OB II Flashcards

Question

non pharmacological analgesic techniques?

Answer 1

* emotional support (doulas) * touch and massage * therapeutic use of heat and cold * hydrotherapy * biofeedback * acupuncture * hypnosis

Answer 2

* an occiput posterior presentation * young maternal age * history of severe dysmenorrhea * increase maternal weight * increased fetal weight * type of labor * use of oxytocin- augments labor

Answer 3

* good to admin during latent period * s/e mom can vomit * opioids do cross placenta * might see FHR with fetal depression and decreased variability in FHR

Answer 4

* 50-100 mg IM q 4 hours or 25-50 mg IV (max dose \<100 mg ) * onset 5-10 min, duration 3-4 hours * fetal exposure highest 2-3 hours after admin * crossess the placenta/fetal acidosis/neonatal respiraotyr depression * active metabolite normeperidine in neonate--\> depressed behavioral assessment score

Answer 5

* linked to neonatal respiratory depression and somnolence * leads to maternal sedation * no longer widely accepted

Answer 6

* high potency and short doa make it reasonable for labor * usual dose 25-200 mcg in hourly increments * onset 2-4 min; doa 30-60 min * potent maternal respiratory depression * may affect newborn feeding

Answer 7

rarely used to potency/maternal respiratory depression/neonatal bradycardia

Answer 8

* ultra-short acting * metabolism by blood esterases therefore maternal and neonatal accumulation low * usual dose * iv bolus 0.4mcg/kg q 1 min * PCA bolus 0.25 mcg/kg then 0.05 mcg/kg/min, lockout 2 min, 4 hours limit 3 mg, and background infusion 0.025-0.05 mcg/kg/min

Answer 9

* Butorphenol (stadol) * 1-2 mg IV or IM, duration 4 hours * 5 times as potent as morphine * Nalbuphine (nubain) * dose 5-10 mg IV, IM duraiton 6 hours * causes less dysophoria than butorphenol * benefiical becaue they cause less N&V, dysphoria * both agents cause significant sedation * both agents rapidly transfer across placenta and produce alterations in FHR tracing

Answer 10

* low doses (0.5-1 mg IV) given to help alleviate anxiety without causing detriment to parturient and fetus * particularly useful in c section patients * causes amnesia

Answer 11

* occasionally intermittnet doses of 10-15 mg IV useful to produce intense analgesia for 10-15 min without causing detriment ot parturient and fetus * routinely co admin low dose midazolam * 25-50 mg (0.5 mg/kg) to supplement an incomplete neuraxial blockade during c section * in higher doses, dissociative anesthetic associated with emergence delirium/hallucinations * in higher doses, increases BP * **induction** **agent of choic in pt with acute asthma undergoing urgent csection**

Answer 12

* varies by country * nitrous oxide in most globally used inhalation agent for labor anes * 62% in UK * 43% Canada * \<1% US * Concentration- usually givne 50/50 mixture * does it cross placenta- yes * affect neonatal ventiatlion- no * s/e - n/v, paresthesia * who adminsiters? mom has to hold the mask, breaths when contraction comes * *book also mentions low dose sevo 0.6% but allan does not see in practice personally*

Answer 13

neuraxial anesthesia * only modality that can provide complete pain relief with minimum maternal or fetal depression * common techniques * eipdural * combined spinal epidural * spinal techniques

Answer 14

* ACOG guidelines state that in absence of medical contraindications, maternal request is a sufficient reason for labor analgesia * *some clinicians may believe that labor needs to be adequatley progressed before epidural, believve that early epidurals slows down labor* * *patient needs to be contracting regularly and have cervicla change*

Answer 15

* More constant level fo analgesia * more even level of block * more stable vital signs * can use to obtain surgical block in event of need for cesarean section

Answer 16

* CSE combines advantages and mitigates the disadvantage of single-shot anesthesia and continuous epidural anesthesia * anesthesia is inititaed with a spinal anesthetic injection of opioid and local anesthetic and maintained via the epidural catheter * *allows you to admin spinla that will work immediately and then admin epidural dose which takes about 30 min to setup for pain relief* *

Answer 17

* Imminent delivery (saddle block) * cerclage- suture placed for incompetent cervix 16-18 weeks * nonobstetric sx during pregnancy * instrumental vaginal devliery (forceps) * removal of retained placenta * postaprtum tubal ligation * postpartum tubla ligation * cesarean section

