Exam 1: uterine blood flow, maternal phys, foundations, epidural, c section Flashcards
uterine blood supply pic
what are changes in the Lt and Rt uterine artery in pregnancy
increase in size and flow on the same side of placenta (so if placenta on L side, so L side increases)
where do uterine arteries branch from
internal iliac arteries
what branch of the uterine arteries suply the myometrium and radial arteries
arcuate arteries
what arteries branch to enter the endometrium to form the convoluted spiral arteries
radial
what space does oxygenated maternal blood enter
intervillous space
what invades the spiral arteries in a hypoxic state resulting in loss of smooth muscle tone
trophoblasts
where does the the exchange of O2, nutrients, and waste occur between fetus and mother
blood directed at chorionic plate bathes the villi
where does blood return fromfetus to mother
returns to basal plate and drains into multiple collecting veins
describe path of venous drainage of uterus
uterine veins-> internal iliac and utero-ovarian plexus-> inferior vena cava on right and renal vein on left
what does blood sample from intervillous space resemble
mixed venous
maternal fetal blood exchange picture
placental blood supply picture
what is uterine blood flow at term
700-900ml/min
uteroplacental blood makes up _________- perecent of maternal cardiac OP
12%
what is umbilical blood flow
110-120ml/min/kg
what are the three stages of changes in uterine blood flow
1- before and during implantation and early placentation
2- Growth and remodelingof uteroplacental vasculature
3-progressive uterine artery vasodilation
as flow to common iliac and uterine arteries increases blood flow to what artery decreases
external iliac
how does increased SVR effect placental blood flow??
decreased
how is SVR in uteroplacental circulation
low
uteroplacental circulation is _______ dependent
pressure
T/F uteroplacental circulation has well controlled autoregulation
false
if maternal BP is decreased, what happens to placental blood flow
decreased
uterine blood flow = __/_____
uterine perfusion pressure/uterine vascular resistance
what are some things that decrease uterine perfusion pressure FROM decreased uterine arterial pressure
supine position (aortocaval compression)
hemorrhage/hypovolemia
drug-induced hypotension
hypotension during sympathetic blockade
what are some things that decrease uterine perfusion pressure from increased uterine venous pressure
venal caval compression
uterine contractions
drug-induced uterine tachysystole (oxytocin, LAs)
skeletal muscle mypertonus (sezures, valsava, peep)
what are uterine effects of high doses of oxytocin
uterine tachysystole and decreased uterine blood flow
what are some causes of increased uterine vascular resistance FROM endogenous vasoconstrictors
catecholamines (stress)
vasopressin (in response to hypovolemia)
what are some causes of increased uterine vascular resistance FROM exogenous vasoconstrictors
epinephrine
vasopressors (phenylephrine>ephedrine)
LAs
does neuraxial anesthesia increase or decrease uteroplacental blood flow?
epidural CAN increase blood flow UNLESS you drop mother HR, BP, or put in supine position
which vasopressor is better at treating maternal hypotension
ephedrine (produces more uterine blood flow, but lower umbilical pH)
but Crouss says phenylephrine is safer
T/F commonly use induction drugs decrease uterine blood flow
false
T/F volatiles anesthetics decrease uterine blood flow
false
T/F hypoxia and hypercarbia decrease uterine blood flow
true
what are we minduful on during induction related to uterine blood flow
hypotension can decrease uterine blood flow
laryngoscopy can decrease uterine blood flow 2/2 NSS response
what effect does SNS response have on uterine blood flow
decreases
what can we do to furhter dilate placental artieries
nothing, they are already maximally dilated from trophoblasts
what is the effect of 5L of O2 on uterine blood flow
can causes vasoconstrictive affects-> decrease UBF
what is the average amount of weight gain in pregnancy
17% or 12 kg
what is the breakdown of weight gain in pregnancy
amniotic fluid 1 kg
fat 4kg
uterus 1 kg
fetus placenta 4kg
blood volume 1 kg
interstitial fluid 1kg
T/F in pregnancy your heart increases in size
true
what heart tone is often heard in pregnancy
4th tone
what causes the grade 2 systolic murmur at L sternal border
tricuspid and pulmonic regurge (benign)
when do pregnant patients develop LVH
12 weeks
how is HR affected by pregnancy
increases
what causes the increase in CO in the first trimester of pregnancy
HR
