Practice Guidelines for Obstetric Anesthesia

Abstract

* Developed by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia: Joy L. Hawkins, M.D. (Chair), Denver, Colorado; James F. Arens, M.D., Houston, Texas; Brenda A Bucklin, M.D., Denver, Colorado; Richard T. Connis, Ph.D., Woodinville, Washington; Patricia A. Dailey, M.D., Hillsborough, California; David R. Gambling, M.B.B.S., San Diego, California; David G. Nickinovich, Ph.D., Bellevue, Washington; Linda S. Polley, M.D., Ann Arbor, Michigan; Lawrence C. Tsen, M.D., Boston, Massachusetts; David J. Wlody, M.D., Brooklyn, New York; and Kathryn J. Zuspan, M.D., Stillwater, Minnesota.PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, practice guidelines are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert opinion, open forum commentary, and clinical feasibility data.This update includes data published since the “Practice Guidelines for Obstetrical Anesthesia” were adopted by the American Society of Anesthesiologists in 1998; it also includes data and recommendations for a wider range of techniques than was previously addressed.For the purposes of these Guidelines, obstetric anesthesia refers to peripartum anesthetic and analgesic activities performed during labor and vaginal delivery, cesarean delivery, removal of retained placenta, and postpartum tubal ligation.The purposes of these Guidelines are to enhance the quality of anesthetic care for obstetric patients, improve patient safety by reducing the incidence and severity of anesthesia-related complications, and increase patient satisfaction.These Guidelines focus on the anesthetic management of pregnant patients during labor, nonoperative delivery, operative delivery, and selected aspects of postpartum care and analgesia (i.e. , neuraxial opioids for postpartum analgesia after neuraxial anesthesia for cesarean delivery). The intended patient population includes, but is not limited to, intrapartum and postpartum patients with uncomplicated pregnancies or with common obstetric problems. The Guidelines do not apply to patients undergoing surgery during pregnancy, gynecologic patients, or parturients with chronic medical disease (e.g. , severe cardiac, renal, or neurologic disease). In addition, these Guidelines do not address (1) postpartum analgesia for vaginal delivery, (2) analgesia after tubal ligation, or (3) postoperative analgesia after general anesthesia (GA) for cesarean delivery.These Guidelines are intended for use by anesthesiologists. They also may serve as a resource for other anesthesia providers and healthcare professionals who advise or care for patients who will receive anesthetic care during labor, delivery, and the immediate postpartum period.The American Society of Anesthesiologists (ASA) appointed a Task Force of 11 members to (1) review the published evidence, (2) obtain the opinion of a panel of consultants including anesthesiologists and nonanesthesiologist physicians concerned with obstetric anesthesia and analgesia, and (3) obtain opinions from practitioners likely to be affected by the Guidelines. The Task Force included anesthesiologists in both private and academic practices from various geographic areas of the United States and two consulting methodologists from the ASA Committee on Standards and Practice Parameters.The Task Force developed the Guidelines by means of a seven-step process. First, they reached consensus on the criteria for evidence. Second, original published research studies from peer-reviewed journals relevant to obstetric anesthesia were reviewed. Third, the panel of expert consultants was asked to (1) participate in opinion surveys on the effectiveness of various peripartum management strategies and (2) review and comment on a draft of the Guidelines developed by the Task Force. Fourth, opinions about the Guideline recommendations were solicited from active members of the ASA who provide obstetric anesthesia. Fifth, the Task Force held open forums at two major national meetings†to solicit input on its draft recommendations. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing the Guidelines. Seventh, all available information was used to build consensus within the Task Force to finalize the Guidelines (appendix 1).Preparation of these Guidelines followed a rigorous methodologic process (appendix 2). To convey the findings in a concise and easy-to-understand fashion, these Guidelines use several descriptive terms. When sufficient numbers of studies are available for evaluation, the following terms describe the strength of the findings.The lack of scientific evidence in the literature is described by the following terms.Formal survey information is collected from consultants and members of the ASA. The following terms describe survey responses for any specified issue. Responses are solicited on a five-point scale ranging from 1 (strongly disagree) to 5 (strongly agree), with a score of 3 being equivocal. Survey responses are summarized based on median values as follows:Although comparative studies are insufficient to evaluate the peripartum impact of conducting a focused history (e.g. , reviewing medical records) or a physical examination, the literature reports certain patient or clinical characteristics that may be associated with obstetric complications. These characteristics include, but are not limited to, preeclampsia, pregnancy-related hypertensive disorders, HELLP syndrome, obesity, and diabetes.The consultants and ASA members both strongly agree that a directed history and physical examination, as well as communication between anesthetic and obstetric providers, reduces maternal, fetal, and neonatal complications.The anesthesiologist should conduct a focused history and physical examination before providing anesthesia care. This should include, but is not limited to, a maternal health and anesthetic history, a relevant obstetric history, a baseline blood pressure measurement, and an airway, heart, and lung examination, consistent with the ASA “Practice Advisory for Preanesthesia Evaluation.”