Operative Delivery Part 1 (in order)

Question 1

What is Macrosomia?

Answer 1

Fetus/Newborn w/ excessive birth weight

Question 2

What is TOLAC?

Answer 2

Trial of Labor after Cesarean

Question 3

What is VBAC?

Answer 3

Vaginal Birth after Cesarean

Question 4

What is PPH?

Answer 4

Post-partum Hemorrhage

Question 5

What is SAB?

Answer 5

Spontaneous Abortion

Or subarachnoid block.

Question 6

What are two types of operative vaginal delivery? How common is operative vaginal delivery?

Answer 6

Forceps or vacuum assisted delivery
-less use today partly d/t legal concerns

Question 7

What are indicators for operative vaginal delivery?

Answer 7

• non-reassuring FHR
• Maternal exhaustion
• Arrested Descent

Question 8

If a denser sensory block is necessary for operative vaginal delivery, what medications can be used?

Answer 8

Epidural:
- Lidocaine 2% 5-10 mL
- 2-Chloroprocaine 2-3% 5-10 mL

Question 9

What is the most common majory surgery in the USA? What is the national delivery rate via C section?

Answer 9

C-section
~30%

Question 10

How does maternal mortality rate of c-section compare to vaginal delivery.

Answer 10

c section mortality is 10x greater than vaginal delivery

Question 11

What are anesthesia complications that can contribute to the increased mortality seen with C-section?

Answer 11

• Pulmonary aspiration
• failed intubation r/t Edematous/friable airways
• Inadequate ventilation when requiring GETA

Question 12

What factors contribute to increased c-section rate?

Answer 12

• ↑ maternal age (delayed childbirth)
• Obesity
• Fetal macrosomia
• ↑ labor inductions
• ↓ TOLAC attempts
• Fewer instrumented vaginal deliveries
• ↑ electronic FHR monitoring
• concern for malpractice litigation

Question 13

What are the statute of limitations for OB litigation?

Answer 13

18 years

Question 14

What are the maternal indications for c-section?

Answer 14

Question 15

What are the fetal indications for c-section?

Answer 15

Question 16

What factors determine the anesthesia plan for unscheduled c-section?

Answer 16

Question 17

What is the anesthetic plan for emergency c-section?

Answer 17

GETA with RSI
-secure airway and immediately let surgeon know when ready

Question 18

Describe the four grades of c-section?

Answer 18

Question 19

What type of skin incision is used for emergencies? Why is this the preferred method?

Answer 19

Low Vertical/Midline incisions
Umbilical to pubic symphysis
-allows for rapid access

Question 20

Low vertical/midline skin incision puts the patient at increased risk for what issue?

Answer 20

↑ risk for umbilical hernias

Question 21

What are the three different types of uterine incisions?

Answer 21

• Low Transverse (best if possible)
• Low Vertical/Midline
• Classical (highest risk)

Question 22

What type of uterine incision will make future TOLAC attempts impossible? What are some other drawbacks to this approach?

Answer 22

Classical incision
-increases risk of uterine abdominal adhesions
-Uterine rupture risk is ~10%

Question 23

What are the benefits of Low Transverse Incision?

Answer 23

-less risk of bladder injury
-low risk of uterine rupture (in future pregnancies)
-TOLAC possible in future pregnancies

Question 24

Describe the low vertical uterine incision?

Answer 24

Lower uterine segment incision.
-may be extended if needed
-low risk of uterine rupture
but higher risk than low transverse incision

Question 25

Why does GETA potentiate blood loss?

Answer 25

Due to GETA **vasodilation**.

Question 26

What is the most common c-section complication?

Answer 26

Hemorrhage *Usually due to uterine atony*.

Question 27

What are the Four T's of hemorrhage? Which of these is easiest for anesthesia to fix?

Answer 27

Tone Trauma Tissue (retained products) Thrombin (coag status) **Uterine tone is easiest to fix**

Question 28

What are the maternal hemorrhage interventions?

Answer 28

Question 29

Who is at risk for uterine atony?

Answer 29

Every maternal patient is at risk for uterine atony -This is why every patient receives Pitocin

Question 30

What medications are given if Pitocin is ineffective? What are the contraindications for these medications?

Answer 30

IM: Methergine ↳CI with Preeclampsia/HTN d/t alpha adrenergic stimulation IM: Hemabate (a prostaglandin) ↳CI in asthma patients d/t prostaglandin

Question 31

Maternal hemorrhage primarily occurs after delivery. What may hemorrhage before delivery indicate?

Answer 31

May Indicate: Uterine rupture Placental abruption (placenta separating from uterine wall)

Question 32

What are possible OB interventions for Maternal Hemorrhage?

Answer 32

Bakri balloon Compression/B Lynch Suture Uterine artery ligation Hysterectomy (last resort)

Question 33

What complications (other than hemorrhage) can happen in c-sections?

Answer 33

- Wound Infection - Uterine/uterocervical lacerations - Bladder dissections - Fetal laceration - Hysterectomy

Question 34

What is the terminology for abnormal placental invasion of surrounding tissues?

Answer 34

Accreta → Increta → Percreta

Question 35

How does placental invasion of uterine wall affect anesthesia plan?

Answer 35

Placenta accreta/increta/percreta -all require GETA -all hands on deck -blood products/rapid transfuser on standby

Question 36

_______ ______ is when the placenta develops in such a way that it blocks the baby's ability to exit out of the cervix & vagina.

