1
Q
Term birth is at > or = to _____ weeks
A
37 week
2
Q
Preterm birth is at ______
A
<37 weeks
3
Q
SROM
A
spontaneous rupture of membrane
4
Q
AROM
A
artificial rupture of membrane
5
Q
OA refers to the fetus in which position
A
Occiput Anterior
back of baby’s head facing mother’s belly button
6
Q
OP refers to fetus in which position
A
Occiput posterior
“sunny side up”
back of baby’s head facing mother’s spine
7
Q
What is the ideal position of the fetus for birth
A
OA
8
Q
CLE stands for
A
Continuous Labor Epidural
9
Q
CSE stands for
A
Combined spinal epidural
10
Q
DPE stands for
A
Dural puncture epidural
11
Q
TPAL stands for
A
Term: 37weeks for >
Preterm
Abortions: spont or elective
Living children
12
Q
What is the duration of 1st stage of labor?
A
Primip = 8-12hrs
Multip= 5-8hrs
13
Q
What are the 2 phases of First Stage of Labor
A
Latent phase and Active phase
14
Q
What are the characteristics of latent phase of 1st stage
A
Latent:
- cervical effacement
- Minor cervical dilation: 2-4cm
- Contractions: every 5-7min, lasting 30-40sec
Active:
- cervical dilation ramps up: from 4 to 10cm (complete)
- contractions: every 2-5min, lasting 50-70sec
- When anesthesia usually becomes involved for epidural
15
Q
When does stage 2 labor begin? What is average duration
A
Duration 15-120mins
- Full cervical dilation (10cm)
- Contractions: every 1.5-2min; duration 60-90sec
- Fetal descent
- Ends with delivery of fetus
16
Q
2nd stage of labor is considered prolonged if > ____hrs
A
> 3-4hrs
17
Q
What are the risks of prolonged stage 2 labor
A
- Cephalopelvic disproportion
- Risk of fetal trauma
- Severe umbilical cord compression possible
- Maternal trauma (phys and emotional)
- Increased risk of postpartum hemorrhage
- Increased risk of infection
- Increased admission to NICU
18
Q
When does 3rd stage of labor begin? Duration?
A
Begins after delivery, ends with delivery of placenta
15-30mins; prolonged after 30min
19
Q
When is the 4th stage of labor?
A
1-2hrs postpartum
Risk of uterine atony &PPH
20
Q
Visceral labor pain is transmitted by ____ fibers that enter the spinal cord at ____
A
unmyelinated C fibers, T10-L1
21
Q
What are the characteristics of Labor Pain: Stage 1
A
Mechanoreceptors stimulated by stretching & distention of lower uterine segment & cervix
- Visceral pain that is hard to localize (lower abd., sacrum, back)
- Can be difficult to treat with opioids (concern for sedation)
22
Q
Latent phase pain dermatome =
A
T10-T12
23
Q
Active phase pain dermatome =
A
T12-L1
24
Q
What are the characteristics of Labor Pain: Stage 2. Which dermatome levels?
