The following are suggested protocols for labour analgesia and anaesthesia for operative delivery. Ultimately, actual dosage depends on multiple factors and sound clinical judgement.
Initiation Of Labour Epidural (all doses should be fractionated)
Test dose:
3ml 2% lidocaine
Early labour:
Bupivacaine 0.125% up to 15 ml
Or pump solution (Bupivacaine 0.08% + 2ug/ml fentanyl ) up to 20 ml
Active labour:
Bupivacaine 0.25% +/- up to 75ug/fentanyl up to 15 ml
OR
Consider CSE
Combined Spinal Epidural (for labour analgesic)
Bupivacaine 0.25% 0.5-1ml + Fentanyl 25ug or Sufentanil 5-7.5ug (needs to be diluted 50ug in 10ml NS)
*Filter needle for all intrathecal / neuraxial medication is recommended.
Maintenance Of Labour Analgesic
Patient-Controlled Epidural Analgesia (PCEA)
Instruct patient on use.
Describe the machine and reassure patient (can’t overdose).
Some patients worry that they must watch the machine or they will be in terrible pain!
Instruct patient that if they are not comfortable after 2 doses, request visit by anesthesiologist for clinician-topup.
Order sheets:
Drug used (only bupivacaine cassette is available), bolus, lockout interval, background infusion, and rescue medication for side effects must be specified.
Typical orders:
Bolus - 5 to 8 ml
Lockout - 10 minutes
Background infusion - 5 to 10 ml/hr (nurse may vary it according to stage of labour).
Alternatively, you can also order Intermittent Bolus instead of background infusion e.g. 8ml q1hr
Other meds: Naltrexone and ondansatron
Pharmacy has prepared CADD pump cassettes of Bupivacaine 0.08% with fentanyl 2ug/ml for use to maintain labour analgesia. Cassette with 0.15% ropivacaine (without fentanyl) is available in PAC on M2 24/7 if required.
Latex allergy: Regular cassettes are not free of latex. However there are special latex free cassettes are available. Please check with the nurses.
Intravenous Opioids For Labour Analgesia
Single shot
Fentanyl is the easiest drug to use.
Initiate with 50 ug and titrate to effect. Usual loading dose 150-250 ug.
IV PCA
Preprinted order sheets for fentanyl. Includes orders for anti-emetics an anti-pruritic.
Initial loading as for single shot.
Maintain with boluses of 25ug, lockout of 5 minutes, no infusion, maximum of 250 to 750ug in 2hrs (depending on stage of labour).
Remind nurse that paediatrics should attend delivery (it is in their protocol).
Cesarean Section
Unless contraindicated, antibiotics should be given between 15 and 60 minutes before skin incision. For patients with true allergy to Cefazolin, Clindamycin + Gentamicin are given as alternative.
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