§When a neuraxial anesthetic is planned or placed, the patient's back should be examined.Recognition of significant anesthetic or obstetric risk factors should encourage consultation between the obstetrician and the anesthesiologist. A communication system should be in place to encourage early and ongoing contact between obstetric providers, anesthesiologists, and other members of the multidisciplinary team.The literature is insufficient to assess whether a routine platelet count can predict anesthesia-related complications in uncomplicated parturients. The literature suggests that a platelet count is clinically useful for parturients with suspected pregnancy-related hypertensive disorders, such as preeclampsia or HELLP syndrome, and for other disorders associated with coagulopathy.The ASA members are equivocal, but the consultants agree that obtaining a routine intrapartum platelet count does not reduce maternal anesthetic complications. Both the consultants and ASA members agree that, for patients with suspected preeclampsia, a platelet count reduces maternal anesthetic complications. The consultants strongly agree and the ASA members agree that a platelet count reduces maternal anesthetic complications for patients with suspected coagulopathy.A specific platelet count of neuraxial anesthetic complications not The to or a platelet count should be and based on a patient's history, physical examination, and clinical A routine platelet count is not in the literature is insufficient to whether obtaining a blood and is associated with maternal anesthetic complications. In addition, the literature is insufficient to whether a blood is for and uncomplicated parturients. The consultants and ASA members agree that an intrapartum blood should be to the blood for all routine blood is not for and uncomplicated parturients for vaginal or operative The whether to or a blood and or should be based on maternal history, complications (e.g. , in a patient with and and local institutional literature suggests that anesthetic and analgesic may the is insufficient literature to that of the or neonatal complications. Both the consultants and ASA members that of the reduces and neonatal complications.The should be by a before and after of neuraxial analgesia for The Task Force that of the may not be in clinical and may not be during of neuraxial is insufficient published evidence to about the between for and the risk of or during The consultants and ASA members both agree that of during labor maternal and the ASA members are equivocal, the consultants agree that of during labor does not increase maternal complications.The of of may be for uncomplicated The uncomplicated patient undergoing cesarean may of to before of anesthesia. of include, but are not limited to, and of is than the of in the patients with risk factors for (e.g. , obesity, or patients at risk for operative (e.g. , may of on a specific for that is of maternal anesthetic complications not is insufficient published evidence to address the safety of any for in obstetric The consultants and ASA members both agree that the of during labor maternal complications. They both strongly agree that patients undergoing cesarean or postpartum tubal should a of on the of (e.g. , Task Force that in patients the of is with a before is not should be in The patient undergoing surgery (e.g. , cesarean or postpartum tubal should a for of on the of (e.g. , literature does not the between and the of or in obstetric patients who evidence the of (e.g. , in during the peripartum the literature is insufficient to the impact of on The literature suggests that are in in obstetric patients and the of in reducing peripartum and The consultants and ASA members agree that the of a before operative reduces maternal (i.e. , cesarean delivery, postpartum tubal practitioners should the of for all anesthetic care during labor or who for labor delivery, are analgesic techniques sufficient for In addition, maternal medical and obstetric may the of neuraxial techniques to improve maternal and neonatal of analgesic on the medical of the of labor, and at the When sufficient (e.g. , anesthesia and are neuraxial techniques should be of the analgesic The of a specific neuraxial should be and based on anesthetic risk obstetric risk patient of labor, and at the neuraxial techniques are used for analgesia during labor or vaginal delivery, the is to provide maternal analgesia with (e.g. , with the of local at with or a neuraxial is for the of complications (e.g. , should be an is for complications (e.g. , should be should be before the