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Coexisting conditions > Analgesia for Labor and Vaginal delivery > Flashcards

Analgesia for Labor and Vaginal delivery Flashcards

1
Q

What are the qualities of the ideal anesthetic in OB?

A
  • Effective and controllable analgesia
  • maternal safety
  • no weakening of maternal powers
  • no alteration of maternal passages
  • no depression of the passenger
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2
Q

What are the analgesia options for labor and vaginal delivery?

A
  • Non pharm
    • hypnosis, TENS, acupuncture, LaMaze, Hot water tubs
  • Parental medications
    • poioids- meperidine, fentanyl, remifentanil
    • agonist-Antagonist drugs- Nubain, Stadol
    • Ketamine
    • Anxiolytics- midaz
  • Neuraxial blocks
    • intrathecal opioids
    • epidural analgesia
  • paracervical and pudendal blocks
  • IA
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3
Q

Meperidine

dose

onset

fetal exposure

metabolite

A
  • Usual dose 25-50 mg IV, max dose < 100 mg IV total
  • Onset 5-10 min; duration 3-4 hours
  • Fetal exposure highest 2-3 hrs
    • crosses placental- causes fetal acidosis and neonatal resp depression
    • active metabolite normeperidine in neonate
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4
Q

Is morphine an option?

A
  • It is infrequently used
  • linked to neonatal respiratory depression and somnolence
  • leads to maternal sedation
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5
Q

Fentanyl

dose

onset

problems

A
  • High potence and short duration make it good for labor
  • Dose 25-50 mcg IV (max 1 mcg/kg without neonatal depression)
  • onset 3-5 min; duration 30-60 min
  • Problems
    • potent maternal respiratory depression
    • cummulative effect over time
    • may affect newbord feeding
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6
Q

Why isnt sufentanyl frequently used?

A

because of potency/maternal resp depression and neonatal bradycardia

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7
Q

Remifentanil

dose IV and PCA

why is it better?

A
  • IV bolus 0.4 mcg/kg q 1 min
  • PCA bolus 0.25 mcg/kg then 0.05 mcg/kg/min, lockout 2 min, 4 hr limit 3 mg and background infusion of 0.025-0.05 mcg/kg/min
  • Metabolism by blood esterases therefore maternal and neonatal accumulation low
  • ultra short acting
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8
Q

Why is butorphenol (Stadol) a good choice?

Dose?

A
  • 1-2 mg IV or IM
    • duration 4 hours
  • it is an Agonist-Antagonist; it has a “ceiling effect” on resp depression
  • 5x as potent as morphine
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9
Q

What is the other Agonist-Antagonist besides butorphanol?

A
  • Nalbuphine (nubain)
  • Dose: 5-10 mg IV, IM , or SQ
    • duration 6 hours
  • causes less dysphoria than butorphanol
  • less N/V than butorphenol
  • similar sedation to butorphanol
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10
Q

Midazolam dose?

A

0.5- 1 mg

to alleviate anxiety w/o causing detriment to parturient and fetus

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11
Q

Ketamine

dose

SE

A
  • 10-15 mg IV for intense analgesia for 10-15 min w/o causing problem to mom or fetus
  • 25-50 mg (0.5 mg/kg) to supplement an incomplete neuraxial block during c/s
  • at higher doses, dissociative anesthetic associated with emergence/delirium and hallucinations
  • High dose can increase uterine tone
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12
Q

What IA are used during labor? How?

A
  • Goal:
    • pain relief while maintaining consciousness and protective laryngeal reflexes
  • Self administered intermittently during contraction or continuously
  • Entonox (50:50 N2O:O2 mixture)
  • Sevo (0.8%)
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13
Q

What are the regional techniques and other blocks used for labor and vaginal delivery?

A
  • Regional
    • epidural- walking epidural
    • spinal
    • CSE
  • Other blocks
    • paracervical block
    • pudendal block
    • local perineal infiltration
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14
Q

What are some problems with epidural anesthesia?

A
  • cessation or slowing of labor
  • asymmetrical/patchy block
  • dense motor block
  • migration of catheteraccidental dural puncture
  • accidental intravascular injection
  • toxicity
  • hypotension
  • fetal compromise
  • N/V
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15
Q

What are some absolute contraindications of epidural or spinal anesthesia?