A
Stretching & compression of pelvis, perineal structures
Somatic Pain becomes more prominent
- sharp, easily localized
T12-S4 (moving further into sacral dermatomes as labor progresses)
Visceral pain still significant - contractions continue
25
Somatic labor pain is transmitted via ____ fibers via the _______ nerve
myelinated A fibers, pudendal nerve
26
Other non-pharmacological modalities of labor pain management include
- Intradermal sterile H2O injections
- TENS
- Hydrotherapy
Management of back pain:
- Counterpressure
- Peanut ball
- Swaying
- Position changes
Form of counterirritation- ex: squeezing hair comb
- gate control theory
- Physiologic distraction
27
Which inhalation agent is used for labor pain management
N2O
- must use sub-anesthetic concentrations
- Parturient must remain conscious
- Partner/coach in verbal contract always
- Patient "doses" self
28
The primary MOA of N2O is _____
Inhibitory action at NMDA glutamate receptors
Modulates dopaminergic, opioid & adrenergic pathways (a1 &a2)
29
How does N2O differ from volatile agents in laboring patients
- N2O has no decrease in uterine contractility or neonatal depression. Volatiles cause smooth muscle relaxation, loss of airway reflexes
- N2O can be administered without anesthesia present
- Volatiles require scavenging system
- Volatiles require controlled airway
30
N2O is blended in a ____ ratio for patient self administration
50:50
31
What are the side effects of N2O
Nausea, dizziness, parasthesia, dry mouth
Synergy with opioids -> hypoxia, LOC, loss of airway reflexes
32
Acetaminophen has effect on what receptors
COX1 and COX2
33
NSAIDs are controversial in labor because ____
Suppresses uterine contractions
- Promotes premature constriction of fetal ductus arteriosus
- Inhibits platelet aggregation
34
When is Ketamine considered for labor
Best for brief, painful OB procedures when neuraxial not possible
- manual removal of placenta
- Uterine exploration
- Laceration repair when epidural failed
- Bridge analgesia while preparing for neuraxial or OR transfer
- Resource-limited settings (much more common globally than in U.S.)
35
The Paracervical block prevents transmission thru _______, and is used when?
paracervical ganglion
Short term pain relief in first stage of labor
36
A regional alternative in the 2nd stage of labor is a _______
Pudendal nerve block
37
What are the downsides of pudendal nerve block
- Minimizes urge to push
- Rapid maternal absorption of local anesthetic (highly vascular area)
- Risk of injection into pudendal artery
- Risk for LAST
- Fetal trauma or injection of local anesthetic
38
What are the benefits of neuraxial for labor analgesia
- **Superior analgesia** with minimal maternal and fetal drug exposure
- **Flexibility:** allows rapid escalation to surgical anesthesia if required
- **Preserves maternal participation** and protective airway reflexes
- **Blunts stress response** and reduces catacholamine release
39
What should you assume for OB anesthesia
- **Assume every labor neuraxial may need conversion** to surgical anesthesia
- **Assume you may have to manage the airway** at any time
- **Anticipate hypotension** and be ready to treat it immediately
40
Which emergency drugs should you have available for epidural placement
- Ephedrine/Phenylephrine
- Atropine/Epi
- Naloxone
- Calcium chloride
- Sodium Bicarb
- Know where lipids are kept
41
Monitoring during neuraxial for labor should include:
- BP: cycle 1-5min during initial dosing for first 20-30min
- Pulse Ox: very important for test dose
- EKG: not required
- Fetal HR/tones
- Continuous monitoring during & after placement
- Document pre & post FHR
42
The superior aspect of iliac crest aligns with which vertebrae
L4
Tuffier's Line (Intercristal line)
43
The posterior superior iliac spine aligns with which vertebrae
S2
44
How does pregnancy affect neuraxial anatomy
- Decreased intervertebral gap associated with lumbar lordosis - "tight spaces"
- Forward rotation of pelvis: Touffier's line can be elevated
- Apex of thoracic curvature: shifted from T8-> T6 = increased risk of cephalad spread (high spinal)
- Epidural vein engorgement: smaller epidural space, higher spread, risk of venous cannulation
45
Why might lateral positioning be better for labor neuraxial insertion
- Epidural veins decompressed = Less risk for intravascular catheter
- May be easier for parturient: comfort and remain still
46
Absolute contraindications of neuraxial are
- Patient refusal
- Uncooperative patient
- Uncontrolled hemorrhage w/ hypovolemia
- Epidural site skin/soft tissue infection
- Moderate to severe bleeding issues/clotting disorder
- Anticoagulation
47
What are relative contraindications of neuraxial
- Elevated ICP d/t mass lesion
- Local anesthetic allergy
- Language barrier w/o interpreter
- Severe fatal depression
- Severe maternal cardiac disease
- Active coagulopathy
- Untreated systemic infection
- Pre-existing neurologic deficit/numbness tingling
- Skeletal anomalies
- Hardware in spine
48
What are the risks of too early timing of neuraxial
- risk for instrumented delivery
- prolonged 2nd stage labor
- risk for epidural becoming ineffective and needing to be replaced
But it provides a nice margin of safety if C/S needed. Continuous assessment is key
49
What are the 5 neuraxial anesthesia options for labor?
