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N934 Adv Principles Fa 21 > Anesthetic Considerations of the Obstetric Patient > Flashcards

Anesthetic Considerations of the Obstetric Patient Flashcards

1
Q

How much does heart rate increase by term

A

20-30%

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2
Q

when does HR peak during pregnancy

A

32 weeks

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3
Q

how much does CO increase (%)

A

40%

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4
Q

how much of the CO perfuses the uterus (%)

A

10%

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5
Q

when does max CO occur and by how much (%)

A

increases by 80% immediately after delivery

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6
Q

when does CO return to baseline after delivery

A

14 days

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7
Q

what happens to ventricular walls and EDV during pregnancy

A

increases

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8
Q

which kind of murmur is not uncommon during pregnancy

A

systolic murmurs

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9
Q

what are two pathologic results of pregnancy

A

diastolic murmurs and cardiac enlargement

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10
Q

explain why dilutional anemia occurs during pregnancy

A

increase in plasma volume > RBC volume

H/H is lower

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11
Q

what is the normal blood loss expected during vaginal delivery

A

500mL

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12
Q

what is the normal expected blood loss during a c section

A

800-1000mL

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13
Q

what happens as a result of decreased SVR during pregnancy

A

venous pooling and decrease in DBP (but VS mostly stay at baseline)

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14
Q

why does supine hypotension occur for parturients

A

aortocaval compression/compression of aorta and vena cava by gravid uterus. normal perfusion to upper extremities but bad perfusion to lower extremities below compression.

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15
Q

what situations would create more severe aortocaval compression (2)

A

polyhydraminos and multiple gestation

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16
Q

how long does HoTN and aortocaval compression develop for the parturient (2)

A

HoTN can occur immediately, but compression takes about ten minutes for sx to develop otherwise

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17
Q

how to relieve aortocaval compression

A

left uterine displacement (LUD). more than 15 degrees

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18
Q

what factors of the parturient contribute to hypercoagulability

A

clotting factors VII-IX increased, fibrinogen increased

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19
Q

what is one of the leading causes of maternal mortality

A

thromboembolic events

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20
Q

what to expect with the parturient and platelet count

A

slight decrease. >100,000 means spinal and epidural ok per book answer

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21
Q

what to expect with parturient and WBC count

A

it will rise by term

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22
Q

capillary engorgement during labor results in what implications for the airway

A

narrowed glottic opening
oral and nasal pharynx edema
laryngeal edema

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23
Q

do you nasally intubate the parturient

A

avoid nasal intubation

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24
Q

what size tube would you consider for a laboring woman

A

smaller tube like a 6.0 or 6.5 You aren’t going for long term intubation but securing the airway quick is the most important

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25
Q

how much % increase in oxygen consumption during rest and how much % increase in oxygen consumption during labor do you expect

A

33%

100%

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26
Q

oxyHGB dissociation curve shifts to the

A

right as a parturient

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27
Q

when minute ventilation increases in the parturient, what would you expect of Vt and RR

A

Vt increases more than RR

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28
Q

what would you expect of PaCO2/ABG/HCO3

A

PaCO2 decreases slightly
ABG compensated
decreases in HCO3

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29
Q

what does the upward pressure of the diaphragm do for the FRC and overall parturient related reserve

A

decrease in FRC and rapid desaturation of apnea patient (worse than obese patient. consider ramping)

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30
Q

during pregnancy, there is an increased sensitivity to these two anesthetics

A

gases, local anesthetics

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31
Q

why is there an increased block height during pregnancy and neuraxial anesthesia

A

engorged epidural veins, increased intra abdominal pressure, decrease in epidural and subarachnoid spaces

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32
Q

why is there an increased risk for regurgitation and aspiration for the parturient? (3)

A

increased levels of gastrin
upward displacement and mechanical obstruction
labor further reduces gastric emptying

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33
Q

prior to c section, give these three medications to decrease risk of aspiration

A

non particulate acid (Bicitra)
H2 receptor blocker (Pepcid. push over 5-10m)
Prokinetic (Reglan)

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34
Q

what happens to albumin and what is the theoretical pharmacological result of this during pregnancy

A

decrease in serum albumin and increase in free fraction of highly protein bound drugs

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35
Q

what happens to GFR and subsequently BUN/creatinine during pregnancy

A

increased GFR and subsequently decreased BUN/creatinine

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36
Q

what can be expected to be excreted in the parturients urine and why (2)

A

glucose and protein. related to high GFR and reduced renal absorption

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37
Q

at term, uterine blood flow increases to a maximum of _____ml/min

A

800mL/min

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38
Q

how does the fetus send oxygen poor blood to the placenta?

