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OB Anesthesia Rotation Guide ​

Most recently updated by Kevin Kim MD, Jason Papazian MD, Kelsey Repine MD, July 2023

Access Codes ​

  • 4th Floor Work Room: 11154
  • 5th Floor Work Room: 11154
  • UCHealth badge access
  • Nutrition Rooms: 11154
  • Women's Locker Room: 84111/ 23985
  • Co-ED Locker Room: 84111
  • Call Room: 0404
  • Epidural Carts: 84111

Phone Numbers ​

Scheduled Meetings ​

  • 06:00: Anesthesia resident sign out
  • 07:00: OB sign-out (we can go to Grand Rounds on Mondays but let the APP know you are leaving the unit)
  • 08:30: MOB signout at nurse station
  • 12:30 on Tuesday: MFM Clinic Meeting
  • 08:00 Thursday: Team meeting after sign-out
  • 18:00 Daily: PM anesthesia signout
  • 20:30: MOB signout at station

Orientation ​

You MUST orient with the OB anesthesia service the WEEK PRIOR to the start of your rotation. You will receive an email with details about 10 days before your rotation but just be aware that this is mandatory.

Reading ​

You will receive an email before your rotation starts with several attachments containing information about the rotation:

Details

Reading list from 2024:

Read these before you start and print out the cookbook and procedure guide to carry with you. You will also receive an OB anesthesia work room. As always, Morgan and Mikhail is not a bad place to start.

Vacation ​

Vacation is allowed on the OB rotation, though, if at all possible, please try to not take vacation the first week of the rotation. This first week is extremely valuable learning and orientation with the OB attendings and will help prepare you for when you go on nights. Nevertheless, we understand that some events cannot be moved (weddings, engagements, etc.), but if you have flexibility in your schedule, please take vacation one of the other three weeks.

Schedule ​

The schedule on OB is different from every other rotation. You will be working 12-hour shifts from 6am-6pm or vice versa. Note: the start time of the shifts may be changed by the residents on any given month (most residents prefer 6-6 so you can get settled prior to sign-out).

There is also an OB-short resident that arrives at the same time but is usually released in the early afternoon by the attending, pending cases, workload and teaching completed for the day. Sometimes, residents decide that this resident comes in an hour earlier than the 12 hr resident, so please check with current residents prior to rotating through to confirm when each shift starts.

Please try to arrive with enough time to get hand off from the on-call resident so they can leave on time (about 15 minutes early). The 2 junior residents covering days during the first two weeks and then nights for the second two weeks and vice versa for the residents with prior OB experience. This will allow the residents new to OB to have more daytime teaching prior to starting nights.

In addition to you, there is a CRNA/AA on at all times. They work 24-hour shifts, 7am-7am, so they will know what happened during the day shift which can be helpful on nights.

Don't plan to get much sleep on OB at night. This is not like an OR overnight call where once you knock out the cases on the board you have a good shot of getting a chunk of sleep for the rest of the night. You will always get the first call for any epidurals, C-sections, etc. This is so that we can get the experience that we need.

A note for people with kids: it will be a hard month if you have small children because you might not see them a lot. Leaving at 5:30am and getting home around 7pm for 3-4 days in a row might mean that you won't see them for 3-4 days. (Not much to do about it - just a word of warning. You may want to enlist help/warn your spouse in advance, so they don't kill you.)

That said, the OB rotation is a really good one, much loved by all for several reasons:

  1. We have great OB attendings that like to teach, and a good syllabus. The OB attendings are Joy Hawkins, Christina Wood, Jaime Daly, Jason Papazian, Rachel Kacmar, and Stephanie Kierstead. They all like to teach and will happily discuss any OB topic that you pick for the day provided that there is time. They are usually on service during the weekdays. That is especially helpful in the first month when you have no idea what you are doing. Most of the attendings that cover nights will let you run the show but should ALWAYS BE IMMEDIATELY AVAILABLE and should be present EVERY PROCEDURE. If you have any questions or concerns do not hesitate to call the attending overnight. This is why we all do a lot of days at the beginning of our first month. Make sure that you learn all you can from the OB attendings during days because at night you are managing much more.

