Unit 3 Module 5 Anes for Delivery (Exam 3) Flashcards
(210 cards)
1
Q
Which of the following best defines macrosomia?
A. Low birth weight infant
B. Fetus with excessive birth weight
C. Premature fetus
D. Small for gestational age
A
B. Fetus with excessive birth weight
Slide 4
2
Q
What does the acronym TOLAC stand for?
A. Trial of labor after cesarean
B. Total obstetric labor and care
C. Term of late active contractions
D. Time of labor and cesarean
A
A. Trial of labor after cesarean
For 2nd or 3rd baby
Slide 4
3
Q
VBAC refers to:
A. Vaginal bleeding after cesarean
B. Vacuum birth after complications
C. Vaginal birth after cesarean
D. Vaginal birth and cesarean
A
C. Vaginal birth after cesarean
Slide 4
4
Q
PPH is a serious concern in the postpartum period. What does it stand for?
A. Prenatal pulmonary hypotension
B. Postpartum hemorrhage
C. Partial placental hemorrhage
D. Parenteral hormone hypersecretion
A
B. Postpartum hemorrhage
Slide 4
5
Q
SAB can refer to which of the following in clinical practice?
Select 2
A. Spontaneous abortion
B. Surgical abdominal birth
C. Subarachnoid block
D. Suprapubic aspiration
A
A. Spontaneous abortion
C. Subarachnoid block
Slide 4
6
Q
Which of the following is an example of operative vaginal delivery?
Select 2
A. Cesarean section
B. Spontaneous vaginal delivery
C. Vacuum-assisted delivery
D. Induction with oxytocin
E. Forcep assisted delivery
A
C. Vacuum-assisted delivery
E. Forcep assisted delivery
Less use these days partly due to medico-legal concerns
Slide 5
7
Q
Operative vaginal delivery can shorten the __________ stage of labor.
A. First
B. Second
C. Third
D. Latent
A
B. Second
Literally pulling the baby out as quickly as possible
Slide 5
8
Q
Which of the following are indications for operative vaginal delivery?
Select 3
A. Arrested descent
B. Maternal exhaustion
C. Breech presentation
D. Nonreassuring fetal heart rate
E. Chorioamnionitis
A
A. Arrested descent
B. Maternal exhaustion
D. Nonreassuring fetal heart rate
Slide 5
9
Q
A denser sensory block may be needed for operative vaginal delivery and can be achieved using higher concentration local anesthetic such as __________.
A. Lidocaine 0.25%
B. Ropivacaine 0.2%
C. Bupivacaine 0.0625%
D. Lidocaine 2%
A
D. Lidocaine 2% 5-10ml
Through a in-situ epidural catheter
Slide 5
10
Q
Which of the following local anesthetics is appropriate for achieving a denser block during operative vaginal delivery?
A. Lidocaine 1%
B. Ropivacaine 0.2%
C. 2-Chloroprocaine 2–3%
D. Bupivacaine 0.0625%
A
C. 2-Chloroprocaine 2–3% 5-10ml
May not be as dense as lidocaine, but does have a quicker onset
Slide 5
11
Q
True or false
Cesarean section is the most common surgery in the US.
A
True!
Slide 6
12
Q
What is the approximate national cesarean delivery rate in the U.S.?
A. 30%
B. 40%
C. 20%
D. 50%
A
A. 30%
Slide 6
13
Q
Compared to vaginal delivery, maternal mortality during cesarean delivery is:
A. Equal
B. 2 times greater
C. 5 times greater
D. 10 times greater
A
D. 10 times greater
Slide 6
14
Q
Which of the following is not a primary anesthesia-related cause of maternal mortality during cesarean delivery?
A. Pulmonary aspiration
B. Failed intubation
C. Uterine atony
D. Inadequate ventilation
A
C. Uterine atony
All related to anesthesia
* Pulmonary aspiration - full stomachs/aspiration risk
* Failed intubation - edemetous airway, “sneaky bad airways”
* Inadequate ventilation when requiring GETA
Slide 6
15
Q
Which of the following are known contributors to rising cesarean delivery rates?
Select 4
A. Increased maternal age and delayed childbirth
B. Increased use of forceps and vacuum deliveries
C. Obesity
D. Increased use of electronic FHR monitoring
E. Fewer TOLAC attempts
F. Increased access to midwifery care
A
A. Increased maternal age and delayed childbirth
C. Obesity
D. Increased use of electronic FHR monitoring
E. Fewer TOLAC attempts
Slide 7
16
Q
Which factors have contributed to a decrease in vaginal delivery attempts and an increase in cesarean births?
Select 4
A. Increased fetal macrosomia
B. Decreased instrumented vaginal deliveries
C. Improved neonatal outcomes with vaginal delivery
D. Concern for malpractice litigation
E. Increased use of spontaneous vaginal delivery
F. Increased labor inductions
A
A. Increased fetal macrosomia
B. Decreased instrumented vaginal deliveries
D. Concern for malpractice litigation - statue of limitations for 18years!!
F. Increased labor inductions -“controversial methods”
Slide 7
17
Q
True or False
Maternal request alone can be considered a valid indication for a cesarean delivery.
A
True
Patients will request to go to sleep, even though it is highly not recommended..but ultimately their choice.
Slide 8
18
Q
True or False
Chorioamnionitis is an absolute contraindication to cesarean delivery.
A
False
Slide 8
19
Q
Which of the following hemorrhagic conditions may warrant a cesarean section?
Select 3
A. Cervical insufficiency
B. Placental abruption
C. Hemophilia
D. Vasa premoria
E. Uterine rupture
F. Placenta previa
A
B. Placental abruption
E. Uterine rupture
F. Placenta previa
Antepartum/intrapartum hemorrhage
Slide 8
20
Q
Which maternal conditions listed below could directly prompt a decision for cesarean delivery?
Select 4
A. Pre-eclampsia
B. Multiple gestation
C. Maternal obesity
D. Failed induction of labor
E. Previous classical uterine incision
F. Premature rupture of membranes
A
A. Pre-eclampsia Deteriorating maternal condition
B. Multiple gestation
D. Failed induction of labor
E. Previous classical uterine incision
Slide 8
21
Q
True or false
Active herpes simplex virus (HSV) lesions during labor are an indication for vaginal delivery.
A
False
Active HSV lesions are an indication for cesarean to prevent neonatal transmission.
Slide 8
22
Q
__________ is a common indication for cesarean delivery when labor has failed to progress despite adequate contractions.
A. Inactive HSV lesions
B. Arrested labor
C. Previous pfannenstiel incision
D. Maternal anorexia
A
B. Arrested labor
Slide 8
23
Q
Fetal Causes of Cesarean section
A __________ cord is an emergency indication for cesarean delivery due to risk of cord compression and fetal hypoxia.
A. Short
B. Nuchal
C. Prolapsed
D. Coiled
A
C. Prolapsed
Slide 9
24
Q
Fetal intolerance of labor may present as a __________ fetal heart rate pattern.
A. Sinusoidal
B. Category I
C. Category II
D. Category III
A
D. Category III
Slide 9
25
A fetus in breech, transverse, or face presentation may be delivered by cesarean due to __________.
A. Cystitis
B. Gestational Diabetes
C. Malpresentation
D. Microsomia
C. Malpresentation
## Footnote
Slide 9
26
Which of the following are fetal indications for cesarean delivery?
Select 3
A. Suspected macrosomia
B. Category II fetal heart tracing
C. Fetal intolerance
D. Prematurity
E. Accelerations
A. Suspected macrosomia
C. Fetal intolerance
D. Prematurity
## Footnote
Slide 9
27
# Match Grades of C-section to the definition of maternal/fetal compromise
**Grades:**
Grade 1 - Emergency
Grade 2 - Urgent
Grade 3 - Scheduled
Grade 4 - Elective
**Descriptions:**
A. At a time to suit the woman and maternity team.
B. Immediate threat to life of woman or fetus.
C. Maternal or fetal compromise that is not immediately life-threatening.
D. Needing early delivery but no maternal or fetal compromise.
Grade 1 → B (Emergency – Immediate threat to life of woman or fetus)
Grade 2 → C (Urgent – Maternal/fetal compromise, not immediately life-threatening)
Grade 3 → D (Scheduled – Early delivery needed, no compromise)
Grade 4 → A (Elective – Planned at a convenient time)
## Footnote
Slide 10
28
The anesthesia plan for an unscheduled cesarean delivery depends on multiple factors including **fetal condition, maternal comorbidities**, and __________.
A. Fetal presentation
B. Patient insurance
C. Urgency of delivery
D. Neonatal APGAR score
C. Urgency of delivery
## Footnote
Slide 11
29
One consideration in anesthesia planning is whether or not there is an ______________ epidural catheter.
