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Advanced Principles A > Test 3: Anesthesia For Operative Delivery > Flashcards

Test 3: Anesthesia For Operative Delivery Flashcards

1
Q

What is macrosomia?

A

Fetus/newborn w/ excessive birth weight

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2
Q

What does TOLAC stand for?

A

Trial of Labor After Cesarean

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3
Q

What does VBAC stand for?

A

Vaginal Birth after Cesarean

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4
Q

What does PPH stand for?

A

Postpartum Hemorrhage

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5
Q

What does SAB stand for?

A

Spontaneous Abortion (miscarriage)

SAB also stands for Subarachnoid Block

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6
Q

What is Operative Vaginal Delivery?

A

Using forceps or vacuum to assist delivery

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7
Q

Why is Operative Vaginal Delivery not used as much anymore?

A

Medico-Legal Concerns

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8
Q

What stage of labor does Operative Vaginal Delivery shorten?

A

Shorten 2nd stage of labor

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9
Q

What are the indications for Operative Vaginal Delivery?

A
  • Nonreassuring FHR
  • Maternal exhaustion
  • Arrested descent
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10
Q

What anesthesia may be required for Operative Vaginal Delivery?

A
  • May need a denser sensory block
  • Use a higher concentration of LA through the in-situ epidural catheter
  • Lidocaine 2% (5-10 mL)
  • 2-chloroprocaine 2-3% (5-10 mL)
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11
Q

What is the most common major surgery in the U.S.?

A
  • Cesarean Delivery
  • National delivery rate (30%)
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12
Q

Why is maternal mortality ten times greater with C-sections than vaginal delivery?

A
  • ↑ Risk of pulmonary aspiration
  • Failed intubation (edematous airways)
  • Inadequate ventilation when requiring GETA
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13
Q

What are factors that can increase the C-section rate (long list)?

A
  • Increased maternal age & delayed childbirth​
  • Obesity
  • Increasing incidence of fetal macrosomia​
  • Increased labor inductions​
  • Fewer TOLAC attempts
  • Fewer instrumented vaginal deliveries​
  • Increased use of electronic FHR ​
  • Concern for malpractice litigation (document, document, document)
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14
Q

Maternal indications for C-section

A
  • Arrested labor
  • Failed induction of labor​
  • Chorioamnionitis ​
  • Active HSV lesions​ (herpes lesion)
  • Multiple gestation (twins, triplets)
  • Previous uterine surgery / classical incision​
  • Maternal request
  • Antepartum/intrapartum hemorrhage
  • Uterine rupture
  • Placenta previa
  • Placental abruption
  • Deteriorating maternal condition (Pre-eclampsia)
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15
Q

Fetal indications for C-section

A
  • Malpresentation (breached)
  • Anomaly
  • Fetal intolerance of labor
  • Suspected macrosomia
  • Non-reassuring FHR (Category III)
  • Prolapsed cord
  • Prematurity
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16
Q

What are the two types of skin incisions for C-section delivery?

A
  • Low Transverse
  • Low Vertical/ Midline

Type of incision is based on how rapidly the fetus must be delivered.

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17
Q

Which skin incision has a lower dehiscence/ uterine rupture incidence and is the least painful?

A
  • Low Transverse
  • Classic skin incision for C-section
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18
Q

Which skin incision is used for rapid access for C-section delivery?

What does this skin incision increase the risk of?

A
  • Lower Vertical/ Midline (umbilicus → pubic symphysis)
  • ↑ Incidence of umbilical hernia
  • “Splash and Slash”, GETA
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19
Q

What are the types of uterine incisions used in C-section delivery?

A
  • Low Transverse
  • Vertical
  • Classical
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20
Q

Which uterine incision is the most common, and what are the benefits of this incision?

A
  • Low Transverse
  • ↓ Risk of uterine rupture during future pregnancies
  • TOLAC possible
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21
Q

Which uterine incision involves the lower uterine segment?

Which uterine incision involves the upper uterine segment?

A
  • Lower uterine segment = vertical incision
  • Upper uterine segment = classical incision
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22
Q

What is the benefit of a vertical uterine incision?

