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S5 - Regional/OB - Test 1 > Labor Analgesia > Flashcards

Labor Analgesia Flashcards

1
Q

Duration of 2-chloroprocaine

A

Short

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2
Q

Do the moms usually like morphine more than meperidine?

A

No
They have less satisfaction and ask for more doses

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3
Q

How to decrease risk of hypotension with neuraxial analgesia?

What totally prevents it?

A

Decrease risk by fluid loading or use of prophylactic pressors

But nothing prevents it

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4
Q

Components of informed consenst for neuraxial technique

A

Risks

Benefits

Expectations: reduction in pain but may feel pressure

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5
Q

Advantages of Bupivacaine

A
  • Good differential block
  • Long duration
  • Lack of tachyphylaxis
  • Limited placental transfer
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6
Q

What receptor do clonidine act on when used regionally?

Hint… same as they always do…..

Are they good to use?

A

Alpha2 agonism

Causes no increase in motor block but they have a black box warning that we need to know about although MBG doesnt even konw what its for and i cant find what its for either

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7
Q

Longggg list of complications with neuraxial analgesia

A
  • Failed analgesia
  • unintended dural puncture
  • Back pain
  • Excessive motor block
  • Urinary retention
  • Maternal hypothermia
  • Fetal HR abnormalities
  • Accidental IV injection
  • Meningitis
  • Epidural hematoma/ abscess
  • Neuro deficits
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8
Q

4 stages of labor

A
  1. Dilation
  2. Expulsion
  3. Placental
  4. Stabilization
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9
Q

Indications for neuraxial analgesia for labor

A
  • Maternal request
  • Anticipation of operative delivery (malposition, multiple gestation)
  • Obstetric disease/ high risk for precipitous, high risk of emergency delivery (pre-ecclampsia, nonreassuring FHT)
  • Maternal conditions (obesity, difficult airway, MH)
  • Maternal coexisting disease (cardiac or respiratory)
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10
Q

How do opioids act when used in regional?

A

Act on both spinal and supraspinal opioid receptors

*increase potency

*won’t change duration or density of block

(from LA handout)

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11
Q

Relative contraindications of neuraxial analgesia for labor

A
  • Elevated ICP
  • Documented LA allergy
  • Untreated systemic infection
  • Preexisting neuro deficit
  • Informed consent difficulties (language)
  • Severe fetal depression
  • Severe maternal cardiac disease
  • Skeletal abnormalities
  • Some types of back surgery
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12
Q

Monitoring necessary for neuraxial placement

A

At minimum:

  • BP
  • FHT (before and after)
  • EKG and pulse oximetry our book says too
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13
Q

Cons of using Volatiles in labor pain control

A

Smooth muslce relaxation and Provider/equipment limitation

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14
Q

How does sterile water injection work?

A

Counterirritation
Gate control theory

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15
Q

Which LA interferes with action of Bupivacaine and opioids?

A

2-Chloroprocaine

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16
Q

Advantages of ambulation during labor

A

Maternal satisfaction/autonomy

Decreased dystocia

Decreased risk of DVT

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17
Q

Maintenance of continuous spinal analgesia

A
  • Bupivacaine 0.08-0.125 plus 1-2 mcg/mL fentanyl at rate of 1-1.5 ml/hour
  • Disconnect PCEA option and may opt for clinical administered top off doses
  • STERILE
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18
Q

Concentration of 2-chloroprocaine used for rapid expansion in cesarean

A

3%

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19
Q

Concentration/Dose of Bupivacaine

A

0.0625-0.125% sometimes up to -.25%

Although MBG says they use 0.5%?

12-20 ml

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20
Q

Should you label your spinal catheter?

A

Yes please

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21
Q

Which opioid provides good pain relief for laboring moms?
What do you need to monitor?

A

Fentanyl
CSHT requires extended monitoring of baby and mom after extended use

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22
Q

What 4 factors related to passenger effect labor?

A
  1. Fetal size
  2. Fetal lie
  3. Presentation
  4. Position
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23
Q
A
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24
Q

What is considered pre-term?

