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Obstetrics > Lecture 3 - Surgery in the Parturient > Flashcards

Lecture 3 - Surgery in the Parturient Flashcards

1
Q

Approximately how many births are C-sections?

A

30% and rising

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2
Q

What are the common indications for a C-section?

A
  • Failure to progress
  • Fetal distress
  • Previous C-section
  • Maternal condition making vaginal delivery unsafe
  • Fetal condition making vaginal delivery unsafe
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3
Q

What are the different anesthetic techniques for birth?

A
  • Local infiltration by surgeon
  • General anesthesia
  • Regional anesthesia: spinal, epidural, combined spinal-epidural
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4
Q

Local infiltration is:

A
  • Rarely performed
  • patient usually in extremis
  • Surgery must be done via MIDLINE incision, gentle retraction, no exteriorization of the uterus
  • Usually done to supplement a regional technique if local anesthetic toxicity not a consern
  • Often combined with “OK Anesthesia
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5
Q

Regional anesthesia for a C-section is:

A
  • Safer than general anesthesia
  • Many patients already have a epidural in place when a C-section is called for
  • Less neonatal depression with regional anesthesia
  • Mother is awake and able to witness the birth of her child
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6
Q

Indications for general anesthesia with C-section:

A

-Acute severe fetal distress with no time for block
-Non functioning epidural catheter
-Parturient has contraindication to regional block
Regional block inadequate
-Patient refusal of block

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7
Q

What are the advantages of general anesthesia:

A
  • Proven track record of safety (Regional is still safer)
  • Produces rapid reproducible conditions for delivery
  • ALWAYS WORKS
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8
Q

What are the disadvantages of general anesthesia:

A

-Still not as safe as regional
-Forces you to deal with a potentially difficult airway often under suboptimal rushed conditions
-Failed intubation
-Failed ventilation causing death or neurological injury
-Aspiration pneumonia
Awareness

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9
Q

What are the anesthesia effects on the fetus:

A
  • Avoid hypotension, hypoxia, acidosis, hyperventilation
  • Limit time between uterine incision and delivery to less than 3 minute
  • Infants exposed to GA have lower Apgar at one minute but no difference at 5 minutes
  • No significant alteration in neurobehavioral scores with regional techniques.
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10
Q

The importance of preoxygenation and denitrogenation in labor and delivery is:

A
  • Critically important

- At term O2 consumption increased 20-30% (with decrease of FRC results in a faster desaturation during apnea)

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11
Q

Preoxygenate patient at _____% O2 with a tight mask fit for at least _ minutes.

A

100

3

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12
Q

What is the induction dose of propofol for the pregnant patient?

A

-2 to 2.8 mg/kg

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13
Q

T/F: Propofol easily crosses the placenta.

A

TRUE

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14
Q

What is the induction dose of Ketamine:

A

1 to 1.5 mg/kg

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15
Q

Ketamine is useful in the face of maternal __________ as it supports the BP, also decreases risk of _______.

A
  • Hemorrhage

- bronchospasm

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16
Q

What are some side effects of ketamine?

A
  • Hypertension

- dysphoria

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17
Q

Why is midazolam not commonly used in induction of a pregnant woman?

A

-Causes more neonatal depression the other agents

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18
Q

Why is etomidate not commonly used in indution of a pregnant woman?

A

-May cause transient adrenal supppression in the neonate

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19
Q

T/F: Rapid sequence induction is mandatory in all but the rarest of cases.

A

TRUE

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20
Q

T/F: A defasciculating does prior to succinycholine is mandatory in patients at term.

A

FALSE (No need for defasciculating dose…._

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21
Q

T/F: Any relaxant is safe as their hydrophilic charged nature significantly limits placental transfer.

A

TRUE

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22
Q

T/F: There have been cases of neonatal paralysis in infants with homozygous atypical pseudocholinesterase.

A

TRUE

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23
Q

What are the two different ways to give general anesthesia to the pregnant mother in the labor and deliverer:

A
  • 50% nitrous oxide and 2/3 MAC of volatile agent
  • NOT to use nitrous oxide until fetus is delivered and use 1.2 MAC with fentanyl 2-3 mcg/kg. After delivery 0.5 MAC with nitrous oxide and midazolam can be given.
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24
Q

In most prospective studies the _________ of neonatal depression is ________ between general and regional anesthesia.

A
  • incidence

- similar

25
Q

T/F: There is a correlation between neonatal depression and the interval between anesthetic induction and delivery.

A

FALSE (There is NO correlation….)

26
Q

T/F: The uterine incision to delivery interval does make a difference, possibly due to uterine artery spasm.

A

TRUE

27
Q

What are the advantages for epidural anesthesia for a C-section?

A
  • Dose can be tailored to patient’s need
  • Ability to prolong the block
  • Ability to provide post op analgesia
  • Ability to produce a gradual block with less rapid and severe hemodynamic changes
28
Q

What are the disadvantages of an epidural for a C-section?

A
  • Some patient have contraindication

- Often the block quality is not as good as a spinal

29
Q

T/F: If an epidural is dosed for C-section and does not produce a surgical block, a general anesthetic may be required as the risks of a total spinal is ten-fold higher in this condition.

