anesthesia for L&D 5/13

Question 0

1. how many phases of the cervical stage? what are they?

2. how long does the cervical stage last in multipara? primapara?

Answer 0

1. 2 phases; latent phase and active phase

2. 8 hours for primapara and 5 hours for multipara

Question 1

what are the 3 stages of labor (actually 4)

Answer 1

1. cervical stage
2. pelvic stage
3. placental stage
   (4. 60 min post delivery)

Question 2

characteristics of latent phase:

Answer 2

regular contractions, cervical softening and effacement; dilation to 2-3 cm

Question 3

characteristics of active phase?

Answer 3

dilation from 4-9 cm; pain d/t stretch and contractions

Question 4

what are 6 causes of pain during labor in stage 1?

Answer 4

1. stretch of lower uterus
2. dilation of cervix
3. pressure on nerve endings
4. ischemia to myometrium (causes release of bradykinin, serotonin and histhamine).
5. vasoconstriction d/t sympathetic activity
6. inflammation of uterus muscle

Question 5

what nerves are stimulated (pain) during stage 1 of labor?

Answer 5

T10-T12, L1

Question 7

epidurals were avoided in the day, what phase did they think they would prolong?

Answer 7

latent phase

Question 8

What is stage 2 and how long does it last in prima and multip?

Answer 8

stage 2= pelvic stage

stage 2 lasts 50 minutes in primapara; 20 min in multipara

Question 9

what nerves are stimulated during stage 2 of labor?

Answer 9

pudendal nerves S2-S4

Question 10

1. what is stage 3 called?

2. what happens here?

Answer 10

1. Placental stage

2. delivery of infant and placenta

Question 11

1. what is stage 4?

2. what is parturient at risk for?

Answer 11

1. stage 4 is the first 60 minutes post delivery

2. H/R for hemorrhage, uterine atony, increased C.O.

Question 12

fetal heart monitoring:

1. how is it done (what is the method)?
2. how is it determined?

Answer 12

1a. can be done indirectly by placing a tocodynameter (on the mothers belly)
1b. or direct by placing a catheter in the amnionic fluid
2. monitors fetal R to R to detect beat to beat variability

Question 13

1. what is tachy and brady for a fetus?

Answer 13

tachy is >160 bpm

brady is <120 bpm

Question 14

how does a fetus compensate for slow developing asphyxia?

Answer 14

increases heart rate

Question 15

1. what does beat to beat variablilty telll us?
2. what is decreased beat to beat variability associated with?
   3(a,b) what is short and long term variability

Answer 15

1. fetal well being
2. decreased beat to beat variability associated with fetal acidosis
   3a. short term variability= 2-3 beats
   3b. long term variability=5-20 beats

Question 16

what diminishes beat to beat variability?

Answer 16

• drugs (atropine, beta blockers),

- cns depression d/t hypoxia

Question 17

1. what are decelerations caused by?

2. what causes this?

Answer 17

1. uterine distress
   2a. decreased maternal oxygenation
   - b. uterine hyperactivity
   - c. oligohydramnios
   - d. cord entrapment
   - e. maternal hypotension d/t sympathetic blockade (regional)

Question 18

1. are early decels normal or abnormal?

2. characteristics of early decels:

Answer 18

1. normal
2. begin with contraction
   - rarely drop below 110 bpm
   - return to baseline with uterine pressure curve
   - probably vaginal in orgin
   - secondary to fetal head compression

Question 19

late decels:

1. normal or pathological? how bad are late decels?
2. what causes late decels?

Answer 19

1. pathological; caused by hypoxia from decreased uterine blood flow
   1b. (bad sign when combined with decreased or absent HR)
2. recurrent bradycardia that begins 20 seconds or more after onset of contraction
   - deoxygenated blood is caried to fetal placenta (takes 20 seconds for fetal chemo receptors to sense high CO2 and cause a vagal (bradycardic) response).

Question 20

variable decels:

1. what causes variable decels?
2. are they normal or pathologic?
3. what are they a sign of when 4 things happen?

Answer 20

1. correlate with insuffecient umbilical blood flow
2. Pathologic:
3. sign of fetal demise when:
   - prolonged
   - if HR drops below 70 for 60 seconds or longer
   - are repetitive
   - heart is slow to return to baseline.

Question 21

what might accelerations ominous for?

Answer 21

may be precursers to variable decels

Question 22

why should glucose IV be avoided if possible?

Answer 22

may stimulate fetal pancreas to secrete insulin causing fetal hypoglycemia

Question 23

As far as the baby is concerned, why should you stay away from benzos:
A- in early pregnancy (1 reason)?
B- during labor(unless a still born) (3 reasons)?

Answer 23

A
--benzo's are a teratogen and redily cross the placenta
B.
--depress neonate, 
--depress beat to beat variability 
--cause hypotonia).

