OB: C-Section: Regional vs. General Anesthesia Flashcards by Linsley Lloyd

most common indications for C-section

Dystocia
Malpresentation
Non-reassuring fetal status
Previous cesarean delivery

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Can be performed for obstetric or medical indications or at the request of the parturient. Typically planned and performed prior to the onset of labor.

Elective C-Section

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Typically occur after the onset of labor (exception: i.e. Non-reassuring fetal nonstress test [NST]). Can be due to a variety of maternal and fetal indications

Urgent/Emergent C-section

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TOLAC

trial of labor after cesarean

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VBAC

vaginal birth after cesarean

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_____ _____ ______ _____ (super STAT emergencies)
Better surgical exposure and visualization
Faster exposure

Midline vertical (skin) incision

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_____ _____ _____ ______
Better cosmesis
Better wound strength

Horizontal suprapubic (skin) incision

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Horizontal uterine incision

_______ incidence of uterine dehiscence or rupture in subsequent pregnancies

lower

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Horizontal uterine incision

______ risk of infection

reduced

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Horizontal uterine incision

______ blood loss

decreased

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Horizontal uterine incision

______ risk of adhesions to bowel and omentum

decreased

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Vertical uterine incision usually only seen if:

Lower uterine segment is underdeveloped (prior to ___ weeks)

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Vertical uterine incision usually only seen if:

Delivery of a preterm infant in a parturient who ___ ____ _____

has not labored

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Vertical uterine incision usually only seen if:

Some ____ _____ and/or malpresentation

multiple gestation

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Vertical uterine incision usually only seen if:

Low lying anterior ____ _____

placenta previa

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Operative Technique - Uterine exteriorization (after delivery)

Good, facilitates ________ and facilitates repair of uterine incision

visualization

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Operative Technique - Uterine exteriorization (after delivery)

controversial effects on blood loss and infection, higher rate of ______, increased risk of ______ ______, and increased post operative ______

N/V
air embolus
pain

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Complications of C-Section

Hemorrhage (MAIN SX COMPLICATION - TEST)
Infection
Thromboembolism
Ureteral and bladder injury
Abdominal pain
Uterine rupture in subsequent pregnancies
Death

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Non-elective cases associated with _____ _____ than elective

greater risk

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Historically, it was thought that neuraxial analgesia ___________ rate of cesarean delivery compared to other techniques. However this has been found to be unfounded in RCTs and sentinel event studies.

increased

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some cesarean deliveries may be avoided with _____ ____ _____, including:

adequate labor analgesia

TOLAC, instrumented vaginal delivery, cephalic version, intrauterine resuscitation (pharmacologic uterine relaxation of uterine tachysystole)

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External Cephalic Version

Breech position occurs in ____% of term singleton pregnancies

3-4%

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External Cephalic Version

Vaginal breech delivery should be done with caution due to increased risk of _______ __________ ________ and risk of ________ _________

emergency c-section delivery
neonatal injury

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External Cephalic Version

Neuraxial analgesia improves success of ECV by up to ____% without increased risk of fetal bradycardia, placental abruption, or fetal death.

50%

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External Cephalic Version Usually done at ___-___ weeks

36-37

External Cephalic Version Average success rate is ___% (with a wide range)

58% wide range associated with providers competency

External Cephalic Version Most likely to be successful - If the presenting part has not entered the _____, Amniotic fluid volume is normal, The fetal back is not positioned ______, Patient is not obese, Position is either ____ ____ or _____

pelvis posteriorly frank breech or transverse

External Cephalic Version Successful version reduces the risk of perinatal _____ & _____ of the breech position

morbidity and mortality

External Cephalic Version Most likely complications of the ECV are: ______ FHR abnormalities ______ FHR abnormalities Vaginal bleeding Placental ______ Emergency cesarean delivery Still birth

Transient Persistent abruption

External Cephalic Version A high ______ dense (anesthetic>analgesic) neuraxial block will improve the success of the ECV

