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AP Summer > Obstetrics: Part 1 > Flashcards

Obstetrics: Part 1 Flashcards

1
Q

Why is conflict of interest possible only in this patient population?

A

Maternal fetal interest can be contrary

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2
Q

By standard of our profession whose needs come first (mother or child)?

A

Mother

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3
Q

Define gravida

A

Number of times the patient has been pregnant

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4
Q

Define parity

A

Number of babies born to patient

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5
Q

Explain the number system for describing parity

A

First number: full-term births
Second number: preterm births
Third number: losses
Fourth number: living children

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6
Q

Define gestational age

A

How far along the fetus is in development

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7
Q

At what point in gestation is the fetus considered full-term?

A

38 weeks

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8
Q

What is effacement?

A

Description of how thick or thin the uterine walls are. (100% is really thin)

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9
Q

The cervical exam for the obstetric patient consists of what three components?

A

Dilation
Effacement
Fetal descent (station)

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10
Q

What EKG changes can be noted at term in the obstetric patient?

A

Left axis deviation due to displacement of diaphragm by uterus

Increased risk for arrhythmias

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11
Q

What is aortocaval compression?

A

Also known as supine hypotension syndrome

-Hypotension associated with pallor, sweating, or nausea and vomiting

20% of women

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12
Q

What is the most common cause of anesthesia related mortality in this population?

A

Loss of airway

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13
Q

What are some physiologic changes that affect the ecstatic patient’s airway status?

A 
Capillary engorgement of the mucosa
Increased risk of epistaxis 
Can continually worsen over hours
Edema (esp with PIH)
Difficulty positioning
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14
Q

What are some gastrointestinal changes seen in the obstetric patient?

A

Delayed emptying
Decreased pH
Incompetent gastroesophageal sphincter

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15
Q

How do the pregnant patients G.I. changes effect the anesthetic plan?

A

ALWAYS a full stomach
-given sodium citrate

If General, cuffed tube, RSI, premeds

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16
Q

What sort of hematologic changes are seen in pregnant women?

A 
Increased total blood volume
Dilutional anemia 
Decreased platelet count
Increased coagulation factors 
Elevated D-dimer

Hypercoagulable

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17
Q

At what point during gestation is there a change in MAC requirements?

A

Decrease in MAC by 8-12 weeks

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18
Q

Historically and worldwide, what is the number one cause of Pregnancy related mortality?

A

Dr. Hall says Murder

Dr. Forkner says hemorrhage (I’d go with that)

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19
Q

In the United States, what is the number one cause of Pregnancy related mortality?

A

Cardiovascular disease

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20
Q

What are some possible explanations for the rising maternal mortality rate in the United States?

A

Rising numbers of the Cesarean sections

Rising number of patients with advanced maternal age and comorbidities

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21
Q

What is the safest and most effective medical intervention for labor pain?

A

Lumbar epidural

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22
Q

What are some things that tend to worsen labor pain?

A

OP Delivery (Occiput Posterior)-face up
Use of Oxytocin
Use of forceps

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23
Q

What are some alternative methods for pain relief during labor?

A

Hypnosis
Lamaze breathing
Acupuncture
Biofeedback

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24
Q

Why are intravenous opioids not the first choice for analgesia in the pregnant patient?

A

Higher risk for baby and mother

Not as effective as epidurals

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25
Q

The uterus and cervix are innervated from which levels?

A

T10-L1

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26
Q

Optimal analgesia for labor requires neural blockade at what levels in the first stage of labor? second stage?

A

1st Stage: T10 - L1

2nd Stage: T10 - S4

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27
Q

When does the spinal cord and 60% of patients?

A

L1

28
Q

List some contraindication to neuraxial blockade

A 
Patient refusal
Coagulopathy
Infection @ site
Presence of foreign bodies
Spinal cord pathologies
Thrombocytopenia
Untreated bacteremia or viremia
Complete dilation of cervix, 2nd stage labor
29
Q

What is given before or during placement of an epidural to help prevent hypotension?

A

Fluid bolus

30
Q

What is an acceptable platelet count for administering an epidural?

A

70-100,000

31
Q

Why is platelet count important to know before doing an epidural?

A

Low platelet count = Increased risk for epidural hematoma

32
Q

What must be monitored when placing an epidural?

A

Blood pressure every five minutes

Pulse ox

33
Q

How are the Spinal cord ligaments different in a pregnant patient?

A

Softer

34
Q

Regional anesthesia for Cesarean section requires what sensory level blockade?

A

T4

35
Q

What is a classic test dose for an epidural and what will it tell you?

