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P&P 3 > Ex1 OB 2 Part 2 > Flashcards

Ex1 OB 2 Part 2 Flashcards

1
Q

Most common type of C/S

A

Low transverse incision

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2
Q

Types of C/S incisions

A
  1. low transverse (lower uterine part, horizontally)
  2. low vertical
  3. Classical incision (middle, vertical)
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3
Q

Pfannenstiel incision

A

Low transverse incision

most common C/S

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4
Q

Why did they stop the classical incision?

A

increased risk of uterine rupture in subsequent pregnancies/labor.

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5
Q

Most common indications for C/S

A
  • failure of labor to progress
  • fetal distress
  • cephalo-pelvic disproportion
  • prior uterine surgery or C/S
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6
Q

Advantages of regional over GETA

A
  • Lower maternal mortality rates
  • Can be used in fetal distress w/o facing difficult intubation + further fetal compromise
  • patient awake, less aspiration risk
  • Less exposure of fetus to depressant drugs
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7
Q

Disadvantages of regional vs GETA

A
  • Accidental intravascular injection (possibility of convulsions, CV collapse, aspiration)
  • Total spinal (severe HOTN, unconsciousness, aspirations)
  • Risk of dural puncture H/A
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8
Q

Advantages of spinal anesthesia

A
  • Simplicity of technique
  • Speed of induction (vs epidural)
  • Reliability
  • Minimal exposure of fetus to Rx
  • Minimization of hazards of aspiration
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9
Q

Disadvantages of spinal anesthesia

A
  • High incidence of HOTN
  • Intrapartum N/V
  • Possibility of H/A after dural puncture
  • Limited DOA (unless a continuous technique is utilized)
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10
Q

spinal anesthesia C/I

A
  • Severe maternal bleeding
  • Severe maternal HOTN
  • Coagulation disorders
  • Some forms of neurological disorders (ex. MS)
  • Patient refusal
  • Sepsis (area of needle insertion or generalized)
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11
Q

C/S Preop considerations

A
  1. Use of aspiration precautions recommended d/t pregnancy-induced GI changes:
    - Metoclopramide 10 mg + an H2 blocker (famotidine 20 mg) IV can be used
    - Nonparticulate antacid (bicitra 30-60 mL) depends on practice
  2. Volume Loading (LR)
  3. T&S (unless emergent)
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12
Q

Vaginal birth EBL

A

300-500mL

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13
Q

C/S EBL

A

800-1,000mL

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14
Q

Volume loading for C/S

A

~1L; doesn’t matter how fast

  • reduces incidence of HOTN
  • no difference in acid/base status, ephedrine use
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15
Q

Spinal for C/S - drug + dose?

A

Hyperbaric Bupivicaine 0.75% 6-15mg

depending on location: 1.4-1.6mL

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16
Q

Bupivacaine 0.75% administering 1.4mL … how many mg is this?

A

1 mL = 7.5 mg
.4mL = 3mg
1.4mL = 10.5mg

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17
Q

Hyperbaric bupivacaine administration is associated with

A

Higher doses = greater reduction in MAP

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18
Q

1.6mL Hyperbaric bupivacaine 0.75% attains what level?

A

T4 - Nipple line

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19
Q

1.6mL Hyperbaric bupivacaine 0.75% lasts how long?

A

1.5-2 hours

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20
Q

C/S Local anesthetic protocol

A
  1. Hyperbaric bupivicaine 0.75% 1.6 mL
  2. Fentanyl 10-20 mcg
  3. Morphine 0.1-0.25 mg
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21
Q

C/S Local anesthetic protocol - fentanyl

A

10-20mcg (in TB syringe)

  • decrease visceral discomfort
  • may lower incidence of N/V during uterine manipulation
  • 15mcg=adequate analgesia, significantly less N/V than 20 mg (research)
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22
Q

C/S Local anesthetic protocol - morphine

A
  • Duramorph = preservative free
    0. 1-0.25 mg (in TB syringe)
  • for postop analgesia from 18-24 hours post op
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23
Q

Why must preservative free analgesics be used intrathecally?

A

To avoid neurotoxicity

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24
Q

If intrathecal morphine is used, what should be implemented?

