkar KK, Yentis SM. Wearing of masks for obstetric regional anaesthesia. A postal survey. Anaesthesia 1996;51:398-400 (I think this is an Australian journal. I also think this is the survey which found a percentage of anesthesiologists don't wear sterile gloves for epidural placement.)

Glad to hear you are getting more comfortable with the epidurals. Remeber, they can be like IV's. Some days, you just aren't holding your tongue right, and the more you do, the better you will be.

Kevin McHugh

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All of which gives me an idea for a lab study, if there are any interested students out there.

Kevin McHugh

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