T4-T6

External Cephalic Version ____ if plan to discharge

SAB

External Cephalic Version Epidural if planning to _____

labor

External Cephalic Version Either way, have backup plan(s) to convert to ____ _____ delivery

emergency cesarean

Intrauterine Resuscitation Intrapartum fetal compromise (nonreassuring fetal status) should prompt _____ _____ _____

intrauterine fetal resuscitation

Intrauterine Resuscitation Optimize maternal position - To relieve ______ compression To relieve _____ _____ compression

aortocaval umbilical cord

Intrauterine Resuscitation administer supplemental _____

Intrauterine Resuscitation Maintain maternal circulation Perform rapid IV infusion of a ___-____ ____ ____ solution

non-dextrose balanced salt

Intrauterine Resuscitation Treat hypotension with _____ or _____

ephedrine or phenylephrine

Intrauterine Resuscitation discontinue _______

pitocin (bc it increases contractions)

Intrauterine Resuscitation Consider administration of a tocolytic agent for treatment of _____ _____

uterine tachysystole

Preanesthetic Evaluation Ideally anesthesia evaluation should occur in the ____ ____ or ____ ____ trimester for high-risk patients

late 2nd or early 3rd

Preanesthetic Evaluation should include:

Review of maternal health Anesthetic history Relevant obstetric history Allergies Baseline BP/HR Airway exam Heart exam Lung exam Informed Consent

Informed Consent Only 12% of English-speaking adults in the US are “proficient” in their health literacy skills Health literacy is the precursor to patient ______ and to patient ____ _____

engagement decision making

Informed Consent 70% of first time mothers are influenced by ________ and ___________ regarding labor analgesia

friends and family

Informed Consent The most frequently utilized resource is the _______________

internet

_______ elements include the ability of the patient to meet the basic definition of competence, which refers to the patient’s legal authority to make a decision about her health care. Although some cognitive functions may be compromised by the effects of pain, exhaustion, and analgesic drugs, evidence suggests that most laboring women retain the capacity to hear and comprehend information during the consent process.

Threshold

Information elements - provider discloses information about ______ risks patient understands ______

material information

_______ elements - provider offers info in a non-coercive manner patient gives authorization voluntarily

consent

Timeline of C-section

- monitors, IV, O2 - T4-T6 level of anesthesia established - left uterine displacement - incision and delivery - delivery of placenta - pitocin 30 unit IV gtt, may need more, may push smaller doses - closure

Pitocin - synthetic hormone ______

oxytocin

Pitocin - given to _____ or _____ uterine contractions or to contract uterus after delivery to prevent _____

initiate or augment hemorrhage

Pitocin - if patient has been induced/augmented with pitocin, it may take _____ dosages to achieve adequate contraction post partum

higher

Pitocin - other uterotonic agents ______

unaffected

monitors

EKG Pulse ox capnography oxygen and volatile agent analyzers ventilator peripheral nerve stimulator

Consent for Blood Products Blood administration should be included in _____ _____/_____

informed consent/discussion.

Consent for Blood Products ____-_____ ______ is the leading cause of maternal mortality worldwide

peri-partum hemorrhage

Consent for Blood Products ______ ______ delivery ≤ uncomplicated elective c-section <<< c-section during labor

Uncomplicated vaginal

Consent for Blood Products preparation for hemorrhage:

Patient history Consult with OB team Ultrasound/MRI of placentation Type and screen/cross Contact blood bank to verify availability Equipment (pumps/filters/pressure bags)

Prepping for hemorrhage

Large-bore IV catheters Fluid warmer Forced air body warmer Availability of blood bank resources Equipment for infusing fluids/blood products rapidly

There is a _____ of ______ as to which patients require a type and screen versus crossmatch. Maternal history (previous transfusion, existence of RBC antibodies), anticipated hemorrhage (placenta accreta), local institutional policies should guide decisionmaking.

lack of consensus

prepping for difficult airway

laryngoscope blades LMAs semirigid stylets retrograde intubation equipment at least one device suitable for emergency non-surgical airway ventilation (jet ventilation, combitube, intubating LMA) fiberoptic intubation equipment equipment for emergency surgical access topical anesthetics and vasoconstrictors (airway will worsen throughout labor)

Drugs for general and neuraxial anesthesia should be readily available Including _____ & _____ medications

vasopressors and emergency

Only _____ ____ controlled substances need to be in a “substantially constructed locked cabinet” Other drugs, including _____ ____ should be “reasonably secure”