- Epidural (CLE)
- Dural puncture epidural (DPE)
- Combined spinal epidural (CSE)
- Single shot spinal/intrathecal: not usual in labor anesthesia
- Continuous spinal/intrathecal: more of a "rescue" technique if you get a wet tap!
50
What is the order of layers passed thru when placing epidural? spinal?
Skin -> SubQ tissue -> Supraspinous ligament -> Interspinous ligament -> ligamentum flavum -> epidural space ...... -> dura mater -> arachnoid mater -> subarachnoid space, CSF
51
How does an epidural work?
Epidural local anesthetics primarily act on:
- **Spinal nerve roots** as they pass through the epidural space
- **Mixed spinal nerves near the intervertebral foramina
- **Dural cuffs** surrounding nerve roots
- **A small amount** diffuses across the dura
**Epidural dose >> Spinal dose**
52
What is the MOA of local anesthetics
Na+ channel blockers, weak bases
- non-ionized drug crosses the axonal membrane
- becomes ionized -> binds intracellularly to **voltage-gated sodium channels** = conduction is blocked
53
Differentiate the neuraxial blockade levels
1. Sympathetic block extends 2-6 levels above sensory block
- Small, lightly myelinated B fibers
2. Sensory block extends ~2 levels above motor block
- A-delta & C fibers
3. Motor block requires the **highest local anesthetic concentration**
- Large, heavily myelinated A fibers
54
With epidural anesthesia: _______ determines spread (height)
Volume
55
With epidural anesthesia: ______ determines density
concentration
56
epidural volume = ~ ____ mL local per targeted dermatome as a starting estimate in adults
~ 1-2mL per level
57
What is the targeted dermatome level required for labor analgesia
T9/10
58
What is the targeted dermatome level required for C-section
T4
59
Epidurals create a _______ block
segmental
60
Epidural spread is _____
- Longitudinal (up/down)
- Circumferential (often uneven)
- Lateral through foramina
61
What are common reasons for why epidurals may be uneven, patchy, sacral sparing.
- Not a uniform tube: irregular/compartmentalized
- Influenced by gravity, curvature, and pressure gradients
- Significant vascular uptake
- Nerve root anatomy not symmetric
- S2 roots sit low/posterior (more difficult to block)
- Scar tissue/septations/differing anatomy can promote unilateral or asymmetric spread
Pregnancy specific:
- engorged epidural veins
- Reduced epidural volume
62
What level of placement should CLE be
L2-3/L3-4/L4-5
63
What are the advantages of a CLE
- continuous analgesia
- No dural puncture required
- Catheter for c-section use
64
What are the disadvantages of a CLE
- Slower onset of analgesia: 10-15min, drug has to diffuse across dura and penetrate nerve roots
- Increased amount of local anesthetic/opioids required
- Risk of sacral "sparing" or uneven block
- Greater risk for maternal LAST
- Greater fetal drug exposure
65
LOR to air has a risk for
- Risk of patchy block
- Risk of pneumocephalus
66
Hanging drop epidural technique
- Small drop of saline placed at hub
- When needle enters epidural space, the drop gets sucked in
- Not considered reliable anymore compared to other techniques
67
Spring Loaded Syringe epidural technique
- **Mechanical detection of pressure change**
- False positives?
- Not widely studied yet
- May have benefit for difficult placement
- Not a replacement for clinical judgement
68
When performing neuraxial anesthesia with US, what are the 5 landmarks to locate?
