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NUNA 693 Obs/Regional > OB: Labor Analgesia > Flashcards

OB: Labor Analgesia Flashcards

1
Q

Many _____ & ____ _____ throughout history
- Princess and the Pea
- Upper class women have more pain than “savages”
- “Modern women” have more pain than “savages” because “the church and culture taught them to expect it.”

A

social and medical connotations

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2
Q

Less than ___% of pregnancies end on the EDD

A

10%

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3
Q

In the US approximately ____% occur preterm (<37 weeks) and 5-7% remain undelivered postterm (>42 weeks)

A

13%

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4
Q

Cause for onset of labor

A

remains unknown

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5
Q

Three (4) stages of labor

A

Dilation
Expulsion
Placental
(4th) Stabilization

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6
Q

Stage 1 has three phases
_____ (0-3 cm)
_____ (4-7 cm)
_____ (8-10 cm)

A

Latent (0-3 cm)
Active (4-7 cm)
Transitional (8-10 cm)

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7
Q

First stage of labor
__________ pain
_____ level

A

visceral
T10 - L1

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8
Q

Second stage of labor
_____ pain
_____ level

A

Somatic
S2 - S4

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9
Q

3 components of labor and delivery (3 P’s)

A

Powers (uterine contraction, maternal voluntary expulsive efforts)
Passageway (pelvis, soft tissues)
Passenger (fetus)

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10
Q

Passenger - Fetal size and relationship of the fetus to the ____ ____ affect labor progress

A

maternal pelvis

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11
Q

Passenger - lie (3)

A

Transverse
Oblique
Longitudinal

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12
Q

Passenger - presentation (3)

A

Cephalic
Breech
Shoulder

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13
Q

Passenger - P____

A

Position

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14
Q

Station - Palpation of the ____ ____ ____ of the fetus

A

leading bony point

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15
Q

3 general methods to control pain in labor

A

nonpharmacologic
neuraxial
non-neuraxial

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16
Q

Nonpharm methods

A

Antenatal health education
Support persons
Relaxation techniques
Massage
Reflexology
Hypnosis
Aromatherapy
Acupuncture/acupressure
Hydrotherapy
TENS
Sterile water injection

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17
Q

neuraxial methods

A

Epidural
Spinal
CSE

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18
Q

non-neuraxial methods

A

Nitrous
Volatile anesthetics
Non-opioids
Opioids

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19
Q

Sterile Water Injection

Injection of small ___ ____ of sterile water

A

0.1mL blebs

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20
Q

Sterile Water Injection

Ideal number of injections ____

A

unknown

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21
Q

Sterile Water Injection

Counterirritation - ____ ____ theory

A

Gate control

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22
Q

Sterile Water Injection

Not recommended for ____ ____

A

active labor

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23
Q

Inhalational Agent for analgesia -

Nitrous
___% blended
Used much more often in Canada & UK
____ effective than epidural
____ nausea

A

50%
Less
More

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24
Q

Inhalational Agent for analgesia -

Volatile anesthetics
Smooth muscle _____
Provider/equipment _____

A

relaxation
limitations

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25
Q

Non-opioid Analgesia and Sedation -

Acetaminophen
____ IV decreased VAS scores and need for rescue meds
___ ____ in neonates

A

1 g
No change

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26
Q

Non-opioid Analgesia and Sedation -

______
Few studies
Can increase HR/BP

A

Ketamine

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27
Q

Non-opioid Analgesia and Sedation -

Benzodiazepines
______ cross placenta
Maternal ____

A

easily
amnesia

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28
Q

Non-opioid Analgesia and Sedation -

Phenothiazines
____ cross placenta
____ fetal HR variability

A

Easily
decrease

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29
Q

Non-opioid Analgesia and Sedation -

Barbiturates
____ cross placenta
Neonatal ____

A

Easily
depression

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30
Q

Opioid Analgesia

Meperidine
Most used and researched
_____ analgesia
Reduced _____
Neonatal depression

