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Coexisting Test 3 > OB II > Flashcards

OB II Flashcards

1
Q

General approach to providing anesthesia for OB patient?

A
  • obtain H and P
  • assess NPO status
    • ACOG guidelines say pt can eat up until they get epidural, but this varies from hospital to hospital
  • ascertain analgesics given
  • IV access
  • aspiration prophylaxis
  • fetal and maternal monitors in place
  • supplement o2? may or may not be needed
  • airway assessment
  • emergency drugs and equipment available
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2
Q

What is parturient?

A

female in labor, about to give birth

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3
Q

what is gravida? multigravida? primigravida? multigravida?

A

gravida- # times pregnant

nulligravaida- never pregnant

primigravida- pregnant to first time

multigravida- pregnant for at least 2 times

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4
Q

What is parity? Abertus?

A

Parity= # pregnancy reaching viable gestational age (live births and still births)

abertus= abortions/miscarriages before viability <20 weeks

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5
Q

Questions ot ask when taking OB history?

A
  • estimated date of delivery- by scan or dates (LMP + 9 months + 7 days)
  • growth of fetus- wnl?
  • placental location- placenta previa may alter delivery plans
  • fetal movement- usually expereicned at around 18-20 weeks gestation
  • labor pains- more relevant in third trimester
  • planned method of delivery- vaginal/c-section
  • medical illness during pregnancy- taking any meds?
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6
Q

What to ask OB pt in regards to details of each pregnancy?

A
  • date of delivery
  • length of pregnancy
  • singleton/twins or more?
  • spontaneous labor or induced?
  • mode of delivery
  • weight of babies
  • current health of babies
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7
Q

What are some antenatal complications of pregnancies?

labor? postnatal?

A
  • antenatal- IUGR (intrauterine growth restriction)/hyperemesis/pre-eclampsia
  • labor- failure to progress/perineal tears/shoulder dystocia
  • postnatal- postpartum hemorrhage/retained products of conecption
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8
Q

Key symptoms to ask the pregnant patient?

A
  • Nausea/vomiting- if severe may suggest hyperemesis gravidarum
  • abdominal pain- may suggest the need for imaging
  • vaginal bleeding- fresh red blood/clots/tissue
  • dysuria/urinary frequency- urinary tract infection
  • fatigue- may suggest anemia
  • HA/visual changes/swelling- pre eclampsia
  • systemic symptos- hever/malaise
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9
Q

What are some theories for what causes labor?

A
  1. progesterone withdrawal hypothesis
  2. corticotropin releasing hyptothesis
  3. prostaglandin hypothesis- prostaglandins increase

HOWEVER, we don’t know what causes labor

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10
Q

What is stage 1 of labor?

A
  • The cervix relaxes, causing it to dilate and thin out
  • Cervical stage- aka latent (mom early in labor) and active (mom is 4-6 cm dilated)
  • begins w/ mom’s perception of regular, painful uterine contractions and ends with complete cervical dilation (10 cm)
    • dull, aching, cramping and poorly localized
    • longest stage of labor (2-20 hours)
    • mostly visceral pain (T10-L1 innervation)
    • slow (unmyelinated) afferent, C fibers, enter spinal cord at T10-L1
      • ​Need to block level T10-L1!!
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11
Q

What is 2nd stage of labor?

A
  • Pelvic stage- uterine contractions increase in strenght and the infant is delivered
  • begins with complete cervical dilation and ends with birth of the baby
  • distention of the pelvic floor, vagina and perineum pain
    • sharp, severe, bloody show, vomiting, bear down–> pushing
    • most painful portion of labor (somatic parin) S2-S4
    • Rapidly conducting A-delta fibers, enter SC at S2-S4
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12
Q

What is 3rd stage of labor?

A
  • Placental stage
  • begins with birth of baby and ends with delivery of the placenta
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13
Q

What is the 4th stage of labor?

A
  • 1st postpartum hour, during which hemorrhage is most likely to occur
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14
Q

What can be done for stage 1 pain relief?

A
  • should be focused on blocking pain impulses from cervix and lower uterine segment to the spinal cord
    • paracervical block–> obstetician administer–> needle to vaginal fornix–> can cause fetal bradycardia if injected into babies’ head
    • lumbar sympathetic block–> in last 3 decades has all but dissappeared in US
    • Epidural @ T10-L1 level! << most common
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15
Q

Pain relief for stage 2 labor?

