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Principles III > Anesthesia for Labor, Vaginal, and C/S deliveries > Flashcards

Anesthesia for Labor, Vaginal, and C/S deliveries Flashcards

1
Q

What is the first stage of labor and delivery?

A

onset of uterine contractions to complete cervical dilation, includes ischemic pain of uterine contraction and visceral pain from T10-L1

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2
Q

What is the second stage of labor and delivery?

A

complete cervical dilation to delivery of fetus, includes somatic pain from fetal descent from S2-S4

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3
Q

What is the third stage of labor and delivery?

A

delivery of placenta

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4
Q

What are the goals for pain relief during labor and delivery?

A
  • decreased sense of uterine contraction and of fetal descent
  • preservation of pressure sensation to facilitate expulsive efforts
  • minimal motor block to improve effectiveness of expulsive efforts
  • inform mom that pressure and pain are not the same thing and pressure is good for baby and her
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5
Q

What inhalation agents are used for labor and delivery?

A

Nitrous oxide
- commonly used in UK
- valuable for brief analgesia such as for emergent forceps
- increased sensitivity of parturient makes it esp. effective
Volatiles agents

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6
Q

Does epidural analgesia change the rate of cervical dilation?

A

don’t know, there’s research that states it increases and decreases cervical dilation

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7
Q

What are the types of analgesia that can be used for labor and delivery?

A
  • local anesthetics
  • opioids
  • adjuvants
  • CLE/SAB/CSE
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8
Q

What local anesthetics can be used?

A

Bupivacaine (Marcaine, Sensorcaine)
Lidocaine (Xylocaine)
2-Chloroprocaine (Nescaine)
Ropivacaine

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9
Q

What opioids can be used?

A

Fentanyl
Sufentanil
Morphine
Meperidine

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10
Q

What are some adjuvants that can be used?

A

alpha 2 receptor agonists
epinephrine - used to prolong spinal anesthetics
Ketamine - good for spotty spinal/epidural
Nubain/Stadol - good for reversing heavy-handed narcotics
Naloxone/Nelmefene - good for reversing effects of intrathecal narcotics such as itching
Barbituates and tranquilizers (used in remote practices)

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11
Q

What are some CV physiologic effects of epidural/intrathecal analgesia?

A

Sympathetic block - veno and arteriodilation with decreased venous return and decreased afterload, hypotension with reflex tachycardia
Bradycardia with high block

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12
Q

What are respiratory effects of epidural/intrathecal analgesia?

A
  • no significant effect if level kept low (
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13
Q

What are some fetal effects from epidural/intrathecal analgesia?

A
  • decreased uteroplacental perfusion can result from prolonged maternal hypotension which can cause fetal acidosis
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14
Q

What are some fetal effects from all the drugs that can be given for analgesia?

A
  • principal concern is sedation and respiratory depression from opioids, timing is important so don’t administer them too close to delivery
  • transient FHR abnormalities have been reported after initial epidural and subarachnoid dose
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15
Q

What are some advantages of intrathecal opioids?

A
  • ease of administration
  • faster onset than epidural
  • typically results in no motor blockade
  • typically results in no alteration of vital signs
  • effects are reversible for both mother and fetus
  • often used in conjunction with CLE (CSE)
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16
Q

What are some disadvantages of intrathecal opioids?

A
  • morphine has long latency and unsatisfactory for second stage of labor
  • brief latency with most that do not last throughout first stage
  • possibility of PDPH
  • side effects that include respiratory depression, urticaria, N/V, urinary retention
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17
Q

What are the effects of intrathecal opioids on labor?

A
  • no apparent effect on progress of labor when intrathecal opiates administered alone or with small amount of bupivacaine (exception of meperidine)
  • more beneficial in use in some cardiac patients and for early or late use in labor
  • no effect on uteroplacental perfusion
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18
Q

What are the opioids that can be given intrathecally?

