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AP: Summer Exam 3 > Obstetric Anesthesia Part 1: Forkner > Flashcards

Obstetric Anesthesia Part 1: Forkner Flashcards

1
Q

What is important information to have about the pregnant patient? (4)

A

Gravida and parity

Gestational age

Cervical exam

Pt specific concerns such as prior cesarean, multiple gestation, placental abnormalities, preeclampsia, etc.

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2
Q

Who is the patient, baby or mom?

A

mom

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3
Q

Define gravida and parity.

A

Gravida = number of times pregnant

Parity = number of babies born

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4
Q

Parity (# # # #)

What does each # represent?

A
  1. full-term births
  2. pre-term births
  3. losses (spontaneous or otherwise)
  4. living children
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5
Q

When is gestational age, or, when full-term starts?

A

38 weeks from gestation

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6
Q

36-37 week babies do worse than 38-39 week babies. True or false

A

True

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7
Q

What information does the cervical exam include?

A

Dilation (from 0 - 10 cm)

Effacement: means thinning of the cervix

Station: means where the baby is relative to the cervix

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8
Q

Immediately after delivery CO increases as much as ____%.

A

80%

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9
Q

Left axis deviation on EKG at term because of displacement of diaphragm by uterus, which also increases the risk of ________.

A

arrhythmia

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10
Q

What is aortocaval compression also called?

A

supine hypotensive syndrome

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11
Q

Gravid uterus in supine women causes aortoiliac compression in ___-___% of women.

However it compresses the IVC in _____% of women.

A

15-20

100%

All women are affected by IVC compression.

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12
Q

What are the respiratory changes in a pregnant woman relating to:

minute ventilation
RR
tidal volume
lung volumes
FRC

A

increased MV
increased RR
increased TV
DECREASED lung volumes
decreased FRC

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13
Q

What is the most common cause of anesthesia-related mortality?

A

Loss of airway

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14
Q

Why is gastric emptying more difficult in the pregnant pt?

A

Upward displacement of the stomach promotes incompetence of the gastroesophageal sphincter.

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15
Q

Gastrin secreted by _____ makes stomach contents more acidic.

A

the placenta

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16
Q

What are the hematologic changes to:

Red blood cell mass
Hb
Hct
Platelet count

A

increases ~20%

normal

normal

platelets decrease

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17
Q

Pregnant women experience _____ coagulation and _______ anti-clotting activity.

A

increased

increased

Note: Pregnant women in a constant state of “chronic compensated disseminated intravascular coagulation” which can easily turn into uncompensated DIC.

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18
Q

Decrease in plasma cholinesterase, not enough to affect succinylcholine clearance significantly. True or false?

A

True

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19
Q

What is the leading cause of mortality worldwide?

What is the leading cause of death according the the CDC?

What is the leading cause of anesthesia-related maternal mortaility?

A

hemorrhage

cardiovascular disease

failure to secure the airway

Note: Maternal mortality is on the rise due to rising cesarean rate and more advanced maternal age/comorbidities.

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20
Q

What are other anesthesia-related maternal mortality causes besides failure in securing the a/w? (3)

A

Pulmonary aspiration of gastric contents

High spinal

Intravascular injection of LA leading to seizure/heart failure

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21
Q

What is the safest and most effective medical intervention for labor pain?

A

lumbar epidural

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22
Q

What are factors that tend to worsen labor pain? (3)

A

OP (occiput posterior) delivery, or, face up

Use of oxytocin

Use of forceps

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23
Q

Opioids cannot be given to the pregnant pt. True or false?

A

False, can be given but are higher risk for baby and mother and are not as effective as epidurals. However, can be best option when epidural is not possible.

Note: If baby gets opioid and cord gets cut, the baby gets the drug and cannot rid of it leading to respiratory depression.

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24
Q

Where does pain during Stage 1 of labor arise from?

