C-section OB Lecture 1 Flashcards by Carlos Valerio

What is Macrosomia?

Fetus/Newborn w/ excessive birth weight

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What is TOLAC?

Trial of Labor after Cesarean

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What is VBAC?

Vaginal Birth after Cesarean

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What is PPH?

Post-partum Hemorrhage

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What is SAB?

Spontaneous Abortion

Or subarachnoid block.

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What are indicators for operative vaginal delivery?

non-reassuring FHR
Maternal exhaustion
Arrested Descent

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If a denser sensory block is necessary for operative vaginal delivery, what medications can be used?

Epidural:
- Lidocaine 2% 5-10 mL
- 2-Chloroprocaine 2-3% 5-10 mL

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What is the most common majory surgery in the USA? What is the national delivery rate via C section?

C-section
~30%

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How does maternal mortality rate of c-section compare to vaginal delivery.

c section mortality is 10x greater than vaginal delivery

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What are anesthesia complications that can contribute to the increased mortality seen with C-section?

Pulmonary aspiration
failed intubation r/t Edematous/friable airways
Inadequate ventilation when requiring GETA

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What factors contribute to increased c-section rate?

↑ maternal age (delayed childbirth)
Obesity
Fetal macrosomia
↑ labor inductions
↓ TOLAC attempts
Fewer instrumented vaginal deliveries
↑ electronic FHR monitoring
concern for malpractice litigation

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What are the maternal indications for c-section?

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What are the fetal indications for c-section?

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What type of skin incision is used for emergencies? Why is this the preferred method?

Low Vertical/Midline incisions
Umbilical to pubic symphysis
-allows for rapid access

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What are the three different types of uterine incisions?

Low Transverse (best if possible)
Low Vertical/Midline
Classical (highest risk)

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What type of uterine incision will make future TOLAC attempts impossible? What are some other drawbacks to this approach?

Classical incision
-increases risk of uterine abdominal adhesions
-Uterine rupture risk is ~10%

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What are the benefits of Low Transverse Incision?

-less risk of bladder injury
-low risk of uterine rupture (in future pregnancies)
-TOLAC possible in future pregnancies

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Why does GETA potentiate blood loss?

Due to GETA vasodilation.

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What is the most common c-section complication?

Hemorrhage

Usually due to uterine atony.

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What complications (other than hemorrhage) can happen in c-sections?

Wound Infection
Uterine/uterocervical lacerations
Bladder dissections
Fetal laceration
Hysterectomy

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What is the terminology for abnormal placental invasion of surrounding tissues?

Accreta → Increta → Percreta

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_______ ______ is when the placenta develops in such a way that it blocks the baby’s ability to exit out of the cervix & vagina.

Placenta Previa

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What is external cephalic version?

Manual external turning of fetus that is in breech/transverse position to head down position

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What is the preferred anesthetic technique for a c-section?

Neuraxial Anesthesia
-safest for mother and baby

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Previous c-sections indicates an increased risk of ______.

bleeding -risk increases with each c/s

What sensations are normal even with a spinal anesthetic?

pushing, pulling, tugging, & pressure

Which two drugs need to be stocked and ready to go in the OB operating room?

Propofol & Succinylcholine *Be ready to RSI*.

What three medications are given to prevent aspiration pneumonitis in parturients?

- Famotidine 20mg IV - Metoclopramide 10mg IV - Na⁺ Citrate (Bicitra) 30mLs PO

What type of drug is famotidine?

H2 receptor antagonist that decreases gastric acid production.

What is the onset & peak of famotidine?

Onset: 30 min Peak: 60 - 90 min

How does metoclopramide work?

- ↓ stomach volume via increased motility. - increased LES tone - ↓ N/V Dopamine D2 antagonist

When should metoclopramide be administered?

15-30 min prior to anesthesia start

What type of drug is Bicitra?

Non-particulate antacid that decreases gastric acidity to > 6pH

When should Bicitra be administered?

20-30 min before going to the OR.

What antibiotic given to parturients should be administered slowly due to risk of N/V?

Azithromyicin

What things/factors put a parturient at risk for higher blood loss?

- GETA - Abnormal placenta - Unscheduled C-section after attempted vaginal - Multiparous - Multiple past c-sections

What monitoring equipment is necessary before spinal placement?

At minimum: - FHT - Mom's BP - Pulse oximetry

Why is versed "discouraged" but not contraindicated?

- readily crosses placenta - Amnesia - interferes with bonding

What is the efficacy of oxygen during c-section?

