Anesthesia in the OB unit Flashcards
1
Q
before birth
A
antepartum
2
Q
dystocia
A
difficult labor
3
Q
intrapartum
A
during the act of birth
4
Q
multiple gestations
A
twins, triplets, etc.
5
Q
multiparous
A
has had multiple gestations
6
Q
normal labor term
A
38-40 weeks
7
Q
nulliparous
A
never completed a pregnancy beyond 20 weeks
8
Q
parturient
A
pregnant patient
9
Q
postpartum
A
after birth
10
Q
preterm labor gestation
A
<37 weeks
11
Q
primapara
A
first pregnancy
12
Q
age of viability
A
~ 24 weeks
13
Q
At what week gestation should we consider immediate intubation after birth?
A
<28 weeks, unless child is pink and active
14
Q
_____ includes the total number of pregnancies, regardless of how they ended
A
Gravida (G)
15
Q
_____ includes the number of live births at any gestation, OR the number of completed pregnancies ( both births and stillbirths) that lasted more than 20 weeks
A
Parity (P)
16
Q
Twin deliveries count as how many pregnancies?
A
one
Parity is the number of completed pregnancies beyond 20 weeks gestation (whether viable or nonviable). The number of fetuses delivered does not determine the parity
17
Q
A woman is pregnant for the first time, and is 12 weeks along. What is her GP status?
A
G1P0
18
Q
A woman is currently pregnant and 25 weeks along. She has had 6 miscarriages and only 1 live birth. What is her GP status?
A
G8P1
19
Q
A woman is pregnant for the second time and delivered twin stillbirths in her first pregnancy at 19 weeks. What is her GP status?
A
G2P0
20
Q
Oxytocic (uterotonic) drugs promote uterine ( contraction/ relaxation)?
A
contraction
21
Q
uterotonic drugs
- ( increase/ decrease) uterine bleeding after delivery
- ( induce/ delay) labor in pregnant patients
A
- decrease
2. induce
22
Q
Pitocin stimulates uterine (contraction/ relaxation)
A
contraction
23
Q
Pitocin is also used to (delay/ induce) labor
A
induce
24
Q
What is the most common side effect of Pitocin?
A
hypotension
other side effects include:
N/V, chest pain, ECG changes/arrhythmias, shortness of breath, myocardial ischemia, pulmonary edema, death
Because of these side effects, Pitocin should by dosed SLOWLY
25
Pitocin is dosed (IV/IM). Pitocin dosing is:
1. _____ units in the IV bag after delivery of the baby and placenta
2. ____ units in each subsequent liter of IV fluid
Pitocin is dosed IV
1. 20-40 units
2. 20
26
What is the ED 90 of Pitocin for c-sections:
1. ____ units for non-laboring patients
2. ___ units for laboring patients
1. 0.35
| 2. 3
27
What is the Pitocin rule of 3s:
1. Give 3 units (the ED90 dose) over 30 seconds
- -If this doesn’t work, the dose may be repeated twice, with 3 minutes in between each dose
2. If there is no response to the Pitocin after 3 doses of 3 units (over 9 minutes), move to another uterotonic
- -The thinking is that higher doses of Pitocin would just cause more side effects but not more uterine tone
3. Give 3 units/hr for maintenance
28
Hemabate is a (uterotonic/ tocolytic)
uterotonic - promotes uterine contraction
29
What is the dose of hemabate and how is it given?
1 mL (250 mcg) IM
30
What is hemabate contraindicated in?
asthmatics
31
Methergine is a (uterotonic/ tocolytic)?
utertonic- promotes uterine contraction
32
What is the dose of methergine and how is it given?