A
  • Pudendal nerve block–> OB administered–> immediately before delivery (forceps deliver)
  • extension of epidurla block from T10- S4
  • Any neuraxial anesthesia that blocks pain at these dermatomes
    • saddleblock- single shot spinal (no epidural) with LA/opioid
      • will give numbness for few hours
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16
Q

What are the componennts of labor and delivery?

A
  1. powers
  2. passageway
  3. passenger
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17
Q

What do the “powers” need to be like in order to progress labor?

A
  • contraction
    • Increase in intensity
      • 40-60 mmHg intensity
    • increased frequency
      • 2-3 min apart
    • increased duration
      • 50-70 sec duration
  • pushing (2nd stage)
    • need to be careful if pt given epidural and taking away motor
      • don’t want mom hurting and need good sensory blockade for that, but don’t want to take away motor/pushing
        • ropivicaine used often
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18
Q

What type of uterus is most optimal for childbirth?

A

gynecoid pelvis

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19
Q

What does the “passenger” need to be like in order to have optimal delivery?

A
  • lie- the relationship of long axis of the fetus to the long axis of the mother (ie transverse, oblique, longitudinal)
  • presentation- portion of fetus overlying the inlet–> cephalic, breech, or shoulder
    • 95% of labors at term, the presentation is cephalic and fetal head is well flexed (vertex presentation)
  • position- refers to the relationship of the presenting fetal bony point to the anterior, post or side (right, left) of the maternal pelvis (ROA, LOA, ROP, LOP)
    *
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20
Q

What position of the fetus facilitates delivery the most?

A
  • LOA- left occiput anterior facilitates delivery the most
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21
Q

What position of fetus makes delivery the most challenging?

A
  • ROP, LOP
  • Never want baby looking up during delivery. sometimes call this “sunny side up”
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22
Q

What are the cardinal movements of labor?

A
  • engagement- means head is at level of ischial spines= station 0
    • ​-1 station= 1 cm above ischial spine
    • +1 station= 1 cm below ischial spine
    • +5= delivery imminent
    • to remember, + is good, want to be positive with delivery becaues baby is coming!
  • descent
  • flexion
  • internal rotation
  • extension
  • external rotation
  • explusion
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23
Q

What are methods for analgesia for labor and vaginal delivery?

A
  • non pharmacological technique
  • parenteral meds
    • opioids- meperidine, fentanyl remifentanil
    • agonists-antagonist- nubain, stadol
    • ketamine
    • anxiolytics- midazolam
  • neuraxial blocks
    • epidural analgesia
    • CSE
    • SAB
  • Inhaled analgesia
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24
Q

Ideal anesthetic in OB?

A
  • Effective and controllable analgesia
  • maternal safety
  • no weakening of maternal powers
  • no alteration of maternal passages
  • no depression of the passenger
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25
Q

non pharmacological analgesic techniques?

A
  • emotional support (doulas)
  • touch and massage
  • therapeutic use of heat and cold
  • hydrotherapy
  • biofeedback
  • acupuncture
  • hypnosis
26
Q

Risk factors for increased pain during childbirth?

A
  • an occiput posterior presentation
  • young maternal age
  • history of severe dysmenorrhea
  • increase maternal weight
  • increased fetal weight
  • type of labor
    • use of oxytocin- augments labor
27
Q

Why /when would IV meds be used? What are some disadvantages? what will it do to FHR variability

A
  • good to admin during latent period
  • s/e mom can vomit
  • opioids do cross placenta
  • might see FHR with fetal depression and decreased variability in FHR
28
Q

Meperidine in OB?

A
  • 50-100 mg IM q 4 hours or 25-50 mg IV (max dose <100 mg )
  • onset 5-10 min, duration 3-4 hours
  • fetal exposure highest 2-3 hours after admin
  • crossess the placenta/fetal acidosis/neonatal respiraotyr depression
  • active metabolite normeperidine in neonate–> depressed behavioral assessment score
29
Q

Morphine in OB patient?

A
  • linked to neonatal respiratory depression and somnolence
  • leads to maternal sedation
  • no longer widely accepted
30
Q

Fentanyl in laboring patient?

A
  • high potency and short doa make it reasonable for labor
  • usual dose 25-200 mcg in hourly increments
  • onset 2-4 min; doa 30-60 min
  • potent maternal respiratory depression
  • may affect newborn feeding
31
Q

Sufentanil in labor?

A

rarely used to potency/maternal respiratory depression/neonatal bradycardia

32
Q

Remifentanil in labor?

