Anesthesia in the OB Unit Flashcards
Lance Carter, CAA
1
Q
Antepartum
A
Before birth
2
Q
Dystocia
A
Difficult labor
3
Q
Intrapartum
A
During the act of birth
4
Q
Multiple gestation
A
Twins, triplets, etc.
5
Q
Multiparous
A
Has had multiple gestations
6
Q
Normal labor
A
38-40 weeks
7
Q
Nulliparous
A
Never completed a pregnancy beyond 20 weeks
8
Q
Parturient
A
Pregnant patient
9
Q
Postpartum
A
After birth
10
Q
Preterm labor
A
<37 weeks
11
Q
Primapara (primip)
A
First pregnancy
12
Q
Age of viability
A
≈24 weeks
If <28 weeks, consider immediate intubation after birth (unless the child is pink & active)
13
Q
G (Gravida)
A
Total number of pregnancies, regardless of how they ended
14
Q
P (Parity)
A
Includes both:
- The number of live births at any gestation, or
- The number of COMPLETED pregnancies (including stillbirths) that lasted more than >20 weeks
“Parity is the number of completed pregnancies beyond 20 weeks gestation (whether viable or nonviable). The number of fetuses delivered does not determine the parity.”
15
Q
A woman is currently pregnant and 25 weeks along. She has had 6 miscarriages and only 1 live birth. What is her GP status?
A
G8P1
16
Q
A woman is pregnant for the first time, and is 12 weeks along. What is her GP status?
A
G1P0
17
Q
A woman is pregnant for the second time and delivered twins in her first pregnancy at 20 weeks. What is her GP status?
A
G2P1
18
Q
Uterotonic (Oxytocic) Drugs
A
19
Q
Pitocin Effects (2)
A
20
Q
Side Effects of Pitocin
A
21
Q
Traditional Pitocin Dosing
A
22
Q
An Alternative Pitocin Dosing Protocol
A
23
Q
Rule of Threes for Pitocin
A
24
Q
Carboprost (Hemabate)
A
25
Methylergonovine (Methergine)
26
Misoprostol (Cytotec)
27
Tocolytic Drugs (5)
28
Nitroglycerin
29
Nitroglycerin For Tocolysis
30
Fetal HR Monitor
Cardiotocography
31
Fetal Heart Rate (From The Cardiotocograph)
32
Fetal Heart Rate Variability
33
Short Term and Long Term Variability
34
Examples of Short Term and Long Term Variability
35
Fetal Tachycardia
[http://www.fetalmonitorstrips.com/learn\_more.html](http://www.fetalmonitorstrips.com/learn_more.html)
36
Fetal Heart Rate Deceleration Patterns (3)
37
Early (Type I) Decelerations
38
Late (Type II) Decelerations
39
Late (Type II) Decelerations With Variability
40
Variable (Type III) Decelerations
41
Respiratory Rate
A normal respiratory rate for newborns is 30-60 breaths/minute
42
Abgar Score
This is a neonatal well being score that can range from 1 to 10 (1 is the worst score you can get and 10 is the best score you can get)
The **1 minute score is associated with survival** and the **5 minute score is associated with neurologic outcome**
43
Normal pH (from fetal scalp monitoring)
\>7.25
As opposed to ~7.4 for adults
\<7.2 in a fetus is considered acidotic, whereas a pH \<7.35 in adults is considered acidotic
44
Preop Management In The OB Unit - Before Delivery (4)
1. A fluid bolus should be given prior to a neuraxial block (500-1500mL LR, error on higher side if doing a spinal)
2. IV solutions containing dextrose should be used with caution and only considered for maintenance doses, but not for fluid boluses (Dextrose can potentially lead to fetal hypersecretion of insulin post delivery and even fetal acidosis)
3. Every patient should have a type & screen since every pregnancy has the potential for unexpected massive hemorrhage
4. As far as NPO status goes, the current thinking is that, generally, modest liquids are allowed for uncomplicated labor, while higher risk pregnancies have stricter restrictions
45
NPO Guidelines In The OB Units
46
NPO Status For Laboring Patients?
47
Drugs To Avoid Before The Baby Is Delivered (3)
48
Analgesic Options For Spontaneous Vaginal Delivery - Epidural
49
Epidural Anesthesia for Spontaneous Vaginal Delivery Considerations (3-4)
50
Epidural Anesthesia for Spontaneous Vaginal Delivery - Spinal
51
Analgesic Options For Spontaneous Vaginal Delivery - OB Nerve Blocks (2)
52
Paracervical Nerve Block (Performed by Obstetrician)
53
Pudendal Nerve Block (Performed by Obstetrician)
54
Analgesic Options For Spontaneous Vaginal Delivery - Nubain
55
Nubain (Nalbuphine)
56
Analgesic Options For Spontaneous Vaginal Delivery - Nitrous Oxide
[http://www.foxnews.com/health/2014/06/15/laughing-gas-for-childbirth-new-way-to-have-pain-free-labor.html](http://www.foxnews.com/health/2014/06/15/laughing-gas-for-childbirth-new-way-to-have-pain-free-labor.html)
57
A patient is **hurting at some point after their epidural was started**. They either never were comfortable to begin with, or they were initially comfortable but started having pain as they approached the second stage of labor. How should this patient be managed?
