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76 Cards in this Set

  • Front
  • Back
Methods of Pain Relief for L & D....hint Dr. France ;-)
Hypnosis
Natural childbirth
Acupuncture
TENS units
Hydrotherapy
Positioning
Systemic medications
T or F: All opioids and sedatives can cross placenta and may have some effect on fetus
True.....so use limited to early stages or situations where regional not available
CNS depression in neonate from opioids and sedatives
can cause
-Resp. acidosis
-Prolonged time to sustained resp.
-Abnormal neurobehavioral exam
T or F: Loss of beat-to-beat variability in FHR can be caused by opioids and sedatives.
True....Degree of depression R/T drug, dose, time from administration to delivery
-Premies more sensitive
Sedatives/Tranquilizers...
Primary indication today
Used for Sedation when delivery not expected for 12-24 hours

-May be used in first stage of labor
-Barbiturates (Seconal, Nembutal, Amytal)
-No longer popular
-No analgesic action – may cause antianalgesic effect
-All cross placenta and may depress neonate
Sedatives/Tranquilizers like Phenothiazine derivatives (Phenergan, Compazine) & hydroxyzine (Vistaril)
-Uses - sedation, antiemetic, reduction of opioid requirements
-Cross placenta, so
See decreased variability in FHR but no increased depression of neonate when added to narcotics given to Mom
Benzodiazepines uses and effects
-May be used as sedatives, narcotic adjuvant, anticonvulsants, premeds
-Decrease FHR variability but do not depress neonate in small doses
-See up to 30 min of antegrade amnesia after 5 mg of midazolam
-Some may not want amnesia
-Teratogenic effects controversial
-Associated with congenital malformations in old studies
-Chestnut says OK if needed for premed
Ketamine max dose & uses
Crosses placenta
1 mg/kg or less and no neonatal depression
Uses
Emergent induction, hypovolemic C-section
Do not exceed 1 mg/kg
To cover “spotty” block or sedation (0.25 mg/kg)
Give 10-15 mg in 2-5 min intervals (don’t exceed 100mg)
Intense analgesia without resp. depression
Ketamine onset and duration
Rapid onset (30 sec) and short duration (3-5 min)
Ketamine adverse/side effects
Undesirable hallucinations can and do occur
Reduced if pleasant verbal reassurance given
Avoid in hypertensive patients
What is the most common narcotic used in L&D...dosing
Demerol
50-100 mg IM
25-50 mg IV
Peak effect 40-50 min IM and 5-10 IV
Duration of action 3-4 hours
Demerol Max tissue uptake__-__ hours after administration
2-3
Best time for delivery within one hour of adm. or more than 4 hours after
Neonatal depression after 4 hours if mom get high doses (normeperidine)
Fentanyl dosing
Effective for IV or IM use
50-100 mcg IM
Peak effect 30 min, lasts 1-2 hours
25-50 mcg IV
Peak effect 3-5 min, duration 30-60 min
T or F: neonatal effects are less in pts given fentanyl vs. demerol
True
Compared to meperidine, analgesia similar, side effects & neonatal complications less in fentanyl group (100 patients)

Apgar scores in 137 neonates no worse than in moms who received no analgesia
Does fentanyl cause ion trapping in the fetus?
Rapidly crosses placenta but no effect on uterine tone or blood flow in sheep
Basic drug
More ionized in fetus than mom (ion trapping if fetal acidosis)
Which narcotic is least popular? Why?
Morphine not popular
Neonate more sensitive to resp. depressant effects than Demerol
Butorphanol (Stadol)
-Compares to Demerol in efficacy and fetal depression
-May see marked maternal dizziness/drowsiness
Anxiety, loss of control
33 vertebrate
7 cervical
12 thoracic
5 lumbar
5 sacral
4 coccygeal
31 spinal nerves pairs
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
3 membranes enclose brain and spinal column...
what are they?
Dura mater – next to bone
Arachnoid – in the middle
Pia mater – next to nervous tissue
Spinal cord ends at ___-___in normal adult
___ in infants until 1 year old
L1-L2, L3
Contents of Epidural Space
-Anterior and posterior nerve roots
-Blood vessels that supply spinal cord
Spinal arteries and vertebral veins
-Fatty tissue
Pathways of Labor Pain:
Early first stage is ____
Late first stage is ____
visceral, somatic
Early first stage of labor pain: Visceral, where do we need to block?
Uterus and perineal structures
T10-12 & L1
Need to block T 10
Late first stage of labor pain: somatic, where do we need to block?
Perineum
Impulses via pudendal nerve to S2-4
When are Lumbar Epidurals placed?
Placed when 3-4 cm dilated for primipara
3 cm for multipara
Best indication – head of fetus firmly against cervix