Midline
Interspinous space
Vertebral level
Estimated depth to epidural space
Spinal anatomy variability
69
What probe and view are needed for neuraxial US?
low-frequency curved probe
paramedian sagittal transverse process (PSTP)
70
What is the sign called that looks like finger acoustic shadows of the transverse processes on US when performing neuraxial anesthesia?
Trident sign
71
What view is needed to visualize lamina and interlaminar window when performing neuraxial anesthesia?
paramedian sagittal oblique (PSO)
72
What is the standard epidural test dose? How much does each mL contain?
Lidocaine 1.5% + 1:200K epi x 3 mL
*Each mL of test dose contains 15mg Lido + 5mcg Epi
73
How do you determine if the epidural is intravascular or intrathecal when giving a test dose?
Intravascular: increase HR 20 bpm within 1 minute (due to 15mcg epi), may have circumoral numbness or tinnitus (due to 45mg lidocaine)
Intrathecal: motor blockade in 3-5 minutes/warm or heavy legs (due to high dose of lido in intrathecal space), risk for high spinal!
74
What are the advantages of CSE?
Rapid onset of analgesia (2-5 minutes)
Low doses of local anesthetic & opioid
Continuous analgesia w/epidural catheter
Epidural catheter to use for c-section
Decreased incidence of failed epidural
75
What are the disadvantages of CSE?
Increased risk of fetal bradycardia (due to degree of sympathetic block and maternal hypotension)
Increased risk of PDPH
Increased risk of postpartum neuraxial infection
Uncertain of “correct” epidural catheter placement until block regression
76
What is the difference between CSE and dural puncture epidural?
Dural puncture epidural is similar to CSE, but no medications injected into subarachnoid space
77
What are the advantages of dural puncture epidural?
Faster onset than an epidural without a DP
Transdural migration of medications injected into epidural space
More rapid sacral analgesia than traditional epidural
Decreased risk of maternal hypotension & fetal bradycardia compared to CSE
78
What are the disadvantages of dural puncture epidural?
Increased risk of PDPH
Increased risk of postpartum neuraxial infection
79
What are the advantages of a single-shot spinal/intrathecal for labor?
Rapid onset of analgesia
Immediate sacral analgesia
Low local anesthetic & opioid dosages
80
What are the disadvantages of a single-shot spinal/intrathecal for labor?
- Limited duration of analgesia (Based on LA & opioid selection)
- Increased risk of maternal hypotension/fetal bradycardia
- Increased risk of PDPH
(Dep on needle type/size/attempts)
- Increased risk of postpartum neuraxial infection
81
When is a continuous spinal infusion used?
Not typically done electively; Used after unintentional dural puncture with epidural needle
82
What are the advantages of a continuous spinal?
Continuous analgesia
Low doses of local anesthetic/opioid
Rapid onset of analgesia
Can use if patient requires c-section
83
What are the disadvantages of a continuous spinal?
Large dural puncture → risk of PDPH
Risk of mistaken identity!!!! (Spinal catheter vs epidural catheter)
84
Which LAs are most commonly used for labor?
Bupivicaine and ropi
85
How do LAs block visceral and somatic pain using epidurals during labor?
Block visceral pain
- Lower uterine segment distention
- Cervical dilation
Block somatic pain
- Descent of fetus into birth canal
86
What are the advantages of bupivacaine for epidural analgesia during labor?
1. Differential block: Separation b/t motor & sensory effects; Sparing of A-⍺ motor neurons
2. Long duration of action (~2 hrs PLAIN)
3. Lack of tachyphylaxis (rapid decrease in response to a drug after repeated doses)
4. Safety: Low concentrations unlikely to cause toxicity; Limited placental transfer (highly protein bound)
87
What are the disadvantages of bupivacaine for epidural analgesia during labor?
