Pregnancy Flashcards
Maternal mortality definition
Death of women while pregnant or within 42 days of termination of pregnancy from any cause per 100 000 deliveries
Timing of first trimester screening
Once, ideally before 12 weeks
What does first trimester screening include
- IPS testing
- Ultrasound for dating
- Labs (CBC, blood type, electrophoresis if anemia, infection (gonorrhea, chlamydia, HIV, VDRL, HBsAg, urine culture and sensitivity, Rubella)
- PAP test
A mother is not immune to rubella on screening. What action do you take?
Must avoid sick contact during pregnancy and immunize postpartum
A mother has gonorrhea, chlamydia, bacterial vaginosis or trichomonad during pregnancy. What do you do?
Treat
What can cause a false VDRL reading?
Lupus
What is included in 2nd trimester screening
- Morphology ultrasound at 18-20 weeks (only mandatory ultrasound)
- Blood - hemoglobin, ABO, Rh, Rh antibody at 24-28 weeks
- Gestational diabetes screen with non-fasting 50g glucose load at 24-28 weeks
Gestational diabetes screening algorithm
Tony’s pg 12
3rd trimester screening
- GBS vaginal and rectal swab at 35-37 weeks
How to interpret symphysial fundal height
Distance from pubic bone crest to top of uterus to measure growth
FSH should be roughly equal to gestational age (+/- 2 cm) and increase 1 cm per week
Use starting at 12 weeks
What is crown rump length
Longest straight line from outer margin of cephalic pole to rump
Most accurate estimation of gestational age in 1st trimester after 6 weeks
What is a biophysical profile
Usually done in high-risk pregnancies in 3rd trimester
U/S evaluation of fetal well-being using Manning’s score system and non stress test
Oligohydramniosis cut off and associations
<5
Associated with placental insufficiency and baby in stress
Polyhydroamniosis
> 25
Associated with diabetes, chromosomal abnormalities and anatomical abnormalities
Trisomy 18
Edwards syndrome
Severe mental retardation and other
<10% survive 1 year
Trisomy 13
Patau syndrome
Severe mental retardation and other
5% survive 3 years
Trisomy 16
Lethal, often first trimester spontaneous abortions
45,X
Turner syndrome
First-trimester spontaneous abortions
Slightly lower IQ
47, XXX; XYY, XXY
Klinefelter syndrome
Tall, eunuchoid habitus and small testes
del(5p)
Cri du chat syndrome
Severe mental retardation, microcephaly, distinctive facial features, characteristic cat’s cry sound
What birth defect risk does not increase with maternal age
Open neural tube defects
What does IPS screen for
Risk of Down’s, Edward’s and neural tube defects
What does IPS include
- Ultrasound (nuchal translucency >3 mm and absence of nasal bone increases risk for Down Syndrome) and PAPP-A (lower in trisomy 21) at 11-14 weeks for Down’s
- Maternal serum screening at 15-21 weeks, ideally at 15+3 weeks
Free beta-hCG - higher in Down’s
AFP - high in NTD
uE3 - low in Down’s and Edward’s
Types of pre-natal screening for birth defects
- Non-invasive – IPS, MSS
- Invasive – chorionic villous sampling and amniocentesis
Now instead of IPS can do EFTS (one stop shop mainly meant to rule out Down Syndrome). EFTS has 7% false positive rate vs 10% false positive rate in IPS
NIPT is probably going to start to replace EFTS soon
Amniocentesis will always be the gold standard (performed if positive screening with IPS or EFTS) and is a diagnostic test
Indications for invasive pre-natal screening
- Positive prior screening test (IPS or maternal serum screening)
- Family history of genetic disease
- Maternal age >40
- Specific u/s finding that need to be f/u
Purpose of invasive pre-natal screening
Test for other genetic and birth defects outside of Down’s, Edward’s and NTD
Chorionic villous sampling
- Done at 11-13 weeks
- Sample taken from placental villi
- 1% miscarriage rate (higher than amniocentesis)
- Results come back in 2-3 weeks
