Recipes & Emergency Drugs

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Hemorrhage

Obstetric Emergencies

EMERGENCY DRUGS

Eclamptic Seizure

• Midazolam 2 mg IV or lorazepam 4 mg IV

• Below drugs stored in Eclampsia box across from OR A + B

• Magnesium 6 g IV (over 20 min) If already on MgSO4, give 2 g

• IV (over 3-5 min)

• Maintenance: 1-2 g/hr

• Propofol 20-40 mg IV

LAST (Local Anesthetic Systemic Toxicity)

• Intralipid 20%

• Drug and dosing guidelines in LAST box across from OR A + B

Fetal Bradycardia

• For uterine uypertonus (most likely cause):

  • • Nitroglycerin SL: 2 sprays PRN (400 mcg/spray)

    • Nitroglycerin IV: 50-100 mcg bolus

    • Terbutaline 0.25 mg SC

• If hypotensive:

  • • Phenylephrine 50-100 mcg IV

    • Ephedrine 5-10 mg IV PRN

Uterotonics

• Pitocin bolus 1-2 U/IV + infusion 7.5-30 U/hr (30 U/500 ml LR at 125-500 ml/h)

• Methylergonovine (Methergine) 200 mcg IM (q2-4 h)

• Carboprost (Hemabate) 250 mcg IM (q15 min)

  • Give Lomotil to prevent diarrhea (two tabs 2.5 mg each)

• Misoprostol (Cytotec) 600-800 mcg SL or 1000 mcg PR

Labor Analgesia

Labor Epidural

• Initiation 15 ml [0.125% bupivacaine + 0.66 mcg/ml suf]

• Infusion PIEB 9 ml q45 min (first dose at 30 min);

• PCEA 10 ml q 10 min [0.0625% bupivacaine + 0.4 mcg/ml suf]

CSE For Labor

• Initiation 0.6-1.1 ml [2.5 mg plain bupivacaine + 5 mcg suf]

• Infusion PIEB 9 ml q45 min (first dose at 30 min);

• PCEA 10 ml q10 min [0.0625% bupivacaine + 0.4 mcg/ml suf]

Labor Epidural Top-Ups

• 5-10 ml 0.125%-0.25% bupivacaine +/- 100 mcg fent

Intrathecal Catheter (The Carvalho Special)

• Initiation 1.1 ml [2.5 mg plain bupivacaine + 5 mcg suf]

• Infusion 1-2 ml/hr [0.0625% bupivacaine + 0.4 mcg/ml suf]

Remifentanil PCA For Labor Analgesia

• Remifentanil syringe: 66 mcg/ml

• 0.25-0.5 mcg/kg bolus, 2 min lockout

• Consider adding an infusion of 0.025 mcg/kg/min

Postpartum Tubal Ligation

Single Shot Spinal or CSE (Note Recent Dose Increase)

• 0.75% Bupivacaine in Dextrose 1.6 to 2.0 ml

• Fentanyl 20 mcg

Epidural in-situ

• 2% lidocaine + epi 1:200,000 15-20 ml

• +/- Fentanyl 100 mcg

Cesarean Delivery

Single Shot Spinal or CSE

• 0.75% Bupivacaine in Dextrose 1.6 to 2.0 ml IT

• Fentanyl 15 mcg IT

• Morphine preservative-free (PF) 50-150 mcg IT (Note recent update on assessing post-op pain risk and assigning morphine dose)

Epidural in-situ

• 2% lidocaine + epi 1:200,000 15-20 ml

• +/- Fentanyl 100 mcg

• After delivery of the baby Morphine preservative-free (PF) 3 mg

• Consider 3% 2-Chloroprocaine for emergent top-up (15-20 ml)

External Cephalic Version

CSE

• 0.75% Bupivacaine in Dextrose 1.2 to 1.6 ml

• Fentanyl 15 mcg

• DO NOT ADD Morphine unless a c-section is performed. Then give Morphine preservative-free (PF) 3 mg

Cerclage

Single Shot Spinal or CSE

• 0.75% Bupivacaine in Dextrose 1.0 to 1.6 ml IT

  • Note variable dosing by different attendings

• Fentanyl 15 mcg IT