Week 16 - OB

Question 1

What are the pain pathways of labor? (what spinal levels are associated)

Answer 1

1st Stage: visceral, non-localized aching or cramping – T10-12 and L1

2nd Stage: cervical dilation complete and presenting part descends into the pelvis – S2-4

Question 2

What four factors are critical to a woman’s childbirth experience?

Answer 2

• Personal expectations
• Amount of support from caregivers
• Quality of patient-caregiver relationship
• Patient’s involvement in decision making

Question 3

What may poorly controlled pain in childbirth result in?

Answer 3

• Increased risk of chronic pain
• Postpartum depression
• Negative impact on newborn care

Question 4

What is considered the gold standard analgesia for labor and vaginal delivery?

Answer 4

Neuraxial techniques

• epidural (indwelling catheter affords ability to produce segmental blockade and provide additional dosing)
• intrathecal
• combined (provides best attributes of both a spinal and epidural w/ minimal disadvantages)

Question 5

What are the benefits of neuraxial imaging?

Answer 5

• May be beneficial when landmarks can’t be palpated
• More accurate at determining inter-spinous level, depth to ligamentum flavum

*Two imaging views – parasagittal and axial

Question 6

Describe epidural dosing

Answer 6

• T10-11 dermatome level is goal
• Incremental dosing (5mL max)
• Low concentration LA (ex. 0.25% bupivacaine)
• Maintain analgesia with intermittent boluses and/or continuous infusion

Question 7

What are the circumstances in which a single shot spinal is appropriate for a laboring patient?

Answer 7

• Multiparous patient in advanced second stage
• Those with poor pain control, to facilitate epidural placement
• Mother laboring without analgesia requiring an instrumented delivery

Question 8

What are the side effects of neuraxial opioids?

Answer 8

• Respiratory depression
• Itching
• Urinary retention
• N/V

Question 9

What are common indications for C-section?

Answer 9

– Cephalopelvic disproportion
– Non-reassuring fetal status
– Arrest of dilation 
– Malpresentation 
– Prematurity
– Previous cesarean section or uterine surgery

Question 10

What are the advantages of neuraxial anesthesia over general anesthesia for C-section?

Answer 10

Neuraxial anesthesia is preferred over general anesthesia:

• decreased risk of mortality due to failed intubation
• decreased risk of aspiration of gastric contents
• better neonatal outcomes
• ability of mother to participate in the birth

Question 11

What is the most common anesthetic technique for C-section?

Answer 11

Single-shot spinal

• simple to perform
• rapid onset
• reliable block
• less toxic

0. 75% hyperbaric bupivacaine is LA of choice
   * T4 level needed

Question 12

The choice of anesthesia for C-section depends on what?

Answer 12

• Maternal status
• Urgency of surgery
• Fetal condition
• Patient’s desires

Question 13

What are the advantages of epidural anesthesia for a C-section? How is it dosed?

Answer 13

• Less abrupt blood pressure changes
• Ability to re-dose catheter
• Epidurals placed for labor analgesia are used to provide surgical anesthesia

Dosing: 2% lidocaine w/ 1:200,000 epi – 10-15 mL required to achieve T4 level

Question 14

What are the indications for general anesthesia for C-section?

Answer 14

• Neuraxial not in place, urgent delivery required
• Patient refusal of neuraxial
• Coagulopathy