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OB > Labor, Vaginal & Cesarean Delivery > Flashcards

Labor, Vaginal & Cesarean Delivery Flashcards

1
Q

Analgesic options for 1st stage labor pain:

A

-neuraxial block
-paravertebral lumbar sympathetic block
-Paracervical block

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2
Q

Analgesic options for 2nd stage labor pain

A

Neuraxial block
Pudendal nerve block

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3
Q

Where is pain in the first stage of labor?

A

Caused mainly from lower uterine contractions

begins in the lower uterine segment and the cervix

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4
Q

Where do pain signals travel in the first stage of labor?

A

T10-L1 posterior nerve roots

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5
Q

Where do pain signals travel in the 2nd stage of labor?

A

from perineum to the S2-S4 posterior nerve roots

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6
Q

Where is the pain felt during the 2nd stage of labor?

A

perineal structures via pudendal nerve

adds in pain impulses from the vagina, perineum and pelvic floor

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7
Q

What are the risks of a paracervical block?

A

accidental injection into the uterine artery

Fetal local anesthetic toxicity

Nerve injury and/or hematoma

High risk of fetal bradycardia

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8
Q

Afferent pathway of the uterus and cervix:

A

Visceral C fibers hypogastric plexus

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9
Q

Afferent pathway of the perineum

A

Pudendal nerve

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10
Q

which local anesthetic reduces the efficacy of epidural morphine?

A

2-chloroprocaine

(antagonizes mu and kappa receptors)

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11
Q

When administered alone, what are the benefits of neuraxial opioids?

A

No loss of sensation or proprioception

no sympathectomy (superior hemodynamic stability)

they do not impair mom’s ability to push

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12
Q

What opioid has local anesthetic properties?

A

Meperidine

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13
Q

What are the most common side effects of neuraxial opioids?

A

Puritus
N/V
sedation
respiratory depression

They don’t meaningfully depress the fetus

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14
Q

Bupivacaine class and DOA:

A

Amide
Long duration

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15
Q

Ropivacaine class and DOA

A

Amide
Long DOA

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16
Q

Levobupivacaine class and DOA

A

Amide
Long DOA

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17
Q

Lidocaine class and DOA

A

Amide
Intermediate duration

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18
Q

2-Chloroprocaine class and DOA

A

Ester
Short duration

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19
Q

What is the risk if lidocaine is given in the subarachnoid space?

A

Neurotoxicity

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20
Q

Why is lidocaine not popular for labor analgesia?

A

Strong motor block (better for c-sections)

Tachyphylaxis can occur with continuous infusions and it crosses the placenta to a greater degree than alternatives

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21
Q

15 mins after a pts epidural was dosed, the pt becomes hypotensive and experiences resp. arrest. What is the MOST likely etiology?

A. epidural catheter migration

B. Loss of accessory respiratory muscle strength

C. Subdural injection

D. Eclampsia

A

C. subdural injection

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22
Q

Ways that a patient can develop a total spinal:

A

1.) An epidural dose injected into the subarachnoid space

2.) An epidural dose injected into the subdural space (s/Sx may be delayed)

3.) a single shot spinal after a failed epidural block

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23
Q

Treatment for total spinal:

A

Supportive:
-airway management
-IVF
-Vasopressors
-left uterine displacement
-leg elevation

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24
Q

Presentation of total spinal:

A

Dyspnea
difficulty phonating
hypotension
LOC d/t hypoperfusion secondary to severe HoTN

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25
Q

Anesthetic implications for Caesarean section under general anesthesia include:

A. administration of a dopamine agonist

B. prolonged neonatal respiratory depression

C. Increased MAC

D. rapid sequence induction

A

D. RSI

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26
Q

An obstetric pt at 33 weeks gestation requires a laparoscopic appendectomy. Which drug presents the greatest risk to fetal well-being?

A. ketorolac

B. succinylcholine

C. propofol

D. Morphine

A

A. ketorolac

After the first trimester, NSAIDs can close the ductus arteriosus

while no anesthetic is a proven teratogen in humans, its wise to stay with drugs w a long track record for safety such as propofol, opioids, NMB, and inhalation agents

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27
Q

Most significant fetal risks with maternal nonobstetric procedures:

A

growth restriction

low birth weight

demise

increased incidence of preterm labor

Highest risk= intraabdominal and pelvic surgery

appendectomy and cholecystectomy most common

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28
Q

How long would be ideal to wait to have a procedure after giving birth?

