Vag and C-section PPT McDizzle's lecture Flashcards
Something to consider epidural analgesia is PAIN control, epidural is blocks LA
ACOG
American Congress of Obstetricians & Gynecologist
on 1993 the ACOG committee on pain relief during labor number 118 stated what?
“…. maternal request is sufficient justification for pain releif during labor….”
ASA
American Society of Anesthesiologist (aka Anesthesiologist are a Sublevel of Anesthetists)
Ingards to Mcd’s research on intrathechal and eidural analgesia he found out what?
that the length of labor was NOT prolonged using intrathechal or epidural opiods, and may shorten the 1st stage of labor in both primi and multiparious women.
Regional anesthesia for child bearing is philosophy both _____ and _____
- Safe
- Participatory (providing the opportunity for individual participation )
What occurs in the 1st stage of labor (5 main body changes)
- Pressure on nerve endings of the uterus
-Contraction of an ischemic myometrium and cervix
-Vasoconstriction
-inflammatory changes
-Dilation of the cervix and lower uterine segment
( how to remember– 1st
the PRESSURE on the nerve ending of the uterus cause VASOCONSTRICTION, which causes the contraction of an ISCHEMIC MYOMETRIUM AND CERVIX, which causes INFLAMMATORY CHANGES, and thus DILATION of the cervix and lower uterine segment)
I dunno maybe it will help???
What causes the 1st stage perceptions?
result of dilation, distention, and stretching of the cervix and lower uterine segment during contraction.
What Causes perception during the 2nd and 3rd stages of labor?
-Traction on the pelvic peritoneum and uterine ligaments
-Tension on the bladder and rectum
-tension on the ligamnets, fascia and muscles of the pelvis
-Pressue on lumbrosacral plexus
(how to remember- stage 2 and 3 the baby is moving down so the pain is lower and it STRETCHES everything by pulling it down)
Somatic pain in the 2nd stage of labor via vaginal and perineal in orgin are from what nerves
pudendal nerves S2-4
What dermatomes cover the perineum
S2-S4
what ligaments are stretched or placed under tension in stage 2 and 3 of labor
- Round ligaments
- Superior pubic ligaments
- Broad ligament
- Cardinal ligament
What factors can influance the perception of Pain r/t labor
- pain tolerance
- Pain threshold
- Individual factors (Intrapersonal, interpersonal, societal)
- Supportive structures
- Cultural factors
What are the 3 NON-pharmacological pain releif THEORIES for prepared child birth?
Grantly Dick-Reed (childbirth without fear)
Lamaze (Psychoprophylaxis)
Fredrick Le Boyer (Birth without Violence)
explain Grantly Dick-Reed non-pharm pain relief for birth
(Childbirth without Fear)
- Natural childbirth
- Believed that pain was a result of not knowing what is happening during labor and delivery
Explain Lamaze non-pharm pain relief for birth
(Psychoprophylaxis)
-Relaxation and breathing techniques
Explain Fredrick Le Boyer non pharm pain relief for birth
(Birth without Violence)
- gentle approach to birthing using “bath” placing women into a bath to ease the transition from the womb to the real world
What are 4 other non pharm pain releif for labor
Hypnosis
TENS
Acupunture
Alternative birthing options
Advantages of systemic analgesics for labor.
5
Ease of use Staffing no IV required (IM) Minimal monitoring Few complications
Disadvantages of systemic analgesics for labor (5)
effectivness depression respiratory decreases N/V Fetal depresion
Main disadvantage of systemic analgesics for labor
Don’t work very well
Opioids for labor with potency
Demerol 0.1 (1/10) Morphine 1 (of historic interest only) Alfentanil 10-5 Fentanyl 75-125 Sufentanil 500-1000
Opioid agonist/Antagonists for labor pains (with potency if u care)
- Nalbuphine (nubain) 0.7-0.8
- Butorphanol (Stadol) 5
- Pentazozine (Talwin) 30-60 mg = 10mg morphine
********** Why is stadol out of favor for use in some OB settings?
Due to a 75% incidence of transient sinusoidal fetal heart pattern (considered benign)
can cause narcotic withdrawl in narcotic addicts
Sedatives for Vaginal OB labor (3)
Phenothiazines
Benzodiazepines
Butyrophenones
Examples of Phenothiazines for sedatives
Thorazine
phenergan
Examples of Benzodiazapines for sedatives
Versed
Valium
Examples of Butyrophenones for sedatives
Haldol
droperidol
Anticholinergics
Atropine
Scopolamine
Glycopyrrolate
What to remember about robinul (glycopyrrolate)
it does NOTcross the BBB
what are 3 periphreal nerve blocks for L&D
field block
Pudendal nerve block
Paracervical Block
What are complications of the paracervical block do to? and what are the complications?
-Do to large volumes
complications are
- LA toxicity
- Fetal bradycardia
hat is the gold standard for INVASIVE intervention r/t labor pains
Epidural
Advantages of epidural
greatful pt excellent anesthesia may improve dysfunctional labor Can be raised for a C-section Minimizes risk of (maternal aspiration, and fetal depression) increased SPo2 Lower VAS pain scores Higher fetal scalp pH
what type of solutions must be used for epidural and intrathecal spaces
preservative free
Is there a better APGAR score from epidurals?
Nope no difference
what causes the higher SPO2 levels with epidurals?
-lower RR when comfortable, (b/c high RR mover primarily dead space air)
**********Epidural dosing rational (one of many
- Find the space
- Loading dose
- —20ml of 1/8 (0.125)% bupivacaine + 100 mcg fentanyl.
