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6-26-10 OB Mid Sess2

6-26-10 OB Mid Sess 2

QuestionAnswer
"maternal request is sufficient justification for pain relief during labor" came from who and when ACOG 1993
What are the other names for "Phase 0" Quiescence (also Latent)
What are the other names for "Phase 1" Activation (also Acceleration)
What are the other names for "Phase 2" Stimulation (also Maximum Slope)
What are the other names for "Phase 3" Involution (also Deceleration)
How many "Phases" of labor are there 4 of them (0,1,2,3)
In relation to "Phases", when does the Gravida become a Parturient (the Parturation takes place) Between Phases 2 and 3
Why is the hormonal feedback mechanism (oxytocin and prostaglandins) considered positive The more oxytocin produced creates more prostaglandins which creates even more oxytocin which creates even more prostaglandins (which increase the strength of contraction
What happens in the "First Stage" of vaginal delivery Cervix dilates
What happens in the "Second Stage" of vaginal delivery Infants head enters this brutal world
What happens in the "Third Stage" of vaginal delivery Baby out of uterus, placenta jumps out and wows the crowd
What are the 3 "P"s of "ComPonents of Labor and Delivery" POWERS (uterine contractions and in 2nd stage, voluntary expulsive efforts), PASSAGEWAY (bony pelvis and the soft tissues contained therein), PASSENGER (the fetus: Lie, presentation, position)
What does PROM stand for Premature rupture of membranes
3 classifications (times) of PROM Preterm, Term, Chorioamnionitis
What is it called during delivery when the fetus's anterior shoulder is trapped above the pubic symphysis "Shoulder Dystocia"
He believed women in primative cultures did not think childbirth was painful Dick-Reed
"poena magna" is from who and means what Romans - means the great pain or great punishment
Who is associated with "Ceiling pain" Hardy and Javert
The McGill Pain Rating Index is scale from 0 to what number 50
What are the two main Components to Labor Pain Visceral Component and Somatic Component
Visceral Component involve what fibers C-fibers
What Stage is Visceral Component part of First Stage
Somatic Component involves what fibers A delta fibers
Somatic Component is part of what Stage Late First Stage and all of Second Stage
What nerve plexus innervates the ovaries Ovarian Plexus from T10
What is the major labor pain pathway called Sympathetic chain from T10, T11, T12, and L1
Five things that happen in the First Stage of Labor Pressure on nerve endings on body and fundus of uterus, Contraction of an ischemic myometrium and cervix, vasoconstriction, inflammatory changes, dilation of the cervix and lower uterine segment
Dilatation, Distention, Stretching, and Tearing of the cervix and lower uterine segment during a contraction is part of what Stage of Labor First Stage
Pain of the second and third stages of labor consists of what three things TRACTION (on the pelvic peritoneum and uterine ligaments), TENSION (on bladder, rectum, ligaments, fascia, and muscles in pelvis), PRESSURE (on lumbosacral plexus)
Factors that influence severity of pain Pain tolerance, environmental suppport and cultural factors ("refined women experience more pain than savages") -Slide 26 makes more sense than this slide 25 - common sense thing like the size of child vs birth canal
Known for "Natural Chilbirth" and "Childbirth without Fear" Dick-Read
Known for "lamaze Method" and Psychoprophylaxis Fernand Lamaze
Known for "Birth without Violence" Leboyer
Ulysses directive is A directive statement wishing not to have an epidural even though they change their mind once they start having pain
What happens with MAOI and Demerol Severe adverse reaction
Why is the timing of demerol and birth time important Peak fetal uptake is 2-3 hours after demerol is given - so birth within 1 hour or more than 4 hours
BLocks given in L&D Pudendal, Paracervical, Caudal, Lumbar sympathetic block, infiltration
Paracervical block stops afferent nerve transmission at the Frankenhauser's Plexus (goes straight to fetus)
Paracervical Block complications Reflex bradycardia, Fetal CNS and myocardial depression, Increase uterine activity, and uterine artery vasoconstriction
Where is the Paracervical block -at the corner of "Vagina" and "Cervix"
Indications for general anesthesia during vaginal delivery (7 of them) Fetal distress during second stage, tetanic uterine contractions, breech extraction, version and extraction, manual removal of a retained placenta, replacement of an inverted uterus, and for psychiatric patients who become uncontrollable
Contraindications for neuroaxial blockade (6 of them) Pt refusal, increased ICP r/t mass, infection at site, frank coagulopathy, uncorrected hypovolemia, and unexperienced personnel performing