A

6 weeks after delivery

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29
Q

If one cannot wait to have a surgical procedure and is pregnant, what trimester is the best time for surgery?

A

2nd trimester (12-24 wks.)

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30
Q

At how many weeks is the pregnant patient always considered a “full stomach”?

A

18-20 wks.

May be earlier if pt has symptoms of GERD

Also applies to the immediate postpartum period

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31
Q

Why is hyperventilation bad?

A

reduces placental blood flow (risk of fetal asphyxia)

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32
Q

Teratogenicity can occur any time during pregnancy but the risk is highest during:

A

organogenesis (day 13-60)

(3-8 wks)

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33
Q

Aspiration prophylaxis:

A

-non-particulate antacid (sodium citrate)

-H2 antagonist (ranitidine) 1 hr before induction

-Gastric prokinetic (metoclopramide) 1 hr before induction

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34
Q

Teratogens are:

A

substances that act to irreversibly alter growth, structure, or function of the developing embryo

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35
Q

a major malformation is defined as:

A

one that is incompatible with survival (anencephaly), one that requires major surgery for correction (cleft palate, heart disease) or one that causes mental retardation

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36
Q

Fetal pH is lower or higher than maternal pH?

A

LOWER

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37
Q

Whats the risk with fetal acidosis?

A

it can significantly increase the fetal concentration of drugs such as local anesthetics

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38
Q

On average, women take ____ drugs during pregnancy

A

4

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39
Q

The US Food and Drug Administration has implemented the:

A

The pregnancy and lactation labeling rule

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40
Q

Which two drug categories have a high risk for adverse fetal effects?

A

Anticonvulsants and antidepressants

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41
Q

what is the safest analgesic in pregnancy?

A

Acetaminophen (NSAIDs should be avoided)

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42
Q

Which 2 cardiac drug classes should be avoided during pregnancy?

A

ACEIs and ARBs

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43
Q

What is an up-to-date resource for the safety of drugs during breast feeding?

A

LactMed

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44
Q

What class of meds is not recommended during breast-feeding?

A

oral opioids- codeine and tramadol

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45
Q

Which anesthetics may interfere with reproductive physiology in vitro?

A

Local anesthetics
nitrous oxide
volatile halogenated agents

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46
Q

what are some of the symptoms that can occur during ovarian hyperstimulation syndrome?

A

ascites
pleural effusion
hemoconcentration
oliguria
thromboembolic events

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47
Q

problems of early pregnancy:

A

ectopic pregnancy
cerclage
molar pregnancy
dilation and curettage
dilation and evacuation

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48
Q

what is cervical insufficiency?

A

the inability of the cervix to hold a pregnancy in the uterus through the 2nd trimester in the absence of labor

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49
Q

Most common cerclage procedures:

A

Shirodkar cerclage
McDonald cerclage

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50
Q

What is a molar pregnancy?

A

an abnormality of the placenta caused by a problem when the egg and sperm join together at fertilization

also called gestational trophoblastic disease (GTD), hydatidiform mole

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51
Q

Anesthetic considerations for GTD

A

Normal GA
2 PIV
immediate availability of blood
etomidate if unstable
Oxytocin infusion 6-15IU per hr after dilation.

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52
Q

Abortion:

A

pregnancy loss or termination before 20 wks gestation or when fetus weighs less than 500g

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53
Q

Anesthetic considerations for D&C/D&E

A

-MAC
-1 PIV
-if more than 15 wks gestation w large fetal size/fetal ossification GA
-Oxytocin available / ergot alkaloid
-observe for HoTN for 5 mins after legs down
-TYPE AND SCREEN

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54
Q

Anesthetic agents deemed safe:

A

thiopental
morphine
meperidine
fentanyl
succinylcholine
NDMRs

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55
Q

What class of medications have been linked to congenital abnormalities (especially in wks 3-8?)