1 mL (200 mcg) IM
33
What is methergine contraindicated in?
hypertension (preeclampsia)
34
What is the drug of choice if there is consistent uterine bleeding despite administration of Pitocin, methergine, and hemabate?
cytotec (misoprostol)
35
how is cytotec administered?
rectally
36
tocolytic drugs promote uterine (contraction/relaxation)
relaxation
37
5 tocolytic drugs
1. Magnesium
2. Beta 2 agonists (terbutaline)
3. Calcium channel blockers (nicardipine, nifedipine)
4. volatile agents
5. nitroglycerin
38
_____ is NORMALLY given to treat hypertension or to relieve angina in patients with coronary artery disease (CAD)
Nitroglycerin
In these situations, even smaller doses of Nitroglycerin (<50mcg) can cause significant drops in blood pressure
39
in pregnant patients, what are two reasons nitroglycerin has less of an effect on blood pressure?
1. OB patients have increased circulating blood volume
| 2. the vessels are already dilated in hydrated patients
40
What is the dose of nitroglycerin for uterine relaxation?
up to 250-500mcg, even up to 1000mcg, with minimal hypotension (if patients are well hydrated)
41
the heart rate between contractions
base line fetal heart rate
42
normal fetal heart rate
120-160 bpm
43
bradycardic fetal HR
<120 bpm
44
tachycardic fetal HR
>160 bpm
45
In healthy fetuses, the heart rate constantly fluctuates. This is referred to as ______
“fetal heart rate variability”. This is NORMAL
| short term and long term variability are both present
46
Absence of variability is considered ______
a sign of fetal distress
47
variability that occurs every heart beat
short term variability
48
variability over a long period anywhere from 6-25 bpm
long term variability
49
A fetal heart rate deceleration (“decel”) refers to _______
a drop in fetal heart rate
50
What type of decelerations has a decrease in heart rate that occurs at the onset of a uterine contraction and pretty much returns to baseline by the end of the contraction?
Early (Type I) deceleration
51
What type of deceleration has a decrease in heart rate that occurs after the onset of the contraction
Late (Type II) decelerations
52
What type of deceleration has a decrease in heart rate that is variable in intensity, duration, and timing
Variable (Type III) decelerations
53
What are Type 1 decelerations most likely caused by?
vagal response (compression of the fetal head)
54
Which type of deceleration patterns are most likely caused by fetal hypoxia (uteroplacental insufficiency)
Late Type II
55
What is the most threatening type of deceleration pattern?
Late Type II
Type II decels with variability loss is as bad as it can get with decels
56
What are Type III deceleration patterns associated with?
umbilical cord compression and decompression
57
normal respiratory rate for newborns
30-60 breaths/ min
58
This is a neonatal well being score that can range from 1 to 10 (1 is the worst score you can get and 10 is the best score you can get)
Apgar score
59
the 1 minute Apgar score is associated with _____ while the 5 minute Apgar score is associated with _____
survival
| neurologic outcome
60
normal fetal pH
>7.25
| fetal scalp monitoring
61
_____ in a fetus is considered acidotic
<7.2
62
before delivery, what should be given prior to a neuraxial block?
500-1,000 mL fluid bolus prior to the block
Some sources say the patient should receive 500mL-1,000mL prior to the block
Other sources say the patient should receive 1,000mL-1,500mL prior to the block
I would personally err on the higher side if doing a spinal, since sympathectomy from spinal has the potential to be more intense
63
IV solutions containing _____ should be used with caution and only considered for maintenance doses, but not for fluid boluses
dextrose
| -Dextrose can potentially lead to fetal hypersecretion of insulin post delivery and even fetal acidosis
64
before delivery, every patient should have a ______ since every pregnancy has the potential for unexpected massive hemorrhage
type & screen
65
Why should NSAIDS be avoided before the baby is born?
suppress uterine contractions and promote closure of the PDA
66
Why should Versed be avoided before delivery of the baby?
post delivery fetal apnea?
can cross the placenta, but doesn't seem to have negative effect on the fetus at low doses (1-2 mg)
for awake C-sections, Versed should probably be avoided prior to birth simply because mother’s would like to remember
67
Why should narcotics be avoided before delivery of the placenta?
post delivery fetal apnea?