A

poor
variability

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31
Q

Opioid Analgesia

Morphine
____ satisfaction than meperidine
More requests for _____ doses

A

Less
additional

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32
Q

Opioid Analgesia

Fentanyl
Good pain relief
Context-sensitive half-life requires ____ ____ mom/baby after prolonged use

A

extended monitoring

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33
Q

Opioid Analgesia

Remifentanyl/Alfentanyl/Sufentanyl
____ ____ ____ to support use

A

No strong evidence

34
Q

Neuraxial Analgesia for Labor Indications

____ request

A

Maternal

35
Q

Neuraxial Analgesia for Labor Indications

Anticipation of ____ delivery (malposition, multiple gestation…)

A

operative

36
Q

Neuraxial Analgesia for Labor Indications

____ _____/____ risk for precipitous, high-risk or emergency delivery (pre-e, nonreassuring FHT…)

A

Obstetric disease/High

37
Q

Neuraxial Analgesia for Labor Indications

_____ conditions (obesity, difficult airway, MH)

A

Maternal

38
Q

Neuraxial Analgesia for Labor Indications

Maternal _____ disease

A

coexisting

(severe cardiac or respiratory disease)

39
Q

Absolute Contraindications of Neuraxial Analgesia for Labor

A

Patient refusal
Uncooperative patient
Moderate/severe bleeding conditions
Anticoagulation
Uncontrolled hemorrhage/severe hypovolemia
Epidural site infection
Unskilled/inexperienced anesthesia provider

40
Q

Relative Contraindications of Neuraxial Analgesia for Labor

A

Elevated ICP
Documented LA allergy
Untreated systemic infection
Preexisting neurologic deficit
Informed consent difficulties (language)
Severe fetal depression
Severe maternal cardiac disease
Skeletal abnormalities
Some types of back surgery

41
Q

Neuraxial Technique Choice - Maternal coexisting disease such as (2)

A

Severe valvular heart disease
Intracranial mass/neurologic disease

42
Q

Neuraxial Technique Choice - Obstetric considerations such as (3)

A

Likelihood of surgical delivery
Stage of labor
Fetal abnormalities

43
Q

Neuraxial Technique Choice - Anesthetic considerations such as (3)

A

Difficult airway
Timing
PDPH

44
Q

Benefits of Epidural Analgesia - Decreased maternal ______

A

catecholamines

45
Q

Benefits of Epidural Analgesia - Decreased maternal ______

A

hyperventilation

46
Q

Benefits of Epidural Analgesia - Ability to rapidly transition to ___ ____ for emergencies

A

epidural anesthesia

47
Q

Preparation:

A

eval and consent
aspiration prophylaxis
labs
IVs
monitoring
positioning
emergency drugs and equipment

48
Q

Evaluation and Consent

History
Relevant _____ exam
_____ consent
Recognition of ____ _____

A

physical
informed
risk factors

49
Q

Aspiration Prophylaxis

____ Liquids
All pregnant women are considered a ….. ____ ____
ASA guidelines – no solid food during ____ labor, no consensus on amount of liquid
What other factors could increase risk of aspiration?

A

Clear
full stomach
active

50
Q

Labs

A

plts?
crossmatch?

generally not needed

51
Q

monitoring

A

BP
FHT
EKG? generally not needed, but must be used during epidural
Pulse ox?

52
Q

Emergency Drugs & Supplies

A

pressors
airway

53
Q

Choice of Local Anesthetics - Bupivacaine

Advantages
_____ block
_____ duration of action
Lack of _____
Limited placental transfer

A

Differential
Long
tachyphylaxis

54
Q

Choice of Local Anesthetics - Bupivacaine

Disadvantages
_____ onset time
____ and ____ toxicity

A

slower
CV and neuro

55
Q

Choice of Local Anesthetics - Bupivacaine

Concentration and dose
0.0625%-0.125% sometimes up to ____
__-__mL

A

0.25%
12-20

56
Q

Choice of Local Anesthetics - Lidocaine

Not routinely used for maintenance of labor analgesia
____ sensory/motor discrimination
Popular as a ____ ___

