OB set up

Epidural

Contraindications

  • Patient refusal
  • Infection at insertion site
  • Increased intracranial pressure
  • Severe, uncorrected hypovolemia
  • Allergy to local anesthetics

Relative Contraindications

  • Preeclampsia with platelets <75-80K
  • Coagulopathy / anticoagulation
  • Prior spine surgery altering anatomy

Epidural Placement Workflow

Preparation

  • Choose kit:
    • Standard epidural kit
    • Pain Management kit (DPE or labor CSE)
  • Consent and confirm:
    • Anticoagulant use
    • Bleeding disorders
    • Scoliosis or prior spine surgery
    • Evaluate for preeclampsia
    • Other pregnancy-related complications
  • Pre-procedure setup:
    • Monitors on and cycling BP Cuff
    • IV functioning with fluid bolus running
    • Pump and medications ready
    • Pre-procedure note completed

Positioning & Setup

  • Position patient sitting at edge of bed
  • Optimize positioning (arched back, relaxed shoulders)
  • Identify and mark insertion level
  • Use ultrasound if indicated
  • Perform time-out

Sterile Technique & Placement

  • Prep and drape sterile field
  • Set up epidural kit (images below)
  • Identify loss of resistance
  • Advance catheter (typically LOS + ~5 cm)

Test Dose

  • 3 mL lidocaine 1.5% with epinephrine (1:200,000)
  • Monitor for:
    • Intravascular: tachycardia, hypertension, tinnitus
    • Intrathecal: rapid dense lower extremity block

Securing & Initial Dosing

  • Secure catheter (Mastisol, Tegaderm, tape)
  • Initial bolus (example):
    • 4 mL ropivacaine
    • Additional 4 mL after ~3 minutes (based on BP)
  • Reposition patient supine after initial dose

Post-Placement

  • Connect to epidural infusion pump
  • Document procedure
  • Reassess block and hemodynamics

C-Sections

🧰 OR Setup

⚙️ Machine / Room

  • Machine: Checked (O₂, circuit, backup airway) 

Suction  

📊 Monitors (Standard ASA)

  • NIBP
  • SpO₂
  • EKG
  • EtCO₂ (if GA)

🫁 Airway

Primary:

  • Simple face mask

Backup (on table):

  • Laryngoscope + blades
  • ETT: 6.0, 6.5, 7.0
  • LMA
  • Oral airways

➡️ Always mentally prepared for RSI

💉 IV Access

  • Usually arrives with IV from L&D
  • may have different infusions (magensium, etc)
  • Always have one if not both IVs connected to a free flow

💊 Drugs 

Pressors

  • Phenylephrine gtt (ready BEFORE spinal)
  • Ephedrine (backup)

Routine

  • Ondansetron (Zofran)
  • Bupivacaine (spinal)
  • Fentanyl
  • Morphine (preservative-free)
  • Pitocin (bolus + infusion ready)

Pre-med

  • Famotidine 20 mg
  • Metoclopramide 10 mg

🧰 Special Equipment

  • None routinely

⚡ C-Section Flow

📌 Technique Selection

Scheduled

  • Spinal
  • CSE 

Urgent (working epidural)

  • Activate epidural:
    • 2% Lidocaine
      • Bicarb (2 mL)
      • Epi (≈5 mcg/mL)
  • Turn off / pause ropivacaine infusion

Emergency

  • General anesthesia (RSI)

🔄 Step-by-Step

1️⃣ Pre-Room

  • Machine + airway check
  • Drugs drawn
  • Phenylephrine ready
  • Spinal kit prepared

2️⃣ Pre-op

  • Consent
    • similar to epidural
  • Pre-med:
    • Famotidine
    • Metoclopramide (slow push)

3️⃣ In Room

  • Move patient to OR table
  • Position sitting 

Attach:

  • BP cuff
  • SpO₂
  • IV fluids + phenylephrine inline
  • Give ondansetron early

4️⃣ Neuraxial Block

  • Perform spinal / CSE
  • Start phenylephrine immediately after injection
    • ✔️ Even in preeclampsia (titrate)

5️⃣ After Block

  • Supine + left uterine displacement
  • Apply:
    • EKG
    • Face mask O₂

➡️ Check level: Goal = T4

6️⃣ Surgical Phase

  • OB prep + drape
  • Time-out

Key moments:

  • Block testing “Dr Alice”
  • Uterine incision → delivery

7️⃣ After Delivery

Pitocin:

  • Small incremental boluses (3units q3min based on tone. Communicate with the OB team)
  • Infusion:
    • ~15 units over 15 min
    • Then maintenance

Note: Causes hypotension

8️⃣ End of Case

  • Remove epidural catheter (if present)
  • Transfer with hovermat
  • Handoff to  L&D
  • Post-chart