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Practice bulletins > #209 Obstetric Analgesia and Anesthesia > Flashcards

#209 Obstetric Analgesia and Anesthesia Flashcards

1
Q

Where do women feel first stage of labor pain?

A

Diffuse. Lower abdominal pain is nearly universal, significant % will experience lower back pain. May be referred to iliac crests, buttocks, or thighs.

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2
Q

As fetus descends in the first stage or second stage of labor, distention of the vagina, pelvic floor, and perineum elicit stimuli through what nerve(s)?

A

Pudendal nerve and the anterior primary divisions of sacral nerves S2 through S4

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3
Q

Which opioid used for labor analgesia has the shortest duration of action?

A

Remifentanil, 3-4 minutes

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4
Q

Which opioid used for labor analgesia has the most rapid onset of action?

A

Remifentanil, 20-90 seconds

next is nalbuphine 2-3min or fentanyl 2-4 min

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5
Q

Which opioid used for labor analgesia has the longest duration?

A

Butorphanol 4-6hrs

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6
Q

In general, how is the pain relief with parenteral opioids for labor analgesia?

A

Some pain relief, but poor, and associated with significant adverse events, mostly nausea, vomiting, drowsiness

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7
Q

True or false, opioids do not cross the placenta

A

False

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8
Q

How does opioid use affect fetus/neonate?

A

Loss of variability in FHR, reduction in FHR baseline, neonatal respiratory depression, or neurobehavioral changes

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9
Q

True or false, opioid drug elimination takes the same time in newborns as adults?

A

False, longer in newborns, particularly in administered near the time of delivery

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10
Q

Why is meperidine generally not recommended for peripartum analgesia?

A

Active metabolite (normeperidine) has a prolonged half life in adults and half life up to 72hrs in neonate; the effect cannot be antagonized by naloxone

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11
Q

What opioids during labor are associated with less respiratory depression (compared to other opioids)?

A

Mixed agonist-antagonists such as nalbuphine and butorphanol. Remifentanil due to easy titration.

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12
Q

What is a common risk of remifentanil PCA for labor analgesia?

A

Maternal apneic episodes (occur in 26% of women with PCA). Respiratory arrest has occurred.

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13
Q

What % of women in the US having a singleton birth in the US select epidural or spinal analgesia?

A

More then 60%

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14
Q

What level of education is associated with higher epidural use during labor? Race? Early or late presentation to prenatal care?

A

Higher education levels, white race, early presentation for prenatal care

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15
Q

Does neuraxial analgesia increase the cesarean delivery rate?

A

No

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16
Q

What medication(s) is placed through an epidural catheter?

A

Mix of local anesthetic and opioid medication; plus or minus epinephrine; plus or minus bicarb

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17
Q

What effect does a local anesthetic have in epidural space?

A

Motor blockade, labor pain relief

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18
Q

What are the commonly used local anesthetics for epidural anesthesia?

A

Bupivacaine and ropivacaine

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19
Q

What opioids are common used for epidural anesthesia?

A

fentanyl and sufentanil

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20
Q

What does addition of epinephrine to epidural block do?

A

prolong duration, increase reliability and intensity of block.

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21
Q

What does the addition of sodium bicarb to epidural block do?

A

Speed up onset of epidural blockade, intensify the effect, or both, especially in sacral dermatomes

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22
Q

What are methods of maintaining epidural anesthesia?

A

Intermittent boluses, continuous infusion or continuous infusion with patient-administered boluses

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23
Q

How does intermittent bolus technique for epidural compare to continuous infusion?

A

No difference in total duration of labor. Significantly shorter second stage, less total anesthetic drug, higher maternal satisfaction

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24
Q

Is epidural or opioids better for controlling labor pains?

A

Epidural

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25
Q

What medication(s) is put into spinal block?

A

Mix of local anesthetic and opioid

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26
Q

What anesthetics are used for spinal block?

A

Lidocaine, bupivacaines, ropivacaine

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27
Q

What opioid(s) is used for spinal block?

A

Fentanyl, sufentanil, or morphine

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28
Q

What is the concern about continuous spinal analgesia for labor?

A

Concerns about postdural puncture headache.

Caution with labeling, use, dosage, and sterility on intrathecal catheter

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29
Q

What is a downside of combined spinal-epidural anesthesia?

A

Epidural catheter placement cannot truly be verified until the spinal component has “worn-off”

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30
Q

How does intrathecal opioids lead to fetal bradycardia?

A

Independent of maternal hypotension. Hypothesized that fast pain relief, lowers maternal plasma epinephrine and beta-endophines, leaving oxytocin and norepinephrine unopposed, which leads to uterine hypertonus and reduction in ureteroplacental blood flow

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31
Q

What is the landmark for pudendal block?