A

uteral and cervical visceral pain which is dull, intense, and crampy pain

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25
The uterus and cervix are innervated by spinal levels \_\_\_-\_\_\_\_.
T10 - L1 Note: T10 is level of belly button.
26
Where does pain during stage 2 of labor arise from?
Somatic pain that is sharper, well-localized from the compression of perineal tissue as well as the uterus and cervix as baby passes the vagina.
27
The perineum is innervated at spinal levels ____ - \_\_\_\_.
sacral innervation at S2-S4
28
During stage 3 of labor, sudden, severe pain should cause concern for _____ \_\_\_\_\_\_.
uterine inversion, which rarely occurs
29
What is stage 4 of labor?
Puerperal period from after delivery of the placenta until return to non-pregnant physiology usually 2-6 weeks after delivery. Puerperal: (py-ûrpr-l)
30
What are the layers encountered when placing an epidural?
Skin Subcutaneous Supraspinous ligament Intraspinous ligament Ligamentum flavum Epidural space Dura Arachnoid space Subarachoid space
31
Where does the spinal cord end? Where do we aim to place epidural?
L1 L 2-3 or L 4-5
32
What are contraindications to neuraxial block? (8)
Patient refusal Thrombocytopenia Coagulopathy, incl. recent anticoagulants Infection at site Untreated intravascular bacteremia Presence of foreign bodies/hardware in back Pathologies of spinal cord, eg. spina bifida 2nd stage labor--complete dilation of cervix
33
What pt information do we need before placing an epidural?
Same info needed for obstetric purposes In addition, VS including temp, height, weight, airway Note: Epidural dosing is height-based.
34
What labs are needed at a minimum before placing an epidural? (4)
Hb Hct Platelet count WBC count Need X fishbone info.
35
Shoulders should be as even as possible (if pt scoliotic, as close to neutral position as possible), and relaxed during epidural placement. True or false?
True
36
How often should the BP be cycled during epidural placement?
At a minimum, q5 minutes.
37
At what levels do the iliac crests lie?
L4-L5
38
What are the typical gauges of epidural needles?
17, 18 gauge
39
How deeply should the epidural catheter be placed in cm?
3-5 cm
40
A test dose will confirm correct placement of epidural. True or false?
False. ## Footnote A test dose will tell if the catheter is in in the intrathecal or intravascular space. Dangerous if provider does not realize it is intrathecal!
41
What must you do with an intravascular epidural catheter.
You must always remove it.
42
What is the classic test dose for an epidural?
1.5% lidocaine, 1:200,000 epi, 3ml
43
What symptoms will arise if the epidural is placed intrathecally? (3)
Warmth in bottom Numbness Difficulty moving legs
44
What symptoms will arise if the epidural is placed intravascularly? (4)
Ringing in ears Metallic taste Circumoral numbness Marked increase in HR
45
What local anesthetics are generally used in epidurals? (2)
Ropivicaine Bupivicaine (0.05%) * Both provide excellend sensory block with low motor block * Injected in 3-5ml boluses
46
What is a CSE?
Combined spinal and epidural After the epidural space is found a spinal needle is inserted through the epidural needle.
47
What are the benefits of CSE?
Near immediate pain relief Confirmation of epidural space
48
What are the risks of CSE? (2)
Spinal headache is a small risk Paresthesia possible if brush nerve root--never inject into paresthesia
49
What is a subdural placement of epidural?
Cannot be placed intentionally Ends up between the dura and the arachnoid Risky because of potential exposure to intrathecal space
50
What are the risks of epidural placement? (8)
* Inadvertent dural puncture * Hypotension, which can affect fetus * Failed block * Accidental intravascular or intrathecal injection of epidural drugs * Nerve injury * Prolongation of 2nd stage of labor * Epidural hematoma * Infection
51
What is a "wet tap"? What are physical signs of a "wet tap"?
Accidental dural puncture Back pain, pain shooting in legs, infection Note: Dramatically increases risk of postdural puncture headache, which results from continual leakage of CSF.
52
What is done in the event of a "wet tap"?
Needle removed and epidural placed adjacently, or Catheter is inserted into intrathecal space
53
What are the pros/cons of a "wet tap" turned into an intrathecal?
Pros: No risk of further wet tap Reduced risk of headach Reliable strong block Cons: risk of high spinal
54
What are the indications for c-section? ( 7)
* Arrest of dilation * Arrest of descent * Nonreassuring fetal HR * **Prior C-section** * Cephalopelvic disproportions * Prior surgery involving uterus * Uterine cord prolapse and other serious conditions
55
What is normal fetal HR?
110-160
56
Fetal accelerations are bad indications of fetal movement. True or false?
False, periodic accelerations are good relative to movement, stimulation. Constant tachycardia is bad.
57
What do early decelations of the fetal HR indicate?
Often associated with head compression as fetus move toward delivery.
58
What do variable decelerations of the fetal HR indicate?
Can be associated with imbilical cord prolapse
59
What do late decelerations of the fetal HR indicate?
Suggestive of fetal asphyxia following contractions such that contractions are cutting fetal blood supply. Note: HR decelerations only measurable fetal responses to stress.
60
What types of anesthesia may you used for c-section?
epidural spinal general
61
What level block is needed for c-section?
T4 to block peritoneal stimulation
62
Epidural rather than general anesthesia preferred because: (3)
Mortality rate 17 times greater with general Pt awakens with greater pain with general Fetal transfer of induction drugs
63
All induction drugs transfer to baby. True or false?
False, paralytics do not.
64
What type of neuraxial block is contraindicated in MS patients?
Spinal, though epidural is not.
65
What type of LAs are commonly used for epidurals?
Bupivicaine, 0.5% Lidocaine, 2% Chlorprocaine, 3%
66
What is the first sign of hypotension in the awake patient when administering regional?
N/V Note: Only consider other causes when hypotension is abosolutely ruled out with 3 BP readings. Hypotension is bad for the baby.
67
Immediately after the baby is born, what drug do you administer?
Pitocin, run wide open to reduce uterine atony and hemhorrage. Remember, can bleed 700ml/min!
68
What must you consider during an emergency c-section? (4)
Pt on oxygen ASAP If epidural in place, dose quickly, but divided doses still apply If epidural not functioning, spinal or general If choose general, pt must be draped and prepped PRIOR to induction
69
What must you consider regarding volatile agents after the baby is delivered?
Lower MAC to reduce uterine atony May incorporate nitrous
70
When should you consider redosing the catheter during a c-section?
After 1-1.5 hours
71
If severe pain not addressed by neuraxial block develops, some providers consider using \_\_\_\_\_\_\_.
ketamine Note: It preserves a/w reflexes and respirations.
72
Moms are hypo/hyperglycemic when pregnant.
hyperglycemic
73
In STAT c-section, how is the induction performed? (2)
RSI Propofol, Sux used
74
What is a "hot spot" epidural?
unilateral block

AP: Summer Exam 3 (7 decks)

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