of neuraxial analgesia or anesthesia and the of the neuraxial analgesic or of a of is not before neuraxial analgesia is of the literature that the of neuraxial analgesia does not the of cesarean The literature also suggests that other (i.e. , or are also The consultants strongly agree and the ASA members agree that early of analgesia (i.e. , at of than 5 to or than 5 They both that or maternal, fetal, or neonatal are by early in early labor (i.e. , 5 should be the of neuraxial analgesia is analgesia should not be on the of an and should be on an may be that the use of neuraxial analgesia does not increase the incidence of cesarean comparative studies that analgesia may be used in a of labor for cesarean patients the incidence of vaginal of other anesthetic techniques were not The consultants and ASA members agree that neuraxial techniques improve the of vaginal for patients vaginal after cesarean techniques should be to patients vaginal after cesarean these patients, it is also to early of a neuraxial that can be used for labor analgesia, or for anesthesia in the of operative literature is insufficient to assess for the the early of a or with of analgesia, maternal or neonatal The consultants and ASA members agree that early of a or for parturients reduces maternal of a or for obstetric (e.g. , or or anesthetic (e.g. , or should be to reduce the for an In these the of a or may the of labor or a patient's for labor literature suggests that the use of local with or opioids quality of analgesia with (i.e. , or The consultants and ASA members strongly agree that local with or opioids provide analgesia with of the literature that is a of labor, with an of for the and a of vaginal local are with of the literature that are in the of cesarean the consultants ASA members agree that local with opioids (1) increase the of labor, (2) the of delivery, (3) increase maternal or increase and neonatal is insufficient literature to assess the analgesic of local with or opioids to opioids with or local The consultants are equivocal, but the ASA members agree that local improve analgesia with both the consultants and ASA members are the of The consultants are equivocal, but the ASA members that the use of with opioids the of They both that local with or opioids to opioids with or local the of or maternal, fetal, or neonatal literature the of analgesia local with opioids with of local opioids for quality and of The consultants strongly agree and the ASA members agree that the of opioids to local they both that or neonatal are The consultants but the ASA members are whether the of opioids maternal literature is insufficient to whether of analgesia local with opioids with of local opioids quality or of The consultants and ASA members are analgesia, and they both that maternal, fetal, or neonatal are of local with of analgesia , the literature suggests that are in the analgesic of of local with opioids with of local The Task Force that the of an to a local anesthetic an of local anesthetic for providing the literature is insufficient to whether a of than or to with an or analgesia with a than an of the literature that of local with opioids with of local opioids are associated with in the of labor, of delivery, or neonatal are local with opioids are with local The literature is insufficient to the of local with opioids on other maternal (e.g. , consultants and ASA members both agree that of analgesia of local with opioids analgesia with of local The consultants but the ASA members are the of of local with opioids are The consultants strongly agree and the ASA members agree that is They agree that maternal are with They are both a in and neonatal selected should patient needs and practitioner or and available The may be used for analgesia for labor and When a of local anesthetic is an may be to reduce the of local improve the quality of analgesia, and analgesia for uncomplicated labor and should be with the of as as by of local with The of local anesthetic that maternal analgesia and should be an than is for labor analgesia in literature suggests that opioids with or local provide analgesia during labor the incidence of neonatal complications. is insufficient literature to opioids with is also insufficient literature to opioids with local opioids local consultants strongly agree and the ASA members agree that opioids provide analgesia with They both that, with opioids increase the of labor, the of delivery, or increase and neonatal The consultants are equivocal, but the ASA members that maternal are with with opioids local the consultants and ASA members both agree that opioids with local provide They both that the of is and that and neonatal are They are both an increase in maternal they both agree that is local are to the consultants but the ASA members are an increase in the of opioids with or local may be used to provide analgesia for labor vaginal is labor is to than the analgesic of the or is a of operative delivery, a of a should be A local anesthetic may be to a to increase and improve quality of The Task Force that the of analgesia by techniques may be for selected patients (e.g. , in literature the use of with to reduce the of The consultants and ASA members both strongly agree that the use of reduces maternal should be used of to the risk of literature a and