A
  • ultra-short acting
  • metabolism by blood esterases therefore maternal and neonatal accumulation low
  • usual dose
    • iv bolus 0.4mcg/kg q 1 min
    • PCA bolus 0.25 mcg/kg then 0.05 mcg/kg/min, lockout 2 min, 4 hours limit 3 mg, and background infusion 0.025-0.05 mcg/kg/min
33
Q

What are some agonist/antagonist agents used in laboring patient?

A
  • Butorphenol (stadol)
    • 1-2 mg IV or IM, duration 4 hours
    • 5 times as potent as morphine
  • Nalbuphine (nubain)
    • dose 5-10 mg IV, IM duraiton 6 hours
    • causes less dysophoria than butorphenol
  • benefiical becaue they cause less N&V, dysphoria
  • both agents cause significant sedation
  • both agents rapidly transfer across placenta and produce alterations in FHR tracing
34
Q

Midazolam in laboring patients?

A
  • low doses (0.5-1 mg IV) given to help alleviate anxiety without causing detriment to parturient and fetus
    • particularly useful in c section patients
      • causes amnesia
35
Q

Ketamine in laboring patients?

A
  • occasionally intermittnet doses of 10-15 mg IV useful to produce intense analgesia for 10-15 min without causing detriment ot parturient and fetus
    • routinely co admin low dose midazolam
    • 25-50 mg (0.5 mg/kg) to supplement an incomplete neuraxial blockade during c section
    • in higher doses, dissociative anesthetic associated with emergence delirium/hallucinations
    • in higher doses, increases BP
    • induction agent of choic in pt with acute asthma undergoing urgent csection
36
Q

Inhalational anesthesia in laboring patients?

A
  • varies by country
  • nitrous oxide in most globally used inhalation agent for labor anes
    • 62% in UK
    • 43% Canada
    • <1% US
  • Concentration- usually givne 50/50 mixture
  • does it cross placenta- yes
  • affect neonatal ventiatlion- no
  • s/e - n/v, paresthesia
  • who adminsiters? mom has to hold the mask, breaths when contraction comes
  • book also mentions low dose sevo 0.6% but allan does not see in practice personally
37
Q

What is the best method of pain relief in labor?

A

neuraxial anesthesia

  • only modality that can provide complete pain relief with minimum maternal or fetal depression
  • common techniques
    • eipdural
    • combined spinal epidural
    • spinal techniques
38
Q

When can laboring mom recieve an epidural?

A
  • ACOG guidelines state that in absence of medical contraindications, maternal request is a sufficient reason for labor analgesia
    • some clinicians may believe that labor needs to be adequatley progressed before epidural, believve that early epidurals slows down labor
      • ​patient needs to be contracting regularly and have cervicla change
39
Q

What are some advantages to labor epidural?

A
  • More constant level fo analgesia
  • more even level of block
  • more stable vital signs
  • can use to obtain surgical block in event of need for cesarean section
40
Q

What is a combined spinal-epdiraul?

A
  • CSE combines advantages and mitigates the disadvantage of single-shot anesthesia and continuous epidural anesthesia
  • anesthesia is inititaed with a spinal anesthetic injection of opioid and local anesthetic and maintained via the epidural catheter
    • allows you to admin spinla that will work immediately and then admin epidural dose which takes about 30 min to setup for pain relief
      *
41
Q

Common indication for spinal anesthesia?

A
  • Imminent delivery (saddle block)
  • cerclage- suture placed for incompetent cervix 16-18 weeks
  • nonobstetric sx during pregnancy
  • instrumental vaginal devliery (forceps)
  • removal of retained placenta
  • postaprtum tubal ligation
  • postpartum tubla ligation
  • cesarean section
42
Q

Advantages/disadvantages for spinal anesthesia for c/s

A
  • Advantages
    • rapid onset
    • dense and reliable anesthesia
    • minimizes risk of aspiration
    • little risk of LA toxicity
    • minimal drug transfer to fetus
    • awake pateint
    • decreased risk of failed intubation
    • decreased blood loss
  • disadvantages
    • hypotension
    • lmiited DOA- generally add opioid (morphine/fentanyl) to opioid. fent acts quick and morphine will last several hours because it’s hydrophilic
    • N &V
    • PDPHA- postdural pucture headache (decrease since advent of blunt tipped needles)
43
Q

Spinal anesthesia doc?

A
  • Bupivicaine is most common cause of LA
  • cSECTION
    • 7.5-15 MG FOR BUPI
  • Most providers add an opioid to LA to improve quality of block and to privde postop analgesia. also opioids decrease n/v
    • fentanyl 20 mcg- intraop analgesia
    • morphine 0.2 mg- postop analgesia
    • epinephrine may be added to decrease systemic absorption–> prolong block
44
Q

What is a teratogen?

