ob anesthesia cheat-sheet

labor spinal: 1 cc of 0.25% bupiv +/- 20mcg fentanyl

you arrive in the morning …

sign-out with post-call resident /staff and incoming residents and staff, using the
sign-out sheet
check and set-up ors (stat c/s ready)
epidural cart set-up
check procedure schedule and pre-op patients when they arrive for their procedure
complete post-op checks (see below)
sign "on shift" / "off shift" on ongoing anesthetic paperwork
check omnicell machine for discrepancies
multidisciplinary rounds  07:30 & 19:30

you pre-op/consent a patient …

we see all patients! (even those planning natural childbirth)
draw an x'd box on the labor board (a blank box indicates that the patient needs to
be seen by our service/a box
with a single slash means pt has been seen but not consented).
refer to emr for relevant history.
leave chart on clip-board outside door.
patient consent. some number of the patients will have been seen during an
outpatient consult (i.e. those with particular anesthetic issues/concerns or those with
scheduled ob-related surgical procedures). these will be filed in our blake 14 office in
the black binder (see below). the risks/benefits of regional anesthesia, including:
potential technique not working headache (roughly 1-2% risk), bleeding, infection,
nerve/neck/back injury (extremely unlikely). patients who are not interested in labor
analgesia should be told about anesthesia (preferentially regional) for c/s. inform
patient, family members that for the sterile portion of the procedure they will be
asked to step out of the room.
anesthetic record. instructions for signing onto anesthetic records and for filling in
a,b,c,d and c/s start times can be found below. please do not sign the blank
anesthesia record when you consult a patient, unless you are initiating an anesthetic.
be aware that patients may be enrolled in the "labor" study, a study to look at
maternal temperature in labor. we do not do anything different for these patients.
discuss issues with anesthesia and ob cohorts.

you see an outpatient consult …

complete anesthesia pre-op/consent form.
discuss relevant issues with anesthesia attending.
place completed consult in ob anesthesia office black binder
if there are "action-steps" needed to be taken, be sure to follow them up yourself or
identify someone to follow-up
on them.
it is appropriate to send a brief consult note to the ob staff or midwife summarizing
the substance of the consult.
this should be printed out and attached to the consult note.
in the rare instance that you are unable to see the patient in a timely manner, please
discuss a) the patient returning to the labor floor after lunch or a planned ob visit b) a
telephone consult later in the day if appropriate.

you place a labor spinal/epidural …

sign out drugs (standard mix is bupivacaine 0.08% with fentanyl 2 mics/cc).
initiate block with test dose of 3 cc's of lidocaine 1.5% to rule out
intravascular/intraneural/intrathecal with epi
followed by an additional 2 cc's lidocaine 2% w/epi, and 10-15cc's (in 5 cc
increments) of standard mix, all administered through the epidural catheter. the goal
is a total volume of 15-20 cc/s
start infusion rate at 12-13.5 cc/o.

complete anesthesia record including "a" time (procedure set-up time), "b" time
(when test dose is given)
on the anesthesia record, in the diagnosis category write "iup" (intrauterine
pregnancy). in the procedure category, write "labor--" when the anesthetic is
placed. when the anesthetic is closed out, complete the procedure line with either:
"nsvd" (normal spontaneous vaginal delivery) or "c/s" or "vacuum assisted vaginal
birth" or "forceps assisted vaginal birth", etc. place consent and anesthetic record in
patient's gray chart.

write "e" on labor board

note: once a labor anesthetic has been initiated, every patient encounter,
including syringe changes, should
be documented on the anesthesia record including information about
time of contact (in military time),
maternal bp, fhr, patient comfort and your initials/signature.

if a "wet tap" occurs:

consider threading a catheter roughly 4 cm into the space for use as a "spinal
catheter". if paresthesia occurs or if you cannot aspirate csf easily, discontinue the
catheter.
if a spinal catheter is to be used in labor or for c/s, several precautions must be
taken:
a) explicit labeling (on the catheter, on the white board, on the patient's chart, that
the catheter is "intrathecal" or "spinal".
b) use of reduced doses of medical (all meds must be preservative free):
1) dose similar to a labor spinal, that is, 2.5-3.0 mg bupivacaine + 20 mics or
less of fentanyl. can be repeated roughly every 2 hours.
2) or alternatively, an epidural infusion (our usual, bupivacaine 0.08% w/fentanyl
2 mics/cc) can be run at a rate of 1-3 cc/hr after the initial 2.5-3.0 mg bupivacaine
+20 mics fentanyl or less
3) it is currently our practice to remove catheter (as we do for labor epidurals)
after delivery (there is some literature that suggests keeping the catheter in situ may
reduce the incidence of pdph but it is not conclusive)
c) a full explanation to the patient, including the risk of headache (shown to be
roughly 55% in a recent meta-analysis) within the first several days after the wet tap
d) for statistic collection purposes, an email to dr. lisa leffert, and greg eriksen
with the patient's name, date of procedure and unit number.
e) a relevant sign-out to the incoming team so the patient can be properly
followed up.