A

Ischial spine

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32
Q

When is a pudendal block useful?

A

Second stage of labor or after delivery to facilitate repair of perineal lacerations

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33
Q

What is maximum recommended bupivacaine dosing w/ and w/o epi?

A

3mg/kg for both

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34
Q

What is the maximum recommended lidocaine w/ and w/o epi?

A

7mg/kg w/.

5mg/kg w/o.

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35
Q

What is recommended maximum dose of ropivacaine w/ and w/o epi?

A

2mg/kg for both

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36
Q

What is the recommended maximum dose of 2-chloroprocaine w/ and w/o epi?

A

14mg/kg w/.

11 mg/kg w/o.

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37
Q

What are possible symptoms of local anesthetic toxicity (eg from injecting into blood stream)?

A

Neurologic symptoms (eg, seizures, coma) or cardiac symptoms (eg, arrhythmias, myocardial depression)

38
Q

Do CNS or cardiac manifestations of local anesthetic toxicity typically manifest first?

A

CNS symptoms

39
Q

What is the interaction between hypoxemia and acidosis with local anesthetic systemic toxicity? What should you do?

A

Hypoxemia and acidosis potentiate local anesthetic systemic toxicity. Treat with IV lipid emulsion

40
Q

What logistics need to be in place to give nitrous oxide during labor?

A

Need supply with apparatus that must use a demand valve. Must have scavenging equipment.

41
Q

How does analgesia from nitrous oxide compare to epidural?

A

Not as good as epidural in regards to pain scores

42
Q

What are maternal adverse effects of nitrous oxide use?

A

Nausea, vomiting, dizziness, and drowsiness

43
Q

When nitrous oxide is used for labor analgesia, is it cleared quickly or slowly from the neonate?

A

Eliminated rapidly by the neonate after he or she begins to breathe

44
Q

Can nitrous oxide be used safely with other forms of analgesia for labor pain?

A

Yes

45
Q

What is the role of general anesthesia in labor and delivery?

A

Typically limited to emergency cesarean deliveries or scenarios in which neuraxial anesthesia cannot be performed or has already failed

46
Q

Do anesthestic needs change before and after delivery of the newborn during general anesthesia?

A

Yes

47
Q

What anesthetics used for general anesthesia can cause decreased uterine tone?

A

Inhaled volatile agents, eg sevoflurane or isoflurane. Typically these will need to be maintained with low concentrations.

48
Q

What is the rate of failed intubations among pregnant patients compared to nonpregnant surgical patients?

A

Pregnant: 1 in 224 to 1 in 390
Nonpregnant: 1 in 2230

49
Q

What is the failure rate of neuraxial anesthesia for cesarean delivery?

A

1.7%

50
Q

The Serious Complication Repository Project was created to estimate the frequency of severe adverse outcomes associated with obstetric anesthesia. How many out of 300,000 recorded cases had events?

A
  1. 2 cardiac arrests, 2 myocardial infarctions, 4 epidural abscess or meningitis (<1:60,000), 1 epidural hematoma (1:250,000), 10 failued intubations, 58 high neuraxial blocks. 7 neurologic injuries. 16 respiratory arrests.
51
Q

Are epidural or spinal blocks at higher risk for high neuraxial blocks?

A

Nearly equally distributed

52
Q

What puts a patient at risk for a high neuraxial block?

A

Unrecognized spinal catheter. Attributed to 24% of cases high neuraxial blocks

53
Q

What is the rate of postdural puncture headache after spinal or combined spinal-epidural anesthesia?

A

0.7%

54
Q

What is the standard therapeutic intervention for a postdural puncture headache?

A

Epidural blood patch

55
Q

Are epidural or intrathecal opioids more likely to lead to pruritis?

A

Intrathecal

56
Q

What are minor maternal adverse effects associated with neuraxial blocks?

A

Maternal hypotension, pruritis, nausea/vomiting. Temperature elevation or fever (epidural related), shivering, urinary retention, and reactivation of oral herpes, respiratory distress.

57
Q

What are treatment options for opioid-induced pruritis (centrally induced)?

A

Small doses of naloxone or nalbuphine (but these can reverse some of the analgesic effect). Antihistamines, but these have little to no effect on centrally-induced pruritis, but may increase drowsiness, leading to improvement in symptoms

58
Q

What % of women will develop hypotension from low-dose neuraxial labor analgesia?

A

About 10%

59
Q

What can be done to help prevent maternal hypotension with neuraxial anesthesia?