A
  • Low risk for uterine rupture
  • But Low transverse has the lowest risk of uterine rupture
  • This incision can be extended
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23
Q

What risks are involved with a classical uterine incision (splash/slash incision)?

A
  • ↑ Risk of abdominal adhesions
  • Uterine rupture risk (10%)
  • TOLAC contraindicated
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24
Q

What is the most common C-section complication?

What are other complications with C-sections?

A
  • Hemorrhage (Uterine atony)
  • Greater EBL w/ GETA
  • OB EBL can be underestimated

Other complications: Wound infections, Uterine/uterocervical lacerations, bladder dissection, fetal laceration, hysterectomy

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25
Q

What complications can C-sections have on future pregnancies?

A
  • Abnormal placental implantation
  • Placenta previa
  • Placenta accreta/increta/percreta
  • Uterine rupture
  • Hemorrhage
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26
Q

What is placenta accreta?

A
  • Placenta attaches too deeply into the uterine wall but does not penetrate the muscle.
  • In a normal pregnancy, the placenta detaches from the uterine wall after childbirth. However, with placenta accreta, the placenta remains firmly attached.
  • This can lead to severe bleeding during childbirth because the placenta cannot be easily separated from the uterine wall.
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27
Q

What is placenta increta?

A
  • Placenta penetrates into the muscle layer of the uterus.
  • Penetration is deeper than with placenta accreta.
  • ↑ Risk of bleeding and complications during delivery.
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28
Q

What is placenta percreta?

A
  • Most severe form of placenta complication
  • Placenta penetrates through the uterine wall and sometimes even beyond, into surrounding organs such as the bladder.
  • Can cause life-threatening bleeding during childbirth, needs hysterectomy after delivery.
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29
Q

What is placenta previa?

A
  • Placenta implants low in the uterus, partially or completely covering the cervix.
  • Normally, the placenta is attached to the upper part of the uterus, away from the cervix.
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30
Q

Ways to prevent unplanned cesarean delivery

A
  • Adequate labor analgesia for TOLAC & instrumented births​
  • External cephalic version​ when appropriate
  • Prompt attention to non-reassuring FHT​/FHR (keep baby happy)
  • Position changes​
  • IVF and pressors for maternal hypotension
  • Maternal oxygen
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31
Q

What does it mean when the baby is in a “breech position”?

A

Baby’s buttocks or feet are positioned to come out first

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32
Q

What is an External Cephalic Version?

A

ECV is a medical procedure performed during pregnancy to try to turn a baby from a breech position to a head-down position (cephalic presentation), which is considered the optimal position for vaginal delivery.

OB provider essential will “spin” the baby

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33
Q

What are the risks involved with an External Cephalic Version?

A

Uterine rupture

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34
Q

When a C-section is planned, what anesthesia plan is preferred and most common that is safest for mother and baby?

A

Neuraxial anesthesia (spinal or epidural)

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35
Q

For an unscheduled C-section, the anesthetic plan depends on what factors?

A
  • Fetal condition
  • Urgency of delivery
  • In situ epidural (or not)
  • Maternal comorbidities
  • Maternal wishes
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36
Q

What is the relationship between the number of C-sections a woman has and it’s correlation to bleeding?

A
  • Proportional relationship
  • More C-section, more bleeding
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37
Q

Components involved Anesthetic Preoperative Interview for a planned C-section.

A
  • Review of maternal health & previous anesthetics​
  • Discuss relevant OB hx​
  • G & P; previous c-sections​
  • Allergies​
  • Maternal vital signs & FHT​
  • Airway, heart & lung exam​
  • NPO status (treat as full stomach)
  • IV access
  • H&H and platelets
  • Order a Type & Screen or Type & Crossmatch if needed
  • Have blood available for any high-risk C-section
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38
Q

During the preoperative interview, what needs to be discussed with the patient about spinal/epidurals/CSE?

A
  • Provide overview of anesthetic procedure​
  • Discuss risks
  • Obtain informed consent
  • Consent for blood products
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39
Q

During the preoperative interview, what maternal concerns and questions need to be addressed regarding the C-section?

