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1. MEDICO SET –UP SURGERY
DAILY OR SET UP
To be done by resident coming on duty
1. Check circuit, machine, ETT(6.0, 6.5, 7.0), laryngoscope, oral airways
2. Check suction
3. Bicitra available in top drawer
4. Epidural and spinal kits available
5. Jet ventilation apparatus and ambu bag on side of machine
6. Check drugs: All ready togo on anesthesia machine: Write date on all
Meds.
 TPL (25mg/cc) 20cc syringe, change Q week from drug machine
 Ketamine (10mg/cc) 10cc syringe, change Q week
 Ephedrine (5mg/cc), 10cc syringe change daily
 Phenylephrine (100ug/cc), 10cc syringe, change daily
 Succinylcholine (20mg/cc), 10cc syringe, change daily
 Pitocin (10u/cc), 5cc syringe, change daily
7. Check location of "Difficult Airway Box" (orange tackle box) and restock
If used.
8. Pressure bag hanging on side of anesthesia machine
9. LMA in bottom drawer of machine
DAILY CART SET UP (IN HALLWAY)
To be done by resident coming on duty
ON TOP OF CART - Ready to go:
1. 30cc syringe 3% nesacaine
2. 30cc syringe 2% lidocaine with epi 1:400K or with epi 1:200K
3. Bicarbonate
4. Bicitra
3rd DRAWER OF EPIDURAL CART
1. Phenylephrine (0.1mg/cc) 10cc syringe, change daily
2. Ephedrine (5mg/cc) 10cc syringe, change daily
3. Check laryngoscope, ETT
ON SIDE OF CART
1. Ambu bag and O2 cylinder
2. DOING THE EPIDURAL
Sittingtechnique
 Bring in cart, checkIV is working, prehydratepatient (LR or saline
no dextrose), placeEKG leads, attach BP cuff, give 30cc bicitrapo

2.  Open epiduralkit and add betadinetoprep dish
 Prep backwidely x 3 with betadinesponge. Attach drape
 Give lidocaine1% subcutaneouswhealat L3-4, L4-5, or L2-3 with 25g
 needle attached to3cc syringe
 AdvanceTouhy needle through whealapproximately3cm, remove
 stylet, attach LORsyringe and advanceslowly
 When you have loss of resistance, thread catheter4-5cm
 Give test dose unless contraindicated(i.e., preeclampsia): 3cc
lidocaine
 1.5% with epinephrine1:200Kafter negativeaspirate. If
contraindicated,
 do air test and plainlido 45mg test dose.
 Watch patientclosely for signs of intrathecalinjection(sudden
analgesia, suddensensory or motor block) or intravascular injection
(tinnitus, perioralnumbness, metallic tasteinmouth, dizziness,
palpitations) inadditiontoobserving EKG for increased heart rate.
 If negativetest dose, tape catheter, aspiratecatheterand give5cc
bupivacaine.125% (or 5cc bupivacaine.25%) insitting position
Repeat 5cc bupivacaine.125% (or bupivacaine.25%) ina few min.
 Add 50ug fentanyl to thisbolus
 Check sensory level and start infusion
CONTINUOUS EPIDURAL INFUSIONS
2 kinds - in refrigerator
1. Bupivacaine0.125%( use rarely) Start at 8-10 cc/hr
2. Bupivacaine.0625%with fentanyl1.6ug/cc with epi 1:400K(the fentanyl
and epi must be added separately). Thisis the preferred infusion.Startat
10-12 cc/hr.
Add 250ug fentanyl to 150cc bag NS
Add .4cc epinephrine1:1000Kto150cc bag
5TOP-UPS/TOP-OFFS (For a patient experiencing painafter theepidural
placement and boluses are administered.)
1. Ask patient whereshe has pain. If she has rectalpressure, the OB may
want to exam the patient first. If she only hassupra pubic pain, she may
have bladder distentionand need a foley or straightcath.
2. Check sensory level bilaterally. You may have a one-sided block.
3. If block is bilateral, give5-10cc bupivacaine0.125%or 0.25% after
Negativeaspiration.NotifyRN that you are giving top-off.
4. Possibly add fentanyl 50ug - 100ug toabove

3. 5. Chart top ups on anesthesia chart and record 3 sets of BP's after top up is
Given.
6. If no improvement, checksensory level againand epiduralsite. The
catheter mayhave migrated out of the epiduralspace.
7. If a patient isfor VBAC, notify OB if patient stillc/o painafter
reasonabletop-up is given.
AFTER DELIVERY
1. All paperworkmust be completed. Thisincludes time, sex of birth and
APGARS. BP should be recorded every 15 minutes.
2. Catheter should be removed and thisshould be documented. Pumps
should be disconnected and put awayproperly. PCEA (Patien
ControlledEpiduralAnalgesia)
Instructionstopatient and RN: Call anesthesia resident after patient has
pressed button3 timeswith no or minimalrelief, severe pain, hypotension
or any concerns
STAT C-SECTION with Epiduralin Place
1. Ask reasonfor C-section(prolonged bradycardia, latedecelerations,
failureto progress) and call attending immediately
2. If truly "STAT" take30cc syringeof 3% nesacaine on anesthesia cart and
add 3cc bicarb. Startgiving thenesacainequicklyinlabor room - 5cc
increments - and watch patient closely while transportingtoOR. Give
30cc bicitra po. Most patientsneed 20-30cc of the nesacaine. Checklevel.
Be prepared for a STAT generalanesthetic iflevel inadequate
3. Left uterinedisplacement and 100% O2 immediatelyinOR
4. Placemonitors.
STAT C-SECTION without Epidural in Place
1. Call attending immediately and ask obstetricians reason for C-section.
2. Ask quick history and do airway exam
3. Be prepared to do a quick spinal and general anesthetic induction. Give
bicitra 30cc po. Place monitors.
a. If spinal: 1.6cc bupivacaine .75% with glucose
(If fentanyl and duramorph available - add 10ug and .2mg
respectively)
b. If GA: Pre oxygenate with good mask fit with patient in left uterine
displacement. IV TPL, SUX, cricoid pressure. Have difficult airway box

