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OB VAGINAAL & C/S

Princinples II (REGIONAL)

QuestionAnswer
Who is ACOG American Congress of Obsteticians and Gynecologist
What is their opionion on pain Relief uring labor #118 1993 states that ....maternal request is sufficient justification for pain relief during labor.
Join statement by ACOG and ASA was approve when was approved by ASA house of delegates on oct 13, 1999.
what was the statements of ACOG and ASA Labor results in severe pain for many women. There is no circumstance where it is considered acceptable for a person to experience untreated severe pain, amennable to safe intervention.
Regional anesthesia for childbearing is Philosophy-> -safe participatory
1st stage of labor is Pressure on nerve endings of the uterus Contraction of an ischemic myometrium & cervix Vasoconstriction Inflammatory changes Dilation of the cervix and lower uterine segment
Who is ACOG American Congress of Obsteticians and Gynecologist
What is their opionion on pain Relief uring labor #118 1993 states that ....maternal request is sufficient justification for pain relief during labor.
Join statement by ACOG and ASA was approve when was approved by ASA house of delegates on oct 13, 1999.
what was the statements of ACOG and ASA Labor results in severe pain for many women. There is no circumstance where it is considered acceptable for a person to experience untreated severe pain, amennable to safe intervention.
Regional anesthesia for childbearing is Philosophy-> -safe participatory
1st stage of labor is Pressure on nerve endings of the uterus Contraction of an ischemic myometrium & cervix Vasoconstriction Inflammatory changes Dilation of the cervix and lower uterine segment
what causes 1st stage perception? First stage of labor is the result of dilation, distention, and stretching of the cervix and lower uterine segment during contraction
Perceptions during 2nd and 3rd stages of labors are? Traction on the pelvic peritoneum & uterine ligaments Tension on bladder and rectum Tension on ligaments, fascia and muscles of the pelvis Pressure on lumbosacral plexus
What kind of pain during 2nd stage of labor Somatic pain. This affect the pudental nerves: S2-4
What dermatones cover the perineum? S2-4
What are the perception of labor experience? Factors influencing severity of pain: pain tolerance pain threshold individual factors (intrapersonal, interpersonal, societal) supportive structures cultural factors
Nonpharmacological pain relief are? Method used to relief pain other than pharmacology. and this is prepared childbirth, hypnosis, tens, accupuncture, and alternative birthing options.
Type of prepared childbirth are? Grantly Dick-Reed (Childbirth without Fear) Lamaze (Psychoprophylaxis) Fredrick Le Boyer (Birth without Violence
TENS transcutaneous electrical nerve stimulation
What the advantage of systemic analgesic for labor Ease of use staffing no IV required (IM) Minimal monitoring few complications
what are disadvantages for systemic analgesic for labor Effectiveness Depression Respiratory decreases N/V Fetal depression
What are some opioids used during labor Fentanyl, Sufentanil, Alfentanil, Demerol, and Morphine (of historical interest only)
Potency: morphine=1; demerol=0.1; alfenta=10-25; fentanyl=75-125; sufenta=500-1000 (S & M, p.113)
Agonist/antagonist Nalbuphine (Nubain), Butorphanol ( Stadol), Pentazozine (Talwin).
Agonist/antagonist potency N & Z, p. 157; S & M, p. 120; Chestnut, p. 315-6 Potency: nubain- 0.7-0.8; stadol- 5; Talwin- 30-60 mg = 10 mg morphine Note: Stadol is out of favor for use in some OB settings due to a 75% incidence of transient sinusoidal fetal heart patterns (consid
Sedatives Phenothiazine; benzodiazepines, and butyrophenones
What are examples of phenothiazines - thorazine, phenergan;
What are examples of benzo Versed, valium
What are example of butyrophenones Haldol and droperidol
Anticholinergic Atropine, scopolamine and glycopyrolate
Does glycopyrolate cross BBB No it does not cross the BBB
Some peripheral nerve blocks for L&D are Field block; Pudendal nerve block, paracervia block ->with complications of local anesthesia toxicity and fetal brady cardia
What are complication of peripheral nerve block in pregnant women local anesthesia toxicity and fetal bradycardia.
What is the "gold standard" of invasive intervention? Epidural
Why Epidural Grateful patient Excellent analgesia May improve dysfunctional labor Can be raised for C-Section Minimizes risk of -maternal aspiration -fetal depression Lower VAS pain scores Inc oxygen sat Higher fetal scalp pH BUT… no signif diffe in Apgar sc
What type of solution is used in epidural and intratechal space? Preservative free solution
VAS Visual analogue score
Why do you need to asked OB anesthetist their protocol for epidural drugs because loading dose and infusion rate may be different at different clinical sites or hospital.
Epidural ( one[of many] dosing rationales Find the space! Loading dose: 20ml of 1/8 (0.125)% bupivacaine + 100mcg fentanyl. Give in divided doses Infusion: 50ml 1/16 (0.0625)% bupivacaine + 100mcg fentanyl infuse at 10-15 ml/hr
What are Epidural complications Hypotension Total spinal Local anesthetic toxicity Headache Local site pain
Epidural anesthesia contraindications Patient refusal Coagulopathies Infection at injection site Uncorrected hypovolemia
Regional anesthesia contraindication Significant fetal distress
Subarachnoid block Possible for delivery but not for labor True “saddle” vs. low spinal Administration position upright vs. lateral position
right lateral decubitus position for SAB ensures that all nerves get bathed with hyperbaric LA solution when pt placed in LUD prior to CS
Intrathecal Analgesia ( with or without any local) 25mcg Fentanyl + 100-150 mcg Morphine (astromorph/duramorph)
What happen with ITA morphine Itching, N&V, and urine retention
what are the advantages of intrathecal analgesia (ITA) Excellent analgesia, No sympathetic block and patient can ambulate
Combine techniques (the best of both world) are Performed ITA for labor and also place an epidural cath for use if needed later.