A. Intermittent
B. In-situ
C. Intraosseous
D. Implanted
B. In-situ
## Footnote
Slide 11
30
Which of the following best reflects the maternal wishes in anesthesia planning for an unscheduled cesarean section?
A. Maternal wishes are irrelevant in emergencies and should not be considered.
B. Maternal preferences are only considered when no comorbidities are present.
C. Maternal wishes should be considered when clinically appropriate and time allows.
D. Maternal wishes always override clinical urgency and fetal status.
C. Maternal wishes should be considered when clinically appropriate and time allows.
## Footnote
Slide 11
31
# Skin Incisions
Which skin incision is most commonly associated with **less postoperative pain 😣 and a lower risk of uterine rupture/dehiscence**?
A. Classical vertical incision
B. Low vertical/midline incision
C. Low transverse incision
D. Fundal incision
C. Low transverse incision
"Traditional skin incision"
| "Pfannenstiel incision"
## Footnote
Slide 12
32
Which of the following is an advantage of the **low vertical/midline incision**?
A. Least postoperative pain
B. Cosmetic appeal
C. Rapid access for fetal delivery
D. Decreased risk of hernia
C. Rapid access for fetal delivery
## Footnote
Slide 12
33
Which of the following are true about low vertical/midline incisions for cesarean delivery?
Select 2
A. Associated with increased risk of umbilical hernia
B. Least painful of the incision options
C. Extends from umbilicus to pubic symphysis
D. Lower instances of dehiscence
A. Associated with increased risk of umbilical hernia
C. Extends from umbilicus to pubic symphysis - *lots of layers and muscle getting cut through*
## Footnote
Slide 12
34
# Uterine Incisions
Which of the following are true about the **Low Transverse** uterine incision?
Select 4
A. Uterine rupture risk ~10%
B. TOLAC may be possible
C. Lowest risk of uterine rupture in future pregnancies
D. Less risk of bladder injury
E. May be extended
F. Most commonly used uterine incision
B. TOLAC may be possible
C. Lowest risk of uterine rupture in future pregnancies - smaller incision and lower on uterus
D. Less risk of bladder injury
F. Most commonly used uterine incision
"Most likely if skin incision is low transverse, the uterine incision will be low transverse"
## Footnote
Slide 13
35
Which of the following are true about the **Low Vertical** uterine incision?
Select 2
A. May be extended if needed
B. No risk of uterine rupture
C. Typically made in the upper uterine segment
D. Incision made in the lower uterine segment
E. TOLAC contraindicated
A. May be extended if needed
D. Incision made in the lower uterine segment
## Footnote
Slide 13
36
# True or false
Low vertical uterine incision has a low risk of uterine rupture but is greater than Low Transverse uterine incision
true ;)
When you extend the low vertical incision higher up, the stretched out part of the uterus is thinner and has greater chance of rupture.
## Footnote
slide 13
37
Which of the following are true about the **Classical uterine** incision?
Select 4
A. Made in the lower uterine segment
B. TOLAC is contraindicated
C. Uterine rupture risk is ~10%
D. Most commonly used for elective cesarean sections
E. Upper uterine segment
F. More risk of abdominal adhesions
B. TOLAC is contraindicated
C. Uterine rupture risk is ~10%
E. Upper uterine segment
F. More risk of abdominal adhesions - how the scar is going to heal and the tissue in the abdomen.
## Footnote
Slide 13
38
What is the most common complication associated with cesarean delivery?
A. Infection
B. Hemorrhage
C. Embolism
D. Anesthesia awareness
B. Hemorrhage
## Footnote
Slide 14
39
Which of the following is a known contributor to increased blood loss during C-section under general anesthesia?
A. Vasoconstriction
B. Oxytocin resistance
C. Use of GETA
D. Regional anesthesia
C. Use of GETA
## Footnote
Slide 14
40
Which of the following are considered among the ACOG “Four T’s” for postpartum hemorrhage causes?
Select 4
A. Trauma
B. Thrombocytopenia
C. Tone
D. Tissue
E. Thrombin
F. Tachysystole
A. Trauma
C. Tone -**"the big one and the easiest to fix"**
D. Tissue (retained placenta)
E. Thrombin (coagulopathy)
## Footnote
Slide 14
41
What is the very first priority when managing a maternal hemorrhage?
A. Administer TXA
B. Give oxytocin
C. Call for help
D. Start methylergonovine
C. Call for help **and get blood!**
What blood products do you have available
## Footnote
Slide 15
42
Which of the following are appropriate first-line interventions in the setting of maternal hemorrhage?
Select 3
A. Open IV fluids
B. Start a central line
C. Give albumin
D. Warm the blood products
F. Delay fluids until labs return
A. Open IV fluids
C. Give albumin
D. Warm the blood products - *helps prevent coagulopathies*
## Footnote
Slide 15
43
In the setting of maternal hemorrhage, which of the following is the most appropriate action?
A. Place a single 20G IV and monitor for deterioration
B. Insert a second large-bore IV and prepare for airway management
C. Intubate all hemorrhaging patients immediately
D. Place an epidural catheter to reduce the need for IV access
B. Insert a second large-bore IV and prepare for airway management
## Footnote
Slide 15
44
What is the first-line medication for promoting uterine tone in the setting of postpartum hemorrhage due to uterine atony?
A. Methylergonovine (Methergine)
B. Misoprostol
C. Carboprost (Hemabate)
D. Oxytocin (Pitocin)
D. Oxytocin (Pitocin)
## Footnote
Slide 15
45
Which secondary medications are used to promote uterine contraction and decrease postpartum hemorrhage if pitocin is not working?
Select 2
A. Hemabate
B. Magnesium sulfate
C. Methylergonovine
D. Esmolol
A. Hemabate (IM) - Carboprost tromethamine
C. Methylergonovine (Methergine)
## Footnote
Slide 15
46
Which of the following uterotonic agents is contraindicated in a patient with asthma?
A. Oxytocin
B. Misoprostol
C. Methylergonovine
D. Hemabate
D. Hemabate
**Hemabate is a prostaglandin and can cause bronchoconstriction, making it contraindicated in patients with asthma.**
## Footnote
slide 15
47
Methylergonovine (Methergine) is contraindicated in which of the following conditions?
A. Diabetes
B. Hypertension
C. Hypotension
D. Asthma
B. Hypertension
**Methergine is known to cause vasoconstriction and can exacerbate high blood pressure.**
## Footnote
Slide 15
48
# True or False
If a patient has asthma and high blood pressure you could give Methergine, considered the lesser of two evils?
FALSE
Hemabate is considered the "lesser of two evils" per Freeman
## Footnote
Slide 15
49
A 1-gram dose of TXA is typically administered over what time frame?
A. 30 minutes
B. 5 minutes
C. 1 hour
D. 10 seconds
B. ..at least 5 minutes - do not slam in
## Footnote
Slide 15
50
A patient is actively hemorrhaging. She has already received 2 liters of fluid and 2 units of blood. Which of the following should be considered next?
Select 2
A. Wait and observe
B. Administer magnesium sulfate
C. Administer calcium
D. Start a beta-blocker
E. Give coagulation factors
C. Administer calcium - *after about 2-4 units of blood*
E. Give coagulation factors - *after 4units of blood*
*Remember "normal" QBL for C/S is 800-1000ml*
## Footnote
Slide 15
51
# OB interventions
What is the purpose of a **Bakri balloon** in the setting of postpartum hemorrhage?
A. To monitor intrauterine pressure
B. To tamponade uterine bleeding
C. To suction blood from the uterus
D. To dilate the cervix for second-stage labor
B. To tamponade uterine bleeding *by applying direct pressure inside the uterus*
## Footnote
Slide 16
52
The ________ suture is a surgical technique that ***compresses*** the uterus externally to reduce bleeding in cases of uterine atony.
A. McDonald
B. Kocher
C. Lembert
D. B-Lynch
D. B-Lynch
| Wrap it up like a turkey 🦃
## Footnote
Slide 16
53
# True or false
Uterine artery ligation can affect future pregnancies
True
## Footnote
Slide 16
54
__________ is considered the definitive surgical treatment for refractory postpartum hemorrhage when all other interventions have failed.
A. Uterine artery embolization
B. Uterine massage
C. Hysterectomy
D. Balloon tamponade
C. Hysterectomy
## Footnote
Slide 16
55
# C-section complications
Which of the following is a possible complication involving the neonate during cesarean delivery?
A. Fetal laceration
B. Bladder prolapse
C. Delayed cord clamping
D. Cervical insufficiency
A. Fetal laceration
## Footnote
Slide 17
56
During cesarean delivery, which structure is most at risk for surgical dissection due to its proximity to the uterus?
A. Rectum
B. Bladder
C. Ovaries
D. Spleen
B. Bladder
**..keep an eye on the foley catheter for blood..**
## Footnote
Slide 17
57
Which of the following are recognized complications of cesarean section?
