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Sp: Methods 1 > 5. Anesthesia in the OB Unit > Flashcards

5. Anesthesia in the OB Unit Flashcards

1
Q

antepartum

A

before birth

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2
Q

dystocia

A

difficult labor

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3
Q

intrapartum

A

during the act of birth

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4
Q

multiple gestation

A

twins, triplets, etc

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5
Q

multiparous

A

has had multiple gestations

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6
Q

normal labor happens at what point in gestation

A

38-40wk

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7
Q

Nulliparous

A

never completed a pregnancy beyond 20 wks

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8
Q

parturient

A

pregnant patient

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9
Q

postpartum

A

after birth

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10
Q

preterm labor

A

<37wks

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11
Q

primapara (primip)

A

first pregnancy

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12
Q

age of viability

A

~24 wks

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13
Q

when would you consider immediate intubation after birth?

A

<28 wks

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14
Q

G (gravida)

A

total number of pregnancies regardless of how they ended

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15
Q

P (parity)

A

number of live births at any gestation OR

the number of completed pregnancies including stillbirths that lasted more than >20wks

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16
Q

does the number of fetuses delivered determine the parity?

A

no

twins = P1

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17
Q

oxytocic (uterotonic)

A

drugs promote uterine contraction

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18
Q

what does promoting uterine contraction do? 2

A

decrease uterine bleeding after delivery

induce labor in pregnant patients

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19
Q

what are 4 uterotonic drugs?

A

pitocin
hemabate
methergine
cytotec

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20
Q

2 effects of pitocin

A

stimulates uterine contraction

induces labor

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21
Q

when is pitocin dosed?

A

after the baby and placenta are delivered

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22
Q

what is the most common side effect of rapid administration of pitocin?

A

hypotension

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23
Q

should pitocin be dosed slowly or quickly?

A

slowly and intravenously

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24
Q

other side effects of pitocin?

A 
N/V
chest pain
ECG changes
chortness of breath
myocardial ischemia
pulmonary edema
death
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25
Q

tradiational Pit dosing?

A

20-40 units in IV bag after delivery of placenta

20 units in each bag after

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26
Q

what is the ED50 of Pit for c-sections?

A

0.35 units non laboring

3 units laboring

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27
Q

Newer pitocin dosing “rule of threes”

A
  1. give 3 units over 30sec (repeat twice if needed)
  2. if no response after 3 doses move to another uterotonic
  3. 3 units/hr for maintenance
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28
Q

Carboprost (hemabate) dose

A

1mL (250mcg) intramuscular

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29
Q

when is hemabate contraindicated?

A

asthma

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30
Q

methylergonovine (methergine) dose

A

1mL (200mcg) intramuscular

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31
Q

when is methergine contraindicated?

A

hypertensive patients

preeclampsia

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32
Q

when is misoprostol (cytotec) considered?

A

if there is still uterine bleeding despite pitocin, methergine, and hemabate admin
given rectally

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33
Q

tocolytic drug

A

promote uterine relaxation and can help prevent labor (also can promote uterine bleeding after birth)

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34
Q

tocolytic drugs 5

A 
1 magnesium
2 beta 2 agonists
3 calcium channel blockers
4 volatile agents
5 nitroglycerin
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35
Q

what are the two calcium channel blockers we would use?

A

nicardipine (cardene)

nifedipine

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36
Q

what is nitroglycerine normally given for?

A

treat HTN or relieve angina in pts with CAD

low doses can cause drops in BP

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37
Q

why does NTG have less of an effect on blood pressure in pregnant patients? 2

A

1 OB pts have increases circ blood volume

2 vessels are already dilated in well hydrated pts

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38
Q

what are the doses of NTG for uterine relaxation?

A

250-500mcg
even up to 1000mcg
(minimal hypotension)

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39
Q

cardiotocography

A

fetal HR monitor

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40
Q

baseline fetal HR

A

HR between contractions

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41
Q

normal fetal HR

A

120-160bpm

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42
Q

bradycardic fetal HR

A

<120bpm

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43
Q

tachycardic fetal HR

A

> 160bpm

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44
Q

fetal heart rate variability

A

healthy fetu the HR constantly fluctuates (associated with fetal movement)

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45
Q

absence of variability of heart rate is a sign of what

A

fetal distress

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46
Q

what else can cause absence of variability other than fetal distress?