you sign-out drugs …

use omnicell (suremed) system for medication sign-out and return of unopened vials.
use 'stat-pack' only for emergencies.
unused controlled substances should be wasted at the end of the procedure in the
presence of another md or rn. the drug and amount wasted should be recorded on
the anesthesia record and co-signed by the md or rn witnessing you waste the drug.
you do a c/s …
remember, any or case can lead to a general anesthetic at any time. position patient
on the or table optimally, with a potential difficult airway in mind (i.e. no fluffy
pillows, etc)

on anesthetic record please note:

time of initiation of dose-up of epidural if c/s follows from labor epidural (in
yellow box).
placement of routine monitors, lud. check off box and record time in dark yellow
boxes of record if c/s
follows labor.
patient positioning: supine, head on blankets, arms abducted < 90 degrees,
ulnar nerve free from pressure. lud roll placed.
time of skin incision
time of uterine incision
time of delivery
apgar scores
presence of nicu team during delivery.
patient comfort/anesthetic sensory level.

if a labor epidural is already in place:

redose oral bicitra
top up with, on average, 15-20 cc's of either 3% chloroprocaine or lidocaine
2% with epi, each
bicarbonated with 2 cc's hco3 / 20 cc's drug.
+/- add fentanyl, 50mics diluted in preservative-free normal saline (pfns) or in
local anesthetic, above,
before case begins.
when baby is born:
pitocin diluted in bag of lr, iv, typically 10u per 500 cc's. dr. greene has taught us
that a small bolus of iv pitocin (2-3u) given at cord clamping facilitates separation of
the placenta and can decrease ebl.
iv ancef, 2 grams if pt not allergic or already receiving abx (if so, check with
ob's)
+/- epidural fentanyl, 50 mics diluted in pfns
confirm whether pt can take nsaids
administer epidural duramorph, 6 cc's = 3 mg
complete post-op sheet to include time and dose of duramorph and apgars and
disposition of baby (i.e. if it went to the nicu)

complete post-op anesthesia orders in cas under post-op anesthesia orders button
followed by postpartum neuraxial anesthetic order template. we routinely select all
of the post-op options unless the patient has a contraindication to a particular
medication indicated.
usual medications given include:
if post-op itching thought to be narcotic induced, administer nubain 5 mg iv
if post-op n/v: consider zofran.
if post-op break-through pain:
if early-on, consider dose of ketorolac 30 mg iv (one dose).
if later, consider oral or iv (eg pca) narcotics.
no patient should be in pain even if it's still within 24 hours of duramorph
administration.
if c/s was initiated with chloroprocaine, consider follow-up dosing with a longer acting
local anesthetic (e.g. lidocaine) before leaving the or.
d/c epidural at end of case unless further surgical intervention seems likely,
or if coagulation status is of
concern.
place anesthetic record/consent in patient's chart, post-op sheet in "post-ops to
be seen" envelope and billing copy in "anesthesia billing" box in ob anesthesia office.

if no regional anesthetic in-situ:

for spinal, use bupivacaine 0.75% with dextrose (pre-mixed in spinal kits):
approximately 1.6 cc's plus duramorph 0.2 mg (=0.4 cc's in most of the vials) and
fentanyl, 10-25 mics (=0.2-0.5 cc's).
aim for roughly t4 sensory level.
for de novo epidural, typically use lidocaine 2% with epi/hco3 (after 3 cc
lidocaine 1.5% with epi test dose): approximately 20 cc's. follow c/s protocol as
above.
post-op orders in cas.

you do a non-c/s or case…

remember, any or case can lead to a general anesthetic at any time. position patient
on the or table optimally, with a potential difficult airway in mind (i.e. no fluffy
pillows, etc)
every time you take a patient to the or, except when transitioning a laboring patient
to the or for c/s, you should start a brand new anesthetic record (even if you are
using an in situ epidural).