A

Benzodiazepines

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56
Q

Nitrous oxide should be avoided in the 1st and 2nd trimesters d/t potential teratogenic effects and its interference with:

A

B12 metabolism

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57
Q

volatile anesthetics may suppress:

A

preterm labor

Also decrease uterine tone

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58
Q

TRUE OF FALSE:
nearly all opioids cross placenta and depress fetus?

A

TRUE
loss of beat-to-beat variability and decreased movement complicate evaluation

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59
Q

TRUE OF FALSE:
nearly all opioids cross placenta and depress fetus?

A

TRUE
loss of beat-to-beat variability and decreased movement complicate evaluation

60
Q

Why isn’t morphine used often?

A

The immature blood brain barrier of the neonate causes resp. depression

61
Q

Meperidine (Demerol)

A

Dose 25-50 mg IV.
Onset 5 min.
Kinetics Half-life 18-23 hrs. in neonate, also has active metabolites.
Causes frequent N/V.
Neonatal respiratory depression unlikely if given less than 1 hour prior to delivery.
Contraindicated in pt. with seizure or renal failure diagnosis

62
Q

Fentanyl

A

50-100 mcg/hr (100x more potent than morphine!).
Onset 3-5 min after IV dose.
Kinetics rapid transfer across placenta.
Respiratory depression may outlast analgesia.
PCA recipe: loading dose 1-2 mcg/kg; dose 50 mcg with 10 min lockout; if persistent pain decrease lockout interval. Use pulse oximetry.

63
Q

Nalbuphine (Nubain)

A

Mu opioid antagonist, kappa agonist.
Has ceiling effect on resp depression but no real large difference in side effects.
Dysphoria common.
Used to treat opioid induced pruritis (5-10 mg iv q 6 H prn).

64
Q

Nalbuphine (Nubain)

A

Mu opioid antagonist, kappa agonist.
Has ceiling effect on resp depression but no real large difference in side effects.
Dysphoria common.
Used to treat opioid induced pruritis (5-10 mg iv q 6 H prn).

65
Q

Butorphanol (Stadol)

A

Dose 1-2 mg.
Some reports suggest better analgesic profile than fentanyl.
Sedation common.
Ceiling effect on resp depression.

66
Q

Butorphanol (Stadol)

A

Dose 1-2 mg.
Some reports suggest better analgesic profile than fentanyl.
Sedation common.
Ceiling effect on resp depression.

67
Q

What dose should MAC be limited to when using volatile anesthetics?

A

0.5 MAC

68
Q

Side effect of volatile agents

A

decreased uterine tone

69
Q

Technique for pudendal block:

A

Technique: Needle is placed bilaterally via transvaginal approach under the ischial spines.

70
Q

Risks of pudendal block

A

fetal injury
infection
hematoma

71
Q

order of ligaments needle will go through to get to epidural /subarachnoid space

A

Suprasinous ligament
interspinous ligament
ligamentum flavum
posterior longitudinal ligament
anterior longitudinal ligament

Ligamentum flavum
epidural space
dura mater “pop”
subdural space (potential space)
arachnoid mater
subarachnoid space (contains CSF- target for spinal)

72
Q

What level does the spinal cord end in adults?

A

L1
5% L2-L3

Spinals should be placed below L3 if possible

73
Q

What dermatomes do you want your spinal to cover?

A

T10-S4

74
Q

What should you do if pt complains of paresthesia while spinal is being dosed?

A

remove the needle

75
Q

Tuffier’s Line:

A

L4/L5
Transverse line passing across the lumbar spine btwn the posterior iliac crests

76
Q

Safe injection would be considered below what level?

A

L2/L3

77
Q

On average how deep is the epidural space?

A

4.75cm deep

78
Q

After space identified- thread catheter until how deep at the skin?

A

10-15 cm mark

79
Q

What should you not do to prevent shearing?

A

do not pull the catheter back through the needle

80
Q

Activating dose or bupiv/ropiv for epidural:

A

10cc 0.15% bupiv/ropiv + 50-100 mcg of fentanyl

81
Q

How should you set your infusion for epidural?

A

8cc/hr of 0.1% bupiv/ropiv +2-4 mcg of fentanyl

82
Q

PCEA bolus:

A

4cc

83
Q

locals and opioids are _____ in nature

A

synergistic

84
Q

are drugs more potent delivered through the spinal or epidural route?