A

general anesthesia

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47
Q

short term variability

A

variability that occurs every heart beat

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48
Q

long term variability

A

variability over a longer period can be a difference from 6-25 bpm

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49
Q

which is normally present? short term or long term variability

A

both are normally present in healthy fetus

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50
Q

decel

A

fetal heart rate deceleration refers to a drop in fetal heart rate

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51
Q

what are the 3 types of decel patterns

A

early (type I) decel
late (type II) decel
variable (type III) decel

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52
Q

early decel (type I)

A

decrease in HR occurs at onset of uterine contraction

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53
Q

late decel (type II)

A

decrease in HR occurs after the onset of contraction

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54
Q

variable decel (type III)

A

decrease in HR is variable in intensity, duration, and timing

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55
Q

what are type I decel most likely caused by?

A

vagal response (compression of fetal head)

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56
Q

what is the most ominous/threatening type of decel?

A

late (type II) decel with variability loss

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57
Q

what are type II decels caused by?

A

fetal hypoxia (uteroplacental insufficiency)

58
Q

what are type III decels caused by

A

umbilical cord compression and decompression

59
Q

normal respiratory rate for newborns

A

30-60 breaths/min

60
Q

APGAR score

A

neonatal wellbeing score
1-10 (10 best)
done at 1 (survival) and 5min (neurologic outcome)

61
Q

normal fetal pH?

A

> 7.25

62
Q

when is the fetal pH considered acidotic?

A

<7.2

63
Q

before delivery these things should be done/assessed: 5

A

1 fluid bolus given prior to neuraxial block
2 IV solutions containing dextrose should be used with caution
3 every pt should have a type and screen
4 NPO- modest liquid for uncomplicated labor, high risk= stricter restrictions
5 ASA status 2 or higher

64
Q

how much of a fluid bolus should be given to patients prior to neuraxial block?

A

anywhere from 500-1,500mL

65
Q

what can giving dextrose solutions cause in the fetus?

A

fetal hypersecretion of insulin post delivery and fetal acidosis

66
Q

why should every pregnancy have a type and screen

A

because they all have potential for unexpected massive hemorrhage

67
Q

what drugs should be avoided before the baby is delivered? 3

A

NSAIDS
versed
narcotics

68
Q

why avoid NSAIDS?

A

suppress uterine contractions and promote closure of ductus arteriosus

69
Q

what are the two reasons to avoid versed?

A

potential for post delivery fetal apnea

for awake c-section the mother wants to remember

70
Q

does versed have a negative effect on fetal wellbeing at low doses (1-2mg)?

A

no

71
Q

why would you avoid narcotics?

A

post delivery fetal apnea

-although low dose fent (1mcg/kg) does not appear to affect apgar scores

72
Q

5 options for SVD

A 
epidural
spinal
obstetrician nerve blocks
IV nubain (nalbuphine)
nitrous oxide
73
Q

what is the most popular analgesic option for SVD?

A

epidural because it can keep them comfortable for hours and hours

74
Q

what is the most common local anesthetic for epidural and why

A

marcaine

motor sparing quality

75
Q

what 3 things need to be done prior to placing an epidural?

A

1 pt receives an adequate fluid bolus
2 lab show normal platelets
3 adequate cervical dilation

76
Q

does an epidural prolong labor?

A

yes stage 1 by 12 min and stage 2 by 42 min

77
Q

why would you do spinal for SVD

A

if pt is in late stages of labor and there isnt enough time for epidural onset

78
Q

what is the spinal dose for SVD?

A

3-6mg of marcaine for motor sparing

79
Q

paracervical nerve block for SVD

A

injected vaginal submucosa
relieve 1st stage labor pain
high incidence of fetal bradycardia

80
Q

pudendal nerve block for SVD

A

transvaginal and perineal infiltration of local

relieve 2nd stage labor pain

81
Q

IV nubain for SVD

A

narcotic agonist/antagonist

treats itching from intrathecal narcotics

82
Q

nitrous oxide for SVD

A

pts start breathing in gas at start of contrac`tion and wears off in a few breaths

83
Q

walking epidural

A

narcotics only
or
lower dose/infusion rates of local

84
Q

A patient is hurting at some point after their epidural was started. They either never were comfortable to begin with, or they were initially comfortable but started having pain as they approached the second stage of labor. How should this patient be managed?

A
  1. Inform patients that epidurals take care of sharp pain but not pressure.
  2. Bolus 5-8mL local anesthetic to increase the block density, preferable with a “Stronger” drug (2% lidocaine).
85
Q

After receiving an epidural, a patient still feels pain on one side. How should she be managed?

A
  1. Have her lay on the side that’s hurting
  2. Pull the catheter back 1-2 cm
  3. Pull the catheter and start another epidural
86
Q

generalized c-section outline 9

A 
1 pt arrive in OR
2 ABX administered
3 analgesic method carried out
4 pt in LUD positioning
5 vasopressions given if spinal anesthesia performed
6 surgery start and baby delivered
7 pitocin given after placenta delivered
8 zofran and decadron admin
9 additional drugs given for pain control
87
Q

nausea and vomiting prevention

A

during c-section usually caused by hypotension

prevented by rapid/prophylactic admin of ephedrine or phenylephrine

88
Q

why would some patients get nausea even though they are normotensive? 2

A

1 dominance of parasympathetic

2 vagal stimulation during procedure

89
Q

what two treatments can be used for a woman who has nausea in normotension?

