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Methods of Anesthesia > OB > Flashcards

OB Flashcards

1
Q

Means before birth

A

Antepartum

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2
Q

Means difficult labor

A

Dystocia

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3
Q

Means twins, triplets, etc

A

Multiple gestation

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4
Q

Means during the act of birth

A

Intrapartum

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5
Q

Means has had multiple gestations

A

Multiparous

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6
Q

Normal labor

A

38-40 weeks

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7
Q

Never completed a pregnancy beyond 20 weeks

A

Nulliparous

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8
Q

Another name for pregnant patient

A

Parturient

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9
Q

Means after birth

A

Postpartum

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10
Q

Preterm labor

A

<37 weeks

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11
Q

Means first pregnancy

A

Primapara (primip)

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12
Q

Age of viability

A

~24 weeks

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13
Q

When should you consider immediate intubation after birth?

A

If <28 weeks and not pink and active

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14
Q

What does gravida mean?

A

Total number of pregnancies, regardless of the outcome

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15
Q

What does parity mean?

A

The number of live births OR number of completed pregnancies that lasted more than 20 weeks

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16
Q

A woman is pregnant for the first time and is 12 weeks along. What is her GP status?

A

G1 P0

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17
Q

A woman is currently pregnant and 25 weeks along. She has had 6 miscarriages and only 1 live birth. What is her GP status?

A

G8 P1

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18
Q

A women is pregnant for the second time and delivered twin stillbirths in her first pregnancy at 19 weeks. What is her GP status?

A

G2 P0

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19
Q

What do oxytocic (uterotonic) drugs do?

A

Promote uterine contraction

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20
Q

Drugs that decrease uterine bleeding after delivery and induce labor in pregnant patients

A

Oxytocic drugs

  1. Pitocin
  2. Hemabate
  3. Methergine
  4. Cytotec
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21
Q

Examples of oxytocic drugs

A
  1. Pitocin
  2. Hemabate
  3. Methergine
  4. Cytotec
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22
Q

Effects of pitocin

A
  1. Stimulates uterine contraction

2. Induce labor

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23
Q

When is pitocin dosed in c-sections and why?

A

AFTER the baby and placenta are delivered because a contracted uterus does not bleed as much

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24
Q

Most common side effect of pitocin

A

Hypotension

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25
Q

Side effects of pitocin

A
  1. Hypotension
  2. N/V
  3. Chest pain
  4. EKG changes/arrhythmias
  5. SOB
  6. Myocardial ischemia
  7. Pulmonary edema
  8. Death
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26
Q

What is important to remember about pitocin?

A

It should be dosed slowly due to the side effects

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27
Q

How is pitocin dosed?

A

IV, slowly

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28
Q

What is the traditional protocol for dosing pitocin?

A
  1. 20-40 units in the IV bag after delivery of the baby and placenta
  2. 20 units in each subsequent liter of IV fluid
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29
Q

What is the ED90 of Pitocin for c-sections?

A

0.35 units for non-laboring patients

3 units for laboring patients

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30
Q

What is the newer Pitocin dosing protocol?

A

“The rule of threes”

  1. Give 3 units over 30 seconds
  2. If there is no response to Pitocin after 3 doses of 3 units (over 9 minutes), move to another uterotonic
  3. Give 3 units/hr for maintenance
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31
Q

What happens if your 3 units over 30 seconds of pitocin does not work?

A

Repeat the dose twice, with 3 minutes between each dose

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32
Q

Why should you move to another uterotonic if Pitocin does not work after 3 doses of 3 units?

A

It could cause more side effects but not uterine tone

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33
Q

Popular uterotonic if pitocin is ineffective

A

Hemabate

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34
Q

Dose of

Carboprost (Hemabate)

A

1 mL IM (250mcg)

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35
Q

When is Carboprost contraindicated?

A

In asthmatics

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36
Q

When is methylergonovine (Methergine) contraindicated?

A

Hypertension (preeclampsia)

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37
Q

When is Methergine used?

A

If Pitocin is ineffective

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38
Q

Dose of Methylergonovine

A

1 mL IM (200 mcg)

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39
Q

When is Misoprostol (Cytotec) used?

A

If there is persistent uterine bleeding despite Pitocin, Methergine and Hemabate administration

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40
Q

How is Cytotec administered?

A

Rectally (200mcg)

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41
Q

Drugs that promote uterine relaxation

A

Tocolytic drugs

  1. Magnesium
  2. Beta 2 agonists (terbutaline)
  3. Calcium channel blockers (Nicardipine, Nifedipine)
  4. Volatile agents
  5. Nitroglycerin
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42
Q

Effects of tocolytic drugs

A
  1. Uterine relaxation to prevent labor

2. Promote uterine bleeding

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43
Q

When does Nitroglycerin cause significant drops in blood pressure?

