OB: C-Section: Regional vs. General Anesthesia Flashcards
most common indications for C-section
Dystocia
Malpresentation
Non-reassuring fetal status
Previous cesarean delivery
Can be performed for obstetric or medical indications or at the request of the parturient. Typically planned and performed prior to the onset of labor.
Elective C-Section
Typically occur after the onset of labor (exception: i.e. Non-reassuring fetal nonstress test [NST]). Can be due to a variety of maternal and fetal indications
Urgent/Emergent C-section
TOLAC
trial of labor after cesarean
VBAC
vaginal birth after cesarean
_____ _____ ______ _____ (super STAT emergencies)
Better surgical exposure and visualization
Faster exposure
Midline vertical (skin) incision
_____ _____ _____ ______
Better cosmesis
Better wound strength
Horizontal suprapubic (skin) incision
Horizontal uterine incision
_______ incidence of uterine dehiscence or rupture in subsequent pregnancies
lower
Horizontal uterine incision
______ risk of infection
reduced
Horizontal uterine incision
______ blood loss
decreased
Horizontal uterine incision
______ risk of adhesions to bowel and omentum
decreased
Vertical uterine incision usually only seen if:
Lower uterine segment is underdeveloped (prior to ___ weeks)
34
Vertical uterine incision usually only seen if:
Delivery of a preterm infant in a parturient who ___ ____ _____
has not labored
Vertical uterine incision usually only seen if:
Some ____ _____ and/or malpresentation
multiple gestation
Vertical uterine incision usually only seen if:
Low lying anterior ____ _____
placenta previa
Operative Technique - Uterine exteriorization (after delivery)
Good, facilitates ________ and facilitates repair of uterine incision
visualization
Operative Technique - Uterine exteriorization (after delivery)
controversial effects on blood loss and infection, higher rate of ______, increased risk of ______ ______, and increased post operative ______
N/V
air embolus
pain
Complications of C-Section
Hemorrhage (MAIN SX COMPLICATION - TEST)
Infection
Thromboembolism
Ureteral and bladder injury
Abdominal pain
Uterine rupture in subsequent pregnancies
Death
Non-elective cases associated with _____ _____ than elective
greater risk
Historically, it was thought that neuraxial analgesia ___________ rate of cesarean delivery compared to other techniques. However this has been found to be unfounded in RCTs and sentinel event studies.
increased
some cesarean deliveries may be avoided with _____ ____ _____, including:
adequate labor analgesia
TOLAC, instrumented vaginal delivery, cephalic version, intrauterine resuscitation (pharmacologic uterine relaxation of uterine tachysystole)
External Cephalic Version
Breech position occurs in ____% of term singleton pregnancies
3-4%
External Cephalic Version
Vaginal breech delivery should be done with caution due to increased risk of _______ __________ ________ and risk of ________ _________
emergency c-section delivery
neonatal injury
External Cephalic Version
Neuraxial analgesia improves success of ECV by up to ____% without increased risk of fetal bradycardia, placental abruption, or fetal death.
50%
External Cephalic Version
Usually done at ___-___ weeks
36-37
External Cephalic Version
Average success rate is ___% (with a wide range)
58%
wide range associated with providers competency
External Cephalic Version
Most likely to be successful - If the presenting part has not entered the _____, Amniotic fluid volume is normal, The fetal back is not positioned ______, Patient is not obese, Position is either ____ ____ or _____
pelvis
posteriorly
frank breech or transverse
External Cephalic Version
Successful version reduces the risk of perinatal _____ & _____ of the breech position
morbidity and mortality
External Cephalic Version
Most likely complications of the ECV are:
______ FHR abnormalities
______ FHR abnormalities
Vaginal bleeding
Placental ______
Emergency cesarean delivery
Still birth
Transient
Persistent
abruption
External Cephalic Version
A high ______ dense (anesthetic>analgesic) neuraxial block will improve the success of the ECV
T4-T6
External Cephalic Version
____ if plan to discharge
SAB
External Cephalic Version
Epidural if planning to _____
labor
External Cephalic Version
Either way, have backup plan(s) to convert to ____ _____ delivery
emergency cesarean
Intrauterine Resuscitation
Intrapartum fetal compromise (nonreassuring fetal status) should prompt _____ _____ _____
intrauterine fetal resuscitation
Intrauterine Resuscitation
Optimize maternal position -
