Obstetric Patient Part 2 Flashcards
The following factors influence a woman’s decision regarding labor & delivery analgesia
natural childbirth training
anxiety about neuraxial analgesia
desire for medication-free delivery
Absence of pain does not guaratee
a satisfying experience
The best analgesic technique is one that allows a woman
to “cope” with pain
In addition to reducing pain & anxiety, a good analgesic
reduces maternal hyperventilation which can cause reduced fetal oxygen tension
limit increases in maternal CO, hypertension, and catecholamine release*
Choice of analgesic may include
simple analgesic techniques
non-pharmacologic
pharmacologic
neuraxial
Simple analgesic techniques include
support breathing and relaxation touch and massage music hydrotherapy acupuncture hypnosis aromatherapy
Non-pharmacologic techniques for analgesic include
TENS
sterile water blocks
*the gate theory)
Pharmacologic techniques for analgesia include
systemic medications
inhalational agents
Advantages of systemic medications relate to
patient acceptability and ease of administration
Nearly all _______ readily cross the placenta
opioid analgesics & sedatives
Concerns over _____ limits its use to early labor or when regional anesthesia is not available or contraindicated
fetal depression
Systemic medications given to parturient may include
fentanyl morphine butorphanol & nalbuphine ketamine (have to give with versed) remifentanil (not a great option)
Inhalational agents used for analgesia include
nitrous oxide
halogenated agents
The gold standard in achieving analgesia for laboring women is
neuraxial techniques
Patient considerations for neuraxial techniques include
H&P- allergies, airway assessment, coagulation studies, preexisting and/or pregnancy related
informed consent- emancipation
contraindications
Studies show epidural labor analgesia may prolong
second stage labor
can affect the incidence of forceps delivery
is NOT associated with increased rates of cesarean section
Epidural dosing goal is
T10-L1 dermatome level
Epidural management of maintaining analgesia includes
intermittent boluses
continuous infusion
PCEA
programmed intermittent boluses
A single shot spinal can be performed or reserve for
multiparous patients in advanced second stage
those with poor pain control to facilitate epidural placement
mother laboring without analgesia requiring an instrumented delivery
A continuous spinal anesthetic can be indicated for
morbid obesity
history of previous spinal surgery
inadvertent dural puncture
Dosing of continuous spinal is
.5-1.0 mL of 0.25% isobaric bupivacaine
Side effects of neuraxial opioids include
respiratory depression
itching
urinary retention
nausea & vomiting
Cesarean section now accounts for
nearly 30% of all deliveries
Common indications for cesarean section icnlude
cephalopelvic disproportion non-reassuring fetal status arrest of dilation malpresentation prematurity previous caesarean section or uterine surgery
The choice of anesthesia for cesarean section depends on
maternal status
urgency of surgery
fetal condition
patient’s desires
Anesthesia for cesarean section may include
neuraxial anesthesia (preferred choice) general anesthesia
The advantages of neuraxial anesthesia over general anesthesia for cesarean section includes
decreased risk of mortality due to failed intubation
decreased risk of aspiration of gastric contents
better neonatal outcomes
ability of mother to participate in the birth
Regardless of technique, ______ is essential
left uterine displacement
To provide adequate anesthesia for C-section using spinal/epidural, _____ dermatome level must be achieved.
T4-6
Preoperatively before C-section, patients should receive
aspiration prophylaxis
antibiotic administration
standard monitoring
nasal oxygen
Single-shot spinal is the most common anesthetic technique for C-section because
simple to perform
rapid onset
reliable block
less toxic
The LA of choice for a spinal for C section is
0.75% hyperbaric bupivacaine
13 mg with a duration of 90-120 minutes
fentanyl & duramorph for analgesia
The dermatome level of a spinal is determined primarily by
spine curvature
80% of patients who receive a spinal develop hypotension. If untreated we will see
N/V
decreased level of consciousness
uteroplacental hypoperfusion
CV collapse
Treatment of hypotension for a spinal may include
pre-load vs. co-load
crystalloid & HES vs. crystalloid alone
ephedrine vs. phenylephrine
Disadvantages of a spinal include
fixed duration of action
hypotension
An epidural is not a first-choice option for elective C-section because of
slow onset & higher dose of LA required to achieve surgical level
Advantages of epidural anesthesia include
less abrupt BP changes
ability to re-dose catheter
_________ is required to achieve T4-6 level with an epidural
10-15 mL (only 5 cc given at a time)
A labor patient who requires multiple doses for breakthrough pain is a significant predictor for
subsequent failure for surgical anesthesia
If an insitu catheter is deemed not reliable:
early recognition
replace (CSE)
single-shot spinal
general anesthetic
Advantages of CSE include
lower spinal dose can be used
ability to augment with epidural catheter
Disadvantages of CSE include
potential lower block height
delay the start of surgery
Indications for general anesthesia for C-section include
neuraxial not in place, urgent delivery required
patient refusal of neuraxial
coagulopathy
______ is common in obstetric patients
difficult airway
- airway changes as labor progresses
- rapid desaturation following induction
Induction should not begin until
patient is prepped and draped
-sufficient de-nitrogenation and pre-oxygenation
Induction includes
rapid sequence induction with cricoid pressure
propofol vs. etomidate vs. ketamine
succinylcholine vs. rocuronium
Maintenance practices for obstetric patients includes
nitrous oxide & oxygen
avoid hyperventilation
MAC less than 1.0
_______ blocks can be placed postoperatively in patients who have not received neuraxial anesthesia or intrathecal morphine.
Transversus abdominus plane blocks
TAP blocks target sensory nerves
T5-11
does not provide visceral pain relief
Obstetric complications include
postpartum hemorrhage preeclampsia- HELLP obesity amniotic fluid embolus prematurity abnormal placental implantation- placenta previa, placenta accrete, placenta abruption