Disadvantages of epidural analgesia for L&D (7 of them) Maternal effects, fetal effects, prolonged labor, c/s rate, motor block, bedrest, and complications
Direct effects of epidural analgesia on labor Uterine muscle hyperactivity, Skeletal muscle issues (decreased expulsive forces, inability to change positions, reduced pelvic floor muscle tone, increase in operative deliveries, and dosage formulas
Indirect effects of epidural analgesia on labor (3 of them) Decreased uteroplacental perfussion (@ 20 min mark), alteration in oxytocin metabolism, and impaired reflex activity
How does labor analgesia cause fetal bradycardia (2 reasons) 1)Pain relief decreases SNS output of epinephrine (which is a tocolytic), without epinephrine uterine tone increases decreasing placental blood flow causing bradycardia. 2)Pain relief and/or spinal/epidural decreases BP which causes increased uterine tone
Treatment for fetal bradycardia (7 things) Uterine displacement, correct hypotension, give O2, turn off Pitocin, fetal scalp stimulation, change materal position, and tocolytics (terbutaline or nitroglycerine IV or SL)
Anesthesia for vaginal delivery (4 of them) Lumbar epidural (local anesthesia only), Caudal block, Saddle block (spinal anesthesia), combined spinal-epidural (trial of forceps/possible C/S)
Criteria for ambulation during labor with neuraxial analgesia (8 of them) Fetal status not jeopardized, engagement of fetal head, stable orthostatic vital signs, able to perform bilateral straight leg lift against resistance, able to step up on stool, no gait problems, never walk alone, and fetal monitoring Q 15 min
What is the half life of LR 20-30 minutes
Pre hydration starting amount for epidural/spinal should be ?ml/kg 20ml/kg to start
What risk increases when inserting an epidural needle during a contraction A venous stick r/t engorgement
What should you do different on an obese pt with regards to taping an epidural Dont tape until they lay down - pre taping may pull cath out when they lay down
On an obese pt, what is the coccyx to L2-L3 distance in inches (approx - used because bad landmarks) About 6 inches (can't wait to put this information to work)
When administering your 1% lido to numb for epidural, what do you add a "splash" of to decrease burning Bicarb
What position should your epidural cath be in before applying tegaderm J hook or dbl J hook - for slack in case it gets pulled on
Which way should you always go with epidural: Cephlad or Caudal Cephlad - r/t nerve roots (caudal leds to follow nerve roots and go outward)
Pain when threading epidural cath is Never good
What might happen if you use more than 5cc or air for loss of resistance Air emboli and/or spotty block
What is the best length for epidural catheter insertion into the epidural space 4-6 cm
When you aspirate from epidural cath what are ways to differentiate between saline and CSF Check temp by dripping on gloved hand, glucose test, and thiopental-bicarb test (CSF stays clear, Local precipitates in high pH)
What are the S/S (first to last) of local anesthetic toxicity during epidural/spinal Numbness of tongue, light headed, visual/hearing disturbances, muscular twitching, unconciousness, convulsions, coma, respiratory arrest, CVS depression, and skid marks
Epidural test dose usually contains Lidocaine 45mg and Epinephrine 15mcg
Series of T/F: #1 Before each injection of an epidural local you should lower the catheter below injection site and check for blood or CSF return True
Series of T/F: #2 Before each injection of an epidural local you should aspirate before injecting each dose of local anesthetic True
Series of T/F: #3 Before each injection of an epidural local you should wait until contraction is over True
Series of T/F: #4 Before each injection of an epidural local you should dilute solutions of LA during labor True
Series of T/F: #5 Injection of an epidural local, you should not give more than 5 ml at a time True
Series of T/F: #6 Before each injection of an epidural local you should maintain verbal contact with your patient True
T/F: Give your test dose during a uterine contraction False - if given during a contraction you can't tell if HR is due to contraction or Epinephrine
To treat bradycardia from LA toxicity use Atropine
To stop convulsions from LA toxicity use (3 things) Barbiturate, Benzodiazepam, and/or Succinylcholine
In LA toxicity support blood pressure with Fluids and vasopressors
T/F: Mepivicaine is used in OB epidurals False - it crosses the placenta
Will mepivicaine or buprivicaine have the fastest onset, why Mepivicaine is fastest, pka = 7.6--- bupivicaine pka = 8.1
T/F: Lipid solubility = potency True
T/F: Protein binding = duration True
T/F: pKa = Onset speed True
The #1 complication of intrathecal opioid injection puritis
Intrathecal fentanyl dose 10-25 mcg
Created by: smorrissey1 on 2010-06-26



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