- Do not detect NTD so AFP need to be done at 15-20 weeks
Amniocentesis
- Done at 15-22 weeks
- Sample taken from amniotic fluid
- <1% miscarriage rate
- Results come back within 3 weeks (rapid aneuploidy 1 week, conventional chromosome study 2-3 weeks)
- Can detect NTD
Cordocentesis
Done at >18 weeks
Normal placenta
- Discoid
- 500 grams, 15-20 cm in diameter, 2-3 cm thick
- Situated in upper uterine segment in fundal portion of uterus
Trimesters in weeks
1- end of 12 - 1st trimester
13- end of 26 - 2nd trimester
27 onward - 3rd trimester
3rd trimester bleeding differential diagnosis
- Pregnancy related
Placenta - placental abruption, placenta previa, vasa previa
Uterus - uterine rupture
Cervix - cervical insufficiency (thin cervix), cervical friability, cervical cancer
Vagina - laceration of trauma
Physiologic - bloody show associated with labour
2. Non-pregnancy related cause PALM COEIN Polyps Adenomyosis Leiomyoma Malignancy (including trophoblastic disease) Coagulopathy Endometrial dysfunction
NIPT
Non invasive prenatal testing
Replacing amniocentesis because of risk of miscarriage
Measures fetal cells in maternal serum
Results in 10 days
Not currently covered by the ministry unless maternal age 40+
HIV contraindications for pregnancy and childbirth
No ergot if post partum hemorrhage
No instrumentation/vacuum
No breastfeeding
Degrees of shock and associated signs and symptoms
Mild - <20% - cool extremities, increased cap refill
Moderate - 20-40% - tachycardia, tachypnea, postural hypotension, oliguria
Severe - >40% - hypotension, agitation/confusion, hemodynamic instability
Limit of neonatal viability
22 weeks
4 main causes of preterm births
Spontaneous
- preterm labour with intact membranes
- PPROM
Indicated
- maternal or fetal complications requiring early delivery
- Twins or high-order multiples
Pre term labour risk factors
SES
Genetic factors (maternal race, history, age)
Increased uterine distension (polyhydramnios, multifetal gestation)
Multifetal gestation
Infection (UTI, periodontal, bacterial vaginosis) —> treat even if asymptomatic in pregnancy
Behavioural (low maternal weight, substance abuse, smoking)
Short inter-pregnancy interval (delivery <12 months)
Vaginal bleeding (T2>T1)
Cervical surgery
Uterine congenital malformations: bicornuate/didelphys
Pathogensis of preterm labour
Stress response via HPA axis
- Increased maternal cortisol or fetal ACTH by fetal adrenals
- Increases CRH production by placenta/membranes and decidua
- Estrogen conversion of adrenal DHEA leads to increased myometrial receptivity
Inflammation/infection -
Decidual hemorrhage
Uterine Stretch
Prevention for preterm labour
Not very successful
Screening in women with risk factors (cervical length 10th centriole <26 mm, bacterial vaginosis swab first trimester)
Interventions:
Modifying behavioural risks - alternating positions (strict bedrest not shown to be of any benefit)
Progesterone in women with previous PTB or short cervix once there is change in cervix
Pre term labour diagnosis
Painful contractions
Pelvic pressure
Back pain
Bleeding
Signs: Palpable contractions Short cervix Open cervix on spec Dilated cervix on digital exam
Diagnosis of PTL
Fetal fibronectin
- Glycoproteins in cervicovaginal secretions, swab for these in posterior fornix
- Marker for impending preterm labour
- Poor sensitivity in asymptomatic women
- Negative predictive value 98%, PPV 30%
- Useful 24-34 weeks with intact membranes
- Can not have had internal examination within 24h
When to avoid doing a digital exam
If you are unsure of the location of the placenta (have not gotten 2nd trimester morphology screen)
Do speculum exam instead
Management of PTL
- Determine fetal presentation
- Celestone
- Tocolytics?
- Antibiotics for GBS prevention
- Transfer to tertiary center
- Paediatric consultation
- Neuroprotection (MgSO4)
What’s the deal with antenatal steroids?