A

fentanyl
sufenta
duramorph
meperidine

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19
Q

What is the onset and duration of fentanyl intrathecally?

A
  • Fast onset within 5 minutes
  • Provides analgesia anywhere from 1-3 hours
  • Smaller incidence of side effects when compared with MSO4
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20
Q

What is the onset and duration of sufenta?

A
  • Fast onset (within 5 minutes)
  • Duration of action anywhere from 1-4 hours
  • Analgesia more profound in reported cases than with fentanyl
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21
Q

What is the onset/characteristics/dose of intrathecal morphine?

A
  • Dose 0.1-0.3 mg
  • Slow onset (45-60 minutes)
  • Typically not adequate to provide analgesia during entire labor
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22
Q

What is the onset/characteristics of intrathecal meperidine?

A
  • onset of action within 10 minutes
  • local anesthetic property
  • higher incidence of nausea and motor blockade
  • can be used to provide surgical anesthesia
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23
Q

What should you remember when combining intrathecal LA with opioids?

A
  • effective and controllable analgesia
  • maternal safety
  • no weakening of maternal POWERS
  • no alteration of maternal PASSAGES
  • no depression of the PASSENGER
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24
Q

What is the most frequent combination of intrathecal LA and opioids?

A

PF isobaric bupivacaine 2.5 mg (small dose) with 20-25 mcg Fentanyl or 10-15 mcg Sufenta

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25
Q

What are some advantages of combining small dose LA with opioids?

A
  • minimal motor blockade
  • minimal alteration of vital signs
  • can be given at any stage of labor
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26
Q

What is a disadvantage of giving a combination of intrathecal LA with opioids?

A

all side effects associated with intrathecal opioids

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27
Q

What helps your determine which type of LA to choose?

A

dependent on when and for what reason block is induced, typically given for immediate analgesia as needed in forceps delivery or if extensive repairs are needed

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28
Q

What LA and doses can be used for a saddle block?

A

Lidocaine 30-35 mg
Tetracaine 3 mg
Bupivacaine 7.5 mg

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29
Q

Why would you use a vasoconstrictor with LA?

A
  • potentiates lidocaine and tetracaine
  • no effect on bupivacaine
  • LA properties
  • use carefully with pre-existing HTN
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30
Q

What monitoring do you do with a spinal/epidural?

A
  • fetal heart rate monitoring (cont.)
  • uterine contraction monitoring (cont.)
  • blood pressure monitoring (q5min for first 30 min then 15 min thereafter)
  • pulse ox (first 30 mins)
  • verbal (cont.)
  • respiratory rate and heart rate
  • anesthetic level monitoring
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31
Q

What is the epidural level and duration dependent on?

A

dose, volume, and concentration of LA

presence or absence of epi

32
Q

What is the level and duration of an epidural not dependent on?

A
  • weight, height, age, and rate of injection
  • baricity of LA
  • maternal position (although can have some influence)
33
Q

What are opioids that can be used in an epidural?

A

fentanyl
duramorph
sufenta

34
Q

What LA are used in epidurals?

A

chloroprocaine (rapid onset and short duration)
lidocaine (intermediate onset and duration)
bupivacaine (slow onset and prolonged duration)
ropivacaine being used more now

35
Q

What are the 2 epidural techniques?

A

segmental block

continuous block

36
Q

What is a segmental block epidural technique?

A

intermittent injections to isolate specific segments

37
Q

What is a complete block epidural technique?

A
  • intermittent or continuous infusions
  • more stable depth of analgesia
  • lower blood concentrations seen with continuous
  • lower risk or complete spinal with continuous
  • lower blood concentrations if migration of catheter
  • lower incidence of hypotension
38
Q

What is the loading dose and starting infusion rate for an epidural?

A

use loading dose to achieve level of analgesia and then start infusion of 8-12 mL/hr

39
Q

At what level do you want a block before initiating continuous infusion?