A

Little
test dose

57
Q

Choice of Local Anesthetics - Chloroprocaine

_____ toxic
___% used for rapid expansion for cesarean

A

least
3%

58
Q

Choice of Local Anesthetics - Chloroprocaine

____ duration
Increased motor block
Interfere with action of ____ & ____ (more in peripheral blocks)

A

least
bupivacaine and opioids

59
Q

Choice of Local Anesthetics - Ropivacaine

Less ____toxic
0.1-0.2% Infusions
Less ____ block
More _____
Lidocaine works as well and is cheaper

A

cardio
motor
expensive

60
Q

Adjuvants - opioids

____ & ____ opioid receptors
Lipophilic > Morphine

A

Spinal and supraspinal

61
Q

Adjuvants - epinephrine

  • Vasoconstriction, decreased clearance
  • ___ agonism
  • Disadvantages: ___ agonism (systemic), Increased ___ block
A

α2
β2
motor

62
Q

Adjuvants - clonidine

α2 agonism
___ ____ in motor block
____ ___ warning in OB

A

No increase
Black Box

63
Q

Adjuvants - neostigmine

In animals
____ ____ in human study
Did increase ____

A

Didn’t work
nausea

64
Q

Analgesia for Vaginal Delivery

Second stage of labor pain - ____ fibers at __-__

A

somatic
S2-S4

65
Q

Analgesia for Vaginal Delivery - Recently placed epidurals may benefit from sacral top offs

5-10mL of ______ ______ with _____ _____
Given in sitting position

A

0.5-1% Lidocaine with 100 mcg fentanyl

66
Q

Analgesia for Vaginal Delivery - Instrumented vaginal delivery

May need a ____ block
__-__ mL of 2% Lidocaine with epi, 0.25% bupivacaine, or 3% 2-chloroprocaine

A

denser
5-10

67
Q

Neuraxial Anatomy - Reduction of _____ gap

A

intervertebral

68
Q

Neuraxial Anatomy - Widening of hips creates a ___ ____ ____ when lateral

A

head down tilt

69
Q

Neuraxial Anatomy - ____ ____ of the pelvis can move the line at the iliac crests higher

A

Forward rotation

70
Q

Neuraxial Anatomy - Higher apex of thoracic _____

A

kyphosis

71
Q

Neuraxial Anatomy - Engorgement of ____ veins

A

epidural

72
Q

Neuraxial Anatomy - Difficult to ID ____ ____

A

ligamentum flavum

73
Q

Types of Maintenance (5)

A

Epidural vs CSE
Continuous spinal
Intermittent Bolus
Continuous Infusion
PCEA

74
Q

Maintenance of Continuous Spinal Analgesia -

Narcotic helps provide analgesia without ____ ____ ____

A

excessive motor block

75
Q

Maintenance of Continuous Spinal Analgesia

Bupivacaine - ___-___ plus 1-2 mcg/mL fentanyl rate of ___-___
Disconnect ____ option
May opt for clinician administered top off doses
Special caution for sterile technique

A

0.8-0.125%
1-1.5 mL/hour
PCEA

76
Q

Maintenance of Continuous Spinal Analgesia

LABEL ____ LABEL

A

LABEL

77
Q

Ambulation in Labor - Advantages (3)

A

Maternal satisfaction/autonomy
Decreased dystocia
Decrease risk of DVT

78
Q

Ambulation in Labor - Disadvantages (5)

A

Falls with slight motor block
Hypotension
Increased workload
Increased need for top off doses
Mediolegal

79
Q

Side effects - hypotension

Up to ___% of parturients
Initial dose or bolus
_____ blockade
Fluid loading or use of prophylactic pressors may decrease risk, but _____ prevents
Can lead to fetal _____

A

80
Sympathetic
nothing
distress

80
Q

Side effects - pruritis

Time limited __ minutes
____ can sedate
____ 5-10mg
Ondansetron

A

90
Benadryl
Nubain

81
Q

Complications

A

failed analgesia
unintended dural puncture
back pain
excessive motor block
urinary retention
maternal hyperthermia
fetal heart rate abnormalities
accidental IV injection
meningitis
epidural hematoma/abscess
neurologic deficits

NUNA 693 Obs/Regional (13 decks)

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