Anesthesia for Operative Delivery (Extra)) Flashcards
What is operative vaginal delivery?
Forceps or vacuum assisted delivery
Less use these days partly due to medico-legal concerns, shortens 2nd stage of labor
What are some factors contributing to operative vaginal delivery?
- Non reassuring FHR
- Maternal Exhaustion
- Arrested Descent
What are the four T’s associated with maternal hemorrhage?
- Tone
- Trauma
- Tissue (retained products)
- Thrombin (coagulation status)
True or False: Maternal mortality is 10 times greater with cesarean delivery compared to vaginal delivery.
True:
Failed intubation
Inadequate ventilation
Pulm. Aspiration
What is the type of skin incision based on?
How rapidly the fetus must be delivered
Differentiate which skin incision is being described:
Lower incidence of uterine rupture
Higher likelihood of umbilical hernia
Less painful
Faster access
Cut from umbilicus to pubic symphasis
Lower incidence of uterine rupture: Low Transverse
Higher likelihood of umbilical hernia: Low Vertical/Midline
Less painful: Low Transverse
Faster access: Low Vertical/Midline
Cut from umbilicus to pubic symphasis: Low Vertical/Midline
What type of uterine incision is most common for cesarean deliveries?
Benefits of this?
Low Transverse
This incision has less risk of bladder injury and uterine rupture in future pregnancies.
True or False:
There is a high risk of uterine rupture with a low vertical incision.
False:
There is a higher risk than low transverse, but still a low risk in general.
What is the risk of uterine rupture with a classical incision?
Approximately 10%
TOLAC is contraindicated with classical incisions due to this high risk.
Comapred to the other 2 uterine incisions, the classical incision puts the patient at a higher risk of these 2 complications:
- Abdominal adhesions
- Uterine rupture
Describe the step-by-step process of how to handle a maternal hemorrhage:
Call for Help/ Blood Products
- IV Fluids, Albumin, Warm products
2nd Large bore IV & Airway
Check uterine tone
- Pitocin
- Consider Methergine/Hemabate
TXA (1g over 5 min)
Coags and Calcium
What can the OB do to aide with Maternal hemorrhage?
- Compression/B Lynch suture
- Hysterectomy
- Uterine artery ligation
- Bakri Balloon
What complications from previous c-sections can affect future pregnancies?
- Placenta Previa
- Placenta accreta, increta, percreta
- Uterine rupture
- Hemorrhage
Known issue = GETA
What classifies a “high-risk” pregnancy?
- Multiparity, Multiple C-sections
- Classical incision
- Anemia
- Abnormal placental implantations (previas)
What should we have readily available in the OR in preparation for an emergent situation?
- Pressors
- Succs/Prop
- Blood tubing
- Blood in blood bank
- LMA, Bougie, Video laryngoscope
Pre-op meds we may need to give for c-sections:
- Pepcid 20 mg
- Reglan 10mg (monitor for EPS)
- Bicitra 30 mls
- ABX (Ancef, Azithromycin –> very high risk of nausea)
What are the advantages of neuraxial anesthesia?
- Mother awake
- Early bonding
- Presence of support person
- Use of opioids
Examples include morphine and fentanyl.
What are the disadvantages of neuraxial anesthesia?
- Maternal discomfort
- Nausea
- Hypotension
- Shoulder pain/ chest pressure
Nausea is not uncommon during a C-section, and hypotension can occur due to sympathetic blockade.
What is the bezhold-jarisch reflex? How does it present?
Mechanoreceptors in the wall of the LV respond to a “low stretch”
- Vasodilation
- Hypotension
- Bradycardia
What is the purpose of administering Ondansetron (Zofran) before spinal anesthesia?
Prevents nausea and hypotension by inhibiting the activation of the Bezold-Jarisch reflex.
5-HT3 antagonism
What is the preferred position to prevent hypotension during cesarean delivery?
Slight head up position (10 degrees)
Left Uterine displacement
This helps prevent aortocaval compression.
What local anesthetic is commonly used in spinal anesthesia?