Schedule II Schedule III

All obstetric patients are considered a _____ stomach.

full

Patient should be asked about oral intake _______ evidence exists regarding the relationship between recent ingestion and subsequent aspiration

Insufficient

Gastric emptying of clear liquids during pregnancy occurs _____ _____ (Remember Wong et al.,2002)

relatively quickly

Healthy patient for elective cesarean may drink modest amounts of clear liquids up to 2 hours prior to induction _______ of _____________ is more important than volume

absence of particulates

Patients with additional risk factors for aspiration (obesity, diabetes, difficult airway, laboring) should have further __________ on a case-by-case basis or as determined by facility policy

restrictions

Ingestion of ____ ____ should be avoided in laboring patients, ___-___ hours

solid foods 6-8

Reduction in acidity and volume is thought to decrease the damage to the _____ if there is ______.

lungs aspiration

Sodium citrate (___________ gastric pH)

increases

treat with H2 receptor antagonists, PPIs, and metoclopramide reduce gastric ________________ and ___________. (In 30-40 minutes)

secretion and volume

The combined use of antacid and H2 antagonist is ____ _____ in reducing acidity than antiacid or placebo.

more effective

ACOG recommends prophylactic administration of a narrow-spectrum antibiotic (_____ generation _______) within one hour of the start of a cesarean delivery.

first cephalosporin

In parturients with significant beta-lactam allergy ______ & ______ are a reasonable alternative.

clindamycin and gentamycin

Higher doses should be considered with BMI greater than 30 kg/m^2 or absolute weight greater than 100 kg due to _____ _____ of ________.

greater volume of distribution

Optimal timing and value of broad-spectrum antibiotics remain ________.

controversial

Even low dose benzodiazepines may result in ______(midazolam 0.02 mg/kg)?

amnesia

For women with severe anxiety, low dose ______ or an ______ may facilitate neuraxial technique or induction

midazolam or an opioid

anxiety proph - May also mitigate feelings of distress and lessen the risk of developing _____

PTSD

Low doses of sedative or anxiolytic agents have minimal to no _____ ______.

neonatal effects

Left Uterine Displacement for all parturients after ____ ____ gestation

20 weeks

A slight (10 degree) head-up position may help reduce the incidence of ____________ after initiation of ____________ spinal anesthesia.

hypotension hyperbaric

A more significant head-up position (30 degrees) significantly improves the _____

FRC

A 30 degree head up position may also be helpful to improve ________, ________, and view of the glottis during direct laryngoscopy

preoxygenation, denitrogenation

Trendelenburg (head down) may augment venous return and cardiac output but…. Has been reported to result in a more _____ _______ of anesthesia.

cephalad spread

Lateral position Reduction of _____ reflexes (dizziness, diaphoresis, pallor, bradycardia, hypotension) Improved uteroplacental blood flow??? More comfortable Limit side-to-side and front-to-back patient motion Minimizes prominence of ____ ____ Decreased severity and duration of ______

vagal dural sac hypotension

Sitting position Landmark recognition (especially in obese) Provider preference Should _____ be utilized in fetal head entrapment, umbilical cord prolapse, footling breech presentation.

NOT

Routine supplemental oxygen administration is common practice since the 70’s when Fox et al. (1971) demonstrated:

Improved oxygenation Better umbilical cord acid-base measurements Less time to sustained respiration of the neonate (when mothers breathed 100% O2 for at least 30 minutes)

More recent evidence has shown that routine oxygen administration may be _______ and _______ or perhaps even ________

unnecessary ineffective detrimental

The most appropriate anesthetic technique depends on many factors:

Maternal Fetal Obstetric (urgency and anticipated duration are important)

Indications for Neuraxial Anesthesia Maternal desire to witness birth and/or avoid _____ _____

general anesthesia

Indications for Neuraxial Anesthesia Risk factors for ____ ____ or aspiration

difficult airway

Indications for Neuraxial Anesthesia Presence of _____ conditions

comorbid

Indications for Neuraxial Anesthesia General anesthesia _____/_____

intolerance/failure

Indications for Neuraxial Anesthesia other benefits:

Plan for neuraxial analgesia after surgery Less fetal drug exposure Less blood loss Allows presence of support person

