Obstetric Anesthesia

Labor epidural

By Patrik Martner, Specialist Physician in Anesthesia & Intensive Care. Sahlgrenska University Hospital.

Updated 2019-10-14


Contraindications

  • Skin infection locally
  • Haemostatic disorder
  • Hypovolaemia

Blood sampling procedures

  • Mild preeclampsia, samples not exceeding 6 hours old – platelets
  • Severe preeclampsia, samples <2 hours – platelets, PT (INR), APT(T)
  • IUFD, samples <4 hours – platelets, PT (INR), APT(T)

Drugs, dosage and pump

  • E.g. bupivacaine 0.6 mg/ml + sufentanil 0.5 μg/ml premaid 100 ml
  • Initial bolus dose is given manually by anaesthesiologist 6 + 6 ml.
  • 12 ml is drawn from the drug bag. The bag is non-sterile.

Local anesthetics for obsteric epidural anesthesia

Local Anaesthetic AgentConcentrationOpioid in additionStart-up doseBolus doseContinuous infusion
Levobupivacaine 0,625 mg/mlSufentanil 0,5 μg/ml12 ml 4-8 ml 8 ml/h
Ropivacaine 1 mg/mlSufentanil 1 μg/ml10 ml 4-8 ml 6-9 ml/h
Bupivacaine 1 mg/mlSufentanil 1 μg/ml6-10 ml (15-25 mg)6-10 ml (15-25 mg)2-5 ml/h (5-12,5 mg/h)
Ropivacaine 2 mg/ml8 ml4-8 ml 2-5 ml/h
PCEA (Patient Controlled Epidural Anaesthesia)
ConcentrationOpioidStart-up doseBolus doseContinuous infusion
Ropivacaine 1 mg/ml plusSufentanil 1 microg/ml12 ml12 ml15 min

PCEA, ie continuous + PCEA

  • Continuous 5 ml/hour
  • Patient-administered bolus dose of 2-5 ml
  • Lockout time is set to 10-30 minutes

Continuous EDA

  • 8 ml/hour

Midwife administered loading dose

  • Charging dose 5 ml, 1 time/hour.

TOP-UP of Epidural for surgery

By Patrik Martner, Specialist Physician in Anesthesia & Intensive Care. Sahlgrenska university hospital.

Updated 2019-10-14


Emergency Caesarean Sectio

  • Sufenta 5 µg/ml, 2-4 ml = 10-20 µg
  • Ropivacaine 7.5 mg/ml, 15-20 ml.
  • Morphine Special 0.4 mg/ml, 5 ml = 2 mg (given postpartum – caution in high prevalence)

Dissolution of the placenta/ Sewing of delivery damage

  • Sufenta 5 µg/ml, 2-4 ml = 10-20 µg
  • Ropivacaine 7.5 mg/ml, about 10 ml

Obstetric anesthesia

Local anesthetics for obsteric epidural anesthesia

Local Anaesthetic AgentConcentrationOpioid in additionStart-up doseBolus doseContinuous infusion
Levobupivacaine 0,625 mg/mlSufentanil 0,5 μg/ml12 ml 4-8 ml 8 ml/h
Ropivacaine 1 mg/mlSufentanil 1 μg/ml10 ml 4-8 ml 6-9 ml/h
Bupivacaine 1 mg/mlSufentanil 1 μg/ml6-10 ml (15-25 mg)6-10 ml (15-25 mg)2-5 ml/h (5-12,5 mg/h)
Ropivacaine 2 mg/ml8 ml4-8 ml 2-5 ml/h
PCEA (Patient Controlled Epidural Anaesthesia)
ConcentrationOpioidStart-up doseBolus doseContinuous infusion
Ropivacaine 1 mg/ml plusSufentanil 1 microg/ml12 ml12 ml15 min

Epidural Block in Caesarian Sectio

Local Anaesthesia AgentConcentrationLoading VolumeLoading Dose
Levobupivacaine5 mg/ml*15–30 ml 75–150 mg
Mepivacaine 20 mg/ml 10–17,5 ml 200–350 mg
Bupivacaine 5 mg/ml15–30 ml 75–150 mg
Chloroprocaine 30 mg/ml (3% )15–20 ml in bolus
Ropivacaine 5 mg/ml15-20 ml 113-150 mg
* By slow injection

Epidural for Obstetric Analgesia

Local Anaesthetic DrugsLocal Anaesthetic AgentOpioidStart-up doseBolus doseContinuous infusion
Levobupivacaine 0,0625%
+ Sufenta 0,05%
Levobupivacaine 0,625 mg/mlSufentanil 0,5 μg/ml12 ml4-8 ml8 ml/h
Ropivacaine 0,1%
+ Sufenta 0,1%
Ropivacaine 1 mg/ml Sufentanil 1 μg/ml10 ml4-8 ml6-9 ml/h
Bupivacaine 0,1%
+ Sufenta 0,1%
Bupivacaine 1 mg/ml plusSufentanil 1 μg/ml10 ml4-8 ml6-9 ml/h
Ropivacaine 0,2%2 mg/ml8 ml4-8 ml2-5 ml/hr
PCEA (Patient Controlled Epidural Anaesthesia)Local Anaesthetic AgentOpioidStart-up doseBolus doseLockout
Levobupivacaine 0,0625%
+ Sufenta 0,05%
Levobupivacaine 0,625 mg/mlSufentanil 0,5 μg/ml12 ml4-8 ml15 min

Conversion of Epidural from Obstetric Analgesia into Caesarian Sectio ("Top-Up for C-Sec")