what causes the increase in CO in the 2nd trimester
SV
what hormone correlates with the increase in SV
estrogen
when does the increase in CO begin
5 weeks
what causes the decrease in SVR in pregnancy
low resistance in pregnancy
how is EF in pregnancy
increased
how is LVESV in pregnancy
same
how is LVEDV in pregnancy
increased
where is perfusion increased in pregnancy
uterus
skin
kidneys
extremities
what does increased skin perfusion lead to
flushing, heat loss
uterine blood flow increases from 50 ml/m to __________ ml/m by term
700-900
what percent of cardiac output goes to uterus in second half of pregnancy
12% (5% pre pregnancy)
what position do you put pregnant patient in to prevent aortocaval compression
left lateral about 30*
when can aortocaval compression begin
13 weeks
what does supine position affect pregnancy patient
10-20% decline in SV and CO, decreased RA filling pressure
how dose supine position affect uterine blood flow
decrease by 20%
how does supine position affect lower extremity blood flow
50%
what are s/s supine hypotension syndrome
light headedness
n/v
chest heaviness
how does sitting up effect BP
can be 10% decrease do to low SVR state
how can we combat decrease in BP when placing spinal/epidural
lateral position OR bend legs up
what happens to CO right after delivery
up to 150% increase above prepregnant baseline
how much does CO increase in early first stage labor
10%
how much does CO increase in late first stage labor
25%
how much does CO increase in second stage labor
40%
how much does CO increase immediate postpartum
75%
how is CO 24 hours post partum
24 hours postpartum decreases to just below prelabor levels
when dose CO return to baseline
12-24 weeks
what causes the rapid increase in CO after delivery
no AV compression
decreased low resistance placenta
how does uterine contraction effect blood
displaces 300-500 ml
when does HR return to baseline
2 weeks
what hormone relaxes ligament and cartilage in pregnancy
relaxin
what happens to the subcostal angle in pregnancy
widens (69-104*)
what happens to the vertical measurement of chest cavity
decreases (4cm)
what happens to the AP and traverse diameters in pregnancy
increase (2 cm by 37 2weeks)
what happens to capillaries of larynx and nasal/oropharyngeal mucosa
capillary engorgement
T/F use nasal trumpets/nasal intubation in preggers
false
what happens to airway in preggers
friable, bleeds
how is nasal breathing
difficult
how is pulmonary resistance in pregnancy
decrease 50%
how is chest wall excursion in pregnancy
decreased
how is diaphragm excursion in pregnancy
increased
how is FEV1 in pregnancy
unchanged
resp changes
how is flow volume loop in resp
no change
how is Total lung capacity in pregnancy
slightly reduced
how is TV in pregnancy
increased by 45%
how is expiratory reserve in pregnancy
decreased by 25%
how is residual volume in pregnancy
decreased by 15%
how is MV in pregnancy
45% increased
how is VC in pregnancy
maintained
how is RR in pregnancy
increased slightly
what are the pulmonary volumes that are decreased in pregnancy
expiratory
residual
(TLC slightly)
how is closing capacity in preggers
no change
T/F dyspnea affects up to 75% of women during pregnancy
true
what ph state are pregnancy in
resp alkalosis
how is PaO2 in pregnancy
increased
how is PaCO2 in pregnancy
decreased
how is pH in pregnancy
increased
how is bicarb in pregnancy
decreased
what causes the increase in PaO2 in pregnancy
increased alveolar ventilation
how is stomach affected by pregnancy
stomach displaced up and to the left, axis is rotated 45*
decreased lower esophageal sphincter tone
at how many weeks does a pregnant patient become aspiration risk
any week, RSI
GI changes chart
when do preggers have delayed gastric emptying
labor
T/F pregnant patients have increased gastric acid secretion
false
what is an important drug to give preop for preggers
antiemetic/zofran (80% have N/V)
fix the N/V before
what is a potential issue with zofran
leads to birth defects
how is liver affected by preggers
liver displaced upward
increased bilirubin,alanine aminitransferease, aspartate aminiotransferease, and lactate dhydrogenase
how does preggers effect gallbladder
gastric smooth muscle relaxes leading to billiary stasis and increased gallstones
increased rates of lap Chole
how long after birth do women still have aspiration risk
7 days
how is renal blood flow affeted by pregnancy
increases by 75%
how is GFR affected by preggers
increased by 50%
how is creatinine clearance in preggers
150-200 ml/min
T/F protenuria is only possible with preeclampsia
false
how is urine glucose in preggers