What is an ideal spinal dose of morphine?

100 - 150mcg

What is an ideal spinal dose of Fentanyl?

5 - 10mcg

What is an ideal dose of morphine to be added to a pre-existing epidural after delivery? What are the pros and cons of this?

3mg Pros: up to 24 hour pain relief Cons: high incidence of itching

What are some disadvantages of neuraxial anesthesia for C-section?

- N/V - C3-C5 stimulated by cold irrigation - Shoulder pain/chest pressure -pulling/tugging can cause discomfort/anxiety

What causes referred shoulder/chest pain during a c-section?

Uterus being pulled out

How are C3-C5 nerves stimulated during a c-section?

Cold/cool irrigation can stimulate the under surface of diaphragm. -This can cause nausea and pain

What reflex can lead to HoTN with neuraxial anesthesia?

Bezold Jarisch Reflex -↓ LV stretch d/t sympathectomy (↓ preload) -l/t ↓ HR to increase filling time → HoTN

What are the Bezold-Jarisch Reflex triad of symptoms?

- Vasodilation - Hypotension - Bradycardia

What causes the Bezold-Jarisch reflex?

Mechanoreceptors sensing a hyperdynamic LV w/ low preload.

Which drug can be administered to prevent the bezold-jarisch reflex associated with a spinal block?

Ondansetron 4mg *Antagonizes 5HT-3 receptors & prevents activation of BJR*.

What position should a patient be in after a spinal block?

Slight (10°) head up *Bed can also be tilted left for slight LUD*.

What are two types of operative vaginal delivery? How common is operative vaginal delivery?

Forceps or vacuum assisted delivery -less use today partly d/t legal concerns

What are the statute of limitations for OB litigation?

18 years

What factors determine the anesthesia plan for unscheduled c-section?

What is the anesthetic plan for emergency c-section?

GETA with RSI -secure airway and immediately let surgeon know when ready

Describe the four grades of c-section?

Low vertical/midline skin incision puts the patient at increased risk for what issue?

↑ risk for umbilical hernias

Describe the low vertical uterine incision?

Lower uterine segment incision. -may be extended if needed -low risk of uterine rupture **but higher risk than low transverse incision**

What are the Four T's of hemorrhage? Which of these is easiest for anesthesia to fix?

Tone Trauma Tissue (retained products) Thrombin (coag status) **Uterine tone is easiest to fix**

What are the maternal hemorrhage interventions?

Who is at risk for uterine atony?

Every maternal patient is at risk for uterine atony -This is why every patient receives Pitocin

What medications are given if Pitocin is ineffective? What are the contraindications for these medications?

IM: Methergine ↳CI with Preeclampsia/HTN d/t alpha adrenergic stimulation IM: Hemabate (a prostaglandin) ↳CI in asthma patients d/t prostaglandin

Maternal hemorrhage primarily occurs after delivery. What may hemorrhage before delivery indicate?

May Indicate: Uterine rupture Placental abruption (placenta separating from uterine wall)

What are possible OB interventions for Maternal Hemorrhage?

Bakri balloon Compression/B Lynch Suture Uterine artery ligation Hysterectomy (last resort)

Why is a fetus descending through a birth canal dangerous with placenta previa?

Increased risk of bleeding.

How does placental invasion of uterine wall affect anesthesia plan?

Placenta accreta/increta/percreta -all require GETA -all hands on deck -blood products/rapid transfuser on standby

What is the goal of external cephalic version?

-Turning baby to head down position - used to enhance chance of successful vag delivery - helps prevent need to convert to c-section

What are the methods to prevent unplanned cesarean delivery?

What are the components of the preoperative anesthesia interview?

For high risk c sections it is important to have the following?

Blood available 2 good IV's

For high risk c-section patients with antibodies found on type and screen you must do what?

Get crossmatch ASAP -may take a long time to identify a match - want blood available before procedure

What are some talking points when discussing neuraxial anesthesia with a patient?

When addressing patient concerns what are some topics to cover?

What are some interventions that can assist with skin to skin

-Placing EKG leads on back -Pulse ox off if patient stable

What are two interventions that can help with highly anxious patients?

Versed (not preferred) -may help in patients that are not tolerating remaining awake Oxygen -may help patient anxiety when chest heaviness sets in.

What are the advantages of neuraxial anesthesia for c-section?

Mother remains awake Earlier mother/baby bonding Support person in room -not allowed in room for GA Opioid use (postpartum pain relief)