Betamethasone 12 mg IM q 24h x 2 doses
<34 weeks
Activates fetal surfactant production to decrease RDS
One course good for each pregnancy
Risk factors for PPROM
Antepartum bleeding Previous cervical surgery Smoker Low SES Cervical incompetency (cervix opens without contractions, presents with pressure, discharge)
PPROM diagnosis
- Pooling
- Cough test
- Nitrazine - pH (amniotic fluid basic, vagina acidic)
- false positive with blood, sperm, BV, alkaline urine - Ferning - false positive 20% (sperm, cervical mucous), false negative 40%
- Swab in the fornix, not in the cervix because mucous will can false positive
Obstetrical ultrasound
- Fetal position
- Amount of amniotic fluid
- Dating
- Fetal well being
PPROM complications
Maternal
- Infection (chorioamniotis, endometriosis, Baxter Emma)
- Increased risk of CS
Fetal
- Infection
- Preterm delivery (50% deliver in first 24h, 70-80% in following week)
- Cord prolapse
- Abruption
- Pulmonary hypoplasia
PPROM Management
- Confirm diagnosis
- Ensure maternal and fetal well being
- Address underlying cause that needs management (ex. Abruption, chorio)
- Avoid digital exam unless in labour (push up bacteria each time)
- GBS swabs
- Ultrasound
- Decide on expectant vs active management
Indications for induction
- Weight gains in maturity against infection risk
- Earlier PPROM more likely to gain significant time
- After 34 weeks gain in time smaller
- Most will induce after 35 weeks
Expectant management
<34 weeks Goal is to increase latency period Antibiotic prophylaxis Maternal and fetal monitoring Antenatal steroids Possible transfer to tertiary center
Infertility definition
1 year of unprotected intercourse without conception
2 most important factors for natural conception rate
- Female age
2. Duration of infertility
What past medical history would be concerning for tubal injury?
Ruptured appendix
What are some screening tests available to predict fertility potential
Day 3 FSH, LH, Estradiol
Antral follicle Count (AFC) - most reliable early in cycle
Anti-Mullerian Hormone (AMH)- don’t need to time in cycle, but not covered by OHIP
Femal einfertility management class 1
Weight gain
GnRH pump
Gonadotropins
IVF
Class II Female management
1st line - Weight loss 1st line med - Femara or Letrizole Aromataste inhibitors Insulin-sensitizing agents (ex. Metformin) Laparoscopic ovarian drilling Gonadotropins IVF Bromocriptine or other dopamine agonist (only in cases of hyperprolactinemia and anovulation)
Class III Infertility Management
Expectant management
?Gonadotropins/IVF
Donor egg - best treatment option to have pregnancy
Adoption
Tubal etiology infertility investigations
Hysterosalpingogram (HSG)
SonoHSG
Laparoscopy
Tubal factor infertility treatment
IVF
Consider tubal surgery if due to tubal ligation or do not want IVF
Hirsutism definition
Excess facial and body hair caused by excess androgen production
Unwanted
Virilization definition
Clitoromegaly, depending of voice, balding, body habitus changes
…
Whole blood contents
RBCs, plasma, fibrinogen
No platelets
Packed RBCs
RBCs only
No fibrinogen, no platelets
Fresh Frozen Plasma FFP
Colloid, fibrinogen
No platelets
Cryoprecipitate
Fibrinogen, other clotting factors
No platelets
Placental abruption risk factors, pathophysiology, presentation, complications, diagnosis, treatment
Risk factors
- Maternal - AMA, prior abruption, prior CS, multi-parity, comorbidity, cocaine
- Current pregnancy - multiple gestation, short umbilical cord, PPROM, Prolonged ROM, polyhydramnios, trauma
Pathophysiology
- placental lining separated from uterus, bleeding from maternal side of placenta
Marginal, partial or complete
Clinical presentation
- Bleeding per vagina with painful uterine contraction
- Tenderness and hard uterus or back pain
- Fetus distress as shown by fetal heart rate monitoring
Complications
Fetal complication usually followed by maternal
- fetal distress
- premature delivery
- fetal hypotension, anemia, CP and developmental problem
- couvelaire uterus (penetration of blood into uterine myometrium and into peritoneal cavity)
- Maternal hypovolemic shock and end organ damage
- Maternal DIC
Diagnosis
- Clinically based on vaginal bleeding, abdo tenderness and/or fetal distress
- Trans abdominal or vaginal u/s to rule out placenta previa and detect large abruption
Treatment
- Stabilize and deliver (unless premature and no fetal distress, then consider close observation)
