OB Anesthesia Hot Topics

Interesting discussion.

1. Bicitra for all C-sections. I don't like it because I think it contributes to intra-op nausea, but the group feels it is "standard of care" so we all do it.

2. Epidurals go in whenever it is clear the patient is in active labor and we are committed to delivery, or whenever the nurse is tired of dealing with her. I would like them to have at least some discomfort with contractions; the women who want an epidural "in case it hurts later" tend to believe their epidural has failed when they get to 5cm and the contractions get intense. I try hard to manage expectations by repeatedly telling them the epidural will make the contractions "less uncomfortable". Needless to say, some of them still wonder why they can feel their legs when I am finished.

3. Everyone gets a CSE.

I was a late convert to this technique, compared to my partners, i.e. just for the last 15-18 years; before that all straight epidurals. Like PGG, I finally realized that the gentle bounce of the spinal needle on the dura, followed by the slight pop through the dura, was excellent confirmation that my epidural needle was indeed in the epidural space. This reassured me that my LOR was true and I was not off the midline (easy to do when you can't feel any landmarks whatsoever). My spinal dose is 2.5mg bupivacaine and 25mcg fentanyl. After the spinal dose I inject 5ml of saline; I think it dilates the space, making intravascular catheters less likely. No data, just experience. Of course, staying in the midline would help, too, but that's not always so easy. No epidural bolus, obviously. My epidurals work; at least 500/year, 31 years. Not to say there aren't failures, but they are quite rare. I don't feel the need to wait for an epidural dose to work. I am in and out of the room in 15-20 minutes, patient loves me, nurse is happy, I am back to the OR where I belong. Many patients begin to feel numbness before I remove the spinal needle, and often don't notice the contractions anymore, by the time the catheter is in.
BTW, my PDPH rate, over approximately 8,000 CSEs, is zero, to the best of my knowledge.
Our OB population is mostly obese. Under 100kg is a treat. I use L3-4 or L2-3, or at least that's where I think I am. We are notoriously bad at judging this. L1-2 is too high for me.

4. Infusion of 0.125% bupivacaine + 2mcg/ml fentanyl at 6ml/hr, PCEA bolus of 6ml available q 20 minutes, one hour limit 18ml.
BTW, my PDPH rate, over approximately 8,000 CSEs, is zero, to the best of my knowledge.

5. My platelet cut-off for epidurals and spinals is 100k. For a really sick hip fracture I might go lower, but for elective labor epidurals I am pretty conservative.

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OB Anesthesia Hot Topics