A
  • Describe appropriate sensations​: “Pushing, pulling, tugging, pressure”​
  • Possibility of nausea​
  • Presence of support person
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40
Q

What needs to be considered if the mother wants skin-to-skin after the C-section?

A
  • EKG leads on back
  • Pulse-ox placement
  • Give family space as appropriate
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41
Q

Anesthesia Equipment for C-section

A
  • Same equipment in the OB OR as in main OR​
  • Leave the anesthesia machine on​ & ready (Check daily or every 12 hrs​)
  • Medications/syringes
  • Vasopressors readily available​
  • Succinylcholine & Propofol readily available
  • May be able to leave a “dry” set-up depending on facility policy
  • IV start kits
  • Blood tubing available (in room, not set up)
  • Airway equipment preparation​
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42
Q

Famotidine (Pepcid)
Action:
Dose:
Onset:
Peak:

A

Action: H2 receptor antagonist, decrease gastric acid production

Dose: 20 mg IV
Onset: 30 mins
Peak: 60-90 mins

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43
Q

Metoclopramide (Reglan)
Action:
Dose:
When to administer:
Symptoms:

A

Action: Increases LES tone / speeds gastric emptying / decreases N/V​. Dopamine D2 antagonist & mixed 5-HT3 antagonist / 5-HT4 agonist​. Prokinetic / promotility​.

Dose: 10 mg IV

When to administer: 10-15 mins before anesthesia start

Symptoms: Extrapyramidal symptoms

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44
Q

Sodium Citrate (Bicitra)
Action:
Dose:
When to administer:

A

Action: Nonparticulate antacid, Decreases gastric acidity​ (↑ gastric pH to > 6 for 1 hr), no effect on gastric volume

Dose: 30 mL

When to administer: 20-30 minutes before rolling

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45
Q

What antibiotics are administered before C-section?

A
  • Choice of abx depends on if parturient has been in labor or if membranes are ruptured
  • Give within one hour of surgery start​
  • Cefazolin 2-3 gm IV​
  • Azithromycin 500 mg IV​ (give slowing d/t risk of nausea) - give if the membrane is ruptured
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46
Q

What factors increase the risk for higher EBL during C-section?

A
  • General anesthesia​
  • Abnormal placentation ​
  • Unscheduled C-Section after attempted labor​
  • Increased parity / grand multiparity​
  • Increased number of C-sections
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47
Q

What should be monitored before and after SAB?

A
  • FHR/FHT
  • Maternal BP
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48
Q

Why is Versed discouraged for C-sections?

A
  • Readily crosses placenta​
  • Amnesia​
  • Potentially interferes with bonding​
  • BUT… may be beneficial for highly anxious parturients
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49
Q

Intraoperative O2 delivery considerations for C-sections.

A
  • Common “traditional” practice to administer O2​
  • May not be necessary during elective c-section​
  • FiO2 of 0.35 – 0.4 does not improve fetal oxygenation​
  • FiO2 of 1.0 in preparation for GETA is ideal
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50
Q

Neuraxial anesthetic advantages for C-sections.

A
  • Mother awake​
  • Early bonding​
  • Presence of a support person​
  • Use of opioids​ in neuraxial blocks
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51
Q

Dose of morphine in a spinal?
Dose of fentanyl in a spinal?

A

100-150 mcg of Morphine
5-10 mcg of Fentanyl

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52
Q

Dose of morphine in a pre-existing epidural after delivery?

A

3 mg of Morphine

PRESERVATIVE-FREE DURAMORPH

53
Q

Neuraxial anesthetic disadvantages for C-sections.

A
  • Maternal discomfort
  • Nausea is not uncommon during a C-section
  • Pulling/tugging can be uncomfortable/cause anxiety
  • Hypotension (Sympathetic blockade → decreased SVR)
  • Decreased preload
  • Bezold-Jarisch Reflex activated
54
Q

What will the patient experience when the undersurface of the diaphragm is stimulated by cool/cold irrigation during a C-section?

A

When the Under-surface of the diaphragm (C3-5) is stimulated by cool/cold irrigation, the patient may experience nausea and pain.

