Term
| percent of deliveries that are operative |
|
Definition
|
|
Term
| indications for operative delivery 7 |
|
Definition
| exhaustion, inability to push, cardiac disease, prolonged second stage, arrest of decent, rotation, NRFHT |
|
|
Term
|
Definition
| easier, acynclytic, prevent larger lacs |
|
|
Term
|
Definition
| rotations, higher success, less than 34 wks |
|
|
Term
|
Definition
| scalp visible without labial separation, ROA/LOA/OA/OP, rotation <45 deg |
|
|
Term
|
Definition
| 2+ station, with/out rotation 45 deg |
|
|
Term
|
Definition
| above 2 station but engaged |
|
|
Term
|
Definition
| 2cm from anterior to posterior fontanel, centered on sagittal suture |
|
|
Term
|
Definition
| saggital suture aligned with shanks, posterior fontanelle 1 finger from shanks, lamboid equadistand from blades |
|
|
Term
| requirements before operative delivery 10 |
|
Definition
| 10cm, ruptured, engaged, position determined, EFW determined, pelvis adequate, empty bladder, consent, willingness to abandon |
|
|
Term
| which episotomy do you do with operative and why |
|
Definition
| mediolateral has less OSASIS |
|
|
Term
| downsides of mediolateral episotomy |
|
Definition
|
|
Term
| maternal complications of operative 3 |
|
Definition
OASIS, 6x increase in 3-4 lacs, increased incontinence only if visible sphincter tears
(no change in sexual, pelvic floor from SVD) |
|
|
Term
| percent recurrence of sphincter tears in next pregnancy |
|
Definition
|
|
Term
| downsides to forceps vs vaccum 5 |
|
Definition
increased OASIS and 3-4 lacs, fetal fx, facial nerve palsies, brachial injury
(no change in incontinence) |
|
|
Term
| fetal complications of operative 13 |
|
Definition
| intracranial hemorrhage, neurologic injury, scalp lac, cephalohematoma, subgaleal hemorrhage, intracranial hemorrhage, hyperbilirubinemia, facal lacs, facial nerve palsies, retinal hemorrhage, corneal abrasions, ocular trauma, scull fx |
|
|
Term
| downsides to vaccum vs forceps 4 |
|
Definition
| cephalohematoma, scalp lacs, fracture, plexus injury |
|
|
Term
| risks of doing CD instead of operative |
|
Definition
| same risks of encephalopathy, hemorrhage, death, future speech/neuro function in operative and CD. indicating that likely these would have occurred either way due to the indication for the operative delivery, not the operative itself |
|
|
Term
| increased risk for macrosomic babies in operative delivery |
|
Definition
| injury rate 1.6 compared to 0.4% in operative in babies >4000g in SVD, 7x increased with forceps but only for 6mo, longer term injury the same, use operative with caution if suspect macrosomia |
|
|
Term
| contraindications to operative 4 |
|
Definition
fetal head not engaged, position not determined, suspect bone demineralization disorder in baby, suspect bleeding disorder in baby
indeterminate fetal heart pattern is NOT a contraindication |
|
|
Term
| failure rate of operative |
|
Definition
|
|
Term
| factors that increase the failure rate of operative 2 |
|
Definition
| increased birth weight, prolonged second state |
|
|
Term
| risk of CD after operative failure 5 |
|
Definition
| increased subdural/cerebral hematoma, need for mechanical ventilation, seizures, all risks increased in NRFHT, NICU admission |
|
|
Term
| when do you called a failed operative |
|
Definition
| no specific number of pop offs studied, failed if no decent |
|
|
Term
| risk of using sequential operative devices 6 |
|
Definition
| subdural/cerebral/subarachnoid hemorrhage, facial nerve injury, brachial injury, severe lacerations, OSASIS, decreased umbilical A pH |
|
|
Term
| benefits of cup types of vaccum |
|
Definition
pliable cup increases pop offs but decreases scalp trauma
no other differences in things like apgars, cord pH, neuro complications, retinal hemorrhages, maternal trauma, or blood loss |
|
|
Term
| risks of prolonged vacumm |
|
Definition
time applied increases risk of cephalohematoma (28% if >5min) but decreasing pressure between pulls dosent help.
overall risk 11.5% |
|
|
Term
| successrate of SVD after operative rotation |
|
Definition
|
|
Term
| forceps used for operative rotation |
|
Definition
|
|
Term
| risk of operative rotation |
|
Definition
| no increased maternal or fetal injury |
|
|
Term
| risk of operative OP delivery |
|
Definition
| increased lacerations if done without rotation |
|
|
Term
|
Definition
| attempt of svd regardless of outcome |
|
|
Term
|
Definition
| decreased hemorrhage, clots, infection, recovery time, hysterectomies, bowel/bladder injury, transfusion, abnormal placentation |
|
|
Term
|
Definition
| uterine rupture/dehissicence |
|
|
Term
| risk of rupture with 1 previous CD |
|
Definition
|
|
Term
| average VBAC success rate |
|
Definition
|
|
Term
| signs unfavorable for vbac 10 |
|
Definition
| AOD, induction, augmentation, increased age, BMI, EFW (4000-4500), >40wk, hx dystocia, induction, unfavorable cervix |
|
|
Term
| signs favorable for vbac (that are not just the opposite of the unfavorable ones) 3 |
|
Definition
| delivery <19mo ago, pre-e, hx of SVD |
|
|
Term
| risk increasing uterine rupture 8 |
|
Definition
| classical/T-incision, hx rupture, transfundal surgery, no hx of SVD, unfavorable cervix, higher Pitocin doses, uterine manipulation, uterine anomalies |
|
|
Term
| how to success rate for vbac correlate with neonatal morbidity rates for vbac |
|
Definition
if success 60-70% then morbidity is equal to RCD
if success <60% then morbidity > RCD |
|
|
Term
|
Definition
| depends on the study 0.9-3.7%, 0.7-0.9%, 1.8% |
|
|
Term
| how does number of previous CD change the success rate for vbac |
|
Definition
|
|
Term
| what are the risk of vbac if >2 CD |
|
Definition
|
|
Term
| how do you decide if they should tolac if macrosomic |
|
Definition
| decreased success if 4000-4500g of hx dystocia, macrosomia alone should not stop tolac, consider previous delivery weights |
|
|
Term
| at how many weeks does vbac success lower, what are the increased risks |
|
Definition
| 40wks, no increased rupture risk |
|
|
Term
| can a low vertical hx cd tolac, what are the risks |
|
Definition
|
|
Term
| what do you do if someone with an unknown uterine incision wants to tolac |
|
Definition
| has similar success to known incisions, allow tolac unless circumstances suspicious for classical |
|
|
Term
| can twins tolac, how does this affect success |
|
Definition
|
|
Term
| what cant you use to induce a tolac, why |
|
Definition
| prostaglandin E1 (misoprostol) increase risk of rupture |
|
|
Term
| what is the percent of rupture in tolac with prostaglandin E1 induction |
|
Definition
| 2.24% (compared with 1.4% in SVD) |
