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OB Test 2 > Pain Pathways > Flashcards

Pain Pathways Flashcards

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1
Q

What is the first stage of labor?

A

0-10 cm dilation of the cervix

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2
Q

What causes pain in the first stage of labor?

A

Distention of the lower uterine segment, upper vagina, and dilation of the cervix

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3
Q

What nerve fibers transmit pain in stage 1 of labor?

A

Visceral afferent C fibers that accompany the sympathetic nerves (join the sympathetic chain at L2-L3) and enter the spinal cord at the T10 - L1 segments

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4
Q

What is the second stage of labor?

A

Full cervical dilation through the delivery of the fetus

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5
Q

What causes pain during the second stage of labor?

A

Distention of pelvic floor, vagina and perineum

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6
Q

What never fibers transmit pain in the second stage of labor?

A

Somatic nerve fbers which enter the spinal cord at S2-S4 segments through the pudendal nerve
-afferent nerve fibers

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7
Q

Which nerve root contains afferent nerve fibers?

A

Dorsal nerve root

AKA posterior nerve root

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8
Q

When is a pudendal nerve block performed?

A

Immediately before delivery

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9
Q

What type of delivery can pudendal block be used for?

A

Spontaneous vaginal delivery and low/outlet forceps delivery

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10
Q

What is the success rate of a pudendal block?

A

50%

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11
Q

What is a pudendal block NOT adequate for?

A

Mid forceps delivery
Post partum exam/manual exploration of the uterine cavity
Repair of upper vagina and cervix

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12
Q

What type of failure can occur with a pudendal block?

A

Unilateral or bilateral failure

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13
Q

Can a pudendal block prolong labor? If so, what stage?

A

It can prolong the second stage of labor

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14
Q

Where does a paracervical nerve block block transmission?

A

Blocks transmission through the paracervical ganglion

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15
Q

What is another name for the paracervical ganglion?

A

Frankenhausers ganglion (uterovaginal plexus)

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16
Q

Does a paracervical block prolong labor? If so, what stage?

A

No

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17
Q

During the first stage of labor how well does a paracervical block work? Second stage?

A

Satisfactory analgesia during the first stage of labor in 50-75% of parturients.
Does not help with second stage

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18
Q

Why is the paracervical block only used in 2-3% of vaginal delveries in the U.S?

A

Fear of fetal bradycardia, the most common fetal compliation

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19
Q

If fetal bradycardia lasts how long, would you most likely change to a stat c-section?

A

> 10 minutes

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20
Q

Where is the paracervical block performed?

A

At the lateral vaginal fornix at about 4 and 8 o’clock

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21
Q

SNS stimulation produced by pain results in higher levels of what in the plasma of mom?

A

Catecholamines

-especially epinephrine

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22
Q

What effect does this increased catecholamines have in the mom, and baby?

A

It increases CO and peripheral vascular resistance, and decreases uteroplacental blood flow

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23
Q

What effect does neuraxial analgesia have on maternal catecholamine concentration?

A

In reduces concentration by 50%

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24
Q

Does neuraxial analgesia also reduce fetal catecholamine concentrations?