- Slow onset time (10 – 15 mins; latency is improved with lipophilic opioid)
- Risk of CV & neuro toxicity
88
What is the initial dose of bupivicaine for epidural labor analgesia?
0.0625% - 0.25%
- 10-20 mL depending on concentration
- Lower concentration / larger volume
- Followed by maintenance infusion
89
What are the advantages of ropivacaine for epidural analgesia during labor?
1. Differential block: Greater differential sensory-motor blockade than bupivacaine
2. ~1.5-2hrs DOA (PLAIN)
3. Does not exhibit Tachyphylaxis
4. Safety: Less risk for toxicity than bupivacaine
90
What are the disadvantages of ropivacaine for epidural analgesia during labor?
Slow onset time (10 – 15 mins; latency is improved with lipophilic opioid)
CV & neuro toxicity (less than bupi, though!)
91
What is the initial dose of ropivacaine for epidurals during labor?
0.1 – 0.2% concentration
- 10 – 20 mL depending on concentration
- Lower concentration / larger volume
- Followed by maintenance infusion
92
Why isn't lidocaine typically used for labor analgesia?
Poor differential block
- Significant motor involvement/blockade
- Dependent on concentration & dose
Risk of tachyphylaxis
Increased placental transfer/ion trapping
93
When is lidocaine useful for labor analgesia?
1. Identifying non-functional catheter
2. Need for rapid sacral analgesia (e.g. late labor/rectal pressure)
3. Instrumented vaginal delivery/Perineal repair
4. Emergent operative delivery (C/S)
94
What dose of lidocaine is used to identify a non-functional catheter?
2% x 5-10 mL – rapid onset (~5-10 min)
95
What dose of lidocaine is used when rapid sacral analgesia is needed?
1-2% x 5-10 mL
96
What dose of lidocaine is used for an instrumented vaginal delivery or perineal repair?
1-2% +/- epinephrine x 5 – 10 mL
97
What are the advantages and disadvantages of using 2-chloroprocaine for neuraxial analgesia?
Advantages:
- Rapid onset (<5 mins)
- Poor differential blockade
Disadvantages
- Interferes with action of bupivacaine / opioids
- Short duration of action (30-60 mins PLAIN) -- Rapid hydrolysis by plasma cholinesterases
98
When is 2-chloroprocaine useful in neuraxial analgesia for labor?
Emergent instrumented (vaccum, forceps), operative delivery (C/S), Perineal repair:
Ex: 2-3% x 10 mL
Quick onset, dense block…
but short DOA
99
Which lamina do opioids act on?
Primary action in substantia gelatinosa (lamina II) - dorsal horn mu receptors
100
Differentiate between lipophilic and hydrophilic opioids in neuraxial
Lipophilic will have faster onset (fentanyl/sufentanil)
Hydrophilic (morphine) will have a later onset (but can cover postoperative pain if needed)
101
What is the dose of clonidine for an epidural additive?
75-100 mg
102
What are the advantages and disadvantages of adding clonidine to an epidural?
Advantages:
- Analgesic effect
- Decreases LA requirements
- Improves block quality & duration
- No motor blockade
Disadvantages
- Maternal hypotension & bradycardia
- Maternal sedation
103
What is the dose of precedex when adding to an epidural?
5-10 mcg
104
Which has a faster onset: clonidine or precedex?
Precedex
105
What are the advantages and disadvantages of adding precedex to an epidural?
Advantages (almost the same):
- Analgesic effect
- Decreases local anesthetic requirements
- Improves block quality & duration – more dense effect than clonidine
- No motor blockade
Disadvantages (same)
- Maternal hypotension & bradycardia
- Maternal sedation
106
What are the doses for continuous epidural infusion of bupivacaine and ropivacaine?
Bupivacaine
0.05-0.125%
8-15 mL/hr
Ropivacaine
0.08-0.2%
8-15 mL/hr
107
What are the advantages and disadvantages of PCEA (patient controlled epidural analgesia)?
