Intrapartum analgesia Flashcards

1
Q

Discuss regional anaesthesia
-Indications (6)
-Contra-indications (5)

A
  1. Indications
    -Maternal request
    -Expectation of operative delivery
    -PET
    -Maternal cardiac disorder where increased HR /BP is wanted to be avoided
    -Breech or multiple delivery
    -Neurological disease
  2. Contra-indications
    -Maternal refusal
    -Infection - local or untreated systemic
    -Coagulopathy Platelets <80 or INR >1.4
    -Uncontrolled hypovolemia
    -Certain spinal disease or previous surgery
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2
Q

What is the care and observations recommended for regional anaesthesia (6)

A

-IV access prior to placement
-Do not administer routine preloading or maintenance fluid
-Check BP every 5 mins for 15 mins during establishment or after further boluses
-Anaesthetic review after 30 mins if woman not pain free
-Sensory check for block every hour
-Continuous CTG

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3
Q

Discuss placement of epidural anaesthesia
-Location (2)
-Medication used (2)
-Time of onset (1)
-Types of delivery system (3)

A
  1. Location
    -Aim for L3-L4. Must be below L1-2 as can hit spinal cord
    -Sits between ligamentum flavum and dura mata in the epidural space outside the CSF
  2. Medication used
    -LA +/- opiate - e.g. 0.1% bupivacaine and 2mcg/mL fentanyl
    -Medication diffuses across the dura mata
  3. Time of onset
    -10-20 mins
  4. Type of delivery
    -Intermittent midwifery top ups
    -Patient controlled epidural pump
    -Continuous infusion
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4
Q

Discuss the risks and benefits of epidural anaesthesia
-Benefits (4)
-Risks (9)

A
  1. Benefits
    -Non-drowsy
    -Very effective analgesia - gold standard
    -Minimal transfer to fetus
    -Capacity to top-up for additional procedures
  2. Risks
    -Failure to work 1:10
    -Significant hypotension 1:50
    -Severe headache 1:100
    -Temporary nerve damage 1:1000
    -Nerve damage > 6 hrs 1:13 000
    -Permanent nerve damage 1: 250 000
    -Epidural abscess 1:50 000
    -Epidural haematoma 1: 170 000
    -Meningitis 1:100 000
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5
Q

Discuss epidural anaesthesia
-Side effects (2)
-Impact to delivery (5)

A
  1. Side effects
    -Pruritis
    -Shivering
  2. Impact to delivery
    -Prolonged second stage
    -Increased instrumental delivery
    -NO difference to CS rates
    -NO difference to duration of first stage
    -NO long term back problems
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6
Q

What are the issues that can arise with epidurals and how can they be managed (4)

A
  1. Patchy epidural
    -Give further bolus
    -Reposition woman
    -Withdraw epidural catheter or re-site
  2. Maternal Hypotension / fetal bradycardia
    -Fluid bolus
    -Stop infusion
    -Consider vasopressors
    -Place woman in left lateral
  3. Accidental dural puncture
    -Re-site epidural
    -Leave catheter in place and have small top-ups by anaesthetist - will act as a spinal
  4. Bolus given into the CSF (Massive dose cf with spinal)
    -Vasopressor support
    -Consider intubation and ventilation
    -Deliver baby
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7
Q

Discuss nerve injury in epidural placement
-Pathophysiology (3)
-Symptoms (4)
-Management (3)

A
  1. Pathophysiology
    -Direct injury
    -Nerve compression due to bleeding into a confined space causing ischemia / necrosis
    -Infection causing damage to nerves
  2. Symptoms
    -Pain
    -Progressive motor deficiency
    -Loss of bowel or bladder control
    -Altered neurology
  3. Management
    -Urgent anaesthetic review
    -Urgent MRI
    -May require urgent decompressive surgery
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8
Q

Discuss post dural puncture headache
-Cause (1)
-Presentation (5)
-Treatment (4)