A

zofran

robinul (not atropine bc atropine crosses the placenta)

90
Q

4 anesthetic options for a c-section

A

spinal
epidural
CSE
GA

91
Q

when would you not chose a spinal?

A

pt has working epidural
pt has CI to neuraxial
pt is hemorrhaging/hypotensive
urgent/emergent c section

92
Q

post op pain control for c section under spinal

A

0.2-0.4 mg duramorph
or
5mcg precedex

93
Q

indications for c-section under epidural

A

if they have a working epidural in place, dose to T4

94
Q

when will you not use epidural for c section

A

CI to neuraxial
urgent/emergent c section without epidural in place

95
Q

when will you maybe use an epidural for c section

A

hemorrhage after epidral placement
patchy epidrual block

96
Q

what can you do for a c section with a patchy epidural

A

dose to T4
remove epidural and place spinal
convert to GA

97
Q

risk of spinal after epidural

A

high spinal or total spinal

98
Q
A
99
Q

While you are on call, the labor and delivery department informs you that the obstetrician on call would like to do a C-section in the next 30 minutes. It is non-emergent. From an anesthetic management standpoint, what is the first question you should ask? What is the second question you should ask?

A
  1. Do they have an epidural?

2. Does the epidural work?

100
Q

While on call, the labor and delivery department calls you to come to the OR in the obstetric unit STAT for an emergent C-section. In addition to wanting to know if they have an epidural and whether or not it works, what do you want to know?

A

What is the emergency?
If the patient is hemorrhaging, they will need a general anesthetic (to avoid the sympathectomy).
If the patient is NOT hemorrhaging, they can consider dosing the epidural with chloroprocaine if there is time.

101
Q

case outline for c-sectioin under spinal anesthesia (4)

A
  1. perform spinal with marcaine+duramorph
  2. dose pressors/ place in LUD
  3. admin pitocin after baby and placenta delivered
  4. dose zofran and consider toradol
102
Q

how long does intrathecal duramorph provide analgesia for?

A

12-24 hr

103
Q

total spinal

A

neuraxial block rises above cervical region and produces respiratory arrest and unconsciousness

104
Q

is the patient more likely to stay conscious with a high epidural or high spinal? why?

A

high epidural because the epidural space only extends to foramen magnum

105
Q

explain how you could get a high spinal from bolusing an epidural with saline or local

A

bolusing the epidural causes the dural sac to compress and any local that had diffused there will travel cephalad

106
Q

A 28-year old, G2P1 is undergoing a repeat, non-emergent C-section under spinal anesthesia. PMH is unremarkable, and she has a Mallampati class I airway. When the patient’s spinal block is tested prior to starting, it appears “patchy,” meaning that the mother can feel some pain. What are the anesthetic options for this patient?

A
  1. RSI with general anesthesia, or

2. Can consider N20/ketamine to support the block

107
Q

A 32-year old, G1P0 is undergoing a non-emergent C-section under spinal anesthesia. PMH includes morbid obesity and a Mallampati class IV airway. When the patient’s spinal block is tested prior to starting, it appears “patchy.” What are the anesthetic options for this patient?

A
  1. Can consider N20/ketamine to support the block

2. RSI with general anesthesia

108
Q

A parturient had a spinal block for a C-section. After the baby has been delivered, the mother is uncomfortable with pain. How should she be managed?

A

IV narcotics

109
Q

Prior to a C-section, a laboring pregnant patient develops a high spinal. She is conscious, but starts to panic because she feels like she can’t breathe. SpO2 is currently 96% on a nasal cannula at 4L. How should she be managed at this point?

A
  1. Reverse Trendelenburg
  2. Possible assist ventilation (with possible N20)
  3. Blood pressure support
  4. Prepare for intubation
110
Q

Prior to a C-section, a laboring pregnant patient develops a high spinal and goes unconscious (this is referred to as a “total” spinal). How should she be managed?

A

Intubate and resuscitate

111
Q

case outline for c-section under epidural anesthesia 6

A

1 give abx ASAP in OR
2 raise epidural block to T4
3 pt in LUD
4 admin pitocin after baby and placenta delivered
5 dose duramorph in epidural prior to epidural catheter removal
6 give zofran and toradol

112
Q

If you are called to perform the anesthesia for a non-emergent C-section on a patient whose epidural is working effectively, how should that patient be managed from an anesthetic standpoint?

