OB Guideline 28: Anesthesia in 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 It applies to obstetrical patients receiving major neuraxial anesthesia (spinal, epidural, combined spinalepidural); 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, video-laryngoscope, and/or fiberoptic intubation devices, bougie, or stylets;^2-4 and
   • lipid rescue therapy.⁵
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, birthing person 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 an 18 gauge canula, or larger bore if indicated.
   • A pre-procedure verification/time-out should be performed.
5. During routine regional anesthesia for labor, birthing person 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 ASA standards for anesthesia, by a qualified anesthesia personnel present in the room who is monitoring the patient’s oxygenation, ventilation, and circulation, and temperature when indicated.
7. The primary responsibility of the primary anesthesiologist is to provide care to the birthing person. Qualified personnel, other than the primary anesthesiologist attending the birthing person, 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), they 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 ASA standards for post-anesthesia care should be applied:
   • A post-anesthesia care recovery area (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 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 comorbid conditions that may pose an increased peripartum risk should be seen by an anesthesia care provider prior to labor to facilitate interdisciplinary planning. Such patient conditions may include, but are not limited to:
    • cardiac lesions that compromise function
    • intracranial or spinal lesions
    • a personal or family history of major adverse reaction to anesthesia (such as malignant hyperthermia),
    • underlying disorder of hemostasis [coagulation factor deficiency, Von Willebrand’s Disease except corrected type 1, gestational or idiopathic thrombocytopenia with platelet count <70, 000 x 10x6]
    • history of difficult intubation
    • lumbar spine hardware (post-surgical) or appliances (e.g., spinal cord stimulator).

1. Practice Guidelines for Obstetric Anesthesia: An Updated Report by the America Society of Anesthesiologists; Anesthesiology. 2016;124(2):1–31.
2. 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. Anesthesia and Analgesia. 2009;109:1560–65.
3. Mushambi M, et al. Obstetric Anaesthetists’ Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia. 2015;70:1286–1306.
4. Aziz M, et al. A retrospective study of the performance of video laryngoscopy in an obstetric unit; Anesthesia and Analgesia. 2012; 115 (4).
5. Bern S, Weinberg G. Local anesthetic toxicity and lipid resuscitation in pregnancy. Current Opinion in Anesthesiology. 2011;24:262–267.