Intrapartum analgesia Flashcards
Discuss regional anaesthesia
-Indications (6)
-Contra-indications (5)
- Indications
-Maternal request
-Expectation of operative delivery
-PET
-Maternal cardiac disorder where increased HR /BP is wanted to be avoided
-Breech or multiple delivery
-Neurological disease - Contra-indications
-Maternal refusal
-Infection - local or untreated systemic
-Coagulopathy Platelets <80 or INR >1.4
-Uncontrolled hypovolemia
-Certain spinal disease or previous surgery
What is the care and observations recommended for regional anaesthesia (6)
-IV access prior to placement
-Do not administer routine preloading or maintenance fluid
-Check BP every 5 mins for 15 mins during establishment or after further boluses
-Anaesthetic review after 30 mins if woman not pain free
-Sensory check for block every hour
-Continuous CTG
Discuss placement of epidural anaesthesia
-Location (2)
-Medication used (2)
-Time of onset (1)
-Types of delivery system (3)
- Location
-Aim for L3-L4. Must be below L1-2 as can hit spinal cord
-Sits between ligamentum flavum and dura mata in the epidural space outside the CSF - Medication used
-LA +/- opiate - e.g. 0.1% bupivacaine and 2mcg/mL fentanyl
-Medication diffuses across the dura mata - Time of onset
-10-20 mins - Type of delivery
-Intermittent midwifery top ups
-Patient controlled epidural pump
-Continuous infusion
Discuss the risks and benefits of epidural anaesthesia
-Benefits (4)
-Risks (9)
- Benefits
-Non-drowsy
-Very effective analgesia - gold standard
-Minimal transfer to fetus
-Capacity to top-up for additional procedures - Risks
-Failure to work 1:10
-Significant hypotension 1:50
-Severe headache 1:100
-Temporary nerve damage 1:1000
-Nerve damage > 6 hrs 1:13 000
-Permanent nerve damage 1: 250 000
-Epidural abscess 1:50 000
-Epidural haematoma 1: 170 000
-Meningitis 1:100 000
Discuss epidural anaesthesia
-Side effects (2)
-Impact to delivery (5)
- Side effects
-Pruritis
-Shivering - Impact to delivery
-Prolonged second stage
-Increased instrumental delivery
-NO difference to CS rates
-NO difference to duration of first stage
-NO long term back problems
What are the issues that can arise with epidurals and how can they be managed (4)
- Patchy epidural
-Give further bolus
-Reposition woman
-Withdraw epidural catheter or re-site - Maternal Hypotension / fetal bradycardia
-Fluid bolus
-Stop infusion
-Consider vasopressors
-Place woman in left lateral - Accidental dural puncture
-Re-site epidural
-Leave catheter in place and have small top-ups by anaesthetist - will act as a spinal - Bolus given into the CSF (Massive dose cf with spinal)
-Vasopressor support
-Consider intubation and ventilation
-Deliver baby
Discuss nerve injury in epidural placement
-Pathophysiology (3)
-Symptoms (4)
-Management (3)
- Pathophysiology
-Direct injury
-Nerve compression due to bleeding into a confined space causing ischemia / necrosis
-Infection causing damage to nerves - Symptoms
-Pain
-Progressive motor deficiency
-Loss of bowel or bladder control
-Altered neurology - Management
-Urgent anaesthetic review
-Urgent MRI
-May require urgent decompressive surgery
Discuss post dural puncture headache
-Cause (1)
-Presentation (5)
-Treatment (4)
- Cause
-Leakage of CSF from the dural space resulting in falling CSF volume and pressure - Presentation
-Onset usually 72hrs post event
-Occipitiofrontal headache radiating to neck and shoulders
-Better lying flat
-Nausea and vomiting
-Vertigo and dizziness - Treatment
-Hydration
-Caffienated drinks
-Simple analgesia
-Blood patch - 70-90% success rate.