|
|
Term
| can you give prostaglandin E2 in vbac |
|
Definition
|
|
Term
| can you ECV a tolac, how does this affect success rate |
|
Definition
| yes only if low transverse incision, no change in success |
|
|
Term
| does epidural effect tolac success or mask rupture |
|
Definition
|
|
Term
| what is the #1 signs of rupture |
|
Definition
|
|
Term
| how can you expect dilation/decent to be different in a tolac |
|
Definition
| it wont, it will be similar to primip |
|
|
Term
| signs of uterine rupture 7 |
|
Definition
| variables (70% of cases), bradycardia, tachysystole, vaginal bleeding, loss of station, pain, hypovolemia |
|
|
Term
| how does an IUPC help diagnose rupture |
|
Definition
| it dosent, no data for IUPC |
|
|
Term
| if you notice a defect in uterus after vaginal delivery of a vbac on manual exploration what should you do |
|
Definition
| if the mom is stable, nothing |
|
|
Term
| risk of rupture if hx of rupture in prior uterine scar |
|
Definition
|
|
Term
| if someone has a history of classical, myomectomy, rupture, etc when should you schedule their CD |
|
Definition
|
|
Term
| how do you induce a 2T delivery in a tolac |
|
Definition
| misoprostol/prostaglandins ok, similar risk as if unscarred uterus, risk <1% |
|
|
Term
| how do you induce a 3T IUFD if a tolac |
|
Definition
| TOLAC should be encouraged as there is no fetal risks, consider CD if hx of classical, induce same as regular tolac |
|
|
Term
| when should you refer a tolac out of your facility |
|
Definition
|
|
Term
| secondary sequale of hemorrhage 6 |
|
Definition
| ARDS, shock, DIC, ARF, infertility, sheenhans syndrome |
|
|
Term
| what percent of maternal mortality is hemorrhage |
|
Definition
|
|
Term
|
Definition
| EBL >1000 plus si/sx anemia/hypovolemia |
|
|
Term
| why is HCT decrease >10 not a marker for hemorrhage |
|
Definition
|
|
Term
| why aernt tachycardia/hypotension the markers for hemorrhage |
|
Definition
| because its too late, by the time these happen there is substantial loss (25% or >1500cc) |
|
|
Term
|
Definition
|
|
Term
|
Definition
| atony 70-80%, lacerations, retained placenta, accrete, DIC, inversion |
|
|
Term
| causes of secondary PPH 4 |
|
Definition
| subinvolution, retained products, infection, inherited conagulation defects |
|
|
Term
| what is the most effective prophylaxis for uterine atony |
|
Definition
| Pitocin IM/IV, adding methergine or cytotec was no more effective, nipple stim and breastfeeding don't do anything either |
|
|
Term
| when should Pitocin be given as atony prophylaxis |
|
Definition
| no change in effect based on exact timing |
|
|
Term
| causes of uterine atony 9 |
|
Definition
| prolonged Pitocin, multiparity, infection, general anesthesia, multigestation, polyhydraminos, macrosomia, fibroids, inversion, long labor |
|
|
Term
| risk factors for uterine inversion 4 |
|
Definition
| fundal placenta, short cord, increased traction, hx inversion |
|
|
Term
| genital trauma / risk factors for it that can cause hemorrhage 6 |
|
Definition
| lacerations, hematomas, episotomy, uterine rupture, precipitous labor, operative delivery |
|
|
Term
| risk factors for retained placenta 4 |
|
Definition
| accrete, succentuate lobe, hx of uterine surgery, incomplete delivery |
|
|
Term
| causes of abnormal coagulation that lead to PPH 9 |
|
Definition
| pre-e, von willibrand, infection, fetal demise, abruption, AFE, fever/sepsis, large amounts of crystalloid, anticoagulants |
|
|
Term
|
Definition
| empty bladder, uterine massage, uterotonics, tamponade/compression sutures |
|
|
Term
| treatment for uterine artery trauma after SVD |
|
Definition
|
|
Term
| treatment for vaginal hematoma |
|
Definition
| I+D if enlarging or abnormal vitals, if not hemostatic after I+D pack or IR embolize |
|
|
Term
| what do you do if you cannot find the source of bleeding and si/sx suggestive of hemorrhage |
|
Definition
| suspect retroperitoneal or intraperitoneal bleeding |
|
|
Term
| how can you rule out retained placenta |
|
Definition
|
|
Term
| treatment of retained placents |
|
Definition
| manual extraction, banjo curette D+C |
|
|
Term
|
Definition
| bleeding into myometrium secondary to abruption, can lead to PPH |
|
|
Term
| how does AFE cause hypovolemia |
|
Definition
| when combined with abruption leads to DIC and decreased fibrinogen |
|
|
Term
|
Definition
| vaginal bleeding, pain, tachysystole (high frequency, low amplitude) |
|
|
Term
| what percent of mass transfusions are for abruption |
|
Definition
|
|
Term
| what are the benefits of TXA |
|
Definition
| do not reduce hyst rate or death but do reduce maternal mortality, decreased blood loss when used prophylactically |
|
|
Term
|
Definition
| studies show no increased risk of thrombi |
|
|
Term
|
Definition
| when initial therapies for PPH fail, earlier use works better |
|
|
Term
| dosing of Pitocin for PPH |
|
Definition
10-40 U / 500-1000cc IV
10 U IM |
|
|
Term
| contraindications to pitocin |
|
Definition
|
|
Term
| side effects of Pitocin 4 |
|
Definition
| nausea, vomiting, hyponatremia, hypotension if fast IV push |
|
|
Term
|
Definition
|
|
Term
| contraindications to methergine 3 |
|
Definition
| hypertension/pre-e, cerebrovascular disease, hypersensitivity |
|
|
Term
| side effects of methergine 2 |
|
Definition
| n/v, hypertension especially if IV |
|
|
Term
| other names for hemabate 2 |
|
Definition
| 15-methyl PFG2a, carboprost |
|
|
Term
|
Definition
| 0.25mg IM or intrauterine, q15-90min, max 8 doses |
|
|
Term
| contraindications to hemabate 6 |
|
Definition
| allergy, asthma, HTN, hepatic/pulmonary/cardiac disease |
|
|
Term
| side effects of hemabate 5 |
|
Definition
| n/v/d, f/c, ha, htn, bronchospasm |
|
|
Term
|
Definition
|
|
Term
| contraindications to misoprostol |
|
Definition
|
|
Term
| side effects of misoprostol 3 |
|
Definition
|
|
Term
| what is the success rate of uterine tamponade |
|
Definition
|
|
Term
| what are the options for uterine tamponade 6 |
|
Definition
| compression sutures, bakri, ebb balloon, packing, multiple foley catheters, combinations |
|
|
Term
| how much is a bakri filled with |
|
Definition
|
|
Term
| how much is a ebb balloon filled with |
|
Definition
| 750cc uterine, 300cc vaginal |
|
|
Term
| how much are foleys used for uterine tamponade filled with |
|
Definition
|
|
Term
| how is uterine packing placed |
|
Definition
| 4in gauze, can soak with 5000U thrombin in 5mL saline, tie together |
|
|
Term
| when to use uterine artery embolization |
|
Definition
| stable but persistent bleeding failed Rx/compression therapy |
|
|
Term
| what does UAE use to embolize |
|
Definition
