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Summer 2020 - APA Foundations 2 - OB > Labor Analgesia, Pharmacology, & Complications - Quiz 2 > Flashcards

Labor Analgesia, Pharmacology, & Complications - Quiz 2 Flashcards

1
Q

Where is the pain in the 1st stage of labor?

A

Lower Uterine - T10 - L1

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2
Q

Where is the pain during the 2nd stage of labor?

A

Perineal structures via Pudendal Nerves - S2 - S4

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3
Q

What are some Non-Pharmacological Analgesics for Labor?

A
  • Hypnosis
  • Psychoprophylaxis (Lamaze) - behavior & breathing techniques
  • Accupunture - Energy flow patterns
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4
Q

What is the problem w/ using Opioids on Parturients?

A

Crosses Placenta & Depresses Fetus

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5
Q

What is the advantage of using PCA’s for pain for parturients?

A

Better Satisfaction

Less Fetus Depression

Less Nausea

Less Respiratory Risk for mom

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6
Q

Why is morphine not normally given to the mom for pain?

A

Baby’s immature blood brain barrier increases risk for respiratory depression

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7
Q

Which pain med given for labor is contraindicated in patients with seizures or renal failure?

A

Meperidine

Can cause frequent N/V

Active Metabolites

Fetal Resp. Depression unlikely if given < 1 hr before delivery

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8
Q

What are some considerations when giving Fentanyl to a parturient?

A

100x more potent than morphine

Rapid transfer across Placenta

Respiratory depression lasts longer than pain control

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9
Q

What is Nalbuphine (Nubain)?

A

Opioid Antagonist, Kappa Agonist

Treats Opioid Pruritis

Causes Dysphoria

Resp. Depression Ceiling

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10
Q

Why is Butorphanol (Stadol) sometimes used instead of Fentanyl?

A

Better pain control & less itching

Sedation

Resp. Depression Ceiling

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11
Q

Why are gases rarely used to control paturient pain?

A

Aspiration

Decreases Uterine Tone

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12
Q

When is a Paracervical Block placed?

A

1st stage of Labor

Inject 5cc of LA submucosally @ 3 & 9oclock beside cervix

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13
Q

What are the risks involved w/ ParaCervical Blocks?

A

Injection into Uterine Artery

Fetal LA Toxicity

Nerve Injury

Hematoma

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14
Q

When are Pudendal Blocks used?

A

2nd Labor Stage

&

When Neuraxial Blocks are Contraindicated

Transvaginal Approach under Ischial Spines w/ Bilateral Needle Placement

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15
Q

What are the risks associated with Pudendal Blocks?

A

Fetal Injury, Infection, and Hematoma

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16
Q

Which Local Anesthetics are derivatives of Para-Aminobenzoic Acid (PABA)?

A

Amino Esters

PABA = Allergen

Metabolized by Cholinesterase

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17
Q

Which class of Local Anesthetics are more often used in OB?

A

Amino Amides

No PABA = No Allergic Reactions

Liver Metabolism

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18
Q

What is the Local Anesthetic relationship b/t its Lipid Solubility & Potency?

A

More Lipid Soluble = More Potent & Enchances Placental Diffusion

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19
Q

How does Protein Binding affect Local Anesthetics?

A

More Protein Binding = Longer Duration & Decreases Placental Transfer

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20
Q

Protein binding Local Anesthetics have a ____ affinity & ____ capacity to A1-acid Glycoprotein

A

Protein binding Local Anesthetics have a High Affinity & Low Capacity to A1-acid Glycoprotein

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21
Q

Protein binding Local Anesthetics have a ____ affinity & ____ capacity to Albumin

A

Protein binding Local Anesthetics have a Low Affinity & High Capacity to Albumin

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22
Q

Which property of Local Anesthetics determines Speed of Onset?

A

pKa

The closer the pKa is to physiological pH, the faster onset

Bicarb is used to artifically raise physiological pH

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23
Q

What would be the results of increasing Local Anesthetic Volume & Dose?

A

Faster Onset & Longer Duration

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24
Q

What can be given to prevent Systemic Absorption of Local Anesthetic?

A

Vasoconstrictors - Epi, Norepi, Neo

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25
Q

How does Temperature affect Local Anesthetics?

A

Warmed LA = faster onset

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26
Q

How does Pregnancy affect Local Anesthetics?

A

Preggos need less LA & has faster onset

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27
Q

Which type of nerves are more susceptible to blocks?

A

C- Fibers - small & unmyelinated

Larger fibers need more LA

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28
Q

What are the most commonly used Epidural Analgesics for Labor?

A

Bupivacaine

Ropivacaine

Lidocaine

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29
Q

What Local Anesthetics are used for Operative Epidural Analgesia?

A

Lidocaine & 2-Chloroprocaine

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30
Q

Which Local Anesthetics are used for Spinal Anesthesia?

A

Tetracaine & Bupivacaine

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31
Q

Which Local Anesthetic can be used to test and activate the Epidural Catheter, has a short duration, and causes a lot of Motor Block?

