Obstetrics as a unique anesthetizing environment

1. Obstetrics as a unique anesthetizing environment Tom Archer, MD, MBA Director, OB anesthesia UCSD

2. Learning objectives • Why is OB a unique environment for us, the anesthesiologist? • How should we the obstetrician? • How should the obstetrician treat us?

3. Obstetrics– a unique environment for the anesthesiologist • A happy, “normal” event, unlike other “surgery”. • Patients are usually in pain when we meet them. • Most patients want to be awake for the birth (the “procedure”). • Lots of family around (and in OR).

4. Cesarean delivery-- a unique psychosocial surgery

5. C-section – a unique psychosocial surgery • Unique surgery, happy event gone awry. • Strike a balance between “happy event” and “risky surgery”. • Most patients are awake– and want to be. • Team approach (patient, family, nursing, OB, anesthesia) • Support person present in OR. • Need for utmost discretion about medical info– JW, drug use, abortions, etc.

6. How should we treat the OB? • “Private practice approach”: we are all here to take excellent, efficient and profitable care of the patient. • Availability • Responsiveness • “Management by walking around” • Proactive (when they call for strip review in Room #7, we go in too).

7. How should we behave on OB? Our antennae need to be out. Don’t wait to be called!

8. Anticipate and be available • Know every patient on the floor. Introduce yourself early. • Be accessible to OBs and nurses. • Get informed early about potential problems (airway, obesity, coagulopathy JW, congenital heart disease) • Remember the basics (IV access, airway)

9. Anticipate and be available • We need a certain knowledge of OB to know what is going to happen. Try to think one or two steps ahead. • “Placenta isn’t out yet in room 7” • “The lady in 6 has a pretty bad tear.” • “Strip review in 3, please.” • “We can’t get an IV on the lady in 4.” • “Can you give us a whiff of anesthesia in 8? We don’t need much.”

10. Good interpersonal relations are part of good medicine • Eager to meet, greet and evaluate the new patients when they first come in. • Good patient care • Good human relations • Good business • Listens well and respectfully answers patient questions. • Proactive approach to problems (obesity, fear, bleeding, coagulopathy, hx of anesthesia problems). • A doctor who, by the way, gives anesthesia (another medical resource, not just a needle jockey).

11. What we like from the obstetrician • Get us involved early! • If we have the right attitude, we will never be upset with your getting us involved early! • Morbid obesity • Asthma • Anesthesia fears, Hx of problems • Any significant medical problem

12. What we like from the obstetrician • Treat us like an consultant, not a technician. • We have our own, valid point of view and concerns. • Just like you, we want the best outcome for mother and child.

13. What we like from you, the obstetrician • Tell us what has happened with the patient and what you need to do– don’t tell us what anesthetic to give. • For you to dictate the anesthetic clouds the picture (and makes us defensive).

14. What we like from you, the obstetrician • For example, say: “The patient has a retained placenta and the uterus appears to have contracted down around it, so we need to relax the uterine muscle and manually take out the placenta.” • This could be achieved with GA or IV analgesia plus nitroglycerin. • Don’t say, “This patient needs a spinal so I can get the placenta out.” • Spinal will not relax uterine muscle.

15. Tell us what is going on with the patient and what you need to do. • Let us design the anesthetic plan to give you and the patient the conditions that you need. • That’s our job!

16. The End