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Obstetric Anesthesia II Flashcards

1
Q

When can systemic medications be used for labor pain relief?

A

When neuraxial analgesia is unavailable, refused, or contraindicated.

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2
Q

What are the disadvantages of using systemic medications for labor pain relief?

A
  • Often inadequate pain relief.
  • Risks of fetal and maternal respiratory depression.
  • Nausea and vomiting.
  • Decreased lower esophageal sphincter tone.
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3
Q

Why are controlled, randomized trials comparing neuraxial and IV analgesia in labor challenging to conduct?

A

High protocol failure rates.

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4
Q

What did a systematic review of studies involving over 9600 women comparing neuraxial analgesia to opiates find?

A
  • Neuraxial techniques offer better pain relief.
  • Reduced risk of fetal acidosis.
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5
Q

How has the use of parenteral narcotics in early labor changed with the evolution of obstetric anesthesia?

A
  • Declined usage.
  • Early labor patients are now acceptable candidates for neuraxial analgesia.
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6
Q

Which Analgesics are used in the parturient?

A
  • Meperidine
  • Fentanyl
  • Butorphanol
  • Nalbuphine
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7
Q

What is the dose, onset, DOA, and PCA dosing for Meperidine (Demerol)?

A

25-50 mg IV (usual dose)
Onset: 5-10 min
DOA: 2-3 hr
PCA dose: 15 mg q10 min

Active metabolite that may last up to 3 days. Neonatal effect are most likely if delivery occurs between 1 and 4 hr after administration.

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8
Q

What is the dose, onset, DOA, and PCA dosing for Fentanyl?

A
  • Dose: 1-2 mcg/kg IV
  • Onset: 2-3 min
  • DOA: 45 min
  • PCA dose: 50 mcg/kg q10 min

Short-acting, no active metabolites, potent respiratory depressant for mother, minimal sedation and nausea.

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9
Q

What is the dose, onset, DOA, and PCA dosing for Butorphanol?

A
  • Dose: 1-2 mg IV
  • Onset: 5 min
  • DOA: 2-3 hr
  • PCA: N/A

Sedating for mother, ceiling effect for both analgesia and respiratory depression, dysphoric reactions, or withdrawal symptoms in opioid-dependent patients can occur.

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10
Q

What is the dose, onset, DOA, and PCA dosing for Nalbuphine?

A
  • Dose: 10 mg IV
  • Onset: 5 min
  • DOA: 2-3 hr

similar profile to butorphanol

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11
Q

What are some nonpharmacologic alternatives for labor pain relief?

A
  • Hydrotherapy.
  • Hypnotherapy.
  • Massage.
  • Movement.
  • Positioning.
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12
Q

What influences maternal satisfaction during childbirth more than the degree of pain endured?

A

Whether the birth event met the mother’s expectations.

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13
Q

What is the role of an obstetric anesthesia provider in supporting laboring women?

A
  • To help women make informed choices that meet their expectations.
  • Ensuring the safety of both mother and infant.
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14
Q

What is considered the best method of pain relief for labor and delivery?

A

Neuraxial analgesia.

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15
Q

What are common types of neuraxial anesthetics?

A
  • Epidural.
  • Combined spinal-epidural (CSE).
  • Spinal techniques.
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16
Q

What defines labor as a prerequisite for neuraxial analgesia?

A

Regular uterine contractions result in cervical dilation and effacement.

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17
Q

When should early initiation of neuraxial anesthesia be considered?

A
  • For parturients at increased risk of anesthetic or obstetric complications.
  • Examples: morbid obesity, severe scoliosis, and known difficult airway.
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18
Q

What are the obstetric indications for early placement of neuraxial anesthesia?

A
  • Multiple gestation pregnancies.
  • Severe preeclampsia.
  • Allows better positioning cooperation and time to confirm block function.
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19
Q

What are the absolute contraindications of neuraxial anesthesia?

A
  • Patient refusal.
  • Inability to cooperate.
  • Uncorrected severe hypovolemia.
  • Uncorrected coagulopathy or pharmacologic anticoagulation.
  • Elevated intracranial pressure due to a mass.
  • Infection at the insertion site.
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20
Q

What are some relative contraindications to neuraxial anesthesia?

A
  • Stable preexisting CNS disease.
  • Chronic severe headaches or back pain.
  • Untreated bacteremia.
  • Severe stenotic valvular lesions.
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21
Q

What should be considered for patients with preexisting conditions before neuraxial anesthesia?