  2. The OB nurses are great. They are very knowledgeable and helpful. They will call us for procedures so that we can get experience. Again, tough in the middle of the night sometimes, but that is what we are here for.

  3. There is a cookbook with standard doses for spinals/epidurals. It is very helpful to print it out and put it in your pocket or attach the card to your badge.

  4. There is a cognitive aid on each epidural cart as well as in the OR that can help you work through decision making, dosing decisions, etc.

Pearls ​

WARNING

ALWAYS CHECK YOUR ORs at the start of the shift. This is especially important at night when there is less help. You never want to be caught off guard when a stat C-section comes in.

  • The ORs should always be set up for an emergent C-section type scenario. Believe me, you do not want this scenario to happen when there is no laryngoscope in the OR… or no Etomidate/Propofol available, etc. So just check that everything is ready to go as if you were going to do a crash section This includes making sure videoscope is prepped/functional (either C-MAC or Glidescope in each L&D OR).

IMPORTANT

Just like the main OR all airway equipment must remain sealed until it is going to be used—this is per hospital infection control requirement.

  • OR Pyxis contains all narcotics. We now have L&D narcotic bags, Type “L&D” to search for the narcotic bag in the pyxis
Details

L&D Narc Bag:

  • P20 x1
  • fent 100 mcg
  • ephedrine 50 mg
  • morphine 5mg (or 10 mg – check prior)
  • midazolam 2mg.

  • We no longer have direct access to uterotonics (other than Pitocin). The floor nurses can pull the other uterotonics for you. If you need everything emergently, you can also request a “tackle box” from the nurses, but these should be reserved for higher acuity situations. During the timeout, please discuss the potential need for other uterotonics so the circulating RN can get it for you.

  • Use the APPs as a resource. The APPs that do OB have had a lot of OB experience. You can ask them questions, ask them for help, whatever. This is especially helpful at night. Don't forget to call them for help with difficult epidurals. They can be a helpful second (or third) set of hands in those situations.

WARNING

Always call the OB APP (x85911) for any STAT cases or other emergencies.

  • OB RNs are very involved with their patients. They really want what is best for their patients. Sometimes that may come across as them trying to push us around. For the majority of them, this is not true. They want us to put epidurals in ASAP so that their patients will not be miserable and in pain. Exactly what we want. However, we all understand that we have to do it safely. As a rule, we have told them that if a patient calls for an epidural, they should expect us within 10 MINUTES. If you do not believe you can be there in that time, please have them call the APP.

  • You may also be called to “consent a patient who wants an epidural but is not ready yet”. This is not a high priority but should be done as soon as reasonably possible as it does allow a more streamline approach at the time of actual request.

  • Figure out how to restock the carts properly at the very beginning of the month. We have to restock our own epidural carts from the workroom supplies. Learn how to do it at the beginning so all of the carts aren't missing stuff by the middle of the month. The carts must be restocked and cleaned in between each patient and then placed back in the clean room ready for the next patient. If you have an AA student rotating with you this is something they are typically VERY helpful with. The floor RN will bring the cart to the anesthesia workroom for cleaning, but you must place it back in the patient rooms. If you do need anesthesia tech support, call the usual phone numbers.

  • EPIC charting on the OB floors will look different than what you are used to in the OR. It is best to log in and open the chart in the workroom or on a computer in the hall. There is a macro listed for OB Labor Epidurals, OB regional C/S, etc. These are really helpful. When doing an epidural, pick the "OB Labor Epidural" macro and then Start Anesthesia and "Link Device" and select the appropriate monitor. This will automatically populate your vitals.

WARNING

If you do not link the device, you will not receive vital signs during the epidural placement.

It's possible to backfill the vitals, but most of the attendings won't know how to do this and it's not intuitive

  • After you finish the procedure unlink the device. If you forget to unlink, the nurses will call you because they cannot do their charting.
  • You should remain near the patient monitoring them for at least 15 minutes after the epidural placement or a bolus. After the initial placement, you must put vital signs in the chart every hour to get these vitals in EPIC under the flowsheet and enter them in our record by hand. It is a good idea to do this a couple times during your shift or whenever you get some downtime, so you don't fall behind. Things can go from quiet to crazy relatively quickly on the floor. After placing an epidural or doing any other procedure (C/S, cerclage, etc), add the patient to our shared OB patient list with any pertinent information to be followed up in a postop visit. More detailed information regarding charting can be found in the procedure handout you receive prior to starting.