Hyperbaric lidocaine 5%
It carries a risk of transient neurologic syndrome (TNS).
Fill in the blank: The most common dosage for Morphine in spinal anesthesia is _______.
100-150 mcg
This dosage can provide postoperative analgesia.
What is the risk associated with the use of Bupivacaine in epidurals?
Cardiac toxicity
This risk is a concern with higher concentrations.
What adjunct can be added to local anesthetics to speed up onset time?
Sodium Bicarbonate
This helps to increase the non-ionized state of local anesthetics.
What is a Combined Spinal Epidural (CSE)?
A rapid block associated with SAB with the option to use an epidural catheter
This allows for sequential dosing if necessary.
What should be monitored before and after SAB placement?
FHT and maternal BP
Monitoring is crucial for maternal and fetal safety.
What is the typical duration for postoperative analgesia with Morphine in spinal anesthesia?
12-24 hours
This duration can vary depending on dosage and individual patient factors.
What is the purpose of administering 15 ml to extend an epidural?
To make adequate for surgery
This dosage is crucial for ensuring effective anesthesia during surgical procedures.
What is the Allis test used for?
To assess level before incision
This test helps in determining the appropriate anesthetic level prior to surgery.
What does Combined Spinal Epidural (CSE) refer to?
A rapid block associated with SAB and an option to use an epidural catheter
CSE provides both immediate and prolonged pain relief.
What are the indications for General Endotracheal Tube Anesthesia (GETA)?
- Fetal distress
- Sustained fetal bradycardia
- Maternal hemorrhage with hypovolemia
- Neuraxial anesthetic not possible
- Coagulopathy/thrombocytopenia
- Infection
- Patient refusal
- Failed block/patient not tolerating
These situations necessitate GETA to ensure the safety of both mother and fetus.
List the benefits of GETA.
- Rapid onset
- Secured airway
- Hemodynamic stability
These benefits make GETA an effective choice in certain emergency situations.
What are the disadvantages of GETA?
- Increased maternal mortality
- Difficulty with airway management
- Failed oxygenation/ventilation
- Risk of aspiration
- Mother not awake during delivery
- No ‘support person’ in the OR
- Potential anesthesia recall
- Neonatal respiratory & CNS depression
- 1-minute APGAR scores lower with GETA
These risks highlight the need for careful consideration before choosing GETA.
What is the initial step in the GETA induction sequence?
Preoxygenate and monitor
This step is crucial for ensuring adequate oxygen supply before intubation.
What is the purpose of cricoid pressure during GETA induction?
To prevent aspiration
Cricoid pressure is an essential technique used during rapid sequence induction.
What medication is often used for intubation in GETA?
Succinylcholine 1-1.5 mg/kg
This neuromuscular blocker is commonly used for rapid intubation.
What should be documented during the GETA procedure?
- Uterine incision time
- Delivery time
Accurate documentation is critical for medical records and future care.
What is the recommended volatile agent concentration after delivery of the fetus?
0.5-0.75 MAC
This concentration helps maintain anesthesia while allowing for uterine tone restoration.
What should be administered after delivery to reduce the risk of recall?
Benzodiazepines
Administering benzodiazepines post-delivery helps mitigate anesthesia recall.
What is the role of magnesium infusion in GETA?
Potentiates neuromuscular blockade
Magnesium can enhance the effects of neuromuscular blockers during anesthesia.
What are the treatments for uterine atony?
- Pitocin/Oxytocin
- Methergine/Methylergonovine
- Hemabate/Carboprost
These medications are critical for managing uterine atony and ensuring uterine contraction.
What is the typical concentration for Pitocin used for uterine contractions?
10 units/mL
This concentration is commonly used to stimulate uterine contractions post-delivery.
True or False: GETA allows the mother to be awake during delivery.
False
GETA typically results in the mother being unconscious during the procedure.
Fill in the blank: The initial medication for pain control postoperatively is _______.
Opioids
Opioids are a primary choice for managing postoperative pain effectively.