55
Q

What causes the referred shoulder pain or chest pain during a C-section

A

Referred pain from uterine exteriorization

56
Q

What is the Bezold-Jarish Reflex?
What are the triad of symptoms you will see?

A
  • Mechanoreceptors in wall of LV responding to “low stretch” d/t decrease preload.
  • TRIAD: Vasodilation, Hypotension, Bradycardia
57
Q

What are medications to prevent hypotension from a neuraxial block?

A
  • Ondansetron (Zofran) 4 mg IV​
  • Phenylephrine 25-50 mcg/min infusion​
  • Bolus doses of Phenylephrine and/or Ephedrine
58
Q

How does Ondansetron prevent hypotension from a neuraxial block?

A
  • Inhibits activation of the BJR by antagonizing 5-HT3 receptors​
  • Prevents triad of vasodilation, hypotension, & bradycardia​
  • Give 5 mins before SAB
59
Q

What positioning techniques can prevent hypotension from a neuraxial block?

A
  • Slight head-up position (10 degrees)
  • Left uterine displacement (prevent aortocaval compression/ supine hypotension syndrome)
60
Q

Fluid management for the prevention of hypotension

A
  • 2 Large bore IVs
  • Crystalloid (rapid redistribution 20-30 mins)
  • Colloids (albumin, hetastarch)
  • Blood Products (may be necessary if pt is anemic)
61
Q

What is the risk of using Hetastarch (Hespan) for fluid management?

A

Risk for Anaphylaxis

62
Q

Use of Ephedrine for Maternal Hypotension
IV dose:
IM dose:
MOA:
Risk:

A

IV dose: 5-10 mg
IM dose: 25 mg
MOA: mixed α and β-adrenergic agonist, readily crosses placenta
Risk: Reactive hypertension, umbilical artery metabolic acidosis

63
Q

Use of Phenylephrine for Maternal Hypotension
IV dose:
Infusion rate:
MOA:

A

IV dose: 50-100 mcg
Infusion rate: TTE 25-100 mcg/min
MOA: Selective α1-adrenergic agonist

64
Q

What is the optimal dermatome level for a C-section?

A

T4 (nipple line)

65
Q

What is the baricity of 0.75% Bupivacaine?

A

Hyperbaric (goes toward the direction of gravity)

66
Q

What is the baricity of 0.5% Bupivacaine?

67
Q

What is the risk of Hyperbaric Lidocaine 5%

A
  • Risk of transient neurologic syndrome (TNS)
  • Pain in the legs and back 24-48 hours after SAB
68
Q

What is the most common LA used in spinal neuraxial anesthesia?

A

Bupivacaine 0.75%

69
Q

How do opioids decrease incidences of N/V when placed in SAB?

A

Opioids attenuate some of the sensations that trigger N/V (ie: pull sensation, cool sensation under diaphragm)

70
Q

What are the benefits of using opioids in neuraxial anesthesia?

A
  • Improve quality of the block
  • ↓ Risk of N/V
  • ↓ Dose of LA
  • Prolong postop analgesia
  • ↓ Postop IV/PO narcotics
71
Q

What is the SAB dose of Fentanyl

A
  • 10-25 mcg
  • Rapid onset (lipophilic)
  • Short-acting
  • Great for intraoperative pain relief
72
Q

What are the side effects of fentanyl in SAB?

A
  • Pruritus
  • Early respiratory depression
73
Q

What is the SAB dose, onset, and duration of Morphine PF (Astamorph, Duramorph)

A
  • 100-150 mcg in SAB
  • 30-60 mins, slower onset (hydrophilic)
  • 12-24 hours, great for post analgesia
74
Q

What is the most common complaint/ side effect of morphine used in spinal anesthesia?

75
Q

What can be used to treat morphine-related pruritis?

A
  • Agonist-antagonist (Nubain/Stadol​)
  • Central mu-opioid receptor antagonist (Naloxone/Naltrexone)
  • Benadryl won’t help, but will make them sleepy.
76
Q

How many hours after administration of morphine will there be signs of respiratory depression?

A

6-18 hours (late respiratory depression)

Caution giving morphine to obese pt/ OSA

77
Q

What is an Epi Wash?