A

spinal route
10x more potent and much smaller needles are used

22-27 g for spinal

17-18ga for epidural

85
Q

What are subarachnoid blocks used for?

A

c-sections

sufenta 5-10mcg or 15-20mcg fent + 2mg bupiv (1.4-1.8 ml typically)

Good for cases where delivery expected soon and not enough time available to place epidural.

86
Q

Physiologic changes of pregnancy that alter neuraxial anatomy:

A

accentuation of lumbar lordosis

softer ligamentum flavum

decreased space in the spinal canal (caused by vascular engorgement of epidural veins

87
Q

what kind of needle for spinal anesthesia can reduce the incidence of post-dural puncture headache?

A

noncutting (pencil-point)

88
Q

How much less local is required for epidural and spinal in pregnant women than in nonpregnant pts?

A

20-30%

88
Q

How much less local is required for epidural and spinal in pregnant women than in nonpregnant pts?

A

20-30%

89
Q

How are amino esters metabolized?

A

plasma cholinesterase

90
Q

What is the metabolite that causes allergies with esters

A

Para-aminobenzoic acid (PABA)

91
Q

how are amides metabolized?

A

Liver

92
Q

what characteristic of locals influences onset the most?

A

pKa

dose and concentration secondary

93
Q

what characteristics of locals influences potency the most?

A

Lipid solubility

intrinsic vasodilating ability

94
Q

what characteristic of locals influences DOA the most?

A

protein binding

lipid solubility
vasodilating effects
addition of vasoconstrictors

95
Q

high protein binding decreases:

A

placental transfer

96
Q

high protein binding decreases:

A

placental transfer

97
Q

A I-acid glycoprotein

A

high affinity, low capacity

98
Q

albumin:

A

low affinity, high capacity

99
Q

site of action for LAs

A

neuronal cell membrane sodium channel in the active/inactivated state

100
Q

the closer pKa is to physiological pH = more LA in nonpolar form=

A

faster onset

101
Q

once across the membrane, polar molecule is responsible for:

A

receptor binding and blocking channel

102
Q

Volume and concentration of LA (total dose) will dictate:

A

onset, quality and duration

increasing doses = faster onset and longer duration

103
Q

warmed LA will reduce:

A

onset time (faster onset)

104
Q

Which fibers are blocked 1st?

A

B- preganglioninc ANS fibers

105
Q

Which fibers are blocked last?

A

A- alpha (skeletal muscle, motor, proprioception)

A-Beta (touch, pressure)

106
Q

_____ and _____ myelinated neurons are more rapidly susceptible to blockade

A

small and poorly myelinated

(C fibers)

107
Q

____ myelinated fibers require higher LA concentration for blockade

A

Larger (type A fibers)

108
Q

differential blockade

A

prevents pain w/o eliminating awareness/ pressure of labor

109
Q

A- gamma

A

skeletal muscle tone
blocked 3rd

110
Q

A-delta

A

fast pain, temperature, touch
blocked 3rd

111
Q

C sympathetic

A

postganglionic ANS fibers
blocked 2nd

112
Q

C -dorsal root

A

slow pain
temperature
touch
blocked 2nd

112
Q

C -dorsal root

A

slow pain
temperature
touch
blocked 2nd

113
Q

Locals for labor epidural analgesia:

A

bupivacaine
ropivacaine
lidocaine

114
Q

Locals for operative epidural anesthesia

A

Lidocaine
2-chloroprocaine

115
Q

Locals for spinal anesthesia

A

tetracaine
Bupivacaine

116
Q

What is a risk of using bupivacaine?

A

highly cardiotoxic - can cause v.tach/v.fib

117
Q

CNS symptoms of LAST

A

Tinnitus
Light-headedness
Metallic taste
circumoral numbness
convulsions
LOC
resp. arrest

increased paco2 and acidosis lower seizure threshold

118
Q

CNS symptoms of LAST

A

Tinnitus
Light-headedness
Metallic taste
circumoral numbness
convulsions
LOC
resp. arrest

increased paco2 and acidosis lower seizure threshold

119
Q

effects of LAST on CV system

A

inhibition of cardiac sodium channels

Decrease rate of depolarization in Purkinje fibers and ventricular muscle

Decreased duration of action potential and effective refractory period

Increased toxicity to bupivacaine and cocaine w preganancy

120
Q

effects of LAST on CV system

A

inhibition of cardiac sodium channels

Decrease rate of depolarization in Purkinje fibers and ventricular muscle

Decreased duration of action potential and effective refractory period

Increased toxicity to bupivacaine and cocaine w preganancy

121
Q

LAST treatment:

A

20% intralipid
1.5 mL/kg as initial bolus followed by 0.25 ml/kg for 30-60 mins

bolus can be repeated 1-2 times for persistent asystole

122
Q

fetal acidosis results in greater accumulation of which class of local in the fetus?

