How do you prepare for performing a regional block or an anesthetic at MWH Birth Center?

Your services may be required for providing regional analgesia for labor or anesthesia (regional or general ) for cesarean section. We provide grief guidelines for preparing the patient for anesthetic procedures. This web synopsis is not a substitute for the Orientation Package compiled and distributed by Dr, Helene Finegold as a printed manual. This manual must be available to you at all times.

Most medications including classified substances and certain local anesthetics (ropivacaine, chirocaine ) are kept in the Accudose dispenser. All local anesthetic infusions are also dispensed by the Accudose dispenser. To access the dispenser, you need an user name and a password which Dr. Helene Finegold (Residency Director) will provide when you start your rotation. Please do not share the password with anyone. All classified drug use must be documented in the anesthesia record which is subject to audit on a routine basis. When you use only a portion of the classified substance, the amount used must be entered in the anesthesia record and the unused portion must be wasted in front of a witness. The witness must have access to the AccuDose dispenser. Unused whole vials of classified substances must be returned to the AccuDose dispenser in front of a witness. Similar rules apply to dealing with broken narcotic containers. Eye-protection must be worn while doing regional blocks for labor and while doing anesthesia for a cesarean section.

Regional Blocks for labor:

1) Please review the Medical Information questionnaire the patients has filled out.

2) If you need further information, ask the patient and fill out the preoperative evaluation sheet. Discuss the case with the attending unless instructed otherwise.

3) Please review the patient’s hospital record thoroughly and make sure that you are

aware of any medical problems or pregnancy related problems. If you think that

the patients has preeclampsia, at least a pallet count is required.

4) Make sure that I.V. is functioning properly. A fluid preload is not necessary

unless otherwise indicated prior to labor epidural analgesia. Fetal heart rate and maternal vital signs should be documented. If you see significant decelerations of fetal heart rate and if you see significant maternal hypertension, please consult your attending.

5) It is s a good idea to ask the patient to rate her pain intensity on a verbal analog scale (1-100) and note in the anesthesia record. If the block is successful there should be a 70% reduction in the VAS score. The patient should not react to pain with hyperventilation and tachycardia. This might take up to 10- 20 min depending on the anesthetic used. Ropivacaine has a slower onset than S-R bupivaciane or S-bupivacaine. You should not leave the patient’s room until good pain relief is established and the maternal vital signs are stable.

6) There are several anesthetic regimens used at MWH depending on the clinical situation. A test dose is commonly utilized with most central neural blocks. A hyperlink is provided on this page to provide dosage guidelines for several regimen used at MWH. It is in your best interest to try all the various regimens and anesthetics to get a first hand experience. If you want to use a combined-spinal epidural technique (CSE), patient selection is important. Discuss this with your attending.

7) You must stay with the patient at least for 25 min to make sure that she is comfortable and there are no untoward complications.

8) If for any reason, the attending is not present in the room when you do the regional block, write the name of the attending with whom you discussed the case in block letters on the anesthesia record. Complications such as wet tap must be clearly documented and the patient must be informed. Please notify the attending of any complications.

9) Fill out the CQI form and describe all the complications clearly in the space provided in that form.

10) Patients must be instructed to lie on one side or the other and switch sides every hour to facilitate even spreading of the local anesthetic.

Regional Blocks for Cesarean Section:

1) An anesthesia consent must be signed by the patient. A resident or an attending physician may obtain the consent.

2) Make sure you do have a properly functioning i.v..

3) Cesarean sections may be performed on elective basis, emergently or on a “stat” basis.

4) A preoperative evaluation including airway assessment must be done and the case

must be presented to the attending before the case. You must know the indication for C.S. and if the C.S. is being performed for placental previa, you must have at least two cross-matched units of blood available in the room. Placenta previa is the #1 risk factor for transfusion in obstetrics in the world.

5) Elective C.S. are usually scheduled the day before and up to 4 elective C.S. may be performed on a single day.

6) If patients require a C.S. for failure to progress, an existing epidural catheter may be used.

7) An elective C.S. is usually performed under spinal anesthesia unless the patient requests a general or an epidural anesthetic.

8) The following drugs must be taken out of the AccuDose dispenser:

1. Sodium citrate – 30 ml P.O. for aspiration prophylaxis

2. Preservative free morphine 10 mg

3) Pitocin 15 units in a premixed bag

4) Fentanyl 100 ug ampoule

5) Antibiotic depending on the surgeon’s preference. At MWH it

is usually 1- 2 G of cephazolin. It is a good idea to ask the surgeon what his preference is.

9) Please prepare two fresh syringes< 1)ephedrine 5 mg/ml and 2) phenylephrine 100

ug/ml. Do not use left-over vasopressors from previous cases.

9) For spinal anesthesia, we use Pencil Point needles (Sprotte 24 G). The use of cutting needles such as Quincke needles is highly discouraged.

General Anesthesia for C.S.:

Support persons are not usually permitted into the OR during C.S. performed under spinal anesthesia. G.A. for cesarean section is not different from G.A. done elsewhere except that the patient is prepped and draped prior to induction. A rapid sequence induction with well-applied cricoid pressure is necessary to prevent aspiration. Make sure that you have done a thorough evaluation of the patient including airway check. A “Difficult Intubation Cart ‘ is available in the Birth Center. Prepare the patient as indicated under G.A. You may need more fentanyl, morphine and midazolam for G.A. You use morphine intravenously for maintenanace.

External Cephalic Version:

While many obstetricians perform external cephalic version without anesthesia, some request epidural anesthesia. All patients regardless of the need for anesthesia must undergo a pre anesthetic evaluation including NPO status. Occasionally, the patient may require a stat C.S. for fetal distress during or after the version. The versions are done in the Labor-Delivery Room (LDR). Use 2% lidocaine with 1:200K epi to induce epidural anesthesia to at least T8 level. You must use left uterine displacement while the version is in progress.

Exit Procedures:

It may be necessary in some instances to operate on the newborn before the umbilical cord is severed during C.S. Congenital heart disease may require ECMO line placement when the partially delivered fetus is still attached to the placenta to facilitate fetal oxygenation. An airway obstruction caused by a giant cystic hygroma may need a tracheotomy at exit. The problem with this procedure is that the unclamped uterine edges may bleed heavily when the baby is being treated. Blood should be available in the room.

Forceps deliveries:

Forceps deliveries may be performed in the LDR, or in the OR if the obstetrician expects a difficult delivery. If forceps delivery fails, the patient may need a C.S. delivery. The obstetrician will usually inform you that he/she is planning a double set up (failed forceps to C.S). You must prepare the patient for a C.S. if a double set up is being planned. Use 2% lidocaine with epi to induce a sensory level to T6. Remember that it is difficult to anesthetize the sacral segments (S2-4) and give yourself a lot of time. You can assess sacral analgesia (pudendal area) using the pinprick method. The forceps deliveries that are performed in the LDR can be done with 2-CP. In any event, all forceps have the potential to end up in a C.S. or even a stat C.S.