increased
T/F twin pregnancy has higher proteinuria
true
T/F later term has higher proteinuria
true
what causes the physiologic anemia in preggers
increased plasma volume
not as much increased RBC
when do RBCs decrease in preggers
8 weeks
when do RBCs return to baseline in preggers
16 weeks
how does blood volume change in pregnancy
increased 45%
how does plasma volume change in pregnancy
increased 55%
how does RBC volume change in pregnancy
increased 30%
what is a typical hgb concentration g/dL
chart says 11.6
crouss said aroun 9
typical hct in pregnancy
chart says 35.5%
how is cholinesterase affected in preggers
25% decrease (drops during first trimester)
how much blood is lost in normal vaginal delivery
600ccs
when is the greatest decrease in psuedocholinesterase activity
3rd day postpartum
when do you use succs during preggers
emergency c section
no need to redose paralytics
T/F the psuedocholinesterase deficiency affects succs metabolism
false
what factors are increased in preggers
1,7,9,10,12
what factors are unchanged in preggers
2,5
what factors are decreased in preggers
11, 13
what bleeding/clotting state is preggers
hypercoag
how are platelets in preggers
greater production and consumption
8% have platelet count <150,000
what is normal blood loss in c section
1000ccs
what makes c section blood hard to estimate
amniotic fluid
irrigation
how are clotting factors post partum
rapid decrease in
platelets,
fibrinogen,
factor 8 and
plasminogen
when does coags return to normal postpartum
2 weeks postpartum
how is immune system in preggers
immunocompromised
how are leukocytes in preggers
increased to 9-11,000 up to 15000
how are autoimmune disorders in preggers
improved
what kind of T cells are in successful preggers
th2
what kind of T cells are in miscarriage
Th1
how is thyroid in preggers
enlarges 50-70%
which Thyroid hormones are increased
estrogen increased T3 T4
how is TSH in preggers
same
how many preggers have gestational hypothyroid
15%
how is insulin affected
insulin resistance
how are cortisol levels
2.5x higher at end of 3rd trimester
how is calcium in preggers
insufficient 2/2 fetal demand
T/F post partum back pain is from epidural
false, relaxin
how does preggers effect sleep
disturbed REM cycle
how is cerebral blood flow in preggers
increased 2/2 decreased cerebral vascular resistance
how is BBB
more permeable
how is epidural space in preggers
epidural fat and venous plexus enlarge
how is CSF volume in preggers
decreased
how is CSF pressure in preggers
same
during preggers dependence on the SNS is (increased/decreased)
decreased
why is it important to stay midline in epidural
enlarged venous plexus
what is best position to avoid AV compression in preggers
L lateral 15%
how do we position after spinal
raise head up (10*)
what do we watch for high spinal
pinky numb/tingle C8
how many class 4 mallampati
increased by 34%
what makes preggers higher to iNtubate
DECREASED FRC
swollen tissue
tissue demands of fetus
class 4 airways
in preggers PaO2 decreases _______ x faster
2
how long do you have till hypoxia in preggers
2-3 min
what kind of airway equip should you have in preggers
videoscope
how is MAC in preggers
40% lower
does not affect anesthesia requirements in practice
T/F use lots of narcs in preggers
false
risk of fetal bradycardia
how are Beta adrenergic receptors in preggers
down regulated
so need higher doses of vasoactives if using
what makes neuraxial anesthetics more difficult in preggers
lordosis
increased weight
increased bleeding
what is a complication for neuraxial
hypotension
difficulty breathing
what are risks for ectopic preggers
previous ectopic
intertility tx
prior pelvic infection
tubal sx
advanced maternal age
where do most ectopic implantation occur
tubal
what are s/s ectopic
pelvic pain
delayed menses
vaginal bleeding
abd pain with or without tenderness
signs of shock
what is the leading cause of maternal death in the US
ruptured ectopic
what is ectopic called before it is diagnosed officially
pregnancy of unknown location
what is the gold standard of diagnosising ectopic
transvaginal ultrasound
how does ectopic appear on ultrasound
adnexal mass with free fluid
how do seerial HCGs diagnose ectopic
serial for 48rs, if it does not increase by 53% then possible PUL
what does a decrease in HCG by 10% tell us
failed pregnancy
what labs do you do for PUL
HCG
progesterone
pregnancy test
what is your induction med for ectopic
etomidate
how do you prepare for ectopic case
2 ivs
fluid
blood
etomidate induction
type and scree/cross
aspiration prophylaxis
urinary catheter
