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OB Anesthesia


OB Anesthesia Denise Weiss DO ... OB Anesthesia Difficult airway Incidence of failed intubation in obstetric pts _at_1:300 1:2330 in general OR population Airway ... – PowerPoint PPT presentation

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Title: OB Anesthesia

OB Anesthesia
  • Denise Weiss DO
  • Anesthesiologist

Goals of obstetrics
  • Healthy mom/baby happy and healthy doctors and
    nurses, family

OB Anesthesia
  • NPO guidelines
  • Solid food (fatty foods) 8hrs
  • Light meal (toast, crackers, etc) 6 hours
  • Clear liquids 2 hours
  • Breast milk 4 hours
  • On L/D clear liquids ok during labor, (often only
    ice chips allowed)
  • Stricter adherence to ice chips if higher risk of
    operative delivery
  • Scheduled inductions should be instructed to be
  • All pregnant pts are considered to have full
    stomachs but the goal is to minimize risk if need
    for intubation occurs

OB Anesthesia
  • Reasons for NPO guidelines
  • Higher risk of aspiration in pregnant patients (1
    in 661 vs 1 in 2131 gen pop)
  • Increased intragastric pressure due to large
  • LES is pushed up and to the left (sim to hiatal
  • Decreased LES tone secondary to progesterone
  • High incidence of GERD
  • Gastric pH is more acidic
  • Active phase of labor slows gastric emptying

OB Anesthesia
  • Higher risk of difficulty in airway management
  • Morbidity/mortality in pregnant pts have been
    attributed often to failed or difficulty managing
    the airway
  • Airway is more friable and edematous in pregnant
  • Increased breast size can make laryngoscopy very
  • Decreased FRC so desaturate quickly

OB Anesthesia
  • pH less than 2.5 and gastric volume greater than
    25ml are identified risk factors for aspiration
  • Pregnant pts going to CS either emergently or
    scheduled receive pharmacologic prophylaxis (we
    use reglan and alka selzer gold, bicitra
    increases pH without altering volume)

OB Anesthesia
  • Difficult airway
  • Incidence of failed intubation in obstetric pts
  • 12330 in general OR population
  • Airway complications are the leading cause of
    anesthesia mortality
  • Single largest class of injury related claims
    from the ASA Closed Claims database involves
    respiratory events

OB Anesthesia
  • Basic Needs for the OR
  • Monitors
  • ECG,NIBP,SPO2, FHR monitor, suction
  • Equipment for difficult airway, and emergency
  • Checked daily

OB Anesthesia for C-Section
  • Spinal
  • Epidural
  • Combined Spinal/epidural
  • General
  • Local

Contraindications for Neuraxial Techniques
  • Pt refusal or inability to cooperate
  • Increased ICP secondary to mass lesion
  • Skin or soft tissue infection at site of needle
  • Coagulopathy
  • Uncorrected maternal hypovolemia
  • Low platelets (depends)

Complications with Neuraxial Techniques
  • Infection
  • Postdural Puncture Headache
  • Incomplete or failed block
  • Neurologic injury(incidence is 20 in 1.2million
    for subarachnoid blocks, 20 in 450,000 for
  • Meningitis or arachnoiditis
  • Spinal hematoma(sharp back and leg pain-numbness
    and motor dysfunction(loss of bowel/bladder fxn)
  • Emergent MRI or CT and referral (6-12 hr window
    for decompression)

Spinal and Epidural Anesthesia
Combined Spinal/Epidural
General Anesthesia
  • Maternal refusal or inability to cooperate with
    neuraxial tech
  • Presence of contraindication to neuraxial tech
  • Insufficient time to induce neuraxial tech(cord
    prolapse with persistent bradycardia)
  • Failure of neuraxial technique
  • Fetal issues (EXIT procedure)

Local Anesthesia
  • Very rarely used
  • Dire emergencies when anesthesiologist/CRNA not
  • Success dep on avoiding use of retractors, and
    not exteriorizing the uterus.
  • After delivery of baby, obtain hemostasis until
    arrival of anesthesia personnel

Local Anesthesia
  • 0.5 lidocaine with epi
  • 25g spinal needle to create skin wheal just below
    umbilicus directed toward symphysis pubis. SQ
    injection along this full area.
  • Ideally wait 3-4 min to take effect?
  • Vertical incision to rectus then local into
    rectus fascia and muscles. Takes 4-5min for
    anesthesia to be complete?

Local Anesthesia
  • Parietal peritoneum infiltration and incision
  • Visceral peritoneum infiltration and incision
  • Paracervical injection
  • Uterine incision and delivery
  • Obtain hemostasis
  • Await availability of general anesthesia

Local Anesthesia
  • Disadvantages
  • Pt discomfort
  • Risk for local anesthetic toxicity (may use up to
    100ml of local
  • Difficult operating conditions to say the least

Maximum Local Anesthetic Dosages
  • Easy formula for bupivicaine (for 0.25 can give
    1cc/kg, for 0.5 can give 1/2cc per kg.
    Lidocaine 4cc/kg plain, 7cc/kg with epi (for
    obese pts keep in mind max dose)

PCA Fentanyl
  • Great alternative for pts who cannot have an
  • All opioids cross placenta by diffusion secondary
    to lipid solubility
  • All are associated with neonatal depression
  • Fentanyl readily crosses placenta but avg
    umbilical to maternal conc ratio is low at 0.31
  • Studies show reduced FHR variability but
    difference in APGAR scores, respiratory
    depression and Neurologic and Adaptive Capacity
    scores at 2-4 hrs or 24 hrs compared to infants
    whose mothers did not have fentanyl(Am Journal of
    Obst/Gyn Anesth/Analgesia)

PCA Fentanyl
  • Rapid onset
  • High potency
  • Short duration
  • No active metabolites
  • One of most commonly used for PCA

PCA Fentanyl
  • Must have resuscitation equip available
  • Pulse oximetry, /- etCO2 monitoring
  • One/one nursing
  • Education of family members
  • Loading dose (50-150mcg
  • Bolus 25-50mcg(start at 25, and assess)
  • Lockout 10min
  • No basal rate

PCA Fentanyl
  • As labor progresses may need to decrease lockout
    time to 5min

OB in Rural Areas
  • Likely will not have immediately available
    anesthesia provider
  • OB nurses can assist with management of epidural
  • ASA has a consultation program that will help
    with setting up the anesthesia service to fit the
    needs of the facility
  • Consensus of all involved that OB anesthesia is a
    priority and a worthwhile goal

OB in Rural Areas
  • Anesthesia provider does NOT have to stay in
    house during course of epidural infusion
  • ASA recommends it but recognizes difficulty

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