A

Lidocaine

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32
Q

Which Ester LA is the only one used in the Epidural Space?

A

2-Chloroprocaine

Rapid Onset, Short Duration

Lots of Motor Bock

Low Toxicity Risk

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33
Q

When in particular would you NOT use 2-Chloroprocaine?

A

In patients w/ Atypical Pseudocholinesterase

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34
Q

What happens when you give Epidural Fentanyl after the patient had 2-Chloroprocaine?

A

Fentanyl would be less effective

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35
Q

What makes Bupivacaine a good Local to use during labor?

A

Long Duration & Less Motor Block

BIG dose = V-Tach/V-Fib

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36
Q

Which of the following LA’s is the most Cardiotoxic: Levobupivacaine, Ropivacaine, Bupivacaine?

A

Bupivicane > Levobupivacaine > Ropivacaine (25% less potent)

Only Bupivacaine is approved for Spinals

37
Q

How should Epidural Drugs be given in OB?

A

Small Doses incrementally as test doses

38
Q

What is the next course of action if the patient experiences paresthesia while a spinal is being dosed?

A

Remove Needle

39
Q

Where should Spinals be placed in Obstetrics?

A

As low as possible, Below L3

40
Q

Where is Tuffier’s Line?

A

Transverse line passing thru lumbar spine b/t posterior iliac crests - L4

41
Q

Which dermatomes should be covered for Obstetrics

A

Lumbar Level - T10 - S4

42
Q

What are contraindications to Neuraxial Blocks?

A

Patient Refuse

Site Infection

Coagulopathy

Intracranial Mass

Aortic Stenosis

Existing Spinal/Neuro Disease

Hemodynamic Instability

43
Q

What are the steps in placing an Epidural?

A
  1. Position Patient
  2. Prep Skin
  3. Numb Skin
  4. Identify Space w/ Midline or Paramedian Approach
  5. Use Tuohy Needle & LOR Technique
44
Q

How far should the Catheter tip be advanced once the Epidural Space is identified?

A

Until 5 cm of the tip lie in the space

45
Q

How should the Epidural Catheter be handled?

A

Dont pull catheter back thru needle - may shear

Aspirate to R/O CSF or Blood

Give Test Dose

Secure Catheter

46
Q

What are the difference b/t Epidurals & Spinals?

A

Drugs thru Spinals are 10x more potent & smaller needle used (22-27ga)

Epidural uses 17-18ga needles

47
Q

When are Subarachnoid Blocks used for Labor?

A

C-Sections

When delivery is soon & no time for Epidural

Opioid only or LA Combo

48
Q

What are the Pros and Cons of Combined Spinal Epidural?

A

Instant Relief, but difficult to test epidural catheter

49
Q

What are signs of LA Toxicity?

A

Tinnitus

Light-Headedness

Loss of Consciousness

Convulsions

Metallic Taste

Numbness

Respiratory Arrest

50
Q

How does Acidosis & High PaCO2 affect Local Anesthetics?

A

Lowers Seizure Threshold

&

Decreases Protein Binding = More Free LA

51
Q

How does Local Anesthetic Toxicity affect the CV System?

A

Inhibits Sodium Channels

↓Rate of Depolarization

↓Action Potential Duration

↓Effective Refractory Period

52
Q

What should be done for a patient with LA Toxicity that started convulsing?

A
  • Clear Airway
  • Position Patient - Avoid Aortocaval Compression
  • Bag Mask Ventilation
  • Benzos
  • Manage arrythmias
  • Immediate Delivery if Possible
53
Q

What can be given for Refractory Local Anesthetic Toxicity

A

20% Intralipid

54
Q

What are symptoms of Subdural Block?

A

(Catheter is b/t Dura & Arachnoid Mater)

Apnea

Loss of Consciousness

Horner’s Syndrome

55
Q

What should be done if a Subdural Block is detected?

A

Dont dose & Replace catheter into Epidural Space

56
Q

What is Term Labor?

A

37 - 42 Completed Weeks

57
Q

What is considered Preterm Labor?

A

Regular contractions every 10 minutes causing cervical change before 37 weeks

58
Q

What infant weight is considered low?

A

Low Birth Weight < 2500g

Very Low Birth Weight < 1500g
(usual wt. @ 29 wks)

59
Q

Mortality is 90% if infants born _____ and Survival rate is > 90% if they’re born ______

A

Mortality is90% if infants born < 24wks and Survival rate is > 90% if they’re born > 30 wks

@ 34 wks = 98% survival

60
Q

What are the Prematurity Comorbidities?

A
  • Respiratory Distress Syndrome
  • Sepsis
  • Necrotizing Enterocolitis
  • Intracranial Hemorrhage
  • Ischemic Cerebral Damage
  • Immature Matabolism
  • Hypoglycemia
  • Hyperbilirubinemia
61
Q

What bacteria is associated with Preterm Labor?

A

Group B Strep, Neisseria Gonorrhoeae, and Bacterial Vaginosis in Genital Tract

62
Q

When is a C-Section safer than delivery in regards to Preterm Labor?