A

amide

123
Q

fetal acidosis results in greater accumulation of which class of local in the fetus?

A

amide

124
Q

American Society of Regional Anesthesia (ASRA) guidelines for the treatment of local anesthetic systemic toxicity (LAST) for cardiac arrhythmias include the use of Intralipid and the AVOIDANCE of all of the following drugs EXCEPT
A. Vasopressin
B. β-Blockers
C. Calcium channel blockers
D. Low-dose epinephrine (<1 μg/kg)

A

D. Low-dose epinephrine (<1 μg/kg)

125
Q

Factors associated with advanced molar pregnancy (i.e., >14- to 16-week size uterus) include all of the following EXCEPT
A. Hypertensive disorders of pregnancy
B. Hypothyroidism
C. Acute cardiopulmonary distress
D. Hyperemesis gravidarum

A

B. Hypothyroidism

126
Q

A woman has been admitted for a dilation and evacuation (D&E) at 10 weeks’ EGA. She has some persistent bleeding and cramping after the expulsion of some tissue. Her obstetric condition is called

A. A threatened abortion
B. An inevitable abortion
C. A complete abortion
D. An incomplete abortion

A

D. An incomplete abortion

127
Q

Agents that are useful for decreasing the incidence of shivering during cesarean section under regional anesthesia or for treating shivering include all of the following EXCEPT

A. Administration of intrathecal local anesthetic with fentanyl and/or morphine
B. Intravenous magnesium sulfate
C. Administration of epidural local anesthetic solu-
tions with epinephrine
D. Intravenous meperidine

A

C. Administration of epidural local anesthetic solu-
tions with epinephrine

128
Q

Which agent is the MOST useful for raising the gastric pH just before induction of general anesthesia for emergency cesarean section?

A. Ranitidine
B. Sodium citrate
C. Metoclopramide
D. Magnesium hydroxide and aluminum hydroxide

A

B. Sodium citrate

129
Q

While moving a parturient from the birthing room to the operating room for an emergency cesarean section for a prolapsed umbilical cord, the patient develops cough, wheezing, and stridor and becomes cyanotic. The trachea is intubated, and food is noted in the pharynx. Appropriate treatment in this patient should consist of

A. Intravenous lidocaine to suppress the cough
B. Glucocorticoids
C. 100% oxygen and positive end-expiratory pressure
(PEEP)
D. Saline lavage

A

C. 100% oxygen and positive end-expiratory pressure
(PEEP)

130
Q

During the second stage of labor, complete pain relief can be obtained with

A. Paracervical block
B. Neuraxial block with fentanyl and morphine
C. Pudendal nerve block
D. Lumbar epidural block with bupivacaine and no
narcotic

A

D. Lumbar epidural block with bupivacaine and no
narcotic

131
Q

Which inhalation anesthetic does NOT produce uterine relaxation?

A. Isoflurane
B. Sevoflurane
C. Nitrous oxide
D. All produce uterine relaxation

A

C. Nitrous oxide

132
Q

Which of the following narcotics has the LONGEST duration of action when added during a cesarean section under epidural anesthesia?

