Anesthesia for Cesarean Delivery – Flashcards
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What is the most common surgery in the US?
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Cesarean section, 30% of all deliveries
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Indications for cesarean section
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1. dystocia 2. malpresentation 3. nonreassuring fetal status 4. previous c/s 5. maternal request
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What does TOLAC and VBAC?
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TOLAC is trial of labor after c/s, and if successful, called a vaginal birth after cesarean (VBAC)
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Midline vertical abdominal incision allows what? When is it used?
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1. Rapid access and greater surgical exposure. 2. Used when... - preterm delivery - lower uterine segment is underdeveloped - certain multiple gestation or malpresentation
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Pfannenstiel incision is what kind of incision and allows better what?
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- horizontal suprapubic incision - allows better cosmesis and wound strength
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Low transverse uterine incision has a lower incidence of what?
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Lower incidence of uterine dehiscence or rupture in subsequent pregnancies
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Name the complications of labor and c/s
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1. Hemorrhage 2. Infection 3. Ureteral, bladder injury 4. Abdominal pain (very stimulating, area close to bladder can be knicked, after baby delivered, water urine to make sure it is cleared) 5. Uterine rupture
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How much blood is estimated to be lost during a c/s?
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1000 mL
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How much higher is the risk of death with a c/s versus vaginal delivery?
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10 times higher
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What can you do to reduce the risk of death for c/s?
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Thromboprophylaxis, put SCDs on prior to going to OR
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Name some things you can do to prevent cesarean delivery
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1. Adequate labor analgesia 2. Analgesia for cephalic version 3. Intrauterine resuscitation, including pharmacologic relaxation in cases of uterine tachysystole - use NTG
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What is tachysystole?
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5 contractions in 10 minutes averaged over 30 minute time period
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What is the dose of NTG used in cases of uterine tachysystole?
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50-100 mcg IV, which allows rapid onset in 40-50 seconds to cause uterine relaxation (not so much cervical relaxation d/t 85% are fibrous fibers) Works by providing uterine relaxation on uterine smooth muscle mediated by nitric oxide production
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T/F NTG relaxes cervix
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FALSE! Relaxes UTERUS
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What is an external cephalic version?
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Manual external pressure is applied to the maternal abdomen to change the fetal position from breech to cephalic. NEED EPIDURAL bc this is painful!
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Define informed medical consent
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Explain to the patient the risks, benefits, and alternatives of a procedure
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Name the 3 elements of informed consent
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1. Threshold 2. Information 3. Consent
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Threshold elements include what?
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The ability of the patient to meet the basic definition of competence
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What defines competence?
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The patient's legal authority to make a decision about her health care
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What do information elements include?
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The patient's being informed about the material risk of a planned procedure in language that the patient understands
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In obtaining consent, care must be taken to preserve what?
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Autonomy by providing information in a non coercive, non manipulative manner (i.e., avoiding a paternalistic or maternalistic approach
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Informed refusal means what?
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A competent pregnant woman is entitled to refuse treatment even when it will benefit her or her baby's health
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Can an anesthesia provider refuse to take care of a patient?
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YES! if the patient is obese, for instance, and refuses neuraxial anesthesia, the anesthesia provider can invoke informed refusal if it conflicts with acceptable risks and benefits
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What standard monitors should you have?
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- EKG - Pulse ox - NIBP - FHM - Check out anesthesia machine - Foley catheter accessible to anesthesia provider - If T4 is blocked, have robinul/atropine drawn up (b/o blockade of cardiac fibers from spinal)
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What other drugs and equipment should you have ready?
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- succinylcholine - vasopressors: neo, ephedrine - propofol - level 1/massive hemorrhage - difficult airway cart - MH cart
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For an elective c/s, when can you have clear liquids up until?
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2 hours pre-procedure, NO particulate matter
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For whom would you say they should be NPO for longer than the normal pregnant patient?
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- morbid obesity - DM - difficult airway - labor
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Food restrictions, how long before c/s
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6-8 hours
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What medications can you give to prevent aspiration?
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- Sodium citrate: 0.3 M increases gastric pH; give 30 minutes before, lasts 3 hours but most potent within 1st hour - H2 receptor blocker reduce secretion of gastric acid, but must be given at least 60 minutes before - Reglan promotes motility, hastens gastric emptying and increases LES tone - Omeprazole, PPI
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When should you give prophylactic antibiotics?
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30 minutes prior to incision (Ancef)
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Why do we give ATB to pregnant women?
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TO reduce... - post-cesarean infections - endometritis - fever - UTI
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What is supine hypotensive syndrome?
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compression of the aorta and inferior vena cava by the gravid uterus
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What are good positions for cesarean delivery?
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- LUD 15 degress - Head up position 10 degress - T-Berg: not recommended d/t cephalad spread of hyperbaric spinal anesthesia
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What are good positions for neuraxial anesthesia and benefits for assuming those certain positions?
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Side lying: better uteroplacental blood flow Sitting: shorter distance from skin to epidural space
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What is the downsize to over-oxygenating your patient?
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Oxygen is converted to reactive oxygen species, including free radicals, term fetuses can withstand oxygen better than preterm or compromised
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What is the level of anesthesia you want for a c/s?
