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OB Guideline 29: Anesthesia in Obstetrics

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OB Guideline 29: Anesthesia in Obstetrics

Related to: Clinical Guidelines, Communication, Documentation, Nursing, Obstetrics

This guideline has been adapted from the Practice Guidelines for Obstetrical Anesthesia and the Guidelines for Regional Anesthesia in Obstetrics as approved by the American Society of Anesthesiologists.1-5  It applies to obstetrical patients receiving major neuraxial anesthesia (spinal, epidural, combined spinal-epidural); general anesthesia; or monitored anesthesia care (MAC) for labor analgesia or operative procedures.

  1. Regional anesthesia should be initiated and maintained only in locations in which appropriate resuscitation equipment and drugs are immediately available to manage procedure-related problems. Resuscitation equipment should include, but is not limited to:
    • sources of oxygen and suction;
    • equipment to maintain an airway and perform endotracheal intubation;
    • a means to provide positive pressure ventilation;
    • drugs and equipment for cardiopulmonary resuscitation;
    • a protocol for the management of failed endotracheal intubation;
    • adjunctive devices for the management of failed intubation such as LMA, Combi-tube, or videolaryngoscope or fiberoptic intubation devices;6,7 and
    • lipid rescue therapy.8,9
  2. Surgical airway management must be available.
  3. Anesthesia should be initiated and maintained by, or under the medical supervision of, a physician with appropriate privileges. Other anesthesia care providers should be credentialed to manage obstetrical anesthesia under the medical direction of a physician as appropriate.
  4. Prior to the initiation of anesthesia for labor or operative obstetrical procedures:
    • The patient must be examined by an appropriate obstetrical care provider.
    • An anesthesia care provider must perform a focused pre-anesthesia evaluation which should include, but is not limited to, maternal health history, anesthesia-related history, an airway exam, and baseline vital signs. Examination of other organ systems should be performed as indicated. Laboratory testing should be performed when appropriate indications exist.
    • A physician credentialed to perform an operative vaginal or cesarean delivery must be available.
    • An intravenous infusion should be established and maintained throughout the duration of the regional anesthetic. Whenever possible, this should be a large bore cannula (≥18 gauge).
    • A pre-procedure verification/time-out should be performed.
  5. During routine regional anesthesia for labor, maternal vital signs and the fetal heart rate should be monitored and documented. Additional monitoring of the parturient or fetus should be employed when indicated.
  6. Patients who receive extensive regional block, MAC, or general anesthesia must be monitored, according to the standards for basic anesthesia, by a qualified anesthesia personnel present in the room who is monitoring the patient’s oxygenation, ventilation, circulation, and temperature.
  7. The primary responsibility of the primary anesthesiologist is to provide care to the mother. Qualified personnel, other than the anesthesiologist attending the mother, should be immediately available to assume responsibility for resuscitation of the newborn.
  8. A physician with appropriate privileges to administer obstetrical anesthesia shall be available in the medical facility from the initiation of an anesthetic until the patient’s post-anesthesia condition is satisfactory and stable. Should this physician become unavailable for reasons that would not permit timely return to the patient (such as surgery), he or she must provide the nursing staff with the name of an alternate clinician who:
    • agrees to assume responsibility for the care of the patient, 
    • is readily available, and 
    • is capable of intervening in emergency circumstances.
  9. All patients recovering from routine regional anesthesia for labor should receive appropriate post-anesthesia care.  Following extensive regional blockade, MAC, or general anesthesia, the standards for post-anesthesia care should be applied:4 
    • A post-anesthesia care unit (PACU) should be available to receive patients. The design, equipment, and staffing should meet requirements of the facility’s accrediting and licensing agencies.
    • Obstetric units must develop a policy for the management of patients in the PACU. This policy should describe who is responsible for the care of patients in the PACU, how they will be monitored, and the process for discharge. Specifically, it must address whether patients will be discharged by a nurse according to protocols, or signed out by an independent licensed practitioner. The protocol for discharge by nurses must be delineated.
    • When a site other than the PACU is used, equivalent post-anesthesia care should be provided.
  10. Whenever possible, pregnant patients with co-morbid conditions that may pose an increased anesthesia risk should be evaluated by an anesthesia care provider prior to labor so that a multi-disciplinary care plan can be created. Such patient conditions include, but are not limited to:
    • morbid obesity,
    • significant cardiac or intracranial lesions,
    • a personal or family history of major adverse reaction to anesthesia (such as malignant hyperthermia),
    • coagulopathy,
    • history of difficult intubation, and
    • significant back surgery (e.g.lumbar scoliosis repair) that might preclude the use of regional anesthesia.



  1. Obstetrical Anesthesia Committee. Guidelines for Neuraxial Anesthesia in Obstetrics. American Society of Anesthesiologists. (Approved by House of Delegates on October 12, 1988 and last amended on October20,2010).
  2. Obstetrical Anesthesia Committee. Practice Guidelines for Obstetric Anesthesia. Anesthesiology. 2007; 106:843–63.
  3. Obstetrical Anesthesia Committee. Standards for Basic Anesthetic Monitoring. American Society of Anesthesiologists. (Approved by House of Delegates on October 21, 1986 and last amended on October20. 2010 with an effective date of July 1, 2011).
  4. Obstetrical Anesthesia Committee. Standards for Post Anesthesia Care. American Society of Anesthesiologists. (Approved by the ASA House of Delegates on October 27, 2004, and last amended on October 21, 2009).
  5. Obstetrical Anesthesia Committee. Optimal Goals for Anesthesia Care in Obstetrics. American Society of Anesthesiologists. Approved by the ASA House of Delegates on October 17, 2007 and last amended on October 20, 2010
  6. Maassen R, et al. A comparison of three videolaryngoscopes: the Macintosh laryngoscope blade reduces, but does not replace, routine stylet use for intubation in morbidly obese patients. Anesth Analg 2009;109:1560–5.
  7. Stroumpoulis K, et al. Videolaryngoscopy in the management of the difficult airway: a comparison with the Macintosh blade. Eur J Anaesthesiol 2009;26:218–22.
  8. Rowlingson JC. Lipid rescue: a step forward in patient safety? Likely so! Anesth Analg 2008;106:1333–6
  9. Weinberg GL. Lipid infusion therapy: translation to clinical practice.

 

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May 1, 2014
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