A
  • *duramorph

- postop monitoring protocol to monitor for respiratory depression (1:1000) + pruritis

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25
Q

Tx for pruritis

A

Benadryl (postop d/t morphine)

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26
Q

Other LAs used for C/S

A
  1. Tetracaine 0.5% in 5% dextrose (lasts 90-120min), in practice up to 8h
  2. Bupi 0.5% in 8% dextrose (90-120m), off label use, sensory density less than hyperbaric
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27
Q

C/S Intraop considerations: prior to placing spinal what should be done?

A

IV x 1 (18g), Monitors, O2 (possibly C/I d/t masking of high spinal), position: R lateral or sitting

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28
Q

After placement of a spinal, what must be done?

A

Lay mom down + place in L uterine displacement until delivery of infant

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29
Q

Tx: HOTN d/t spinal

A

Ephedrine 5-10mg
+/or
Phenylephrine 50-100mcg IV

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30
Q

Tx: HOTN + bradycardia d/t spinal

A

*sympathectomy
Tx: atropine 0.4mg PRN
–> or reverse trendelenberg

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31
Q

Definition: maternal HOTN

A

Decrease in SBP < 100 mmHg
or
Decrease > 30 mmHg from preanesthetic value
**depends on moms baseline

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32
Q

Incidence of maternal HOTN

A

80%

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33
Q

Higher the sympathetic block, the greater the risk of ______

A

HOTN + emesis (> T4)

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34
Q

Incidence of HOTN from spinal (prior to C/S) is less if ______ because _____

A
  • mom has been in active labor
  • Autotransfusion (500 mL+) d/t uterine contractions
  • decrease in size of uterus d/t loss of amniotic fluid if membranes have ruptured
  • Higher maternal catecholamines in labor
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35
Q

warning signs of maternal HOTN d/t spinal

A

lightheadedness, nausea, difficulty breathing, and diaphoresis
*SET BP to 1-2.5 minutes!

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36
Q

DOC maternal HOTN

A

Ephedrine (or phenylephrine)

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37
Q

MOA Ephedrine

A

stimulates both alpha + beta adrenergic receptors, cardiac stimulation + subsequent increase in peripheral/uterine blood flow

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38
Q

Ephedrine - disadvantages

A

crosses placenta + increases fetal heart rate + heart rate variability

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39
Q

Given 10mg/mL vial phenylephrine …. how to draw up/administer?

A

Draw up vial, inject into 100mL saline, draw 10 mL from bag

=100mcg/mL

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40
Q

Disadvantage of using Phenylephrine

A

Profound bradycardia

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41
Q

Tx of phenylephrine induced bradycardia

A

Atropine or glycopyrrolate (0.1 rather than 0.2)

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42
Q

Which one is better for maternal HOTN: phenyl or ephedrine?

A

Depends on moms HR:

give ephedrine if large dose of phenyl drops HR

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43
Q

When do we administer a test dose during neuraxial anesthesia?

A

During epidural placement - to confirm correct placement (NOT INTRAVASCULAR)

(Any ringing in ear? Funny taste in mouth?)

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44
Q

Complications specific to epidural anesthesia

A
  1. PDPH
  2. unintentional intravascular injection
  3. shivering
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45
Q

Peak onset of shivering after epidural

A

10 minutes

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46
Q

MOA + Tx: shivering after epidural

A

vasodilation to BLE –> upper body compensates

Tx: full lower bair hugger

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47
Q

Epidural anesthesia: Local anesthetics used

A
  1. Chloroprocaine 3%
  2. Lido 2% + Epi 1:200,000
  3. Bupi/Ropi 0.5%
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48
Q

When is Bupi/Ropi used in epidural?

A

Labor epidural d/t greater ratio of sensory:motor blockade

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49
Q

When is Lido/Chloropr. used for epidural?

A

C/S d/t greater motor blockade

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50
Q

Stat C/S: which LA in epidural?

A

Chloroprocaine

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51
Q

Duration of surgical anesthesia: Chloroprocaine

A

30-40 min

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52
Q

Duration of surgical anesthesia: Lidocaine 2% with Epi 1:200,000

A

75-90 min

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53
Q

Duration of surgical anesthesia: Bupivicaine 0.5%

A

75-90 min

54
Q

DOC OB Epidural

A

Lido 2% + Epi 1:200,000

55
Q

ideal local anesthetic in the presence of fetal distress d/t rapid onset, short maternal half-life and fetal plasma half-life

A

chloroprocaine 3%

56
Q

Chloroprocaine average onset of action

A

6-12 minutes

  • up to 10 minutes for 2-choloroprocaine to attain a T4 level in a newly placed epidural
  • to go from a T10 level with sensory blockade appropriate for labor analgesia up to a T4 block for surgical anesthesia can be obtained in approximately 5 minutes
57
Q

Why isn’t Chloroprocaine used more often?

