Education

OB Rotation Primer

Sign Out

• Make sure to arrive before 7 AM to take the signout from the post-call anesthesia resident. Learn about the patients in observation, labor rooms, and recovery room.
• Remember to get the pagers!  At Downstate there are 2 pagers: one regular OB and one stat OB pager.
• At LICH, remember to get the call room key from the post-call resident.
• Check the log book/front desk to see if there are any scheduled C/S or cerclages.
• Check which pts still have PCAs, PCEAs, or epidurals post-C/S.
• Check if there are pts with post-anesthesia complications on floor that need f/u notes.
• At Downstate, post-C/S pts who are on PCEA longer than 24 hrs must have a separate billing/pain sheet; ask Dr. Velickovic to show you.

Check the OB Anesthesia Cart

• Make sure there are emergency drugs: 
  • Two 10ml syringes of (Lidocaine 2% 9ml + 1ml of bicarb)
  • One 20 ml syringe of Chloroprocaine 3% for stat C/S. 
• Have Succinylcholine, Phenylephrine, Ephedrine, Sodium Citrate, Metoclopramide.
• Check the laryngoscope, and make sure you have an ETT size 6, 6.5, ambubag
• At Downstate, you should stop by the OR pharmacy to get an OB drug kit: it includes Midazolam 2mg (x2), Propofol 20ml, Succinylcholine, Rocuronium, Fentanyl 2ml (x2), Ketamine vial, Morphine (Astramorph for epidural), +/- Thiopental.
• Keep your OB drug kit with you as these have been stolen before (2007)
• At LICH, take Fentanyl, Morphine, and Ondansetron from the Pyxis as needed.  Have Bupivacaine 0.25%, 0.5%, and Ropivacaine 0.2%, 0.5% stocked.  Ketamine and Thiopental should be available in each OR.

Check the Two Operating Rooms

• MAIDS:  Make sure to check the anesthesia machine for leaks. Set up the standard anesthesia table top equipment, check laryngoscope, oral airway, size 6,6.5 ETT, ambubag, LMA 3,4,5, shoulder roll, head strap, IV bag/line, Ephedrine, Phenylephrine, Succinylcholine
• Have Pitocin, Cefazolin, Methergine, Carboprost available.
• Know where to set up A-line kit in case it’s needed.
• Have a suction/OG tube in case the pt needs GETA.
• Have longer spinal needles available.  5” and 7” needles come in gauges 22, 25, 27.

Standard Bedside Labor Epidural

• Take an H& P.  Pay attention to airway and NPO status.  Explain R/B/A of CSE, check PT/PTT/INR for preeclamptic or heme problems.
• Obtain consent, laterality sheet (Downstate) and timeout sheet (LICH)
• At Downstate, the top half of anesthesia record is the place to write the H&P and vitals.  
• At LICH, the H&P is written on the green consult form; use the regular anesthesia form for the vitals.
• Inform the attending about the patient. Sit the patient up.  Place the BP cuff and pulse ox. Positioning is key!  Have the patient hug their belly and arch their back out, with their shoulders down and chin to chest. 
• Use Chlorhexidine to clean the patient’s back.  Open the CSE kit in sterile fashion. The CSE kits in LICH & Downstate are different!!  Make sure you see/try  the open kits which are in the callroom at Downstate, and in the OB anesthesia office at LICH.
• At LICH:  take Bupivacaine 0.5% vial and get Fentanyl 2ml from pyxis.  Ask attending if they prefer to use both for the spinal dose or if they only want fentanyl. (usually 0.4ml of  Bupivacaine 0.5% and 0.4ml of Fentanyl used for spinal dose, but ask b/c this is attending dependent!)
• After CSE performed, put tegaderm and tape epidural catheter.  Use test dose of 3ml lidocaine 1.5% with epi.  If catheter not intrathecal/intravascular, start Epidural bag Fentanyl 2mcg/ml with Bupivacaine 0.0625% at 12 ml/hr.   You must program the pump and connect the epidural at LICH (nurses do not do this)
• At Downstate:   Obtain a 250ml bag of Fentanyl 2mcg/ml with Ropivacaine 0.1% from the Pyxis.  Dr. Velickovic uses 3ml from this bag and gives that as the spinal dose (Fentanyl 6mcg + Ropivacaine 3mg).  Perform CSE and secure epidural catheter, use test dose. Start PCEA with 10ml basal, 10ml bolus q 10 minutes, up to 3 boluses max per hour.  Make sure to write this on the PCEA order form and let the nurse know.  The nurse will program the pump according to your order, but you must connect the epidural to pump yourself!
• If the pt had a vaginal delivery, pull out the epidural catheter before they leave the labor floor.

C-Sections

• Neuraxial Technique:
  • At Downstate:   Usually, CSE is used because C-sections take longer and the PCEA is used post-op.  Usually use bupivacaine 0.75% +/- fentanyl for the spinal dose –ask attending for specifics.
  •  At LICH:  Spinal anesthesia is commonly used.  Ask the attending for the specific dose based on pt details:  (usually fentanyl 20mcg +morphine PF 0.3-0.4mg+bupivacaine 0.75% 9mg)
• Remember to document your neuraxial technique.  If the pt has a preexisting epidural catheter, record the local anesthetic bolus on the anesthesia chart. 
• In cases of emergency C/S, an epidural bolus of 3% Chloroprocaine is usually given while in transport.  (Make sure epidural has been working, if you’re unsure perform a test dose again!!)  Give 5-10ml of ephedrine IVP for possible hypotension.
• In the case of a semi-elective/urgent C/S, use 2% lidocaine (5ml epidural bolus x 4).
• For an elective C/S, place standard ASA monitors on the patient while she is sitting up prior to start of neuraxial anesthesia. 
• After the pt has received the spinal or CSE, carefully lay her down, place her in LUD (left uterine displacement), and connect your ETCO2 monitor. 
• Assess level of sensory/sympathetic block with blunt needle/alcohol swab.
• After baby is delivered, start Cefazolin and put Pitocin 20-40units/L into 1L IV bag (ask OB how much they want).
• After C/S, and prior to transferring pt to stretcher, assess epidural catheter, and re-tape if needed.
• At Downstate, transfer the pt to recovery room, write orders and start same PCEA regimen

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