Select 3
A. Bladder extrophy
B. Wound infection
C. Uterine artery aneurysm
D. Uterocervical laceration
E. Hysterectomy
F. Ectopic pregnancy
B. Wound infection - *everyone gets prophylactic antibiotics*
D. **Uterine/**Uterocervical laceration
E. Hysterectomy - for refractory uterine atony - PPH
## Footnote
Slide 17
58
**Placenta previa** is defined as placental implantation __________.
A. Into the myometrium
B. Below the internal cervical os
C. At the fundus of the uterus
D. Across the cornua
B. Below the internal cervical os
## Footnote
Slide 18
59
Placenta __________ is the term for abnormal placental attachment that does not invade the myometrium but remains adherent to the endometrium.
A. Accreta
B. Increta
C. Percreta
D. Previa
A. Accreta
## Footnote
Slide 18
60
Which of the following best describes **placenta increta**?
A. Placental villi partially invade the myometrium
B. Placental villi adhere to the decidua without invading the myometrium
C. Placental villi penetrate through the entire uterine wall and into adjacent organs
D. Placenta covers the internal cervical os
A. Placental villi partially invade the myometrium
## Footnote
Slide 18
61
# True or False
**Placenta percreta** is the worst type of placental implantation
True!
"the placenta is "enmeshed" through the uterine wall and into other structures like the bladder."
## Footnote
Slide 18
62
Anyone with Placental accreta/increta/percreta are at lower risk for problems and can give birth vaginally
FALSE
**"They need 'all hands on deck', always be GETA, need blood and potential MTP, rapid infuser"**
## Footnote
Slide 18
63
Which of the following is a serious risk in future pregnancies after previous C-section?
A. Cervical dysplasia
B. Uterine rupture
C. Vaginal stenosis
D. Umbilical cord prolapse
B. Uterine rupture
**and Hemrrohage**
## Footnote
Slide 18
64
# Preventing unplanned c-section
Which of the following are strategies to help prevent unplanned cesarean deliveries?
A. Adequate labor analgesia
B. Routine general anesthesia for breech deliveries
E. Allowing prolonged fetal bradycardia before intervening
F. Keeping the same position in response to fetal decelerations
A. Adequate labor analgesia for *TOLAC and instrumented birth*
## Footnote
slide 19
65
Non-reassuring fetal heart tones should prompt interventions such as _____ , IV fluids with pressors, and ______.
Select 3
A. Rapid delivery
B. Continuous oxytocin infusion
C. Position changes
D. Maternal oxygen administration
E. Epidural bolus
F. Correcting maternal hypotension
C. Position changes
D. Maternal oxygen administration
F. Correcting maternal hypotension -**Giving IVF and pressors**
| Keep baby happy
## Footnote
Slide 19
66
Why is **external cephalic version** performed during pregnancy?
A. To induce labor early
B. To reposition the baby
C. To improve maternal circulation
D. To stimulate fetal heart rate variability
B. To reposition the baby **to reduce risk of cesarean delivery, but can cause issues as well**
## Footnote
Slide 19
67
Why is neuraxial anesthesia typically preferred over general anesthesia for cesarean delivery?
A. It reduces maternal cooperation
B. It lowers risk for fetal trauma during delivery
C. It is safer for both mother and baby
D. It is faster than general anesthesia
C. It is safer for both mother and baby
*Most common*
Plan can change depending on scheduled or unscheduled procedure
## Footnote
Slide 20
68
# Anesthesia Preoperative Interview
Which of the following are essential components of the anesthesia preoperative interview for a cesarean delivery?
Select 3
A. NPO status
B. Type of prenatal vitamins used
C. Allergy history
D. Vital signs and fetal heart tones
E. Neuro screening
A. NPO status - (all are full stomach)
C. Allergy history
D. Vital signs and fetal heart tones
## Footnote
Slide 21
69
Which of the following should be included in a focused anesthesia pre-op interview before a cesarean section?
A. Airway, lung and neuro check
B. Heart, Visual acuity check
C. Airway, heart, and lung exam
D. Mental status, heart and lung exam
C. Airway, heart, and lung exam
## Footnote
Slide 21
70
What is the significance of reviewing Gravida (G) and Para (P) during the preoperative anesthesia interview for a cesarean?
A. To determine epidural catheter size
B. To assess maternal nutrition
C. To predict potential complications
D. To calculate NPO status
C. To predict potential complications and understand OB history
**Maternal health and previous anesthetics/cesarean section hx**
## Footnote
Slide 21
71
A __________ is performed if antibodies are found on a Type & Screen, to ensure compatible blood is available.
A. Crossmatch
B. Rhogam test
C. Coagulation panel
D. Serum compatibility assay
A. Crossmatch
## Footnote
Slide 22
72
A ________ & _________ and **platelet count** help guide the anesthesia plan, particularly in patients with preeclampsia or suspected coagulopathy.
Select 2
A. BMP
B. AST
C. Hgb
D. Hct
C. Hgb - Hemoglobin
D. Hct - hematocrit
Have blood available
## Footnote
Slide 22
73
When planning for a cesarean section, it's important to assess whether the IV is __________ and in a reliable location.
A. Flushed
B. Heparin-locked
C. Color-coded
D. Large-bore
D. Large-bore
Two good IV’s for any high-risk C-section!
**Do not put in the AC!!**
## Footnote
Slide 22
74
# How do we know it's high risk?
Which of the following maternal history features indicate a high-risk cesarean delivery?
Select 2
A. First pregnancy
B. Classical uterine incision
C. Multiparity
D. Epidural placement
E. No prior surgeries
B. Classical uterine incision
C. Multiparity
**Multiple previous c-sections, 2nd, 3rd, 4th**
## Footnote
slide 23
75
Which of the following are surgical or anatomic factors that increase the risk of complications during a C-section? (select 2)
A. Multiple gestation
B. Previous spinal anesthesia
C. Classical incision
D. Vaginal bleeding during labor
E. Epidural bolus
A. Multiple gestation
C. Classical incision
## Footnote
Slide 23
76
Which of the following findings should prompt preparation for a high risk C-section? (select 2)
A. Low-risk singleton term pregnancy
B. Scheduled induction with Pitocin
C. Maternal anemia
D. Prior uncomplicated vaginal delivery
E. Abnormal placental implantation
C. Maternal anemia
E. Abnormal placental implantation
## Footnote
Slide 23
77
Which of the following are valid reasons to consider placing a second IV and having blood available before a cesarean?
Select 2
A. Scheduled repeat cesarean at 39 weeks
B. Conversion to general anesthesia
C. Patient has a strong epidural in place
D. Unscheduled cesarean after labor attempt
E. Baby estimated to weigh under 2500g
B. Conversion to general anesthesia
D. Unscheduled cesarean after labor attempt
| and in your Spidey senses tell you
## Footnote
Slide 24
78
# Discuss plan and present options
When discussing the anesthetic procedure, what is important to include?
A) The specific drugs used during the procedure
B) Overview of the procedure and risks
C) The expected length of the procedure
D) The specific surgical steps
B) Overview of the procedure and risks
Get your patient to trust you - your patient is going to be awake.
## Footnote
slide 25
79
Informed consent during the preoperative interview is required for: (select 2)
A) The surgical procedure only
B) Anesthesia administration
C) The use of EKG leads
D) Blood products
B) Anesthesia administation
D) Blood products
## Footnote
slide 25
80
Which of the following is a key maternal concern that should be addressed during the preoperative interview?
A) Understanding the sensation of pushing, pulling, tugging, and pressure
B) Managing postoperative pain only
C) The number of people allowed in the operating room
D) The cost of the surgery
A) Understanding the sensation of pushing, pulling, tugging, and pressure
## Footnote
slide 25
81
Which of the following is important to discuss with the patient before anesthesia administration? (select 2)
A) Family support in the recovery room
B) Blood loss during surgery
C) Presence of support person
D) Possibility of nausea
C) Presence of support person
D) Possibility of nausea
## Footnote
slide 25
82
Where should you place the EKG leads for a patient who would like to do skin to skin after the baby is born?