A

Washing the syringe with 0.1-0.2 mg of epinephrine before drawing up LA. This will prolong the duration of spinal block by 15%.

78
Q

What is the dose of dexmedetomidine to prolong the sensory and motor blockade of a spinal?

79
Q

What are the pros of using dexmedetomidine as an additive to a spinal?

A
  • Prolong sensory/ motor blockade
  • Postoperative pain control
  • Minimize shivering
80
Q

What are the cons of using dexmedetomidine as an additive to a spinal?

A
  • Bradycardia
  • Hypotension
81
Q

How is a T4 sensory level achieved with an epidural?

A
  • Volume of LA solution
  • Concentration
82
Q

Doses for epidurals are how many more times than spinal?

A

5-10x spinal doses

83
Q

Compare the onset of spinal and epidural

A
  • Spinal: Rapid/Immediate onset
  • Epidural: Gradual onset
84
Q

Why are epidurals not common for elective C-sections?

A
  • Reliability
  • Epidural can be less dense than a SAB
  • Patchy
85
Q

When will an Epidural be used in a C-section?

A

Unplanned C-section where epidural is already in situ

86
Q

What are considerations to take into account when epidurals are used for C-sections?

A
  • Dose up for operative anesthesia
  • Check/assess levels for “hot spots”
  • May require additional IV anesthesia
  • May require inhaled N2O
  • Conversion to GETA if not adequate
87
Q

What LA will be used for Epidurals?

A
  • Lidocaine 2% (rapid onset, short duration)
  • 2-Chloroprocaine 2-3% (rapid onset, short duration)
  • Bupivacaine 0.5% (intermediate onset, long duration)
  • Ropivacaine 0.5% (intermediate onset, long duration)
88
Q

How is 2-chloroprocaine 2-3% metabolized?

A

Pseudocholinesterase

89
Q

What receptors does 2-chloroprocaine 2-3% antagonize?

How does this affect morphine?

A
  • Mu & Kappa Opioid Receptors
  • Reduces efficacy of epidural morphine
90
Q

What can be added to Lidocaine 2% for an even faster onset?

91
Q

What is the risk of using Bupivacaine 0.5%?

A

Risk of cardiac toxicity

92
Q

Epidural dose of fentanyl for denser block

A

50-100 mcg

93
Q

What are the side effects of fentanyl in epidurals?

A
  • Pruritus
  • Early respiratory depression
  • Maternal somnolence
94
Q

What is the dose of morphine in epidurals to provide post-op analgesia for 12-24 hours?

Side Effects?

A
  • 1-3 mg morphine
  • Pruritus (dose-dependent)/ Late respiratory depression
95
Q

Dexmedetomidine dose for epidurals.
Risk?

A
  • 4-5 mcg per mL of LA
  • Risk of maternal bradycardia and hypotension
96
Q

How does Sodium Bicarbonate increase the onset of Lidocaine 2% in epidurals?

A
  • There will be more LA in the non-ionized state, which will increase the onset time
  • This will be very useful when there is an urgent need to dose up an epidural to avoid GETA
97
Q

When converting an epidural from a labor analgesia to surgical anesthesia, what do you do if there is a unilateral block?

A

Replace catheter if necessary​/if there is time

98
Q

When converting an epidural from a labor analgesia to surgical anesthesia, what do you do if there is a patchy block?

A
  • May be able to supplement with epidural opioids/adjuncts
  • Sometimes 50 mcg fentanyl in epidural can eliminate a “hot spot”
99
Q

What is the volume of LA to dose up an epidural for surgical anesthesia?

100
Q

What test is used to assess sensation before incision?