A

To treat HTN or relieve angina in patients with CAD at smaller doses (<50 mcg)

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44
Q

Why does NTG have less of an effect on blood pressure in pregnant patients?

A
  1. OB patients have increased circulating blood volume

2. Vessels are already dilated in well hydrated patients

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45
Q

Doses of NTG for uterine relaxation

A

250-500 mcg, even up to 1000 mcg

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46
Q

Normal fetal heart rate

A

120-160 bpm

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47
Q

Bradycardic fetal HR

A

<120 bpm

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48
Q

Tachycardic fetal HR

A

> 160 bpm

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49
Q

Why is fetal HR variability considered normal?

A

It is associated with fetal movement

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50
Q

What can cause absence of variability in a fetal HR?

A
  1. Fetal distress

2. General anesthesia

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51
Q

Variability that occurs every heart beat

A

Short term variability

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52
Q

Variability anywhere from a difference in 6-25 bpm

A

Long term variability

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53
Q

Common causes of fetal tachycardia

A
  1. Lack of nourishing blood supply

2. Resultant effects of some drugs

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54
Q

Drop in fetal heart rate

A

deceleration

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55
Q

Decrease in HR occurs at the onset of uterine contraction and pretty much returns to baseline by the end of the contraction

A

Early (Type I) deceleration

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56
Q

The decrease in HR occurs after the onset of the contraction

A

Late (Type II) decelerations

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57
Q

The decrease in HR is variable in intensity, duration and timing

A

Variable (Type III) decelerations

58
Q

Most likely cause of Type I deceleration patterns

A

Vagal response (compression of the fetal head)

59
Q

Most likely cause of Type II deceleration pattern

A

Fetal hypoxia (uteroplacental insufficiency)

60
Q

Most threatening type of decel

A

Type II with variability loss

61
Q

Most likely cause of Type III deceleration patterns

A

Umbilical cord compression and decompression

62
Q

Normal respiratory rate for newborns

A

30-60 breaths/min

63
Q

Newborn monitoring associated with survival

A

1 minute Apgar score

64
Q

Newborn monitoring associated with neurologic outcome

A

5 minute Apgar score

65
Q

Normal fetal pH

A

> 7.25

66
Q

Amount of fluids that should be given prior to a neuraxial block

A

1000-1500 mL

67
Q

Why should dextrose be used with caution during delivery?

A

It can lead to fetal hypersecretion of insulin and fetal acidosis

68
Q

Important test to have before delivery

A

Type and screen

69
Q

NPO status during delivery

A

Modest liquids are allowed for uncomplicated labor, with stricter restrictions for higher risk pregnancies

70
Q

Drugs to avoid before the baby is delivered

A
  1. NSAIDs
  2. Versed
  3. Narcotics
71
Q

Why should NSAIDs be avoided during delivery?

A

They can suppress uterine contractions and promote closure of the ductus arteriosus

72
Q

Why is versed avoided before the baby is delivered?

A

It can cross the placenta.. possible post delivery fetal apnea??
-Want the mother to remember

73
Q

Why are narcotics avoided before the baby is delivered?

A

Post delivery fetal apnea??

1mcg/kg on induction of GA does not appear to affect Apgar scores

74
Q

Analgesic options for spontaneous vaginal delivery

A
  1. Epidural
  2. Spinal
  3. Obstetrician nerve blocks
  4. IV Nubain (Nalbuphine)
  5. Nitrous oxide
75
Q

Most popular analgesic option for spontaneous vaginal delivery

A

Epidural

76
Q

When is it acceptable to place an epidural?

A
  1. After the pt receives an adequate fluid bolus
  2. Normal platelet count
  3. “Adequate cervical dilation?” (may cause prolonged labor??)
77
Q

Most common local anesthetic for labor epidurals, and why

A

Marcaine due to motor sparing quality

78
Q

When is a spinal block an option in OB?

A

If the patient is going to have a C-section or if the patient is in the late stages of labor and is expected to deliver soon

79
Q

Dose of marcaine for a spinal block

A

3-6 mg to prevent significant motor block

80
Q

Local anesthetic injected into the vaginal submucosa

A

Paracervical nerve block

81
Q

When is a paracervical nerve block used?

A

To relieve 1st stage labor pain

82
Q

Adverse effect of paracervical nerve blocks

A

Higher incidence of fetal bradycardia

83
Q

Transvaginal and perineal infiltration of local anesthetic

A

Pudendal nerve block

84
Q

When is a pudendal nerve block used?

A

To relieve 2nd stage labor pain

85
Q

What is Nubain?