1. Inform patient that epidurals take care of sharp pain but not pressure
2. Bolus 5-8cc local anesthetic to increase the block density, preferably with a stronger drug like (2% lidocaine). BE COMPLETELY STERILE BOLUSING EPIDURALS.
58
After receiving an epidural, a patient **still feels pain on one side**. How should she be managed?
1. Have her lay on the side that is hurting
2. Pull the catheter back 1-2cm
3. Pull the catheter and start another epidural
59
C-section Background
60
Airway equipment that should be available during a C-section (3)
61
Generalized C-section Outline (9)
**1. The patient arrives in the operating room**
**2. Abx are administered**
* *3. The analgesic method is carried out (epidural, spinal, or general)**
- Consider avoiding intravenous versed/opioids before the baby is out
**4. The patient is placed in left uterine displacement (LUD)**
* *5. Vasopressors are usually given if spinal anesthesia is performed (because sympathectomy is so common)**
- Pressors are also used with epidural anesthesia, but less frequently
* *6. The surgery is started, and the baby is delivered in short order**
- The baby should be delivered within 3 minutes of uterine incision (Handbook of Nurse Anesthesia, 4thedition, page 420)
- Longer uterine incision to delivery times = more maternal bleeding, lower Apgar scores, and more acidotic blood gases
* *7. Pitocin is given**
- Hemabate/Methergine/Cytotec are given if Pitocin is ineffective)
**8. Zofran and Decadron are administered**
* *9. Additional drugs can now be administered for pain control**
- Intravenous opioids if the patient becomes uncomfortable
- Possible Toradol prior to leaving the operating room (surgeon preference)
62
Nausea and Vomiting Prevention During C-Section (2)
1. Hypotension induced nausea can be prevented with rapid (and even prophylactic) administration of Ephedrine or phenylephrine
2. Normotensive induced nausea, in addition to Zofran, can be treated with Robinul because Robinul is a vagolytic drug
63
Name two reasons patients get nauseous during a C-Section, even if they are normotensive
64
Different Anesthetic Options for a C-section (4)
65
While you are on call, the labor and delivery department informs you that the obstetrician on call would like to do a C-section in the next 30 minutes. It is **non-emergent**. From an anesthetic management standpoint, what is the first question you should ask? What is the second question you should ask?
1. Do they have an epidural?
2. Does it work?
66
While on call, the labor and delivery department calls you to come to the OR in the obstetric unit STAT for an **emergent C-section**. In addition to wanting to know if they have an epidural and whether or not it works, what do you want to know?
* *What is the emergency?
- **If the patient is hemorrhaging, they will need a general anesthetic (to avoid the sympathectomy)
* *-**If the patient is not hemmorrhaging, anesthesia can consider dosing the epidural with chloroprocaine if there is time
67
Case Outline for C-section Under Spinal Anesthesia (4)
68
“Total Spinal” Anesthesia
69
Although “Total Spinal” anesthesia is normally caused by spinal administration, how does an epidural sometimes produce a high "Total Spinal"?
70
A 28-year old, G2P1 is undergoing a repeat, non-emergent C-section under spinal anesthesia. PMH is unremarkable, and she has a Mallampati class I airway. When the patient’s spinal block is tested prior to starting, it appears “patchy,” meaning that the mother can feel some pain. What are the anesthetic options for this patient?
1. Can consider N20 (70/30)/ketamine (50mg) to support the block
2. RSI with general anesthesia
71
A 32-year old, G1P0 is undergoing a non-emergent C-section under spinal anesthesia. PMH includes morbid obesity and a Mallampati class IV airway. When the patient’s spinal block is tested prior to starting, it appears “patchy.” What are the anesthetic options for this patient?
1. Can consider N20 (70/30)/ketamine (50mg) to support the block
2. Can consider RSI with general anesthesia if the ketamine/N20 is ineffective
72
A parturient had a spinal block for a C-section. After the baby has been delivered, the mother is uncomfortable with pain. How should she be managed?
IV narcotics
73
Prior to a C-section, a laboring pregnant patient develops a high spinal. She is conscious, but starts to panic because she feels like she can’t breathe. SpO2 is currently 96% on a nasal cannula at 4L. How should she be managed at this point?
1. Reverse trendelenburg
2. Possible assist ventilation (with possible N20)
3. Blood pressure support
4. Prepare for intubation
74
Prior to a C-section, a laboring pregnant patient develops a high spinal and goes unconscious (this is referred to as a “total” spinal). How should she be managed?