A. on the chest
B. on the abdomen
C. on the back
D. on the arms
C. on the back
## Footnote
slide 25
83
# True or false
You can spot check the oxygen saturation after baby is born to help facilitate skin to skin as long as the patient is stable
True
| also give the family some space
## Footnote
slide 25
84
# Preparation: Anesthesia Equipment
All of the following are needed for preparation of C-section **except**:
A. Anesthesia machine on and ready
B. Set up when needed
C. Vasopressors readily available
D. Succs and propofol available
E. IV kits
F. Blood tubing
G. Airway equipment
B. set up when needed
Check machine daily or q12 hours
call blood bank and verify if blood is available
Glidescope, bougies, LMAs
## Footnote
slide 26
85
Which preop medications should be given to our C-section patients (select 4)
A. Famotidine
B. Metoclopromide
C. Bicitra
D. Propofol
E. Antibiotics
F. Versed
A. Famotidine
B. Metoclopromide
C. Bicitra
E. Antibiotics (ancef, azithromycin)
## Footnote
slide 27-29
86
Which are true regarding Famotidine (select 3)
A. 10mg IV onset 10min/peak 30-60min
B. H2 receptor antagonist
C. decrease gastric acid production
D. 20mg IV onset 30min/peak 60-90min
E. H1 receptor antagonist
F. increase gastric acid production
| Pepcid
B. H2 receptor antagonist
C. decrease gastric acid production
D. 20mg IV onset 30min/peak 60-90min
## Footnote
slide 27
87
Reglan is a dopmaine D2 antagonist mixed with 5-HT3 antagonist/ 5-HT4 agonist that will
A. decrease gastric pH
B. increases N/V
C. slow gastric emptying
D. increase LES tone
D. increase LES tone
* decrease n/v
* speeds gastic emptying
| also has prokinetic/ promobility
## Footnote
slide 27
88
How soon do you administer Reglan before anesthesia start
A. 10-20min
B. 15-30 min
C. 30-45 min
D. 5-15 min
B. 15-30min
Give diluted, "shoot it into the bag" before anesthesia start
## Footnote
slide 27
89
Symptoms of metoclopromide
A. extrapyramidal
B. intrapyramidal
C. N/V
D. decrease in HR
A. extrapyramidal
## Footnote
slide 27
90
What is Bicitra and what does it do? (select 2)
A. H2 antagonist
B. nonparticulate antacid
C. decrease gastric pH
D. increase gastric pH
E. decrease gastric volume
B. nonparticulate antacid
D. increase gastric pH **-to >6 for 1hr**
* decreases gastric acidity - remember Mendelsson syndrome aka aspiration pneumonitis
## Footnote
slide 28
91
What is the dose of bicitra?
A. 30mL
B. 20mL
C. 50mL
D. 40mL
A. 30mL
## Footnote
slide 28
92
When should you administer Bicitra before going to the OR?
A. 20-40min
B. 15-30min
C. 20-30min
D. 10-15 min
C. 20-30min
## Footnote
slide 28
93
What decides which antibiotics to choose? (select 2)
A. if it is an emergent
B. if parturient is in labor
C. if membranes have ruptured
D. time of surgery
B. if parturient is in labor
C. if membranes have ruptured
## Footnote
slide 29
94
How soon do you give the antibiotics?
A. when surgery starts
B. within 2 hours of surgery start
C. 30min after of surgery start
D. within 1 hour of surgery start
D. 1 hour of surgery start
## Footnote
slide 29
95
How should you administer antibiotics
A. slowly
B. IVP
C. fast
D. over an hour
A. slowly - *d/t risk of nausea and vomiting*
## Footnote
slide 29
96
What are two common antibiotics given for a parturient patient that has been in labor or ruptured membranes?
Select 2
A. Cefazolin 1-2gm IV
B. Cefazolin 2-3gm IV
C. Azithromycin 250 mg IV
D. Azithromycin 500mg IV
B. Cefazolin 2-3gm IV
D. Azithromycin 500mg IV
## Footnote
Slide 29
97
# Intraoperative
When will you monitor FHR and maternal BP with a SAB placement
A. Before only
B. During only
C. After only
D. before and after
D. before and after
## Footnote
slide 30
98
# True or false
You will never use versed for the parturient patient
False
it is discouraged BUT can be beneficial for highly anxious parturient
## Footnote
slide 30
99
Why is versed discouraged in a parturient?(select 3)
A. readily crosses placenta
B. takes too long to work
C. interferes with bonding
D. increases anxiety
E. amnesia
A. readily crosses placenta
C. interferes with bonding
E. amnesia
## Footnote
slide 30
100
A FiO2 of _______ does not improve fetal oxygenation.
A. 0.5-0.6
B. 0.4-0.5
C. 0.6-0.7
D. 0.35-0.4
D. 0.35-0.4
## Footnote
slide 30
101
FiO2 of ___ in preparation for GETA is ideal
A. 1.0
B. 0.5
C. 0.35
D. 0.4
A. 1.0
## Footnote
slide 30
102
# True or false
Oxygen is required to be on the patient during a C-section
False.
May not be necessary during elective c-section
## Footnote
slide 30
103
# Neuraxial
What are 3 advantages of neuroaxial anesthesia?
Select 3
A. maternal discomfort
B. mother is awake
C. protected airway
D. early bonding
E. presence of support person
B. mother is awake
D. early bonding
E. presence of support person
*also use of opioids (morphine (100-150mcg and fentanyl 5-10mcg into spinal)*
*Morphine 3mg into pre-existing epidural after delivery*
## Footnote
slide 31
104
What are the 2 disadvantages of neuroaxial anesthesia?
Select 2
A. no use of morphine or fentanyl
B. hypertension
C. maternal discomfort
D. hypotension
C. maternal discomfort
D. hypotension
## Footnote
slide 32 and 33
105
What are the factors that cause maternal discomfort during a C-section with neuroaxial anesthesia (select 4)
A. nausea
B. shoulder/chest pain
C. sharp equipment
D. cool cold irrigation
E. pulling/ tugging
A. nausea
B. shoulder/chest pain- *from referred utering exteriorization 🐘*
D. cool cold irrigation- *under surface of diaphragm **(C3-5)** causing pain and nausea*
E. pulling/tugging
## Footnote
slide 32
106
What is the shoulder/chest pain caused by in a c-section
A. CO2 gas
B. uterine exteriorization
C. placenta previa
D. delivery of baby
B. uterine exteriorization
"elephant on chest"
## Footnote
slide 32
107
Hypotension is caused by a sympathetic blockade from neuraxial anesthesia, which then ________
A. decreases SVR
B. increases SVR
C. decreases Afterload
D. Benzold-Jarisch reflex deactivated
A. decreases SVR
* decreases preload
* Bezold-Jarisch reflex ACTIVATED
## Footnote
slide 33
108
The Benzold-Jarish reflex is caused by mechanoreceptors in the __ responding to ____
A. diaphragm, extra stretch
B. LV, extra stretch
C. diapragm, low stretch
D. LV, low stretch
D. LV; low stretch
## Footnote
slide 33
109
What is the **triad** associated with Bezold- Jarisch reflex
A. vasoconstriction, hypotension, bradycardia
B.vasodilation, hypotension, tachycardia
C. vasodilation, hypotension, bradycardia
D. vasoconstriction, hypertension, tachycardia
C. vasodialtion, hypotension, bradycardia
## Footnote
slide 33
110
What is the primary mechanism of action of Ondansetron (Zofran) in preventing hypotension?
A) Inhibits activation of the BJR by antagonizing 5-HT3 receptors
B) Blocks alpha-adrenergic receptors to cause vasoconstriction
C) Increases heart rate by stimulating beta-adrenergic receptors
D) Decreases vascular permeability
A) Inhibits activation of the BJR by antagonizing 5-HT3 receptors
## Footnote
slide 34
111
When should Ondansetron (Zofran) 4 mg IV be administered to prevent hypotension during a spinal anesthesia procedure?
A) Immediately after the procedure
B) 5 minutes before spinal anesthesia
C) 10 minutes after spinal anesthesia
D) At the time of hypotension onset
B) 5 minutes before spinal anesthesia
## Footnote
slide 34
112
What is the effect of Phenylephrine 25-50 mcg/min infusion in preventing hypotension during spinal anesthesia?
A) It induces vasodilation to lower blood pressure
B) It stimulates the beta-adrenergic receptors to increase heart rate
C) It causes vasoconstriction, helping to prevent hypotension
D) It inhibits the 5-HT3 receptors to prevent bradycardia
C) It causes vasoconstriction, helping to prevent hypotension
## Footnote
slide 34
113
Which of the following interventions helps prevent aortocaval compression and supine hypotension syndrome?
A) Placing the patient in a left uterine displacement
B) Administering Ephedrine bolus doses
C) Raising the head of the bed by 30 degrees
D) Using a higher dose of Ondansetron
A) Placing the patient in a left uterine displacement
## Footnote
slide 34
114
Which of the following best describes the position that can help prevent hypotension during spinal anesthesia?