Answer 18

* Advantages * rapid onset * dense and reliable anesthesia * minimizes risk of aspiration * little risk of LA toxicity * minimal drug transfer to fetus * awake pateint * decreased risk of failed intubation * decreased blood loss * disadvantages * hypotension * lmiited DOA- *generally add opioid (morphine/fentanyl) to opioid. fent acts quick and morphine will last several hours because it's hydrophilic* * N &V * PDPHA- *postdural pucture headache* (decrease since advent of blunt tipped needles)

Answer 19

* Bupivicaine is most common cause of LA * cSECTION * 7.5-15 MG FOR BUPI * Most providers add an opioid to LA to improve quality of block and to privde postop analgesia. also opioids decrease n/v * fentanyl 20 mcg- intraop analgesia * morphine 0.2 mg- postop analgesia * epinephrine may be added to decrease systemic absorption--\> prolong block

Answer 20

* any postnatal change in fucntion or form in an offspring after prenatal treatment * 1200 drugs are teratogenic in animals and 30 teratogenic in humans (all drugs in general) * Gestational age at which exposure occurs determine the target organs or tissues, types of defect and severity of damage * structural abnormalities--\> occurs during organogenesis (day 31-71 after 1 day of LMP) * Function (learning disabilities)--\> a/w exposure during late pregnancy or postnatally because CNS continues to mature until 2nd year of life

Answer 21

* CNS * Eyes * teeth * external genitalia

Answer 22

* animal studies of reporductive effect of anesthetic agnets * epidemiological surveys of OR personnel routinely exposed to subanesthetic concentration of inhalational agnets * outcomes in females who have undergone sx while pregnany * agents: mentioned in class * toxoplasmosis * alcohol * cocaine * warfarin * enalapril * caprtopril * accutane * VPA * ETOH * metabolic imbalances: * diabetes * hyperthermia

Answer 23

* hypoglycemia * hypoxia * hyperglycemia * hyperthermia (maternal fever) * congenital abnormalities, esp CNS, have repeatedly been a/w maternal fever durign the first half of pregnnacy * remember, fetal temp is 0.5-1 degree higher than maternal temp

Answer 24

* teratogenic have not been a/w use of any commonly used induction agents- barbs, ketamine and benzos, when they are admined in clinical doses during anesthesia * diazepam/midazolam- controversial because noted increased risk for cleft lip/palate with valium * *many providers don't give it for that reason* * **although anesthesia and sx are associated with a higher inciedence of abortion, fetal growth restriction and perinatal mortaility, these outcomes can be attributed to the procedure, site of sx (proximity to uterus) and/or underlying medical condition** * ****evidence do not suggest that anesthesia during prengnacy results in overall increase in congenital abnormalities

Answer 25

* in contrast to VA, N2O has been shown to be a weak teratogen in rodent * neuronal apoptosis and learning impairments * reproductive effects occur only after lone exposure to **high** concentrations that are unlikely to be encountered in humans during clinical anesthesia * *early weeks of pregnancy probably avoid*

Answer 26

* elective sx should not be performed during pregnancy * avoid sx in 1st trimester (organogensis) * optimal time- 2nd trimester * preterm labor risk is lowest!

Answer 27

* indomethacin/ketoralac * used often in preterm labor * MOA: inhibit COX and thus prevent the synthesis of prostaglandins * prostaglandins play an important role in stimulation of uterine contraction * maternal admin may cause a closure of PDA * in 2nd half of pregnancy need to be avoided because of promotion of closure of PDA

Answer 28

Preoperatively * History /Physical * Airway evaluation * Informed Consent * LUD (*\>20 weeks don't lie on back!)* * IV access(free flowing 18-16 gauge) * Hydration (minimal 500 mL) * Aspiration prophylaxis (bicitra, metoclopramide, ranitidine) * Supplemental O2 * Anesthetic plan/ postoperative analgesia plan Choice of anesthetic depends on: * Indications for surgery * Degree of urgency * Maternal status * Condition of fetus * Desires of the patient

Answer 29

Most popular technique: * typically admin 10-15 mg hyperbaric bupi with 10-25 mcg fent and/or 0.1-0.25 mg preservative free morphine * studies indicate that 12 mg bupi optimal dose * duration block 1.5-2 hours! * level of block T4 * Hypotension may be prevented by LUD, crystalloid coloading, and treated with ephedrine (5-10 mg) or phenyl (50-100 mcg IV)