4. in room. See details below.
GENERAL ANESTHESIA FORSTAT C-SECTION
1. Do quick airway exam and ask patient if any med problems, allergies. If
good airway, proceed with rapid sequence induction. If bad airway, attending to decide
plan- probable STAT spinal.
2. Check if patient has working IV
3. Bicitra premed
4. Preoxygenate with good mask fit- 4 vital capacity breaths, cricoid
pressure
5. IV TPL and/or ketamine and sux and intubate
6. 50% O2 and 50% N2O with forane .6 - 1 %; vecuronium 1-3 mg or sux
drip (500 mg in 500 cc bag NS with microdrip), versed if needed
7. After baby out, 70% N2O, 30% O2, forane .2 -.6% ( turn off if atony),
MSO4 and/or fentanyl, versed if needed
8. Extubate awake
URGENT CSEC with Epidural in Place
1. Ask reason for C-section and call attending.
2. If not truly STAT, take 30cc syringe of 2% lidocaine with epi 1:400K or epi
1:200K on anesthesia cart and add 3cc bicarb. Give lidocaine in labor room
with 5cc increments. Follow and chart BP's. Give bicitra po.
3. Get "regional" kit from drug machine.
URGENT C-SECTION without Epidural in Place
1. Ask reason for C-section and call attending.
2. Anesthesia options are spinal, epidural, general depending on situation.
Be prepared for each option as attending decides.
3. Ask quick history and do airway exam
4. Most patients will develop adequate level with 15-20 cc lido 2% with epi
1:400k.
ELECTIVE C-SECTION
1. Consent patient (see "Epidural Basics") and write note
2. Check NPO status.
3. Have IVF running wide open. Give bicitra 30cc po within 15 min. of going
to OR.
4. If spinal: 1.6cc bupiv. 0.75% with fentanyl 10ug (.2cc) and duramorph
0.2mg (.2cc)
If epidural: lidocaine 2% with epi 1:400K or 1:200K with bicarb (1cc/10cc
lidocaine)

5. 5. Complete duramorph orders
6. If patient is at risk for postpartum hemorrhage, make sure type and
screen or type and crossmatch has been sent. Routine standing orders on
L & D are for type and hold only.
7. All c-section patients must be signed out by a resident.
FORCEPS DELIVERY with Epidural in Place
1. Take 30cc of 3% nesacaine on top of anesthesia cart and add 3cc bicarb.
2. Raise head of bed so that the patient is in sitting position
3. Inject 5-15cc of nesacaine with 5c increments until sacral anesthesia is
achieved
4. Stay with patient until delivery and record BP's for at least 15 mins.
Remember a failed forceps delivery will likely become a STAT C-section.
5. Replace 3% nesacaine syringe
D & C'S AND D & E'S
1. Consent patient: (see "Epidural Basics")
Be sure to ask weeks of gestation, NPO status
2. Spinal vs. MAC
a. If spinal: 3cc lidocaine 1.5% with glucose
May add fentanyl 10ug
Have midazolam available
b. If MAC: (only an option if patient is less than 10 weeks) midazolam,
fentanyl +/-propofol.
BTL (Bilateral Tubal Ligation)
1. If epidural in place for delivery, working well, and the patient is stable and
NPO during labor, then a BTL can be performed immediately after delivery.
Give bicitra 30cc po. Inject epidural with 15- 20cc 3% nesacaine or 2%
lidocaine with epi 1:400k toobtain T6- T4 block. Obtain regional kit. Can add
fentanyl 50-100ug . No duramorph!
2. If patient is NPO and scheduled for BTL post-delivery day 1, then we
administer a spinal anesthetic ( 4cc lidocaine 1.5% with dextrose) . Can
add fentanyl 10ug. Bicitra premed. Have regional kit with versed available.
3. General anesthesia is not offered for BTLs since it is an elective case.
Please consult with your attending if a patient is refusing a spinal.
CHARTING- VERY IMPORTANT
1. Write preop (see "Epidural Basics")
2. Legible Chart - Be sure to document bicitra 30cc po and "LUD" (left uterine
displacement), time of delivery, APGAR scores on all charts.
Be sure to chart a set of vitals (BP, HR, FHR) at least once every 2 hours for
patients with a labor epidural.
Be sure to document top-off meds given and 3 BPs after the top-off.
Document fentanyl given and infusion concentration and rate
3. Postops. See and write a brief postop note for all of your patients. Place a
check next to the patient's name in the black marble book in the call room
after the postop is done.

6. 4. All patients (C-section, labor epidurals, D & C's) should be recorded in the
black marble book in call room.
5. See "Sample OB Record" enclosed.
6. Completed anesthesia records:
Pink copy to chart
Yellow copy with billing sheet to marble book in call room
White copy with yellow drug form to drug machine