Indications for General Anesthesia Maternal refusal or failure to cooperate with ______ technique

neuraxial

Indications for General Anesthesia Presence of comorbid conditions that contraindicate neuraxial:

Coagulopathy Infection at insertion site Sepsis Severe uncorrected hypovolemia Intracranial mass with increased ICP Known allergy to local anesthetic

Indications for General Anesthesia Insufficient time to induce neuraxial anesthesia for ____ ____

urgent delivery

Indications for General Anesthesia failure of _____ technique

neuraxial

Indications for General Anesthesia _____ issues

fetal

Neuraxial versus General Neuraxial anesthesia has been used in more than ____% of c-sections since 1992

Neuraxial versus General increased use due to: (6)

- Increased use of LEA - Increased awareness of in situ epidural catheter, even if not used in labor, may decrease necessity of general anesthesia in an urgent situation - Improvement of neuraxial anesthesia quality - Appreciation of the airway risks with general - Desire for limited neonatal drug transfer - Ability of mother to remain awake and have support person present for birth

Neuraxial versus General Spinal anesthesia is considered appropriate even in the most ____ _____

urgent settings

Neuraxial versus General “____ _____ Spinal” SAB 8.1 +/- 3.8 minutes General induction 4.5 +/-1.4 minutes

Rapid Sequence

Neuraxial versus General Maternal _____ after general anesthesia is a huge motivator for the shift

mortality

Neuraxial versus General Maternal _____ is also lower with neuraxial

morbidity

Neuraxial versus General _____ blood loss

decreased

Neuraxial versus General _____ shivering

decreased

Neuraxial versus General _____ nausea

Neuraxial versus General _____ intraoperative perception of pain

Neuraxial versus General _____ time elapsed before first request for pain meds

longer

Neuraxial versus General neonatal outcomes??

not a huge factor

epidural advantages

No dural puncture required Can use in situ placed earlier Ability to titrate sensory blockade Continuous postoperative analgesia

epidural disadvantages

Slow onset of anesthesia Larger dose required > greater risk of maternal systemic toxicity > greater fetal drug exposure

CSE advantages

May be technically easier than spinal in obese Low doses of local anesthetic and opioid Rapid onset of dense block Ability to titrate sensory blockade Continuous intraoperative anesthesia Continuous postoperative analgesia

CSE disadvantages

Delayed verification of functioning epidural catheter

one shot spinal advantages

Technically simple Low doses of local anesthetic and opioids Rapid onset of dense lumbosacral and thoracic anesthesia

one shot spinal disadvantages

Limited duration of anesthesia Limited ability to titrate extent of sensory blockade

continuous spinal advantages

Low doses of local anesthetic and opioid Rapid onset of dense anesthesia Ability to titrate sensory blockade Continuous intraoperative anesthesia

continuous spinal disadvantages

Large dural puncture > increased risk of PDPH Possibility of overdose and total spinal

SAB simple, reliable, _____ onset, _____ block (more profound than epidural), _____ amount of LA needed

rapid dense small

SAB decreased risk of _____ ______, minimal drug transfer to fetus, _____ and prompt recovery, most common anesthesia technique for cesarean delivery in the developed world

LA toxicity predictable

SAB ______ bevel rarely used in OB, increased incidence in PDPH

cutting

SAB ___-____ needles used almost exclusively

non-cutting (aka pencil point needles)

believed to cause _____ trauma to the dura (pencil point)

more but the subsequent inflammation seals the hole and prevents a leak

SAB: Needle Size Larger needles

Greater tactile fidelity More likely to withstand high resistance (bone) without damage

SAB: Needle Size Smaller needles

Lower incidence of PDPH Use introducer needle

SAB: Approach Midline - Need more patient ______ cooperation Faster for most patients ____ painful for most patients Easier to teach

positioning Less

SAB: Approach Paramedian - _____ target Must think of the anatomy in ___ planes instead of 2 Still trying to puncture the dura in the midline May need a ____ ____

Larger 3 longer needle

SAB: Local Anesthetics Typically use ______ doses in pregnancy than non-pregnant Smaller CSF volume ______ movement of hyperbaric LA Greater sensitivity

lower Cephalad

SAB: Local Anesthetics _______ is predominant agent for SAB for Cesarean delivery in the USA