To relieve ______ compression
To relieve _____ _____ compression
aortocaval
umbilical cord
Intrauterine Resuscitation
administer supplemental _____
O2
Intrauterine Resuscitation
Maintain maternal circulation
Perform rapid IV infusion of a ___-____ ____ ____ solution
non-dextrose balanced salt
Intrauterine Resuscitation
Treat hypotension with _____ or _____
ephedrine or phenylephrine
Intrauterine Resuscitation
discontinue _______
pitocin (bc it increases contractions)
Intrauterine Resuscitation
Consider administration of a tocolytic agent for treatment of _____ _____
uterine tachysystole
Preanesthetic Evaluation
Ideally anesthesia evaluation should occur in the ____ ____ or ____ ____ trimester for high-risk patients
late 2nd or early 3rd
Preanesthetic Evaluation should include:
Review of maternal health
Anesthetic history
Relevant obstetric history
Allergies
Baseline BP/HR
Airway exam
Heart exam
Lung exam
Informed Consent
Informed Consent
Only 12% of English-speaking adults in the US are “proficient” in their health literacy skills
Health literacy is the precursor to patient ______ and to patient ____ _____
engagement
decision making
Informed Consent
70% of first time mothers are influenced by ________ and ___________ regarding labor analgesia
friends and family
Informed Consent
The most frequently utilized resource is the _______________
internet
_______ elements include the ability of the patient to meet the basic definition ofcompetence, which refers to the patient’s legal authority to make a decision about her health care. Although some cognitive functions may be compromised by the effects of pain, exhaustion, and analgesic drugs,evidence suggests that most laboring women retain thecapacityto hear and comprehend information during the consent process.
Threshold
Information elements -
provider discloses information about ______ risks
patient understands ______
material
information
_______ elements -
provider offers info in a non-coercive manner
patient gives authorization voluntarily
consent
Timeline of C-section
- monitors, IV, O2
- T4-T6 level of anesthesia established
- left uterine displacement
- incision and delivery
- delivery of placenta - pitocin 30 unit IV gtt, may need more, may push smaller doses
- closure
Pitocin - synthetic hormone ______
oxytocin
Pitocin - given to _____ or _____ uterine contractions or to contract uterus after delivery to prevent _____
initiate or augment
hemorrhage
Pitocin - if patient has been induced/augmented with pitocin, it may take _____ dosages to achieve adequate contraction post partum
higher
Pitocin - other uterotonic agents ______
unaffected
monitors
EKG
Pulse ox
capnography
oxygen and volatile agent analyzers
ventilator
peripheral nerve stimulator
Consent for Blood Products
Blood administration should be included in _____ _____/_____
informed consent/discussion.
Consent for Blood Products
____-_____ ______ is the leading cause of maternal mortality worldwide
peri-partum hemorrhage
Consent for Blood Products
______ ______ delivery ≤ uncomplicated elective c-section «< c-section during labor
Uncomplicated vaginal
Consent for Blood Products
preparation for hemorrhage:
Patient history
Consult with OB team
Ultrasound/MRI of placentation
Type and screen/cross
Contact blood bank to verify availability
Equipment (pumps/filters/pressure bags)
Prepping for hemorrhage
Large-bore IV catheters
Fluid warmer
Forced air body warmer
Availability of blood bank resources
Equipment for infusing fluids/blood products rapidly
There is a _____ of ______ as to which patients require a type and screen versus crossmatch. Maternal history (previous transfusion, existence of RBC antibodies), anticipated hemorrhage (placenta accreta), local institutional policies should guide decisionmaking.
lack of consensus
prepping for difficult airway
laryngoscope blades
LMAs
semirigid stylets
retrograde intubation equipment
at least one device suitable for emergency non-surgical airway ventilation (jet ventilation, combitube, intubating LMA)
fiberoptic intubation equipment
equipment for emergency surgical access
topical anesthetics and vasoconstrictors
(airway will worsen throughout labor)
Drugs for general and neuraxial anesthesia should be readily available
Including _____ & _____ medications
vasopressors and emergency
Only _____ ____ controlled substances need to be in a “substantially constructed locked cabinet”
Other drugs, including _____ ____ should be “reasonably secure”
Schedule II
Schedule III
All obstetric patients are considered a _____ stomach.
