OB: Labor Analgesia Flashcards by Linsley Lloyd

Many _____ & ____ _____ throughout history
- Princess and the Pea
- Upper class women have more pain than “savages”
- “Modern women” have more pain than “savages” because “the church and culture taught them to expect it.”

social and medical connotations

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Less than ___% of pregnancies end on the EDD

10%

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In the US approximately ____% occur preterm (<37 weeks) and 5-7% remain undelivered postterm (>42 weeks)

13%

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Cause for onset of labor

remains unknown

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Three (4) stages of labor

Dilation
Expulsion
Placental
(4th) Stabilization

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Stage 1 has three phases
_____ (0-3 cm)
_____ (4-7 cm)
_____ (8-10 cm)

Latent (0-3 cm)
Active (4-7 cm)
Transitional (8-10 cm)

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First stage of labor
__________ pain
_____ level

visceral
T10 - L1

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Second stage of labor
_____ pain
_____ level

Somatic
S2 - S4

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3 components of labor and delivery (3 P’s)

Powers (uterine contraction, maternal voluntary expulsive efforts)
Passageway (pelvis, soft tissues)
Passenger (fetus)

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Passenger - Fetal size and relationship of the fetus to the ____ ____ affect labor progress

maternal pelvis

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Passenger - lie (3)

Transverse
Oblique
Longitudinal

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Passenger - presentation (3)

Cephalic
Breech
Shoulder

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Passenger - P____

Position

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Station - Palpation of the ____ ____ ____ of the fetus

leading bony point

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3 general methods to control pain in labor

nonpharmacologic
neuraxial
non-neuraxial

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Nonpharm methods

Antenatal health education
Support persons
Relaxation techniques
Massage
Reflexology
Hypnosis
Aromatherapy
Acupuncture/acupressure
Hydrotherapy
TENS
Sterile water injection

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neuraxial methods

Epidural
Spinal
CSE

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non-neuraxial methods

Nitrous
Volatile anesthetics
Non-opioids
Opioids

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Sterile Water Injection

Injection of small ___ ____ of sterile water

0.1mL blebs

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Sterile Water Injection

Ideal number of injections ____

unknown

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Sterile Water Injection

Counterirritation - ____ ____ theory

Gate control

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Sterile Water Injection

Not recommended for ____ ____

active labor

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Inhalational Agent for analgesia -

Nitrous
___% blended
Used much more often in Canada & UK
____ effective than epidural
____ nausea

50%
Less
More

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Inhalational Agent for analgesia -

Volatile anesthetics
Smooth muscle _____
Provider/equipment _____

relaxation
limitations

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Non-opioid Analgesia and Sedation - Acetaminophen ____ IV decreased VAS scores and need for rescue meds ___ ____ in neonates

1 g No change

Non-opioid Analgesia and Sedation - ______ Few studies Can increase HR/BP

Ketamine

Non-opioid Analgesia and Sedation - Benzodiazepines ______ cross placenta Maternal ____

easily amnesia

Non-opioid Analgesia and Sedation - Phenothiazines ____ cross placenta ____ fetal HR variability

Easily decrease

Non-opioid Analgesia and Sedation - Barbiturates ____ cross placenta Neonatal ____

Easily depression

Opioid Analgesia Meperidine Most used and researched _____ analgesia Reduced _____ Neonatal depression

poor variability

Opioid Analgesia Morphine ____ satisfaction than meperidine More requests for _____ doses

Less additional

Opioid Analgesia Fentanyl Good pain relief Context-sensitive half-life requires ____ ____ mom/baby after prolonged use

extended monitoring

Opioid Analgesia Remifentanyl/Alfentanyl/Sufentanyl ____ ____ ____ to support use

No strong evidence

Neuraxial Analgesia for Labor Indications ____ request

Maternal

Neuraxial Analgesia for Labor Indications Anticipation of ____ delivery (malposition, multiple gestation…)

operative

Neuraxial Analgesia for Labor Indications ____ _____/____ risk for precipitous, high-risk or emergency delivery (pre-e, nonreassuring FHT…)

Obstetric disease/High

Neuraxial Analgesia for Labor Indications _____ conditions (obesity, difficult airway, MH)

Maternal

Neuraxial Analgesia for Labor Indications Maternal _____ disease

coexisting (severe cardiac or respiratory disease)

Absolute Contraindications of Neuraxial Analgesia for Labor

Patient refusal Uncooperative patient Moderate/severe bleeding conditions Anticoagulation Uncontrolled hemorrhage/severe hypovolemia Epidural site infection Unskilled/inexperienced anesthesia provider

Relative Contraindications of Neuraxial Analgesia for Labor

Elevated ICP Documented LA allergy Untreated systemic infection Preexisting neurologic deficit Informed consent difficulties (language) Severe fetal depression Severe maternal cardiac disease Skeletal abnormalities Some types of back surgery

Neuraxial Technique Choice - Maternal coexisting disease such as (2)

Severe valvular heart disease Intracranial mass/neurologic disease

Neuraxial Technique Choice - Obstetric considerations such as (3)

Likelihood of surgical delivery Stage of labor Fetal abnormalities

Neuraxial Technique Choice - Anesthetic considerations such as (3)

Difficult airway Timing PDPH

Benefits of Epidural Analgesia - Decreased maternal ______

catecholamines

Benefits of Epidural Analgesia - Decreased maternal ______

hyperventilation

Benefits of Epidural Analgesia - Ability to rapidly transition to ___ ____ for emergencies

epidural anesthesia

Preparation:

eval and consent aspiration prophylaxis labs IVs monitoring positioning emergency drugs and equipment

Evaluation and Consent History Relevant _____ exam _____ consent Recognition of ____ _____

physical informed risk factors

Aspiration Prophylaxis ____ Liquids All pregnant women are considered a ….. ____ ____ ASA guidelines – no solid food during ____ labor, no consensus on amount of liquid What other factors could increase risk of aspiration?