A

No

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25
What effect does prepardness have on pain scores?
Childbirth prepared moms have decreased pain scores compared to those with no preparation
26
Intermittent labor pain has what effect on the respiratory system?
Stimulation | -periods of intermittent hyperventilation
27
Without supplemental oxygen how does the body compensate for these intermittent periods of hyperventialtion?
Hypoventilation between contractions that can result in transient episodes of maternal and fetal hypoxemia
28
Are these periods of intermittent respiratory and cardiovascular stimulation d/t labor pain well tolerated?
Generally in healthy paturients and their fetusus, yes, with normal uteroplacental perfusion
29
What may help prevent compromise of this respiratory and cardiovascular stimulation r/t labor pain with maternal or fetal disease?
Good analgesia
30
What effect does labor pain, anxiety and emotional distress have on the GI system?
It increases gastrin release and inhibits the segmental and suprasegmental reflexes of GI motility -results in an increase is gastric acid and volume
31
What effect does labor pain, anxiety and emotional distress have on the urinary system?
It inhibits the segmental and supresegmental reflexes of urinary motility -restuls in delay in bladder emptying
32
Does maternal labor pain have a direct effect on the healthy fetus? Why?
No it does not, because of the absence of direct neural connections from the mom to the fetus
33
In what 3 ways CAN maternal labor pain affect uteroplacental perfusion though?
1. uterine contraction frequency and intensity, by the effect of pain on the release of oxytocin and epinephrine 2. uterine artery vasoconstriction, the the effect of pain on the relase or NE and Epi 3. maternal oxyhemoglobin desaturation from intermittent hyperventilation followed by hypoventilation (Effects are well tolerated in normal circumstances, but fetal well-being may be affected in situation if limited uteroplacental reserve)
34
What is Stadol?
Butorphanol | -opioid agonist/antagonist (kappa/mu)
35
When can Stadol be used with labor?
Early labor if birth is expected to be 4 hours away
36
What is the dose and route of Stadol?
1-2mg IV
37
Does Stadol cross the placenta?
Yes, rapidly
38
Butorphanol potency vs Dermerol
Stadol is more potent than Demerol (which is more potent than Morphine)
39
After how many cm dilated should Stadol not be used?
Do not give after 8 cm of dilation
40
Does Stadol have a ceiling effect? If so, on what?
Stadol has a ceiling effect on analgesia and respiratory depression
41
What aspects of taking a history would indicate a possible bleeding concern for neuraxial anesthesia?
``` Easy bruising Excessive bleeding from gums Family Hx of bleeding problems Medicatons that increase bleeding risk -Rx, ASA, The Gs ```
42
What laborary tests could be performed to assess for bleeding problems?
``` Plt count PT, PTT Fibrinogen Bleeding time Thromboelastography Platelet function analyzer ```
43
What is the concern with possible bleeding risk and neuraxial anesthesia?
Epidural hematoma
44
What are absolute contraindications to neuraxial anesthesia?
Patient refusal | Frank coagulopathy
45
What heparin prophylaxis is NOT a contraindication to neuraxial anesthesia?
Standard unfractionated heparin SQ
46
If patient IS on standard unfractionated heparin prophylaxis, what steps should you take to ensure safety of neuraxial anesthesia?
``` Verify prope dose is being used Meausre Plt count with prolonged therapy Atraumatic needle placement Early placement of epidural cathetier Use midline technique Use small need and cathetier Use saline to distend epidural space before inserting catheter ```
47
Can neuraxial anesthesia be used for a patient receiving low molecular weight heparin prophylaxis?
Neuraxial anesthesia can be used 10-12 hours after last dose of LMWH
48
When can LMWH prophylaxis be resumed after surgery?
6-8 hours after surgery
49
When should an epidural catheter be removed if pateint is receiving LMWH prophylaxis?
At least 10-12 hours after last dose
50
When can LMWH be resumed after removal of epidural catheter?
At least 2 hours after catheter removal
51
Can neuraxial anesthsia be used if mother is on HIGH doses of LWMH?
Yes, but not till 24 hours after last dose
52
In a patient who is receiving high dose or twice daily doses of LMWH when can the first postop dose be given?
Not till 24 hours after surgery
53
When should an epidural catheter be removed before initiating high dose LMWH?
At least 2 hours before initiating therapy
54
Can neuraxial anesthesia be used in a patient with thrombocytopenia?
``` Possibly, it's a clinical judgement -evidence of bleeding -plt count -recent change in plt count quality of plts -adequacy of other coag factors -weigh risks vs benefits ```