Placenta previa risk factors, pathophysiology, clinical presentation, complication, investigation, diagnosis, treatment
Risk factors
- Maternal factors
- AMA, prior placenta previa, multiparity >5, previous uterus surgery
- illicit drugs, smoking - Current pregnancy factors
- multiple gestation
Pathophysiology
Placenta inserted in lower uterine segment such that it is near or partially covers or completely covers the internal cervical os
Grade 1 - low lying, placenta within 5 cm of internal cervical os
Grade 2 - marginal, placenta reaches margin of os but does not cover
Grade 3 - Partial previa, placenta partially covers os
Grade 4 - Complete previa, placenta completely covers os
Clinical Presentation
- Painless bright red vaginal bleeding during 2nd half of pregnancy
Complication
- Maternal hypovolemic shock
- Preterm delivery
Investigation
- Blood work including Kleihauer-Betke stain, HIV, Hepatitis B
- TA or TV U/S
Diagnosis
- definitive diagnosis with TA/TV U/S
Treatment
Definitive treatment delivery by C-section
Vasa Previa risk factors
- Pregnancy achieved with assisted reproductive technology
2. Placenta - resolved placenta previa, bilobed or succinturiate lobed placenta
Vasa previa pathophysiology
Fetal vessels unsupported by umbilical cord that overlie the cervix or lies between cervix and fetal presenting part
Vasa previa clinical presentation
Classic triad
- Membrane rupture
- leading to painless vaginal bleeding
- and fetal bradycardia (or sinusoidal pattern)
Pelvic exam - rarely, pulsating vessel in membrane overlying cervical os
Vasa previa diagnosis
Pre-natally - identification of membranous fetal vessel passing internal cervical os on ultrasound
May be diagnosed clinically based on presentation of triad
Vasa previa treatment
Definitive treatment is delivery by C section
Definition and classification of hypertension in pregnancy
Hypertension in pregnancy diagnosed based on blood pressure 9mean of at least 2 measurements taken at least 15 minutes apart using same arm)
- SBP 140+ and or/ DBP 90+
- Severe hypertension 160+ SBP or 100+ DBP
Classification:
1. Pre-existing (chronic) hypertension less than 20 weeks GA
2. Gestational hypertension that develops 20+ weeks GA
Both of these are defined as hypertension with resistance, proteinuria, adverse condition or severe complications
Pathophysiology of preeclampsia and eclampsia syndrome
- Decidual immune cell and extravillous trophoblast interactions cause invasion and uteroplacental artery remodelling
Interaction can be precipitated by
- Immune factors causing antigen exposure such as primi-gravidity, primi-paternity, donor gametes
- Genetic factors including epigenetic, familial risks
- Lowered threshold from metabolic syndrome, chronic infection or inflammation, CKD, diabetes - Interactions of decidual cells and extravillous trophoblast result in inadequate placentation and uteroplacental mismatch, resulting in release of mediators (intervillous soup)
Intervillous soup includes placental debris, innate immune activation, oxidative stress, eicosanoids, cytokines - Intervillous soup results in endothelial cell activation and dysfunction within vulnerable multi-organ systems, resulting in systemic effects
What are the symptoms, signs, lab tests and diagnostic methods for gestational hypertension
Investigations:
Pre-existing hypertension/early
- CBC, lytes, Cr, fasting blood glucose
- Urine analysis (protein without RBCs or casts)
Suspected pre-eclampsia
- O2 sat (<97% in pre-eclampsia)
- CBC (anemia in HELLP, thrombocytopenia in pre-eclampsia), film (RBC framgentation in micro-angiopathy), Cr (renal failure), uric acid (increased) glucose, AST, ALT, bilirubin (liver dysfunction), albumin (decreased due to liver dysfunction), LDH, INR, aPTT (increased in DIC), fibrinogen (decreased in DIC)
Fetal testing
- Monitoring
- Deepest amniotic fluid pocket (oligohydramnios)
- Uterine artery doppler velocimetry (uni or bilateral notching, elevated plurality or resistance index suggestive of placental insufficiency)
- Fetal growth (IUGR)
- Umbilical artery doppler (increased resistance, absent or reversed end diastolic flow in pre-eclampsia)
- Ductus venous doppler (increased resistance, absent or reversed A wave in pre-elclampsia)
- MCA doppler (cerebral redistribution with decreased resistance or brain sparing effect)
Gestational hypertension prevention and management
Prevention - calcium, folic acid, lifestyle
