For Cesarean deliveries we are assessing individual risk for:
A Respiratory Depression Risk Assessment
A PONV Risk Assessment
An Analgesic Protocol Choice
In the preoperative note:
The respiratory depression and PONV assessments are a series of yes/no questions and once completed they will be flagged in the anesthesia plan section.
If the patient is high risk for respiratory depression and/or PONV, warning buttons will automatically display in the intraoperative record.
In addition, if there is an intraoperative respiratory depression risk factor identified, a specific event icon will need to be fired. All the events that qualify are outlined in the event icon and include the following: desaturation <94%, oxygen requirement, EBL >1500 ml, general anesthesia, magnesium administration, or other event increasing risk of postoperative respiratory depression.
If the respiratory depression risk assessment is marked as high risk, or an intraop event: Please click the pulse oximetry order in the standard ‘OB Anesthesia Post-Cesarean Pain Orders’ orderset.
If PONV risk: In addition to ondansetron 4 mg IV (which is administered to all patients), administer dexamethasone 4 mg IV to patients identified as having a PONV risk (we currently do not routinely administer dexamethasone to all patients).
For Analgesic Protocol Choice
There is a script in the preoperative note that you can use as a template to instruct women to help make their choice. The script states: “Pain relief medication given after surgery decreases pain but may increase side effects (e.g. nausea, vomiting, itching, sedation, dizziness). All drugs and doses we use are safe for mother and baby, but while larger doses may reduce pain more, they may increase the risk of side effects. We would like to offer you a choice between a lower, standard, or a higher pain relief protocol”. Patient selection: Lower Standard Higher The anesthesia choice will be highlighted in the anesthesia plan note.
Based on what the patient selects, please give:
Lower: 50 mcg IT morphine, or 2 mg epidural morphine
Standard: 100 mcg IT morphine, or 3 mg epidural morphine
Higher: 150 mcg IT morphine, or 4 mg epidural morphine