A
  • antagonizes mu-agonist narcotics (fentanyl, morphine) in epidural
  • may interfere w/ subsequent epidural bupi
58
Q

Epidural of choice in emergency C/S

A

Chloroprocaine 3%

59
Q

Bupivicaine advantages + disadvantages in epidural

A
  • slower onset
  • lesser degree of HOTN
  • only available in .5% and below
60
Q

What can speed the onset of action + spread block of epidural?

A
  • 1 mL Sodium Bicarb (7.5 or 8.4%) per 10mL LA
    • with Lido
    • NOT with Bupi
61
Q

Administration of epidural

A
  1. Confirm negative test dose
  2. 15-20mL LA administered slowly in 5mL increments (wait 5 min, monitor BP, inject another 5mL)
  3. Verification of catheter placement by aspiration is done with each new injection
  4. Injection completed when T4 level achieved
62
Q

Mom is on OR table, prior to C/S, LA injection is not working via epidural. What next?

A

Possible that

  • epidural catheter migrated
  • epidural not bathing all nerves (“hot spot”)
63
Q

Best option when Epidural is not working + mom has “hot spot” in middle of C/S

A

Kiss of ketamine: 10-20 mg

or 30% N2O

64
Q

After delivery via C/S, mom is in severe pain, what is another option?

A

IV narcotics PRN
or
Fentanyl 100 mcg diluted into 10mL saline via epidural

65
Q

Anticipation of post-op C/S pain: Tx (dose, DOA)

A

Preservative free morphine via epidural, 3-5mg

*lasts 12-24h

66
Q

In addition to epidural morphine, post operative pain can be managed by _________

A
  • patient-controlled epidural anesthesia (PCEA) with LA of low concentration +/or epidural narcotics
  • ketorolac (Toradol)
67
Q

NSAIDs - pain management post-op

A
  • *no NSAIDs before baby is out
  • verify with surgical team this is okay
  • 30mg IM (or IV)
68
Q

Why no NSAIDs before baby is out?

A
  • suppresses uterine contractions

- promotes closure of fetal PDA

69
Q

Failed epidural rate

A

12% (“high”)

70
Q

s/s failed epidural

A

High # of top offs

71
Q

Management of failed epidural

A 
Management with RACE:
Recognize the problem
Assess the fetal heart rate
Consider the options
Evaluate the airway
72
Q

Failure of epidural during labor: Tx

A

Replace epidural.

Sit mom up, go to different space, place epidural.

73
Q

Failure of epidural during C/S: Tx

A

*Reason for C/S: baby stable or unstable?

Unstable: no time to replace epidural/spinal – GETA

Stable: time to evaluate next plan (replace epidural, spinal, etc.)

74
Q

Failed epidural: General Options

A
  • replace catheter if not urgent procedure

- remove + perform spinal

75
Q

Failed epidural: Replace with Spinal

A
  • if dose of epidural was < 10mL can use normal intrathecal dose
  • hyperbaric
  • Leave sitting 1 – 2 min (control level of block)
76
Q

Failed epidural: do not give spinal if

A
  • bolus given in last 30 min
  • pt weighs > 120 kg
  • height < 4’ 10”
77
Q

CSEs are most commonly used for

A

-repeat C sections or for patients who have had previous abd surgery (prolonging surgical time)

78
Q

what MUST occur prior to induction?

