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OB Test 2 > Pain Pathways > Flashcards

Pain Pathways Flashcards

1
Q

What is the first stage of labor?

A

0-10 cm dilation of the cervix

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2
Q

What causes pain in the first stage of labor?

A

Distention of the lower uterine segment, upper vagina, and dilation of the cervix

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3
Q

What nerve fibers transmit pain in stage 1 of labor?

A

Visceral afferent C fibers that accompany the sympathetic nerves (join the sympathetic chain at L2-L3) and enter the spinal cord at the T10 - L1 segments

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4
Q

What is the second stage of labor?

A

Full cervical dilation through the delivery of the fetus

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5
Q

What causes pain during the second stage of labor?

A

Distention of pelvic floor, vagina and perineum

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6
Q

What never fibers transmit pain in the second stage of labor?

A

Somatic nerve fbers which enter the spinal cord at S2-S4 segments through the pudendal nerve
-afferent nerve fibers

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7
Q

Which nerve root contains afferent nerve fibers?

A

Dorsal nerve root

AKA posterior nerve root

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8
Q

When is a pudendal nerve block performed?

A

Immediately before delivery

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9
Q

What type of delivery can pudendal block be used for?

A

Spontaneous vaginal delivery and low/outlet forceps delivery

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10
Q

What is the success rate of a pudendal block?

A

50%

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11
Q

What is a pudendal block NOT adequate for?

A

Mid forceps delivery
Post partum exam/manual exploration of the uterine cavity
Repair of upper vagina and cervix

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12
Q

What type of failure can occur with a pudendal block?

A

Unilateral or bilateral failure

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13
Q

Can a pudendal block prolong labor? If so, what stage?

A

It can prolong the second stage of labor

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14
Q

Where does a paracervical nerve block block transmission?

A

Blocks transmission through the paracervical ganglion

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15
Q

What is another name for the paracervical ganglion?

A

Frankenhausers ganglion (uterovaginal plexus)

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16
Q

Does a paracervical block prolong labor? If so, what stage?

A

No

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17
Q

During the first stage of labor how well does a paracervical block work? Second stage?

A

Satisfactory analgesia during the first stage of labor in 50-75% of parturients.
Does not help with second stage

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18
Q

Why is the paracervical block only used in 2-3% of vaginal delveries in the U.S?

A

Fear of fetal bradycardia, the most common fetal compliation

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19
Q

If fetal bradycardia lasts how long, would you most likely change to a stat c-section?

A

> 10 minutes

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20
Q

Where is the paracervical block performed?

A

At the lateral vaginal fornix at about 4 and 8 o’clock

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21
Q

SNS stimulation produced by pain results in higher levels of what in the plasma of mom?

A

Catecholamines

-especially epinephrine

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22
Q

What effect does this increased catecholamines have in the mom, and baby?

A

It increases CO and peripheral vascular resistance, and decreases uteroplacental blood flow

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23
Q

What effect does neuraxial analgesia have on maternal catecholamine concentration?

A

In reduces concentration by 50%

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24
Q

Does neuraxial analgesia also reduce fetal catecholamine concentrations?

A

No

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25
Q

What effect does prepardness have on pain scores?

A

Childbirth prepared moms have decreased pain scores compared to those with no preparation

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26
Q

Intermittent labor pain has what effect on the respiratory system?

A

Stimulation

-periods of intermittent hyperventilation

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27
Q

Without supplemental oxygen how does the body compensate for these intermittent periods of hyperventialtion?

A

Hypoventilation between contractions that can result in transient episodes of maternal and fetal hypoxemia

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28
Q

Are these periods of intermittent respiratory and cardiovascular stimulation d/t labor pain well tolerated?

A

Generally in healthy paturients and their fetusus, yes, with normal uteroplacental perfusion

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29
Q

What may help prevent compromise of this respiratory and cardiovascular stimulation r/t labor pain with maternal or fetal disease?

A

Good analgesia

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30
Q

What effect does labor pain, anxiety and emotional distress have on the GI system?

A

It increases gastrin release and inhibits the segmental and suprasegmental reflexes of GI motility
-results in an increase is gastric acid and volume

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31
Q

What effect does labor pain, anxiety and emotional distress have on the urinary system?

A

It inhibits the segmental and supresegmental reflexes of urinary motility
-restuls in delay in bladder emptying

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32
Q

Does maternal labor pain have a direct effect on the healthy fetus? Why?