Bupivacaine

SAB: Adjuvant Agents - opioids Improve comfort intra and postoperative _____ Decreased need for ______ opioids

comfort intraoperative

SAB: Adjuvant Agents Fentanyl - Increased postoperative opioids (after 6 hours) - Decreased intraoperative ____ & _____ (20 mcg fentanyl is superior to ___ mg of _____) - Large (40-65 mcg) vs. small (15-35 mcg) (Decreased pruritus, nausea, and vomiting in small dose No difference in supplemental analgesia need)

nausea and vomiting 4 ondansetron

SAB: Adjuvant Agents Preservative free _____ More effective for prolonged (12-24 hr) postoperative analgesia Intrathecal morphine analgesia similar analgesia from 0.1 mg and 0.5 mg. Occurrence of pruritus appeared to be ____ _____ Occurrence of nausea and vomiting were ___ ____dependent

morphine dose dependent not dose

SAB: Adjuvant Agents _____- hyperbaric

Dextrose

SAB: Adjuvant Agents Epinephrine - increase density of _____ and _____ block, may prolong ______

sensory and motor duration

SAB: Adjuvant Agents Clonidine - improve _____, decreases ______, reduces peri-incisional hyperanalgesia, BLACK BOX warning in OB pts because of concerns with _______ instability

analgesia shivering hemodynamic

SAB: Adjuvant Agents Neostigmine - reduction in postoperative _____, no effect of FHT or _____ scores, 100% of patients in the study complained of ______

pain Apgar nausea

Use of epidural anesthesia for cesarean delivery has ______

increased

Use of epidural anesthesia for elective cesarean delivery is becoming less common: Block is ____ reliable Higher doses (5-10 times) _____ systemic absorption Risk of local anesthetic toxicity Slower onset of _____ _____ Ability to titrate level, density, and duration

less Greater sympathetic blockade

Combined spinal epidural (CSE) anesthesia _____ onset Reliable anesthesia block Ability to _____/______ blockade Dural puncture may enhance movement of drugs into ___________ space

Rapid augment/prolong subarachnoid

Most common local anesthetic for initiation and maintenance of epidural for cesarean delivery is ___ ______ with ______

2% Lidocaine with epinephrine (less than 2% may result in inadequate anesthesia)

3% 2-chloroprocaine has most _____ onset and ______ duration Rapid onset of hypotension Reduced clinical efficacy if administered with _____

rapid shortest opioids

0.5% Bupivacaine can result in surgical anesthesia - ______ onset - risk of LA toxicity from _______ _______

slower intravascular injection

______ 50-100 mcg results in spinal and supraspinal sites of action Improves quality of anesthesia Does not adversely affect the neonate

Fentanyl

________ 10-20 mcg improves intraoperative anesthesia Prolongs postoperative analgesia Minimal maternal side effects, no neonatal adverse effects

Sufentanyl

Clonidine Reduced requirement for postop ______ _____tension _____ _____ Warning

morphine Hypo Black Box

Neostigmine Modest postop analgesia, given after ____ _____

cord clamped

Epinephrine - Minimize systemic absorption Increase _____ & _____ blockade density Prolong duration Controversial in ______ women

sensory and motor preeclamptic

Sodium Bicarbonate - More ___-____ molecules Speeds onset Improves _____

non-ionized quality

Combined Spinal-Epidural Anesthesia: CSE Combines the rapid and predictable onset of a spinal with the ability to _____ with the epidural catheter

titrate

Combined Spinal-Epidural Anesthesia: CSE Epidural needle functions as a longer _____

introducer

Combined Spinal-Epidural Anesthesia: CSE Use of ____ ____ to confirm correct positioning

spinal needle

Combined Spinal-Epidural Anesthesia: CSE May be able to use _____ spinal doses

lower

Laboring patient > turns to unscheduled c-section Assess how/is the epidural ______

functioning

Local anesthesia choices

0.5% Bupivacaine 2% Lidocaine 3% 2-Chloroprocaine More non-ionized molecules speeds onset, improves density

Extension of a T10 level of analgesia to a T4 level of anesthesia typically requires ___-___ mL of local with one or more adjuvants

15-20 mL

Cesarean Section General Anesthesia: Induction Neuraxial technique is ______, but there are some cases where general is indicated

preferred

Cesarean Section General Anesthesia: Induction All parturients are considered __________________

full stomachs

Cesarean Section General Anesthesia: Induction In contrast to general surgical procedures, the abdomen is prepped and draped _____ induction of general anesthesia.