full
Patient should be asked about oral intake
_______ evidence exists regarding the relationship between recent ingestion and subsequent aspiration
Insufficient
Gastric emptying of clear liquids during pregnancy occurs _____ _____ (Remember Wong et al.,2002)
relatively quickly
Healthy patient for elective cesarean may drink modest amounts of clear liquids up to 2 hours prior to induction
_______ of _____________ is more important than volume
absence of particulates
Patients with additional risk factors for aspiration (obesity, diabetes, difficult airway, laboring) should have further __________ on a case-by-case basis or as determined by facility policy
restrictions
Ingestion of ____ ____ should be avoided in laboring patients, ___-___ hours
solid foods
6-8
Reduction in acidity and volume is thought to decrease the damage to the _____ if there is ______.
lungs
aspiration
Sodium citrate (___________ gastric pH)
increases
treat with H2 receptor antagonists, PPIs, and metoclopramide reduce gastric ________________ and ___________. (In 30-40 minutes)
secretion and volume
The combined use of antacid and H2 antagonist is ____ _____ in reducing acidity than antiacid or placebo.
more effective
ACOG recommends prophylactic administration of a narrow-spectrum antibiotic (_____ generation _______) within one hour of the start of a cesarean delivery.
first
cephalosporin
In parturients with significant beta-lactam allergy ______ & ______ are a reasonable alternative.
clindamycin and gentamycin
Higher doses should be considered with BMI greater than 30 kg/m^2 or absolute weight greater than 100 kg due to _____ _____ of ________.
greater volume of distribution
Optimal timing and value of broad-spectrum antibiotics remain ________.
controversial
Even low dose benzodiazepines may result in ______(midazolam 0.02 mg/kg)?
amnesia
For women with severe anxiety, low dose ______ or an ______ may facilitate neuraxial technique or induction
midazolam or an opioid
anxiety proph - May also mitigate feelings of distress and lessen the risk of developing _____
PTSD
Low doses of sedative or anxiolytic agents have minimal to no _____ ______.
neonatal effects
Left Uterine Displacement for all parturients after ____ ____ gestation
20 weeks
A slight (10 degree) head-up position may help reduce the incidence of ____________ after initiation of ____________ spinal anesthesia.
hypotension
hyperbaric
A more significant head-up position (30 degrees) significantly improves the _____
FRC
A 30 degree head up position may also be helpful to improve ________, ________, and view of the glottis during direct laryngoscopy
preoxygenation, denitrogenation
Trendelenburg (head down) may augment venous return and cardiac output but…. Has been reported to result in a more _____ _______ of anesthesia.
cephalad spread
Lateral position
Reduction of _____ reflexes (dizziness, diaphoresis, pallor, bradycardia, hypotension)
Improved uteroplacental blood flow???
More comfortable
Limit side-to-side and front-to-back patient motion
Minimizes prominence of ____ ____
Decreased severity and duration of ______
vagal
dural sac
hypotension
Sitting position
Landmark recognition (especially in obese)
Provider preference
Should _____ be utilized in fetal head entrapment, umbilical cord prolapse, footling breech presentation.
NOT
Routine supplemental oxygen administration is common practice since the 70’s when Fox et al. (1971) demonstrated:
Improved oxygenation
Better umbilical cord acid-base measurements
Less time to sustained respiration of the neonate
(when mothers breathed 100% O2 for at least 30 minutes)
More recent evidence has shown that routine oxygen administration may be _______ and _______ or perhaps even ________
unnecessary
ineffective
detrimental
The most appropriate anesthetic technique depends on many factors:
Maternal
Fetal
Obstetric
(urgency and anticipated duration are important)
Indications for Neuraxial Anesthesia
Maternal desire to witness birth and/or avoid _____ _____
general anesthesia
Indications for Neuraxial Anesthesia
Risk factors for ____ ____ or aspiration
difficult airway
Indications for Neuraxial Anesthesia
Presence of _____ conditions
comorbid
Indications for Neuraxial Anesthesia
General anesthesia _____/_____
intolerance/failure
Indications for Neuraxial Anesthesia
other benefits:
Plan for neuraxial analgesia after surgery
Less fetal drug exposure
Less blood loss
Allows presence of support person
Indications for General Anesthesia
Maternal refusal or failure to cooperate with ______ technique
neuraxial
Indications for General Anesthesia
Presence of comorbid conditions that contraindicate neuraxial:
Coagulopathy
Infection at insertion site
Sepsis
Severe uncorrected hypovolemia
Intracranial mass with increased ICP
Known allergy to local anesthetic