- High risk (history, abnormal uterine artery Doppler before 24 weeks gestation) - low dose aspirin, L-arginine, rest, prostaglandin precursor, Mg supplementation, heparin to prevent VTE, LMWH
Management
1. Lifestyle
- BP control
No comorbidity target - SBP 130-155 and DBP 80-105
Comorbidity target - SBP 130-139 and DBP 80-89
1st line - Methyldopa (but makes moms dopey), lebatalol, nifedipine XL
2nd line - BB except atenolol, HCT, hydralazine - Manage non severe pre-eclampsia (inpatient)
a) <24 weeks GA
- counselling about delivery within days
b) 24-34 weeks
- expectant management
- consider ante-natal corticosteroid for fetal maturation
c) 34-37 weeks
- expectant management or immediate delivery
- consider ante-natal CS if CS delivery
d) 37+ weeks
- immediate delivery - Manage severe pre-eclampsia
- Vitals monitoring, investigations
- BP control 1st line - Nifedipine, Hydrazine, Labetalol
Refractory treated with sodium Nitroprusside IV
- Prophylaxis against eclampsia with MgSO4 4g IV loading dose followed by 1g/h (can also treat existing eclampsia)
- HELLP treated with FFP transfusion or plasma exchange
- Consult OB
- Delivery is the only definitive intervention to resolve pre-eclampsia, thus all severe pre-eclampsia are OB emergencies and require immediate delivery regardless of GA - Post-partum management within 6 weeks
- Continuous monitoring and labs
- Control BP with anti-hypertensives according to CHEP guidelines - Post partum long term management after 6 weeks
- Screen for pre-existing HTN, renal disease
- Address CVD risk factors
Maternal and fetal complications of gestational hypertension, and signs and symptoms of each
Recurrence of pre-eclampsia Chronic hypertension TIIDM, metabolic syndrome CKD Premature CVD including CAD, CVD, PVD
Pre-eclampsia definition
Hypertensive disorder of pregnancy defined as SBP 140+ and/or DBP 90+ with 1+ of the following:
- New proteinuria >300 mg/24h
- 1+ Adverse condition
- 1+ severe complication
Severe pre-eclampsia is pre-eclampsia with 1+ severe complication
What is HELLP syndrome
Type of severe pre-eclampsia
Hemolysis, Elevated Liver enzymes, Low Platelets
What is eclampsia
Generalized tonic clonic convulsive seizure, which is a complication of pre-eclampsia
What does expectant management for pre-eclampsia entail?
IV access (no volume expansion)
Administration of anti-hypertensives
CS for fetal lung maturation
Daily bio-physical profile and fetal assessment
Daily maternal pre-eclampsia labs
Daily clinical assessment of mother and fetus
Indication for hospitalization with maternal hypertension
Severe hypertension >160/110
or
Severe pre-eclampsia
Normal post partum blood pressure pattern
Drop PP day 1-2
Peak PP day 2-7
Decline after PP day 7
Normalize by 3 months
Anti-hypertensives acceptable for use during breast feeding
Nifedipine Labetalol Methyldopa Captopril Enalapril
Dopey Ned took some ace inhibitors and beta blocker
Ectopic pregnancy risk factors
- Demographics: older women, African descent
- Uterine structural abnormality: fibroids, adhesions, abn anatomy
- Ob/Gyn history: prior ectopic, IUD, PID, salpingitis, infertility
- Surgery: abdo, pelvic, IVF
- Medication: clomiphene citrate
Ectopic pregnancy signs and symptoms
Pain, vaginal bleeding
Missed menstrual period, Chadwick’s sign, Hegar’s sign, fever, peritoneal signs, cervical motion tenderness, palpable adnexal mass, tenderness on bimanual
Ectopic pregnancy labs and diagnostic tests
Serial beta-hCG
- <8 weeks gestation normally doubles ever 2 days
- Non viable has slower rise, plateau or decreasing before 8 weeks
U/S (tubal ring on TVUS)
- visible on u/s when b-hCG >1500 for TVUS and >6000 for TAUS
Laparoscopy
Diagnosis – elevated b-hCG and visualization on U/S or laparoscopy
Ectopic pregnancy management
- Stabilize
- Abortion (medical or surgical, similar success rate)
a) Surgical - linear salphingostomy (preserve tube) or salpingectomy (remove tube)
b) Medical - methotrexate IM
Ectopic pregnancy implications for fertility
With surgical abortion 40-60% of cases will be fertile and become pregnant again after surgery
With medical abortion 80% preserve Fallopian tube patency
Most common site for ectopic pregnancy
Fallopian tube (98%) specifically in the ampulla (70%)
Indications for surgical abortion
- > 3.5 cm ruptured ectopic pregnancy
- Fetal heart rate present
- b-hCG >5000
- Liver or renal or hematological disease
- Poor compliance, unable to follow up