A
  • any postnatal change in fucntion or form in an offspring after prenatal treatment
    • 1200 drugs are teratogenic in animals and 30 teratogenic in humans (all drugs in general)
  • Gestational age at which exposure occurs determine the target organs or tissues, types of defect and severity of damage
    • structural abnormalities–> occurs during organogenesis (day 31-71 after 1 day of LMP)
    • Function (learning disabilities)–> a/w exposure during late pregnancy or postnatally because CNS continues to mature until 2nd year of life
45
Q

What is still developing in fetus as mom approaches term?

A
  • CNS
  • Eyes
  • teeth
  • external genitalia
46
Q

Investiagtion of anesthetic agents for teratogenicity?

A
  • animal studies of reporductive effect of anesthetic agnets
  • epidemiological surveys of OR personnel routinely exposed to subanesthetic concentration of inhalational agnets
  • outcomes in females who have undergone sx while pregnany
  • agents: mentioned in class
    • toxoplasmosis
    • alcohol
    • cocaine
    • warfarin
    • enalapril
    • caprtopril
    • accutane
    • VPA
    • ETOH
    • metabolic imbalances:
      • diabetes
      • hyperthermia
47
Q

What are non drug factors for teratogenicity?

A
  • hypoglycemia
  • hypoxia
  • hyperglycemia
  • hyperthermia (maternal fever)
    • congenital abnormalities, esp CNS, have repeatedly been a/w maternal fever durign the first half of pregnnacy
    • remember, fetal temp is 0.5-1 degree higher than maternal temp
48
Q

Are any anesthetic agents a/w tertogenicity?

A
  • teratogenic have not been a/w use of any commonly used induction agents- barbs, ketamine and benzos, when they are admined in clinical doses during anesthesia
  • diazepam/midazolam- controversial because noted increased risk for cleft lip/palate with valium
    • many providers don’t give it for that reason
  • although anesthesia and sx are associated with a higher inciedence of abortion, fetal growth restriction and perinatal mortaility, these outcomes can be attributed to the procedure, site of sx (proximity to uterus) and/or underlying medical condition
    • ​evidence do not suggest that anesthesia during prengnacy results in overall increase in congenital abnormalities
49
Q

Nitrous teratogenicity?

A
  • in contrast to VA, N2O has been shown to be a weak teratogen in rodent
    • neuronal apoptosis and learning impairments
    • reproductive effects occur only after lone exposure to high concentrations that are unlikely to be encountered in humans during clinical anesthesia
      • early weeks of pregnancy probably avoid
50
Q

Practical considerations for OB patient and anesthesia?

A
  • elective sx should not be performed during pregnancy
  • avoid sx in 1st trimester (organogensis)
  • optimal time- 2nd trimester
    • preterm labor risk is lowest!
51
Q

Can we admin COX inhibitors?

A
  • indomethacin/ketoralac
  • used often in preterm labor
  • MOA: inhibit COX and thus prevent the synthesis of prostaglandins
    • prostaglandins play an important role in stimulation of uterine contraction
  • maternal admin may cause a closure of PDA
    • in 2nd half of pregnancy need to be avoided because of promotion of closure of PDA
52
Q

Anesthesia concern for c-section?

A

Preoperatively

  • History /Physical
  • Airway evaluation
  • Informed Consent
  • LUD (>20 weeks don’t lie on back!)
  • IV access(free flowing 18-16 gauge)
  • Hydration (minimal 500 mL)
  • Aspiration prophylaxis (bicitra, metoclopramide, ranitidine)
  • Supplemental O2
  • Anesthetic plan/ postoperative analgesia plan

Choice of anesthetic depends on:

  • Indications for surgery
  • Degree of urgency
  • Maternal status
  • Condition of fetus
  • Desires of the patient
53
Q

Spinal anesthesia for c/s?

A

Most popular technique:

  • typically admin 10-15 mg hyperbaric bupi with 10-25 mcg fent and/or 0.1-0.25 mg preservative free morphine
    • studies indicate that 12 mg bupi optimal dose
  • duration block 1.5-2 hours!
  • level of block T4
  • Hypotension may be prevented by LUD, crystalloid coloading, and treated with ephedrine (5-10 mg) or phenyl (50-100 mcg IV)
54
Q

What are some key levels of dermatomal blockade?

A

Way to remember

  • C6= thumb= sex yes!
  • C7= pointer
  • C8= ate a burger (with pinky)
55
Q

Advantages/disadvantages to epidural anesthesia for C/S?

