OB anesthesia

[Direct Laryngoscopy]

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Just inquiring what combo of drugs are you guys using for labor epidurals, sections, post op sections, stat sections and top offs?

For labor epidurals I like to do CSE with 20mcgs of fentanyl and then a PCEA pump.

For for primary sections (non fatty), I've done single shot spinal with hyberbaric bupi, fentanyl and duramorph. For the repeat sections, CSE hyperbaric bupi, fentanyl and epidural duramorph, and then pull the cath (I have not had a good experience with intrathecal duramoprh (I'm only a CA2). Pt's more often than not, are complaining of pain and wind up on PCA.) PCEA is variable. Some of the OB docs don't want their patients on it, some don't care. If it's not contraindicated I try to give all of them Toradol.

If a patient with a cath gets a section, I usually give chlorprocaine 18ml + NaBicarb 2ml although I have given Lidocaine 2% 10ml.

For top offs (even though they're on a PCEA the midwife or nurse will call me for a top-off 😕 Most times the mother is not pushing for a bolus), I like Ropi 0.2%. I've also used some Lido.

My program is very inbred, so everyone is pretty much the same in what they use for OB. What combination are you guys using for your OB patients? Looking to try something different. I wonder if combination of drugs is a regional thing. I'm in NY BTW.

 

[pgg]

For the repeat sections, CSE hyperbaric bupi, fentanyl and epidural duramorph, and then pull the cath (I have not had a good experience with intrathecal duramoprh (I'm only a CA2). Pt's more often than not, are complaining of pain and wind up on PCA.)

I don't routinely do CSEs for repeat sections now that I'm out of residency, because the OBs are fast. I did a bunch for that reason when residents were operating.

I don't think I've ever put a post-section patient on a PCA. I'm at a loss to explain why you're seeing patients who got intrathecal morphine having PCA-requiring pain after a routine section.

If a patient with a cath gets a section, I usually give chlorprocaine 18ml + NaBicarb 2ml although I have given Lidocaine 2% 10ml.

I'll use chloroprocaine if there's some concern about fetal well being, because of its fast metabolism.

I don't use it for routine tired-of-pushing or making-no-progress sections, because it reduces the efficacy of neuraxial narcotics.

I usually find that more than 10 mL of 2% lido is needed to get through a section but I suppose it depends on how dense your labor analgesic block is to start with.

For top offs (even though they're on a PCEA the midwife or nurse will call me for a top-off 😕 Most times the mother is not pushing for a bolus), I like Ropi 0.2%. I've also used some Lido.

I think there's utility in manual topoffs even if the patient is appropriately using the PCEA. I infuse 0.125% bupiv + fent 2 mcg/mL via the PCEA, but usually use 0.25% bupiv (with or without some extra fentanyl) for topoffs. I think the faster manual bolus may help with hot spots better than the slow trickle in from the PCEA, maybe better spread.

Only time I topoff with lido is the rare post-delivery lac repair. A short acting dense block when I don't care about motor block is great then. As an intra-labor topoff, those characteristics are less desirable to me.