| gell, sponge, coils, or microparticles |
|
|
Term
| what is the success rate of UAE |
|
Definition
|
|
Term
| what percent of people who get UAE will need hyst |
|
Definition
|
|
Term
|
Definition
<5% incidence: DVT, uterine necrosis, peripheral neuropathy
5-15% incidence: preterm delivery
7% incidence: IUGR
note that the incidence of those OB ones are the same as the general population |
|
|
Term
| how do you do laparotomy for PPH |
|
Definition
|
|
Term
| what are the types of vascular ligations for PPH |
|
Definition
O'Leary: uterine artery ligation suture
internal iliac A ligation: less successful requires retroperitoneal |
|
|
Term
| what is the success rate of vascular atery ligation of PPH |
|
Definition
|
|
Term
| what is the risks and incidence of complications of c-hyst |
|
Definition
bladder injury 6-12%
ureter injury 0.4-41% |
|
|
Term
| what are the uterine compression sutures |
|
Definition
|
|
Term
| success rate of uterine compression sutures |
|
Definition
|
|
Term
| what suture do you use for b-lynch and why |
|
Definition
| chromic, rapidly absorbed |
|
|
Term
| risk of uterine compression sutures |
|
Definition
| low risk of uterine necrosis |
|
|
Term
| risk factors for accrete 2 |
|
Definition
| hx uterine sx, placenta previa |
|
|
Term
| risk of accrete based on CD number |
|
Definition
| 0.2, 0.3, 0.6, 2.1, 2.3, 6.7% |
|
|
Term
| risk of accrete if previa based on CD number |
|
Definition
|
|
Term
|
Definition
| curette, wedge, medical management, hysterectomy |
|
|
Term
| risk of uterine consveration when accreta |
|
Definition
| 40% risk of hyst, 42% risk major morbidity |
|
|
Term
| risk of accreta recurrance |
|
Definition
|
|
Term
| incidence of uterine inversion |
|
Definition
1:3700-20000 SVD
1:1860 CD |
|
|
Term
| signs of uterine inversion 4 |
|
Definition
| hemorrhage, CV collapse, firm mass at or below cervix, decreased fundal height |
|
|
Term
| what to do initially in inversion |
|
Definition
| leave placenta in place, manually replace uterus, relax with terb/Mg/general anesthesia/nitro if needed |
|
|
Term
| what do you do if you cant revert the uterus with traditional methods |
|
Definition
| laparotomy: huntingtons/haultain procedure |
|
|
Term
|
Definition
| progressive upward traction with babcock or allis during laparotomy for inversion |
|
|
Term
|
Definition
| during laparotomy for inversion incise cervix posteriorly and digitally reposition then repair |
|
|
Term
| when should you transfuse 2 |
|
Definition
| >1500cc loss and abnormal vitals, HBG <7/HCT <20 and symptomatic |
|
|
Term
| define mass transfusion 4 different ways |
|
Definition
10U PRBC in 24h
or
4U in 1h
or
anticipate need for ongoing replacement
or
replacing total blood volume |
|
|
Term
| what are the blood products that are 1:1 |
|
Definition
|
|
Term
|
Definition
|
|
Term
| risk of autologous transfusion |
|
Definition
| safe in OB, can cause allimmunization give rhogam, no risk of AFE |
|
|
Term
| what is the increased risk of hemorrhage mortality in jehovas witness in OB |
|
Definition
|
|
Term
| transfusion complications 10 |
|
Definition
hyperkalemia
hypokalemia
hypothermia
worsening coagulopathy
dilutive coagulopathy
pulmonary edema
febrile non-hemolytic reactions
acute hemolytic reactions
lung injury / TRALI
infection (hepatitis, HIV, west nile, Chagas, lyme, malaria) |
|
|
Term
| what causes hyperkalemia/hypocalcemia/hypothermia in transfusion |
|
Definition
| citrate preservative in blood increases K which decreases Ca which causes acidosis and hypothermia, worsening coagulopathy |
|
|
Term
| what causes dilutive coagulopathy in transfusion |
|
Definition
| excessive crystalloid use |
|
|
Term
| what is the risk of infection from transfusion |
|
Definition
|
|
Term
| what are prothrombin concentrates made of, when do you use them |
|
Definition
human plasma derived vitamin K dependent clotting factors
warfarin reversal, specific factor deficiencies ( II, IX, I, or combination II/VII/IX/X) |
|
|
Term
| when do you use fibrinogen concentrates |
|
Definition
| acute bleeds if congenital fibrin deficiency |
|
|
Term
| when do you use recombinant factor VII |
|
Definition
| hemophilia A+B, last resort in PPH |
|
|
Term
| how does recombinant factor VII work |
|
Definition
| vitamin K dependent serine protease |
|
|
Term
| complications of recombinant factor VII |
|
Definition
|
|
Term
| how much do you transfuse at a time |
|
Definition
|
|
Term
|
Definition
| PO is better at 14d but their the same at 40-42d |
|
|
Term
| what is the #1 site of ob laceration |
|
Definition
|
|
Term
| what are the parts of the perineal body 3 |
|
Definition
| transverse perineal muscles, bulbocavernosus attachments, connective tissue |
|
|
Term
| muscle type and function of external anal sphincter |
|
Definition
| skeletal muscle voluntary |
|
|
Term
| muscle type and function of internal anal sphincter |
|
Definition
| autonomic smooth muscle, 80% of resting pressure |
|
|
Term
| how large is the anal sphincter complex and what are the components |
|
Definition
| external and internal sphincter overlap 1-2cm, total 4cm |
|
|
Term
| what percent of deliveries will get a laceration |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
A <50% of external sphincter
B >50% of external sphincter
C internal and external sphincter |
|
|
Term
|
Definition
| external and internal sphincter and rectal mucosa |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| within 3mm of midline in posterior forchette 0-25 deg of saggital plane |
|
|
Term
|
Definition
| midline in USA, mediolateral in Europe |
|
|
Term
| define mediolateral episotomy |
|
Definition
| within 3mm of midline in posterior forchette, lateral 60 deg from midline towards ischial tuberosity |
|
|
Term
| which episotomy is recommended |
|
Definition
|
|
Term
| risk of oasis in 3-4 deg lac |
|
Definition
|
|
Term
| what increases the risk of POP |
|
Definition
multiple SVDs and multiple lacerations
NOT episotomy |
|
|
Term
| does episotomy increase incontinence |
|
Definition
yes, increases anal incontinence even if no evident oasis
no increased urinary incontinence or pop |
|
|
Term
| risk factors for oasis 10 |
|
Definition
| forceps, vaccum, midline episotomy, increased birth weight, mother/sister with oasis, Asian, primip, IOL, augmentation |
|
|
Term
| what is an exacerbating factor increasing 3-4 deg lacs with episotomy |
|
Definition
|
|
Term
| does episotomy cause dysparunea |
|
Definition
| initially but same rate at 6-11y as SVD |
|
|
Term
| does perineal massage work, when should it be done |
|
Definition
at 34wk+: decreased trauma/episotomy and PP pain in multips only