A

at least T10-L1

40
Q

How often should epidurals be monitored?

A

Check level carefully for first 30 min then hourly rounds on patients to check vital signs and level of block and note on anesthesia record

41
Q

What are some of the effects on labor that can be caused by an epidural block?

A
  • slow progression of labor
  • cessation of labor
  • can disrupt uteroplacental perfusion due to hypotension
  • fetal hypoxia/asphyxia
  • somnolence/hypoxemia
  • nausea/vomiting
42
Q

What are some problems with epidural analgesia?

A
  • asymmetrical sensory block
  • diminishing analgesia
  • dense motor block
  • patchy block
  • migration of catheter
  • LA toxicity
  • hypotension
  • maternal and fetal compromise
43
Q

What do you monitor during epidural analgesia?

A
  • vital signs
  • fetal heart rate
  • contractions
  • level of block
  • level of maternal consciousness/awareness
  • oxygenation
  • urinary output (lose sensation of when bladder is full)
44
Q

What are some complications of epidural analgesia?

A
  • inadvertent dural puncture
  • subdural injection
  • massive epidural analgesia
  • vital signs
  • inadvertent intravascular injection
45
Q

What are characteristics of PDPH?

A
  • positional, occurs when mom sitting up
  • frontal to occiput
  • visual disturbances
  • nausea
  • time
46
Q

What is the treatment for PDPH?

A
  • bedrest
  • fluids
  • caffeine
  • theo-dur
  • epidural blood patch
47
Q

What can cause backaches and are they common?

A
  • not common
  • dependent on technique
  • dependent on skill of practitioner
  • studies show no increase in incidence when compared to normal labor
48
Q

What are some obstetrical causes of neurological complications?

A
  • prolapsed intervertebral disk (from exertional efforts causing spinal root compression)
  • L4-L5 compression from descending head or use of forceps (see foot drop, hypothesia of foot and calf, quadriceps weakness)
  • femoral nerve (L2-L4) injured from lithotomy position (see knee problems and quadriceps paralysis)
  • LFC (L2-L3) injured during lithotomy and c-section, see transient numbness of thigh
  • sciatic nerve (L4-S3) can be injured during lithotomy, see pain that radiates from gluteal to foot and inability to flex the leg
  • obturator (L2-L4) injured with lithotomy causing weakness or paralysis of thigh adductors
  • common peroneal nerve (L4-S2) injured during lithotomy position due to prolonged compression of lateral aspect of knee, lose ability to assume the erect position with foot drop
  • saphenous nerve (L2-L4) injured during lithotomy position, loss of sensation over the medial aspect of the foot and anteriomedial aspect of the lower portion of leg
49
Q

What are anesthesia related causes of neurological complications following spinal/epidural for analgesia?

A
  • prolonged neural blockade (delayed recovery more pronounced with high concentrations of bupivacaine and tetracaine)
  • bladder dysfunction
  • shivering and shaking
  • Horner’s syndrome
  • Nerve root trauma
  • Cauda equina syndrome/adhesive arachnoiditis
  • epidural abcess/hematoma
50
Q

What are anesthetic goals for regional anesthesia for a c-section?

A
  • fetal safety
  • maternal comfort
  • no adverse impact on mode and/or duration of delivery
  • no adverse impact on “birth experience”
51
Q

What level do you want for regional anesthesia for a c-section?

A

T4

52
Q

What types of regional anesthesia are available for c-section?

A

spinal/SAB

epidural (lumbar or caudal)

53
Q

What are positioning considerations for a c-section?

A
  • aortocaval compression
  • left uterine displacement
  • avoid systemic hypotension
  • maintenance of uterine blood flow
54
Q

What are problems with spinal anesthesia for c-section?

A
  • hypotension
  • n/v
  • headache
  • technical problems (large patients)
55
Q

What premeds should you give before doing spinal/epidural anesthesia for a c-section?