A

Preloading or coloading with crystalloid or by administering small doses of vasopressors (ephedrine or phenylephrine)

60
Q

Is the risk of spinal or epidural hematoma higher with spinal or epidural?

A

Epidural

61
Q

What is the risk of spinal-epidural hematoma in patient with platelets between 70k-100k?

A

0-0.6%

62
Q

Can epidural/spinal anesthesia be used in patients with platelets <70k?

A

It may be acceptable in some circumstances. There is insufficient data to assess risk in patients with platelets <70k

63
Q

What is the risk of serious morbidity from general anesthesia during a cesarean delivery?

A

6.5%

64
Q

Is use of low-dose aspirin a contraindication for neuraxial techniques?

A

No

65
Q

Is the presence of a space-occupying brain lesion a contraindication to epidural anesthesia?

A

Not necessarily. If it does not result in increased ICP (no mass effect, hydrocephalus), risk of herniation is minimal and epidural anesthesia can be considered

66
Q

What % of women will experience an increase in maternal temperature (>99.5oF) with neuraxial analgesia?

A

30%

67
Q

What makes a woman more likely to have an increased temperature with epidural anesthesia?

A

Nulliparity. Prolonged use of epidural.

68
Q

Does giving prophylactic antibiotics prior to epidural placement reduce the risk of developing fever?

A

No

69
Q

How does intrathecal opioids vs systemic opioids affect the length of the first stage of labor?

A

90 minutes shorter in women with intrathecal opioids

70
Q

How does epidural, compared to no epidural, affect length of second stage of labor?

A

Epidural prolongs the second stage of labor by a mean difference of 7.66 minutes without negative effects to fetus and neonate

71
Q

Does initiation of epidural anesthesia at any stage of labor increase the risk of cesarean delivery?

A

No

72
Q

Does HELLP syndrome affect platelet number or quality?

A

Both. Consumption of platelets coupled with impaired platelet function

73
Q

Can women breast feed after general anesthesia?

A

Yes, as soon as they are awake, stable, and alert

74
Q

How does maternal opioid use affect infants?

A

Can cause neonatal depression or drowsiness and can interfere with suckling

75
Q

What is the dermatone level goal for a cesarean section?

A

T4

76
Q

What anesthesia options are available if a woman needs an emergent cesarean section?

A

If epidural in place can titrate this in ~10mins.
Place spinal (~8 min).
General anesthesia (~2 min)
Local anesthetic

77
Q

If patient is feeling pain during cesarean section, what can you do as a surgeon to improve tolerability?

A

Gentle tissue handling.

Do not exteriorize the uterus (requires higher sensory level than in situ repair)

78
Q

What are the pros and cons of preservative-free morphine used in spinal or epidural anesthesia for cesarean section?

A

Provides 12-24hrs of post op analgesia.

Risks of pruritus, nausea, respiratory depression

79
Q

Does wound infiltration with local anesthetic at the time of cesarean delivery decrease post op opioid consumption?

A

Yes, during first 12-24hrs

80
Q

How does transversus abdominis plane blocks affect post op opioid use after cesarean section?

A

Decrease post op morphine requirements by more than 70%. However, do not improve pain relief when intrathecal morphine is given.

81
Q

What particular opioid is not recommended for breastfeeding mothers?

A

Codeine

82
Q

Oxycodone greater than how many miligrams per day is not recommended for breastfeeding women?

A

30mg/day

83
Q

How long after SQH 5000u BID injection can neuraxial catheter be placed or removed?

A

More than 4-6 hours since last dose

84
Q

How long after intermediate-dose unfractionated heparin (7.5-10k u) can neuraxial catheter be placed or removed?

A

More than 12 hours

85
Q

How long after high-dose unfractionated heparin (>20k u/day) can neuraxial catheter be placed or removed?

A

More than 24 hours with aptt in normal range or anti-factor Xa level undetectable

86
Q

After how many days of heparin use, should a platelet count be checked prior to placement or removal of neuraxial catheter to check for possible heparin-induced thrombocytopenia?

A

If taking for more than 4 days

87
Q

How soon after neuraxial catheter removal can you resume unfractionated heparin?

A

Resumed more than 1 hour after catheter removal

88
Q

How long after prophylactic LMW heparin administration should you wait for neuraxial needle or catheter placement or removal?

A

Delay by at least 12 hours after last dose

89
Q

How long after therapeutic LMW heparin administration should you wait for neuraxial needle or catheter placement or removal?

A

24 hour delay

90
Q

How long after neuraxial catheter removal can you resume thrombopropylaxis with LMW heparin?

A

Resume more than 4 hours after catheter removal

91
Q

Does neuraxial analgesia increase the cesarean delivery rate?

A

No

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