tubal ligation (btl)

aim for roughly t4 sensory level

must be done on new anesthetic record, even if epidural is in situ!!
if using existing epidural, check to make sure epidural has not fallen out.
if skin markings are unchanged from placement, give "test dose" of 3 cc's
followed by an additional; 4-6 cc's of lidocaine 2% w/ epi in divided doses or 2-
chloroprocaine 3% to document that epidural is still working.
if initiating a spinal, dose with bupivacaine 0.75% with dextrose (pre-mixed in spinal
kits): approximately 1.6 cc's if within hours of delivery. if >6 hours post delivery,
consider increasing dose of local anesthetic. also, if short acting spinal is
appropriate, consider (mepivacaine 1.5% : 4 cc's) plus 1 cc (dextrose, 10%). for
post-op pain, give toradol in or (if appropriate after discussion with ob) and iv or po
narcotics.
note patient's phone number on post-op sheet if patient is to be discharged within 24
hours.
place anesthetic record/consent in patient's chart, post-op sheet in "post-ops to be
seen" envelope and billing copy in "anesthesia billing" box in ob anesthesia office.

d&e

must be done on new anesthetic record (even if using an in-situ epidural for
postpartum d&e).
if 1st trimester: typically done as a mac (use fentanyl/versed/ +/- propofol, toradol).
if 13-22 weeks: typically done as spinal vs. get.
note patient's phone number on post-op sheet if patient is to be discharged within 24
hours.
note on post-op sheet that there is "no baby" (to avoid embarrassing mistakes).
place anesthetic record/consent in patient's chart, post-op sheet in "post-ops to be
seen" envelope and billing copy in "anesthesia billing" box in ob anesthesia office.

cerclage

aim for saddle block.

use bupivacaine 0.75% with dextrose (premixed in spinal kits), roughly 1.2-1.5 cc's
+/- fentanyl 25 mics (0.5 cc's) or mepivacaine 1.5%, 4cc's plus 1 cc dextrose, 10%.
note patient's phone number on post-op sheet if patient is to be discharged within 24
hours.
place anesthetic record/consent in patient's chart, post-op sheet in "post-ops to be
seen" envelope and billing copy in "anesthesia billing" box in ob anesthesia office.

you d/c an epidural…

if patient is scheduled to have a tubal ligation, or another surgical intervention is
likely (e.g. re-exploration for post-
partum bleeding), leave epidural in situ. consider administering duramorph
before d/c'ing the epidural for
patients in whom one expects greater than normal postpartum pain (e.g. for
patients with fourth degree tears)
after vaginal delivery, after discussion with ob's and nursing.
if duramorph is administered, patient must stay in-house for the subsequent 24
hours, and the duramorph
orders and nursing flow sheets must be completed.
when epidural is d/c'd:
record "tip intact", delivery date, time, apgars on anesthesia record. note: "c" =
"d" time = delivery time
unless epidural is used for a post-delivery procedure/bolus for perineal
repair, etc. "c" and "d" times for vaginal delivery are the same and are the time of
birth.
place anesthetic record/consent in patient's chart, post-op sheet in "post-ops to
be seen" envelope and billing copy in "anesthesia billing" box in ob anesthesia office.

after or cases…
c time = time out of or
d time = transfer to nursing
before a patient is transferred to post-partum floor, a brief "pacu" style note should
be written by anesthesia in the progress notes.
it wasn't your fault, but let's say there was a wet tap: in addition to or record
charting, also check off box on billing copy of or record. discuss case with attending
to plan appropriate follow-up of patient. notify dr's leffert/pian-smith for ob stats
database.

you do a post-op check…

write note in patient's chart (in the progress note section):
if post-partum neurapraxia, discuss case with ob nurse practitioner and
anesthesia staff. neurapraxia is rarely due to epidural, therefore it is ob service (via
the ob nurse practitioner) who subsequently follows-up with patient.
if post-partum headache, discuss conservative therapy vs. blood patch. follow
patients closely to facilitate
prompt treatment as needed. patients should, in general, not have
extended length of stay because of
pdph.
if no further f/u needed, file paper copy of post-op check in alphabetical folders in
anesthesia office.
if further follow-up needed, place post-op sheet in "postops to be seen" folder.
if you are giving a patient a telephone number to reach us (e.g. s/p wet tap)
please give them 617-724-9410 (labor floor desk).

you sign-out…
morning sign-out is at 7:00 am each day except thursday when it's 6:45 am;
residents then to go case
 conference/grand rounds and staff cover floor until 9:00 am.
each time a resident comes for a shift, the team should review each patient on the
floor with incoming anesthesia team; include age, gp status, gestational age, medical
and intrapartum issues and course of labor to date. pass along an updated sign-out
sheet. the omnicell should be checked to make sure there are no drug discrepancies.
hand over beeper!!!!
incoming residents at 07:00 and 15:00 should:
a) check for discrepancies in omnicell and
b) sign "on shift" on anesthetic records for labor epidurals and or cases.
c) check the or to ensure they are setup fully with working equipment in case of
stat c-section
d) stock the epidural cart

rev. 8/1/05