*see Page 127, Tables 8.2, 8.3, & 8.4 for techniques
Distance from skin to epidural space in 1000 parturients – mean of _____
4.23-4.78
Ligamentum flavum____ mm thick
5.0-6.0, May be “softer” in parturient
Why a test dose?
To recognize accidental dural or IV puncture
significance of Test dose amounts of epi and local
-Amount of local
Enough to produce LOW spinal block
Not enough to harm mom or fetus

-Amount of epinephrine
Enough to cause reliable tachycardia
Not enough to harm mom or fetus

-Hyperbaric local ideal but not stable with epi added to dextrose containing solution
Usual test dose
3 mL lidocaine 1.5% with epi 1:200,000
45 mg lidocaine
Should not reach thoracic dermatomes if SAB
15 mcg epi
Should reliably produce tachycardia in app. 30 sec for about 30 sec
Why place a SaO2 monitor during test dose?
SaO2 placed for HR not O2 saturation
Initial block – loading doses for epidurals
Bupivacaine 0.25% (10 mL in divided doses)

Bupivacaine 0.125% - 0.25% 8 mL + 1-2 mL Fentanyl (or 10-15 mcg sufentanil)

Fentanyl 50-100 mcg or sufentanil 10-15 mcg in 10 mL NS
epidural Maintenance
Intermittent bolus to maintain comfort
Same as with loading dose technique repeated as patient needs
Epidural Maintenance – continuous infusion instead of boluses
Bupivacaine 0.0625% - 0.125% with Fentanyl 1-3 mcg/mL (or sufentanil 0.1-0.3 mcg/mL) at 10-15 mL/hr

Bupivacaine 0.125% - 0.25% without Fentanyl
What should be assessed every 1-2 hrs during continuous infusion with epidurals?
VS, FHR, degree of block should be assessed every 1-2 hours
What is the dosing if If perineal anesthesia needed
10-20 mL of local (lidocaine or Nesacaine) in sitting position
most common side effect of epidurals?
Hypotension

The higher the level of sympathetic block, the greater the incidence and severity of hypotension
Mom will tolerate systolic of 80-90 but fetus may not...Why?
Uterus not autoregulated
Blood flow decreases linearly with B/P
When do we treat BP if hypotensive during epidural and what can we do to prevent this from occurring?
-Treat B/P if less than 100 mm Hg (30% lower than baseline)
-Preload, have vasopressor ready, LUD, monitor mom and fetus
Paresthesias
*5-25% incidence of transient paresthesia
*5-42/10,000 c/o paresthesia lasting 4-6 weeks
*Don’t use epidural if paresthesia persists after insertion
Accidental dural puncture:
Incidence of headache app. ____ in parturient
80%

Incidence varies
Most report 1-2% at teaching facilities
Puncture by catheter rare, but what happens if this occurs?
Total spinal
When do we treat BP if hypotensive during epidural and what can we do to prevent this from occurring?
-Treat B/P if less than 100 mm Hg (30% lower than baseline)
-Preload, have vasopressor ready, LUD, monitor mom and fetus
Treatment of total spinal
_Establish AW, ventilate with 100% oxygen
-Maintain B/P:
LUD, fluids, ephedrine
-Treat cardiac arrhythmias and collapse
-CPR and prompt delivery of baby if necessary
When do we treat BP if hypotensive during epidural and what can we do to prevent this from occurring?
-Treat B/P if less than 100 mm Hg (30% lower than baseline)
-Preload, have vasopressor ready, LUD, monitor mom and fetus
Paresthesias
*5-25% incidence of transient paresthesia
*5-42/10,000 c/o paresthesia lasting 4-6 weeks
*Don’t use epidural if paresthesia persists after insertion
Accidental dural puncture:
Incidence of headache app. ____ in parturient
80%