Advantages:
- Patient self-administers based on need
- Significant decrease in repeat dosing by provider
- Better analgesia & increased maternal satisfaction
- Less attentiveness required by pt
Disadvantages:
- Pump programming errors: Bolus dose volume, Lockout interval, Background infusion rate, Max allowable dose/hour
- Non-patient initiated boluses
Language/cognitive/age barriers
- Inappropriate clientele
- Increased total drug dose
108
What are the doses for bupivacaine and ropivacaine in spinals?
Bupivacaine
- Hyperbaric 0.75%
- Isobaric 0.5%
Ropivacaine
- Not typically used for spinal analgesia/anesthesia in U.S.
- Isobaric 0.5%
109
How many mg of 0.75% bupivacaine are in 1.7ml?
12.75 mg 0.75% Bupivacaine
110
How many mg of 0.5% bupivacaine are in 1.7ml?
8.5 mg
0.5% bupivacaine
111
What are the doses for continuous spinal dosing for labor of ropivacaine and bupivacaine?
- 0.0625 – 0.125% bupivacaine +/- fentanyl 1-3 mcg/mL @ 1–1.5 mL/hr
- 0.1–0.2% ropivacaine +/- fentanyl 1-3 mcg/mL @ 1–1.5 mL/hr
112
What kinds of neuraxial analgesia are used throughout labor?
* Early labor → CLE; bolus off the pump (dilute local +/- opioid)
* More advanced labor → CLE, DPE, CSE (bolus = dealer’s choice)
* Imminent delivery → Single-shot spinal/saddle block, or super speedy epidural bloused with something STRONG (ex: 2% lido, 0.25% bupi)
* Wet tap → Continuous spinal or replace epidural
* High likelihood of C-section → CLE/DPE – when it’s time, bolus with 2% lido or 3% chloroprocaine
113
What level block is necessary for labor?
T10
114
How much local is used per targeted dermatome?
~1-2 mL
115
Volume determines ______, while concentration determines _______
volume = spread
concentration = density
116
What are the red flags after dosing neuraxial?
Rapid dyspnea, numb hands/face, LOC, severe hypotension → high/total spinal
Tinnitus, metallic taste, circumoral numbness, seizures → LAST
Sudden tachycardia /HTN after test dose w/ epi → intravascular
Unexpected dense motor block early → intrathecal/ subdural/too concentrated mix
117
What are some options when an epidural is in place and mom is complaining of pain still?
1. Assess location of epidural catheter
2. Assess sensory level
3. Redose/top up if needed (examples):
- Fentanyl 50-100 mcg
- Lidocaine 1-2% x 5-10 mL
- Bupivacaine 0.25% x 5-10 mL
- Chloroprocaine 2-3% x 5-10 mL
118
What are some options after a spinal is placed and mom is complaining of pain still?
Single shot spinal/intrathecal:
- Redo intrathecal
Can do… BUT! Generally not recommended d/t risk of PDPH; careful of dosing
- Place epidural & dose per initial CLE guidelines; Dose incrementally (Essentially a DPE)
Continuous spinal:
- Assess location of intrathecal catheter
- Use spinal/ intrathecal dosing guidelines
119
What are the causes and treatment for hypotension during neuraxial?
Causes
- Sympathetic blockade
- Peripheral vasodilation
- Increased venous capacitance
- Decreased venous return
SBP < 90-100 mmHg or 20-30% decrease in baseline SBP (AND/OR FETAL DISTRESS)
- Mitigate with IV fluid
- Treat with positioning / vasopressors
120
What are the causes of failed analgesia after neuraxial?
- Unilateral / asymmetric block
- Patchy or absence of block
- Catheter out of epidural space
(or subarachnoid space if intrathecal)
121
What is the most common side effect of neuraxial if opioids are administered?
Pruritus - central mu-opioid receptors (unrelated to histamine)
122
What is the treatment for pruritus after neuraxial?
