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Anaesthesiology
Obstetric Anesthesia
Built from Barash Clinical Anesthesia, 9th Edition
What’s inside
12 sections · 190 slides
Overview
- Scope of obstetric anesthesia
- Roadmap of this topic
Anatomic and Physiologic Changes of Pregnancy
- Drivers of maternal physiologic change
- Airway changes in pregnancy
- Ventilation, lung volumes and inhaled agent uptake at term
- Oxygen use, acid-base status and rapid desaturation
- Hyperdynamic circulation of pregnancy
- Vascular resistance, cardiac output and remodelling
- Aortocaval compression and regional blood flow
- Blood volume, anemia and coagulation changes
- Why aspiration risk rises in pregnancy
- Gastric emptying, renal and hepatic changes
- Endocrine changes and reading the physiology table
- Summary of physiologic changes of pregnancy at term
- Summary of physiologic changes of pregnancy at term (continued)
Placental Transfer and Fetal Exposure to Anesthetic Drugs
- The placenta and what determines drug transfer
- Mechanisms of placental drug transfer
- Fick law, molecular weight and lipid solubility
- Ion trapping in the fetus
- Drug classes, protein binding and maternal factors
- Uteroplacental blood flow and drug delivery
- Circulation and oxygen saturations in the mature fetus
- Reading the fetal circulation and its clinical effect
- Drug exit, newborn metabolism and toxicity sensitivity
- Anesthetic exposure and the developing brain
Analgesia for Labor and Vaginal Delivery
- Pain pathways of labor
- Benefits of epidural analgesia beyond pain relief
- Benefits of labor analgesia and the methods available
- Nonpharmacologic labor analgesia and its evidence
- Evidence for the nondrug labor analgesia methods
- Systemic opioids for labor pain
- Remifentanil PCA, agonist-antagonists and naloxone
- Ketamine as a labor analgesic
- Neuraxial analgesia techniques and contraindications
- Local anesthetic choice and starting a labor epidural
- Patient-controlled and programmed intermittent bolus epidural
- Sacral block and the combined spinal-epidural technique
- Intrathecal drugs, side effects and fetal heart rate change
- Who benefits from combined spinal-epidural, and the concerns
- Dural-puncture epidural and single-shot spinal analgesia
- Neuraxial analgesia, mode of delivery and the second stage
- Paracervical, lumbar sympathetic and pudendal blocks
- Inhalation analgesia and general anesthesia for vaginal delivery
Anesthesia for Cesarean Delivery
- Indications and anesthetic choice for cesarean delivery
- Advantages of neuraxial anesthesia for cesarean delivery
- Aspiration prophylaxis, monitoring and positioning
- Block height, spinal anesthesia and visceral discomfort
- Epidural anesthesia, test dose and agent choice
- Bupivacaine, ropivacaine and combined spinal-epidural anesthesia
- Indications for general anesthesia at cesarean delivery
- Preoxygenation, rapid-sequence induction and relaxants
- Managing the difficult obstetric airway
- Master algorithm for obstetric general anesthesia and failed intubation
- Reading the failed intubation algorithm
- Maintenance of anesthesia and neonatal effects
- Postoperative analgesia after cesarean delivery
- Analgesia and breastfeeding
Anesthetic Complications
- Aspiration risk and how to reduce it
- Hypotension after neuraxial anesthesia, and fluid loading
- Choosing a vasopressor for maternal hypotension
- Prophylactic vasopressors for spinal hypotension
- Total spinal anesthesia and its management
- Preventing and treating local anesthetic systemic toxicity
- Postdural puncture headache: risk, needles and treatment
- Long-term sequelae after dural puncture
- Nerve trauma, infection and obstetric palsies
- Anesthesia-related maternal mortality and its causes
- Modifications to resuscitation in the pregnant patient
- Practical points in maternal cardiac arrest
Management of High-Risk Parturients
- The high-risk pregnancy: definition, goals and reserve
- Levels of maternal care
- Levels of maternal care and the resources each requires
- What to notice in the levels of maternal care
- Categories of hypertensive disorders and severe features
- Reading the severe features of preeclampsia
- Severe features of preeclampsia
- Pathophysiology of preeclampsia
- Neurologic, hepatic and renal effects of preeclampsia
- Pulmonary, vascular, hematologic and fetal effects
- Prevention, delivery timing and antihypertensive therapy