A
  • surgical team + patient prepped + draped, ready to start w/ scalpel in hand
  • regardless of emergency vs. planned
79
Q

Non-emergent + emergent preoxygenation

A

emergent: 4 VC breaths

non-emergent: 100% O2 for 3 minutes

80
Q

Induction agents

A 
Thiopental  
Propofol 
Etomidate  
Ketamine  
Succinylcholine
81
Q

Induction agents that cross placenta

A

thiopental, propofol

both lipid soluble

82
Q

Induction agent: Thiopental

A

4mg/kg

83
Q

Induction agent: Propofol

A

2-2.5mg/kg

84
Q

Induction agent: Etomidate

A

.3mg/kg

85
Q

Induction agent: Ketamine

A

1-2mg/kg

86
Q

Induction agent: Succinylcholine

A

1-1.5mg/kg

87
Q

Induction agent: mom bleeding or hypovolemic

A

Reduce doses or use etomidate/ketamine

88
Q

Maintenance Drugs

A

Until delivery: mix of 50% N2O/O2 + Sevo/Iso @ 75% MAC

  • judicious use of NDMR after Sux wears off
  • avoid hyperventilation (AE on UBF)
89
Q

What does hyperventilation cause?

A

Hypocarbia

90
Q

What does hypocarbia do to the placenta?

A

Decreases UBF (uterine blood flow)

91
Q

What inhalational agents cross the placenta?

A

Volatiles + Nitrous

-lipid soluble + have LMW

92
Q

What NMBA cross the placenta?

A

Poorly lipid soluble + highly ionized - cross very slowly but pose no problems to fetus

93
Q

Recall during C/S

A

Maternal awareness: 17-35%

high

94
Q

Maintenance: Oxytocin

A

10 – 30 units/L
added to IV infusion + administered after delivery of placenta to stimulate uterine contraction
AE: vascular relaxation (rapid infusions after C/S can cause HOTN)
-needs to be diluted
-Can double dose if needed.

95
Q

Maintenance: Methergine

A

0.2 mg IM
or Hemabate 0.25 mg IM
may be given for uterine atony and/or increased bleeding

96
Q

Once baby is delivered, what should be done?

A

Decrease VA to 0.5 MAC

higher doses = decreased uterine tone = bleeding

97
Q

Once cord is clamped, what may be done?

A

Balanced technique: N2O, narcotic + relaxant

98
Q

Antibiotics for C/S

A
  • Surgeon preference
  • normally 2g Ancef
  • given before incision
99
Q

Timing of delivery

A

Neonatal status with C/S delivery under GA investigated using 2 time intervals:

  1. Induction to delivery time (I – D)
  2. Uterine incision to delivery time (U – D)
100
Q

2 time intervals

A
  1. Induction to delivery time (I – D)

2. Uterine incision to delivery time (U – D)

101
Q

I-D

A

Induction to delivery time

102
Q

U-D

A

Uterine incision to delivery time

103
Q

I-D outcomes

A

better outcomes when:

I-D time < 20 minutes

104
Q

U-D outcomes

A

Uterine incision – delivery intervals > 180 seconds associated with low Apgar scores + acidotic babies
Increased U – D intervals also result in elevated fetal umbilical artery norepinephrine levels which may be a sign of fetal hypoxia

105
Q

Adverse outcomes with prolonged U – D intervals may be the result of:

A
  • The effect of uterine manipulation on uteroplacental + umbilical blood flow
  • Pressure on uterus with accentuated aortocaval compression
  • Compression of fetal head during difficult extraction
  • Inhalation of amniotic fluid d/t gasping respirations by fetus in utero
106
Q

Uterine Incision-Delivery Time Prolonged d/t tightened uterine muscle

A

Low dose nitroglycerin to relax muscle temporarily
1-2 mL of 100 mcg/mL Nitroglycerin
only if OB wants

107
Q

C/S with GETA - no spinal/epidural/CSE

A

Anticipate postop pain

**administer analgesics during emergence

108
Q

C/S GETA emergence

A
  • NDMR reversal if used
  • Anticipation of postop pain (admin analgesics)
  • Ondansetron 4 mg IV for N/V prophylaxis
  • Extubate when pt wide awake
109
Q

What drugs cross the placenta?

A 
Induction agents 
Inhalation agents
Neuromuscular blocking agents 
Opioids (all) 
Local anesthetics
Anticholinergics
Neostigmine
Benzodiazepines
Vasoactive drugs
110
Q

Drugs crossing placenta: Local Anesthetics

A
  • LAs have to be absorbed in systemic circulation before can be transferred across placenta.
  • BUPIV + ROPIV are highly lipid soluble + can transfer with simple diffusion
  • LIDO is less lipid soluble but has a lower degree of protein binding, so it will also cross placenta
111
Q

Drugs crossing placenta: anticholinergics

A
  • Glycopyrrolate is fully ionized + therefore poorly transferred across placenta
  • Atropine demonstrates complete placental transfer
112
Q