Indications for General Anesthesia
Insufficient time to induce neuraxial anesthesia for ____ ____
urgent delivery
Indications for General Anesthesia
failure of _____ technique
neuraxial
Indications for General Anesthesia
_____ issues
fetal
Neuraxial versus General
Neuraxial anesthesia has been used in more than ____% of c-sections since 1992
80
Neuraxial versus General
increased use due to: (6)
- Increased use of LEA
- Increased awareness of in situ epidural catheter, even if not used in labor, may decrease necessity of general anesthesia in an urgent situation
- Improvement of neuraxial anesthesia quality
- Appreciation of the airway risks with general
- Desire for limited neonatal drug transfer
- Ability of mother to remain awake and have support person present for birth
Neuraxial versus General
Spinal anesthesia is considered appropriate even in the most ____ _____
urgent settings
Neuraxial versus General
“____ _____ Spinal”
SAB 8.1 +/- 3.8 minutes
General induction 4.5 +/-1.4 minutes
Rapid Sequence
Neuraxial versus General
Maternal _____ after general anesthesia is a huge motivator for the shift
mortality
Neuraxial versus General
Maternal _____ is also lower with neuraxial
morbidity
Neuraxial versus General
_____ blood loss
decreased
Neuraxial versus General
_____ shivering
decreased
Neuraxial versus General
_____ nausea
more
Neuraxial versus General
_____ intraoperative perception of pain
more
Neuraxial versus General
_____ time elapsed before first request for pain meds
longer
Neuraxial versus General
neonatal outcomes??
not a huge factor
epidural advantages
No dural puncture required
Can use in situ placed earlier
Ability to titrate sensory blockade
Continuous postoperative analgesia
epidural disadvantages
Slow onset of anesthesia
Larger dose required > greater risk of maternal systemic toxicity > greater fetal drug exposure
CSE advantages
May be technically easier than spinal in obese
Low doses of local anesthetic and opioid
Rapid onset of dense block
Ability to titrate sensory blockade
Continuous intraoperative anesthesia
Continuous postoperative analgesia
CSE disadvantages
Delayed verification of functioning epidural catheter
one shot spinal advantages
Technically simple
Low doses of local anesthetic and opioids
Rapid onset of dense lumbosacral and thoracic anesthesia
one shot spinal disadvantages
Limited duration of anesthesia
Limited ability to titrate extent of sensory blockade
continuous spinal advantages
Low doses of local anesthetic and opioid
Rapid onset of dense anesthesia
Ability to titrate sensory blockade
Continuous intraoperative anesthesia
continuous spinal disadvantages
Large dural puncture > increased risk of PDPH
Possibility of overdose and total spinal
SAB
simple, reliable, _____ onset, _____ block (more profound than epidural), _____ amount of LA needed
rapid
dense
small
SAB
decreased risk of _____ ______, minimal drug transfer to fetus, _____ and prompt recovery, most common anesthesia technique for cesarean delivery in the developed world
LA toxicity
predictable
SAB
______ bevel rarely used in OB, increased incidence in PDPH
cutting
SAB
___-____ needles used almost exclusively
non-cutting (aka pencil point needles)
believed to cause _____ trauma to the dura (pencil point)
more
but the subsequent inflammation seals the hole and prevents a leak
SAB: Needle Size
Larger needles
Greater tactile fidelity
More likely to withstand high resistance (bone) without damage
SAB: Needle Size
Smaller needles
Lower incidence of PDPH
Use introducer needle
SAB: Approach
Midline -
Need more patient ______ cooperation
Faster for most patients
____ painful for most patients
Easier to teach
positioning
Less
SAB: Approach
Paramedian -
_____ target
Must think of the anatomy in ___ planes instead of 2
Still trying to puncture the dura in the midline
May need a ____ ____
Larger
3
longer needle
SAB: Local Anesthetics
Typically use ______ doses in pregnancy than non-pregnant
Smaller CSF volume
______ movement of hyperbaric LA
Greater sensitivity
lower
Cephalad
SAB: Local Anesthetics
_______ is predominant agent for SAB for Cesarean delivery in the USA
Bupivacaine
SAB: Adjuvant Agents - opioids
Improve comfort intra and postoperative _____
Decreased need for ______ opioids
comfort
intraoperative
SAB: Adjuvant Agents
Fentanyl
- Increased postoperative opioids (after 6 hours)
- Decreased intraoperative ____ & _____
(20 mcg fentanyl is superior to ___ mg of _____)
- Large (40-65 mcg) vs. small (15-35 mcg)
(Decreased pruritus, nausea, and vomiting in small dose
No difference in supplemental analgesia need)
nausea and vomiting
4
ondansetron
SAB: Adjuvant Agents
Preservative free _____
More effective for prolonged (12-24 hr) postoperative analgesia
Intrathecal morphine analgesia similar analgesia from 0.1 mg and 0.5 mg.