A

30 mL NaCitrate PO
10 mg reglan
volume expansion and pre-load with crystalloid

56
Q

What size and type of needle can you use to administer spinal anesthesia for a c-section?

A

25-27 g Sprotte or Whitacre

57
Q

What is the concentration and dose of tetracaine for spinal anesthesia before a c-section?

A

1% Tetracaine in 10% dextrose
90-120 minutes
65” - 14 mg

58
Q

What is the concentration and dose of bupivacaine for a spinal before a c-section?

A

0.75% bupivacaine in 8.5% dextrose
90-120 minutes
65” - 1.6 mL or 12 mg

59
Q

What is the dose for opioids you can add to a spinal for postoperative analgesia following a c-section?

A

Fentanyl 25 mcg

MSO4 200 mcg

60
Q

What are contraindications to spinal anesthesia for a c-section?

A
  • severe maternal bleeding
  • severe maternal hypotension
  • coagulation disorders
  • neurological disorders
  • patient refusal
  • short stature and morbidly obese
  • sepsis in local area or generalized
61
Q

What are advantages of epidural anesthesia for c-sections?

A
  • less incidence and severity of maternal hypotension
  • avoidance of dural puncture
  • with catheter placement it can be redosed and give opioids
62
Q

What are disadvantages of epidural anesthesia for c-sections?

A
  • increased complexity of technique with greater incidence of failure
  • slower onset (not used for emergent cases unless already in place )
  • need for much larger amts of LA which can potentiate LAST
63
Q

How much volume of LA do you need to give in an epidural for a c-section to achieve at least a T4 level?

A

about 20 mL

64
Q

What concentration of bupivacaine can you use in an epidural for a c-section and how long will it last?

A

bupivacaine 0.5%

75-90 mins

65
Q

What concentration of chloroprocaine can you use in an epidural for a c-section and how long will it last?

A

chloroprocaine 3%

35-40 mins

66
Q

What concentration of lidocaine can you use in an epidural for a c-section and how long will it last?

A

lidocaine 2%

75-90 mins

67
Q

What can you add to an epidural to speed the onset for a c-section?

A

NaBicarb

68
Q

What are contraindications to epidural anesthesia?

A
  • severe maternal hypotension
  • coagulation disorders
  • some forms of neurological disorders
  • patient refusal
  • technical problems
  • sepsis, local or generalized
69
Q

Can you use 0.75% Bupivacaine for an anesthesia epidural?

A

no, causes cardiac and CNS toxicity

70
Q

What are some complications of chloroprocaine?

A
  • arachnoiditis
  • diminishing analgesia
  • effect on bupivacaine
71
Q

What are some differences between spinal and epidural anesthesia for c-sections?

A
  • spinal more profound block
  • epidural easier to control block height
  • epidural better control of hemodynamics
  • epidural opioids have less systemic side effects
72
Q

What are other anesthetic blocks you can do for labor and delivery?

A

caudal block
paracervical block - manages visceral pain in 1st stage
pudendal block - manages somatic pain during 2nd stage

73
Q

What are some indications for general anesthesia for a c-section?

A
  • patient refusal of regional anesthesia
  • fetal emergencies (abruption, prolapsed cord, etc)
  • certain neuromuscular diseases - particularly with neurologic compromise
74
Q

What are advantages of general anesthesia for a c-section?

A
  • speed of induction
  • reliability
  • reproducibility
  • controllability
  • avoidance of hypotension
75
Q

What are some disadvantages of general anesthesia for a c-section?

A
  • possibility of maternal aspiration
  • airway management
  • narcotization of the neonate
  • maternal awareness during light and general anesthesia (no midaz or narcs until cord is clamped)
76
Q

What are complications of general anesthesia for a c-section?

A
  • maternal aspiration
  • maternal awareness
  • anticholinergics
  • airway management (dec. FRC)
77
Q

Which causes more cardiovascular depression, regional or general anesthesia for c-sections?

A

regional

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