RSI
vasopressors ready
a-line if unstable
Ng tube
warming device
pitocin
when does aspiration risk begin in preggers
1st week
what is EPL
early pregnancy loss, term for spontaneous incomplete abortions
when do EPLs occur
8-14 weeks
what is surgical procedure for EPL
D&C or D&E
what is D&E for
larger fetus
what is complication of retained fetus
sepsis
what is anesthetic technique for EPLs
type and cross/screen
aspiration prophylaxis
urinary catheter
large bor IV
RSI
etomidate
monitors
vasopressors
a line if unstable
NG tube
warming device
what do we give after D&C
methergine, hemobate, pitocin
when do we stop pitocin for DC
before instrumentation
when do we restart pitocin
after removal of fetus
what can long term use of pitocin use
uterine atony after dc, give smaller dose after long term use
what is the inability of a cervix to hold a pregnancy
cervical insufficiency/incompetency
what procedure is performed for cervical insufficiency
cerclage procedure
what is preferred if cervix is not dilated and membranes are bulging
spinal anesthesia (sacral to T10)
what is goal of cerviccal insufficiency tx
prevent rupture of membranes
what is the most common medical disorder in preggers
HTN
what is risk of HTN
fetal complications
what is the most common cause of HTN in pregnancy
gestational HTN
how often does HTN occur
10% of preggers
what is true gestational HTN
HTN that is new onset and returns to normal after birth
what is the only cure for preeclampsia
delivery of fetus/placenta
how is PREclampsia defined
new onset HTN and proteinuria AFTER 20 weeks gestation
what is the leading cause of indicated preterm delivery
peeclampsia
what are the two kinds of preeclampsia
with or without severe features
sever features vs without sever features preeclampsia
what kind of preeclampsia is for blood pressure greater than or equal to 140/90
without severe features
what kind of preeclampsia has BP > 160/110, thrombocytopenia, pulmonary edema, visual disturbances, impaired liver function
severe preeclampsia (with complications)
what are complications of Preeclampsia
narrowing of airway
40% reduction in plasma volume
pulmonary edema
thrombocytopenia
DIC
HELLP
placental abruption
fluid volume overload
increased LVEDP
Pump Htn
Swollen legs
what is HELLP syndrome
hemolysis, elevated liver enzymes, low platelets
what is goal week for preeclampsia delivery
after 37 weeks
when is delivery for sever preeclampsia
<34 weeks
what do you do to treat delivery for preeclampsia <34 weeks
delay for 24-48 hours for corticosteroid treatment
administer anti htn and mag
what are preffered anesthesia methods for preeclampsia
CLE and CSE or spinal over GA
how often do you monitor platelets for preeclampsia
every 24 hours, can get below 100,000
how is CO affected by birth
it increases, so with preeclampsia pulmonary edema can occur and sharp spike in BP
preeclampsia tests
HELLP chart
hypertensice disorders of pregnancy
what is eclampsia
new onset of seizures/coma with symptoms of preeclampsia
when can eclampsia occur
4 weeks postpartum
what happens to fetus after seizures for eclampsia
fetal bradycardia
what do we give for eclamptic seizures
magnesium (4-6 grams over 20 min)
what are goals of spinal/epidural anesthesia for labor
pain relief
safety for mother and fetus
continued progression of labor
retain ability to push
minimize SE
have a long duration
be flexible
minimize time demands for anesthesia provider
T/F epidurals delay labor
false
what does pain in the first stage of labor come from
distention of lower uterus and cervix
-visceral pain
T10,11,12
what does pain in the second sage of labor come from
somatic
pudendal S2,3,4
what are benefits of analgesia in labor
-better uteroplacental perfusion and uterine activity
- decreased hyperventilation
-decreased paternal anxiety/fear
-decreased catecholamines = increased blood flow to fetus
T/F epidurals are elective
true
Can someone who got a tattoo right on epidural spot 4 months ago have epidural
no
Can someone who got a tattoo right on epidural spot 6 months ago have epidural
yes
Can someone who got a tattoo with metalic ink right on epidural spot 4 months ago have epidural
no
contraindications to epidural
what are some other contraindications to neuraxial
mechanical valves
blood thinners
T/F you have have neuraxial anesthesia with porcine valve
false
what are indications for Spinal/epidural
Maternal/OB request
Breech deliveries
Twins
what are some benefits for spinal epidural
facilitates BP control in preeclampsia
blunts hemodynamic fluctuations during contraction
what is gynecological recommendation for epidural