A

via two umbilical arteries and perfusion of capillary networks of the placental villi

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39
Q

what does the placental villi do

A

exchanges nutrients, respiratory gases, and waste. oxygen and CO2 are perfusion limited.

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40
Q

fetal transfer of nutrients, respiratory gases, and waste dependent on _________, not ________

A

perfusion, not gases rate of diffusion

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41
Q

most drugs transfer to placenta via

A

diffusion

42
Q

what is the placental diffusion dependent upon (5)

A 
concentration gradient
molecular weight
lipid solubility
state ionization
protein binding
43
Q

weight (in daltons) and cross-ability (easy versus poor)

A

<500 daltons crosses easily

>1000 daltons crosses poorly

44
Q

if the drug has increased protein binding, what does that mean for placental crossover

A

decreased placental crossover

45
Q

do most drugs administered to parturient cross easily

A

yes

46
Q

fetal effects of drugs transferred into placenta have minimized effects via

A

dilution of intervillous blood
redistributed once in the fetus
umbilical blood passes through liver (first pass)
increase in maternal hepatic enzymes decreases serum drug levels

47
Q

how does one fifth of the fetal cardiac output return to the placenta

A

shunt flow from foramen ovale and ductus arteriosus

48
Q

acid base status may affect drug accumulation via

A

ion trapping

49
Q

explain stage 1 of labor

A

effacement and dilation of the cervix. there is a latent and active stage

50
Q

describe the latent stage of stage 1 labor

A

onset of labor to point of rapid cervix dilation irregular contractions

51
Q

describe the active stage of stage 1 labor

A

cervix dilation 2cm to full dilation (10cm) (regular rapid contractions)

52
Q

explain stage 2 of labor

A

cervix 10cm dilation fo delivery of the fetus (active pushing)

53
Q

explain stage 3 of labor

A

delivery of the placenta

54
Q

describe where the pain would be expected during stage 1 labor

A

non localized aching or cramping. T10-12-L1. initial pain is in lower thoracic and upper lumbar nerves

55
Q

describe where the pain would be expected during stage 2 labor

A

cervical dilation complete and presenting part descends into the pelvis. S2-S4
pressure in perineal area
thicker fibers and therefore harder to block. roots are larger and harder to get to here

56
Q

describe what stages the labor epidural is good for

A

great for stage 1 and maybe not so much for stage 2

57
Q

what coverage would you need for c section

A

T6

58
Q

what pharmacologic agent works great for this second stage labor

A

dexmedetomidine. the downfall is this prolongs relaxation

59
Q

four factors are critical to a woman’s childbirth experience

A

personal expectations
amount of support from caregivers
quality of parent caregiver relationship
patients involvement in decision making

60
Q

what is the most readily available method to determine fetal condition

A

FHR monitor

61
Q

describe the two types of FHR monitors

A

external (doppler on maternal abdomen)

internal (electrode on fetal scalp, have to break amniotic sac)

62
Q

normal FHR

A

110-160

63
Q

when is deceleration in relation to contraction ok and what may it mean

A

decelerations prior to contraction OK and therefore HR110-160 variability ok
may mean head compression (coming through vagina)

64
Q

describe FHR in relation to uterine contractions during uteroplacental insufficiency

A

decelerations after contractions mean BF is compromised to baby.
ex) mom mat be Hotensive and need fluid bolus

65
Q

describe FHR in relation to uterine contractions with umbilical cord compressions

A

will present as variable decelerations (decelerations are not lined up with contractions- occur randomly)
amniotic sac rupture for internal FHR monitoring- can inject some fluid.

66
Q

fetal accelerations indicate (2)

A

fetal movement and adequate oxygenation

67
Q

changes in heart rate indicates

A

fetal oxygen reserve. hypoxia (CNS depression) decreases it via interaction in ANS

68
Q

describe early deceleration considerations

A

occur in concert with uterine contractions
consistent with each
decrease in FHR approx 20BPM expected

69
Q

describe variable deceleration considerations

A

related to baby
ex) fetal movement, lack of fluid
abrupt decrease in FHR irrespective of contractions
baroreflex mediated response to umbilical cord compression

70
Q

describe late deceleration considerations

A

r/t mom
lowest point o deceleration occurs after peak contraction
represent uteroplacental insufficiency (not sufficient O2 to baby)
ex) mom HoTN, preexisting condition, NC O2, fluid bolus, last result is pressors

71
Q

categories for FHR evaluation: category 1

A

best. normal baseline HR and moderate variability with no variable decels

72
Q

categories for FHR evaluation: category 2

A

all tracings no included in I or III
do not indicate acid base imbalance
warrant continued observations