Indication for salphingectomy - damaged tube, recurrent ipsilateral ectopic
Indication for salpingostomy - if no indication for salphingectomy
Indications for medical abortion
- <3.5 cm ruptured ectopic pregnancy
- Fetal heart rate absent
- b-hCG <5000
- No liver, renal, hematological disease
- Good compliance, able to follow up
Clinical presentation of spontaneous abortion
Abdominal cramping, vaginal bleeding, ROM, passage of tissue and clots
Spontaneous abortion definition
non-induced embryonic or fetal death or passage of products of conception before 20 weeks GA
Threatened abortion definition
Vaginal bleeding with closed cervix and viable fetus, which can resolve or progress to spontaneous abortion
Inevitable abortion
Dilated cervix, but conception products have not been expelled, will progress to spontaneous abortion
Incomplete abortion
Some, but not all of conception products have been passed, retained products may include fetus, placenta or membrane
Complete abortion
All conception products have been passed without need for surgical or medical intervention
Missed abortion
Fetal demise but no uterine activity to expel conception products
Septic abortion
Spontaneous abortion complicated by intra-uterine infection
Most common fetal cause of spontaneous abortion
Chromosomal abnormalities in 50% of cases
Cause of recurrent spontaneous abortions
MAKE ID
Mechanical uterine anomalies including congenital septate uterus, leiomyoma, endometrial polyps, intra-uterine adhesions
Autoimmune factors including anti-phospholipid syndrome
Karyotype including aneuploidy, chromosomal rearrangement
Endocrinopathy including thyroid disease, DM, PCOS
Maternal infection including TORCH, listeria
Drugs including smoking, illicit drugs and other environmental factors
Complication of spontaneous abortion and presentation
Septic spontaneous abortion, which presents with fever, hypotensive shock, abdo pain and leukocytosis
Management of spontaneous abortion with retained products
- Watch and wait
- Misoprostol
- D&C +/- Oxytocin
Vaginal bleeding in 1st and 2nd trimester
- Physiologic - implantation of placenta
- Abortion
- Abnormal pregnancy - ectopic, gestational trophoblastic disease
- Trauma
- Genital lesion - polyps, cancer
What are the only non-pharmacological pain relief methods that have been shown to have some benefit in relieving pain
Vertical position during 1st stage of labour
Continuous support
Acupuncture
Types of opioids that can be used in intermittent bolus parenteral method of pain control, and the pros and cons of each
- fentanyl - fastest onset, shortest duration, lower effect re neonatal respiratory depression
- Meriperine - slowest onset
- Morphine - longest duration
- Nalbuphine - longest duration, lower effect re neonatal respiratory depression
Indication for intermittent bolus parenteral opioid administration
- 3rd line
- Early labour or very late stage labour where epidural is not an option
Patient controlled analgesia types of opioids used
- Fentanyl most commonly
- Remifentanil
Disadvantage of Patient controlled analgesia
Requires continuous O2 sat monitoring and one-on-one nursing
PCA indication
- 2nd line pain control
- Epidural refused on contraindicated
- Intrauterine fetal demise or termination of pregnancy
Inhalation nitrous oxide (entonox (50NO: 50 oxygen) indication
Usually used before or in conjunction with opioids or epidural
First line pain management in labour option
Epidural
Epidural contraindications
Absolute
- Patient must be able to sit still for procedure
- Patient refusal
- Increased intra-cranial pressure
- Infection at site of injection
- Systemic infection
- Coagulopathy
Relative
- Uncorrected maternal hypovolemia
- Active neurological disorder
- Inadequate training or equipment
Epidural procedure steps
- Needle inserted at L2-L5 (usually L3-4) between vertebrae midline into epidural space just beyond the ligamentum flavum
- Catheter inserted through needle and left in-situ
- Local (bupivicaine or ropivicaine) +/- opioids are inserted via catheter
Role of local anesthesia in epidural
- Block nerve endings bathed in epidural space innervating the birth canal
- Ideally blocks only sensory component (motor intact)
- 15-20 minutes to take effect
What is the effect of epidural analgesia on labour?
- Prolong 2nd stage of labour, but not clinically significant
- Epidural analgesia does not increase risk of C section
- Does not increase risk of back pain postpartum