4-5 cm dilation
what do you do to prepare for spinal/epidural
review OB history
preanesthetic eval
physical exam
review labs
inform and answer question
signed consent
T/F you can have spinal/epidural with Skin infection
T, as long as infection is not right on insertion site
T/F you can have spinal/epidural with systemic infection
F, look for increased WBCs
T/F you can have spinal/epidural with platelets <100,000
F, >100,000 is okay
T/F you can have spinal/epidural with anticoagulants
F
off ASA for 7 days
off heparin for 24 hours
what equipment do we need for spinal/epidural
Airway cart
epidural cart
lipids
resuscitation meds
working IV
what monitors do we need for spinal/epidural
BP, EKG, pulse ox, ambu, suction, FHR monitor
how do we pretreat for spinal/epidural
1000ccs crystalloid
colloid
how do you position for epidural/spinal
side of bed, straight back
how often do you check vitals after test dose/ initial bolus
Q5 min for 15 minutes
what is the benefit to lateral position over sitting for spinal placement
lower csf pressure
what are layers for epidural /spinal placement in medial approach
skin
subq
supraspinous ligament
interspinous ligament
ligamentum flavum
epidural space
dura
interthecal spinal space
what are the benefits of continuous epidural
contnuous and variable levels of anesthesia
ability to extend to C section
no dural puncture
caudad and cephalad spread
controlled by pump with bolus feature
what are negatives of continuous epidural
slower onset
large volumes of LA required
higher failure rate
what two layers do you skip in paramedian approach
supraspinous and interspinous ligaments
which approach has more vessels, medial or paramedian
paramedian
what are benefits of CSE
confirms epidural space
same benefits as epidural
more rapid onset
much faster sacral analgesia
less chance of failure
T/F CSEs have an increased chance of postdural puncture HA
false
what are negatives of CSE
can cause pruritis
possible inadvertant intrathecal catheter insertion
dont know if epidural is working
hypotension
spinal will wear off
high spinal
when bolusing epidural what is the rule for volume/dermatome
1 level = 1 ml
what is normal CC injection
6-8 ccs
epidural vs CSE
what are benefits of DPE
same benefits as epidural
faster onset for sacral spread and overall more dense block
less failed blocks
less unilateral blocks
faster onset
which has faster onset CSE or DPE
CSE
what is negative of DPE
possible intrathecal cath placement
how do you make sure your catheter is not in spinal space
test dose
what is benefit of continuous spinal
extends block beyond typical intrathecal injection
can be used in event of accidental dural puncture
what are negatives of continuous spinal
high risk for post-dural puncture HA
risk for high spinal
when do we use continuous caudal caths
typically only used for chronic pain
can be used for prior surgery where epidurals are not an option
what are benefits of single shot spinals
provides almost immediate analgesia
dense block
low LA dosage
what are negatives of single shot spinal
limited effective analgesia time
can block motor function
what do we do to identify unintentional cannulation of the subarachnoid space or blood vessel
epidural test dose
what meds do we give for test dose
3ml of
1.5 lido (45 mg)
1:200,000 epi (15mcg)
T/F we give test dose during a contraction
F, time it between contractions
what is a positive epidural test dose
risk in HR or BP 20% above baseline
symptoms of lidocaine toxicity (ringing in ears, metalic taste, numb feet)
what do you do if you have a postive test dose
pull back catheter
redo test dose
replace epidural
which shoulder do you put epidural line on
same side as IV
how far do you put epidural catheter in space
text book like 3-5 cm, palmer says 7-10 cm
which epidural drug treats visceral pain
opioids
which epidural drug treats somatic pain
LAs
where are dense concentrations of opioid receptors located
dorsal horn of spinal cord
what epidrual drug would you give for lower uterine segment and cervicle dilation pain
opioids (visceral)
what epidural drug would you give for descent of fetus into birth canal pain
LA (somatic)
what is concentration of epidural bupivicaine
0.125%
T/F bupivicaine blocks motor
false
bupivicaine facts
highly protein bound
pain relief in 8-10 minutes
peaks in 20 min
duration 90 minute single dose
cardiotoxic
doesnt block motor
what is concentration of ropicivaine for rescure
0.25-0.5% 8-10 ccs rescue
what is relationship of ropivicaine and bupivicaine
ropivicaine is the single levorotary enantiomer of bupivicaine?