A
  1. Cause
    -Leakage of CSF from the dural space resulting in falling CSF volume and pressure
  2. Presentation
    -Onset usually 72hrs post event
    -Occipitiofrontal headache radiating to neck and shoulders
    -Better lying flat
    -Nausea and vomiting
    -Vertigo and dizziness
  3. Treatment
    -Hydration
    -Caffienated drinks
    -Simple analgesia
    -Blood patch - 70-90% success rate.
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9
Q

Discuss anticoagulation and timing of epidural placement
-On low dose aspirin
-On prophylactic LMWH
-On treatment dose LMWH
-On warfarin
-On anti-platelet agents

A
  1. On LDA
    -If <75mg can be continued
  2. Prophylactic LMWH
    -Stop 12 hrs before epidural/spinal placement
  3. Treatment dose LMWH
    -Stop 24hrs before epidural/spinal placement
  4. Warfarin
    -Check INR <1.5
    -Discuss with haematology
  5. Anti-platelet agents
    -Discuss with haematology
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10
Q

Discuss general anaesthesia in obstetrics
-Indications (5)
-Risks (8)

A
  1. Indications
    -Maternal refusal for regional techniques
    -Inadequate regional block
    -Multiple failed attempts at regional block
    -Contraindications to regional anaesthesia
    -Rapid delivery required
  2. Risks
    -Increased risk of fatality cf regional anaesthesia 2.3x
    -Failed intubation 1:300
    -Increased pulmonary aspiration 1:600
    -Increased anaesthetic awareness 1:400
    -Drug effects on neonate
    -Requirement for increased post-op pain relief
    -Post operative nausea and vomiting
    -Mother and partner not awake / present at birth
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11
Q

Discuss placement of pudendal nerve block
-Function of pudendal nerve (3)
-Contra-indications for placement (3)
-Steps to perform (6)

A
  1. Function of pudendal nerve
    -From S2-S4
    -Sensory function of external genitalia
    -Motor function of perineal muscles
  2. Contra-indication
    -Coagulopathy
    -Local infection
    -LA allergy
  3. Steps to perform
    -Use 20mL 1% lignocaine
    -Identify ischial spine (4 and 8 o’clock)
    -Place injection 1cm anterior and medial to spine
    -Infiltrate 5-7mL each side
    -Make sure to aspirate needle to avoid direct injection into circulation
    -Onset of analgesia in about 10mins
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12
Q

Discuss local anaesthetic toxicity
-Causes (2)
-Symptoms (6)
-Max dose of bupivocaine
-Max dose of Lidocaine

A
  1. Causes of LA toxicity
    -Direct injection into circulation
    -More than max dose given
  2. Symptoms
    -Severe agitation
    -Sudden altered mental status
    -Seizures/muscle twitching/convulsions
    -LOC
    -Hypotension
    -Cardiovascular collapse
  3. Max dose of bupivacaine
    2mg/kg max dose 150mg - 20mL of 0.75%
  4. Max dose of lidocaine
    3mg/kg max dose 200mg - 20mL 1%
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13
Q

Discuss management of LA toxicity

A
  1. Stop administration
  2. Call for help
  3. Assess patient and do ABC
  4. If seizures manage with benzo’s / propofol
  5. Give lipid emulsion 20%
    -Max 3 bolus of 1.5mL/kg every 5 mins
    -Start infusion of 15mL/kg concurrently
  6. Manage arrythmias as per shockable/ non-shockable rhythms
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14
Q

Discuss entonox for intrapartum pain relief
-Make up (1)
-Mechanism of action (4)
-Timing of effect (1)
-Side effects to mother (4)
-Side effects to fetus (1)
-Risks of prolonged use (2)
-Evidence (1)

