Obstetrics / GYN Guidelines

Updated May 4, 2015
Author: Sutherland, VerLee

Description:  A compilation of various techniques and information for anesthesia care of Obstetrical & GYN patients

Childbirth

MMC OB Anesthesia Manual 2015

References:

GYN & Other Surgery


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Obstetric Consults

August 2001-Sutherland/Ascanio

  • Use only the special triplicate form. Location: above printer shelf on Labor/Delivery Nurse's Station.
  • If you need to print a form, click here.
  • Complete and return to Anesthesia Secretary (662-2526). She will forward copies to:

  • Anesthesia for PUBS (percutaneous umbilical blood sampling):

    (9/2000)

    Indications: therapeutic & diagnostic purposes in:

     

    Anesthetic Management: either MAC-sedation or GA.


    IntraThecal Analgesia for Labor

    Indications:

    Suggested Therapy:

    1. 1cc Bupivacaine 0.25% (5 mg) + Fentanyl 20-25 mcg

    Anesthesia for Caesarian Section

      • A. Spinal: Suggested Recipe:
        • 1.6 cc 0.75% Bupivacaine w/ Dextrose
        • 200 mcg Duramorph (not at Mercy Hospital)
        • 20-25 mcg fentanyl
           
      • B. Using the Labor Epidural For C/S Suggested Guidelines
        • 1. Selection of appropriate candidates
          • a. Quality of epidural: few boluses required during labor
          • b. Duration of epidural: - < 6 hours usually work well, >18 hours much less effective. There is no literature on this, although discussions with some OB anesthesiologists at the BI raise the possibilities of expansion of the epidural space due to large volume infused over long time or desensitization to effects of local anesthetics as causes of a recognized problem. I use approx 12 hours as my cutoff, although this is clearly not based on any hard evidence.
          • c. Personality of patient if very sensitive to discomfort, may be uncomfortable with sensations experienced with epidural (consider spinal instead)
          • d. Quality of labor/fetal factors---if very dysfunctional labor/very large fetus, may have greater discomfort with epidural than with spinal.
        • 2. Dosing
          • a. Emergent/STAT: 3% chloroprocaine , 20cc with 2cc NaHCO3
            Rebolus as below after 20 minutes
          • b. Non-emergent: 2% Lidocaine 20-30cc with NaHCO3 plus 100 mcg Fentanyl Rebolus after ~ 30 minutes
            • 1. More 2% lido if expect case to be completed within 30-45 minutes
            • 2. Bupiv 0.5% if expect case to be longer
          • c. Morphine 3 mg after delivery of infant
        • 3. IV Supplementation (after delivery if at all possible to avoid transfer to fetus)
          • a. Midazolam: 2-4 mg
          • b. Fentanyl: Average 100-200 mcg
          • c. Alfenta: 500-1000 mcg boluses very effective for acute discomfort
          • d. Propofol: Usually 30-40 mg boluses for sedation
          • e. Ketamine: 20-30 mg/dose very effective (give Versed prior)
          •  
      • C. Emergency C/S Protocol after Hours
      • 4 PM- 7AM weekdays (8AM on Thursdays), and weekends
        Blackstone, Tarraza, Sweatt, Sutherland 11/2005
         
      • 1. Attending Obstetrician to page 662-4800-0610 when decision is made for emergency C/S
        • a. Communication is to be between attending obstetrician and attending anesthesiologist, not involving residents
      • 2. Information conveyed should include
        • a. Degree of emergency (need to start in 2 minutes vs 15 minutes)
        • b. Brief OB synopsis (i.e. 28 wk GA with bleeding previa)
        • c. Medical hx (i.e. asthma, etc)
        • d. Allergies
        • e. Medications
      • 3. Upon receiving notification of emergency C/S, anesthesiologist should send an available person to assess the patient and prepare the OR
      • 4. Staff in OR should be kept to a minimum to lessen confusion
        • a. Anesthesia team
        • b. Obstetric team
        • c. Scrub tech or nurse
        • d. Circulating nurses—maximum of 2
        • e. Neonatology team
      • 5. Communication between all staff in OR should remain clear, direct and respectful at all times

    Twins/Double Setup

    August 2001- Ascanio


    Spinals for Tension Vaginal Tape (TVT) Procedures

    1) Ascanio/ D.Dean March 2008

    Over the past several weeks we have been trialing various spinal marcaine mixtures here at SSC for Mary Brandes' TVT cases. The goal is to provide safe and adequate surgical anesthesia as well as maintaining efficiency and timely discharge from PACU to home. Given the above we have settled on the following recommendation:

    Isobaric marcaine, 0.25%, 2cc (5mg total dose) + 20 mcg fentanyl.