ropivicaine facts
less potent than bupivicaine
less motor blockade than bupivicaine
less cardiotoxic than bupivicaine
when do we use lidocaine for epidural
c section
lidocaine facts
shorter DOA
less protein bound
increased motor blockade
very dense block
when do we use 2-chloroprocaine
emergency c section, good drug to top off crowning or retained placenta
2-chloroprocaine facts
ester LA
rapid onset
short DOA
what are characteristics of lipid soluble opioids for epidural
rapid onset
short DOA
greater systemic absorption
reduce amount of LA needed
what is best combo of epidural opioids
a lipid-soluble and a water soluble
what are examples of water soluble opioids
morphine, hydromorphone, meperidine
which opioid has some LA properties
merperidine
what are properties of water soluble opioids
long latency
long DOA
inconsistent analgesia
more sedation
what is benefit of epinephrine as an adjuvant
1.25-5 mcg
shortens latency, prolongs doa, reduces LA dose by 29%
how does clonidine work as an adjuvant
direct stimulation of Alpha 2 adrenergic
what is action of acetylcholine as adjuvant
inhibits breakdown of acetylcholine which increased GABA
what is benefit of LA and opioid
lower total dose of anesthetic
decreased motor blockade
reduced shivering
greater patient satisfaction
what two locals are usually in epidural pump
ropivicaine
bupivicaine
how can you test if epidural is working
have raise legs, if they can its no good
what do you do with bad epidural
replace it
managing bad epidural chart
what do you do if you accidentally puncture dura
remove needle and try another level
transition to CSE
place catheter intrathecal
what increases risk of ectopic pregnancy
previous ectopic
infertility treatment
prior pelvic infection
tubal sx
advanced maternal age
esters vs amines
which LA does not contain a desaturated carbon ring and a tertiary amine
cocaine
T/F pregnancy requires higher doses of LA
false
smaller
how does pregnancy affect LAs
engorgement of epidural veins
increased neuronal sensitivity
progesterone or its metabolite
higher pH
what are s/s LAST
tongue numbness
lightheaded
muscle twitching
unconsciousness
convulsions
coma
resp arrest
cardiovascular collapse
how do we treat LAST in preggers
call for help
position for L uterine displacement
20% lipids
100% O2
maintain airway
control seizures
support BP with pressors fluid
consider bypass
T/F LA allergies are common
false
rare
T/F LAs easily cross placenta
T
protein biding
lipid soluble
ionizing
neonatea are (more/less) sensitive to CNS depressant effects of LAs
less
what are Fetal heart rate changes usually related to
LA effect on mother such as hypotension
opioid receptor types
what kind of receptors do opioids bind to
G protein coupled opioid receptors which inhibit adenylate cyclase and voltage gated calcium channels
what is the result of opioids inhibiting clacium channels
release of glutamate and supstance P
-ionhibition of ascending nociceptive stimuli form dorsal horn of spinal cord
what is the site of action of epidural opioids
dorsal horn of spinal cord
what can happen to fetus if opioids get transmitted
resp depression
decreased APGAR
bradycardia
how do opioids cause fetal bradycardia
linked to decreased maternal epinephrine
leads to uterine hyperactivity
what is the most common major surgicial procedure performed worldwide
c section
what is the most common indication for C section
labor arrest (34%)
T/F prior c section means you will always have C section
F (VBAC)
what are indications for C section
fetal heart tones (23)
breech presentation (17)
multiple fetus (7)
when do they do vertical c section incision
preterm, more emergent, lower presentation
what is uterine exteriorization
take uterus
what type of incision for nonemergent c section
horizontal
what happens when putting uterus back in
nausea- pretreat with zofran
T/F c section have a higher death rate than vaginal
F, just as safe as vaginal
T/F neuraxial anesthesia results in higher C section rates
false
T/F epidurals slow down labor
false
how do you position after epidural
wedge hip alternate