A) Head down position (Trendelenburg)
B) Left uterine displacement
C) Full supine position
D) Slight head-up position (10 degrees)
D) Slight head-up position (10 degrees)
## Footnote
slide 34
115
How many large bore IVs should a patient have
A. 4
B. 2
C. 3
D. 1
D. 1
1 vs. 2 IVs
## Footnote
slide 35
116
When will rapid redistribution occur with cystalloid administration
A. 20-30min
B. 30-40min
C. 15-20min
B. 10-20min
A. 20-30min
## Footnote
slide 35
117
Which colloids are available for administration to manage hypotension (select 2)
A. Dextrose
B. Lactated RIngers
C. Albumin
D. hetastarch
C. Albumin
D. hetastarch
## Footnote
slide 35
118
Why would albumin be picked over hetastarch (select 2)
A. Hetastarch is expensive
B. Albumin has been around longer
C. risk for anaphylaxis for hetastarch
D. patient do better with hetastarch
A. Hetastarch is expensive
C. risk for anaphylaxis for hetastarch
## Footnote
slide 35
119
What should you consider or be prepared for, for the anemic patient
A. fluids
B. blood products
C. albumin
D. hetastarch
B. blood products
## Footnote
slide 35
120
What is the dose for ephedrine (select 2)
A. 25mg IM
B. 5-10mg IV
C. 25mg IV
D. 60mg IM
A. 25mg IM
B. 5-10mg IV
## Footnote
slide 36
121
Ephedrine is ______ adrenergic agonist
A. alpha
B. beta
C. alpha and beta
D. beta 2
C. alpha and beta
## Footnote
slide 36
122
Ephedrine is known to readily cross the placenta. It also has the risk for _________ and ________ (select 2)
A. reactive hypotension
B. reactive hypertension
C. umbilical vein metabolic alkolosis
D. umbilical artery metabolic acidosis
B. reactive hypertension
D. umbilical artery metabolic acidosis
## Footnote
slide 36
123
Phenylephrine dose is
A. 25-30mcg
B. 150-300 mcg
C.100-200mcg
D. 50-100mcg
D. 50-100mcg
## Footnote
slide 36
124
A coninuous infusion of phenylephrine can go at _______mcg/min
A. 100-200
B. 75-150
C. 25-100
D. 50-100
C. 25-100
## Footnote
slide 36
125
Phenylephrine is a ____________ adrenergic agonist
A. alpha 1
B. Alpha 2
C. beta 1
D. beta 2
A. alpha 1
## Footnote
slide 36
126
What level is optimal for neuroaxial anethesia for a c-section
A. T2
B. T4
C. T6
D. T10
B. T4
## Footnote
slide 37
127
How is spinal anesthesia achieved? (select 2)
A. patient position
B. baracity of LA
C. opioids used
D. reverse trendelenburg
A. patient position
B. baracity of LA (hyperbaric, isobaric)
## Footnote
slide 37
128
Which concentration of Lidocaine is hyperbaric
A.10%
B.15%
C.20%
D. 5%
D. 5%
Not really used for spinal anesthesia
## Footnote
slide 35
129
What are 2 risk associated with Lidocaine 5% (select 2)
A. tachycardia
B. transient neurological syndrome
C. pain in legs and back
D. hypotension
B. transient neurological syndrome (TNS)
C. pain in legs and back - **24-28hrs after SAB**
## Footnote
slide 38
130
Which concentration of Bupivacaine is hyperbaric?
A. 0.75
B. 0.5
C. 0.25
D0.3
A. 0.75
most commonly used
## Footnote
slide 38
131
# True or false
You can only use 1 opioid in spinal anesthetics
false
you can use more than one opioid in block is desired
## Footnote
slide 39
132
Opioids used in spinal anesthesia has many benefits. These include all the following **except**
A. improve quality of anesthetic block
B. decreased incidence of intraoperative N/V
C. decrease dose of LA
D. prolongs postoperative analgesia
E. helps the baracity of the block
E. helps the baracity of the block
* opioids may attenuate some of the sensations that trigger n/v
* may decrease need for post op IV or PO narcotics
## Footnote
slide 39
133
Fentanyl is known for being __________ due to being _____
A. slow onset; lipophobic
B. rapid onset; lipophilic
C. slow onset; lipophilic
D. rapid onset; lipophobic
B. rapid onset; lipophilic
| *10-25mcg in SAB*
## Footnote
slide 40
134
Fentanyl in a spinal would be good for which pain relief due to short acting nature?
A. intraoperative
B. postoperative pain
C. slow
D. prolonged
A. intraoperative
| Not as good for postoperative pain relief!
## Footnote
slide 40
135
What are some side effects of fentanyl in spinal anesthesia (select 2)
A. n/v
B. late respiratory depression
C. pruritus
D. early respiratory depression
C. pruritus
D. **early** respiratory depression
## Footnote
slide 40
136
Morphine PF dose is 100-150mcg in SAB and is________.
A. hydrophilic
B. hydrophobic
C. lipophilic
D. lipophobic
A. hydrophilic
## Footnote
slide 41
137
Duramorph is good for what specifically mentioned in lecture?
A. emergency spinal
B. postoperative analgesia
C. intraoperative analgesia
D. preoperative analgesia
B. postoperative analgesia
## Footnote
slide 41
138
Duramorph has an onset of ________ and duration of ________
A. 20-30 min: 12-24hours
B. 30-60min; 24-48hrs
C. 30-60 min; 12-24hrs
D.15-20min; 24-48 hours
C. 30-60min; 12-24hrs
## Footnote
slide 41
139
What are 2 side effects of Morphine PF mentioned in lecture
A. long lasting pruritus
B. N/V
C. late respiratory depression
D. early respiratory depression
A. long lasting pruritus (12-24 hours)
C. **late** respiratory depression
## Footnote
slide 41
140
Pruritis is a common complaint associated with Duramorph and is considered (select 2)
A. treatable with nubain/stadol
B. treatable with benadryl
C. dose dependent
D. worse then giving birth
A. treatable with nubain/stadol (treat with agonist-antagonist
C. dose dependent
* Benadryl wont help but will make them sleepy
* can also use naloxone/naltrexone (central mu opioid receptor)
## Footnote
slide 41
141
When will you see respiratory depression with duramorph
A. 5-10 hours
B.30-45 min
C. 1-2 hours
D. 6-18 hours
D. 6-18 hours
## Footnote
slide 41
142
Which patient would you use duromorph cautiously for?
A. obese/ OSA
B. placenta previa
C. late term
D. early labor
A. obese/OSA
## Footnote
slide 41
143
What is the typical dose range for Epinephrine when used as an additive in spinal anesthesia?
A) 0.1 – 0.2 mg
B) 1 – 2 mg
C) 5 – 10 mcg
D) 0.5 – 1 mg
A) 0.1 – 0.2 mg
"Epi-wash"
## Footnote
slide 42
144
What is the primary action of Epinephrine in spinal anesthesia when used as an additive?
A) Increases motor blockade
B) Enhances sensory blockade with vasodilation
C) Causes vasoconstriction and prolongs the block
D) Reduces the incidence of postoperative pain
C) Causes vasoconstriction and prolongs the block **by 15% or more**
## Footnote
slide 42
145
What is the typical dose of Dexmedetomidine used as an additive in spinal anesthesia?
A) 0.1 – 0.2 mg
B) 1 – 2 mg
C) 10 – 20 mg
D) 5 – 10 mcg
D) 5 – 10 mcg
## Footnote
slide 42
146
What is one of the primary benefits of adding Dexmedetomidine to spinal anesthesia?
A) It decreases the duration of the block and pain control
B) It provides postoperative pain control and minimizes shivering
C) It increases the risk of nausea and vomiting
D) It increases the incidence of bradycardia and hypertension
B) It provides postoperative pain control and minimizes shivering
## Footnote
slide 42
147
Which of the following is a potential adverse effect of using Dexmedetomidine in spinal anesthesia?
A) Hypertension
B) Tachycardia
C) Bradycardia and hypotension
D) Respiratory depression
C) Bradycardia and hypotension
## Footnote
slide 42
148
# Epidural Anesthesia
Which of the following factors primarily determines the T4 sensory level in epidural anesthesia?
Select 2
A) Type of local anesthetic used
B) Volume of the solution
C) Rate of administration
D) Concentration of the local
E) Duration of anesthesia
B) Volume of the solution
D) Concentration of the local anesthetic
## Footnote
slide 43
149
Compared to spinal anesthesia, how much higher are the doses of local anesthetics used in epidural anesthesia?
A) 5-10 times higher
B) 2-3 times higher
C) 20-30 times higher
D) The same
A) 5-10 times higher
## Footnote
slide 43
150
Which of the following best describes the onset of the block in epidural anesthesia?
A) Rapid onset, similar to spinal anesthesia
B) Onset depends on the patient’s age
C) Immediate onset with no gradual phase
D) Gradual onset of block
D) Gradual onset of block
## Footnote
slide 43
151
Is epidural anesthesia commonly used for elective cesarean sections (C-sections)?
A) Yes, it is the preferred method for elective C-sections
B) No, it is not common for elective C-sections
C) It is used for emergency C-sections only
D) It is used for all types of C-sections
B) No, it is not common for elective C-sections
## Footnote
slide 43
152
What is a potential issue with the reliability of epidural anesthesia when compared to spinal anesthesia?