Question 24

what is involved in systemic anesthesia (IV):

1. what type drug is most common?
2. when are 4 situations where systemic anesthesia would be used?

Answer 24

1. opioids most common
2. When is it used:
   - a.useful when there isnt much monitoring
   - b.when neuraxial anesthesia is contraindicated
   - c.can be used with neuraxial anesthesia (von wildebrands etc.)
   - d.used during early labor

Question 25

when can barbs be used

Answer 25

only when delivery not iminent in next 12-24 hours

Question 26

ketamine 1. when is it good to use? 2. what are bad side effects?

Answer 26

1. not usually used, but can be used if a bad spinal or CV unstable 2. can depress neonate if doses >2mg/kg

Question 27

Narcotics: 1. when part of labor are they used for? 2. what are side effects of using narcotics during labor? 3. what might be positives to using narcotics?

Answer 27

1. used for early labor or when labor well established (correct inordinate uterine contractions, decrease pain and anxiety). 2. may slow cervical dilation, decrease uterine activity, slow labor, may cause resp depression, hypoventilation, postural hypotension 3. (some feel) narcotics may decrease circulation catecholamines which helps to potentiate uterine contractions

Question 28

meperidine: 1. what is the dose? 2. how long before detected in fetal blood? what time frame is highest exposure post administration? 3. what does metabolite do? 4. when should it be administered?

Answer 28

1. 50-100 mg IM; 25-50 mg IV 2. detected in fetal blood in 90 seconds (2-3 hours post maternal administration is highest exposure) 3. normeperidine is the metabolite and causes more resp depression than meperidine (in fetus and mom); decreases apgar in fetus 4. should be administered: - less than 1 hour before delivery or - greater than 3 hours before delivery

Question 29

what is the dose of narcan?

Answer 29

2-5 mcg/kg (or .1 mg at a time)

Question 30

fentanyl: 1. how long before in fetal blood? 2. metabolites? 3. what is the dose, onset, peak & duration? 4. why better than meperidine?

Answer 30

1. appears in fetal blood within 1 minute 2. no metabolites 3. dose: 25-50 mcg iv; - -onset: immediate; - -peak: 3-5 min; - -duration 30-60 min 4. less neurobehavior s/e; less n/v for mom than meperidine

Question 31

1. what are the agonist/antagonists? 2. why use it? 3. what are the potential problems of its use?

Answer 31

1. stadol (bu-tor-phanol)1-2 mg - -nubain (nal-bu-phine) 15-20 mg 2. ceiling effect on respiratory depression 3. may produce FHR changes; bad for narc addicts (put them into withdrawl); itching is big side effect.

Question 32

what are 5 causes pain in stage 2 of labor?

Answer 32

1. traction on the pelvic parietal peritoneum and uterine ligaments 2. stretching and tension on the bladder, urethra and rectum 3. stretching and tension of ligaments, fascia, and muscles in pelvic cavity 4. pressure on one or more of the lumbosacral plexus 5. distention of vaginal vault and perineum

Question 33

remifentanil: 1. how can it be used? 2. how commonly used where?

Answer 33

1. used in replacement when regional cannot be used | 2. most commonly used opioid for obstetrics in UK

Question 34

paracervical block: 1. only effective when? 2. why not used anymore for L & D? 3. when should it never be used for labor? 4. how is it done?

Answer 34

1. only in first stage of labor (but not used for that; used for D & Cs) 2. was absorbed into mother then fetal blood stream causing fetal bradycardia for > 30 min 3. should never be used if fetal distress or risk of poor placenta circulation (diabetes, pre-eclampsia) 4. 10 cc low concentration LA injected submucosally into fornix of vagina into Frankenhausers ganglion on one side; if no bradycardia it is repeated on other side

Question 35

lumbar epidural block: 1. why done? 2. what must you do or have ready? 3. how should mother be positioned?

Answer 35

1. provides reliable anesthesia that can be maintained during labor and delivery 2. recussitory equipment, monitors, vasopressors; patient platelets >100,000; pre hydration (500 ml); corrected or no coagulopathy; 3. position: sitting or left lateral

Question 36

lumbar epidural block: 4. what about tattoos? 5. what is the side effect on labor? 6. when should epidural be done for prim and multip?

Answer 36

4. dont go thru tattoos (tramp stamp) mercury in black ink may go into spine 5. may prolong second stage (higher incidence of forceps births). 6. give epidural when prim dilated to 4-6 cm ; multip dilated to 3-4 cm

Question 37

medications for epidural anesthesia: 1. what is the criteria for choosing meds for epidural 2. what is one of the choice local anesthetics? 3. how is it given 4. which med gives the best sensory with less motor block?

Answer 37

1. should give best block with optimal mother and fetal safety 2. Bupivicaine .125% (1/8%) or .0625% (1/16%); 3. 8-10 cc bolus will get you to T10 to L2; then give infusion of 10-12 cc/hr 4. Ropivicaine .1-.2% (has less affect on children apgar scores and less motor block)

Question 38

1. what is the test dose for checking an epidural | 2. why might it not be an effective test?