analgesia with local with opioids local with The literature is the impact of local with opioids on maternal with analgesia, of delivery, and of the literature that the of is with consultants and ASA members both agree that local with opioids provide early analgesia with local with They are the impact of with opioids on analgesic of labor, and The consultants and ASA members both that the risk of or neonatal The consultants but the ASA members are whether the incidence of maternal techniques may be used to provide and of analgesia for literature the of analgesia in providing analgesia with of the literature that the of labor is with with for the (e.g. , an of but not the of of the literature also that of delivery, of and are is with The literature analgesic for with a with a of the literature also in the of or of The consultants and ASA members agree that with analgesia and reduces the for anesthetic they also agree that maternal The consultants and ASA members are a in an of delivery, or a in maternal with with They both agree that with a analgesia, maternal and reduces the for anesthetic The ASA members are equivocal, but the consultants that a the of or maternal The consultants and ASA members are the of a on the incidence of analgesia may be used to provide an and for the of labor The Task Force that the use of may be to for providing anesthetic and of local may be used with or a literature is insufficient to assess whether a of anesthetic is than for removal of retained The consultants strongly agree and the ASA members agree that, a is in place and the patient is anesthesia is the for the removal of retained The consultants and ASA members both agree that, in major maternal is neuraxial Task Force that, in is anesthetic for removal of retained an is in place and the patient is anesthesia is should be before neuraxial anesthesia. should be should be to the of and during the immediate postpartum In major maternal with an may be to neuraxial literature suggests that is for during the removal of retained The consultants and ASA members both agree that the of for in a retained may be used as an to or general anesthesia with for during removal of retained with of or (i.e. , may the complications (e.g. , literature is insufficient to evaluate the of providing and in the labor and to that available in the The consultants and ASA members strongly agree that the available and should be and available in the labor and should be to available in the for the of complications (e.g. , analgesia, should also be available in the labor and and should be available to care for obstetric patients from major neuraxial anesthesia or literature suggests that for are with or anesthesia and that a of maternal may be associated with or of the literature that at 1 and 5 are for with anesthesia and suggests that are for anesthesia. The literature is in values is with or consultants and ASA members agree that reduces the to with or they also agree that maternal complications. The consultants are and the ASA members agree that and neonatal complications. The consultants and ASA members both agree that anesthesia the to and the quality of anesthesia with anesthesia. They both that anesthesia maternal anesthesia is with of the literature that are for anesthesia. The literature is and The consultants and ASA members agree that anesthesia to and reduces the quality of anesthesia with anesthesia. They both that anesthesia maternal is with of the literature in the of or in the literature is insufficient to evaluate associated with the use of with anesthesia. The consultants and ASA members agree that anesthesia anesthesia and reduces to with anesthesia. The ASA members are equivocal, but the consultants that maternal are The consultants and ASA members both that anesthesia with anesthesia. The ASA members are equivocal, but the consultants that maternal are The consultants strongly agree and the ASA members agree that with anesthesia of and they both agree that the to is to use a anesthetic for cesarean should be based on several These or risk factors (e.g. , the of the and the of the anesthesiologist. techniques are to for cesarean may provide of anesthesia with of anesthesia for cesarean anesthesia is should be used of may be the in (e.g. , severe severe should be of the anesthetic literature and the consultants and ASA members agree that for anesthesia reduces the of maternal with may be used to reduce the of maternal after anesthesia for cesarean reduces the of maternal of anesthesia should not be to a of literature the of and suggests that is in reducing maternal during neuraxial anesthesia for cesarean The literature is the of patients with of are with values are after The consultants agree and the ASA members strongly agree that is for during neuraxial anesthesia. The consultants strongly agree and the ASA members agree that is an for the of and are both for during neuraxial anesthesia. In the of maternal may be of in uncomplicated postoperative analgesia after cesarean during the literature the use of opioids with of or a of was with The literature is insufficient to evaluate the impact of opioids with In addition, the literature is insufficient to evaluate opioids with The consultants strongly agree and the ASA members agree that neuraxial opioids for postoperative analgesia