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T4 is goal - afferent nerves innervate abdominal & pelvic organs accompany sympathetic fibers that ascend & descend in the sympathetic trunk (T5 & L1) - a sensory block that extends rostrally from the sacral dermatomes to T4 is goal - absence of cold sensation with alcohol wipe to T4, midclavicular line from caudad to cephalad
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What do you want to do prior to giving the spinaL?
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Hydrate your patient!
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What is spinal dose based on?
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Height, baricity matters most, always going to give small amount, higher potency
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What is the drug of choice for elective cesarean for spinal?
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Bupivacaine 0.75% with 8.25% dextrose, 4.5-15 mg Adjuncts: - fentanyl 2.5-60 mcg - morphine 0.1-0.25 mg for 12-24 hrs relief - hydromorphone 100 mcg
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What medication is not approved for spinal anesthesia?
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Ropivacaine
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What is the safest mode of anesthesia for c/s?
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Epidural - CSE used more frequentyl - If already have epidural from labor, use it - Slower onset of sympathetic blockade - Allows for compensatory mechanisms to hypotension Drug choices - 2% lidocaine with epinephrine (20 mL) - 5% bupivacaine (5-10 mL) - 0.5-0.75% of ropivacaine or levobupivacaine
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What is the drug that has the fastest onset and shortest duration of action?
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2-chloroprocaine 3% (not enough to do c/s so must add something stronger)
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What does sodium bicarbonate do for your epidural?
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Hastens onset and augments quality of blockade, more molecules in non-ionized state
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Why is more potent lidocaine bad to use for blocks?
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- Causes transient neurological symptoms, cauda equina syndrome - only approved for 45 minutes or less cesarean
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T/F: Ropivacaine is approved by the FDA for use in neuraxial anesthesia for cesarean
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False, it is not approved - 40% less potent, slower onset, faster recovery, less hypotension
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Why would you use a CSE as opposed to just an epidural?
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- cesarean may take longer - difficulty with identifying structures - laboring patient is 8 cm or greater (incorporated rapid & predictable onset of spinal blockade with the ability to augment anesthesia by injection of additional medication through the epidural catheter later)
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How many mL of LA is required to go from a T10 to T4 level if you had to re-dose your laboring epidural to a c/s epidural?
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about 15-20 mL (every patient is different, so every patient needs assessed)
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What is the dose of propofol for induction during c/s and what should you watch for?
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2-2.8 mg/kg reduction in maternal BP and CO
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What is the dose of thiopental for induction during c/s and what kind of drug is it?
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4.5 mg/kg negative inotrope and vasodilator
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What is the dose of ketamine for induction during c/s and what kind of drug is it? SE?
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1-1.5 mg/kg - sympathomimetic - analgesic - hypnotic - amnestic - minimal respiratory depression - NMDA receptor anatagonist - Emergence delirium - Hallucinations
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What is the dose for etomidate during induction for c/s?
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0.3 mg/kg
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What is the dose for succ during induction for c/s?
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1-1.5 mg/kg
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What is the dose of rocuronium during induction for c/s?
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0.6-1 mg/kg
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What does excessive ventilation do to uteroplacental flow?
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- Decreases it, causing vasoconstriction, which decreases perfusion to baby - Left shift of oxyhemoglobin curve
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What does hypercapnea do to mom?
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tachycardia
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What is normocapnea for pregnancy?
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30-32 mmHg
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What happens to MAC during pregnancy?
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Decreases
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T/F: Good MAP is needed in Mom to perfuse placenta
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TRUE
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What can you ask the OBGYN to do if the patient is having pain during cesarean?
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To infiltrate the incision area with local anesthetic
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What medication do you want to give once the baby is out to prevent recall?
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Versed
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Name some complications of neuraxial anesthesia for cesarean?
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1. Dyspnea - can pt vocalize - strong hand grip - maintain sats - intubate? 2. Hypotension (from preganglionic sympathetic nerve fibers being blocked) Have ephedrine and neosynephrine ready to go, fluid bolus
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What can you do if your neuraxial block fails?
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- adjuvant of LA by OBGYN - redose epidural - redo spinal - general anesthesia - opioids, ketamine, nitrous oxide
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What are some patient issues with neuraxial anesthesia?
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1. Pruritis - benadryl 25 mg - nubain 2.5 mg - atarax 2. Nausea/vomiting - ondansetron - compazine - phenergan 3. Shivering - demerol 25 mg
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How much blood flows through the placenta/minute?
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600-700 mL/min
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Name drugs to give to prevent postpartum hemorrhage?
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Oxytocin - hypotension - tachycardia - pulmonary edema from water intoxication Methergonovine - IM only, 0.2 mg - ergot alkaloid - vasoconstriction - uterotonic effect - nausea/vomiting
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What drug is CI if hypertensive (for post-partum hemorrhage)?
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Hemabate, 200-250 mcg IM only - prostaglandin - increases force of contraction - diarrhea - HTN - vomiting
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What drug is CI if asthmatic (for post-partum hemorrhage)?
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Misoprostol, 600-1000 mcg oral, sublingual, rectal
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Other interventions for postpartum hemorrhage
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1. Intravascular balloon occlusion catheters 2. Uterine tamponade balloon catheters 3. Cesarean hysterectomy
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What is the first intervention done to prevent postpartum hemorrhage?
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Massaging the funds of uterus (top of uterus)