73
Q

categories for FHR evaluation: category 3

A

worst
fetal bradycardia and absent variability with variable or late decels
warrants prompt intervention

74
Q

what is the best technique of pain management during the birthing process

A

the one that allows a woman to cope with pain

75
Q

in addition to reducing pain and anxiety, a good analgesic does what (2 things)

A

limit increases in maternal CO, HTN, and catecholamine release
reduce maternal hyperventilation, which can cause reduced fetal oxygen tension

76
Q

non pharmacological techniques for labor analgesia

A

TENS, sterile water blocks

77
Q

concerns over fetal depression limits the use of systemic medications to

A

early labor or when regional anesthesia is not available or contraindicated

78
Q

some systemic medications that should be avoided during labor include

A 
meperidine
morphine
butorphanol and nalbuphine
remifentanil
ketamine
79
Q

the epidural labor analgesic is associated with these three things

A

may prolong second stage labor
can affect the incidence of forceps delivery
is not associated with increased rates of cesarean section

80
Q

an indwelling catheter placed during the epidural affords these two things

A

the ability to produce segmental blockade

the ability to provide additional dosing

81
Q

what is the goal dermatome level when dosing an epidural

A

T10-L1 (labor)

82
Q

how is analgesia most popularly maintained with an epidural in place

A

intermittent bolus’

83
Q

describe two methods of CSE

A

spinal placed first, epidural placed one level above OR

needle through needle technique. (spinal placed through epidural needle)

84
Q

the spinal technique is reserved for (3)

A

multiparous patients in advanced second stage
those with poor pain control, to facilitate spinal placement
mother laboring without analgesia requiring an instrumented delivery

85
Q

under which circumstances would a continuous spinal be placed using a macro bore epidural catheter (3)

A

morbid obesity
history of previous spinal surgery
inadvertent dural puncture

86
Q

dosing of continuous spinal

A

.5-1mL of .25% isobaric bupivicaine

87
Q

opioids have a ceiling effect. side effects include (4)

A

respiratory depression
itching (most common)
urinary retention
n/v

88
Q

if you have a c section patient and want immediate analgesia, which neuraxial opioid is recommended

A

fentanyl

89
Q

common indications for c section include (6)

A 
cephalopelvic disproportion
non reassuring fetal status (FHR <100, late decels)
arrest of dialtion
malpresentation
prematurity (<36w)
previous c section or uterine surgery
90
Q

VBAC

A

vaginal birth after ceserean

91
Q

choice of anesthesia for c section depends on (4)

A

maternal status
urgency of surgery
fetal condition
patients desires

92
Q

before neuraxial anesthesia for parturient, what should the patient receive preoperatively (4)

A

aspiration prophylaxis
antibiotic administration
standard monitoring
nasal oxygen

93
Q

what dermatome level is required to provide adequate neuraxial anesthesia for a c section

A

T4-T6

94
Q

what is the most common neuraxial technique for a c section and why

A

single shot spinal.

simple to perform, rapid onset, reliable, less toxic

95
Q

dosage of spinal for c section is

A

.75% hyperbaric bupivicaine is LA of choice

fentanyl and duramorph for analgesia

96
Q

when a labor epidural is used to provide surgical anesthesia, what kind of dose would be considered a surgical dose

A

2% lidocaine with 1:200,000 epinephrine. consider sodium bicarbonate or duramorph
10-15mL required to achieve T4-T6 level

97
Q

if an in situ (dwelling) epidural catheter is not reliable, these 4 things can ensue

A

early recognition (chance of surgical anesthesia)
replace (CSE)
single shot spinal
GA

98
Q

CSE advantages (2) and disadvantages (2)

A

lower dose spinal can be used, ability to augment with epidural catheter
potential lower block height, can delay the start of surgery

99
Q

indications for GA include

A

neuraxial not in place, urgent delivery required
patient refusal of neuraxial
coagulopathy

100
Q

induction during GA for the parturient sequence of events

A

should not begin until patient is prepped and draped
sufficient de nitrogenation and pre oxygenation
RSI with cricoid pressure (prop v etomidate v ketamine and succ v roc)

101
Q

GA maintenance practices for c section include

A

N2O and O2, avoid hyperventilation, try for a mac less than 1

102
Q

TAP blocks for the c section patient

A

can be placed postop in patients who have not received neuraxial anesthesia or intrathecal morphine
targets sensory nerves T5-11
does not provide visceral pain relief, so no uterine coverage
posterior tap block is best

N934 Adv Principles Fa 21 (23 decks)

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