Its become very evident that obstetric anesthesiology is an entirely different animal compared to my other rotations. I haven’t intubated anyone in three weeks. All my patients are relatively young, pregnant women. I haven’t even seen a vial of propofol in a week! For various reasons, the preferred means of anesthesia for parturients remains a neuraxial technique: spinal, epidural, or combined spinal-epidural (CSE).
After familiarizing myself with the extensive documentation workflow in the first 2-3 days, I’m now in pursuit of mastering the procedural skills involved with placing neuraxial anesthetics. Before this rotation, I considered myself to be fairly skilled with most procedures: advanced airway management, line placement (IV, arterial line, central line, PA catheter), peripheral nerve blocks, and ultrasound-guided variants to the aforementioned.
Neuraxial techniques are different because, to a large extent, they’re completely blind and really rely on a “feel” for the tissues one traverses when introducing a needle. After assessing the patient’s spinal column (finding midline, determining any degree of lumbar scoliosis, etc.), I palpate spinous processes to find a nice interspace to introduce my epidural or spinal needle (typically L3/L4 or L4/L5). With the midline approach, the needle traverses the following layers (in order): skin, subcutaneous tissue, supraspinous ligament, interspinous ligament, ligamentum flavum, epidural space (target for epidurals), dura, subdural space, arachnoid, and subarachnoid space (cerebrospinal fluid lives here, this is the target for spinals). Without getting into all the procedural details, some epidurals were very straightforward while others posed challenges. Never the less, it’s nice to see the immediate relief patients receive! 🙂
Overall, learning about the physiological changes associated with pregnancy, the pharmacology of neuraxials (local anesthetics, opioids, and other adjuncts), and just getting to work with the pregnant patient population has been enjoyable thus far! All the attendings have been incredibly patient, the obstetric residents have been nice to work with, and my colleagues and I continue to work well as a team.
Here are some random pictures I took over the last three weeks.