what are methods to do intrauterine resuscitation
positioning (L lateral)
O2
maintain BP
stop pitocin
treatment of uterine tachysystole
what medications do we give to maintain BP in intrauterine resuscitation
Phenyl, ephedrine
T/F only get consent for mothers who say they want a C section
F, everyone is possible
what can we do for high risk patients before they are admitted for birth to ensure safe anesthetic delivery
pre anesthesia consult
what is the leading cause of maternal mortality
peripartum hmmg
what anesthesia medications do we avoid in c section
narcs
non-depolarizers
volatiles
what can non-depolarizers lead to
paralyze the uterus=uterine atony= bleeding
what can volatiles cause in c section
uterine atony
what paralytic do we use for c section under general
succs
what can we give mother after baby is taken out in C section
turn up N2O
give narcs
turn down sevo
what is the limit for clear liquids for c section
nonlaboring healthy patients can have clear liquids up to 2 hours
how can we prophylactically treat for aspiration in c-section
antacid
H2 antagonist (pepcid_
PPIs
promotility (reglan)
what is a consideration for treating aspiration with meds
use multiple agents
30 minute onset
how much ancef do we give for <100 kg
2 gm
how much ancef do we give for >120kg
3gm
how do we dose ABX
weight
when do we give ABX
within 60 minutes of incision
what fluids do we give before spinal
1L cystalloid BUT
albumin is better (500)
how many IVs for csection
2 large bore
what neuraxial do we do for scheduled C section
spinal
what neuraxial do we do for emergent c section
general
what neuraxial do we do for failure to progress c section
epidural
what is positioning for c section
at least 15 degree L lateral
head up 10 degrees after spinal
what position do we put c section patient in for neuraxial
lateral or sitting
when do we give mother O2
fetal distress
what kind of oxygen do we give for scheduled C section
NC
what kind of oxygen do we give for emergent C section that may turn to general
100%
what is a good pretreat medication for C section
anxiety
emergent vs urgent vs scheduled c section
what kind of C section is for prolonged fetal bradycardia
emergency
what kind of C section is for deep variable dcels with cervical dilation of 3 cm
urgent
what kind of C section is for ruptured memebranes with previously undiagnosed breech presentation
scheduled
what kind of C section is for repeat C section
elective
what type of C section is for immediate threat of life to mother or fetus
emergent
what type of C section is for maternal or fetal compromise that is not immediately life threatening
urgent
what type of C section is for needing early delivery but no maternal or fetal comprimise
scheduled
what type of C section is at a time that suits the mother and delivery team
elective
what is goal level of epidural redose for C section
T4
what medication can we give in epidural to speed up onset
bicarb
what is the type of anesthetic for c section determined by
urgency of c section
once a mother is under GA, how long does the surgeon have to get the baby out
8 minutes
when should surgeon cut under Genderal C section
as soon as eyes are closed/meds pushed
what do you always do after C section? why
Xray, see if anything left
how often is nueraxial used in emergent C section
80%, sometimes not enough time
what is goal sensory level for c section
T4
what are advantages of spinal for C sec
visualization of CSF
technically easier
more rapid
more dense
less risk of LA
predictable recovery
what is the duration of spinal
2-3 hrs
what is the max dose of spinal
2 ccs total
Why do we give dextrose in spinal
baricity (dextrose is hyperbaric)
what is the drug of choice for spinals
bupivicaine 0.75% in 8.25% dextrose
what is the most common dose of spinal
10-15 mg
spinal med doses
what kind of morphine do you use for spinals
duramorph-preservative free
how is resp depression with duramorph
delayed reaction
what are benifits of intrathecal opioids
-reduce intraoperative supplemental analgesia by 20%
-reduces N/V
what are lipid soluble (fast) opioids
fent
alfent
sufent
remifent