in 2nd stage of labor: decreased 3-4 deg lacs |
|
|
Term
| does perineal support decrease oasis |
|
Definition
| 50/50 results in trials, insufficient evidence |
|
|
Term
| do warm compresses help oasis |
|
Definition
| decreased 3-4 deg lacs but not lacs in general |
|
|
Term
| do any labor positions help with lacerations, how specifically |
|
Definition
upright/lateral position decreased episotomy and operative delivery but increased second deg lacs
lithotomy decreased second deg lacs
lateral with delayed pushing decreased lacs
insufficient evidence |
|
|
Term
| does delayed pushing decreased lacs |
|
Definition
| one study said with lateral position but insufficient evidence, in general no |
|
|
Term
| is there risk of routine episotomy with operative delivery |
|
Definition
| no change in oasis, pph, neonatal trauma, urinary morbidities, anal incontinence, dysparunea at 1y or immediately PP |
|
|
Term
| effect of midline episotomy on lacerations |
|
Definition
| increased 3-4 deg, increased length by 3cm |
|
|
Term
| benefits of restrictive episotomy practice |
|
Definition
| decreased severe perineal trauma and healing complications |
|
|
Term
| down sides of restrictive episotomy practice |
|
Definition
| increased anterior vaginal trauma, mediolateral decreases oasis in primpis but not multips |
|
|
Term
| incidence of oasis in routine vs restrictive use of episotomy |
|
Definition
| routine 0.2%, restrictive 1% |
|
|
Term
| risks specific to mediolateral episotomy |
|
Definition
| increased perineal pain and dysparunea at 3mo |
|
|
Term
| althrough not enough evidence to specifically recommend, what is the soft recommendation for preferred episotomy and why |
|
Definition
| mediolateral due to decreased 3-4 deg lacs, but may increase pain/dysparunea |
|
|
Term
| risks specific to midline episotomy |
|
Definition
|
|
Term
|
Definition
| heal spontaneous or sutured, if they distort anatomy or are bleeding suture, if not can leave alone |
|
|
Term
| treatment of 1-2 deg lacs |
|
Definition
| insufficient evidence to recommend suturing, no difference at 6-12wk PP in urinary or anal incontinence or sexual function |
|
|
Term
| what is the incidence of clinically recognizable oasis |
|
Definition
|
|
Term
| what is the incidence of non-clinically recognizable oasis, occult |
|
Definition
|
|
Term
| benefits/risks of sewing 1st deg lac |
|
Definition
more effecting, decreased dysparunea and perineal pain
increased gaping wounds at 48h
no need to repair if no distortion in anatomy |
|
|
Term
| dermabond vs suture in 1st deg lacs |
|
Definition
| similar results, glue decreases repair time and need for local anesthetic, glue is less painful |
|
|
Term
| continuous vs interrupted suture for 2nd deg lacs |
|
Definition
continus causes less pain, less analgesia need, less need for suture removal postpartum
no difference in long term pain, dysparunea, or need to resuture |
|
|
Term
| preferred suture in 2nd deg lacs and why |
|
Definition
synthetic absorbable decreases pain and need for analgesia
catgud requires more resuturing
synthetic may increase need for removal if not rapidly absorbing kind |
|
|
Term
| suture vs glue for skin closure in 2nd deg lacs |
|
Definition
| closing skin/SQ ok with glue or suture, glue takes less time, no pain difference |
|
|
Term
| suture type and method of vaginal lacs |
|
Definition
running locking or interrupted
2-0 chromic or polyglactin |
|
|
Term
| suture type for internal anal sphincter |
|
Definition
| 3-0 polyglactin if with rectal muscularis, 3-0 monofilament if muscle alone |
|
|
Term
| suture type for external anal sphincter |
|
Definition
| 3-0 polyglactin, 3-0 polydioxaone, or 2-0 polyglactin |
|
|
Term
| how to suture external anal sphincter |
|
Definition
and to end repair including muscle and fascial sheath
overall repair 1-1.5cm of muscle in overalp
if 3A-B don't do overlap |
|
|
Term
| how to repair anal mucosa |
|
Definition
| subcuticular running or interrupted |
|
|
Term
|
Definition
delayed absorbable 4-0 or 3-0 polyglactin or chromic
if second layer through rectal m uscularis too 3-0 polyglactin running or interrupted |
|
|
Term
| which is better for external anal sphincter muscle repair |
|
Definition
end to end and overlap same in perineal pain and dysparunea and flatal incontinence at 12 mo
overlap decreased fecal urgency, fecal incontinence at 12mo but no difference at 36mo |
|
|
Term
| antibiotics for 3-4 deg lacs |
|
Definition
| 1 dose of 2nd gen ceph decreases PP wound complications at 2wk (cefotetan, cefoxitin) |
|
|
Term
| signs of retained sponge 4 |
|
Definition
| fever, pain, infection, psychological harm |
|
|
Term
| rate of wound breakdown in oasis |
|
Definition
|
|
Term
| rate of infection of oasis repair |
|
Definition
|
|
Term
| what percent of fistulas are caused by oasis |
|
Definition
|
|
Term
| benefits of laxatives after oasis |
|
Definition
| decreased pain, decreased time to first bm |
|
|
Term
| what are proven things that decrease perineal pain |
|
Definition
cooling - limited evidence
suppositories - decrease need for additional meds but no improvement |
|
|
Term
| complications of suppositories for perineal pain |
|
Definition
| decreased wound healing in 4MLL |
|
|
Term
| treatment of superficial perineal lac wound breakdown |
|
Definition
|
|
Term
| treatment of extensive breakdown of perineal lac wound |
|
Definition
| needs primary closure, inadequate repair leads to fistulas |
|
|
Term
| when do you repair a fistula |
|
Definition
|
|
Term
| prevention of urinary / anal incontinence PP |
|
Definition
pelvic floor exercises with vaginal device that increases resistance decreases urinary but not anal incontinence
biofeedback improves motor/sensory function and cortical awareness of sphincter but no benefit for fecal incontinence |
|
|
Term
| what is the risk of repeat oasis |
|
Definition
|
|
Term
| can you screen to see if oasis damage is so significant that they shouldn't have an svd again |
|
Definition
| no, US of oasis evidence was not benifit |
|
|
Term
| when should you offer cd if history of oasis |
|
Definition
| had incontinence, had wound infection, needed repeat repair, other wound complications, had psych trauma |
|
|
Term
| risk factors for shoulder dystocia |
|
Definition
| persistent AP diameter at prlvic brim, mid pelvic operative delivery, macrosomia, hx dystocia, large chest to BP diameter, truncal rotation does not occur, precipitous labor, diabetes (but most cases are in non-DM) |
|
|
Term
| poor predictors of dystocia that we often use |
|
Definition
| prolonged second stage, excessive weight gain, operative delivery, Pitocin, fetal BP diameter, multiparity, epidural, induction, precipitous deliery |