A

Breech Presentation

63
Q

How does Ethanol work as Tocolytic Therapy?

A

Inhibits ADH & Oxytocin Release

Risk for Intoxication, Loss of Consciousness, and Aspiration

64
Q

How does Aminophylline work as Tocolytic Therapy?

A

Phosphodiesterase that relaxes Uterus by increasing cAMP

Narrow Therapeutic Margin & Toxic

65
Q

How does Nifedipine work for Tocolytic Therapy?

A

Decreases free calcium to decrease Myometrium Contractility

66
Q

What are the side effects of using Nifedipine as a Tocolytic?

A

Hypotension

Tachycardia

Peripheral Edema

Myocardial Depression

Postpartum Hemorrhage

Decreased UBF & Fetal Hypoxemia/Acidosis

67
Q

Which type of Tocolytic Therapy makes the patient more prone to Cardiac Depression from Volatile Agents?

A

Calcium Channel Blockers

68
Q

What are some Prostaglandin Inhibitors that are used for Tocolytic Therapy?

A

Indomethacin & Sulindac

Decreases CycloOxygenase to decrease Prostaglandin

69
Q

What are the Maternal side effects of Prostaglandin Inhibitors?

A

Nausea

Heartburn

Decreased platelets & bleeding

Pulm. HTN

70
Q

What are the Fetal side effects of Prostaglandin Inhibitors?

A

Premature closure of ductus

Persistent Circulation

Renal Impairment

71
Q

Which medication is the most commonly used for Tocolytic Therapy?

A

Magnesium

Prevents Calcium Increase

Increases cAMP

72
Q

How does Magnesium affect MAC & NMBs?

A

Decreases MAC

Patient more sensitive to all NMBs

73
Q

What would you see with a Magnesium level of 8 - 10?

A

Loss of Deep Tendon Reflexes

74
Q

What would you see with a Magnesium level of 10 - 15?

A

Resp. Depression & Wide QRS & P-R Interval

75
Q

How should Magnesium toxicity be treated?

A

Calcium Gluconate or Calcium Chloride

76
Q

What are the Beta Adrenergic Agonists used for Tocolytic Therapy?

A

Terbutaline & Ritodrine

Directly increases cAMP to Relax Uterus

77
Q

What are the side effects of using Terbutaline or Ritodrine?

A

N/V

Anxiety

Hyperglycemia

Hyperinsulinemia

Hypokalemia

Acidosis

Pulmonary Edema

78
Q

How much does the risk of Fetal Death increase w/ having twins vs singleton?

A

5-6x d/t increased risk of prematurity

Second twin has greater risk d/t placental abruption, cord prolapse, & malpresentation

79
Q

What are the Maternal complications of having Mutliple Gestations?

A

Increased CO earlier

Anemia

↓TLC & FRC

↑O2 Consumption

Bigger Uterus = Aortocaval Compression & Aspiration

80
Q

What can be expected with Multiple Gestations?

A

Preterm Labor - 50%

Placental Abruption

Pregnancy Induced HTN

Malpresentation

Placenta Previa

C-Section for triplets or more

81
Q

What are the Anesthetic considerations for Multiple Gestations?

A

Early Epidural Placement

Hemorrhage

Treat as C-Section

Dense Block

2-Chloroprocaine for Rapid Onset

Nitroglycerine to Relax Uteus for Rotating Baby

82
Q

What are the signs and symptoms of a Uterine Rupture?

A

Sudden & Severe Abdominal Pain

Vaginal Bleed

Hypotension

Labor Stops

Fetal Distress - Most Reliable Sign

83
Q

What is the best presentation for delivery?

A

Faced down, Flexed C-Spine w/ chin to chest

84
Q

What is a Breech Presentation?

A

Both feet down

Frank: Both Legs Up Near Head

Incomplete: One leg up one leg down

90% of Breech = C-Section

85
Q

Why is there an Increased Risk for Fetal Death associated w/ Breech Presentation?

A

Asphyxia

Birth Trauma

Cord Prolapse

Maternal infection d/t Manipulation

86
Q

Which presentation is an Absolute Indication for C-Section?

A

Transverse Lie Presentation

87
Q

What are problems with Postmaturity (Gestation > 42 wks)?

A

↓UBF

Cord Compression

Meconium Staining of Amniotic Fluid

Big Baby w/ Big Shoulders

88
Q

What are the causes of Intrauterine Fetal Demise (IUFD)?

A
  • Abnormal Chromosomes
  • Congenital Malformations
  • Infections
  • Cord Accidents
  • Multiple Gestations
  • Placental Factors
  • Isoimmunization
  • Maternal Trauma
  • Maternal Immune/Thyroid Disease
89
Q

What can happen to the cord that results in Intrauteral Fetal Demise?

A

Prolapse

Entanglement

Torsion

< 30 cm Length = compression, constriction, rupture

> 72 cm Length = Entanglement

Summer 2020 - APA Foundations 2 - OB (4 decks)

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