A

TRUE

30
Q

Local anesthetic diffuses to epidural nerve _____ where ______ channels are blocked, reducing sensory and motor function.

A

roots

Sodium

31
Q

T/F: Some of the epidural is absorbed by the vascular system and taken to other organs and metabolized.

A

TRUE

32
Q

T/F: No portion of the epidural is diffused into the CSF to the cord itself.

A

FALSE (A samll amount diffuses into CSF to the cord itself)

33
Q

Local Anesthetics: Mid-throracic block height results in ___________ of lower extremity and ________ beds, decreseases ________ return and decreased BP via this mechanism, and also direct ______ dilation.

A
  • sympathectomy
  • splanchnic
  • venous
  • arterial
34
Q

If a local block extends to T1 a ________ in heart rate and __________ may be seen, cardiac accelerator fibers T1-4.

A
  • reduction

- contractility

35
Q

A sensory block above __ often gives patients a sense of dyspnea - reassurance is helpful.

A

T2

36
Q

What is the epidural management for a C-section?

A
  • Dose catheter slowly
  • 15 cc of 2% LIDOCAINE OR 15 cc of 3% 2-CHLOROPROCAINE should be given over 5 minutes and continued monitoring for signs of local toxicity
  • 100 to 150 mcg of FENTANYL via epidural
  • NaHCO3 speed onset
37
Q

Where is the ideal block for a C-section?

A

T4 - T8

38
Q

What percentage of patients will have a break through of pain with epidurals?

A

10 - 50%

39
Q

What treatment can be done with break through pain for a C-section with an epidural?

A
  • Bolus of 5 cc of local
  • Epidural or IV fentanyl
  • Nitrous oxide
  • Ketamine IV (Keep total dose blelow 1 mg/kg) ~10 mg at a time
  • Ask surgeon to infiltrate with some local
  • If epidural is clearly inadequate, convert to GA
40
Q

What are the advantages of a spinal over an epidural for a C-Section?

A
  • Extensive dense block with a single injection
  • Defined end point - if you get CSF flow, you are in the correct place
  • Intavascular injection is not a concern
  • Technically simple, usually quick does not involve placing a catheter
41
Q

What are the disadvantages of a spinal over an epidural for a C-section?

A
  • Finite duration
  • Risk of postdural puncture headache
  • Risk of total spinal
  • Maternal hypotension is more common
42
Q

T/F: Laboring women have more hypotension with spinals then non-laboring women.

A

FALSE (Laboring women have LESS hypotension….)

43
Q

T/F: Prehydration has limited ability to prevent hypotension.

A

TRUE

44
Q

What is the drug of choice for the pregnant patient with hypotension?

A

Phenylephrine

45
Q

Which local anesthetic is the best choice for a local anesthetic in a spinal?

A

Bupivicaine

46
Q

What is the typical dose for a spinal?

A

-Bupivicaine 12-14 mg with 10-25 mcg of fentanyl and 0.1-0.3 mg of duramorph

47
Q

During a C-section the baby is delivered what is the next step?

A

-Pitocin 20 units in a 1 liter IV bag

48
Q

Currently ____% of pregnant patient require non-obstetric surgery during their pregnancy. The common procedure are ____________ and ____________..

A

1-2

  • appendectomy
  • cholecystectomy
49
Q

What are other general anesthesia consideration to a pregnant mother:

A
  • effect of the disease process/therapy
  • Possible teratogenicity of anesthetic agents
  • Intraoperative effects on uteroplacental blood flow
  • Increased risk of preterm labor/risk of abortion
  • ALREADY MENTIONED AS BEFORE PROBLEMS
50
Q

What are the Maternal consideration of anesthesia?

A
  • Decrease in MAC
  • Increase sensitivity to neuraxial agents
  • Decreased plasma cholinesterase
  • Decreased protein binding
  • Limited drug information in parturients
51
Q

What are the fetal considerations of anesthesia:

A

TERATOGENICITY
-Limited ability to conduct trial
-Guidelines based on:
Effects on reproduction in animals
Epidemiological surverys of OR personnel
Studies on pregnant women who had to have
surgery

52
Q

T/F: No anesthetic agent is a proven teratogen in humans.

A

TRUE

53
Q

What anesthetic agents have been deemed safe from teratogenicity affect in the fetus:

A
  • Thiopental
  • morphine
  • meperidine
  • Fentanyl
  • Succinylcholine
  • NDMR
54
Q

Anesthetic management in the parturient should be directed to:

A

AVOID

  • hypoxemia
  • hypotension
  • acidosis
  • Maintain normal PCO2 levels
  • Minimize effects of aortocaval compression
55
Q

What gestational age should fetal heart rate and uterine activity be monitored at:

A

20 weeks

56
Q

What drugs should be avoided in the development of the fetus?

A
  • benzodiazepines (especially during weeks 3 - 8)

- AVOID Nitrous oxide due to interference with B12 metabolism

57
Q

T/F: Volatile agnent may suppress preterm labor.

A

TRUE

58
Q

T/F: The physiological effects of pregnancy are usually well established by 30 week of gestational age.

A

FALSE (…established by 20 week of gestational….)

59
Q

How long should elective procedure be postponed after delivery?

A

6 weeks

Obstetrics (10 decks)

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