A

<37 weeks

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25
Q

Aspiration prophylaxis considerations in neuraxial

A
  • Clear liquids allowed
  • All pregnant women are a full stomach
  • No solid food during active labor but no consensus on amount of liquid
  • Obesity, diabetes, and sedation are all additional risk factors
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26
Q

Are barbiturates good for labor pain and sedation?

A

Nah

  • Easily cross placenta
  • Cause neonatal depression
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27
Q

Sacral top offs in recently placed epidurals for vaginal delivery

A

5-10 mls of 0.5-1% lidocaine with 100 mcg of fentanyl

Given in sitting position

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28
Q

Does your patient need an IV before or after neuraxial placement?

A

Before

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29
Q

Obstetric considerations that affect neuraxial technique choice

A

Likelihood of surgical delivery

Stage of labor

Fetal abnormalities

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30
Q

Is neostigmine a good adjuvant in regional?

A

In animals yes, in humans nope

Increased nausea

Can also cause fetal bradycardia

also FYI - for GA if you give it fast it can cause an increase in ACh which can cause contractions

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31
Q

What percent of pregnancies end on expected due date?
Preterm?
Post-term?
Prob dont need to know this but…..

A

<10% on EDD
~ 13% pre-term
~5-7% post-term

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32
Q

How long does pruritis last associated with neuraxial analgesia?

A

90 minutes?

33
Q

What hemodynamic effects can ketamine cause?

A

Increase HR and BP

34
Q

Which way do you want their head to be facing when they come out? as in front or back of mom?

A

Back

35
Q

What type of pain and where does it occur in first stages of labor?

A

Visceral pain
T10-L1

36
Q

Drugs for pruritis

A
  • Avoid benadryl (causes sedation)
  • Nubain 5-10 mg
  • Ondansetron (8 mg *book)

Didnt we learn in another class that you can put some narcan in there to help with the itching or did i make that up??

yup that sounds familiar

37
Q

Concentration of ropivacaine used for infusions

A

0.1-0.2%

38
Q

Effect of epidural analgesia on maternal catecholamines?

Hyperventilation?

A

Both decreased

39
Q

What type of pain occurs and where in second stage of labor?

A

Somatic pain
S2-S4

40
Q

Which LA is popular as a test dose, has little sensory/motor discrimination, and is not routinely used for maintenance of LEA?

A

Lidocaine

41
Q

What presentation is optimal?

A

Cephalic- head down

42
Q

What may you need for instrumented vaginal delivery?

A

Denser block

5-10 mls of 2% lidocaine with epi, 0.25% bupivacaine, or 3% 2-chloroprocaine

43
Q

Disadvantages of bupivacaine

A

Slower onset time

CV and neuro toxicity

44
Q

Which opioid is the most widely used but provides poor analgesia and reduced variability and neonatal depression?

A

Meperidine

45
Q

Are remi, al, and su good choices for pain relief for laboring moms?

A

No strong evidence to support use

46
Q

anatomic changes in pregnancy that can affect neuraxial placement (6)

A
  1. Reduction in intervertebral gap
  2. Widening of hips creating a head down tilt when lateral
  3. Forward rotation of the pelvis can move the line at iliac crest higher–> important because you might think you are at L4 or L5 but actually closer to L2
  4. Higher apex of thoracic kyphosis
  5. Engorgement of epidural veins
  6. Difficult to ID ligamentum flavum
47
Q

What is considered post-term?

A

>42 weeks

48
Q

3 phases of Stage 1 Labor and their amount of Dilation

A
  1. Latent: 0-3 cm
  2. Active: 4-7 cm
  3. Transitional: 8-10 cm
49
Q

Side effects of neuraxial analgesia

A
  • hypotension
  • pruritis
  • urinary retention
50
Q

Name some non-pharmacologic methods of pain control that we spent reading hours about that she said we dont really need to know about

A
  • Antenatal health education
  • Support persons
  • Relaxation techniques
  • Massage
  • Reflexology
  • Hypnosis
  • Aromatherapy
  • Acupuncture/acupressure
  • Hydrotherapy
  • TENS
  • Sterile water injection
51
Q

Maternal coexisting diseases that effect neuraxial technique choice

A

Severe valvular heart disease

Intracranial mass/neuro disease

52
Q

Is acetaminophen good for labor pain?