|
|
Term
|
Definition
|
|
Term
| maternal complications not associated with maneuvers for dystocia |
|
Definition
| PPH 11%, lacs (4deg 3.8%), symphysis separation, lateral femoral cutaneous neuropathy due to hyperflexion |
|
|
Term
| maternal complications associated with maneuvers for dystoci |
|
Definition
OASIS increased with 4+ maneuvers
cervical/vaginal injury, uterine rupture, urethra/bladder lacs - associated with zavanelli or sphyphsotomy |
|
|
Term
| complications of dystocia for baby |
|
Definition
| brachial plexus injury, clavicle/humerus fx, diaphragmatic paralysis, horners syndrome, facial nerve injury, laryngeal nerve palsy, encephalopathy, death |
|
|
Term
| what increases encephalopathy risk with dystoci |
|
Definition
| >5 maneuvers, time average 10min |
|
|
Term
| rate of fetal injury in dystoci |
|
Definition
|
|
Term
| rate of transient brachial plexus injury after dystoci |
|
Definition
|
|
Term
| rate of complete recovery after brachial plexus injury |
|
Definition
|
|
Term
| rate of recovery in C5-6 or C5-7 injuries of fetus |
|
Definition
|
|
Term
| rate of recovery in C5-T1 injuries of fetus |
|
Definition
|
|
Term
| mechanism of fetal demise or major injury in dystoci |
|
Definition
| vagal stimulation, compression of neck decreasing blood to brain |
|
|
Term
| what is the time of dystocia associated with fetal demise or major morbidities |
|
Definition
|
|
Term
| recurrence rate of dystocia |
|
Definition
|
|
Term
| is CD recommended after dystocia |
|
Definition
| universal elective CD not recommended but discuss benefits with patient |
|
|
Term
| does IOL vs spontaneous labor in macrosomia (4000-4500g) change rate of brachial plexus injury or dystoci |
|
Definition
| each had 20% risk dystocia, 30% risk of CD, no change in brachial plexus injury |
|
|
Term
| does expectant management vs induction of diabetic change rate of dystocia |
|
Definition
10% in expectant
1.4$ in induction at 38-39wk
but insufficient evidence to recommend IOL for macrosomia in DM |
|
|
Term
| when should elective CD be recommended in macrosomia |
|
Definition
| EFW >5000g in DM, >4500 in non-DM |
|
|
Term
| what percent of brachial injury occurs without dystocia |
|
Definition
| 50%, even seen in CD and in posterior arms |
|
|
Term
| explain how downward traction should be done in dystocia |
|
Definition
| axial traction 25-45 deg below horizontal in lithotomy, lateral traction increases brachial injury |
|
|
Term
|
Definition
| causes cephalid rotation of symphysis and flattening of lumbar lordosis |
|
|
Term
| how does suprapubic pressure work in dystocia |
|
Definition
| push down and lateral to abduct and rotate the anterior shoulder |
|
|
Term
| what are the risks of fundal pressure during dystocia |
|
Definition
| uterine rupture, impaction of shoulder |
|
|
Term
| what is the most successful maneuver during dystocia |
|
Definition
| delivery of posterior arm 95% within 4min |
|
|
Term
|
Definition
| rotate posterior shoulder anterioe |
|
|
Term
|
Definition
| pressure on anterior clavicle of posterior shoulder to turn baby until anterior shoulder moves |
|
|
Term
| explain axillary sling in dystocia |
|
Definition
| 12-14F catheter posterior shoulder traction |
|
|
Term
|
Definition
| all 4s, causes downward traction of posterior shoulder |
|
|
Term
| what are the initial dystocia maneuvers |
|
Definition
| mcroberts, suprapubic pressure, posterior arm, robin, woodscrew, axillary sling, gaskin |
|
|
Term
| what do you do if initial dystocia maneuvers don't work |
|
Definition
repeat them all, episotomy to provide more space for them...
zavanelli, abdominal rescue, clavicle fx |
|
|
Term
|
Definition
| replaces fetal head then cd |
|
|
Term
| explain abdominal rescue in dystocia |
|
Definition
| laparotomy and hysterectomy to dislodge shoulder |
|
|
Term
| what percent of births are preterm |
|
Definition
|
|
Term
| what percent of neonatal deaths are due to preterm |
|
Definition
|
|
Term
| what percent of lifelong neurological issues are due to preterm |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| preterm contractions and change in dilation (minimal cervix 2cm) or effacement |
|
|
Term
| what percent of preterm labor delivery in 7d |
|
Definition
|
|
Term
| why aernt cervical length and/or FFN good for diagnosis of PTD/PTL |
|
Definition
| poor positive predictive value |
|
|
Term
| what percent of PTL resolves |
|
Definition
|
|
Term
| what percent of PTL will deliver at term |
|
Definition
|
|
Term
| what percent of PTL will delivery in 14d |
|
Definition
|
|
Term
| why give tocolytics if preterm |
|
Definition
to give 48h steroids
after an event known to cause contractions (abdominal sx)
for transport |
|
|
Term
| when is it ok in pregnancy weeks to give tocolytics |
|
Definition
|
|
Term
| contraindications to tocolytics 9 |
|
Definition
iufd
lethal anomaly
nrfht
pre-e with sf/eclampsia
hemodynamically instability
chorio
pprom
agent specific allergy/contraindication |
|
|
Term
|
Definition
| 23-34wk if risk of delivery in 7d, decreases morbidity at 34-36wk as well |
|
|
Term
|
Definition
| decreased RDS, intercranial hemorrhage, necrotizine enterocolitis, and death |
|
|
Term
| when can you give rescue steroids |
|
Definition
| same weeks, >14d from last course (may do as little as 7d) |
|
|
Term
|
Definition
|
|
Term
| if someone is going to deliver before second steroid dose what do you do |
|
Definition
| give 1st dose anyways, don't accelerate dosing no benifit |
|
|
Term
| what is the benefit of mag in preterm |
|
Definition
does not prolong pregnancy
decreased cerebral palsy |
|
|
Term
| when do you give mg for neuro protection |
|
Definition
|
|
Term
| side effects of CCB tocolytic |
|
Definition
| dizzy, flushing, hypotension, bradycardia (with Mg), elevated LFTs |
|
|
Term
| contraindications to CCB tocolytic |
|
Definition
| hypotension, aortic insufficiency or other cardiac lesions |
|
|
Term
| side effects of nsaid tocolytic |
|
Definition
| n/v/d, gerd, thrombocytopenia without affecting platelet function, fetal ductus constriction, oligohydraminos, necrotizing enterocolitis, patent ductus arterosis |
|
|
Term
| complications of nsaid tocolytic |
|
Definition
| bleeding, gerd, pud, renal dysfunction, asthma |
|
|
Term
| complications of b-agonist tocolytic |
|
Definition
| tachycardia, hypotension, palpitations, sob, cp, pumpnary edema, hypokalemia, hyperglycemia, fetal tachycardia |
|
|
Term
| contraindications of b-agonist tocolytic |
|
Definition
| cardiac disease, DM poorly controlled |
|
|
Term
|
Definition