Occurrence of pruritus appeared to be ____ _____
Occurrence of nausea and vomiting were ___ ____dependent
morphine
dose dependent
not dose
SAB: Adjuvant Agents
_____- hyperbaric
Dextrose
SAB: Adjuvant Agents
Epinephrine -
increase density of _____ and _____ block, may prolong ______
sensory and motor
duration
SAB: Adjuvant Agents
Clonidine - improve _____, decreases ______, reduces peri-incisional hyperanalgesia, BLACK BOX warning in OB pts because of concerns with _______ instability
analgesia
shivering
hemodynamic
SAB: Adjuvant Agents
Neostigmine - reduction in postoperative _____, no effect of FHT or _____ scores, 100% of patients in the study complained of ______
pain
Apgar
nausea
Use of epidural anesthesia for cesarean delivery has ______
increased
Use of epidural anesthesia for elective cesarean delivery is becoming less common:
Block is ____ reliable
Higher doses (5-10 times)
_____ systemic absorption
Risk of local anesthetic toxicity
Slower onset of _____ _____
Ability to titrate level, density, and duration
less
Greater
sympathetic blockade
Combined spinal epidural (CSE) anesthesia
_____ onset
Reliable anesthesia block
Ability to _____/______ blockade
Dural puncture may enhance movement of drugs into ___________ space
Rapid
augment/prolong
subarachnoid
Most common local anesthetic for initiation and maintenance of epidural for cesarean delivery is ___ ______ with ______
2% Lidocaine with epinephrine (less than 2% may result in inadequate anesthesia)
3% 2-chloroprocaine has most _____ onset and ______ duration
Rapid onset of hypotension
Reduced clinical efficacy if administered with _____
rapid
shortest
opioids
0.5% Bupivacaine can result in surgical anesthesia
- ______ onset
- risk of LA toxicity from _______ _______
slower
intravascular injection
______
50-100 mcg results in spinal and supraspinal sites of action
Improves quality of anesthesia
Does not adversely affect the neonate
Fentanyl
________
10-20 mcg improves intraoperative anesthesia
Prolongs postoperative analgesia
Minimal maternal side effects, no neonatal adverse effects
Sufentanyl
Clonidine
Reduced requirement for postop ______
_____tension
_____ _____ Warning
morphine
Hypo
Black Box
Neostigmine
Modest postop analgesia, given after ____ _____
cord clamped
Epinephrine -
Minimize systemic absorption
Increase _____ & _____ blockade density
Prolong duration
Controversial in ______ women
sensory and motor
preeclamptic
Sodium Bicarbonate -
More ___-____ molecules
Speeds onset
Improves _____
non-ionized
quality
Combined Spinal-Epidural Anesthesia: CSE
Combines the rapid and predictable onset of a spinal with the ability to _____ with the epidural catheter
titrate
Combined Spinal-Epidural Anesthesia: CSE
Epidural needle functions as a longer _____
introducer
Combined Spinal-Epidural Anesthesia: CSE
Use of ____ ____ to confirm correct positioning
spinal needle
Combined Spinal-Epidural Anesthesia: CSE
May be able to use _____ spinal doses
lower
Laboring patient > turns to unscheduled c-section
Assess how/is the epidural ______
functioning
Local anesthesia choices
0.5% Bupivacaine
2% Lidocaine
3% 2-Chloroprocaine
More non-ionized molecules speeds onset, improves density
Extension of a T10 level of analgesia to a T4 level of anesthesia typically requires ___-___ mL of local with one or more adjuvants
15-20 mL
Cesarean Section General Anesthesia: Induction
Neuraxial technique is ______, but there are some cases where general is indicated
preferred
Cesarean Section General Anesthesia: Induction
All parturients are considered __________________
full stomachs
Cesarean Section General Anesthesia: Induction
In contrast to general surgical procedures, the abdomen is prepped and draped _____ induction of general anesthesia.