    Given the low dose of local anesthetic most patients will be moving their legs on arrival to PACU. The fentanyl is essential as it not only will complement the spinal with its narcotic effect it actually has a mild local anesthetic effect as well.

    Obviously there will be a patient now and then who does not achieve an adequate surgical anesthesia level. In these cases I would encourage supplementing with IV alfenta or remifentanil (once we are comfortable using it.)

    If you have a case of inadequate anesthesia using this recipe, make sure you document such on the QA form; tracking this will allow objective assessment and appropriate adjustment.

    2) Charles Higgins January 09

    I have used the following with great results for Mary's TVTs at MMC:

    2% (not 3%) Chloroprocaine (Nesacaine) 3cc with fentanyl 20ug.

    The kinetics are the same as lidocaine. The incidence of TNS is 0% in studies. Patients are generally fully recovered from the spinal in about 90 min.

    This dose has been well studied and published and is the drug of choice at the Mason Clinic. I haven't found a clear statement of it's baricity, but I've used it sitting and supine with, usually around a T10 level. Charlie


    Reference: 2-Chloroprocaine for Spinal Anesthesia (ASA Refresher Course 2012)

    Chloroprocaine spinal anesthesia: back to the future?

    The problems associated with lidocaine spinal anesthesia, particularly the high incidence of TNS(Transient Neurologic Symptoms) have led many clinicians to abandon the use of this anesthetic for spinal anesthesia. While there are reports describing the use of low-dose bupivacaine combined with fentanyl (19), many practitioners report a high failure rate with this technique, and complete recovery may still be delayed. Of other available options, neither procaine (20) nor mepivacaine (21) appear to offer sufficient advantage with respect to TNS.

    Despite a rather blemished past, considerable attention has been focused on the possibility of using chloroprocaine to fill this anesthetic void. Introduced into clinical practice over 50 years ago, chloroprocaine never evolved as a spinal anesthetic agent, perhaps related to the development and marketing of the amide, lidocaine. In any case, reports of neurologic deficits associated with possible intrathecal injection of epidural chloroprocaine in the early 80s raised concern regarding the potential neurotoxicity of this anesthetic, which, until recently, would have subdued any enthusiasm for deliberate intrathecal administration. The dissatisfaction with spinal lidocaine encouraged Kopacz and colleagues to re-investigate the use of spinal chloroprocaine. Their rigorous systematic volunteer studies documented effective spinal anesthesia with little, if any, risk of TNS (22-26). Duration of effect was shorter with chloroprocaine than with an equal dose of lidocaine (23), and institutional discharge criteria were achieved more rapidly than with lidocaine (23), procaine (22), or low-dose bupivacaine (26). As expected, anesthesia could be prolonged or enhanced by co-administration of fentanyl (25) or epinephrine (24). However, an unexpected and worrisome finding was the occurrence of “flu-like” symptoms in volunteers receiving chloroprocaine containing epinephrine (24), the etiology of which remains obscure. Several small clinical reports have confirmed the suitability of chloroprocaine for outpatient spinal anesthesia, both in terms of its short duration and low risk of TNS (27,28), though the published data regarding chloroprocaine as a spinal anesthetic is limited, and certainly insufficient to establish safety. However, the evolving “off-label” clinical experience with this drug is fairly substantial. Whether this unpublished information provides adequate evidence of safety is a judgment that needs to be made by the individual anesthetist.

    However, should chloroprocaine be used for spinal anesthesia, the available data and clinical experience would suggest that the solution should be bisulfite-free, the dose limited to 60 mg, and the use of epinephrine be avoided.