A
  • Careful pre-anesthetic evaluation and consultation.
  • Assessing risks and benefits of the procedure.
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22
Q

Can patients with preexisting conditions safely receive neuraxial anesthesia?

A

Yes, with proper recognition and optimization of these conditions.

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23
Q
A
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24
Q

What technique is essential during the insertion of neuraxial anesthetics?

A

Strict aseptic technique.

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25
What antiseptic should be considered the choice for neuraxial anesthetic placement?
Chlorhexidine gluconate in an alcohol-based solution.
26
What is often the easiest position for a laboring parturient during neuraxial anesthetic placement?
* Sitting position. | Offers maximum interspace width.
27
What advantage does the lateral position offer during neuraxial anesthetic placement?
Reduces the incidence of intravascular catheter placement.
28
What is the patient's position for Epidural anesthesia?
- sitting up - Laying down (sideways)
29
What are the characteristics of epidural analgesia for labor?
* Popular, safe, and effective. * Provides labor analgesia.
30
What advantage does the use of an indwelling epidural catheter provide?
* Ability to produce a segmental block of varying density. * It can be adapted to the patient's changing requirements.
31
At which interspaces is an epidural for labor analgesia optimally inserted?
* L2-L3 or L3-L4 interspace. * To block the T10-L1 dermatomes for first-stage labor analgesia.
32
What is required for analgesia in the second stage of labor and subsequent repair?
* Extension of the block to include the S2-S4 dermatomes. * Innervates the perineum and vagina.
33
Why is the high cephalic spread of a neuraxial block a concern in obstetrics?
* One of the most common causes of anesthesia-related maternal mortality.
34
What is the purpose of a test dose in epidural analgesia?
* To identify epidural catheters inadvertently inserted into the subarachnoid space or an epidural vein. * Aspiration for blood or CSF is essential after catheter placement and before each dose.
35
What is a commonly used test dose for epidural analgesia?
3 mL of lidocaine 1.5% with epinephrine 1:200,000.
36
What are the effects of the lidocaine test dose if administered in the subarachnoid space?
* Produces a noticeable but manageable spinal anesthetic within 3 to 5 minutes. * There is no appreciable effect in the epidural space.
37
What are the effects of lidocaine if administered intravascularly?
* Early signs of modest systemic toxicity (e.g., circumoral numbness, lightheadedness, auditory changes). * Includes 15 mcg of epinephrine, increasing HR if given intravascularly in nonpregnant patients.
38
What is the drawback of maintaining epidural analgesia with intermittent bolus administration?
* Alternating periods of analgesia and pain. * Frequent provider interventions.
39
What are common infusions used to maintain epidural analgesia?
* **Bupivacaine** (0.0625%–0.125%) or * **Ropivacaine** (0.1%-0.2%) * **With fentanyl** (1–3 mcg/mL) or **sufentanil** (0.3–0.5 mcg/mL). * Infusion rates of 8 to 12 mL/hour.
40
When should the epidural infusion be maintained during labor?
* Through the transition to second-stage labor. * Provided block is stable, effective, and preserves adequate motor function.
41
What is Patient-Controlled Epidural Analgesia (PCEA) and its advantages?
* Allows parturients to self-administer bolus doses as needed. * Reduces unscheduled interventions, total drug dose, and lower extremity motor block. * Effective analgesia without sacrificing quality.
42
What is the perceived advantage of the Combined Spinal-Epidural (CSE) technique?
Provides superior analgesia for labor and vaginal delivery.
43
How does CSE combine the attributes of spinal and epidural techniques?
* **Spinal component**: Effective, rapid-onset analgesia. * **Epidural catheter**: Prolongs analgesia and allows conversion to surgical level if needed.
44
What methods are used for performing CSE?
* **Early technique**: Spinal needle insertion/removal followed by epidural insertion. * **Needle-through-needle technique**: Spinal needle through the epidural needle.
45
How is the spinal component of a CSE dosed?
* With a lipid-soluble narcotic alone or in combination with isobaric bupivacaine. * Common for early first-stage labor: Fentanyl (15–25 mcg) or sufentanil (10 mcg).
46
What percentage of deliveries are by cesarean in the United States?
* Over 30% of all deliveries.
47
What are the indications of Cesarean Delivery in the United States?
* Cephalopelvic disproportion. * Nonreassuring fetal status, arrest of dilation. * Malpresentation. * Prematurity, prior cesarean, prior uterine surgery.