A

Dose to T4 gradually with lidocaine (or chloroprocaine)

113
Q

If you are called to perform the anesthesia for a non-emergent C-section on a patient whose epidural is “patchy” (not working completely), what are the anesthetic options?

A
  1. Supplement the block with ketamine/N20
  2. RSI
  3. Try and dose the epidural to T4 and see what happens
  4. Pull the epidural catheter and perform a spinal with a reduced dose
114
Q

should you do a spinal after a patchy/failed epidural?

A

some say no

some say you can but you need to lower the dose by 20-30%

115
Q

Let’s say that for this emergent C-section case, the patient is obese, has a Mallampati IV airway, and also does not have an epidural. What options does an anesthetist have in this scenario?

A

RSI with videoscope and LMA as a backup

116
Q

Let’s say that for this emergent C-section case, the patient has an epidural that is “patchy” (not working very effectively). What options does an anesthetist have in this scenario?

A
  1. If the airway looks easy, perform an RSI
  2. If the airway looks difficult, perhaps think about dosing the epidural to T4 with chloroprocaine and/or trying ketamine/N20
117
Q

Let’s say that for this emergent C-section case, the patient has an epidural that is working effectively. How should this patient be managed?

A

Dose to T4 immediately with chloroprocaine/bicarb

118
Q

A laboring pregnant patient is taken to the OR to undergo a C-section for failure to progress. The epidural was dosed to T4 with 15mL of 3% chloroprocaine. 30 minutes into the procedure, the patient starts complaining of pain. How should this patient be managed at this point?

A

5-10mL epidural bolus of local anesthetic

119
Q

3 opteions for postop pain control for c-sections under epidural

A
  1. duramorph 2-4mg through epidural prior to pulling it
  2. order an epidural PCA (walking epidural)
  3. order an IV PCA (if you forget to dose duramorph before you pull the catheter)
120
Q

what is the most common method of postop pain control for c-section with epidural

A

duramorph in epidural prior to pulling

121
Q

how long does epidural duramorph provide analgesia for?

A

18-26 hr

122
Q

PCA

A

patient controlled analgesia

123
Q

advantage to c-section under GA

A
  1. can be started quickly
  2. no sympathectomy
  3. avoids risk of epidural hematoma in pts with low platelet or bleeding disorders
124
Q

disadvantages to c-section under GA

A
  1. increased fetal exposure to drugs
  2. exposed to airway risk including aspiration
  3. mother isnt awake for birth of child
  4. increased risk of PPD
125
Q

when should the anesthetist induce the patient?

A

when the patient is drapped and prepped and the surgeon is ready with knife in hand

126
Q

indications for c-section under GA 5

A

1 emergency with no block in place
2. hypotensive and will not tolerate sympathectomy
3. any contraindication to neuraxial anesthesia or if they request GA
4. spinal or epidural fails
5. pt gets apnea from high spinal

127
Q

placenta previa

A

placenta covers the cervical os

128
Q

symptom of placenta previa

A

painless vaginal bleeding

129
Q

placental abruption

A

placeta detaches from uterus and lead to massive bleeding

130
Q

placenta accreta

A

placenta grows through uterine wall, cause massive bleeding from both organs

131
Q

when would you choose propofol as the induction agent for GA c-section?

A

non hemorrhaging normotensive parturients

132
Q

when would you choose ketamine as the induction agent for GA c-section?

A

internally bleeding or hypotensive parturients

133
Q

when should ketamine be avoided for c-sections?

A

hypertensive or preeclamptic patients

134
Q

case outline for c-section under GA 7

A
  1. give abx ASAP in OR
  2. induce patient
  3. place in LUD
  4. paralyze if needed
  5. admin pit after baby and placenta are delivered
  6. give zofran, fentanyl and reversal (maybe toradol)
  7. plan on IV PCA for postop pain control
135
Q

do muscle relaxants cross the placenta?

A

no

136
Q

are fasiculations more or less noticable in pregnant patients?

A

less noticeable due to progesterone?

137
Q

A laboring pregnant patient is taken to the OR to undergo a C-section for failure to progress (non-emergent). Past medical history includes preeclampsia and thrombocytopenia. General anesthesia is planned. After induction, the anesthesiologist is unable to intubate the patient. What should be done at this point?

A

awaken the mother

138
Q

What if the patient in the previous example was having an emergent C-section for type II fetal decelerations. What is the correct thing to do if intubation is unsuccessful?

A

Place an LMA and hold cricoid pressure until the patient can be intubated

139
Q

how do you reverse muscle relaxants in pregnant pts

A

neostigmine with atropine

(atropine crosses placenta, robinul does not)

140
Q
A

Sp: Methods 1 (15 decks)

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