A
  1. Make up
    1:1 mix of nitrous oxide with oxygen
  2. Mechanism of action
    -Acts as analgesic and anxiolytic at lower concentrations
    -Increases release of endogenous endorphins and dopamine
    -Half life of 2-3 mins
    -Cleared via the lungs
    -Can cross the placenta but doesn’t impact fetal heart rate
  3. Side effects to mother
    -Nausea and vomiting
    -Dizziness
    -Dehydration
    -Respiratory alkalosis
  4. Fetal side effects
    -May cause respiratory depression in neonate
  5. Risks of prolonged use
    -Megaloblastic anaemia with agranulocytosis
    -Myeloneuropathy
  6. Evidence
    -Works according to Cochrane review
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15
Q

Discuss opioid use in labour
-Types (3)
-Mode of action (2)
-Adverse effects to mother (7)
-Adverse effects to baby (6)

A
  1. Types
    -Pethadine - IM 150mg Q4H
    -Diamorphine IM 10-15mg Q4H - better than pethadine for pain relief
    -Remifentanyl PCA 1mcg/kg with 2 min block out
  2. Mode of action
    -Acts on opioid receptors in brain and spinal cord to reduce neuronal cell excitability and reduce transmission of nociceptive impulses
  3. Adverse effect to mother
    -Drowsiness
    -Hypoventilation
    -Nausea and vomiting
    -Urinary retention
    -Pruritis
    -Respiratory depression (32% in remifentanyl use)
    -Tolerance to remifentanyl after 1 hr
  4. Affects to baby
    -Can cross placenta and cause prolonged sleep phase with decreased variability
    -Respiratory depression
    -Hypothermia
    -Poor feeding
    -Altered crying
    -Decreased alertness
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16
Q

Discuss non-pharmacological pain management in labour
-Measures which maybe effective (3)
-Measures where insufficient evidence exists (3)

A
  1. Measures which may be effective
    -Water immersion
    -Acupuncture
    -Relaxation
  2. Measures where there is insufficient evidence
    -TENS
    -Hypnosis
    -Aromatherapy
    Sterile water injections
17
Q

Discuss water immersion in birth
-When to use (1)
-How it works (2)
-Evidence (4)
-Risks (6)
-Practicalities (3)

A
  1. When to use
    -NICE advise OK for latent and first stage in low risk women
  2. How it works
    -Increases uterine perfusion
    -May promote endorphin and oxytocin release
  3. Evidence
    -Reduces pain
    -Reduces first stage of labour
    -Less requirement for neuraxial analgesia
    -No difference in CS, assisted vaginal birth, perineal trauma, maternal infection.
  4. Risks
    -Prolonged labour if immersion commenced too early
    -Maternal and neonatal infection
    -Fetal hypoxia
    -Neonatal freshwater drowning
    -Neonatal hypothermia
    -Cord rupture and haemorrhage
  5. Practicalities
    -Still need to do fetal monitoring
    -Keep water at 37 degrees
    -If fetal head comes out of water in second stage don’t re-enter water as baby may gasp and inhale fresh water
18
Q

Discuss epidural infection
-Incidence
-Risk factors
-Presentation

A
  1. Incidence
    -1:50 000 (Epidural abscess)
    -1:100 000 (Meningitis)
  2. Risk factors
    -Insertion of epidural into bacteremic patient
    -Prolonged insertion >48hrs
    -Poor sterile technique
  3. Presentation
    -Local pain and swelling, erythema
    -Progressive sensory and motor disturbance
    -Incontinence
    -Severe headache, photophobia, nausea, vomitting
19
Q

Discuss management of epidural site infection

A

-Remove epidural tip
-Send tip for culture
-Swab epidural site
-Urgent MRI if neurological deficits or suspected abscess
-Commence brad spec Abx that cover skin commensals
-Immediate surgical evacuation if spinal epidural abscess

20
Q

Discuss the pain pathways of labour
-Origin of pain (2)
-First stage (1)
-Second stage (1)

A
  1. Origin of pain
    Myometrial ischemia
    Mechanoreceptor triggering through:
    -stretching of lower segment
    -dilation of cervix
  2. First stage:
    -Sympathetic nerves to superior and inferior hypogastric plexus to T10 to L1
  3. Second stage:
    -Pudendal nerve to S2-S4
21
Q
A