A

A narcotic agonist-antagonist that has not appeared to be very effective

86
Q

What can Nubain be used for other than analgesia?

A

To treat itching from duramorph

87
Q

Benefits of nitrous oxide for spontaneous vaginal delivery

A

The patient starts breathing in the gas at the start of a contraction and breaths it off by the end of it

88
Q

How should a patient be managed if they are hurting at some point after their epidural was started?

A

5-8mL local anesthetic bolus to increase block density, preferably with a stronger local anesthetic (≈5mL 2% lidocaine)

89
Q

How should a patient be managed if they still feel pain on one side after an epidural?

A
  1. Have patient lay on side that’s hurting
  2. Pull the epidural catheter back 1-2 cm, or
  3. Pull the epidural catheter and start another one
90
Q

Airway equipment should include:

A
  1. Smaller diameter ETT (for edema)
  2. Short laryngoscope handle (to avoid large breasts)
  3. LMA and videoscope ready
91
Q

General outline of a c-section (9)

A
  1. Pt arrives in OR
  2. Antibiotics are administered
  3. Analgesic method is carried out
  4. Pt placed in LUD
  5. Vasopressors are given w/spinals
  6. Surgery begins, baby is delivered w/in 3 minutes of uterine incision
  7. Pitocin is given
  8. Zofran and decadron are administered
  9. Additional drugs for pain control are given
92
Q

General outline of a c-section (9)

A
  1. Pt arrives in OR
  2. Antibiotics are administered
  3. Analgesic method is carried out
  4. Pt placed in LUD
  5. Vasopressors are given w/spinals
  6. Surgery begins, baby is delivered w/in 3 minutes of uterine incision
  7. Pitocin is given
  8. Zofran and decadron are administered
  9. Additional drugs for pain control are given
93
Q

Most common cause of N/V during a c-section

A

Hypotension from the spinal block

94
Q

Prophylactic dose (ED50 and ED90) of a phenylephrine infusion for preventing hypotension during a spinal for a C-section

A

0.31-0.54 mcg/kg/min

95
Q

Causes of N/V for normotensive patients

A
  1. Dominance of the parasympathetic system

2. Vagal stimulation with the surgeon in the abdomen

96
Q

Treatment of nausea in the presence of normotension

A

Robinul

97
Q

Why is Robinul preferred over atropine to treat nausea?

A

Atropine crosses the placenta

98
Q

Why is Robinul preferred over atropine to treat nausea?

A

Atropine crosses the placenta

99
Q

What is the first and second question you should ask for a non-emergent C-section?

A
  1. Do they have an epidural?

2. Does it work?

100
Q

What would you like to know prior to an emergent C-section? (other than if they have an epidural and if it works)

A

How is their airway?

101
Q

Anesthetic options for a C-section

A
  1. Spinal
  2. Epidural
  3. CSE-Combined Spinal Epidural
  4. General anesthesia
102
Q

Case outline for a c-section under spinal anesthesia (4)

A
  1. Perform a spinal with marcaine and duramorph
  2. Dose pressors as needed and place pt in LUD
  3. Administer Pitocin after the baby and placenta are delivered
  4. Give zofran and consider Toradol prior to leaving OR
103
Q

How long does duramorph (intrathecal) provide analgesia for?

A

12-24 hours

104
Q

What is the purpose of intrathecal duramorph?

A

Postop pain control

105
Q

What is a total spinal?

A

A neuraxial block that rises above the cervical region and produces respiratory arrest and unconsciousness

106
Q

True/false. The patient has a higher chance of staying conscious following a high epidural level when compared to a high spinal level (and why is it true or false?)

A

True. The epidural space only extends to the foramen magnum

107
Q

When does “total spinal” happen with an epidural?

A

After bolus of saline

108
Q

What are anesthetic options for a non-emergent C-section with mallampati I airway with a patchy spinal block?

A
  1. General anesthesia, or

2. Consider using N2O/ketamine to supplement the block

109
Q

How would you manage a Non-emergent C-section, working epidural in place

A

Dose to T4 gradually with lidocaine (or chloroprocaine)

110
Q

How would you manage Emergent C-section, working epidural in place

A

Dose epidural to T4 immediately with 20mL 3% chloroprocaine and bicarb

111
Q

How would you manage Non-emergent C-section, “patchy” epidural

A
  1. Try to dose the epidural up to T4, or
  2. Supplement the block with ketamine or nitrous oxide, or
  3. Pull the epidural catheter and perform the spinal with a reduced dose, or
  4. Perform general anesthesia with an RSI
112
Q