Lower dose fentanyl (1mcg/kg) on induction of general anesthesia does not appear to affect Apgar scores
68
What is the most common local anesthetic for labor epidurals and why?
marcaine because of its motor sparing ability
69
if using a spinal for a vaginal delivery, how should the dose of marcaine be changed?
the dose needs to be reduced (3-6 mg) so the patient will not have significant motor block
70
What are 2 reasons you would use a spinal?
1. c-section
| 2. vaginal delivery that is in the late stages of labor
71
With a paracervical nerve block, where is local anesthetic injected?
vaginal submucosa
72
What stage of labor does a paracervical block relieve?
1st stage labor pain
73
What side effect does a paracervical block cause?
fetal bradycardia
74
With a pudendal nerve block, where is local anesthetic injected?
transvaginal and perineal
75
What stage of labor does a pudendal nerve block relieve?
2nd stage labor pain
| -It is an alternative to “perineal dose” of local anesthetic through an epidural catheter
76
_____ is a narcotic agonist-antagonist that can be used as an analgesic in the OB unit for patients who refuse epidural analgesia
IV Nubain (Nalbuphine)
77
What is another use for Nubain besides labor analgesia?
treats itching from the duramorph
78
When using nitrous oxide for spontaneous vaginal delivery, the patient starts breathing in the gas at the (start/ middle/ end) of a contraction, and it wears off within a few breaths, so the effects end with the contraction
start
79
Airway equipment from a c-section should include:
1. what type of ETT?
2. what type of laryngoscope handle?
3. what two other airway devices?
1. smaller diameter ETT (better for edema)
2. short laryngoscope handle
3. LMA and a videoscope
80
in a c-section, the baby should be delivered within _____ minutes of uterine incision
3 minutes
| -Longer uterine incision to delivery times = more maternal bleeding, lower Apgar scores, and more acidotic blood gases
81
What is the most common cause of nausea and vomiting in c-section?
How should it be treated?
hypotension from the spinal block
| rapid administration of ephedrine or phenylephrine
0.31 and 0.54 mcg/kg/min phenylephrine infusion
82
What are 2 ways in which patients can get nauseous despite being normotensive?
1. spinal blocks the sympathetic (thoracolumbar) nerves to a greater degree than the parasympathetic nerves (craniosacral) which can lead to dominance of the parasympathetic system and subsequent nausea
2. The patient can experience vagal stimulation during the procedure with the surgeon’s hands all up in the abdomen
83
How is nausea in the presence of normotension treated?
Robinul
| -opposes these surges in parasympathetic activity
84
Why is Robinul preferred over atropine in c-sections before the baby is out?
Atropine crosses the placenta and robinul does not
85
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?
1. do you have an epidural?
| 2. is it working?
86
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?
When was the last time it was bolused
87
How long does spinal duramorph provide post-op pain?
12-24 hours
88
a neuraxial block that rises above the cervical region and produces respiratory arrest and unconsciousness
total spinal anesthesia
-Because the epidural space only extends to the foramen magnum, a patient has a much higher chance of staying conscious following a high epidural level compared to a high spinal level
89
Although total spinal anesthesia is much more common with spinal placement, it has been reported with epidural placement after a _______
bolus of saline (used to speed up return of motor function) or local anesthetic
-epidural boluses will compress the dural sac and cause any local that had diffused into the subdural space to ascend cephalad
90
for a c-section under epidural anesthesia, at what level should the block be raised?
T4
91
What drug should be dosed into the epidural after delivery of the baby but before removal of the epidural?
duramorph
92
how long does epidural duramorph provide analgesia?
18-26 hours
93
What is the dose of duramorph through an epidural catheter?
2-4 mg
94
What is an epidural PCA?
epidural catheter that is left in place in the recovery room and dosed with a dilute local anesthetic or narcotic only infusion
-This is an example of a “walking epidural” (which is a low enough dose that enough motor function is preserved to walk)
95
What is an IV PCA?