Discuss anticoagulation and timing of epidural placement
-On low dose aspirin
-On prophylactic LMWH
-On treatment dose LMWH
-On warfarin
-On anti-platelet agents
- On LDA
-If <75mg can be continued - Prophylactic LMWH
-Stop 12 hrs before epidural/spinal placement - Treatment dose LMWH
-Stop 24hrs before epidural/spinal placement - Warfarin
-Check INR <1.5
-Discuss with haematology - Anti-platelet agents
-Discuss with haematology
Discuss general anaesthesia in obstetrics
-Indications (5)
-Risks (8)
- Indications
-Maternal refusal for regional techniques
-Inadequate regional block
-Multiple failed attempts at regional block
-Contraindications to regional anaesthesia
-Rapid delivery required - Risks
-Increased risk of fatality cf regional anaesthesia 2.3x
-Failed intubation 1:300
-Increased pulmonary aspiration 1:600
-Increased anaesthetic awareness 1:400
-Drug effects on neonate
-Requirement for increased post-op pain relief
-Post operative nausea and vomiting
-Mother and partner not awake / present at birth
Discuss placement of pudendal nerve block
-Function of pudendal nerve (3)
-Contra-indications for placement (3)
-Steps to perform (6)
- Function of pudendal nerve
-From S2-S4
-Sensory function of external genitalia
-Motor function of perineal muscles - Contra-indication
-Coagulopathy
-Local infection
-LA allergy - Steps to perform
-Use 20mL 1% lignocaine
-Identify ischial spine (4 and 8 o’clock)
-Place injection 1cm anterior and medial to spine
-Infiltrate 5-7mL each side
-Make sure to aspirate needle to avoid direct injection into circulation
-Onset of analgesia in about 10mins
Discuss local anaesthetic toxicity
-Causes (2)
-Symptoms (6)
-Max dose of bupivocaine
-Max dose of Lidocaine
- Causes of LA toxicity
-Direct injection into circulation
-More than max dose given - Symptoms
-Severe agitation
-Sudden altered mental status
-Seizures/muscle twitching/convulsions
-LOC
-Hypotension
-Cardiovascular collapse - Max dose of bupivacaine
2mg/kg max dose 150mg - 20mL of 0.75% - Max dose of lidocaine
3mg/kg max dose 200mg - 20mL 1%
Discuss management of LA toxicity
- Stop administration
- Call for help
- Assess patient and do ABC
- If seizures manage with benzo’s / propofol
- Give lipid emulsion 20%
-Max 3 bolus of 1.5mL/kg every 5 mins
-Start infusion of 15mL/kg concurrently - Manage arrythmias as per shockable/ non-shockable rhythms
Discuss entonox for intrapartum pain relief
-Make up (1)
-Mechanism of action (4)
-Timing of effect (1)
-Side effects to mother (4)
-Side effects to fetus (1)
-Risks of prolonged use (2)
-Evidence (1)
- Make up
1:1 mix of nitrous oxide with oxygen - Mechanism of action
-Acts as analgesic and anxiolytic at lower concentrations
-Increases release of endogenous endorphins and dopamine
-Half life of 2-3 mins
-Cleared via the lungs
-Can cross the placenta but doesn’t impact fetal heart rate - Side effects to mother
-Nausea and vomiting
-Dizziness
-Dehydration
-Respiratory alkalosis - Fetal side effects
-May cause respiratory depression in neonate - Risks of prolonged use
-Megaloblastic anaemia with agranulocytosis
-Myeloneuropathy - Evidence
-Works according to Cochrane review
Discuss opioid use in labour
-Types (3)
-Mode of action (2)
-Adverse effects to mother (7)
-Adverse effects to baby (6)
- Types
-Pethadine - IM 150mg Q4H
-Diamorphine IM 10-15mg Q4H - better than pethadine for pain relief
-Remifentanyl PCA 1mcg/kg with 2 min block out - Mode of action
-Acts on opioid receptors in brain and spinal cord to reduce neuronal cell excitability and reduce transmission of nociceptive impulses - Adverse effect to mother
-Drowsiness
-Hypoventilation
-Nausea and vomiting
-Urinary retention
-Pruritis
-Respiratory depression (32% in remifentanyl use)
-Tolerance to remifentanyl after 1 hr - Affects to baby
-Can cross placenta and cause prolonged sleep phase with decreased variability
-Respiratory depression
-Hypothermia
-Poor feeding
-Altered crying
-Decreased alertness
