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OB > Analgesia For L&D > Flashcards

Analgesia For L&D Flashcards

1
Q

Benefits of Analgesia L&D

A
  1. Decreased catecholamines
  2. Decreased maternal oxygen consumption
  3. Decreased hyperventilation
  4. Indwelling epidural can avoid emergency GA (especially difficult airway, obese, pre-eclamptic, anyone with increased risk of C/S)
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2
Q

Increased pain reported by

A

Nulliparous
Fetal malposition/dystocia
Dysfunctional labor
Induced labor

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3
Q

What decreases pain sensitivity

A

Upregulation of descending pain modulating pathways (NE & serotonin)
Increased endogenous endorphins
Progesterone mediated tolerance

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4
Q

What stage of labor involves uterine contraction & dilation

  • involves the cervix, uterus, upper vagina
  • visceral afferent fibers enter spinal cord at T10-L1 (paracervical ganglion)
  • sympathetic chain at L2 and L3
A

First stage of labor

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5
Q

What stage of labor involves the expulsion of the fetus

  • involves mid and lower vagina, vulva, perinum
  • somatic afferent fibers enter spinal cord at S2-S4 pudendal nerve
A

Second stage of labor

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6
Q

What stage of labor involves the delivery of the infant to expulsion of the placenta?

A

Third stage

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7
Q

Estrogen competes for which receptor

A

Mu

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8
Q

Opioids do what to FHR variability

A

Reduced FHR variability

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9
Q

Efficacy and side effects are drug dependent or dose dependent

A

Dose dependent

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10
Q

Which systemic opioid does not accumulate in the fetus?

A

Remifentanil 25-50 mcg IV q5-10min

But maternal monitoring required

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11
Q

Why is meperidine no longer popular in OB

A

Active metabolite - respiratory neonatal depression and neurobehavioral changes
25-50 mcg IV q2hr

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12
Q

Which systemic opioid accumulates in fetal blood

A

Sufentanil

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13
Q

Systemic opioid doses for Morphine and Fentanyl

A

Morphine 2-5 mg IV q2-3 hr

Fentanyl 25-50 mcg IV q 30-45 min

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14
Q

Which two systemic opioids have a ceiling effect on respiratory depression?

A

Nalbuphine 10-20 mg IV q3-6hr

Butorphanol 1-2 mg IV q4-6 hr

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15
Q

Why should nitrous gas be used alone for pain relief?

A

When used alone, no risk of maternal hypoxia and no adverse effects on the neonate

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16
Q

What effect does nitrous have on early stages of labor

A

Preserves contractility and no neonatal depression

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17
Q

Which regional anesthesia method is not continuous for vaginal delivery

A

Single shot spinal

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18
Q

Which regional anesthesia method has a slow onset compared to the others

A

Continuous epidural

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19
Q

Which three regional anesthesia methods have the ability to extend to anesthesia for C/S

A

Continuous epidural
Continuous spinal
CSE

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20
Q

Epidural requires smaller or larger doses compared to spinal

A

Larger

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21
Q 
Which regional anesthesia method avoids the need to access neuraxial canal through lumbar interspace?
Also requires large volumes/doses 
May be more technically difficult
Higher r/o infxn
Risk of inadvertent fetal injection
A

Continuous Caudal

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22
Q

Which regional anesthesia methods require low dose LA and opioids?

A

CSE, continuous spinal, single shot spinal

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23
Q

Which regional anesthesia method has a higher risk of maternal toxicity and fetal drug exposure; and which has a higher risk of fetal bradycardia?

A

Continuous epidural and CSE

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24
Q

Which regional anesthesia method has a complete analgesia with opioid alone thus an increased risk of puritis

A

CSE

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25
Q

Which regional method has no dural puncture requirement and which has a large dural picture increased risk of PDPH

A

Epidural and Spinal

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26
Q

Which regional method has a possibility of OD and total spinal if mistaken for epi cath

A

Continuous spinal

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27
Q

Neuraxial contraindications

A 
Refusal or inability to cooperate
Elevated ICP
Coagulopathy and recent pharmacologic anticoag
Skin infection at site
Uncorrected Maternal hypovolemia
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28
Q

Which skin prep is preferred for neuraxial anesthesia?

