Analgesia in Labor Lecture Powerpoint

Question 1

Pain of uterine contraction

Answer 1

Conducted thru small sensory nerve fibers of the paracervical and inferior hypogastric plexuses to join the sympathetic nerve chain at L2 L3, pain of uterine contractions often referred to the area over the upper sacrum and the lower lumbar spine (diffuse and not well localized), as fetus descends thru pelvic floor pain becomes predominantly somatic and is better localized, high progesterone levels reduce anesthetic requirements by activating endorphins which increases threshold to pain, but augmentation with oxytocin increases strength of contraction and pain

Question 2

Parenteral or systemic opioids

Answer 2

Play a role in labor pain relief, inexpensive and require no specialized expertise other than IV access, however often have little effect on maternal pain scores and provide unreliable analgesia and commonly have ADR’s

Question 3

2 commonly used systemic opioids for labor

Answer 3

• fentanyl

- morphine

Question 4

Opioid agents impact on fetus

Answer 4

• Reduce fetal heart rate
• neonatal respiratory suppression
• freely crosses placenta
• drug elimination takes longer than in adults

Question 5

Nonopioid with similar effect to morphine in pain control in labor

Answer 5

IV tylenol

Question 6

Local infiltration agent for pain relief during labor

Answer 6

1% lidocaine

Question 7

Excess lidocaine ADR’s (8)

Answer 7

• relaxed feeling
• drowsiness
• lightheaded
• tinnitus
• metalic taste
• cardiac arrhythmia
• arrest
• slurred speech

Question 8

Pudendal block

Answer 8

Provides analgesia of the vaginal introitus and perineum by bilateral injections of 1% lidocaine 5-10mL for pain relief of the 2nd stage of labor, relatively small systemic absorption therefore little opportunity to affect fetus

Question 9

Paracervical block

Answer 9

Rarely used for labor pain relief as associated with fetal acidosis and bradycardia, good for excellent pain relief in the first stage of labor, very effective and fast

Question 10

Regional (neuraxial) analgesia and anesthesia

Answer 10

-Includes epidural and spinal techniques, require administration by qualified healthcare provider, suitable for labor analgesia and operative analgesia, provides pain relief during labor with minimal maternal and neonatal adverse effects, >60% of US women use

Question 11

Lumbar epidural analgesia

Answer 11

Injection in the potential space between the bone and the dura mater

Question 12

Epidural advantages (3)

Answer 12

• patient remains awake and cooperative
• incidence of complication is very low
• can be used for analgesia or anesthesia for vaginal or c section delivery

Question 13

Epidural disadvantages (6)

Answer 13

• possibility of poor perineal analgesia
• presence of hotspots where analgesia is insufficient
• delayed onset of action up to 10 min
• technical difficulty
• accidental dural puncture
• hypotension

Question 14

Spinal block

Answer 14

Not often used lidocaine or tetracaine not used until all criteria for forceps delivery are met, , excellent anesthetic for C section

Question 15

Intrathecal narcotic only injection

Answer 15

-used during first stage of labor, no local anesthetic and therefore no paralysis, allowing for ambulation, causes “itching”, 2 hours excellent analgesia, uses fentanyl and morphine

Question 16

Post spinal headache

Answer 16

Postural headache in 1% of parturients developed after spinal, caused by CSF leaking from puncture site and incidence is reduced with use of noncutting needles in administration of spinal, duration 5-12 days and blood patch can treat in severe cases (draw blood and inject it to clot the CSF leak really fixing headache quick)

Question 17

General anesthesia for labor

Answer 17

Uncommon method for vaginal or cesarean delivery usually limited to emergency deliveries or when epidural is contraindicated or has already failed, problems is that labor begins without warning so can’t do if on a full stomach (causes aspiration)

Question 18

General anesthesia and airway management

Answer 18

More challenging in pregnancy, awake intubation with videolaryngoscopy is alternative option

Question 19

Anethesia risk factors for complication (8)

Answer 19

• marked obesity
• severe edema or anatomical anomalies of face and neck
• small mandible
• short stature, arthritis of neck
• large thyroid
• asthma, copd, cardiac disease
• severe pre/eclampsia
• previous history of anesthetic complications

Question 20

Anesthesia related death causes (5)

Answer 20

• aspiration
• intubation problems
• inadequate ventilation
• respiratory failure
• cardiac arrest

Question 21

Anesthestics complications (4)

Answer 21

• all cross placenta
• risk of aspiration of gastric contents
• fasting not always possible
• failed intubation uncommon but serious when occurs

Question 22

General anesthetic agents (3)

Answer 22

• gaseous nitrous oxide
• inhaled isoflurane and halothane
• IV thiopental or propofol

Question 23

Epidural does NOT increase ____ rate

Answer 23

C section

Question 24

Spinal or general anesthesia is appropriate for emergency c section when there is no…

Answer 24

…epidural

Question 25

Relative contraindication to neuraxial (epidural or spinal)

Answer 25

Thrombocytopenia (safe generally at >80,000)

Question 26

In absence of contraindication, maternal request is sufficient medical indication for pain relief in...

Answer 26

...labor

Question 27

Neuraxial (epidural or spinal) procedures must be withheld for 10-12 hours of the last dose of...

Answer 27

...LMW heparin