A. 50 to 100 μg fentanyl
B. 10 to 20 μg sufentanil
C. 3 to 4 mg morphine
D. 50 to 75 mg meperidine

A

C. 3 to 4 mg morphine

133
Q

The MOST common side effect of intraspinal narcotics in the obstetric population is

A. Pruritus
B. Nausea and vomiting
C. Respiratory depression
D. Urinary retention

A

A. Pruritus

134
Q

True statements regarding inclusion of intrathecal morphine, fentanyl, or sufentanil in obstetric anesthesia practice include each of the following EXCEPT

A. The chief site of action is the substantia gelatinosa
of the dorsal horn of the spinal column

B. There is no motor and no sympathetic blockade

C. Pain relief is adequate for the second stage of labor

D. Lipophilic narcotics are associated with less
respiratory depression than nonlipophilic narcotics

A

C. Pain relief is adequate for the second stage of labor

135
Q

A 23-year-old parturient in the first trimester is brought to the operating room for emergency appendectomy. General anesthesia is planned. Which drug has a U.S. Food and Drug Administration (FDA) Use-In-Pregnancy rating of D (studies in humans and in investigational or postmarketing data demonstrate fetal risk; nevertheless, potential benefits may outweigh potential risk)?

A. Nitrous oxide
B. Isoflurane
C. Midazolam
D. None of the above

A

C. Midazolam

136
Q

Which intrathecal narcotic can be used as a sole agent for cesarean section (i.e., without an ester or amide local anesthetic)?

A. Morphine
B. Fentanyl
C. Meperidine
D. None of the above; a local anesthetic is needed

A

C. Meperidine

137
Q

Which of the following properties of epidurally administered local anesthetics determines the extent to which epinephrine will prolong the duration of blockade?

A. Molecular weight
B. Lipid solubility
C. pKa
D. Concentration

A

B. Lipid solubility

138
Q

General anesthesia is induced in a 35-year-old patient for elective cesarean section. No part of the glottic apparatus is visible after two unsuccessful attempts to intubate, but mask ventilation is adequate. The most appropriate step at this point would be to

A. Wake up the patient
B. Attempt a blind nasal intubation
C. Continue mask ventilation and cricoid pressure D. Use a laryngeal mask airway

A

A. Wake up the patient

139
Q

A 38-year-old primiparous patient with placenta pre- via and active vaginal bleeding arrives in the operating room with a systolic blood pressure of 85 mm Hg. A cesarean section is planned. The patient is lightheaded and scared. Which of the following anesthetic induction plans would be most appropriate for this patient?

A. Spinal anesthetic with 12 to 15 mg bupivacaine

B. General anesthetic induction with 2 to 2.8 mg/kg propofol and paralysis with 1 to 1.5 mg/kg succinylcholine

C. General anesthesia induction with 0.75 to 1 mg/kg ketamine and paralysis with 1 to 1.5 mg/kg succinylcholine

D. Replace lost blood volume first, then use any anesthetic the patient wishes

A

C. General anesthesia induction with 0.75 to 1 mg/kg ketamine and paralysis with 1 to 1.5 mg/kg succinylcholine

140
Q

The MOST common injury recorded in the American Society of Anesthesiologists’ (ASA’s) Closed Claim Project regarding obstetric anesthetic claims is
A. Pain during anesthesia
B. Maternal nerve damage
C. Headache
D. Aspiration pneumonitis

A

B. Maternal nerve damage

141
Q

A 29-year-old gravida 1, para 0 parturient at 8 weeks of gestation is to undergo an emergency appendectomy under general anesthesia with isoflurane, N2O, and oxygen. Which of the following is a proven untoward consequence of general anesthesia in the unborn fetus?
A. Congenital heart disease
B. Cleft palate
C. Behavioral defects
D. None of the above

A

D. None of the above

142
Q

Which of the following drugs should NOT be used during transvaginal oocyte retrieval (TVOR) for assisted reproductive technology (ART)?

A. Propofol
B. Ketamine
C. Midazolam
D. All are safe and can be used

A

D. All are safe and can be used

143
Q

When is the fetus most susceptible to the effects of teratogenic agents?

A. 1 to 2 weeks of gestation
B. 3 to 8 weeks of gestation
C. 9 to 14 weeks of gestation
D. 15 to 20 weeks of gestation

A

B. 3 to 8 weeks of gestation

144
Q

A32-year-old parturient with a history of spinal fusion, severe asthma, and hypertension (blood pressure 180/110) is brought to the operating room wheezing. She needs an emergency cesarean section under general anesthesia for a prolapsed umbilical cord. Which of the following induction agents would be MOST appropriate for her induction?
A. Sevoflurane
B. Midazolam
C. Ketamine
D. Propofol

A

D. Propofol

OB (8 decks)

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