Incidence varies
Most report 1-2% at teaching facilities
Paresthesias
*5-25% incidence of transient paresthesia
*5-42/10,000 c/o paresthesia lasting 4-6 weeks
*Don’t use epidural if paresthesia persists after insertion
Puncture by catheter rare, but what happens if this occurs?
Total spinal
Accidental dural puncture:
Incidence of headache app. ____ in parturient
80%

Incidence varies
Most report 1-2% at teaching facilities
Treatment of total spinal
_Establish AW, ventilate with 100% oxygen
-Maintain B/P:
LUD, fluids, ephedrine
-Treat cardiac arrhythmias and collapse
-CPR and prompt delivery of baby if necessary
Puncture by catheter rare, but what happens if this occurs?
Total spinal
When do we treat BP if hypotensive during epidural and what can we do to prevent this from occurring?
-Treat B/P if less than 100 mm Hg (30% lower than baseline)
-Preload, have vasopressor ready, LUD, monitor mom and fetus
Treatment of total spinal
_Establish AW, ventilate with 100% oxygen
-Maintain B/P:
LUD, fluids, ephedrine
-Treat cardiac arrhythmias and collapse
-CPR and prompt delivery of baby if necessary
Paresthesias incidence
*5-25% incidence of transient paresthesia
*5-42/10,000 c/o paresthesia lasting 4-6 weeks
*Don’t use epidural if paresthesia persists after insertion
Accidental dural puncture:
Incidence of headache app. ____ in parturient
80%

Incidence varies
Most report 1-2% at teaching facilities
Puncture by catheter rare, but what happens if this occurs?
Total spinal
Treatment of total spinal
_Establish AW, ventilate with 100% oxygen
-Maintain B/P:
LUD, fluids, ephedrine
-Treat cardiac arrhythmias and collapse
-CPR and prompt delivery of baby if necessary
Subdural injection
local between dura and arachnoid
Incidence of subdural injection
0.1-0.82%

Increased during rotation of epidural needle after LOR

Increased in patients with previous back surgery
What will you see with subdural injection
See wide spread of sensory anesthesia with small amt of local

Usually weak, patchy block with cephalad spread

Delayed onset (10-30 min), faster resolution

Hypotension may be first symptom
Massive epidural analgesia
More common in massively obese, patients with arteriosclerosis and DM

Onset gradual
Accidental IV injection
May be at initial dosing or migration of catheter

May see seizures and CV collapse if direct injection of local into epidural vein
Backache
30-40% incidence

Increased by multiple needle sticks

Some studies show no increase in incidence with or without epidural
Broken epidural catheter
Most say leave in place if in lumbar epidural space

Implanted catheter in cats in lab covered by fibrous tissue after 3 weeks
Neuro problems related to pregnancy or L&D: incidence and causes
*1:2600 – 1:6400 (1:40,000-1:100,000 incidence of neuro problems r/t anesthesia)

*Prolapsed disk during labor

*Compression of lumbosacral trunk (L4-L5) by descending fetal head and sacrum
-May be associated with forceps delivery
-Foot drop (peroneal – branch of sciatic)
-Lateral foot and calf numbness (peroneal – branch of sciatic)
-Weakness of hip adductors and quadriceps (obturator)
If a L&D pt is on Remifentanil must they be a 1:1 nurse: patient ratio?
Yes
T or F: Narcan can be given if the neonate is suffering from neonatal depression concerning Demerol administration to mom?
True
Ketmaine will cause what effects to the patient? HR, BP, etc?
Sympathetic (increased HR, BP) unless catecholamine depleted.
Is pt able to maintain airway on Ketamine?
Yes. It is a powerful analgesic and may cause nystagmus but pt can maintain airway.
What happens to the cervix during the early first stage of labor?
cervix dilates from 0-10
Will you see toxic effects from a test dose?
should not....its a small amount of lidocaine and epi.
Is it good if the patient can move their legs after 3 mins after the test dose?
Yes, you should be in the epidural space.
How long should you montior a pt after administering an epidural?
20-30 mins
Why do obese people have a higher level and massive epidural analgesia sometimes after administration of an epidural?
increased intra abdominal pressure