NOTE

OB is a very service-oriented rotation, if you get called while you are doing something and cannot get there in a timely manner, please let the RN know and ask them to call the APP that is on or if both you and APP are busy, please let attending know.

TIP

As always, it is best to spend some time on the OB floor getting oriented before your first day on OB.

There are many differences to your OB month, so it's best to know where the OR/workroom/pyxis/call rooms are located. This rotation can be a lot of fun, but things happen quickly and it's nice to be prepared.

Common Situations on the OB Floor ​

Called for Labor Epidural ​

  1. Ask how far along they are (dosing for spinal depending on how far along they are; see cookbook for details)
  2. Log into Pyxis (under OR anesthesia, not floor. This is important in order to find fent and epidural bag)
  3. Prior to heading into the room go to intraop tab, anesthesia start, link anesthesia device (Important to do this step or else you will not get vitals)
  4. Grab materials from either workroom or cart outside the room.
  5. Call OB attending
  6. Help RN position patient (sitting edge of bed, expose back, and remove anything that will be in your way)
  7. Remove ALL jewelry, watches, and sleeves below the elbow.
  8. Open kit and have everything ready to go.
  9. Glove up.
  10. Place epidural with attending present
  11. Set up CADD pump with epidural bag. a. Full epidural: "PIB+PCEA" @ 10cc/q45 mins w/ 10min PCEA lockout b. Walking epidural: “Continuous + PCEA” run 5cc/q1h continuous remove PCEA button. c. Intrathecal catheter: “Continuous + PCEA” run 2cc/1h continuous remove PCEA button.
  12. Obtain “timeout” and “IT” time for chart from RN.
  13. Finish charting “Staff”, “Px Note” and “Meds” given.
  14. Update handoff

Patient having more pain with an epidural ​

  1. Look at chart and see if patient has walking vs full epidural. a. If walking attempt to talk to patient about converting to a full epidural b. Change pump settings and attach the PCEA button. c. Can also give bolus of 10-20 cc of bupi 0.125% if having a lot of pain or one-sided coverage.
  2. Ask how far along she is, if 8-10 cm or quick progress she may have sacral sparing. a. If sacral sparing (vaginal pain or low back or buttock pain) bolus with bupivacaine 0.125% (15-20cc) in increments of 5 cc at a time. Can add Fentanyl 100mcg into epidural as well. b. Ask RN to get frequent vitals for next 20 minutes to evaluate blood pressures. c. Reevaluate in 20-30 minutes. i. If comfortable: good job! ii. If not comfortable or slight relief: would attempt to replace epidural.
  3. Unilateral coverage with full epidural. a. Consider pulling back 1-2cm, discuss with attending. b. Bolus with 10-20 cc bupi 0.125% and see if you can get better bilateral coverage in 20-30 minutes. i. If unable would replace epidural
  4. "Failed epidural" (2 boluses given with relief but repeat breakthrough pain) a. Replace epidural unless strong reason not to (patient refusal, extremely difficult initial placement, etc.)

Called for Stat C-section with Epidural ​

  1. Grab 20 cc syringe and chloroprocaine 3%.
  2. Attempt to find charge RN or OB chief/attending (most likely at bedside) to see timing of c-section.
  3. If going back emergently or urgently dose all 20 cc of 3% 2-chloroprocaine into epidural stay with patient, have phenylephrine on hand, call OB CRNA to start setting up whichever OR, and call OB Attending. WILL NEED TO REDOSE at 30-45minute mark DURING CASE as Chloroprocaine has a very short half-life. Discuss with attending whether to use 2-Chloroprocaine or another local anesthetic.

CAUTION

Depending on timing of how quickly you are rolling back, be ready to convert to general

  1. If NON-emergent discuss with attending prior to dosing.