48
What factors influence the choice of anesthesia for cesarean delivery?
* Maternal status. * Urgency of surgery. * Condition of the fetus. * Patient's desires.
49
What are the advantages of neuraxial anesthesia for cesarean delivery?
* Decreased risk of mortality (failed intubation, aspiration). * Better neonatal outcomes (less depressant agents). * Mother can be awake for delivery.
50
What is the typical range of blood loss during cesarean delivery?
Between 500 and 1000 mL.
51
Why is the visual estimation of blood loss during cesarean delivery often inaccurate?
* Complicated by large volumes of amniotic fluid and variably saturated sponges. * Normal amniotic fluid volume: 300–1400 mL (average ~700 mL).
52
What are the advantages of single-shot spinal anesthesia for cesarean delivery?
* Rapid onset of action. * Denser block. * Requires less local anesthetic compared to epidural anesthesia.
53
What dermatome level is required for effective anesthesia in cesarean delivery, and what are its potential effects?
* T4 level. * It can cause profound sympathectomy, leading to maternal hypotension and potential fetal compromise.
54
What measures are commonly used to minimize hypotension during spinal anesthesia for cesarean delivery?
* Left uterine displacement. * Intravenous (IV) fluid administration. * Vasopressor use.
55
What is the effective dose of hyperbaric bupivacaine for spinal anesthesia in cesarean delivery, and how long does it provide surgical anesthesia?
* 0.75% 13 mg (ED95). * Provides 90 to 120 minutes of surgical anesthesia.
56
What vasopressors are commonly used to treat maternal hypotension during spinal anesthesia?
* Ephedrine. * Phenylephrine.
57
How are opioids used in conjunction with hyperbaric bupivacaine for spinal anesthesia in cesarean delivery?
* Added to provide intraoperative and postoperative analgesia. * Do not affect block height. * Examples: Fentanyl (10–20 mcg) or Sufentanil (2.5–5 mcg).
58
When should oxytocin be administered during cesarean delivery under spinal anesthesia?
After the delivery of the placenta, as directed by the obstetrician.
59
What are alternative methods for postoperative analgesia in cesarean delivery if intrathecal morphine is not an option?
* Transversus abdominis plane blocks. * Quadratus lumborum blocks. * Used when neuraxial anesthesia is contraindicated or for patients under general anesthesia.
60
What are the spinal bolus, Epidural bolus, and Epidural continuous infusion doses for BUPIVACAINE?
* Spinal Bolus: 1.25- 2.5 mg * Epidural Bolus: 0.0625-0.125% * Epidural Continuous: 0.05-0.125%
61
What are the spinal bolus, epidural bolus, and continuous epidural infusion doses for ROPIVACAINE?
* Spinal Bolus: 2-3.5 mg * Epidural Bolus: 0.08-0.2% * Epidural Continuous: 0.08-0.2 %
62
What are the spinal bolus, epidural bolus, and continuous epidural infusion doses for FENTANYL?
* Spinal bolus: 15-25 mcg * Epidural bolus: 50-100 mcg * Epidural continuous: 1.5-3 mcg/mL
63
64
Converting Epidural Anesthesia to Cesarian Anesthetic
65
What are the common complications of regional anesthesia?
* Hypotension. * Nausea and vomiting. * Postdural puncture headache. * Local anesthetic systemic toxicity. * Accidental subdural injection. * Total spinal block. * Neurologic injuries.
66
What causes total spinal anesthesia?
* Excessive cephalic spread of local anesthetic in subarachnoid or epidural space. * Inadvertent large epidural dose into subarachnoid space. * Epidural catheter migration into subarachnoid space.
67
What are the early signs of a total spinal block?
* Rapid onset. * Dyspnea. * Difficult phonation. * Hypotension.
68
What cardiovascular effect can a total spinal block have?
* Bradycardia * From blockade of sympathetic innervation to the heart (T1-T4 segment).
69
What is the initial treatment for total spinal block?
* Vasopressors. * IV fluids. * Left uterine displacement. * Leg elevation. * Prepare for intubation if consciousness is lost or airway protection is compromised.
70
What conditions should be considered in the differential diagnosis of total spinal block?
* Anaphylactic shock. * Eclampsia. * Amniotic fluid embolism.
71
Dermatomes
72
In what situations might general anesthesia be indicated for cesarean delivery despite its disadvantages?
* Better airway control and hemodynamic stability. * Useful in hypovolemic shock or maternal cardiac disease. * Urgent surgical delivery precluding neuraxial anesthetic placement. * Patient refusal or coagulopathy present. * As an alternative in failed neuraxial technique cases.
73
Why has the use of neuraxial techniques become more prevalent than general anesthesia for cesarean delivery?
To reduce maternal mortality from airway complications.

Special Population-RCM (8 decks)

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