Answer 30

Way to remember * C6= thumb= sex yes! * C7= pointer * C8= ate a burger (with pinky)

Answer 31

Advantages * Less impact on maternal/fetal hemodynamics * Can use if already in place * Can place electively if patient high-risk of needing emergency c/s later * Can re-bolus * Can use for postoperative analgesia * Less chance of PDPHA Disadvantages * Increased complexity of insertion and management * Slower onset (up to 30 minutes) * Can be less dense * Large doses of LA--increased risk of toxicity

Answer 32

Typically bolus with * 15-20 ml 2% lidocaine (with/without epinephrine) * 10-20 ml 0.5% bupivacaine or ropivacaine * 5-15 ml 2-3% chloroprocaine Can add opioids * 50-100 mcg fentanyl * 10-20 mcg sufentanil * 1.5-4 mg preservative free morphine (Duramorph) DON'T NEED TO MEMORIZE FOR TEST!

Answer 33

* Preop assessment of airway * Large bore IV * Aspiration prophylaxis (Non-particulate antacid, H2-blocker, Reglan) * Monitors/suction/ emergency airway cart * Optimal airway positioning/ LUD * **Preoxygenate! (3 min or longer)** * Prep + drape –surgeon ready * RSI w/cricoid (10 N while awake; inc to 30 N after LOC) * Agents available * Ketamine (used with maternal hypotensive crisis) 1 mg/kg * Etomidate 0.3 mg/kg * Propofol 2-2.5 mg/kg * Succinylcholine 1-1.5 mg/kg * Preferred muscle relaxant * Intubate-- ***let surgeon know you have tube placed because they will cut right away!*** * Expect difficult intubation * Proper positioning * Short handled laryngoscope (Datta) recommended * Use minimal amount of time; first attempt best attempt * Smaller ETT 6.0 or 6.5 * Use caution…friable tissues and decreased airway size * Verify placement of ETT, then * Surgeon makes skin incision * Ventilate with 50% O2/50% N2O & volatile agents (~1 MAC) * Secure ETT, tape eyes, OGT * \*\*\*\*Critical interval of 3 minutes between uterine incision and delivery of fetus * Delivery of baby-- **i*area with tremendous recall in anesthesia, generally don't give versed, fent, etc for emergeny csection- gas may not be at appropraite level yet*** * **Reduce volatile agents (.75 MAC), may increase N2O to 70%, and give opioids and benzodiazepine** * *reduce VA to reduce r/f vasodilation* * Possible NDMR * Delivery of placenta * Then can add oxytocin to IV \<-- so uterus can begin to clamp/contract * At end: * Suction OGT * Reverse NDMR if necessary * Extubate AWAKE * Emergence and recovery is a critical period for anesthesia-related deaths from airway factors! * •

Answer 34

* Small dose oxytocin sufficient to produce adequate uterine contraction after cesarean devliery Rule of 3's * oxytocin 3 units, 3 min evaluation intervals, 3 total doses and oxytocin infusion 3 units/hr maintenance * 3 units given slow bolus * uterine tone reassessed 3-6 min * if inadequate, additional 3 doses are given after each reassessment * if uterine atony persists after 3 doses--\> switch to another drug * after establishment of uterine tone, infuse 3 units/hr x 5 hours * Oxytocin as a rapid IV bolus * direct smooth muscle relaxant--\> decrease SVR, hypotension, tachycardia * hypotension may result in CV collapse * chest pain, MI may develop * **structural similarities b/t oxytocin and vasopression--\> water intoxication and hyponatremia**

Answer 35

* Methylergonovine (methergine- ergot alkaloid) * dosage 0.2 IM * onset 10 min * duration 2-4 hours * **Cannot give IV! causes intense vasoconstriction, acute HTN, sz, retinal detachment, coronary artery spasm, CVA** * May be repeated x 1 after 30 min * contraindications: HTN, preeclampsia, CAD

Answer 36

* 15 methylprostaglandin F (carboprost- hemobate) * dose 250 mg IM, may repeat q 15 min x 8 doses (2mg) * S/E : fever chills, N/V, diarrhea and bronchoconstricitons * who should not receive this drug? * asthmatics