Answer 36

Placenta Previa

Question 37

Why is a fetus descending through a birth canal dangerous with placenta previa?

Answer 37

Increased risk of bleeding.

Question 38

What are the methods to prevent unplanned cesarean delivery?

Answer 38

Question 39

What is external cephalic version?

Answer 39

Manual external turning of fetus that is in breech/transverse position to head down position

Question 40

What is the goal of external cephalic version?

Answer 40

-Turning baby to head down position - used to enhance chance of successful vag delivery - helps prevent need to convert to c-section

Question 41

What is the preferred anesthetic technique for a c-section?

Answer 41

Neuraxial Anesthesia -safest for mother and baby

Question 42

What are the components of the preoperative anesthesia interview?

Answer 42

Question 43

For high risk c sections it is important to have the following?

Answer 43

Blood available 2 good IV's

Question 44

For high risk c-section patients with antibodies found on type and screen you must do what?

Answer 44

Get crossmatch ASAP -may take a long time to identify a match - want blood available before procedure

Question 45

Previous c-sections indicates an increased risk of ______.

Answer 45

bleeding -risk increases with each c/s

Question 46

What are some talking points when discussing neuraxial anesthesia with a patient?

Answer 46

Question 47

When addressing patient concerns what are some topics to cover?

Answer 47

Question 48

What are some interventions that can assist with skin to skin

Answer 48

-Placing EKG leads on back -Pulse ox off if patient stable

Question 49

What sensations are normal even with a spinal anesthetic?

Answer 49

pushing, pulling, tugging, & pressure

Question 50

Which two drugs need to be stocked and ready to go in the OB operating room?

Answer 50

Propofol & Succinylcholine *Be ready to RSI*.

Question 51

What three medications are given to prevent aspiration pneumonitis in parturients?

Answer 51

- Famotidine 20mg IV - Metoclopramide 10mg IV - Na⁺ Citrate (Bicitra) 30mLs PO

Question 52

What type of drug is famotidine?

Answer 52

H2 receptor antagonist that decreases gastric acid production.

Question 53

What is the onset & peak of famotidine?

Answer 53

Onset: 30 min Peak: 60 - 90 min

Question 54

How does metoclopramide work?

Answer 54

- ↓ stomach volume via increased motility. - increased LES tone - ↓ N/V Dopamine D2 antagonist

Question 55

When should metoclopramide be administered?

Answer 55

15-30 min prior to anesthesia start

Question 56

What type of drug is Bicitra?

Answer 56

Non-particulate antacid that decreases gastric acidity to > 6pH

Question 57

When should Bicitra be administered?

Answer 57

20-30 min before going to the OR.

Question 58

What antibiotic given to parturients should be administered slowly due to risk of N/V?

Answer 58

Azithromyicin

Question 59

What things/factors put a parturient at risk for higher blood loss?

Answer 59

- GETA - Abnormal placenta - Unscheduled C-section after attempted vaginal - Multiparous - Multiple past c-sections

Question 60

What monitoring equipment is necessary before spinal placement?

Answer 60

At minimum: - FHT - Mom's BP - Pulse oximetry

Question 61

Why is versed "discouraged" but not contraindicated?

Answer 61

- readily crosses placenta - Amnesia - interferes with bonding

Question 62

What are two interventions that can help with highly anxious patients?

Answer 62

Versed (not preferred) -may help in patients that are not tolerating remaining awake Oxygen -may help patient anxiety when chest heaviness sets in.

Question 63

What is the efficacy of oxygen during c-section?

Answer 63

Question 64

What are the advantages of neuraxial anesthesia for c-section?

Answer 64

Mother remains awake Earlier mother/baby bonding Support person in room -not allowed in room for GA Opioid use (postpartum pain relief)

Question 65

What is an ideal spinal dose of morphine?

Answer 65

100 - 150mcg

Question 66

What is an ideal spinal dose of Fentanyl?

Answer 66

5 - 10mcg

Question 67

What is an ideal dose of morphine to be added to a pre-existing epidural after delivery? What are the pros and cons of this?

Answer 67

3mg Pros: up to 24 hour pain relief Cons: high incidence of itching

Question 68

What are some disadvantages of neuraxial anesthesia for C-section?

Answer 68

- N/V - C3-C5 stimulated by cold irrigation - Shoulder pain/chest pressure -pulling/tugging can cause discomfort/anxiety

Question 69

What causes referred shoulder/chest pain during a c-section?

Answer 69

Uterus being pulled out

Question 70

How are C3-C5 nerves stimulated during a c-section?

Answer 70

Cold/cool irrigation can stimulate the under surface of diaphragm. -This can cause nausea and pain

Question 71

What reflex can lead to HoTN with neuraxial anesthesia?

Answer 71

Bezold Jarisch Reflex -↓ LV stretch d/t sympathectomy (↓ preload) -l/t ↓ HR to increase filling time → HoTN

Question 72

What are the Bezold-Jarisch Reflex triad of symptoms?

Answer 72

- Vasodilation - Hypotension - Bradycardia

Question 73

What causes the Bezold-Jarisch reflex?

Answer 73

Mechanoreceptors sensing a hyperdynamic LV w/ low preload.

Question 74

Which drug can be administered to prevent the bezold-jarisch reflex associated with a spinal block?

Answer 74

Ondansetron 4mg *Antagonizes 5HT-3 receptors & prevents activation of BJR*.

Question 75

What position should a patient be in after a spinal block?

Answer 75

Slight (10°) head up *Bed can also be tilted left for slight LUD*.