| flushing, diaphoresis, decreased DTRs, respiratory depression, cardiac arrest, if with CCB bradycardia and LV systolic dysfunction, neuromuscular blockage, neonatal depression |
|
|
Term
|
Definition
|
|
Term
| why cant mg just be my tocolytic if on it anyways |
|
Definition
| it can, but usually give something else too it isn't great, don't give ccb has side effects, if <32wk give indomethican |
|
|
Term
| when is it ok to use terb |
|
Definition
| not as a long term tocolytic, reserve for uterine tachysystole, must be in-patient, no longer than 48-72h use |
|
|
Term
| can you give maintinence tocolytics |
|
Definition
| atosiban is the only drug that is effective but it isn't approved in the us |
|
|
Term
|
Definition
| VTE, deconditioning, bone deminieralization, employment loss |
|
|
Term
| can you use tocolytics in multiples |
|
Definition
no they cause pulmonary edema, risk>benefit - BP on pre-term
ok to give in multiples to get steroids on board up to 48h, still increased pulmonary edema risk - multiples PB |
|
|
Term
| can you use Mg and steroids in multiples pre-term |
|
Definition
| yes, no good studies, extrapolating benefit from singletons |
|
|
Term
| risk of still birth in multiples |
|
Definition
|
|
Term
| risk of neonatal death in multiples |
|
Definition
|
|
Term
| cause of most neonatal deaths in multiples |
|
Definition
|
|
Term
| increases all risks in multiples in general |
|
Definition
| monochorionic and increased babies |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| increased maternal age, increased ART |
|
|
Term
| fetal complications in multiples |
|
Definition
| stillbirth, neonatal death, intra/periventricular hemorrhage, leukomalacia, cerebral palsy, prematurity, IUGR |
|
|
Term
| mean gestation age at birth of singleton, twins, triplets, quads |
|
Definition
singleton 38+7
twins 35+3
triplets 31+9
quads 29+5 |
|
|
Term
| rate of cerebral palsy in 1000 pregnancies of singltons, twins, triplets |
|
Definition
singletone 1.6
twins 7
triplets 28 |
|
|
Term
| mortality per 1000 pregnancies in singleton, twins, triplets, quads |
|
Definition
single 5.4
twins 23
triplets 52
quads 96 |
|
|
Term
| what percent of multiples are not diagnosed until delivery |
|
Definition
|
|
Term
| when is it best to determine chorionicity |
|
Definition
|
|
Term
| maternal complications of multiples |
|
Definition
| hyperemesis, GDM, HTN/pre-e, hemorrhage, CD, PP depression, abruption, hysterectomy |
|
|
Term
| rate of HTN disorders in singleton, twins, triplets |
|
Definition
singleton 6.5%
twins 12.7%
triplets 20% |
|
|
Term
| how does pre-e present in multiples |
|
Definition
|
|
Term
| if 40yo or greater what is the natural risk of multiples |
|
Definition
|
|
Term
| why is there a recent decrease in multiples |
|
Definition
| decreased embryos transferred |
|
|
Term
| ART forms most likely to cause multiples |
|
Definition
|
|
Term
| rate of twins and more than twins in IVF |
|
Definition
|
|
Term
| benefits of multifetal reduction |
|
Definition
| decreases pregnancy loss and antepartum complications, increases birth weight, decreases pre-e, decreases fetal deaths |
|
|
Term
| how do you choose which fetus in multifetal reduction |
|
Definition
|
|
Term
| when can you not do multifetal reduction |
|
Definition
|
|
Term
| how do you choose which fetus in selective termination |
|
Definition
| fetus with increased risks |
|
|
Term
| what are the difference in outcomes of selective termination vs multifetal reduction |
|
Definition
| selective termination has increased risks due to later gestational age at time of anomaly diagnosis, but it still prolongs pregnancy |
|
|
Term
| how often is chorionicity correct |
|
Definition
|
|
Term
| what are ways to determine if dichorionic |
|
Definition
| different sexes, twin peak/deta/lambda sign |
|
|
Term
| what can prevent PTD in multiples |
|
Definition
| nothing, do not screen if asymptomatic, CL/FFN is not good predictor in singleton or multiples |
|
|
Term
| effects of cerclage in multiples |
|
Definition
|
|
Term
| risks of tocolysis in multiples |
|
Definition
| pulmonary edema, maternal and fetal cardiac stress, GDM, cardiac events, death |
|
|
Term
| effects of pessary in multiples |
|
Definition
|
|
Term
| effects of prophylactic progesterone in multiples |
|
Definition
| increases 2T loss in triplets |
|
|
Term
| why is trisomy increased in multiples |
|
Definition
| only due to statistics, more fetuses, more risk of trisomy |
|
|
Term
| detection of t21 in twins with maternal serum screening |
|
Definition
| 60% if one and 71% if both twins, average 63% |
|
|
Term
| false positive for t21 in maternal serum screening in twins |
|
Definition
|
|
Term
| detection rate of t21 and t18 with 1t screening with nt in multiples |
|
Definition
|
|
Term
| false positive for trisomy in multiples with 1T screening with nt |
|
Definition
|
|
Term
| what does a NT >95% in multiples mean |
|
Definition
|
|
Term
| can nipt be used in multiples |
|
Definition
|
|
Term
| risks of CVS in multiples |
|
Definition
| increased risk of loss, 1% risk of sampling error |
|
|
Term
| how is amniocentesis done in multiples |
|
Definition
| inject dye into first sample sac to decrease double sampling one sac |
|
|
Term
| if monocoryonic do you need to karyotype both fetuses |
|
Definition
| no, different karyotype chance is low |
|
|
Term
| define multifetal discordnence |
|
Definition
|
|
Term
| how is discordnence calculated |
|
Definition
| (EFW A - EFW B) / EFW of largest |
|
|
Term
| what are the risks of discondinent multiples with normal EFWs |
|
Definition
|
|
Term
| what are the risks of discondinent multiples with IUGR |
|
Definition
|
|
Term
| what combined with discordinence increases morbidity in multiples |
|
Definition
| IUGR, oligo, fetal anomalies |
|
|
Term
| risk of vanishing twin in twins, triplets, quads |
|
Definition
twins 36%
triplets 63%
quads 65% |
|
|
Term
| risk of death of a twin or triplet in 2T and 3T |
|
Definition
|
|
Term
| risk of co-twin death in mono and di twins |
|
Definition
|
|
Term
| if a twin dies what is the risk of neuro abnormality in the surviving twin in mono and di |
|
Definition
|
|
Term
| does immediately delivering the surviving twin after a multiple dies inutero help |
|
Definition
|
|
Term
| when does growth of twins stop occurring at a similar rate from singletons |
|
Definition
|
|
Term
| what APFT things are recommended for twins |
|
Definition
serial US q4-6wk if did, q2wk if mono starting at 16wk
no NST needed for didi unless other indication like IUGR
no benefit of dopplers unless discordnence or fluid abnormalities |
|
|
Term
| what percent of mono-di get TTTS |