Drugs crossing placenta: Neostigmine

A
  • Neostigmine = a small molecule able to cross placenta more rapidly than glycopyrrolate
  • In a few cases where neostigmine used with glyco to reverse NDMB in pregnancy, profound fetal bradycardia reported
  • SO, for GA in pregnancy where baby is to remainin utero, advisable to use neostigmine with atropine rather than glycopyrrolate
113
Q

Drugs crossing placenta: Benzos

A

Benzos = highly lipid soluble + un-ionized

= complete transfer

114
Q

Non-OB surgery

A

1-2% of women undergo non-OB surgery during pregnancy
Most common procedure during 1st trimester = laparoscopy
Most common open abd procedure in pregnancy = appendectomy + cholecystectomy

115
Q

Pregnancy + elective surgery

A
  • avoid surgery during period of organogenesis during 1st trimester
  • all elective procedures postponed until after delivery
116
Q

Pregnancy + non-elective surgery

A

non-elective procedures should be performed in 2nd trimester if feasible

117
Q

Fetal safety: teratogenic agents

A
  • No agent proven to be teratogenic in humans
  • nitrous oxide + diazepam in animal models = aroused concern, now questioned

Now we avoid N2O + all benzos

118
Q

Non-OB cases: planning

A

-consult OB for all but the most minor surgical cases

**use regional techniques (esp spinal) when able!

  • Continuous FHR monitoring may be indicated depending on operative site + fetal gestation
  • A uterine tocodynamometer should be used to detect preterm labor (especially in posto)
119
Q

If a pregnant pt is having a non-obstetric surgery and needed paralysis, how do you reverse?

A

Atropine rather than Glyco

adjunct to neuromuscular blockade reversal:
25–30 mcg/kg 30–60s before neostigmine

120
Q

Atropine dosage when used in reversal with Neostigmine

A

25–30 mcg/kg 30–60s before neostigmine

dose is approx half of neostigmine (atropine 20µg/kg for neostigmine 40µg/kg)

121
Q

FHR monitoring - non-OB surgery

A
  • After 18 weeks gestation, FHR monitoring is practical

- After 25 weeks gestation, FHR variability is a reliable sign of fetal wellbeing

122
Q

Cervical cerclage

A

Shirodkar + McDonald cerclages performed for cervical incompetence

  • transvaginally during 1st/2nd trimester, prophylactically or emergently
  • sutures removed @ 38 weeks
  • no anesthesia req’d
123
Q

Cervical cerclage: prophylaxis

A

12-14 weeks

124
Q

Cervical cerclage: technique

A
  • Spinal anesthesia is technique of choice, although an epidural may also be performed
  • Avoid sedation or intrathecal adjuncts if possible d/t effect on fetus
  • Avoid nitrous oxide + midazolam
125
Q

cervical cerclage: spinal technique

A

Less medication, pt sits up for “dense saddle block”, do not need T4 coverage

1-1.2mL Hyperbaric 0.75% Bupi

126
Q

Postpartum Tubal Ligation

A
  • Usually done 8h after vaginal birth if no complications

- Surgeons make small sub-umbilical incision d/t fundus being at level of umbilicus

127
Q

Postpartum tubal ligation: anesthetic considerations

A
  • Delayed gastric emptying persists during early postpartum
  • Bicitra, metoclopramide, famotidine given preop
  • Easiest to use labor epidural (Keep in mind LA doses decreased with pregnancy)
  • Otherwise, spinal most commonly done
  • Ensure pt NPO between delivery + surgical procedure
128
Q

VBAC

A

Vaginal birth after cesarean

-TOLAC: trial of labor after cesarean delivery (60-80% able to VBAC)

129
Q

VBAC Risks

A
  • Maternal hemorrhage
  • Infection
  • Operative injury
  • Hysterectomy
  • Uterine Rupture: Incidence of 0.7% - 0.9%, declines with each successful VBAC
130
Q

Uterine Rupture: S/S

A 
Vaginal bleeding
Sharp pain between contractions
Contractions slow or become less intense
Bulging under pubic bone (baby’s head protruding outside of uterine scar)
Uterine atony
Maternal tachycardia
131
Q

Uterine Rupture: Tx

A

Emergency C/S

Supportive Care

P&P 3 (9 decks)

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