week 3 pain pathways (everything) Flashcards
which labs need to be obtained during the initial visit of the mother (11)
CBC Typing, Rubella antibody, Cervical gonorrhea and chlamydia culture. VDRL, HBsAg (Hep B) Pap, Urine complete, PPD (TB) HIV (with consent) BG
15-20 weeks
MATERNAL ALPHA FETOPROTEIN: increase in neural tube defects (NTD) and decrease in Downs syndrome. Triple screening (AFP,HCG, Estriol). If abnormal, do U/S or amniocentesis
Folic acid decrease risk of NTD
18-20 weeks
U/S for dating. Best time to access fetal development
24-28 weeks
Glucose test for ALL
28-30 weeks
RhoGAM to Rh(-ve) mom
34-38 weeks
CBC
36-40 weeks
Cervical chlamydia and gonorrhea culture in high risk patients
does oxytocin level increase during labor
NO!
so how does labor start if there is not increase to level of oxytocin
(2 answers)
there is increase sensitivity of myometrium to oxytocin
increase synthesis of prostaglandins by fetal membrane and decida helps to start labor
the physiological presentation of labor:
- Increased sensitivity of myometrium to oxytocin
- synthesis of prostaglandins by fetal membrane and decida
- Lightening
- Braxton Hicks contraction
- Cervical effacement
- Bloody show due to breaking down of mucous plug
- Rupture of amniotic membrane
- Cervical dilatation
Maternal physiology at labor there is a 300% increase in
in minute ventilation
in labor what happens to maternal oxygenation?
60% increase in oxygen consumption
maternal Hyperventilation in labor results in:
decrease PCO2 < 20 mmHg; transient hypoventilation; maternal and fetal hypoxemia; reduce uterine blood flow and fetal acidosis
Each contraction pushes what vol of blood into the circulation?
what is this called?
300-500 ml of blood into circulation – auto transfusion
maternal CO results in (increases by how much)
a 45% increase in cardiac output
After delivery ,involution of uterus relieves inferior vena caval obstruction resulting in:
80% increase in cardiac output and stroke volume
First
Latent
CO?
15% increase
first
active phase
co
30% increase
second phase CO
45%
third phase CO
80%
First latent phase start/end
events
Regular uterine contractions/ 4 cm dilatation
Cx effaces and slowly dilate
first active phase start end
events
4 cm/10 cm (complete dilatation)
Regular intense contractions, fetal head descends into pelvis
second phase start/end
events:
Complete cervical dilatation/delivery of baby
Baby undergoes all stages of cardinal movements (Engagement, Descent, Flexion, Internal rotation, Extension, External rotation, Expulsion)
third phase start/end
events:
Delivery of baby/delivery of placenta
Placenta separates and uterus contracts to establish hemostasis
first stage– pain initial spot- progression.
level of spinal anesthesia must cover what sections
Pain is initially T11-T12 then progress to T10-T12 and L1 during active labor.
level of spinal anesthesia must cover T10-L1
second stage- pain spot
level of spinal anesthesia must cover what sections:
Pain through by pudendal nerve (S2-S4)
Somatic pain caused by stretching of vagina and perineum by descent of fetus
Level of spinal anesthesia is needed for S2-S4
first stage- cause of pain? what is the pressure ?
1st stage: Cause of pain is uterine contractions and exceeds 25 mmHg pressure and dilate Cx.
level of anesthesia for c section
T4
how is pain and temperature mediated in the genitalia
autonomic nervous system- not lateral spinothalamic tract
Uterus and Cx- pain levels ?
pain is carried by what fibers
T10 to L1-2
Pain impulses carried in visceral afferent C fiber
Perineum
S2,S3,S4
Pain impulses carried by somatic nerve fiber; pudendal nerves
Inhalation agents
effects on uterus
Cause uterine relaxation - increase blood loss
Parentral agents effects on labor
Opioids minimally decrease progression of labor
Regional anesthesia is given for:
Primigravida Prolong labor High parenteral analgesic requirement Use of oxytocin Large baby Small pelvis Fetal malpresentation
Vasopressors
a1 stimulation effects
uterine contraction
Vasopressors
b2 stimulating effects
uterine relaxation
Small dose on phenylephrine effects
increase blood flow increase bp
Oxytocin uses
Used to induce labor and to prevent postpartum blood hemorrhage
oxytocin complications:
Complication: fetal distress, uterine tetany, maternal water retention, hypotension, reflex tachycardia
Ergot alkaloids
uses
to treat uterine atony
What is used to treat PPH?
Prostaglandins
Magnesium
uses
Use to stop premature contraction and to prevent eclamptic seizures
magnesium side effects
Side effects: hypotension, heart block, muscle weakness and sedation. Also INCREASES blockage of non-depolarizing agents. Cardiac and respiratory arrest can occur
treatment for magnesium side effects
Treatment
D/C- mag
Calcium
Lasix
B2 agonist
stop premature labor
Hypotension
Ephedrine, oxygen, left uterine displacement and IV fluids. Small doses of phenylephrine can also be used
Unintentional IV injection (of epidural)
Place supine with left uterine displacement
Thiopental or propofol to stop seizures
Unintentional intrathecal injection
Place supine with left uterine displacement
Ephedrine and fluids
Intubation and ventilation in high spinal
Postdural puncture headache
Bed rest
Hydration
Oral analgesic
Caffeine
Postdural puncture headache
blood patch
Signs of Fetal Distress (7)
Repetitive late deceleration Loss of beat-to-beat variability Fetal heart rate < 80 Fetal scalp pH < 7.20 Meconium stained amniotic fluid Oligohydramnios Intrauterine growth retardation
Obesity what % of ideal body weight
BMI
morbid obesity BMI
> 20% of ideal body weight
BMI >30
BMI>40
obesity labs
High glucose, cholesterol and TG
obesity PFT results
restrictive lung disease
obesity breathing issues
increase work of breathing
decrease ERV (expiratory reserve volume)
decrease FRC
decrease chest wall compliance
in morbid obesity- closing capacity results in
In morbid obesity, closing capacity exceeds FRC - V/Q mismatch - arterial hypoxemia
obesity distribution of lipid soluble drugs
Increase volume of distribution for lipid-soluble drugs
treatment for pickwickian syndrome
Oropharyngeal appliances
Positive pressure nasal mask
Surgery
Obesity-hypoventilation syndrome leading to (ten things total listed)
Hypercapnia Hypoxemia Somnolence; poor sleep at night Pulmonary HTN Systemic HTN RVH / LVH Dependent edema Cyanosis-induced polycythemia Rales Pulmonary edema