- — Give in divided doses
- Infusion
- — 50ml 1/16 (0.0625)% bupivacaine + 100mcg fentanyl
- — infuse @ 10-15 ml/hr
Complications of an epidural
hypotension total spinal LA toxicity Headache Local site pain
Epidural contraindications
Pt refusal
Coagulopathies (plt <100)
Infection at injection site
Uncorrected hypovolemia
what is always a regional anesthesia contraindication
significant fetal distress
what position for SAB ensures that all nerves get bathed with hyperbaric LA solution whan pt is placed in LUD prior to c-section
Right lateral decubitus
ITA (intrathechal Anesthesia) morphine SE:
itching
N/V
urinary retention
ITA doses of fent and morph WITH or WITHOUT any LA
25mcg fentanyl + 100-150 mcg morphine called astromorph/duramorph)
—–side note i know it says mcg for morphine that is per his slide not my typo
ITA advantages
excellent analgesia
No sympathtic block
Ambulatory block
SAB are possiable for devivery but not for what
Labor
What is teh best combined tech for labor OB pain control
Perform ITA for Labor and also place an epidural cath for use later
Beware of what, b/c you must be prepared for emergent intervention
VBACS (vaginal birth afetr c-section)
Epidural analgesia for L&D advantages
- awake pt
- avoids risk of somulence
- decreased hypoxia
- decreased hypercarbia
- decreased aspiration
- continuous
- ready for C/S
- safe
Epidural analgesia for L&D disadvantages
- Maternal affects
- fetal affects
- ? prolonged labor (not according to McD)
- ? increase in C/S rate
- ? motor block (if too high conc given)
- ? bed rest
Indirect effects of epidural analgesia on hemodynamics
- uteroplacental perfusion usually secondary to hypotension (preload)
- oxytocin metabolism
- circulatory reflex depression
epidural tech issues to condsider
- lateral vs sitting
- LOR tech (air vs saline, glass vs plastic) ((LOR= loss of resistance)
- catheter direction
- How for to insert catheter (2-3 cm per McD) or 3-5 cm
How do u know where you are at with an epidural?
aspiration -CSF -Blood Test dose monitoring
what are the doses for test doses with an epidural placement check?
3ml of 1.5% lidocaine w/ 1:200,000 epi (5mcg/ml)
what will occur with a test dose of fentanyl if not in the correct space?
drop in HR
S/S suggesting that it may be a SAB not an epidural
Signs
- sensory block
- Motor weakness
- Hypotension
Symptoms
- Warm sensation
- Pain releif
- Numbness
What are pregnancy issues that can cause problems inassociation with epidural placement?
- Epidural space volume changes
- venous sinuses
- physical size
- positioning (ICV syndrome)
ICV syndrome?
between epidural and intrathecal modes of delivery is … Intracerebroventricular (ICV)
Common local agents
Bupivacaine
Lidocaine
2.3 chloroprocaine
(opiates are usually added)
what are problems u may have to deal with from performing SAB
- wet tap
- blood in catheter
- hypotension
- high block
- motor block
- inadequate analgesia
what type of anesthesia is seldom used for vaginal delivary and according to M&M is worse than regional
General
Advantages of GETA withC/S
Speed of induction
reliability
control
avaoidence of hypotension
Potential GETA problems
Maternal aspiration Airway difficulties Awareness Stress response Increased blood loss
Indications for GETA
- Acute fetal distress
- Hemodynamic instability
- Cardiac disease
- Coagulopathy
- Sepsis
- failed regional
if the stomach is full (as we already learned they all are) what should we give prior to GETA
Metacloprimide 10 mg IV +
Randetidine 50 mg IV +
Na Citrate 30 ml PO (chill it, it is disgusting otherwise)
Why should u make sure you fully denitrogenate prior to GETA
decrease apnea to hypoxia time
With GETA prior to sux’s what should you pretreat with to prevent fasiculations, myalgia, gastric pressure increase?
NDNMBD (lol thats long) NDMB)
Induction agents for GETA for labor?
sodium thiopental methohexitol hetamine etomidate propofol midazolam
GETA concerns r/t HYPERventilation
- decreased uterine blood flow
- left shift of maternal O-HDC
- decreased ability to deliver O2 to baby
What is the most important factor r/t neonatal depression with a GETA?
time from induction to delivery
3 major indications for C/S
- labor unsafe for mother or fetus
- Dystocia
- immediate or emergent delivery is necessary
GA is not routinely used for elective C/S it is typically reserved for what?
Obstretrical emergencies
4 main indications for GA with labor
- contraindications to regional
- Failed regional block
- fetal distress
- patient refusal
When time is limiting ________ ________ is sometimes necessary b/c it offers speed of induction, reliability, controllability, and avoidance of sympathectomy induced hypotension
general anesthesia
preparation for GETA for labor
- Airway elavuation
- Aspiration prophylaxis
- experienced personal and backup plans
- fetal considertions
How to conduct GETA with labor
- basic prep
- positioning and monitoring
- induction (RSI with cricoid pressure) (intubate with 6.0-7.0 cuffed ETT)
-Maintance - emergence (pt extubated awake with airway reflexes intact)
(if pt unstabe OETT remains in place)
The obese parturient is at greater risk for medical diseases r/t what systems
- CV
- Respiratory
- Endocrine and metabolic
- GI
What are the 4 airway considerations wit the obese parturent?
- limited neck flexion and mouth opening
- narrowed view of pharyngeal opening
- Higher incidense of failed intubation
- proper positioning of the head and neck may facilitate ET intubation
What may position facilatates endotracheal intubation for the paturient
elevation of shoulder
flexion of cervical spine
extension of atlanto-occipital joint