Local Anaesthetic AgentConcentrationVolume (ml)Dose (mg)Opioid
Ropivacaine 5 mg/ml15-20 ml 113-150 mg+ Sufentanil 25 μg
Levobupivacaine *5 mg/ml15–20 ml 75–100 mg
Bupivacaine 5 mg/ml15–20 ml75–100 mg
Chloroprocaine 3%30 mg/ml15–20 ml
* Slow injection

Spinal Anaesthesia for Caesarian Sectio (C-Sec)

Local Anaesthetic AgentConcentrationDose (ml)Opioid
Bupivacaine with glucose5 mg/ml1,8–2,4 ml (7,5–12,5 mg)
Bupivacaine with glucose 5 mg/ml1,8-2,4 ml + Fentanyl 15-25 μg
Bupivacaine with glucose 5 mg/ml1,8-2,4 ml + Morphine 0,1 mg (0.4 mg/ml 0.25 ml)
Bupivacaine with glucose 5 mg/ml1,8-2,4 ml + Fentanyl 15-25 μgram + Morphine 0,1 mg (0,4 mg/ml 0,25 ml)
Ropivacaine 5 mg/ml1,5-3 ml (7,5-15 mg)

Spinal Anesthesia for pain during delivery final

Local Anaesthetic AgentBrand name
Local Anaesthetic Agent
ConcentrationDose (ml)Opioid
Ropivacaine Naropin®5 mg/ml0,2-0,3 ml (1-1,25 mg)Sufentanil 5 μg/ml 1-1,5 ml (7,5 mikrog)
Bupivacaine Marcaine Spinal®5 mg/ml0,2-0,4 ml (1-2 mg)Sufentanil 5 μg/ml 1-1,5 ml (7,5 mikrog)

Opiates as Adjuncts in Spinal Anesthesia

Local Anaesthetic AgentConcentrationDose in mgDose in ml
Morphine0.4 mg/ml0,1–0,2 mg0,25-0,5 ml
Fentanyl50 mikorg/ml20–40 μg0,4-0,8 ml
Sufentanil5 μg/ml5–10–(15) μg1-1,5 ml

 


Large postpartum haemorrhage

By Patrik Martner, Specialist Physician in Anesthesia & Intensive Care. Sahlgrenska university hospital.

Updated 2019-10-14


Samples

  • TEG, Hgb, platelets, APTT, PK, Fibrinogen, D-dimer, antithrombin, I-Calcium, Blood gas analysis, Temperature

Measures

  • Bimanual uterine compression / aortic compression
  • Lowered head end
  • Large bore needles
  • Syntocinone -> Methergin -> Prostinfenem -> Cytotec
  • Antibiotics
  • Tranexamic acid 2 g

Rehydration

  • Crystalloid solutions Ringer Acetate 1000 ml (caution at > 2 L), Voluvene 500 ml – maximum dose 1 l
  • O neg blood
  • E-conc / plasma / platelet concentrate in a 4: 4: 1 ratio
  • Fibrinogen 4 g
  • Antithrombin of <0.5 KIE/ml
  • Ev. cancel inhalation anesthesia

Anesthesia Form

  • Propofol/Ketalamine?
  • Optimize N2O/O2 + Fentanyl

General anesthesia for urgent caesarian sectio and elective sectio

By Patrik Martner, Specialist Physician in Anesthesia & Intensive Care. Sahlgrenska University Hospital

Updated 2019-10-14


Preliminary preoperative assessment

  • Allergy? Previous illnesses? Respiratory Assessment!
  • Preoxygenate 3-5 minutes alt. 8 big breaths.
  • Optimize sniffing position – if obese / short neck = pillow under shoulder blade

Start of anesthesia

  • Inj alfentanil 10 µg/kg total 100 µg nitro iv in severe preeclampsia.
  • Inj Pentothal 5-7 mg/kg iv (rarely below 500 mg)
  • Inj suxamethonium 1 mg/kg iv (by real weight)
  • Anesthetist intubate and confirm with ET CO2
  • If necessary ProSeal laryngeal mask according to “Unexpected difficulty in cesarean section”
  • Anesthetist announces when surgery can start
  • Ventilate with O2 50%, N2O 50% and Sevoflurane ET 1.2-1.3%.
  • Anesthetist insert extra needle and infusion

When the child is delivered

  • Inj Fentanyl 200- (400) µg iv.
  • Gastric drainage tube

Prior to postoperative pain relief

  • Inj Morphine 0.15 – 0.2 mg/kg
  • Inj acetaminophene (paracetamol) 1 g iv
  • Inj ketorolac 30 mg iv – Observe contraindications
  • Infiltration Bupivacaine 5 mg/ml in the wound, possibly TAP blockade
  • Prescribe PCA and fill in protocol.

Obstetric Spinal Anesthesia

By Patrik Martner, Specialist Physician in Anesthesia & Intensive Care. Sahlgrenska university hospital.

Updated 2019-10-14


Spinal anesthesia for caesarian sectio

  • Bupivacaine spinal heavy 5 mg/ml 1.8-2.2 ml = 9-11 mg
  • Fentanyl 50 µg/ml 0.2 ml = 10 µg
  • Morphine special 0.4 mg/ml 0.25 ml = 100 µg

Spinal at vaginal delivery

The spinal anesthesia provides approximately 1.5 – 2.5 hours of analgesia

  • Sufentanil 5 µg/ml 1.5 ml = 7.5 µg
  • Marcain spinal 5 mg/ml 0.25 ml = 1.25 mg
  • CAVE: Opiat for the last 6 hours,
  • Abnormal CTG curve, contraindicated with regional anesthesia (?)

Spinal at birth injury/placental release

– low spinal

  • Bupivacaine spinal heavy 5 mg/ml 1.2-1.4 ml = 5-7 mg
  • Fentanyl 50 µg/ml 0.2 ml = 10 µg