This option is available if the anesthetist forgets to dose epidural Duramorph before pulling the catheter at the end of the case
96
What is the only difference in performing a CSE for c-section?
duramorph would not be placed in the spinal because the epidural would provide post-op pain
97
if a patient is at risk for hypotension from hemorrhage (placenta previa, accreta, abruption, etc), _______ anesthesia is indicated
general
98
which type of anesthesia has increased fetal exposure to drugs?
general
99
in general anesthesia, how should the anesthetist limit drug exposure to the fetus?
by not inducing the patient until the patient is prepped, draped, and the surgeon is ready for incision
100
In this condition, the placenta covers the cervical os, and the classic symptom is painless vaginal bleeding
placenta previa
101
In this condition, the placenta detaches from the uterus, which can lead to massive bleeding
placental abruption
102
In this condition, the placenta grows through the uterine wall, which can cause massive bleeding from both organs
placenta accreta
103
what is the agent of choice in non-hemorrhaging, normotensive parturients undergoing general anesthesia for a c-section?
propofol
104
What is the agent of choice in internally bleeding, or hypotensive parturients?
ketamine
| -Ketamine should be avoided in hypertensive or preeclamptic patients
105
If Ketamine is used to supplement a “patchy” epidural or spinal block, the dose can be started at _____ and titrated up if needed
0.25 mg/kg
106
Do muscle relaxants cross the placenta?
no
107
For a c-section under general anesthesia, what is used for post-op pain control?
an IV PCA
| -the patient does no have a block
108
scenario:
A patient is still hurting after the epidural has started, or, the epidural was initially working but stopped working towards the end of labor
5-8mL local anesthetic bolus to increase block density, preferably with a stronger local anesthetic (≈5mL 2% lidocaine)
109
Scenario:
| After receiving an epidural, a patient still feels pain on one side
1. Have patient lay on side that’s hurting
2. Pull the epidural catheter back 1-2 cm, or
3. Pull the epidural catheter and start another one
110
Scenario:
| Non-emergent C-section, working epidural in place
1. Dose to T4 gradually with lidocaine (or chloroprocaine)
111
scenario:
| Emergent C-section, working epidural in place
Dose epidural to T4 immediately with 20mL 3% chloroprocaine and bicarb
112
scenario:
| Non-emergent C-section, “patchy” epidural
1. Try to dose the epidural up to T4, or
2. Supplement the block with ketamine or nitrous oxide, or
3. Pull the epidural catheter and perform the spinal with a reduced dose, or
4. Perform general anesthesia with an RSI
113
scenario:
| Emergent C-section, “patchy” epidural
1. If the airway looks easy, RSI with general anesthesia
2. If the airway looks difficult, can consider trying to dose the epidural to T4 with 3% chloroprocaine and using ketamine and/or N2O to supplement the block (as an alternative to intubating with a videoscope)
114
scenario:
| Working epidural at the start of a C-section; pain 30 minutes into the procedure
5-10mL epidural bolus of lidocaine or chloroprocaine
115
scenario:
| Non-emergent C-section, Mallampati I airway, “patchy” spinal block
1. General anesthesia, or
| 2. Consider using N2O/ketamine to supplement the block
116
scenario:
| Non-emergent C-section, Mallampati IV airway, “patchy” spinal block
1. First try N2O/ketamine to supplement the block, or
| 2. Consider GA with a videoscope if the ketamine/N2O fails
117
scenario:
| Spinal was performed, patient is uncomfortable after the baby is out
give IV fentanyl
118
secnario:
| High spinal, patient is anxious, but still conscious and breathing
1. Reverse Trendelenburg
2. Possible assist ventilation (and possible N2O)
3. Blood pressure support
4. Prepare for intubation
119
scenario:
| High spinal, patient is unconscious and apneic
1. Intubate
| 2. Resuscitate
120
scenario:
| Emergent C-section, no epidural, Mallampati I airway
RSI with GETA
121
scenario:
| Emergent C-section, no epidural, obese and Mallampati IV airway
RSI with videoscope and GETA with LMA as backup
122
scenario:
| Non-emergent C-section, unable to intubate (even with a videoscope)
Awaken the patient
123
scenario:
| Emergent C-section, unable to intubate (even with a videoscope)
Place an LMA and hold cricoid pressure until the patient can be intubated
