Patients come into the hospital once they begin the active part of labor. OB anesthesiologists get involved to provide analgesia during both labor, delivery (C-section or vaginal), and post partum
Labor Analgesia
Labor can be prolonged and painful, the most flexible option for pain control during labor is a lumbar epidural or a Combined Spinal Epidural (CSE). A lumbar epidural only will need a bolus/load.
CSE Dosing
| Opiate | Local | |
|---|---|---|
| 0cm - 4cm or ”walking PCEA” | Fent 10-25mcg or Sufent 2.5-mcg | None |
| 4cm - 8cm | Fent 10-25mcg | 0.5mL of B0.25% |
| 8cm - 10cm | Fent 10-25mcg | 1.0mL of B0.25% |
- Always draw up spinal dose before skin local in the following order: Bupi → Morphine → Fent
Epidural only
- Bupi 0.125% + Fent 5mcg/mL
- Can use Bupi 0.25% may be used in advanced labor but will cause motor block and needs attending approval
PCEA settings
- Stock concentration is Bupi 0.08% + Fent 2mcg/mL
| Basal | PCEA bolus | |
|---|---|---|
| ”walking” PCEA | 5cc/hr CONT | None |
| Standard PCEA | 5cc/30min PIEB | 5cc q 10min |
| Intrathecal catheter | 2-3cc CONT | None |
- remember: LA requirements reduced by 30% in pregnancy
- assess frequently for motor block
- Consider incr PIEB dosing if inadequate level despite button
- 6cc/30min or 10cc/45min
Safety Tips
- Motor block is intrathecal catheter until proven otherwise
- High block (above T2-4) is intrathecal until proven otherwise
- Lack of block is intravascular catheter until proven otherwise
- Nausea after spinal or epidural dose is hypotension until proven otherwise
- Patchy bblock is likely a subdural catheter; Plan to replace
Cesarean Delivery
CS with epidural
Cesarean deliveries under epidural require a more dense analgesia than laboring. Typical LA dose is 20cc bolus for cesarean delivery (T4 level) but some parturients may require up to 40cc. C-Section’s can occur across a spectrum of urgencies and will impact LA choice.
-
Emergent → 20cc 3% 2-CP
- This is least toxic, has the fastest onset, but is short duration (<45min)
- May need to bolus Bupi 0.25% in PACU to cover pain until morphine hits
-
Non-emergent → 1-20cc LEBF (see table below)
- LEBF is a mix of Lido + Epi + Bicarb + Fentanyl
- after 20cc of lido if more LA needed always switch to 2-CP for LAST considerations
| Component | Dose (per mL LA) | Max Dose |
|---|---|---|
| Lido 2% | 1-19mL | 20cc |
| Epi | 2-5 mcg | 40-100mcg |
| Bicarb | 0.1mL | 2mL |
| Fentanyl | 100mcg |
CS with spinal
A cesarean spinal mix should contain Local anesthetic (LA) + Fent +/- morphine or dilaudid +/- Epi
| Component | Primary | Alternative |
|---|---|---|
| LA (Bupi 0.75%) | 1.5cc (11mg) | 1.6cc (12mg) |
| Fast narcotic | fent 12.5 - 25mcg | |
| Long narcotic | morphine 100-250mcg | hydromorphone 50-100mcg |
| Prolong | Epi 100-200mcg |
- CSE is also an option if 12-48hrs of extended analgesia is needed
- 2nd dose of neuraxial morphine can be given prior to epidural removal at ~18-24h mark
CS with GETA
Almost all GETA C-sections are emergent. Anes Att. (preferably OB) should always be present for induction. No exceptions
-
Preoxygenate immediately w/ 100% FiO2 by facemask
-
RSI w/ hypnotic + succinylcholine with cricoid pressure (required)
-
Hypnotics
- Etomidate 0.2-0.3mg/kg (most readily availble and HDS)
- Ketamine 1-1.5mg/kg IV
- Propofol 1.5-2.5mg/kg
-
Acute hypertension adjuncts
- lido 1.5 mg/kg
- esmolol 0.5-1 mg/kg
- labetalol 5-20 mg
- nitroglycerin 2mcg/kg
- remi 1mcg/kg
-
in emergent GA use high conc. sevo (1-1.5 MAC) w/ 100% FiO2 until delivery
- After delivery reduce to <0.5MAC to prevent uterine atony. Supplement with N2O 50-70%
- Consider switching to TIVA; ask attending.
Postpartum tubal ligation
Discuss use of epidural vs single shot spinal (SSS) with attending Regardless of choice, never use neuraxial long acting opioids
- if using epidural:
- 2-chloroprocaine 3% or
- Lidocaine 2%
- if using spinal:
- Heavy bupi (0.75%) 11-12mg + Fent 15-25mcg
These are NOT elective cases per ACOG, however following NPO guidelinens is mandatory
Cervical Cerclage
- Spinal preferred; T10 level required
- Subarachnonid block is most commonly used w/ 7.5mg spinal bupi + fent 10-25mcg
- Do not use long acting opioids