A

No it does not, because of the absence of direct neural connections from the mom to the fetus

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33
Q

In what 3 ways CAN maternal labor pain affect uteroplacental perfusion though?

A
  1. uterine contraction frequency and intensity, by the effect of pain on the release of oxytocin and epinephrine
  2. uterine artery vasoconstriction, the the effect of pain on the relase or NE and Epi
  3. maternal oxyhemoglobin desaturation from intermittent hyperventilation followed by hypoventilation
    (Effects are well tolerated in normal circumstances, but fetal well-being may be affected in situation if limited uteroplacental reserve)
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34
Q

What is Stadol?

A

Butorphanol

-opioid agonist/antagonist (kappa/mu)

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35
Q

When can Stadol be used with labor?

A

Early labor if birth is expected to be 4 hours away

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36
Q

What is the dose and route of Stadol?

A

1-2mg IV

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37
Q

Does Stadol cross the placenta?

A

Yes, rapidly

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38
Q

Butorphanol potency vs Dermerol

A

Stadol is more potent than Demerol (which is more potent than Morphine)

39
Q

After how many cm dilated should Stadol not be used?

A

Do not give after 8 cm of dilation

40
Q

Does Stadol have a ceiling effect? If so, on what?

A

Stadol has a ceiling effect on analgesia and respiratory depression

41
Q

What aspects of taking a history would indicate a possible bleeding concern for neuraxial anesthesia?

A 
Easy bruising
Excessive bleeding from gums
Family Hx of bleeding problems
Medicatons that increase bleeding risk
-Rx, ASA, The Gs
42
Q

What laborary tests could be performed to assess for bleeding problems?

A 
Plt count
PT, PTT
Fibrinogen
Bleeding time
Thromboelastography
Platelet function analyzer
43
Q

What is the concern with possible bleeding risk and neuraxial anesthesia?

A

Epidural hematoma

44
Q

What are absolute contraindications to neuraxial anesthesia?

A

Patient refusal

Frank coagulopathy

45
Q

What heparin prophylaxis is NOT a contraindication to neuraxial anesthesia?

A

Standard unfractionated heparin SQ

46
Q

If patient IS on standard unfractionated heparin prophylaxis, what steps should you take to ensure safety of neuraxial anesthesia?

A 
Verify prope dose is being used
Meausre Plt count with prolonged therapy
Atraumatic needle placement
Early placement of epidural cathetier
Use midline technique
Use small need and cathetier
Use saline to distend epidural space before inserting catheter
47
Q

Can neuraxial anesthesia be used for a patient receiving low molecular weight heparin prophylaxis?

A

Neuraxial anesthesia can be used 10-12 hours after last dose of LMWH

48
Q

When can LMWH prophylaxis be resumed after surgery?

A

6-8 hours after surgery

49
Q

When should an epidural catheter be removed if pateint is receiving LMWH prophylaxis?

A

At least 10-12 hours after last dose

50
Q

When can LMWH be resumed after removal of epidural catheter?

A

At least 2 hours after catheter removal

51
Q

Can neuraxial anesthsia be used if mother is on HIGH doses of LWMH?

A

Yes, but not till 24 hours after last dose

52
Q

In a patient who is receiving high dose or twice daily doses of LMWH when can the first postop dose be given?

A

Not till 24 hours after surgery

53
Q

When should an epidural catheter be removed before initiating high dose LMWH?

A

At least 2 hours before initiating therapy

54
Q

Can neuraxial anesthesia be used in a patient with thrombocytopenia?

A 
Possibly, it's a clinical judgement
-evidence of bleeding
-plt count
-recent change in plt count
quality of plts
-adequacy of other coag factors
-weigh risks vs benefits
55
Q

Is there a significant bleeding risk from placing an epidural in a patient taking ASA?

A

Not if they are taking normal doses

56
Q

What is the life of a platelet?

A

7-10 days

57
Q

Why does neuraxial anesthesia lead to hypotension?

A

Vasodilation

58
Q

Is there a difference between phenylephrine use and ephedrine use as far as maternal hypotension or HTN and neonatal apgar scores?

A

No

59
Q

Which vasopressor causes more bradycardia?

A

Phenylephrine

60
Q

Which vasopressor causes lower umbilical arterial pH?

A

Ephedrine

61
Q

Which is the favored vasopressor currently?

A

Phenylephrine

62
Q

What dose of ephedrine can be used d/t fetal acidosis?

A

Less than 30mg

63
Q

What causes nausea/vomiting with hypotension?