A

Yes, 1 g IV reduced VAS pain scores and need for rescue meds with no change in neonates

53
Q

Which type of opioids are best to add to your regional?

A

More lipophilic opioids

Not morphine

54
Q

Which LA is less cardiotoxic and has less of a motor block, but is expensive and you might as well just use lidocaine?

A

Ropivacaine

55
Q

Benefits of epidural analgesia

A
  • Decreased maternal catecholamines
  • Decreased maternal hyperventilation
  • Ability to rapidly transition to epidural anesthesia for emergencies
56
Q

Is sterile water injection indicated for active labor?

A

No

57
Q

what emergency equipment should always be available with neuraxial placement?

A

Pressors (ephedrine, neo)

Emergency airway equipment

58
Q

Are phenothiazines good for labor pain and sedation?

A

Easily cross placenta
Decrease fetal HR variability so no

59
Q

Which LA is least toxic and has increased motor block making it a good choice for C-sections?

A

2-Chloroprocaine

60
Q

Hypotension r/t neuraxial analgesia in parturients can lead to fetal _________

A

distress

61
Q

Pros and cons of Nitrous oxide use
How much do you use?

A

Use 50% Nitrous
Cons:
- Less effective than epidural
- More nausea
Dont see any pros here…

62
Q

How much water do you give in sterile water injections and how many times?

A

give 0 bc this is stupid

0.1 ml blebs
Ideal number unknown

63
Q

Disadvantages of ambulation during labor

A

Falls with slight motor block

Hypotension

Increased workload

Increased need for top-off doses

Medicolegal issues

64
Q

MOA of using epinephrine in regional

A

alpha2 agonism

beta2 agonism (systemic)- slows delivery

Result is vasoconstriction and decreased clearance and increased motor block

65
Q

Absolute contraindications for neuraxial analgesia for labor

A
  • Patient refusal
  • Uncooperative - dont stick a nut
  • Moderate/severe bleeding conditions
  • Anticoagulation
  • Uncontrolled hemorrhage/ severe hypovolemia
  • Epidural site infection
  • Unskilled/inexperienced anesthesia provider
66
Q

Are benzos good for labor pain and sedation?

A

Not really since they easily cross placenta and cause maternal amnesia
And make for a floppy baby according to her last lecture

67
Q

Anesthetic considerations affecting neuraxial technique choice

A
  • Difficult airway
  • Timing
  • PDPH
68
Q

If cephalic presentation is best, what are the other possible presentations that are suboptimal?

A
  • Breech- butt first
  • Shoulder first
69
Q

What percent of parturients have hypotension during neuraxial analgesia?

When usually?

A

80%

During initial dose or bolus

70
Q

What is responsible for hypotension associated with neuraxial analgesia?

A

Sympathetic blockade

71
Q

Advantage of using narcotics in continuous spinal analgesia

A

Analgesia without excessive motor block

72
Q

What labs should you get before neuraxial placement?

A

Platelets and crossmatch

73
Q

3 components of labor and delivery (3 Ps)

A
  • Powers- contractions, maternal voluntary expulsive efforts
  • Passageway- pelvis, soft tissues
  • Passenger- fetus
74
Q

what is the advantage of a combined spinal-epidural (CSE) over a conventional labor epidural (LEA)?

*quiz*

A

faster onset

75
Q

components of the ideal local anesthetic for labor

*quiz*

A
  1. rapid onset
  2. minimal side effects
  3. long duration
  4. differential blockade
76
Q

effective blockade for both stages of labor requires coverage from ___ to ___

*quiz*

A

T10-S4

77
Q

is anticipated operative delivery an indication or contraindication for neuraxial labor analgesia?

*quiz*

A

indication

78
Q

Which maternal position reduces risk of vascular injection?

Sitting or lateral?

A

Lateral due to better draining of epidural veins

S5 - Regional/OB - Test 1 (13 decks)

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