1. Labor Analgesia
Epidural Anesthesia in Obstetric Practice. Which of the following is false?
a) Commonly causes itching
b) Can be used to control blood pressure in pre-eclampsia
c) Causes uterine relaxation
d) Causes urinary retention
e) Contributes to the effects of aortocaval compression
Correct Answer: c) Causes uterine relaxation. Itching is one of the most common side-effects of opioids when delivered in the epidural space. Their use allows for a decreased concentration of local anesthetic whilst maintaining excellent analgesia. Patients have better motor function and retain the ability to push.
2. The patient desires an epidural analgesia
22-year-old primi 5 cm dilated and 70% effaced; the fetus is at -1 station. The fetal heart rate has a baseline in the 150s and is reactive. Which of the following should be given orally shortly before the epidural is placed?
d) Clear liquid meal
e) Regular “house” meal
Correct Answer: a) Antacid. Aspiration pneumonitis is a major cause of anesthesia-related death in obstetrics. Pregnant patients are at greater risk for aspiration because of the delayed gastric emptying that occurs during pregnancy and labor. Pregnancy is associated with increased levels of progesterone and displacement of the pylorus by the pregnant uterus. Labor is associated with pain and stress. All of these factors lead to delayed gastric emptying. Aspiration pneumonitis is caused by acidic gastric juices entering the lungs and inducing a sometimes-lethal chemical pneumonitis. When epidural anesthesia is administered, there is a risk of complications, including the development of total spinal anesthesia. Therefore, when an epidural is going to be placed, the patient should be given an antacid. Patients in labor should be allowed small sips of water.
3. All are suitable techniques for pain relief in labor EXCEPT
a) Transcutaneous electrical nerve stimulation
b) White noise
c) Epidural bupivacaine
d) Intrathecal narcotics
e) 70% Nitrous oxide in Oxygen
Correct Answer: e) 70% Nitrous oxide in Oxygen.
The concentration of nitrous oxide in oxygen when used for analgesia is 50%. Higher concentrations can result in loss of consciousness.
White noise or Audioanalgesia is the relief of pain using or music without using pharmacological agents while doing painful medical procedures. It has also been suggested that music may stimulate the production of endorphins and catecholamines.
4. Which of the following is a contraindication to epidural analgesia in labor?
a) Previous caesarean section
b) Fetal distress
c) PT/INR 1.6
d) Maternal exhaustion
e) Maternal multiple sclerosis
Correct Answer: c) PT/INR 1.6.
1) Epidural analgesia is not contraindicated in patients who have had a prior C/S. The pain caused as a result of uterine rupture is not effectively masked by epidural analgesia.
2) Fetal distress is not clearly defined in the question, wheathe non-reassuring, suspicious or pathological or abnormal. Not all kind of foetal heart rate pattern require urgent attention.
3) Maternal exhaustion is an indication for epidural analgesia.
4) Maternal multiple sclerosis is not a contraindication to epidural analgesia as long as the concentration of local anesthetic is reduced
5) Coagulopathy is an absolute contraindication to epidural analgesia
5. Labor Pain
Pain due to uterine contractions and cervical dilatation is transmitted via uterine sympathetic nerves – what are their roots?
a) T10 – L1
b) T9 – T11
c) T10 – T12
d) L1 – L3
e) L3 – L4
Correct Answer: a) T10 – L1. Contraction of the uterus, dilatation of the cervix, and distention of the perineum cause pain during labor and delivery. Somatic and visceral afferent sensory fibers from the uterus and cervix, course with the hypogastric nerves and the sympathetic chain to enter the spinal cord at T10 to L1.
During the second stage of labor (pushing and expulsion), afferents innervating the vagina and perineum cause somatic pain.
Neuraxial analgesic techniques that block levels T10 to L1 during the first stage of labor must be extended to include S2 to S4 for efficacy during the second stage of labor.
6. An epidural analgesia during labor is usually inserted between
a) L2/3 or 4
b) L4/5 or 6
c) L3/4 or 5
d) S1/2 or 3
e) L4/S1 or S2
Correct Answer: c) L3/4 or 5. The anesthesiologist’s goal during the first stage of labor should be to provide segmental sensory anesthesia of the T10-L1 dermatomes. Segmental extent of epidural analgesia has spread to include the S2-4 nerve roots to maintain analgesia during this stage of labor.
7. Pethidine is used in obstetrics because
a) It is 75% excreted unchanged
b) It does not cross the placenta
c) It causes less respiratory depression than an equipotent dose of morphine
d) It can be used without medical supervision
e) It does not affect uterine contractility
Correct Answer: d and e.
It can be used without medical supervision. It does not affect uterine contractility.
Pethidine can provide short-term relief of acute pain, but it is not effective for everyone. During labour, intramuscular or intravenous pethidine sedates women, but may not give them adequate analgesia. Pethidine and its active metabolite, norpethidine, can have adverse effects on the neonate as well as the mother, especially if repeated doses are given during labour. There is little evidence to show that other drugs have greater efficacy than pethidine, so epidural analgesia may be a more effective option.
The most recent National Institute of Clinical Excellence (NICE) Intrapartum Care Clinical Guideline in fact reports that there is evidence, albeit limited, that morphine (in the form of diamorphine) does provide more analgesia with fewer side effects for women than pethidine, and calls for more research to compare the two (NICE).
“Pethidine is widely used as an analgesic during labour. Its ease of administration and the fact that the Central Midwives’ Board approved it in 1950 has probably contributed to its widespread use. Pethidine did not undergo RCTs [Randomised Controlled Trials] prior to its introduction into clinical practice in the UK, and its perceived analgesic efficacy could in part be due to its sedative effects.” (NICE)Prev Next
"Authored By Dr.Niraj Mahajan"
MD- Gynecologist, Laparoscopic Surgeon, Uro-gynecologist , Infertility specialist & Cosmetic Gynecologist.Read more [+]