A

CHG

Immediate action, residual activity, effectiveness against wide range of microorganisms

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29
Q

Which skin prep is contraindicated

A

Providine iodine and iodine base

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30
Q

What are the disadvantages of Epidurals

A

Side effects
Prolongs labor (15-20 min)
Inhibits ability to push
Fetal bradycardia after CSE

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31
Q

Which neuraxial anesthesia has the most effective mode in pain relief, best benefit to risk ratio, safest for CS, provides anesthesia for 1st and 2nd stages of labor, provides a differential blockade

A

Epidural

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32
Q

Preload patient with how many cc’s of fluid before an epidural

A

250-500

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33
Q

True or False: Temperature increase is likely in epidural

A

True

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34
Q

What physiological changes do you consider with epidural placement

A

Hormonal : Progesterone in CSF, Alkalinity of CSF (give acid prophylaxis)
Epidural veins engorged

Physical: exaggerated flexion causes aortocaval compression, iliac crest level

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35
Q

What happens with intravascular injection of epidural test dose

A

HR changes 20 BPM within 45 seconds

Circum-oral numbness/ringing in ears

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36
Q

What happens with subarachnoid injection with epidural test dose

A

Rapid onset of sensory and motor blockade

With/without hypotension

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37
Q

What should you do after injection of epidural test dose?

A

Aspirate

Check BP q5 min after bolus up to 15-30 min

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38
Q

What is the most commonly used amide LA in OB (concentration too)…

A

0.25% bupi

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39
Q

What about bupi limits placental transfer?

A

Its highly protein bound

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40
Q

What is the onset and peak of bupi

A

Onset 8-10 min

Peak 20

41
Q

How long does 8-10 mls of 0.25% bupi lasts?

A

2 hours

42
Q

Why would you want diluted bupi (0.125%)?

A

You would want diluted bupi to provide a differential blockade (sensory)
And you are able to give more volume to provide adequate analgesic spread

43
Q

What are the continuous infusions of bupi?

A

0.0625 or 0.125% with fentanyl 2mcg/ml

44
Q

What bupi concentration is contraindicated with epidurals?

A

0.75%

45
Q

Which is the ester LA with the fastest onset of action for epidurals?

A

2-Chloro

Metabolized by pseudocholinesterase

46
Q

5-10mls of 2% 2chloro provides relief for how long

A

40 min

47
Q

Which LA adversely effects the efficacy of subsequent epidural bupi and opioids by antagonizing mu and kappa receptors

A

2 chloro

48
Q

What makes 2 chloro the best choice for stat CS for fetal distress?

A

Fetal acidosis doesn’t increase placental transfer

49
Q

Intermediate duration of action (between 2chloro and bupi)

A

Lidocaine

50
Q

Concentrations of Lidocaine used for epidurals

A

1% and 0.75%

51
Q

Lidocaine crosses placenta much or less easier than bupi?

A

Much Easier

52
Q

What effect does IV lidocaine have on UBF

A

Decreases UBF with vasoconstriction

53
Q

Which LA provides a strong motor block

A

Lidocaine

54
Q

Which LA provides an increased risk of neurotoxicity if injected into the subarachnoid space?

A

Lidocaine

55
Q

What are the epidural bolus and continuous infusions doses for bupi?

A

Bolus 0.065-0.25% initially 5-10ml slowly titrate more to expand segmental block
Continuous 0.065-0.125% (fentanyl 1-2mcg/ml)

56
Q

Lidocaine is not used for epidurals due to placental transfer, strong motor block, and _______

A

Tachyphylaxis

57
Q

What is a top off dose of bupi?

A

0.25% 4-10 ml

58
Q

Someone calls you saying that the catheter is in the epidural space but the extent of the block is inadequate
What steps do you take?

A
  1. Is infusion rate high enough? Have they used bolus option?
  2. fetal malpresentation? (Not getting enough relief depending on their position)
  3. Inject dilute solution of LA with or without opioid
  4. Alter maintenance technique
  5. If unsuccessful replace catheter
59
Q

Someone calls you for an asymetric block

What do you do?

A
  1. Inspect and withdraw 1cm and resecure
  2. Inject dilute LA with or without opioids
  3. Alter maintenance technique
  4. Place less blocked side in dependent position
  5. If unsuccessful replace catheter
60
Q

Someone calls you that the catheter is in the epidural space but there is breakthrough pain
What do you do?

A
  1. Is the infusion rate high enough? Have they used the bolus option?
  2. Inspect catheter site and withdraw 1cm
  3. Inject more concentrated solution of LA with/without opioid
  4. Alter maintenance technique
  5. If unsuccessful replace catheter
61
Q

What effect does epidural analgesia have on uterine activity

A

Decreases it for 10-15 min but resumes to normal within 30

Affects more intensity of uterine contractions instead of frequency

62
Q

What does epidural analgesia do to pitocin?

A

Inhibits secretion of it

63
Q

Uterine vasoconstriction happens when with epidural analgesia?

A

If it’s placed intravascularly

64
Q

CSE doses

A

10 mcg of sufentanil and 2.5 mg of bupi

25 mcg of fentanyl and 2.5 mg of bupi

65
Q

Which needle is inserted first with CSE

A

Epidural with positive LOR

Then spinal inserted to reach intrathecal space

66
Q

What causes CSE to have a rostral spread?