How would you manage Emergent C-section, “patchy” epidural

A
  1. If the airway looks easy, RSI with general anesthesia
  2. If the airway looks difficult, can consider trying to dose the epidural to T4 with 3% chloroprocaine and using ketamine and/or N2O to supplement the block (as an alternative to intubating with a videoscope)
113
Q

How would you manage Working epidural at the start of a C-section; pain 30 minutes into the procedure

A

5-10mL epidural bolus of lidocaine or chloroprocaine

114
Q

How would you manage Non-emergent C-section, Mallampati IV airway, “patchy” spinal block

A
  1. First try N2O/ketamine to supplement the block, or

2. Consider GA with a videoscope if the ketamine/N2O fails

115
Q

Spinal was performed, patient is uncomfortable after the baby is out

A

Give IV fentanyl

116
Q

High spinal, patient is anxious, but still conscious and breathing

A
  1. Reverse Trendelenburg
  2. Possible assist ventilation (and possible N2O)
  3. Blood pressure support
  4. Prepare for intubation
117
Q

High spinal, patient is unconscious and apneic

A
  1. Intubate

2. Resuscitate

118
Q

Emergent C-section, no epidural, Mallampati I airway

A

RSI with GETA

119
Q

Emergent C-section, no epidural, obese and Mallampati IV airway

A

RSI with videoscope and GETA with LMA as backup

120
Q

Non-emergent C-section, unable to intubate (even with a videoscope)

A

Awaken the patient

121
Q

Emergent C-section, unable to intubate (even with a videoscope)

A

Place an LMA and hold cricoid pressure until the patient can be intubated

122
Q

Case outline for a C-section under epidural anesthesia

A
  1. Give abx as soon as the patient arrives to the OR
  2. Raise epidural block up to T4
  3. Place pt in LUD
  4. Administer Pitocin after baby and placenta are delivered
  5. Dose duramorph in the epidural prior to epidural catheter removal
  6. Give zofran and consider toradol
123
Q

Duration of duramorph epidurally

A

18-26 hours

124
Q

Post-op pain control options for c-sections under epidural

A
  1. Duramorph 2-4 mg
  2. Order an epidural PCA
  3. Order an IV PCA
125
Q

Most common method of post op pain control for C-section epidurals

A

Duramorph

126
Q

Advantages to C-sections under GA

A
  1. Can get started quickly
  2. No sympathectomy
  3. Avoid risk of epidural hematoma in pts with low platelet counts or bleeding disorders
127
Q

Disadvantages to C-sections under GA

A
  1. Increased fetal exposure to drugs
  2. Mother is exposed to airway risk, including aspiration
  3. Mother is not awake for birth of her child
128
Q

When should you induce the patient for general anesthesia C-section?

A

After the patient is prepped, draped and the surgeon is ready

129
Q

Indications for C-sections under general anesthesia

A
  1. Emergencies where there are fetal decels with no block in place and not enough time to do a spinal
  2. Hypotension and won’t tolerate sympathectomy
  3. Contraindication to neuraxial or if they request GA
  4. When a spinal or epidural attempt fails
  5. If the pt is apneic due to a high spinal
130
Q

Condition where the placenta covers the cervical os

A

Placenta previa

131
Q

Classic symptom of placenta previa

A

Painless vaginal bleeding

132
Q

Condition where the placenta detaches from the uterus, leading to massive bleeding

A

Placental abruption

133
Q

Condition where the placenta grows through the uterine wall, causing massive bleeding from both organs

A

Placenta accreta

134
Q

Agent of choice in non-hemorrhaging, normotensive parturients

A

Propofol

135
Q

Agent of choice for induction of internally bleeding or hypotensive parturients

A

Ketamine

136
Q

Ketamine dose used to supplement a patchy epidural or spinal block

A

0.25 mg/kg

137
Q

Case outline for a C-section under GA

A
  1. Give abx as soon as the patient arrives in the OR
  2. Induce the patient when the surgeon is ready
  3. Place pt in LUD
  4. Paralyze the pt if needed
  5. Administer Pitocin after the baby and placenta are delivered
  6. Give Zofran, start dosing fentanyl and give reversal
  7. Place on an IV PCA for postop pain control
138
Q

True/false. Fasiculations are more intense in pregnancy due to progesterone

A

False, they are less intense

139
Q

Option for postop pain control for C-section under general anesthesia

A

IV PCA only

140
Q

Options for postop pain control for C-section under spinal

A
  1. Intrathecal duramorph

2. IV PCA

141
Q

Options for postop pain control for C-section under epidural

A
  1. Epidural duramorph
  2. Leave the epidural catheter in postop
  3. IV PCA
142
Q

Options for postop pain control for C section under CSE

A
  1. Leave the epidural catheter in postop

Methods of Anesthesia (20 decks)

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