improve analgesia and maternal postoperative analgesia after neuraxial anesthesia for cesarean delivery, neuraxial opioids are of is insufficient literature to evaluate the of neuraxial anesthesia with for postpartum tubal In addition, the literature is insufficient to evaluate the impact of the of a postpartum tubal on maternal outcome. The consultants and ASA members both agree that neuraxial anesthesia for postpartum tubal reduces complications with The ASA members are but the consultants agree that a postpartum tubal within of does not increase maternal postpartum tubal ligation, the patient should of within of the on the of (e.g. , should be Both the of the and the to use a anesthetic (i.e. , neuraxial should be based on anesthetic risk obstetric risk factors (e.g. , blood and patient neuraxial techniques are to for postpartum tubal The anesthesiologist should be that will be in patients who opioids during labor, and that an for labor may be likely to with a postpartum tubal is to be performed before the patient is from the the should not be at a it other aspects of patient care on the labor and studies and reports that the of for may be associated with maternal complications. The consultants and ASA members both strongly agree that the of for reduces maternal providing obstetric care should available to In an the use of or blood is In of blood is not available or the patient should be is insufficient literature to whether is associated with maternal, fetal, or neonatal in patients with pregnancy-related hypertensive The literature is the management of obstetric patients with The consultants and ASA members agree that the routine use of or does not reduce maternal complications in to should be and based on clinical that the patient's medical history and risk The Task Force that not all practitioners to for use of or in obstetric reports that the of for the management of may be associated with maternal, fetal, and neonatal complications. The consultants and ASA members both strongly agree that the immediate of for the management of reduces maternal, fetal, and neonatal and should and available to to a and consistent with the ASA Practice Guidelines for of the management should be available during the of neuraxial analgesia 2). In addition, for management should be available in the operative of labor and The anesthesiologist should a for of the When with and or with a or (e.g. , should be for an and the it is not to or the an should be literature is insufficient to evaluate the of in the obstetric patient during labor and In of the American that is the will to whether the can be by and of the may improve of the by The American that for to in the of the than 5 after the This that the the about after consultants and ASA members both strongly agree that the immediate of basic and in the labor and reduces maternal, fetal, and neonatal and should be available in the operative of labor and during labor and delivery, should be In addition, should be maternal is not within cesarean should be performed by the team.The scientific of these Guidelines was based on evidence or between clinical and The were to assess their impact on a of to obstetric evidence was from research literature, and evidence was from open and other activities (e.g. , purposes of literature relevant clinical studies were and of the The and a from than were a of that to the evidence review of the studies not provide evidence and were A of in a was as an evidence a or equivocal. The were summarized to obtain a for evidence before conducting a to 11 evidence studies with and information sufficient for These were (1) (2) of local with or opioids (3) of analgesia local with opioids of local of of of local with opioids of local local with opioids local with general anesthesia anesthesia for cesarean delivery, anesthesia anesthesia for cesarean delivery, use of or reduces maternal during neuraxial and neuraxial opioids opioids for postoperative analgesia after neuraxial anesthesia for cesarean or were for and were for were used as (1) the values based on of the values from the and (2) the providing of the studies by of the by the of the based on the for was used with was at for of the studies were to the were significant was To for a was for studies was and for research were are in To be as significant agree with both of data are In the of findings from both the and agree with other to be as Task Force members and two methodologists was by a for were as (1) of (2) of (3) evidence and literature for values were (1) (2) of (3) and literature These values to of was from including (1) survey opinion from consultants who were selected based on their or in obstetric anesthesia or maternal and (2) survey opinions solicited from active members of the (3) from of held open forums at two national anesthesia commentary, and Task Force opinion and The survey of was of for the and surveys were from active ASA of the surveys are in 5 and in the of the consultants were asked to of the evidence their clinical practices the Guidelines were The of was The of consultants associated with were as anesthetic care for labor and removal of retained anesthetic for cesarean postpartum tubal and management of of the that the Guidelines on the of on a that be an increase of 5 in the of on a with the of these Guidelines.