A

Volume in epidural compresses intrathecal space

Achieving a higher level with a smaller dose

67
Q

Neuraxial anesthesia method for an unintended intrathecal placement of a planned epidural catheter?

A

Continuous spinal

68
Q

Continuous spinal has what doses?

A

Fentanyl 10-25mcg with bupi 1-2.5mg

Bupi 0.125% with fentanyl 2mcg/ml run at 1-1.5 ml/hr

69
Q

When is a single shot spinal or “saddle block” done?

A

Immediately prior to delivery with patient in sitting position for 3-5 min

70
Q

For what stage of labor is a saddle block done for?

A

STAGE 2 - S2-S4

71
Q

What LAs are used for single shot spinal?

A

25-50mg of lido
4-6mg of tetra
6-8mg of bupi

72
Q

How do you make a single shot spinal adequate for stage 1 of labor

A

Give larger amounts of LA to get to T10 level

73
Q

What neuraxial anesthesia method is useful for forceps delivery and breech babies

A

Single shot spinal

74
Q

Fluid bolus for single shot spinal

A

500-1000ML

75
Q

When is saddle block performed with contractions?

A

Between them to minimize cephalad spread

76
Q

Level of block following a spinal is affected by what three things

A

Baricity of LA
Position of patient
Drug dosage

77
Q

Which neuraxial anesthesia method is available for patient with lumbar fusion history

A

Caudal block

78
Q

Co-administration of opioid with LA decreases or increases pruritis
Co-admin of opioid and epi decreases or increases pruritis

A

Decreases

Increases

79
Q

What other side effects are there for neuraxial anesthesia besides hypotension and pruritis

A

Fever, shivering, urinary retention

80
Q

Tx of pruritis for neuraxial anesthesia

A

Centrally acting opioid agonist/antagonist or partial agonist-antagonist

  • narcan 40-80mcg IV, 1-2 mcg/kg/hr infusion
  • Nalbuphine 2.5-5mg IV
  • naltrexone 6mg PO

Benadryl

81
Q

What hormone enhances the cardiac toxic potential of bupi?

A

Progesterone

82
Q

How can you prevent PDPHA

A
  • Spinal needle 25-27g
  • U/S
  • caffeine and hydration
83
Q

Tx for PDPHA

A 
Intrathecal catheter placement 
Analgesics
Horizontal position
Caffeine
Sumatripan (imitrex)
Epidural blood patch epidural access 12-20 ml of pt’s blood
84
Q

Which nerve injury is associated with the compression between the descending fetal head and sacrum
Also associated with mid to high forceps use

A

Lumbosacral trunk L4 L5

85
Q

Nerve injury associated with injury in the lithotomy position bc of hyperacute hip flexion and use of retractors during CS

A

Femoral L2-L4 and lateral femoral cutaneous nerve L2-L3

86
Q

Nerve injury associated with incorrect lithotomy positioning with knee extension and external hip rotation

A

Sciatic L4, L5 S1-3

87
Q

Nerve injury with lithotomy positioning from acute flexion in thigh to groin
Esp with obese women

A

Obturator L2-L4

88
Q

Nerve injury from lithotomy that shows foot drop

A

Common peroneal L4-5 S1-2

89
Q

Saphenous nerve injury is affected from what

A

Lithotomy

90
Q

What complications can you see with paracervical block

A

Maternal rare
Fetal transient bradycardia
Direct injection into presenting part

91
Q

DOA of paracervical block

A

30-60 min

92
Q

Which block Does not affect duration of labor

A

Paracervical

93
Q

How do you perform paracervical block

A 
Inject 2ml of LA under epithelium, not deeper than 3mm
NO EPI
At 3, 5, 7, 9 o’clock
Optional 2 and 10 oclock
Aspirate prior to injection
94
Q

What are the two approaches for pudendal block

A

Transvaginal and transperineal

95
Q

What are the complications from pudendal block besides provider needle stick?

A

Maternal hematoma, systemic toxic reaction, trauma to sciatic, puncture of rectum, fetal injection

96
Q

Steps for a pudendal block

A 
Needle embedded in sacrospinous ligament
Need LOR
Aspirate through 180 degree rotation
3-5ml of LA injected
Needle advanced 1cm further and another 3-5ml solution injected
97
Q

Which drug is safer for uterine relaxation and episiotomy repair ?

A

Uterine relaxation - NTG

Episiotomy repair - local and ketamine < 0.5 mg/kg

98
Q

If you must do GA, which induction drugs are preferred with GA

A

Thiopental, prop, ketamine, or etomidate

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