|
Definition
|
|
Term
| what is the physiology behind TTTS |
|
Definition
| AV anastomosis in the plaecenta |
|
|
Term
|
Definition
|
|
Term
|
Definition
| laser coagulation, amnioreduction |
|
|
Term
| incidence of natural mono multiples |
|
Definition
|
|
Term
| #1 mortality in mono multiples |
|
Definition
|
|
Term
|
Definition
1. MVP <2 or >8
2. absent bladder
3. abnormal dopplers
4. hydrops
5. death |
|
|
Term
| monitoring if TTTS and delivery |
|
Definition
| consider in-pt with daily survellence at 24-28wk, deliver 32-34wk |
|
|
Term
| acardiac twin: define, incidence |
|
Definition
1% of monos
no heart or head
survives due to placental anastomoses
causes cardiac failure in living twin
50% rate of demise |
|
|
Term
| conjoined twins: incidence, survival |
|
Definition
18% survival of 1 twin from diagnosis to separation
1:50,000-100,000 |
|
|
Term
| when to delivery twins and why |
|
Definition
| increased mortality in twins at 38wk, delivery uncomplicated didi at 38wk, mono di at 34-37wk, and monomono at 32-34wk |
|
|
Term
| how to deliver mono twins and why |
|
Definition
| CD due to risk of cord complications |
|
|
Term
| how to deliver di twins and why |
|
Definition
| SVD if presenting cephalic, CD if <32wk |
|
|
Term
|
Definition
| if uncomplicated and presenting cephalic SVD |
|
|
Term
| what nerves do labor pain come from |
|
Definition
| pudendal and anterior primary devision of S2-4 |
|
|
Term
| does labor anesthesia increase cd rates |
|
Definition
|
|
Term
|
Definition
| fentanyl, morphine, nalbuphine, butorphanol, remifentanil |
|
|
Term
|
Definition
|
|
Term
| patient controlled iv labor meds |
|
Definition
|
|
Term
| fetal effects of iv labor leds |
|
Definition
| decreased variability, decreased baseline, respiratory depression, neurovariable changes, prolonged elimination in infants increases effects |
|
|
Term
| why is merperidine not recommended |
|
Definition
| active metabolite normeriperidine has long half life in adults and up to 72h in neonate |
|
|
Term
| labor iv meds by increasing duration |
|
Definition
| remifentanil 3-4m, fentanyl 30-60m, morphine 1-3h, nalbuphine 2-4h, butorphanol 4-6h |
|
|
Term
| moa of nalbuphine and butorphanol, what to avoid with them |
|
Definition
| mixed agonist/antagonists, avoid full opioids due to decreased effect and increased withdrawal |
|
|
Term
|
Definition
| less acute respiratory depression in newborn, better pain control |
|
|
Term
| down sides of remifentanyl |
|
Definition
| needs 1:1 nursing, 26% maternal apnea, needs O2 monitoring, needs supplemental O2 access |
|
|
Term
| why don't we use Tylenol or nsaids for pain control in labor |
|
Definition
|
|
Term
| what percent of patient select epidural |
|
Definition
|
|
Term
| what type of patients select epidural |
|
Definition
| increased education, white, good prenatal care |
|
|
Term
| what is an epidural what med categories used |
|
Definition
| local anesthetic and opioid combination lowers concentration of each agent |
|
|
Term
| local anesthetics used in epidural |
|
Definition
bupivacaine, ropivicaine
both are equals |
|
|
Term
|
Definition
|
|
Term
| why add epinephrine to epidural |
|
Definition
|
|
Term
| why add NaHCO3 to epidural |
|
Definition
| increases onset speed, increases sacral division coverage |
|
|
Term
| what is best way to administer epidural medications |
|
Definition
| intermittent bolus increases patient satisfaction and decreases total meds given |
|
|
Term
| how does epidural effect labor |
|
Definition
| increases second stage but total overall no difference in timing |
|
|
Term
| what are the components of a single spinal, what is it |
|
Definition
| opioid +/- local anesthetic into subarachnoid space |
|
|
Term
| what are the benefits of single spinal |
|
Definition
| rapid onset, dense sensory block |
|
|
Term
| meds used in single spinal |
|
Definition
lidocaine, bupivacaine, ropivicaine
can add fentanul, entanil, or morphine to increase comfort |
|
|
Term
| down sides to continuous spinal |
|
Definition
| increased post dural puncture headache, cauda equine syndrome |
|
|
Term
| what do you do if single spinal accidently punctures the dura |
|
Definition
|
|
Term
| what is the benefit of adding local into spinal anesthesia |
|
Definition
| covers later labor, the more somatic pain |
|
|
Term
| what is a combined spinal epidural, what med classes are used |
|
Definition
| subarachnoid injection with opioid +/- local plus epidural |
|
|
Term
| opioids and local used in combined spinal epidural |
|
Definition
fentanul or sulfentail opioids
local bupivacaine or ropivicainie |
|
|
Term
| benefits of combined spinial epidural |
|
Definition
| decreased need for rescue anesthesia, decreased urinary retention |
|
|
Term
| risks of combined spinal epidural |
|
Definition
| increased pruritis, fetal bradycardia independent of maternal hypotension |
|
|
Term
| what causes fetal bradycardia after epidural |
|
Definition
| it is independent of maternal hypotension, it is due to opioid decreasing epinephrine and B-endorphins leaving oxytocin and norepinephrine unopposed causing uterine hypertonicity |
|
|
Term
| how does a pudendal block work |
|
Definition
|
|
Term
| what is the benefit of adding epinephrine to local |
|
Definition
| delays absorption so longer onset but increases duration and vasoconstricts, also a marker for venous injection as will increase HR/BP |
|
|
Term
| what is a contraindication to adding epi to local in ob |
|
Definition
|
|
Term
| what anesthetics can cause allergy |
|
Definition
| chlorpracaine, tetracaine, the preservitives in methylparabe, the sulfites |
|
|
Term
| signs of local anesthetic toxicity |
|
Definition
| seizure, arrhythmia, coma, myocardial depression, hypoxia, acidosis |
|
|
Term
| what is inhaled anesthetic composed of |
|
Definition
|
|
Term
| benefits of inhaled anesthetic |
|
Definition
| does not require additional monitoring, crosses placenta but eliminated rapidly when baby breathes |
|
|
Term
| risks of inhaled anesthetic |
|
Definition
| maternal dizziness, n/v, drowsiness, less effective than epidural |
|
|
Term
| risk of general anesthesia |
|
Definition
| aspiration, decreased FRC can increase MV and cause rapid desaturation, increased failed intubation in pregnancy |
|
|
Term
| how to give general anesthesia / meds |
|
Definition
| pre-oxygenate, give propofol or ketamine with muscle relaxer (succinylcholine or rocurnoium) then intubate, maintain with sevoflurane or isoflurane, inhaled low dose |
|
|
Term
| why can you maintain general with high dose medications |
|
Definition
|
|
Term