A) The block is always more "dense" than spinal anesthesia
B) Epidurals are always less effective than spinal anesthesia
C) It can be “less dense” or “patchy” compared to spinal anesthesia
D) Epidurals provide more "complete" anesthesia than spinal anesthesia
C) It can be “less dense” or “patchy” compared to spinal anesthesia
## Footnote
slide 43
153
In the case of an unplanned C-section, what is a common approach if an epidural is already in place?
A) "Dose up" the existing epidural for operative anesthesia
B) Convert to general anesthesia immediately
C) Administer oral analgesics for pain control
D) Perform a spinal anesthesia as a backup
A) "Dose up" the existing epidural for operative anesthesia
## Footnote
slide 44
154
What should be done to assess the effectiveness of the epidural block during an unplanned C-section?
A) Check the patient's vital signs regularly
B) Perform a sensory level check and assess for "hot spots"
C) Administer additional sedation and perform a motor test
D) Test the patient about pain level with a sharp needle
B) Perform a sensory level check and assess for "hot spots"
| Use ice
## Footnote
slide 44
155
# Epidural Anesthesia
Lidocaine 2% can be used with or without ____.
A. Bicarbonate
B. Epinephrine
C. Opioids
D. Pseudocholinesterase
Lidocaine has a ____ onset, which is faster when **bicarbonate** is added.
A. Slow
B. Moderate
C. Rapid
D. Delayed
Lidocaine has a ____ duration of action.
A. Long
B. Prolonged
C. Intermediate
D. Short
Concentrations of Lidocaine less than 2% are _____ for surgical procedures.
A. Ideal
B. Common
C. Not adequate
D. Frequently used
Lidocaine 2%
With or without **Epinephrine (B)**
**Rapid (C)** onset, faster when bicarb is added
**Short (D)** duration of action
Concentrations < 2% **not adequate (C)** for surgical procedure
## Footnote
Slide 45
156
# Epidural Anesthesia
2-Chloroprocaine 2–3% has a ____ onset of action.
A. Slow
B. Moderate
C. Very rapid
D. Delayed
2-Chloroprocaine 2–3% has a ____ duration of action.
A. Long
B. Intermediate
C. Extended
D. Short
2-Chloroprocaine is metabolized by _____.
A. Cytochrome P450
B. Monoamine oxidase
C. Acetylcholinesterase
D. Pseudocholinesterase
2-Chloroprocaine antagonizes _____ opioid receptors.
A. Delta
B. Sigma
C. Mu & kappa
D. Alpha
2-Chloroprocaine ____ the efficacy of epidural morphine.
A. Enhances
B. Has no effect on
C. Reduces
D. Doubles
2-Chloroprocaine 2-3%
**Very rapid (C)** onset & **short (D)** duration of action
Metabolized by **pseudocholinesterase (D)**
Antagonizes **mu & kappa (C)** opioid receptors
**Reduces (C)** efficacy of epidural morphine
## Footnote
Slide 45
157
# Epidural Anesthesia
Bupivacaine 0.5% has an ____ onset of action.
A. Rapid
B. Intermediate
C. Slow
D. Delayed
Bupivacaine 0.5% has a ____ duration of action.
A. Short
B. Moderate
C. Long
D. Variable
Bupivacaine has a risk of ____ toxicity d/t large amounts being used and leeching into vascular system.
A. Renal
B. Pulmonary
C. Hepatic
D. Cardiac
Bupivacaine 0.75% is not used in ____.
A. Spinals
B. Epidurals
C. Peripheral nerve blocks
D. Local infiltration
Bupivacaine 0.5%
**Intermediate (B)** onset
**Long (C)** duration of action
Risk of **cardiac (D)** toxicity
Bupivacaine 0.75% not used in **epidurals (B)**
## Footnote
Slide 46
158
# Epidural Anesthesia
Ropivacaine 0.5% has an ____ onset of action.
A. Rapid
B. Intermediate
C. Slow
D. Immediate
Ropivacaine 0.5% has a ____ duration of action.
A. Short
B. Long
C. Variable
D. Brief
Ropivacaine has ____ risk of cardiac toxicity than Bupivacaine.
A. Greater
B. Similar
C. Less
D. No
Ropivicaine 0.5%
**Intermediate (B)** onset
**Long (B)** duration of action
**Less (C)** risk of cardiac toxicity than Bupivacaine
## Footnote
Slide 46
159
# Epidural Anesthesia
Fentanyl used in epidurals acts at which of the following sites?
A. Only spinal
B. Only supraspinal
C. Peripheral nerve endings
D. Spinal and supraspinal sites
D. Spinal and supraspinal sites
| Fentanyl 50 – 100 mcg in epidural
## Footnote
Slide 47
160
# Epidural Anesthesia
What are the benefits of adding fentanyl to epidural anesthesia? (Select 2 that apply)
A. Improved intraoperative anesthetic quality
B. Denser block
C. Prolonged motor blockade
D. Faster recovery time
E. Reduced need for oxygen supplementation
A. Improved intraoperative anesthetic quality
B. Denser block
## Footnote
Slide 47
161
# Epidural Anesthesia
Which of the following is NOT a known side effect of epidural fentanyl?
A. Pruritus
B. Early respiratory depression
C. Maternal somnolence
D. Bradycardia
D. Bradycardia
## Footnote
Slide 47
162
# Epidural Anesthesia
Epidural morphine provides postoperative analgesia for approximately:
A. 2–6 hours
B. 4–8 hours
C. 6–12 hours
D. 12–24 hours
D. 12–24 hours
| preservative-free morphine given 1-3 mg in epidural
## Footnote
Slide 48
163
# Epidural Anesthesia
True or False
Epidural morphine commonly causes early respiratory depression and dose dependent pruritus.
FALSE
Epidural morphine commonly causes **late** respiratory depression and *dose dependent* pruritus.
## Footnote
Slide 48
164
# Epidural Anesthesia: Adjuncts
Which of the following are potential maternal side effects of dexmedetomidine when used in epidural anesthesia?
A. Tachycardia and hypertension
B. Bradycardia and hypotension
C. Fever and shivering
D. Nausea and vomiting
B. Bradycardia and hypotension
| Dexmedetomidine 4 – 5 mcg/mL local anesthetic
## Footnote
Slide 49
165
# Epidural Anesthesia: Adjuncts
Sodium bicarbonate increases the amount of local anesthetic in the (1) ____ state and (2) ____ the onset time.
Choices:
A. Ionized
B. Non-ionized
C. Protein-bound
D. Speeds
E. Slows
F. Prolongs
1 → B. Non-ionized
2 → D. Speeds
More local anesthetic in **non-ionized** state
**Speeds** onset time
## Footnote
Slide 49
166
# Epidural Anesthesia: Adjuncts
In which of the following clinical situations is sodium bicarbonate particularly useful in epidural anesthesia?
A. When managing post-op pain
B. When transitioning from regional to spinal anesthesia
C. When there is an urgent need to dose up an epidural to avoid general anesthesia (GETA)
D. When prolonging the duration of local anesthetics
C. When there is an urgent need to dose up an epidural to avoid general anesthesia (GETA)
## Footnote
Slide 49
167
# In-situ Epidural
What should you consider if a patient has a unilateral block after epidural placement?
A. Add more fentanyl
B. Replace the catheter if there is time
C. Convert to spinal anesthesia immediately
D. Decrease the dose of local anesthetic
B. Replace the catheter if there is time
## Footnote
Slide 50
168
# In-situ Epidural
Which of the following can be used to eliminate a “hot spot” in a patchy epidural block?
A. 100 mcg morphine
B. 5 mL sodium bicarbonate
C. 50 mcg fentanyl in the epidural
D. Dexmedetomidine infusion
C. 50 mcg fentanyl in the epidural
*magical*
| May be able to supplement with epidural opioids/adjuncts
## Footnote
Slide 50
169
In an emergent C-section where time does not permit epidural supplementation, what is the likely course of action?
A. Increase local anesthetic volume
B. Wait for the block to settle
C. Proceed with GETA
D. Add IV acetaminophen
C. Proceed with GETA (general endotracheal anesthesia)
## Footnote
Slide 50
170
What volume of local anesthetic is typically used to dose up an epidural for surgical anesthesia?
A. 5 mL
B. 8–10 mL
C. 10–15 mL
D. 15–20 mL
C. 10–15 mL
| ALWAYS assess level
## Footnote
Slide 50
171
True or False
The Allis test should be performed after the incision to assess block adequacy.