Intubate and resuscitate
75
Case Outline for a C-section Under Epidural Anesthesia (6)
76
If you are called to perform the anesthesia for a **non-emergent** C-section on a patient whose epidural is working effectively, how should that patient be managed from an anesthetic standpoint?
Dose to T4 gradually with lidocaine (or chloroprocaine)
77
If you are called to perform the anesthesia for a **non-emergent** C-section on a patient whose epidural is “patchy” (not working completely), what are the anesthetic options? (4)
1. Supplement the block with ketamine/nitrous, or
2. RSI, or
3. Try and dose the epidural to T4 and see what happens, or
* 4. Pull the epidural catheter out and perform a spinal with a reduced dose (last choice, especially if we already tried to bolus the epidural to raise the block)*
78
Spinal Anesthesia After A Patchy/Failed Epidural
79
Let’s say that for this **emergent** C-section case, the patient is obese, has a Mallampati IV airway, and also does not have an epidural. What options does an anesthetist have in this scenario?
RSI with videoscope and LMA as backup
80
Let’s say that for this emergent C-section case (obese/Mallampati IV), the patient has an epidural that is “patchy” (not working very effectively). What options does an anesthetist have in this scenario?
1. If airway looks easy, perform an RSI
2. If airway looks difficult, perhaps think about dosing the epidural to T4 with chloroprocaine, and/or tyring ketamine/nitrous
81
Let’s say that for this emergent C-section case (obese/Mallampati IV), the patient has an epidural that is working effectively. How should this patient be managed?
Dose to T4 immediately with chloroprocaine/bicarb
82
A laboring pregnant patient is taken to the OR to undergo a C-section for failure to progress. The epidural was dosed to T4 with 15mL of 3% chloroprocaine. 30 minutes into the procedure, the patient starts complaining of pain. How should this patient be managed at this point?
5-10cc epidural bolus of local anesthetic
83
Postop Pain Control Options
For C-Sections Under Epidural (3)
* *1. Dose Duramorph (2-4mg) through the epidural catheter prior to pulling the catheter at the end of the case**
- Most common
- Epidural Duramorph provide analgesia for upto 18-26 hrs
* *2. Order an epidural PCA (PCEA) "Walking epidural"**
- Here, the catheter is left in place in the recovery room, and dosed with a very dilute local anesthetic or narcotic only infusion
* *3. Order an IV PCA**
- This option is available if the anesthetist forgets to dose epidural Duramorph before pulling the catheter at the end of the case
84
C-section Under CSE Anesthesia
85
Advantages To C-sections Under GA (3)
86
Disadvantages To C-sections Under GA (3)
87
Indications for Doing C-sections Under General Anesthesia (5)
88
Classic Symptom of Placenta Previa
89
Placental Abruption
90
Induction Agents For C-Sections Under GA in Non-Hemorrhaging, Normotensive Parturients
91
Induction Agents For C-Sections Under GA With Internal Bleeding, Hypotensive Parturient
92
Case Outline For A C-section Under GA (7)
**1. Give Abx as soon as the patient arrives in the operating room**
* *2. Induce the patient**
- DO NOT push drugs until patient is prepped & draped, and the surgeon is ready with the knife in hand!!!
- Perform an RSI in the sniff position and preoxygenate as long as possible
- Fasiculations are less intense (unnoticeable?) in pregnancy (due to progesterone?)
- Consider avoiding Versed/opioids
**3. Place the patient in left uterine displacement (LUD)**
* *4. Paralyze the patient if needed (optional)**
- Muscle relaxants don’t cross the placenta
**5. Administer Pitocin after the baby and placenta are delivered** (Give Hemabate or Methergine if Pitocin is ineffective)
* *6. Give Zofran, start dosing fentanyl, and give reversal** (if necessary)
- Consider giving Toradol prior to leaving the operating room
* *7. Plan on an IV PCA for postop pain control**
- Remember, it’s because they don’t have a block
93
A laboring pregnant patient is taken to the OR to undergo a C-section for failure to progress (**non-emergent**). Past medical history includes preeclampsia and thrombocytopenia. General anesthesia is planned. After induction, the anesthesiologist is unable to intubatethe patient. What should be done at this point?
Awaken the mother
94
What if the patient in the previous example was having an emergent C-section for type II fetal decelerations. What is the correct thing to do if intubation is unsuccessful?
Place an LMA and hold cricoid pressure until the patient can be intubated
95
Emergent Airway Algorithm in OB
96
Management Of Epidurals In The OB Unit
97
Management Of C-Sections With Epidural Anesthesia
98
Management Of C-Sections With Spinal Anesthesia
99
Management Of C-Sections Without A Neuraxial Block
100
Options For Postop Pain Control In C-Sections