Answer 38

1. xylocaine with epinephrine 15 mcg; look for sensory response 2. patient may be tachy already d/t labor

Question 39

what else can be done to epidural for pain control

Answer 39

can bolus with 50 mcg of fentanyl in 10 cc preservative free saline (like in IV bag etc.) or put in 10 ml of LA

Question 40

1. what must you do every hour with epidural? | 2. what are the 4 crtiterion of the scale?

Answer 40

1. check motor block using a Bromage scale 2. complete (100%) - --almost complete (66%) - --partial (33%) - --none

Question 41

accidental dural puncture: 1. what percent get it? 2. treatment? 3. of those that get an accidental dural puncture, what percent get headaches?

Answer 41

1. 2% 2. inject 10-20cc blood 3. 75% get headache with dural puncture

Question 42

treatment of bupivicaine toxicity: | 1. what dose of interlipid (bolus & gtt)

Answer 42

1. Interlipid 20%; 100 ml bolus then (or 1.5 ml/kg- (max 10ml/kg)) .5 mg/kg x 2 hours

Question 43

1. combined . spinal/epidural done at what stage of labor? 2. how is it done? 3. what is the dose (gtt rate)? 4. what is an advantage? 5. side effects/ complications?

Answer 43

1. early stages 2. spinal needle thru epidural needle; inject narcotic with 1 ml NS 3. .9 (100 ml), fentanyl(5 ml) and bupivicaine (.5% 20 ml) =125 ml - ---run at 10-20 ml hour 4. earlier pain relief than epidural alone, ability to ambulate, avoid sympathectomy and ability to maintain re-dose or do continuous drip 5. PDPH, spread of previous spinal drug, pruritis (with >15 mcg fentanyl), hypotension, resp depression, fetal heart rate changes

Question 44

what is best way to secure epidural

Answer 44

with patient lying down

Question 45

augments to labor: 1. pitocin what does it do? what is needed for it to work in the body 2. what are side effects (a,b,)? 3. what does pitocin naturally do for mothers?

Answer 45

1. stimulates force of contractions, prevents blood loss; needs presence of estrogen to work. 2a. causes relaxing of smooth muscle (of vessles) causing hypotension and reflex tachycardia 2b. has anti diuretic effect after 60 units (worsens water retention (is cousin of vasopressin) 3. stimulates lactation

Question 46

1. what does the CRNA document as far as placenta? | 2. what do you do as soon as this happens?

Answer 46

1. time placenta is delivered | 2. add pitocin to bag (20u to 1000 ml or 10u to 500 ml bags).

Question 47

1. what is in the anti bleeding kit? 2. which one do we give IM? 3. which one is given directly into the uterus by the OBGYN?

Answer 47

1. ergots (methergine) & prostaglandins (15 methyl F2A hemabate) 2. methergine 0.2 mg IM if pitocin unsuccessful 3. hemabate

Question 48

1. what does methergine do? 2. what is most common s/e? 3. what are signs of ergot poisoning?

Answer 48

1. increases motor activity almost immediately (not used to augment labor though--only to control bleeding) 2. marked hypertension is the most common side effect d/t contraction of smooth muscle of blood vessels 3. n/v, headache, diarrhea

Question 49

1. what do B2 agonists do to uterus (and other organs)? 2. what are these meds called? name them: 3. what are side effects/ adverse reactions to these meds?

Answer 49

1. cause uterine relaxation, decrease vascular and broncial tone (bronchodilator) 2. Tocolytics; terbutaline and ritodrine 3. increased renin and decreased urinary output, increases risk for MI and pulmonary edema

Question 50

prostaglandins: 1. what is the name (again)? its use? route? 2. what are side effects/ adverse reactions? 3. what patient should you use caution in?

Answer 50

1. hemabate (F2a or 15 methyl); clamps down uterus to control bleeding; intrauterine injection 2. tachycardia, bronchospasm 3. asthmatics

Question 51

``` anesthesia meds summary: narcotics: 1. fentanys 2. meperidine 3. remifentanil sedatives: 1. ketamine 2. barbiturates agonist/antagonists: 1. stadol 2. nubane ```

Answer 51

I. narcotics: 1. fentanyl: seen in fetal blood in 60 sec; 25-50 mcg iv; 2. meperidine:50-100 mg IM; 25-50 mg IV; detected in fetal blood in 90 seconds (2-3 hours post maternal administration is highest exposure)should be administered:than 3 hours before delivery 3. remi is most used med in UK for obstetrics II. sedative/ induction meds: 1. ketamine: only use if bad spinal, >2 mg/kg causes neonate depression 2. barbiturates: only use if >12-24 hours before labor III. agonist/antagonists: 1. stadol:1-2 mg 2. nubane: 15-20 mg