Clear full stomach active

Labs

plts? crossmatch? generally not needed

monitoring

BP FHT EKG? generally not needed, but must be used during epidural Pulse ox?

Emergency Drugs & Supplies

pressors airway

Choice of Local Anesthetics - Bupivacaine Advantages _____ block _____ duration of action Lack of _____ Limited placental transfer

Differential Long tachyphylaxis

Choice of Local Anesthetics - Bupivacaine Disadvantages _____ onset time ____ and ____ toxicity

slower CV and neuro

Choice of Local Anesthetics - Bupivacaine Concentration and dose 0.0625%-0.125% sometimes up to ____ __-__mL

0.25% 12-20

Choice of Local Anesthetics - Lidocaine Not routinely used for maintenance of labor analgesia ____ sensory/motor discrimination Popular as a ____ ___

Little test dose

Choice of Local Anesthetics - Chloroprocaine _____ toxic ___% used for rapid expansion for cesarean

least 3%

Choice of Local Anesthetics - Chloroprocaine ____ duration Increased motor block Interfere with action of ____ & ____ (more in peripheral blocks)

least bupivacaine and opioids

Choice of Local Anesthetics - Ropivacaine Less ____toxic 0.1-0.2% Infusions Less ____ block More _____ Lidocaine works as well and is cheaper

cardio motor expensive

Adjuvants - opioids ____ & ____ opioid receptors Lipophilic > Morphine

Spinal and supraspinal

Adjuvants - epinephrine - Vasoconstriction, decreased clearance - ___ agonism - Disadvantages: ___ agonism (systemic), Increased ___ block

α2 β2 motor

Adjuvants - clonidine α2 agonism ___ ____ in motor block ____ ___ warning in OB

No increase Black Box

Adjuvants - neostigmine In animals ____ ____ in human study Did increase ____

Didn’t work nausea

Analgesia for Vaginal Delivery Second stage of labor pain - ____ fibers at __-__

somatic S2-S4

Analgesia for Vaginal Delivery - Recently placed epidurals may benefit from sacral top offs 5-10mL of ______ ______ with _____ _____ Given in sitting position

0.5-1% Lidocaine with 100 mcg fentanyl

Analgesia for Vaginal Delivery - Instrumented vaginal delivery May need a ____ block __-__ mL of 2% Lidocaine with epi, 0.25% bupivacaine, or 3% 2-chloroprocaine

denser 5-10

Neuraxial Anatomy - Reduction of _____ gap

intervertebral

Neuraxial Anatomy - Widening of hips creates a ___ ____ ____ when lateral

head down tilt

Neuraxial Anatomy - ____ ____ of the pelvis can move the line at the iliac crests higher

Forward rotation

Neuraxial Anatomy - Higher apex of thoracic _____

kyphosis

Neuraxial Anatomy - Engorgement of ____ veins

epidural

Neuraxial Anatomy - Difficult to ID ____ ____

ligamentum flavum

Types of Maintenance (5)

Epidural vs CSE Continuous spinal Intermittent Bolus Continuous Infusion PCEA

Maintenance of Continuous Spinal Analgesia - Narcotic helps provide analgesia without ____ ____ ____

excessive motor block

Maintenance of Continuous Spinal Analgesia Bupivacaine - ___-___ plus 1-2 mcg/mL fentanyl rate of ___-___ Disconnect ____ option May opt for clinician administered top off doses Special caution for sterile technique

0.8-0.125% 1-1.5 mL/hour PCEA

Maintenance of Continuous Spinal Analgesia LABEL ____ LABEL

LABEL

Ambulation in Labor - Advantages (3)

Maternal satisfaction/autonomy Decreased dystocia Decrease risk of DVT

Ambulation in Labor - Disadvantages (5)

Falls with slight motor block Hypotension Increased workload Increased need for top off doses Mediolegal

Side effects - hypotension Up to ___% of parturients Initial dose or bolus _____ blockade Fluid loading or use of prophylactic pressors may decrease risk, but _____ prevents Can lead to fetal _____

80 Sympathetic nothing distress

Side effects - pruritis Time limited __ minutes ____ can sedate ____ 5-10mg Ondansetron

90 Benadryl Nubain

Complications

failed analgesia unintended dural puncture back pain excessive motor block urinary retention maternal hyperthermia fetal heart rate abnormalities accidental IV injection meningitis epidural hematoma/abscess neurologic deficits

OB: Labor Analgesia Flashcards

(81 cards)