A

Advantages

  • Less impact on maternal/fetal hemodynamics
  • Can use if already in place
  • Can place electively if patient high-risk of needing emergency c/s later
  • Can re-bolus
  • Can use for postoperative analgesia
  • Less chance of PDPHA

Disadvantages

  • Increased complexity of insertion and management
  • Slower onset (up to 30 minutes)
  • Can be less dense
  • Large doses of LA–increased risk of toxicity
56
Q

What is usually given in epidural for c/s?

A

Typically bolus with

  • 15-20 ml 2% lidocaine (with/without epinephrine)
  • 10-20 ml 0.5% bupivacaine or ropivacaine
  • 5-15 ml 2-3% chloroprocaine

Can add opioids

  • 50-100 mcg fentanyl
  • 10-20 mcg sufentanil
  • 1.5-4 mg preservative free morphine (Duramorph)

DON’T NEED TO MEMORIZE FOR TEST!

57
Q

GA induction in emergency c-section?

A
  • Preop assessment of airway
  • Large bore IV
  • Aspiration prophylaxis (Non-particulate antacid, H2-blocker, Reglan)
  • Monitors/suction/ emergency airway cart
  • Optimal airway positioning/ LUD
  • Preoxygenate! (3 min or longer)
  • Prep + drape –surgeon ready
  • RSI w/cricoid (10 N while awake; inc to 30 N after LOC)
    • Agents available
      • Ketamine (used with maternal hypotensive crisis) 1 mg/kg
      • Etomidate 0.3 mg/kg
      • Propofol 2-2.5 mg/kg
      • Succinylcholine 1-1.5 mg/kg
      • Preferred muscle relaxant
  • Intubate– let surgeon know you have tube placed because they will cut right away!
  • Expect difficult intubation
  • Proper positioning
  • Short handled laryngoscope (Datta) recommended
  • Use minimal amount of time; first attempt best attempt
  • Smaller ETT 6.0 or 6.5
  • Use caution…friable tissues and decreased airway size
  • Verify placement of ETT, then
  • Surgeon makes skin incision
  • Ventilate with 50% O2/50% N2O & volatile agents (~1 MAC)
  • Secure ETT, tape eyes, OGT
  • ****Critical interval of 3 minutes between uterine incision and delivery of fetus
  • Delivery of baby– iarea with tremendous recall in anesthesia, generally don’t give versed, fent, etc for emergeny csection- gas may not be at appropraite level yet
  • Reduce volatile agents (.75 MAC), may increase N2O to 70%, and give opioids and benzodiazepine
    • ​reduce VA to reduce r/f vasodilation
  • Possible NDMR
  • Delivery of placenta
  • Then can add oxytocin to IV <– so uterus can begin to clamp/contract
  • At end:
    • Suction OGT
    • Reverse NDMR if necessary
    • Extubate AWAKE
    • Emergence and recovery is a critical period for anesthesia-related deaths from airway factors!
  • •
58
Q

How much oxytocin is given?

A
  • Small dose oxytocin sufficient to produce adequate uterine contraction after cesarean devliery

Rule of 3’s

  • oxytocin 3 units, 3 min evaluation intervals, 3 total doses and oxytocin infusion 3 units/hr maintenance
    • 3 units given slow bolus
    • uterine tone reassessed 3-6 min
    • if inadequate, additional 3 doses are given after each reassessment
    • if uterine atony persists after 3 doses–> switch to another drug
    • after establishment of uterine tone, infuse 3 units/hr x 5 hours
  • Oxytocin as a rapid IV bolus
    • direct smooth muscle relaxant–> decrease SVR, hypotension, tachycardia
    • hypotension may result in CV collapse
    • chest pain, MI may develop
    • structural similarities b/t oxytocin and vasopression–> water intoxication and hyponatremia
59
Q

2nd line meds if oxytocin doesn’t work to stop bleeding?

A
  • Methylergonovine (methergine- ergot alkaloid)
    • dosage 0.2 IM
    • onset 10 min
    • duration 2-4 hours
  • Cannot give IV! causes intense vasoconstriction, acute HTN, sz, retinal detachment, coronary artery spasm, CVA
  • May be repeated x 1 after 30 min
  • contraindications: HTN, preeclampsia, CAD
60
Q

3rd line to stop bleeding s/p csection?

A
  • 15 methylprostaglandin F (carboprost- hemobate)
  • dose 250 mg IM, may repeat q 15 min x 8 doses (2mg)
  • S/E : fever chills, N/V, diarrhea and bronchoconstricitons
    • who should not receive this drug?
      • asthmatics

Coexisting Test 3 (8 decks)

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