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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
How does Temperature affect Local Anesthetics?
Warmed LA = faster onset
26
How does Pregnancy affect Local Anesthetics?
Preggos need less LA & has faster onset
27
Which type of nerves are more susceptible to blocks?
C- Fibers - small & unmyelinated Larger fibers need more LA
28
What are the most commonly used Epidural Analgesics for _Labor_?
Bupivacaine Ropivacaine Lidocaine
29
What Local Anesthetics are used for _Operative_ Epidural Analgesia?
Lidocaine & 2-Chloroprocaine
30
Which Local Anesthetics are used for Spinal Anesthesia?
Tetracaine & Bupivacaine
31
Which Local Anesthetic can be used to test and activate the Epidural Catheter, has a short duration, and causes a lot of Motor Block?
Lidocaine
32
Which Ester LA is the only one used in the Epidural Space?
2-Chloroprocaine Rapid Onset, Short Duration Lots of Motor Bock Low Toxicity Risk
33
When in particular would you NOT use 2-Chloroprocaine?
In patients w/ Atypical Pseudocholinesterase
34
What happens when you give Epidural Fentanyl after the patient had 2-Chloroprocaine?
Fentanyl would be less effective
35
What makes Bupivacaine a good Local to use during labor?
Long Duration & Less Motor Block BIG dose = V-Tach/V-Fib
36
Which of the following LA's is the most Cardiotoxic: Levobupivacaine, Ropivacaine, Bupivacaine?
Bupivicane \> Levobupivacaine \> Ropivacaine (25% less potent) Only Bupivacaine is approved for Spinals
37
How should Epidural Drugs be given in OB?
Small Doses incrementally as test doses
38
What is the next course of action if the patient experiences paresthesia while a spinal is being dosed?
Remove Needle
39
Where should Spinals be placed in Obstetrics?
As low as possible, Below L3
40
Where is Tuffier's Line?
Transverse line passing thru lumbar spine b/t posterior iliac crests - L4
41
Which dermatomes should be covered for Obstetrics
Lumbar Level - T10 - S4
42
What are contraindications to Neuraxial Blocks?
Patient Refuse Site Infection Coagulopathy Intracranial Mass Aortic Stenosis Existing Spinal/Neuro Disease Hemodynamic Instability
43
What are the steps in placing an Epidural?
1. Position Patient 2. Prep Skin 3. Numb Skin 4. Identify Space w/ Midline or Paramedian Approach 5. Use Tuohy Needle & LOR Technique
44
How far should the Catheter tip be advanced once the Epidural Space is identified?
Until 5 cm of the tip lie in the space
45
How should the Epidural Catheter be handled?
Dont pull catheter back thru needle - may shear Aspirate to R/O CSF or Blood Give Test Dose Secure Catheter
46
What are the difference b/t Epidurals & Spinals?
Drugs thru Spinals are 10x more potent & smaller needle used (22-27ga) Epidural uses 17-18ga needles
47
When are Subarachnoid Blocks used for Labor?
C-Sections When delivery is soon & no time for Epidural Opioid only or LA Combo
48
What are the Pros and Cons of Combined Spinal Epidural?
Instant Relief, but difficult to test epidural catheter
49
What are signs of LA Toxicity?
Tinnitus Light-Headedness Loss of Consciousness Convulsions Metallic Taste Numbness Respiratory Arrest
50
How does Acidosis & High PaCO2 affect Local Anesthetics?
Lowers Seizure Threshold & Decreases Protein Binding = More Free LA
51
How does Local Anesthetic Toxicity affect the CV System?
Inhibits Sodium Channels ↓Rate of Depolarization ↓Action Potential Duration ↓Effective Refractory Period
52
What should be done for a patient with LA Toxicity that started convulsing?
* Clear Airway * Position Patient - Avoid Aortocaval Compression * Bag Mask Ventilation * Benzos * Manage arrythmias * Immediate Delivery if Possible
53
What can be given for Refractory Local Anesthetic Toxicity
20% Intralipid
54
What are symptoms of Subdural Block?
(Catheter is b/t Dura & Arachnoid Mater) Apnea Loss of Consciousness Horner's Syndrome
55
What should be done if a Subdural Block is detected?
Dont dose & Replace catheter into Epidural Space
56
What is Term Labor?
37 - 42 Completed Weeks
57
What is considered Preterm Labor?
Regular contractions every 10 minutes causing cervical change before 37 weeks
58
What infant weight is considered low?
Low Birth Weight \< 2500g Very Low Birth Weight \< 1500g (usual wt. @ 29 wks)
59
Mortality is 90% if infants born _____ and Survival rate is \> 90% if they're born \_\_\_\_\_\_
Mortality is90% if infants born **\< 24wks** and Survival rate is \> 90% if they're born **\> 30 wks** @ 34 wks = 98% survival
60
What are the Prematurity Comorbidities?