BEFORE
Cesarean Section General Anesthesia: Induction
Rapid-sequence induction following ______
preoxygenation
Cesarean Section General Anesthesia: Induction
Propofol 2-2.8 mg/kg is typically used to induce
______ (1-1.5 mg/kg) or ______ (0.3 mg/kg) may be used in the case of hemodynamic instability
Ketamine
etomidate
Cesarean Section General Anesthesia: Induction
Succinylcholine (__-___ mg/kg) or Rocuronium (__mg/kg)
1-1.5
1
Cesarean Section General Anesthesia: Induction
Smaller diameter endotracheal tube (___-___) with a semirigid stylet
6.0-6.5
Cesarean Section General Anesthesia: Induction
Anticipation of a difficult airway or failed intubation attempt should invoke the ____ ____ ____
difficult airway algorithm.
Indications for General Anesthesia
Maternal _____ or failure to cooperate with neuraxial technique
refusal
Indications for General Anesthesia
Presence of comorbid conditions that contraindicate neuraxial:
Coagulopathy
Infection at insertion site
Sepsis
Severe uncorrected hypovolemia
Intracranial mass with increased ICP
Known allergy to local anesthetic
Indications for General Anesthesia
Insufficient time to induce neuraxial anesthesia for ____ ____
urgent delivery
Indications for General Anesthesia
Failure of neuraxial technique
_____ issues
Fetal
General Anesthesia: Maintenance - GOALS
Adequate maternal and fetal oxygenation with maintenance of normocapnia (30-32 mmHg)
Appropriate depth of anesthesia to promote maternal comfort and optimize surgical conditions
Minimal effects on uterine tone
Minimal adverse effects on the neonate
Fetal oxygenation is maximal when maternal FiO2 _____ is used, but it does not seem to alter Apgar scores.
1.o
Excessive ventilation can cause uteroplacental vasoconstriction and shift the oxyhemoglobin dissociation curve to the ______.
left
___ inhalational agent has been shown to be superior to others.
No
ET levels of inhalational agent of _______ MAC may reduce the effect of oxytocin on uterine tone > increased blood loss.
1-1.5
TEST QUESTION
IV _____ are usually withheld until after the clamping of the umbilical cord.
opioids
Additional _____ _____ is rarely needed
neuromuscular blockade
U-D interval longer than ____________ = lower Apgar scores and fetal pH
180 seconds
Post partum women are considered full stomachs for at least ___ weeks.
6
emergence and extubation
________ position
Purposeful response to verbal commands
Return of _____ _____ reflexes
Semirecumbent
airway protective
Majority of deaths associated with hypoventilation or airway obstruction occurs during ______, _______, or _______!
emergence, extubation, or recovery
Propofol
Rapid onset, rapid recovery, favorable side effect profile
More ____ ______ in pregnancy
Readily crosses the placenta
_____ Apgar and neurobehavioral scores for neonates than thiopental
Greater incidence of maternal hypotension
______ depth of anesthesia
rapid clearance
Lower
Lighter
Ketamine
________ properties make it an ideal induction agent for urgent delivery in patient with hypotension or acute asthma exacerbation
____ _____ in preeclampsia
Hallucinations/delirium
Ketamine for induction -> decreased _____ _____ _____ than thiopental induction
Sympathomimetic
Not desirable
postop morphine consumption
Etomidate
Rapid onset – minimal _______ effects
Ideal for hemodynamic instability or severe cardiac disease
Rapid ______/rapid ______
Nausea and vomiting
Transient reduction in neonatal _____ _____
cardiorespiratory
hydrolysis
recovery
cortisol production
Midazolam
____ acting, ______ soluble
Typically avoided due to amnestic properties
Used with _____
Short
water
ketamine
Succinylcholine
Muscle relaxant of choice for RSI of general anesthesia
1-1.5 mg/kg = Ideal intubating conditions in about 45 seconds
Highly ______, ______ soluble, small amounts cross placenta
Very large doses (10 mg/kg) required to lead to _____ _____ sufficient to cause neonatal weakness
Rapidly metabolized by _________ (decreased in pregnancy)
ionized, water
placental transfer
pseudocholinesterase
Rocuronium
Suitable alternative for RSI
0.6 mg/kg = ideal intubating conditions in about ____ ______