BEFORE

Cesarean Section General Anesthesia: Induction Rapid-sequence induction following ______

preoxygenation

Cesarean Section General Anesthesia: Induction Propofol 2-2.8 mg/kg is typically used to induce ______ (1-1.5 mg/kg) or ______ (0.3 mg/kg) may be used in the case of hemodynamic instability

Ketamine etomidate

Cesarean Section General Anesthesia: Induction Succinylcholine (__-___ mg/kg) or Rocuronium (__mg/kg)

1-1.5 1

Cesarean Section General Anesthesia: Induction Smaller diameter endotracheal tube (___-___) with a semirigid stylet

6.0-6.5

Cesarean Section General Anesthesia: Induction Anticipation of a difficult airway or failed intubation attempt should invoke the ____ ____ ____

difficult airway algorithm.

Indications for General Anesthesia Maternal _____ or failure to cooperate with neuraxial technique

refusal

Indications for General Anesthesia Presence of comorbid conditions that contraindicate neuraxial:

Coagulopathy Infection at insertion site Sepsis Severe uncorrected hypovolemia Intracranial mass with increased ICP Known allergy to local anesthetic

Indications for General Anesthesia Insufficient time to induce neuraxial anesthesia for ____ ____

urgent delivery

Indications for General Anesthesia Failure of neuraxial technique _____ issues

Fetal

General Anesthesia: Maintenance - GOALS

Adequate maternal and fetal oxygenation with maintenance of normocapnia (30-32 mmHg) Appropriate depth of anesthesia to promote maternal comfort and optimize surgical conditions Minimal effects on uterine tone Minimal adverse effects on the neonate

Fetal oxygenation is maximal when maternal FiO2 _____ is used, but it does not seem to alter Apgar scores.

1.o

Excessive ventilation can cause uteroplacental vasoconstriction and shift the oxyhemoglobin dissociation curve to the ______.

left

___ inhalational agent has been shown to be superior to others.

ET levels of inhalational agent of _______ MAC may reduce the effect of oxytocin on uterine tone > increased blood loss.

1-1.5 TEST QUESTION

IV _____ are usually withheld until after the clamping of the umbilical cord.

opioids

Additional _____ _____ is rarely needed

neuromuscular blockade

U-D interval longer than ____________ = lower Apgar scores and fetal pH

180 seconds

Post partum women are considered full stomachs for at least ___ weeks.

emergence and extubation ________ position Purposeful response to verbal commands Return of _____ _____ reflexes

Semirecumbent airway protective

Majority of deaths associated with hypoventilation or airway obstruction occurs during ______, _______, or _______!

emergence, extubation, or recovery

Propofol Rapid onset, rapid recovery, favorable side effect profile More ____ ______ in pregnancy Readily crosses the placenta _____ Apgar and neurobehavioral scores for neonates than thiopental Greater incidence of maternal hypotension ______ depth of anesthesia

rapid clearance Lower Lighter

Ketamine ________ properties make it an ideal induction agent for urgent delivery in patient with hypotension or acute asthma exacerbation ____ _____ in preeclampsia Hallucinations/delirium Ketamine for induction -> decreased _____ _____ _____ than thiopental induction

Sympathomimetic Not desirable postop morphine consumption

Etomidate Rapid onset – minimal _______ effects Ideal for hemodynamic instability or severe cardiac disease Rapid ______/rapid ______ Nausea and vomiting Transient reduction in neonatal _____ _____

cardiorespiratory hydrolysis recovery cortisol production

Midazolam ____ acting, ______ soluble Typically avoided due to amnestic properties Used with _____

Short water ketamine

Succinylcholine Muscle relaxant of choice for RSI of general anesthesia 1-1.5 mg/kg = Ideal intubating conditions in about 45 seconds Highly ______, ______ soluble, small amounts cross placenta Very large doses (10 mg/kg) required to lead to _____ _____ sufficient to cause neonatal weakness Rapidly metabolized by _________ (decreased in pregnancy)

ionized, water placental transfer pseudocholinesterase

Rocuronium Suitable alternative for RSI 0.6 mg/kg = ideal intubating conditions in about ____ ______ No impact on _____ ____