A word of warning? Beware of VBACS ( vaginal birth after c/s). Be prepared for emergent intervention
What are the advantages for epidural analgesia for L&D awake patient avoids risks of somulence ↓ hypoxia ↓ hypercarbia ↓ ASPIRATION continuous ready for C/S safety
What are the disadvantages of epidural analgesia for L&D Maternal affects Fetal affects ? Prolonged labor ? ↑ C/S RATE ? Motor block ? Bed rest
Epidural analgesia effects on labor Potential Effects: UTERINE MUSCLE SKELETAL MUSCLE ? explusive forces ? ability to change positions pelvic floor muscle tone ? Operative deliveries
hemodynamics with epidural analgesia Indirect effects: uteroplacental perfusion oxytocin metabolism circulatory reflex depression
Technique issues are Lateral Vs sitting LOR tech (air Vs saline, glass Vs plastic) Catheter direction How far to insert catheter
What is LOR loss of resistance; Catheter should be inserted about 3-5cm
Where is the catheter? Do you ever REALLY know? Aspiration -CSF -blood Test dose -what -why Monitoring
Is that CSF Amount of return and the temperature
S&S suggesting that it may be a SAB (Spinal anesthesia block Signs are Sensory block; Motor weakness; and Hypotension Symptoms are Warm sensation; Pain relief and Numbness
Test dose Epinephrine & local Monitor HR & B/P Alternatives (eg fentanyl) 3 ml local anesthetic with 1:200,000 epinephrine (15 mcg/ml). Brown, p340
What are pregnancy issues with epidural? Epidural space volume changes Venous sinuses Physical size Positioning (ICV syndrome)
What are the common Local agent Bupivacaine Lidocaine 2,3-Chloroprocaine Opiates usually added
WDosing Issues are Incremental Vs continuous Infusion formulae “Top off” doses (5 mL increments)
Problem Management with Epidural “ wet tap “ Blood in catheter Hypotension High block Motor block Inadequate analgesia
Epidural failure ? Drug dose, ? Catheter placement, and ?time
General Anesthesia during labor Fortunately, seldom used for vaginal delivery M & M : worse than with regional anesthesia
Proxima Causa Mortae Aspiration - -3X more common FAILED INTUBATION: -general surgery - 4.5/10,000 -OB & C-Sections - 35/10,000
Advantages of GETA Speed of induction Reliability Control Avoidance of hypotension
Potential GETA problems Maternal aspiration Airway difficulties Awareness Stress response Increased blood loss
What are the indications for GETA Acute fetal distress Hemodynamic instability Cardiac disease Coagulopathy Sepsis Failed regional techniques
If the stomach is full ( as they all) Metoclopramide 10 mg IV + Randetidine 50 mg IV + Na Citrate 30 ml PO
GETA techniques Airway assessment Know (and practice!) failed intubation procedures Difficult airway cart available Staff education Aspiration prophylaxis
GETA considerations are Positioning, monitors and preoxygination
Why preoxygenate? alterations in respiratory physiology. decrease apnea to hypoxia time denitrogenation
Pretreat with NDNMBD for fasiculations after suc. Myalgia gastric pressure
Induction Agents Sodium thiopental Methohexitol Ketamine Etomidate Propofol Midazolam
GETA Concerns Hyperventilation: -↓ uterine blood flow -Left shift of maternal O-HDC -↓ ability to delivery oxygen to baby Neonatal depression: -time from induction to delivery is THE important factor
General anesthesia is not routinely used for elective cesarean section.(true or false) True: because it typically reserve for obstetrical emergencies
What are major indications for c/s Labor unsafe for mother and fetus. Dystocia Immediate or emergent delivery necessary
Indications for general anesthesia are? Contraindications to regional anesthesia (e.g) coagulapathy Fetal distress Failed regional block Patient refusal
When time is limiting factor then GA is When time is a limiting factor, general anesthesia is sometimes necessary because it offers speed of induction, reliability, controllability, and avoidance of sympathectomy induced hypotension
Problems associated with GA are? Problems associated with general anesthesia principally involve failed intubation and aspiration. Physiologic changes of pregnancy increase the incidence of failed intubations and aspiration
Preparation for GA Airway evaluation: -Vital to identify patients with problematic airways early -Physical factors and physiologic changes of pregnancy may complicate ET intubation Aspiration prophylaxis Experienced personnel and backup plans Fetal considerations
Conduct of GA Basic prep Positioning and monitoring Maternal preoxygenation Induction: -RSI with cricoid pressure -Intubate with 6.0-7.0 cuffed endotracheal tube Maintenance Emergence: -Patient extu awake with airway reflexes intact -if pt is unstable, ETT rem
The Obese parturient consideration: Considerations: BMI = wt (kg) / ht (m)2 Morbid obesity defined as body weight more than twice the ideal weight, or BMI greater than 35
The obese parturient is at greater risk for medical diseases: Cardiovascular system Respiratory system Endocrine and metabolic system Gastrointestinal system
In the Obese parturient with difficult airway every effort should be made to initiate an early regional anesthetic Cesarean section rate is significantly higher Anxiolytic drugs and opioids ought to be administered with great caution in the morbidly obese parturient
Airway considerations for the obese parturient -Limited flexion and mouth opening -Narrowed view of pharyngeal opening -Higher incidence of failed intubation -Proper positioning of the head and neck may facilitate endotracheal intubation
Optimal positioning for the obese parturients Proper positioning may facilitate endotracheal intubation; elevation of shoulders, flexion of the cervical spine, and extension of atlanto-occipital joint.
Created by: eonaodow