55
Is there a significant bleeding risk from placing an epidural in a patient taking ASA?
Not if they are taking normal doses
56
What is the life of a platelet?
7-10 days
57
Why does neuraxial anesthesia lead to hypotension?
Vasodilation
58
Is there a difference between phenylephrine use and ephedrine use as far as maternal hypotension or HTN and neonatal apgar scores?
No
59
Which vasopressor causes more bradycardia?
Phenylephrine
60
Which vasopressor causes lower umbilical arterial pH?
Ephedrine
61
Which is the favored vasopressor currently?
Phenylephrine
62
What dose of ephedrine can be used d/t fetal acidosis?
Less than 30mg
63
What causes nausea/vomiting with hypotension?
The area post rema in the medulla in the chemoreceptor trigger zone becomes ischemic
64
What can be given preoperatively to help prevent the N/V d/t hypotension?
Zofran | -can give up to 16 mg to an adult
65
What needs to be monitored with Zofran use?
Monitor for QT prolongation
66
What can exacerbate this QT prolongation risk with Zofran use?
Bradycardia from phenylephrine
67
What causes a post dural puncture headache? Time frame?
CSF leakage through the dural hole -leak can exceed rate of production (20 mL/hr) Within 5 days of lumbar puncture
68
What are the symptoms associated with PDPH?
``` Nausea Vomiting Neck stiffness Ocular Auditory ```
69
What occurs due to the loss of CSF?
Low CSF presure > loss of cushioning effect of CSF
70
What specifically causes the pain associated with PDPH?
Cerebral vasodilation occurs to increase cerebral blood flow in order to fix it
71
What patient risk factors increase risk of PDPH?
``` Age <40 y Gender Vaginal delivery Morbid obesity Air travel (within a couple days) Hx of PDPH Multiple dural punctures ```
72
What are the risk factors for PDPH related to neuraxial technique?
Cutting needle > pencil point Larger size needle Quinke bevel perpendicular to long axis of the spine (parallel reduces risk)
73
What neuraxial techniques have conflicting evidence on the risk of PDPH?
``` Midline vs paramedian Skin prep Air vs NaCl in loss of resistance Choice of LA Combined Spinal Epidural Continuous spinal anesthesia ```
74
What percentage of law suits pertained to PDPH?
14% - Whitacre 1.5% - Quinke 11-12%
75
What PDPH treatment has the greatest liklihood of success?
Epidural blood patch | -can be repeated if the first didn't do it
76
What are other treatments of PDPH?
``` Psychological support Bed rest Caffeine Epidural morphine Epidural/intrathecal saline ```
77
Why may caffeine help with PDPH?
It is a cerebral vasoconstrictor - transient benefit - side effects: arrhythmias, SZ
78
What side effect could epidural morphine have?
May predispose to respiratory depression
79
Why may epidural/intrathecal saline help PDPH?
If given continuously, fills the space
80
What patient position should a epidural blood patch be placed?
Lateral | -sitting up is when HA hurts
81
How much blood is used in a blood patch?
10-20mL of patients own blood
82
How long does a patient need to lay after a blood patch is placed?
1-2 hours
83
What is the optimal timing for administration of a blood patch?
Not adequately studied - observational studies suggest that failure is more likely if the patch is perfomred within 24-48 hours or dural puncture - some stuides say there is a positive correlation with time interval and success (move in tandum, further way from puncture more success)
84
What are the contraindications of a blood patch?
Coagulopathy Local infection Increased ICP Patient refusal
85
What are the complications of a blood patch?
``` Infection/hematologic - meningitis Seeding of cancer cells Neurological: -low back pain -subdural hemorrhage Arachnoiditis Radicular back pain Pneumoencephalus Seizures Meningeal irritation Cranial nerve palsy ```
86
What is the third stage of labor?
Begins with birth of the infant and ends with delivery of the placenta
87
What are is another name for the stages of labor (besides the number)
First: cervical stage Second: pelvic stage Third: placental stage
88
What is the fourth stage of labor?
Some identify a fourth stage of labor, it is the first postpartum hour
89
What is most likely to occur in the fourth stage of labor?
Postpartum hemorrhage
90
When is labor said to begin?
When contractions occur regularly and the cervix begins to change
91
Describe the 2 phases of stage 1 labor
Phase 1: The latent phase -onset of labor with regular contractions and slight cervical changes Phase 2: The active phase -begins when the cervix begins to change rapidly -usually when cervix dilates 2-3 cm -during this phase cervix usually dilates 1.2 cm per hr
92
What is considered a preterm birth?
Before 37 weeks gestation
93
What is considered a post-term birth?
42 weeks gestation

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