79 seconds Apgar scores

Vecuronium

0.1 mg/kg Slower onset (144 seconds)

Atricurium Less desirable agent for RSI because of ____ _____ required May result in significant ______ release and hypotension

high doses histamine

Nitrous Oxide _____ effect on maternal blood pressure Minimal effect on uterine _____ Allows for reduction in use of halogenated agents 50-67% nitrous alone => awareness in 12-26% of cases Transferred rapidly across the placenta Neonates exposed to nitrous required more ______

Minimal tone resuscitation

Volatile Agents Decreased uterine tone Oxytocin induced contractions completely _____ at ___ _____ Decreased (28%) MAC Return to normal by 72 hours post partum

inhibited at 2 MAC

Opioids All cross the placenta, especially high _______ solubility Usually avoid until after delivery Meperidine’s active metabolite _________________ can accumulate in the mother and neonate resulting in respiratory and neurobehavioral alterations

lipid normeperidine

Few reports of malignant hyperthermia during pregnancy The rarity of MH events in pregnancy suggests pregnancy _____ _____ the occurrence of MH

protects against

MH is an ________ __________ _________ gene

inherited autosomal dominant

All anesthetic agents ____ the _____

cross placenta

Cesarean delivery is a major abdominal surgical procedure May go to PACU, patient’s room, or somewhere else _____ _____ _____ has been cited as a recurring factor in maternal deaths

Inadequate postoperative care

“Appropriate equipment and personnel should be available for obstetric patients recovering from major _____ or ______ anesthesia.”

neuraxial or general

Oral intake – early intake (4-8 hours) associated with shorter time to return of ____ ____ and shorter hospital stay

bowel sounds

Urinary catheter No differences for general vs neuraxial Risk factors for urinary retention:

Post op opioid analgesia (especially epidural) Multiple gestation Low BMI

Anesthesia Complications _____ & ______ Avoidance of sedative premedication Deliberate low volatile concentration Use of muscle relaxants Reduced anesthetic doses in hypotension or hemorrhage Conversion to general after failed neuraxial technique Mistaken assumption that high baseline sympathetic tone is responsible for intraoperative tachycardia

Awareness and Recall

Dyspnea Hypo______ of brainstem Blunted thoracic ______ Position

perfusion proprioception

Anesthesia Complications Hypo______ Severe preeclampsia IV fluids Vasopressors

tension

Anesthesia Complications Neuraxial blockade _____ 4-14% of epidurals 0.5-4% of spinals

failure

Anesthesia Complications High neuraxial blockade Impaired ______ Unconsiousness Respiratory depression ______cardia Hypotension

phonation Brady

Anesthesia Complications ____ and _____ Hypotension Uterotonic agents, ergot alkaloids Surgical stimuli

Nausea and vomiting

Anesthesia Complications perioperative _____

pain

Anesthesia Complications Pruritus ___-____% incidence More common intrathecally than epidurally Not an _____

30-100 allergy

Anesthesia Complications Hypothermia and shivering 66 and 85% incidence respectively Spinal reduces ____ ____ more rapidly than epidural Shivering incidence similar but less severe in spinal group ______ improves for epidural, but not spinal

core temp Prewarming

Obstetric Complications _____ _____ Leading cause of maternal and fetal morbidity and mortality worldwide

Postpartum Hemorrhage

Obstetric Complications _____ _____ More common with c-section High parity Overdistended uterus (multiple gestation, polyhydramnios, macrosomia) Prolonged labor (augmented by oxytocin) Chorioamnionitis Abnormal placentation Retained placental tissue Poor perfusion of the uterine myometrium (hypotension)

Uterine atony

Obstetric Complications Obstetric _______ 0.03-0.33% incidence High risk procedure GU injuries are common

hysterectomy

Obstetric Complications _________ ________ Operative delivery Physiologic changes of pregnancy History Highest risk in first week postpartum Prophylaxis? Hydration Early mobilization Pneumatic compression devices Pharmacologic prophylaxis in high risk patients

Thromboembolic events