Centrally acting mu-opioid antagonist
- Naloxone 40-80 mcg IV bolus or 1-2 mcg/kg/hr
- Naltrexone 6 mg po
123
How is an unintended dural puncture (wet trap) prevented?
- ID ligamentum flavum while advancing Tuohy
- Appreciate probable depth of epidural space (~4-6cm)
- Advance Tuohy b/t contractions
- Maintain control of needle-syringe always
- Clear Tuohy of blood clots
124
How is an unintended dural puncture (wet trap) treated?
- Intrathecal cath or replace with epidural cath
- Do not reinject CSF from syringe – risk for contamination/pneumocephalus
- Epidural blood patch if headache develops vs. SPG block vs. conservative treatment
125
How is an epidural blood patch performed?
- Performed under sterile conditions using a Tuohy needle
- Typically 15–20 mL of the patient’s own blood is injected.
- Immediate relief is often experienced.
126
What is the target of an SPG block? What is the mechanism?
Target: Sphenopalatine ganglion, located posterior to the middle turbinate in the pterygopalatine fossa.
Mechanism: Blocks parasympathetic fibers contributing to cranial vasodilation and pain
127
What is the technique used to perform an SPG block?
- Patient is supine, neck extended.
- A cotton-tipped applicator or soft catheter soaked in local anesthetic (e.g., 2–4% lidocaine) is inserted along the floor of the nostril, directed posteriorly.
- Held in place for ~5–10 minutes.
128
What are the advantages of an SPG block?
- Rapid, bedside treatment
- Minimally invasive
- Can reduce the need for an epidural
blood patch in some patients
129
What are the symptoms and treatment of intravascular catheter cannulation during neuraxial?
- Bupivacaine 0.75% not available for epidural block – risk for CV toxicity
- Increased possibility R/T engorgement of epidural veins
- Tinnitus, circumoral numbness, restlessness, difficulty speaking,
seizures, LOC
Tx: Lipid emulsion therapy & Benzodiazepines
130
What is the treatment for LAST?
- Over 70 kg: Start with a 100 mL bolus for 2-3 minutes, followed by a 250 mL infusion over 15-20 minutes. Repeat or double if unstable.
- Under 70 kg (less likely in OB): Start with a 1.5 mL/kg bolus for 2-3 minutes, followed by a 0.25 mL/kg/min infusion. Repeat or double if unstable.
- Continue the infusion until 15 minutes after stability is regained.
Maximum dose: 12 mL/kg. BUT
- Do not withhold lipid therapy bc of dosing uncertainty
- Underdosing lipid is more dangerous than overdosing
131
What are the symptoms and treatment of a high spinal?
- Agitation / dyspnea / inability to speak; profound hypotension → loss of consciousness; Apnea
- Treatment:
Assist ventilation
Volume resuscitation
Vasopressors
132
What are the spinal levels of concern with a high spinal?
Cardioaccelerator Fibers = T1-T4
Pinky/hand numbness = C8
C3-C5 = Diaphragm
133
What are the symptoms of a subdural block?
- Space b/t dura & arachnoid mater, extends intracranially
- Unexpectedly high blockade with
patchiness
- Hypotension
- Minimal motor blockade: onset time 10-20 min, Cranial > caudal spread (may involve cranial nerves)
- Horner’s syndrome / apnea / LOC possible
134
What is the triad of Horner's syndrome?
1. Miosis (constricted pupil)
2. Ptosis (droopy eyelid)
3. Anhidrosis (reduced sweating on affected side)
135
What are other complications or side effects of neuraxial?
- Delayed gastric emptying if opioids administered
- N/V: Assess blood pressure, may be R/T neuraxial induced hypotension
- Shivering
- Back pain
- Excessive motor block
- Urinary retention
- Maternal fever
- FHR abnormalities in 6-8%
- Meningitis
- Epidural hematoma/abscess
- Neuro deficits
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