A

Allis test

101
Q

Indications for GETA for C-section

A
  • Fetal distress​ (Sustained fetal bradycardia​, “Heart tones are down”)
  • Maternal hemorrhage w/hypovolemia​ (Placental abruption, Uterine rupture)
  • Neuraxial anesthetic not possible​ (Coagulopathy / thrombocytopenia​, Infection​, Patient refusal)
102
Q

Pros of GETA for C-section

A
  • Rapid onset​ (Propofol & Sch)
  • Secured airway
  • Hemodynamic stability​
103
Q

Cons of GETA for C-section

A
  • Increased maternal mortality
  • Difficulty with airway management​
  • Failed oxygenation/ventilation​
  • Risk of aspiration
  • Mother not awake during delivery
  • No “support person” in the OR (depends on policy/provider)
  • Potential anesthesia recall​
  • Neonatal respiratory & CNS depression​
  • 1-minute APGAR scores lower with GETA
104
Q

GETA: Induction Sequence Part 1

A

GETA: Induction Sequence Part 2

105
Q

When do you initiate oxytocin (Pitocin) infusion during a C-section?

A
  • After delivery of the fetus
  • Announce that you are giving it
106
Q

Decrease VA to ______ MAC (range) after delivery of the fetus.

A

0.5-0.75 MAC

107
Q

Effects of Hypocapnia during C-section

A
  • Uteroplacental vasoconstriction​
  • Oxyhemoglobin dissociation curve shifts left​
  • Compromised fetal oxygenation​
108
Q

Effects of Hypercapnia during C-section

A

May cause maternal tachycardia

109
Q

Why would you give BZD during a GETA C-section?
When would you give BZD?

A
  • Reduce the risk of recall
  • Give after delivery
110
Q

When do you want to give systemic opioids during a GETA C-section?

A

Give after delivery​ (Reduced risk of neonatal respiratory depression​)

111
Q

_________ infusion potentiantes NDMB.

112
Q

ALWAYS check twitches after Succinylcholine (and before NDMD) due to the potential for___________ deficiency that can occur in pregnancy

A

Pseudocholinesterase

113
Q

Do you want to extubate awake or deep for a GETA C-section?

A
  • Awake d/t risk of airway aspiration
  • Suction OGT prior to extubation
114
Q

Pain management options for GETA Emergence of a C-section

A
  • Titrate in opioids
  • Transversus abdominis plane (TAP) block​
  • IV PCA​ post-op
  • Ketorolac and/or Tylenol administration​
  • Always verify that Ketorolac is OK with surgeon
115
Q

What are the treatments for Uterine Atony?

A
  • Pitocin/Oxytocin
  • Methergine/Methylergonovine
  • Hemabate/Carboprost
116
Q

What is the concentration of Pitocin?

A

10 units/mL

117
Q

What is the dose of Pitocin?
When do you give it?

A
  • 20 units in bag AFTER umbilical cord is CUT
118
Q

Side effects of Pitocin

A

Hypotension/Flusing (slow down infusion)

119
Q

Dose of Methergine/Methylergonovine.
Caution in what type of patients?

A
  • 0.2mg IM or IV
  • Caution with Hypertensive Patients
120
Q

Dose of Hamabate/Carboprost.
Caution in what type of patients?

A
  • 250mcg vial (1mL) given IM
  • Caution with Asthmatic Patients
121
Q

How does Hypotension cause N/V?

A
  • Cerebral & brainstem hypoperfusion → stimulation of medullary vomiting center​
  • Gut ischemia → release of emetogenic substances from intestines​
122
Q

How does Surgical Stimulation cause N/V?

A
  • Uterine exteriorization​
  • Intra-abdominal manipulation​
  • Peritoneal traction stimulation of vagal fibers
123
Q

How does Oxytocin cause N/V?

A

R/t hypotension

124
Q

How does Ergot Alkaloids (Methylergonovine) cause N/V?

A

Interaction with dopaminergic & serotonergic receptors​

125
Q

How does Hemabate cause N/V?

A

Stimulation of GI tract smooth muscle​

126
Q

Treatment for Shaking Moms post C-section?

A
  • Meperidine
  • Fentanyl
  • Give mom something in her hand to squeeze
127
Q

What can be supplemented if there is a failed or inadequate block?

A
  • Supplement with ketamine, precedex, N2O, moral support
  • If mom can’t tolerate → GETA
128
Q

What to do if a block is too high?
What can happen if a block is too high?

A
  • Supplement with O2, moral support, and pressors, may need to bag/mask (C3-C5)
  • Loss of consciousness, respiratory drive, or refractory HOTN → GETA

Advanced Principles A (17 decks)

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