Adapted from the CU OB Anesthesia Cookbook 2023

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 Ropi 0.1% + Fent 2mcg/mL

	Basal	PCEA bolus
"walking" PCEA	5cc/hr CONT	None
Standard PCEA	10cc/45min PIEB	5cc q 10min
Intrathecal catheter	2-3cc CONT	None

• remember: LA requirements reduced by 30% in pregnancy
• assess frequently for motor block

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