A
  • refusal
  • no resuscitative equipment
  • increased ICP
  • hypotension/instability
  • coagulopathy
  • infection at site
  • untreated bacteremia
  • severe stenotic valvular heart lesions
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16
Q

What shuold you do to prepare for an epidural placement?

A
  • informed consent
  • monitor vital signs, FHR, contractions
  • fluid load
  • supplemental oxygen
  • ? labs
17
Q

where do you insert an epidural for labor?

A

below L2

18
Q

What is the technique for epidural placement?

A
  • Parturient should be in active labor with cervical dilation about 4 cm- bigger is too late
  • sitting or lateral position
  • BP q 2 min
  • insert below L2
  • Insert catheter 4-6 cm
    • this is deeper than normal because of movement during labor
19
Q

How do you manage an epidural?

A
  • place test dose to make sure it is not subarachnoid or intravascular
  • administer bolus
    • do not start continuous infusion until satisfactory block is obtained to at least T-10 level
    • continuouse infusion (CLE) is used to maintain the block, not elevate or intensify
20
Q

When is a Spinal indicated?

advantages and disadvantages?

A
  • very early labor
  • distressed parturient to enable epidural placement under controlled conditions
  • instrumental deliveries
  • when epidural analgesia not possible
  • Advantage: rapid onset
  • disadvantage: lacks flexibility, finite duration
21
Q

What are some side effects of neuraxial opioids?

A
  • pruritis
  • N/V
  • urinary retention
  • drowsiness
  • resp dep
  • fetal bradycardia
22
Q

Why would you consider a combined spinal/epidural?

A
  • spinal is rapid and effective analgesia
  • epidural is prolonged and can convert to surgical anesthesia
  • Adv: greater sensory block, minimal motor block
  • dis: increased frequency of nonreassuring FHR tracing and fetal bradycardia
23
Q

How should you manage Neuraxil analgesia?

A
  • monitor the level of the block q 1 hr
  • monitor mother VS/FHR
  • monitor contractions
  • monitor mother’s LOC
  • look for signs of toxicity
  • keep LUD/ avoid supine
  • treat hypotension
24
Q

What level do you need blocked for a C-section?

A

T4

may affect cardiac accelerators

25
Q

What level do you need blocked for the first stage of labor?

3rd stage?

A

T-10

sacral region

26
Q

What is the significance of a numb little finger?

A

C-8 block

All cardioaccelerator fibers are blocked

27
Q

What is the significance of a numb inner aspect of arm and forearm

A

T1 & T2 block

Some degree are cardiac accelerators are blocked

28
Q

What is the significance of numbness at the niple line?

A

T4-T5

possibility of cardiac accelerator block

29
Q

What is the significance of numbness at the umbilicus?

A

T10

sympathetic blockade is limited to lower limbs

30
Q

What are some side effects of LA toxicity?

first signs progressing to later/more significant

A
  • circumoral numbness
  • tinnitus
  • vision changes
  • slurred speech
  • muscle twitching
  • irrational conversation
  • unconsciousness
  • Grand Mal confulsion
  • Coma
  • apnea
31
Q

How to treat LA toxicity?

A
  • 100% O2 and intubate if necessary
  • barbituates or benzos if seizing
  • support BP with IVF and pressors
  • CPR
  • treat bradycardia with atropine
  • intralipids
  • consider delivery of fetus
32
Q

What are the symptoms for postdural puncture?

treatment?

A
  • HA with stiff neck and photophobia
  • onset may be 1-2 days
  • treatment
    • bedrest
    • over the counter analgesics
    • hydration
    • caffeine( 300 mg oral or IV)
    • Epidural blood patch
33
Q

How is an epidural blood patch done?

A
  • place Tuohy needle into epidural space, preferably at same interspace
  • assistant draws 15-20 ml of venous blood from pt
  • inject blood into epidural space
  • remove Tuohy needle
  • bedrest 1 hr
  • then light activites for few hours
  • effective in 90% of patients
  • can perform 2nd patch
34
Q
A

Coexisting conditions (34 decks)

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