FALSE
Allis test should be performed **before** the incision to assess block adequacy
| Allis forcep is a instrument with blunt 'teeth' used for pinching skin
## Footnote
Slide 50
172
Which of the following are TRUE about the Combined Spinal Epidural (CSE)? (Select 3 that apply)
A. Provides rapid onset of block
B. Always requires sequential dosing
C. Full SAB dose should be given
D. Epidural catheter may be used if procedure is prolonged
E. Slower onset compared to spinal anesthesia
A. Provides rapid onset of block
C. Full SAB dose should be given
D. Epidural catheter may be used if procedure is prolonged (might be in a teaching facility)
*Sequential dosing optional*
*Refer to dosing for spinal & epidural*
## Footnote
Slide 51
173
Which of the following is a common fetal indication for initiating GETA in obstetric anesthesia?
A. Breech presentation
B. Sustained fetal bradycardia
C. Oligohydramnios
D. Meconium-stained fluid
B. Sustained fetal bradycardia
*Fetal distress*
| "Heart tones are down"
## Footnote
Slide 52
174
Which of the following is a maternal indication for general endotracheal tube anesthesia (GETA)?
A. Mild gestational hypertension
B. Maternal hemorrhage with hypovolemia
C. Previous cesarean section with early decels
D. Stable patient requesting elective cesarean under neuraxial block
B. Maternal hemorrhage with hypovolemia
*Placental abruption*
*Uterine rupture*
## Footnote
Slide 52
175
Which of the following is NOT a valid reason to proceed with GETA during a cesarean section?
A. Patient refusal of neuraxial anesthesia
B. Maternal infection at injection site
C. Well-tolerated spinal block
D. Coagulopathy or thrombocytopenia
E. Patient not tolerating
C. Well-tolerated spinal block
*Failed block*
## Footnote
Slide 52
176
Which of the following are benefits of general endotracheal tube anesthesia (GETA) in obstetric cases?
(Select 3 that apply)
A. Rapid onset
B. Secured airway
C. Decreased maternal mortality
D. Hemodynamic stability
E. Patient remains awake during delivery
A. Rapid onset
B. Secured airway
D. Hemodynamic stability
## Footnote
Slide 53
177
Which of the following are disadvantages of general endotracheal tube anesthesia (GETA) in obstetric patients?
(Select 4 that apply)
A. Increased maternal mortality
B. Difficulty with airway management
C. Reduced likelihood of intraoperative bleeding
D. Risk of aspiration
E. Anesthesia recall
F. Enhanced fetal neurologic assessment at delivery
A. Increased maternal mortality
B. Difficulty with airway management
*Failed oxygenation/ventilation
D. Risk of aspiration
E. Anesthesia recall
*Mother not awake during delivery*
## Footnote
Slide 53
178
Which of the following are neonatal consequences of GETA during cesarean delivery? (Select 2 that apply)
A. Neonatal respiratory & CNS depression
B. 1-minute APGAR scores lower with GETA
C. Improved muscle tone
D. Enhanced neurological reflexes
A. Neonatal respiratory & CNS depression
B. 1-minute APGAR scores lower with GETA
## Footnote
Slide 53
179
What intraoperative limitation is associated with GETA that impacts the birthing experience?
A. Increased motor blockade
B. Inability to administer opioids
C. No support person allowed in the OR (depending on policy)
D. Continuous fetal monitoring
C. No support person allowed in the OR (depending on policy)
## Footnote
Slide 53
180
# GETA: Induction Sequence
Which of the following correctly describes the order of key steps in the GETA induction sequence prior to surgical incision for an emergent cesarean delivery?
A. Surgical time-out → Cricoid pressure and RSI → Intubation with 6.0–7.0 mm ETT → Preoxygenation → Confirm ETT placement → State “OK to cut” → Incision
B. Abdomen prep and drape → Preoxygenation and monitors → Surgical time-out → Succinylcholine administration → Intubation → Confirm ETT placement → State “OK to cut” → Incision
C. Preoxygenation and apply monitors → Abdomen prep and drape (may “Splash & Slash” if emergent) → Surgical time-out → Cricoid pressure with RSI using induction agents and succinylcholine (1–1.5 mg/kg) → Intubate with 6.0–7.0 mm ETT → Confirm placement with EtCO₂ → State “OK to cut,” “Tube is in” → Incision
D. RSI with induction agents → Preoxygenation → Surgical time-out → Abdomen prep and drape → Intubate → Confirm placement → Incision
C. Preoxygenation and apply monitors
→ Abdomen prep and drape (may “Splash & Slash” if emergent)
→ Surgical time-out
→ Cricoid pressure with RSI using induction agents and succinylcholine (1–1.5 mg/kg)
→ Intubate with 6.0–7.0 mm ETT
→ Confirm placement with EtCO₂
→ State “OK to cut,” “Tube is in”
→ Incision
*Ventilator & vaporizer on
Secure ETT
Place temperature probe
Place orogastric tube
Use warm air blanket*
## Footnote
Slide 54-55
181
# GETA: Induction Sequence
Why is Versed (midazolam) typically administered only after delivery during a cesarean section under GETA?
A. It causes uterine relaxation
B. It enhances maternal analgesia during incision
C. It crosses the placenta and may affect the fetus if given before delivery
D. It reduces bleeding during uterine closure
C. It crosses the placenta and may affect the fetus if given before delivery
*Patients under GETA are at high risk for **intraoperative recall** if no amnestic agents are given*
## Footnote
Slide 54
182
# GETA: Induction Sequence
Which of the following should be documented by the anesthesia provider during a cesarean section under general endotracheal anesthesia (GETA)?
A. Time of abdominal prep and surgical hand scrub
B. Time of uterine incision and time of delivery
C. Time of induction medication pharmacy verification
D. Time the neonatal team enters the room
B. Time of uterine incision and time of delivery
## Footnote
Slide 55
183
# GETA: Induction Sequence
Which of the following are commonly used for postoperative pain control following GETA for cesarean delivery?
(Select 4 that apply)
A. Opioids
B. Acetaminophen
C. Toradol (ketorolac)
D. Succinylcholine
E. Midazolam
F. Patient-controlled analgesia (PCA)
A. Opioids
B. Acetaminophen
C. Toradol (if not contraindicated)
F. Patient-controlled analgesia (PCA)
## Footnote
Slide 54
184
# GETA: Induction Sequence
Which regional anesthesia technique may be used postoperatively to enhance pain control following cesarean delivery under GETA?
A. Paravertebral block
B. Interscalene block
C. TAP block
D. Stellate ganglion block
C. TAP block
## Footnote
Slide 54
185
When should you initiate an oxytocin (Pitocin) infusion during a cesarean section under GETA?
A. After skin incision
B. Before uterine closure
C. After delivery of the fetus
D. After patient extubation
C. After delivery of the fetus
*Announce that you are giving it*
## Footnote
Slide 56
186
# GETA: Maintenance
Why should the volatile anesthetic agent be decreased to 0.5–0.75 MAC after delivery of the fetus during a cesarean section under GETA?
A. To minimize neonatal respiratory depression
B. To enhance maternal analgesia
C. To reduce the risk of uterine atony due to dose-dependent relaxation
D. To facilitate faster extubation postoperatively
C. To reduce the risk of uterine atony due to dose-dependent relaxation
*Consider adding N2O to decrease volatile agent
*Consider benzodiazepine administration to decrease recall
*Titrate in opioids for pain control
## Footnote
Slide 56
187
# GETA: Maintenance
During GETA for cesarean delivery, maintaining normocapnia is essential.
Hypocapnia can result in ____, a shift of the ____ to the **left**, and ultimately compromised ____.
Hypercapnia, on the other hand, may lead to maternal ____.
A.
Uteroplacental vasoconstriction
Oxyhemoglobin dissociation curve
Fetal oxygenation
Tachycardia
B.
Uteroplacental vasodilation
Myoglobin saturation curve
Fetal heart rate
Bradycardia
C.
Increased uterine tone
Carbon dioxide curve
Maternal perfusion
Hypotension
D.
Fetal bradycardia
Hemoglobin saturation graph
Placental transfer
Hypertension
A.
Uteroplacental vasoconstriction
Oxyhemoglobin dissociation curve
Fetal oxygenation
Tachycardia
During GETA for cesarean delivery, maintaining normocapnia is essential.
*Hypocapnia* can result in **Uteroplacental vasoconstriction**, a shift of the **Oxyhemoglobin dissociation curve** to the left, and ultimately compromised **Fetal oxygenation**.
*Hypercapnia*, on the other hand, may lead to maternal **Tachycardia**
## Footnote
Slide 57
188
# GETA: Maintenance
Systemic opioids are administered after delivery during GETA primarily to achieve which of the following benefits?
A. Enhanced maternal recall
B. Increased uterine tone
C. Reduced risk of neonatal respiratory depression
D. Improved maternal respiratory rate
C. Reduced risk of neonatal respiratory depression
## Footnote
Slide 58
189
# GETA: Maintenance
Magnesium infusion can potentiate the effects of ____, requiring close monitoring of neuromuscular function.