A

The area post rema in the medulla in the chemoreceptor trigger zone becomes ischemic

64
Q

What can be given preoperatively to help prevent the N/V d/t hypotension?

A

Zofran

-can give up to 16 mg to an adult

65
Q

What needs to be monitored with Zofran use?

A

Monitor for QT prolongation

66
Q

What can exacerbate this QT prolongation risk with Zofran use?

A

Bradycardia from phenylephrine

67
Q

What causes a post dural puncture headache? Time frame?

A

CSF leakage through the dural hole
-leak can exceed rate of production (20 mL/hr)
Within 5 days of lumbar puncture

68
Q

What are the symptoms associated with PDPH?

A 
Nausea
Vomiting
Neck stiffness
Ocular
Auditory
69
Q

What occurs due to the loss of CSF?

A

Low CSF presure > loss of cushioning effect of CSF

70
Q

What specifically causes the pain associated with PDPH?

A

Cerebral vasodilation occurs to increase cerebral blood flow in order to fix it

71
Q

What patient risk factors increase risk of PDPH?

A 
Age <40 y
Gender
Vaginal delivery
Morbid obesity
Air travel (within a couple days)
Hx of PDPH
Multiple dural punctures
72
Q

What are the risk factors for PDPH related to neuraxial technique?

A

Cutting needle > pencil point
Larger size needle
Quinke bevel perpendicular to long axis of the spine (parallel reduces risk)

73
Q

What neuraxial techniques have conflicting evidence on the risk of PDPH?

A 
Midline vs paramedian
Skin prep
Air vs NaCl in loss of resistance
Choice of LA
Combined Spinal Epidural
Continuous spinal anesthesia
74
Q

What percentage of law suits pertained to PDPH?

A

14%

  • Whitacre 1.5%
  • Quinke 11-12%
75
Q

What PDPH treatment has the greatest liklihood of success?

A

Epidural blood patch

-can be repeated if the first didn’t do it

76
Q

What are other treatments of PDPH?

A 
Psychological support
Bed rest
Caffeine
Epidural morphine
Epidural/intrathecal saline
77
Q

Why may caffeine help with PDPH?

A

It is a cerebral vasoconstrictor

  • transient benefit
  • side effects: arrhythmias, SZ
78
Q

What side effect could epidural morphine have?

A

May predispose to respiratory depression

79
Q

Why may epidural/intrathecal saline help PDPH?

A

If given continuously, fills the space

80
Q

What patient position should a epidural blood patch be placed?

A

Lateral

-sitting up is when HA hurts

81
Q

How much blood is used in a blood patch?

A

10-20mL of patients own blood

82
Q

How long does a patient need to lay after a blood patch is placed?

A

1-2 hours

83
Q

What is the optimal timing for administration of a blood patch?

A

Not adequately studied

  • observational studies suggest that failure is more likely if the patch is perfomred within 24-48 hours or dural puncture
  • some stuides say there is a positive correlation with time interval and success (move in tandum, further way from puncture more success)
84
Q

What are the contraindications of a blood patch?

A

Coagulopathy
Local infection
Increased ICP
Patient refusal

85
Q

What are the complications of a blood patch?

A 
Infection/hematologic - meningitis
Seeding of cancer cells
Neurological: 
-low back pain
-subdural hemorrhage
Arachnoiditis
Radicular back pain
Pneumoencephalus
Seizures
Meningeal irritation
Cranial nerve palsy
86
Q

What is the third stage of labor?

A

Begins with birth of the infant and ends with delivery of the placenta

87
Q

What are is another name for the stages of labor (besides the number)

A

First: cervical stage
Second: pelvic stage
Third: placental stage

88
Q

What is the fourth stage of labor?

A

Some identify a fourth stage of labor, it is the first postpartum hour

89
Q

What is most likely to occur in the fourth stage of labor?

A

Postpartum hemorrhage

90
Q

When is labor said to begin?

A

When contractions occur regularly and the cervix begins to change

91
Q

Describe the 2 phases of stage 1 labor

A

Phase 1: The latent phase
-onset of labor with regular contractions and slight cervical changes
Phase 2: The active phase
-begins when the cervix begins to change rapidly
-usually when cervix dilates 2-3 cm
-during this phase cervix usually dilates 1.2 cm per hr

92
Q

What is considered a preterm birth?

A

Before 37 weeks gestation

93
Q

What is considered a post-term birth?

A

42 weeks gestation

OB Test 2 (4 decks)

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