* Respiratory Distress Syndrome * Sepsis * Necrotizing Enterocolitis * Intracranial Hemorrhage * Ischemic Cerebral Damage * Immature Matabolism * Hypoglycemia * Hyperbilirubinemia
61
What bacteria is associated with Preterm Labor?
Group B Strep, Neisseria Gonorrhoeae, and Bacterial Vaginosis in Genital Tract
62
When is a C-Section safer than delivery in regards to Preterm Labor?
Breech Presentation
63
How does Ethanol work as Tocolytic Therapy?
Inhibits ADH & Oxytocin Release Risk for Intoxication, Loss of Consciousness, and Aspiration
64
How does Aminophylline work as Tocolytic Therapy?
Phosphodiesterase that relaxes Uterus by increasing cAMP Narrow Therapeutic Margin & Toxic
65
How does Nifedipine work for Tocolytic Therapy?
Decreases free calcium to decrease Myometrium Contractility
66
What are the side effects of using Nifedipine as a Tocolytic?
Hypotension Tachycardia Peripheral Edema Myocardial Depression Postpartum Hemorrhage Decreased UBF & Fetal Hypoxemia/Acidosis
67
Which type of Tocolytic Therapy makes the patient more prone to Cardiac Depression from Volatile Agents?
Calcium Channel Blockers
68
What are some Prostaglandin Inhibitors that are used for Tocolytic Therapy?
Indomethacin & Sulindac Decreases CycloOxygenase to decrease Prostaglandin
69
What are the Maternal side effects of Prostaglandin Inhibitors?
Nausea Heartburn Decreased platelets & bleeding Pulm. HTN
70
What are the Fetal side effects of Prostaglandin Inhibitors?
Premature closure of ductus Persistent Circulation Renal Impairment
71
Which medication is the _most commonly_ used for Tocolytic Therapy?
Magnesium Prevents Calcium Increase Increases cAMP
72
How does Magnesium affect MAC & NMBs?
Decreases MAC Patient more sensitive to all NMBs
73
What would you see with a Magnesium level of 8 - 10?
Loss of Deep Tendon Reflexes
74
What would you see with a Magnesium level of 10 - 15?
Resp. Depression & Wide QRS & P-R Interval
75
How should Magnesium toxicity be treated?
Calcium Gluconate or Calcium Chloride
76
What are the Beta Adrenergic Agonists used for Tocolytic Therapy?
Terbutaline & Ritodrine Directly increases cAMP to Relax Uterus
77
What are the side effects of using Terbutaline or Ritodrine?
N/V Anxiety Hyperglycemia Hyperinsulinemia Hypokalemia Acidosis **Pulmonary Edema**
78
How much does the risk of Fetal Death increase w/ having twins vs singleton?
5-6x d/t increased risk of prematurity Second twin has greater risk d/t placental abruption, cord prolapse, & malpresentation
79
What are the Maternal complications of having Mutliple Gestations?
Increased CO earlier Anemia ↓TLC & FRC ↑O2 Consumption Bigger Uterus = Aortocaval Compression & Aspiration
80
What can be expected with Multiple Gestations?
Preterm Labor - 50% Placental Abruption Pregnancy Induced HTN Malpresentation Placenta Previa C-Section for triplets or more
81
What are the Anesthetic considerations for Multiple Gestations?
Early Epidural Placement Hemorrhage Treat as C-Section Dense Block 2-Chloroprocaine for Rapid Onset Nitroglycerine to Relax Uteus for Rotating Baby
82
What are the signs and symptoms of a Uterine Rupture?
Sudden & Severe Abdominal Pain Vaginal Bleed Hypotension Labor Stops **Fetal Distress** - Most Reliable Sign
83
What is the best presentation for delivery?
Faced down, Flexed C-Spine w/ chin to chest
84
What is a Breech Presentation?
Both feet down Frank: Both Legs Up Near Head Incomplete: One leg up one leg down 90% of Breech = C-Section
85
Why is there an Increased Risk for Fetal Death associated w/ Breech Presentation?
Asphyxia Birth Trauma Cord Prolapse Maternal infection d/t Manipulation
86
Which presentation is an Absolute Indication for C-Section?
Transverse Lie Presentation
87
What are problems with Postmaturity (Gestation \> 42 wks)?
↓UBF Cord Compression Meconium Staining of Amniotic Fluid Big Baby w/ Big Shoulders
88
What are the causes of Intrauterine Fetal Demise (IUFD)?
* Abnormal Chromosomes * Congenital Malformations * Infections * **Cord Accidents** * Multiple Gestations * Placental Factors * Isoimmunization * Maternal Trauma * Maternal Immune/Thyroid Disease
89
What can happen to the cord that results in Intrauteral Fetal Demise?
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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