No impact on _____ ____
79 seconds
Apgar scores
Vecuronium
0.1 mg/kg Slower onset (144 seconds)
Atricurium
Less desirable agent for RSI because of ____ _____ required
May result in significant ______ release and hypotension
high doses
histamine
Nitrous Oxide
_____ effect on maternal blood pressure
Minimal effect on uterine _____
Allows for reduction in use of halogenated agents
50-67% nitrous alone => awareness in 12-26% of cases
Transferred rapidly across the placenta
Neonates exposed to nitrous required more ______
Minimal
tone
resuscitation
Volatile Agents
Decreased uterine tone
Oxytocin induced contractions completely _____ at ___ _____
Decreased (28%) MAC
Return to normal by 72 hours post partum
inhibited at 2 MAC
Opioids
All cross the placenta, especially high _______ solubility
Usually avoid until after delivery
Meperidine’s active metabolite _________________ can accumulate in the mother and neonate resulting in respiratory and neurobehavioral alterations
lipid
normeperidine
Few reports of malignant hyperthermia during pregnancy
The rarity of MH events in pregnancy suggests pregnancy _____ _____ the occurrence of MH
protects against
MH is an ________ __________ _________ gene
inherited autosomal dominant
All anesthetic agents ____ the _____
cross
placenta
Cesarean delivery is a major abdominal surgical procedure
May go to PACU, patient’s room, or somewhere else
_____ _____ _____ has been cited as a recurring factor in maternal deaths
Inadequate postoperative care
“Appropriate equipment and personnel should be available for obstetric patients recovering from major _____ or ______ anesthesia.”
neuraxial or general
Oral intake – early intake (4-8 hours) associated with shorter time to return of ____ ____ and shorter hospital stay
bowel sounds
Urinary catheter
No differences for general vs neuraxial
Risk factors for urinary retention:
Post op opioid analgesia (especially epidural)
Multiple gestation
Low BMI
Anesthesia Complications
_____ & ______
Avoidance of sedative premedication
Deliberate low volatile concentration
Use of muscle relaxants
Reduced anesthetic doses in hypotension or hemorrhage
Conversion to general after failed neuraxial technique
Mistaken assumption that high baseline sympathetic tone is responsible for intraoperative tachycardia
Awareness and Recall
Dyspnea
Hypo______ of brainstem
Blunted thoracic ______
Position
perfusion
proprioception
Anesthesia Complications
Hypo______
Severe preeclampsia
IV fluids
Vasopressors
tension
Anesthesia Complications
Neuraxial blockade _____
4-14% of epidurals
0.5-4% of spinals
failure
Anesthesia Complications
High neuraxial blockade
Impaired ______
Unconsiousness
Respiratory depression
______cardia
Hypotension
phonation
Brady
Anesthesia Complications
____ and _____
Hypotension
Uterotonic agents, ergot alkaloids
Surgical stimuli
Nausea and vomiting
Anesthesia Complications
perioperative _____
pain
Anesthesia Complications
Pruritus
___-____% incidence
More common intrathecally than epidurally
Not an _____
30-100
allergy
Anesthesia Complications
Hypothermia and shivering
66 and 85% incidence respectively
Spinal reduces ____ ____ more rapidly than epidural
Shivering incidence similar but less severe in spinal group
______ improves for epidural, but not spinal
core temp
Prewarming
Obstetric Complications
_____ _____
Leading cause of maternal and fetal morbidity and mortality worldwide
Postpartum Hemorrhage
Obstetric Complications
_____ _____
More common with c-section
High parity
Overdistended uterus (multiple gestation, polyhydramnios, macrosomia)
Prolonged labor (augmented by oxytocin)
Chorioamnionitis
Abnormal placentation
Retained placental tissue
Poor perfusion of the uterine myometrium (hypotension)
Uterine atony
Obstetric Complications
Obstetric _______
0.03-0.33% incidence
High risk procedure
GU injuries are common
hysterectomy
Obstetric Complications
_________ ________
Operative delivery
Physiologic changes of pregnancy
History
Highest risk in first week postpartum
Prophylaxis?
Hydration
Early mobilization
Pneumatic compression devices
Pharmacologic prophylaxis in high risk patients
Thromboembolic events