what are the water soluble (slow opioids)
morphine
T/F higher doses of intrathecal opioids increase analgesia
F, increase pruritus
what can we give to treat pruritis from intrathecal opioids
narcan in NS slow dripped
what are some spinal analgesia adjuvents
dextrose
epi
clonidine
dexmetomidine
how much bicarb do we give for spinal
1/10th total volume
T/F clonidine and precedex have less side effects than opioids
true
what is potential side effects of clonidine/precedex
vasodilation
what is the best range for fentanyl dosing
10-15mcg
T/F epidural anesthesia is more reliable than spinal anesthesia
false
how are epidural doses compared to spinal doses
5-10x higher
what are adjuvents for epidurals
fentanyl
sufenta
morphine
hydromorphone
clonidine
epi
sodium bicarb
dexmetomidine
epidural anesthesia doses
what medication do we give with epidural to prolong block
epi
what is the goal block for epidural
T10-T4
how is intubation for GA for C section
difficult
reduce ETT size
short laryngoscope handle
video laryngoscope
what operative prep must be done BEFORE initiatiating GA in c section
prepped and draped
T/F delay C section incision until ETT confirmation
T, but palmer says F in practice
what is the benefit of GA in C section
less aspiration
what are goals for anesthesia and C section
adequate maternal and fetal O2
adequate depth of anesthesia
minimize effects on uterine tone
minimize effects on the neonate
when can we give mother IV opiods
after delivery
what kind of Muscle relaxers are avoided in C section
non-depolarizing
how do volatiles affect c section
decrease uterine tone and BP
decreased uterine blood flow
what are recovery issues from C section
pain
sedation
N/V
pruritis
prolonged neuroblockade
drug treatment
bleeding
T/F a one time dose of toradol causes bleeding
false
what can cause lower neonatal apgar scores
depth of maternal anesthesia
delivery time > 8 minutes
T/F we want lack of recall with C section
false
T/F at T4 blockade you can still feel yourself breathing
false
how do we respond to high spinal
RSI
what is a common side effect of neuarxial block and what causes it
hypotension, sympathetic nerve fibers blocked
how can we prevent hypotension from spinal
IV fluid bolus 1 L (or 15 ml/kg)
colloid is better
ephedrine vs phenylephrine
lower doses of LAs
how do we prevent N/V
pretreat with zofran
what other complication can hypotension lead to in neuraxial
n/v
what are causes of N/V in C section
exteriorization of uterus
intra-abd manipulation
hypotension
risk factors for NV chart
what is optimal dose of intrathecal morphine
0.1mg
what is optimal dose of epidural morphine
3.75mg
what is another block to treat pain in c section
tap block
what is the most effective treatment for pruritis in neuraxial
narcan
what is the best drug to treat shivering
merperidine
why does neuraxial cause hypothermia
vasodilation
T/F uterine atony is more common after C section
true
T/F push oxytocin
false
drip it in (40 units in a liter wide open)
what can rapid bolus of oxytocin lead to
hypotension and cardiovascular collapse
what route do we give methergine and hemabate
IM
Pka 2-chloroprocaine
8.9
Pka tetracaine
8.6
Pka lidocaine
7.9
Pka bupivacaine
8.2
Pka ropivacaine
8.0
Fentanyl spinal
10-25 mcg
Sufenta spinal dose
2.5-5 mcg
Morphine spinal dose
100-200mcg
(0.1-0.2mg)
Dilaudid dose spinal
60-75 mcg
(0.060-0.075mg)
Demerol spinal dose
60-70mg
Epi spinal dose
100-200mcg
(0.1-0.2mg)
Just do epi wash
Fentanyl epidural dose
50-100mcg
Sufenta epidural dose
10-20mcg
Morphine epidural dose
3-4 mg
Dilaudid epidural dose
0.6-1.5 mg
Merperidine epidural dose
50-75mg
Normal TV
500
Normal ERV
1100
Normal residual volume
1200
Normal IRV
3000
Normal FRC
2300
Normal inspiratory capacity
3500
Normal vital capacity
4500
Normal Total Lung Capacity
6000
Factor 1
Fibrinogen
Factor 2
Prothombin
Factor 3
Thromboplastin
Factor 4
Calcium
Factor 5
Labile factor
Factor 7
Stable factor
Factor 8
Antihemophilic factor
Factor 9
Christmas factor
Factor 10
Stuart prower factor
Factor 11
Plasma thromboplastin antecedent
Factor 12
Hageman factor
Factor 13
Fibrin stabilizing factor
