Obstetric Case Set up

Obstetric Room Setup
This a standard OB room setup. Provider preferences may vary.  Regardless of the type of anesthesia planned, be sure to set up for general as well. Prepare for possibly difficult airway, unsuccessful neuraxial anesthesia, hemorrhage, and hemodynamic instability.

1. Perform an anesthesia machine. Turn on Etco2 machine and BIS (if used). Emergency equipment.
2. Set up.
   1. Laryngoscopes (2), Mac and Miller blade (1 each). Make sure laryngoscope light is functional. Have Glidescope or other preferred difficult airway equipment in room.
   2. Airway Bougie
   3. Eye tape
   4. Tongue blade
   5. Oral airway (appropriate size)
   6. Endotracheal tube- Size 6.5 and 7.0. SMALLER TUBE NEEDED.
   7. ETT Stylet
   8. Endotracheal tape
   9. 10ml syringe for Endotracheal tube. Check tube cuff for leaks
   10. Skin/Esophageal temperature probe.
3. Additional equipment: Ensure availability.
   1. Laryngeal Mask Airway - High risk Difficult airway
   2. Nasogastric/Orogastric tube - High risk of Aspiration
   3. Rapid infuser - Risk of Hemorrhage
   4. Fluid Warmer - Rapid Fluid Administration related Hypothermia
   5. Central line Kit (Ultrasound if needed)- Risk of Amniotic Air Embolism
   6. Surgical lube
   7. BIS monitor
   8. Esophageal Temperature probe
   9. Bair hugger (lower and upper)
   10. Head rest
   11. V lead EKG cord
   12. Arm straps, padding
   13. IV start kits (Large Bore)
4. Set up syringes for the day. Include 30ml, 10ml, 5ml and 3ml
5. Draw and dilute emergency drugs (check vial concentration)
   1. Succinylcholine 20mg/ml = 5ml = 100mg
   2. Ephedrine 5mg/ml (Review "General" tab on dilution instructions)
      • Indication: Hypotension with Bradycardia
      • Class: Synthetic, Non Selective Symphathomimetic drug
      • Action: Direct Beta stimulation and indirect alpha stimulation causes release of endogenous norepinephrine.
      • Onset: Quick Duration: 5 minutes
      • Metabolism: Liver; 40% excreted unchanged in Kidneys.
      • Risks: Tachyphylaxis, fetal acidosis
   3. Phenylephrine 100mcg/ml (Review "General" tab on dilution instructions)
      
      • Indication: Hypotension with Tachycardia
      • Class: Alpha 1 agonist
      • Action: Peripheral vasoconstriction
      • Onset: Quick
      • Metabolism: MAO and sulfotransferase enzymes in enterocytes and liver
6. Standard Induction Medication:
   
   1. Fentanyl- Preferred in OB- High potency, short duration, in Fetal circulation in 1 minute
   2. Propofol (other Hypnotics)
   3. Succinylcholine- for RSI
   4. Non Depolarizing muscle relaxant.
     
   Obstetric Physiologic changes
   
   • Dilutional anemia
   • Increased minute ventilation due to increase in VT
   • Increased CO. Highest immediately post delivery up to 180%.
   • Displaced gastrointestinal system. Increased risk of aspiration. Increase in acid volume.
   • Difficult airway. Narrowing of glottic opening, generalized edema, capillary engorgement.

Obstetric Pharmacology

• Pitocin (Oxytocin) 20u - 40 u in 1000ml LR over 15-20 minutes
  
  • Indication: Uterine Atony, immediate post delivery
  • Class: Endogenous Hormone produced by posterior pituitary gland
  • Action: Lowers threshold for depolarization in uterine smooth muscle
  • Risks: Vasodilation, Tachycardia
• Methergine (Ergotrate)- 0.2mg IM dose
  
  • Indication: Secondary to Pitocin Uterine atony.
  • Class: Ergot Alkaloids
  • Action: Agonist effects on the alpha adrenergic receptors
  • Onset: 1-2 minute, Repeated in 15-20minutes to a total of 0.8mg
  • Risks: Profound Hypertension
  • DO NOT USE IN: Eclampsia (or Pre), chronic hypertension, ischemic heart disease, peripheral vascular disease.
• Hemabate (Methylprostaglandin) - 250mcg IM or IU
  • Indication: Secondary to Methergine, contraindication to Methergine. Uterine atony
  • Class: Synthetic Prostaglandin
  • Action: Increased myometrium calcium levels causing increase in myosin light chain kinase activity resulting in uterine contraction
  • Risks: Bronchospasm, VQ mismatch
  • DO NOT USE IN: Asthmatics, reactive airway disease, pulm. HTN
  • Alternative: Misoprostol (for asthmatics, pulm. HTN)
• Nitroglycerin - 50mg IV Dose
• Uses: Uterine relaxation in external version, fetal head entrapment, extraction of second twin, retained placenta, or uterine inversion.
• Action: Uterine and cervical relaxation via nitric oxide
• Quick, profound uterine relaxation
• Risks: Hypotension