A. opioids
B. benzodiazepines
C. non-depolarizing muscle relaxants (NDMBs)
D. volatile agents
C. non-depolarizing muscle relaxants (NDMBs)
## Footnote
Slide 58
190
Following administration of succinylcholine, always check twitches to assess for prolonged neuromuscular blockade, which may indicate ____ deficiency that can occur in pregnancy.
A. acetylcholinesterase
B. pseudocholinesterase
C. dopamine beta-hydroxylase
D. G6PD
B. **pseudocholinesterase** deficiency
*Always, ALWAYS check twitches after Succinylcholine *
## Footnote
Slide 58
191
# GETA: Emergence/Postoperative
Patients undergoing GETA for cesarean delivery should be extubated ___ and only after suctioning the orogastric tube.
A. deeply anesthetized
B. semi-conscious
C. awake
D. in lateral decubitus position
C. awake
## Footnote
Sllde 59
192
# GETA: Emergence/Postoperative
Before administering ketorolac for postoperative pain, always confirm that it is acceptable to the ____.
A. CRNA
B. OB nurse
C. anesthesiologist
D. surgeon
D. surgeon
## Footnote
Sllde 59
193
# GETA: Emergence/Postoperative
Which of the following is NOT typically used as an antiemetic during emergence after GETA for cesarean delivery?
A. Scopolamine
B. Zofran
C. Phenergan
D. Ketorolac
E. Droperidol
D. Ketorolac
## Footnote
Sllde 59
194
Which of the following statements about Pitocin (Oxytocin) are true? (Select 3 that apply)
A. It is a prostaglandin derivative
B. It should be given 20 units in bag after the umbilical cord is cut
C. It stimulates uterine contractions
D. It can cause flushing and hypertension if given rapidly
E. It is usually 10 units/mL concentration
B. It should be given 20 units in bag after the umbilical cord is cut
C. It stimulates uterine contractions
E. It is usually 10 units/mL concentration
## Footnote
Slide 60
195
Methergine is an ergot alkaloid that is administered almost always__ and should be avoided or used cautiously in patients with__
A. IV; diabetes
B. IM; hypertension
C. SC; asthma
D. PO; renal failure
B. IM; hypertension
Methergine is an *ergot alkaloid* that is administered almost alway **IM** and should be avoided or used cautiously in patients with **hypertension**
| Nice to give below the level of the spinal in the thigh
## Footnote
Slide 60
196
The typical dose of Methergine (Methylergonovine) used to treat uterine atony is ______.
A. 0.1 mg IV
B. 0.25 mg IM
C. 0.2 mg IM
D. 500 mcg SC
C. 0.2 mg IM
(200 mcg IM)
## Footnote
Slide 60
197
Hemabate (Carboprost) is administered as a:
A. 500 mcg IV bolus
B. 250 mcg IM dose
C. 1 mg intrathecal injection
D. 0.2 mg oral tablet
B. 250 mcg IM dose
## Footnote
Slide 60
198
Match each uterotonic agent with its correct caution or side effect
(A → 2) Hemabate → Asthma **+ massive diarrhea**
(B → 3) Pitocin → Hypotension/Flushing
(C → 1) Methergine → Hypertension
Memory tric: Hemabate leads to intubate; Methergine sounds close to Hyperten; Pitocin sounds close to Potesion
## Footnote
Slide 60
199
# C-Section Anesthesia Complications
Which of the following are common causes of nausea and vomiting during cesarean section under anesthesia? (Select 3)
A. Hypotension
B. Surgical stimulation
C. Use of regional anesthesia only
D. Uterotonics/antibiotics
E. Epidural catheter migration
A. Hypotension
B. Surgical stimulation
D. Uterotonics/antibiotics
## Footnote
Slide 61
200
# C-Section Anesthesia Complications
Which of the following mechanisms explain how **hypotension** during cesarean section can lead to *nausea and vomiting*?
(Select 2 that apply)
A. Cerebral & brainstem hypoperfusion, which stimulates the medullary vomiting center
B. Enhancing uterine contractions through baroreceptor activation
C. Renal perfusion and diuresis from kidneys
D. Gut ischemia and release of emetogenic substances from the intestines
A. Cerebral & brainstem hypoperfusion, which stimulates the medullary vomiting center
D. Gut ischemia and release of emetogenic substances from the intestines
## Footnote
Slide 61
201
# C-Section Anesthesia Complications
Which of the following **surgical factors** can contribute to *nausea and vomiting* during cesarean section?
(Select 3 that apply)
A. Uterine exteriorization
B. Intra-abdominal manipulation
C. Peritoneal traction stimulating vagal fibers
D. Epidural catheter placement
E. Rapid bladder decompression
A. Uterine exteriorization
B. Intra-abdominal manipulation
C. Peritoneal traction stimulating vagal fibers
## Footnote
Slide 61
202
# C-Section Anesthesia Complications
Match each uterotonic agent with its associated mechanism contributing to *nausea and vomiting*:
(A → 1) Oxytocin → R/t hypotension
(B → 2) Methylergonovine →Interaction with dopaminergic & serotonergic receptors
(C → 3) Hemabate → Stimulation of GI tract smooth muscle *d/t prostaglandins*
| Also don't push your antibiotics fast, can cause nausea
## Footnote
Slide 61
203
# C-Section Anesthesia Complications
Why is general endotracheal anesthesia (GETA) for emergent cesarean section associated with a high risk of awareness and recall?
A. High doses of benzodiazepines are given early
B. It prevents the patient from receiving oxygen
C. Periods of lower MAC are common before delivery
D. Spinal anesthesia is not used in emergencies
C. Periods of lower MAC are common before delivery -*need it low to help with uterus toning back up*
***Give Benzodiazepines (2mg versed) as soon as baby is out***
## Footnote
Slide 62
204
# C-Section Anesthesia Complications
Hypotension during cesarean section under anesthesia can be caused by __________.
A. Increased cerebral perfusion and parasympathetic stimulation
B. Sympathetic blockade and bleeding
C. Hypercapnia and elevated systemic vascular resistance
D. High MAC levels and decreased catecholamine release
B. Sympathetic blockade and bleeding
## Footnote
Side 62
205
# C-Section Anesthesia Complications
Which of the following is an appropriate response to a failed or inadequate neuraxial block during cesarean section?
Select 4
A. Increase the MAC to 2.5%
B. Supplement with ketamine
C. Start N20 therapy
D. Start oxytocin infusion early
E. Moral/Emotional support
F. Immediately intubate and start GETA
G. Supplement with Precedex
B. Supplement with ketamine
C. Start N20 therapy
E. Moral/Emotional support - "coach them through this"
G. Supplement with Precedex
*if mom can't tolerate → GETA*
## Footnote
Slide 63
206
GWhich of the following is an appropriate response to a High neuraxial block during cesarean section?
Select 4
A. Increase the MAC to 2.5%
B. Supplement with oxygen
C. Start N20 therapy
D. Start oxytocin infusion early
E. Moral/Emotional support
F. Administer pressors
G. May need to bag/mask
B. Supplement with oxygen
E. Moral/Emotional support
F. Administer pressors
G. May need to bag/mask
207
# C-Section Anesthesia Complications
**High neuraxial block** can lead to ___, requiring airway support and possibly GETA.
Select 2
A. Elevated heart rate and hypertension
B. Increased awareness and anxiety
C. Loss of consciousness and respiratory drive
D. Nausea from uterine manipulation
E. Refractory hypotension
C. Loss of consciousness and respiratory drive
E. Refractory hypotension
## Footnote
Slide 63
208
# C-Section Anesthesia Complications
Which of the following may be used to manage intraoperative maternal **shaking** during cesarean section?
(Select 3 that apply)
A. Precedex
B. Meperidine
C. Warming the operating room to 80°F
D. Giving mom something to squeeze in her hand
E. Phenytoin
A. Precedex
B. Meperidine
* *or Fentanyl may help*
D. Giving mom something to squeeze in her hand
| VERY common, hard to control; Hormonal
## Footnote
Slide 63
209
Match each medication or intervention with the correct timing of its use:
Perioperative pain or Postoperative pain
1. Opioids
2. IV PCA
3. Tylenol (Acetaminophen)
4. Ketorolac
5. PO Medications
6. Precedex
7. TAP Block
1. Opioids → Perioperative pain
2. IV PCA → Postoperative pain
3. Tylenol (Acetaminophen) → Perioperative pain
4. Ketorolac → Perioperative pain
5. PO Medications → Postoperative pain
6. Precedex → Perioperative pain
7. TAP Block → Postoperative pain
## Footnote
Slide 64
210
Pruritus after cesarean delivery is most commonly associated with the use of ____.
A. Fentanyl boluses
B. Intrathecal morphine
C. General anesthesia
D. NSAIDs
B. Intrathecal morphine
| Risk for itching weighed against risk for pain
## Footnote
Slide 64