- Magnesium sulfate in preeclampsia
- Neuraxial and spinal anesthesia in preeclampsia
- General anesthesia hazards and drug interactions in preeclampsia
- Antepartum hemorrhage and placenta previa
- Management of and anesthesia for placenta previa
- Placental abruption: diagnosis and management
- Defining postpartum hemorrhage and uterine atony
- Reading the causes of postpartum hemorrhage
- Etiologies of postpartum hemorrhage
- Placenta accreta spectrum and the anesthetic role
- Reading the uterotonic therapy table
- Uterotonic therapy
- Uterotonic choice, tamponade and resuscitation
- Viscoelastic testing, tranexamic acid and protocols
- Cardiac disease in pregnancy: burden and diagnosis
- Invasive monitoring and cardiac risk stratification
- Congenital heart disease and septal defects in pregnancy
- Eisenmenger syndrome
- Referral in complex congenital heart disease
- Valvular heart disease in pregnancy
- Stenotic versus regurgitant lesions in pregnancy
- Reading the valvular hemodynamic goals table
- Hemodynamic goals with valvular heart lesions
- Anticoagulation with mechanical heart valves
- Pulmonary hypertension: definition, delivery and anesthesia
- Peripartum cardiomyopathy and its anesthetic goals
- Myocardial infarction in pregnancy: features and risk factors
- Arrhythmias in pregnancy
- Aortic disease in pregnancy
- Types and outcomes of diabetes in pregnancy
- Ketoacidosis and glycemic management in pregnancy
- Anesthesia for the parturient with diabetes
- Obesity in the obstetric population
- Risks of advanced maternal age
- Thrombosis risk and anticoagulation in pregnancy
- Maternal cardiac arrest and perimortem cesarean delivery
- Preterm delivery: scale, problems and tocolysis
- Preterm drug sensitivity, priorities and tocolytic effects
- Tobacco and alcohol use in pregnancy
- Opioid use disorder in pregnancy
- Marijuana and cocaine effects in pregnancy
- Reading the cocaine and amphetamine considerations table
- Anesthetic considerations with cocaine or amphetamine use
- Anesthesia in the patient using cocaine
- Amphetamine use in pregnancy
Fetal Monitoring
- Intrapartum fetal monitoring: external and internal
- Fetal heart rate baseline, variability and accelerations
- Causes of reduced variability and accelerations
- Classification and mechanism of fetal heart rate deceleration patterns
- What to notice in the deceleration figure
- Early, late and variable decelerations
- Reading the three-tier fetal heart rate system
- Three-tier fetal heart rate interpretation system
- Category I and III tracings and their management
- Category II tracings and the limits of monitoring
Newborn Resuscitation in the Delivery Room
- Newborn depression and fetal blood gases in labor
- Causes of severe fetal asphyxia
- Acid-base changes during fetal asphyxia
- Consequences of severe hypoxia and acidosis
- Two simultaneous events at birth
- Circulatory transition at birth
- Pressure changes that close the foramen ovale
- Ductal closure, output redistribution and the first breaths
- Preparing the delivery room and the three initial questions
- Neonatal resuscitation algorithm for the delivery room
- Newborn stabilization, assessment and ventilation
- Oxygen use and chest compressions in newborn resuscitation
- Drugs and volume expansion in newborn resuscitation
- Therapeutic guidelines for neonatal resuscitation
- The Apgar score
- Apgar scores
- The EXIT procedure: indications, technique and team
- Team organization for the EXIT procedure
Anesthesia for Nonobstetric Surgery in the Pregnant Woman
- Frequency and type of nonobstetric surgery in pregnancy
- Teratogenicity of anesthetic drugs and nitrous oxide
- Altered physiology and pharmacology during pregnancy
- Timing of nonobstetric surgery in pregnancy
- Decision pathway for surgical procedures in the pregnant patient
- What to notice in the surgical decision pathway
- Choice of technique for emergency surgery in pregnancy
- Practical checklist for anesthesia in the pregnant surgical patient
- Practical checklist for the pregnant surgical patient
- Fetal and uterine monitoring around surgery
Key Points
- Key points on physiology and drugs reaching the fetus
- Key points on labor, cesarean and high-risk care
- Key point on nonobstetric surgery
References
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- Barash, Cullen, and Stoelting's Clinical Anesthesia, 9th Edition