| what med can you use with general at induction to decrease intraoperative awareness |
|
Definition
|
|
Term
| in SVD what percent get neuraxial, epidural, combined, and spinal |
|
Definition
| 76% neuraxial, 63% epidural, 37% combined, 1% spinal continous |
|
|
Term
| in cd what percent get neuraxial and what percent get general due to neuraxial failure |
|
Definition
| 94% neuraxial, 1.7-5.6% general |
|
|
Term
| side effects of neuraxial blocks |
|
Definition
| cardiac arrest, MI, hypotension, epidural abscess, meningitis, epidural hematoma, failed intubation, increased risk of operative delivery, fluid retention and pulmonary edema, aspiration, high block, neurological injury, anaphylaxis, pruritis, ha, n/v, hyperthermia, shivering, hsv activation, urinary retention |
|
|
Term
| what percent of high neuraxial blocks get a headache and what percent get bloodpatch |
|
Definition
|
|
Term
| what causes pruritis after anesthesia, what makes it worse |
|
Definition
opioid binding to u-receptor
worse with iv opioids, intratechal > epidural |
|
|
Term
| treatment of post anesthesia pruritis |
|
Definition
| self limited, naloxone or nalphburine but this decreases pain control, antihistamines have little effect just make drowsy |
|
|
Term
| which has more high neuraxial blocks spinal or epidural |
|
Definition
|
|
Term
| what increases chances of hypotension with epidural |
|
Definition
| increased speed on onset, increased dose of anesthetic |
|
|
Term
| what percent of women get hypotension with epidural |
|
Definition
|
|
Term
| how can you prevent hypotension with epidural |
|
Definition
| preload with crystalloid or with vasopressors (nor/epinephrine, phenylephrine) |
|
|
Term
| what vasopressor is best and why for fixing hypotension |
|
Definition
| norepi decreases bradycardia and preserves CO better than phenylepherine |
|
|
Term
| side effects of neuraxial opioids in mom |
|
Definition
| increased minute ventilation, hypocarbia, respiratory acidosis, increased catecholamines and cortisol |
|
|
Term
| side effects of neuroaxial opiods in baby |
|
Definition
| decreased apgars, respiratory depression, decreased muscle tone, decreased suckle |
|
|
Term
| what percent have increased uterine tone in combined and epidural |
|
Definition
|
|
Term
| when do FHR abnormalities occur after epidural |
|
Definition
|
|
Term
| is epidural or spinal more likely to cause hematoma |
|
Definition
|
|
Term
| rate of hematoma from neuraxial anesthesia in PLT<100 |
|
Definition
|
|
Term
| rate of seroious morbidity from general anesthesia |
|
Definition
|
|
Term
| contraindications to regional anesthesia |
|
Definition
coagulopathy
thrombocytopenia PLT <80
non-functional PLT
ICP
mass effect
hydronephrosis |
|
|
Term
| how long do you have to wait for epidural after ASA 81mg |
|
Definition
|
|
Term
| what percent of epidural will cause temp >100.4 |
|
Definition
|
|
Term
| what increases risk of elevated temp from epidural |
|
Definition
|
|
Term
| what is the benefit of abx with epidural |
|
Definition
| decreases placental inflammation |
|
|
Term
| how to systemic meds vs intrathecal effect labor timing |
|
Definition
90min longer with systemic meds
epidural prolongs second stage 13min |
|
|
Term
| why do pre-eclamptics have protective effect from hypotension with epidural |
|
Definition
|
|
Term
| what causes hypertension in general anesthesia |
|
Definition
| larngoscopy and intubation itself |
|
|
Term
| what are the risk of the hypertension associated with general anesthsia |
|
Definition
|
|
Term
| how can you decrease risk of hypertension associated with general anesthesia |
|
Definition
|
|
Term
| what population specific in pregnancy have increased risk of intubation and why |
|
Definition
|
|
Term
| how much of general anesthesia can be found in breast milk once mom wakes up |
|
Definition
|
|
Term
| why is it ok to breastfeed after the opioids in epidural |
|
Definition
| negligible amount in blood |
|
|
Term
| low long does it take to transition lidocaine epidural/spinal to surgical T4 level |
|
Definition
|
|
Term
| how long does it take to do a spinal and have it be adequate in surgical emergency |
|
Definition
| 8 min, 4 is to get to level |
|
|
Term
| how often does conversion from epidural/spinal to surgical level emergently fail |
|
Definition
|
|
Term
| what do you do if anesthesia cannot get surgical control for CD |
|
Definition
| repeat spinal, repeat combined epidural, IV med supplement, general anesthesia, done exterorize uterus, be gentile |
|
|
Term
| what can you do in or to help with post op pain relief |
|
Definition
| intrathecal morphine, intraoperative nerve blocks, local injection, wound irrigation with meds |
|
|
Term
| how long does intrathecal morphine last |
|
Definition
|
|
Term
| risks of intrathecal morphine for post op pain |
|
Definition
| pruritis, nausea, respiration depression |
|
|
Term
| where can you do nerve blocks to help post cd |
|
Definition
| ilioinguinal, iliohypogastric, transverse abdominous plane |
|
|
Term
| what should you use for transverse abdominous plane nerve block and why |
|
Definition
| ropivicaine decreases morphine use by 70%, increased effect with paracentamol and nsaids |
|
|
Term
| what pain med should be avoided in breastfeeding |
|
Definition
| codeine >30mg/d due to fetal effects |
|
|
Term
| what are signs of codeine transmission to baby |
|
Definition
| drowsiness, sedation, difficulties feeding, limpness |
|
|
Term
| what are signs of opiods in mom |
|
Definition
|
|
Term
| how long can wound infiltration with local in cd provide pain relief |
|
Definition
|
|
Term
| why should you consult anesthesia intrapartum |
|
Definition
bmi>50
organ transplant
myasthenia gravis
sickle cell
neurofibromatosis
difficult airway
osa
hx failed nerve block
malignant hyperthermia
allergy to anesthesia/local
accreta
non-ob surgery in pregnancy
CD with other surgery combined
congenital cardiac disease
cardiomyopathy
valve disease
pulmonary htn
eisenmenger
abnormal cardiac rhythm
pacemaker
defibulater
ITP
gestationl thrombocytopenia
anticoagular use
jehovas witness
vertebral abnormalities/ surgery
sx spinal cord injury
AV malformations
aneurysm
chiari malformation
AV shunt
renal insufficiency
hepatitis/cirrhosis
elevated LFTs
coagulopathy |
|
|
Term
| how long do you have to wait for epidural after prophylactic heparin 5000U BID |
|
Definition
|
|
Term
| how long do you have to wait for epidural for prophylactic and tx dose LMWH |
|
Definition
|
|
Term
| how long do you have to wait for epidural after >prophylactic dose of unfractionated heparin |
|
Definition
unknown safety
if >4d use get PLT to assess for HIT |
|
|