A

3mL = Lidocaine 1.5% (45mg) w/ 1:200000 epi

-Will tell you if catheter is intrathecal or intravascular

36
Q

A positive test dose when placing an epidural will present with what symptoms if it is intrathecal? Intravascular?

A

Intrathecal: Immediate spinal block, numbness, difficulty moving legs

Intravascular: Increased HR, ringing in ears, numbness and tingling around mouth, metallic taste

37
Q

What is true of epidural dosing?

A

Always incremental
Usually 3 or 5 mL boluses
Will see pain reduced on patient’s face before patient endorses reduced pain

38
Q

1st Stage labor pain is what kind of pain?

A

Visceral, not localized

39
Q

The sensations of pain, touch, temperature and motor function are blocked in what order?

A
  1. Pain / temperature
  2. Touch
  3. Motor
40
Q

What are the risks and benefits of combined spinal epidural (CSE)?

A

Benefits: near immediate pain relief, confirmation of epidural space

Risks: slight increase in risk of spinal headache, paresthesia possible

41
Q

What is the risk of a subdural catheter?

A

Cannot be placed intentionally

Risk = Potential for arachnoid rupture and intrathecal exposure to epidural medication

42
Q

List some possible risks of epidural placement

A 
Inadvertent dural puncture
Hypotension
Failed block
Intravascular or intrathecal injection
Nerve injury
Prolongation of 2nd stage labor
Epidural hematoma
Infection
43
Q

What is the Ferguson reflex?

A

Urge to push

44
Q

What is an inadvertent dural puncture?

A

“Wet tap”

-Epidural needle punctures the Dura and CSF comes through

45
Q

What are the two options in the event of a wet tap?

A

A) Remove needle and place epidural at an adjacent level

B) Insert catheter into intrathecal space

46
Q

What are the benefits and risks of a spinal catheter?

A

Benefits: no risk of further wet tap, reduced risk of headache, reliable, strong block

Risks: high spinal

47
Q

What is the most common indication for a C-section?

A

Arrest of dilation

48
Q

What are some indications for C-section

A 
Arrested dilation
Nonreassuring fetal heart rate
Cephalopelvic disproportion
Prior C-section
Malpresentation
Prior surgery involving the uterine corpus
Arrest of descent

Uterine cord prolapse, placental abruption, placenta previa (rarer)

49
Q

What is a normal fetal heart rate?

A

110 - 160 BPM

50
Q

When monitoring fetal heart rate, the tracing is evaluated for what?

A

Decelerations (in relation to contractions)
Accelerations (related to fetal movement)
Variability (fine and coarse)

51
Q

Early decelerations in fetal heart rate tracings are associated with what?

A

Head compression as fetus moves toward delivery

52
Q

Very well decelerations can be associated with what?

A

Umbilical cord prolapse

53
Q

Late decelerations are suggestive of what?

A

Fetal asphyxia following contractions, such that contractions are cutting off fetal blood supply

54
Q

Why are fetal heart rate decelerations important?

A

One of the only measurable fetal responses to stress

55
Q

What type of anesthetic is preferred for a C-section and why?

A

Neuraxial preferred

For General:
Mortality rate 17x greater
Increased pain 
Fetal transfer of induction drugs
Risk of losing the mother's airway
56
Q

What are some advantages and disadvantages of spinal anesthesia?

A

Advantages: better block, smaller needle, confirmation of placement

Disadvantages: procedure must finish before dose wears off, hypotension risk, not for MS patients

57
Q

How can you create a denser epidural block?

A

Add narcotics

58
Q

What is the first sign of hypotension?

A

Nausea and vomiting

59
Q

What is the first drug given after the baby is born and the cord is clamped?

A

Pitocin (oxytocin)

20-40U in 1L bag

60
Q

In the event of neonatal distress, what is the first priority?

A

The mother. Once she is stable the provider may assist with the neonate

61
Q

Why is a stat C-section called?

A

Emergency C-section necessary to save life of the mother or fetus

62
Q

What is the most important element of a stat C-section?

A

Time

Speed is Key

63
Q

Is a stat C-section is performed under general anesthesia, what must be done to the patient prior to induction?

A

Prepped and draped so if induction goes badly fetus can be section and saved

64
Q

What are some important considerations for general anesthesia for a stat C-section?

A

Always RSI
Limit opioids and volatile anesthetics until baby is out
Surgery starts when tube placement confirmed

65
Q

At what point during a C-section do you consider redosing the epidural catheter?

A

1-1.5 hrs

66
Q

If single shot spinal is wearing off, or there is a “hotspot” what other drug is often given to provide analgesia?

A

Ketamine

-be prepared for hallucinations

AP Summer (24 decks)

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