Appendix AGuidelines for Regional

Anesthesia in Obstetrics�

These guidelines apply to the use of regional anesthesia oranalgesia in which local anesthetics are administered to theparturient during labor and delivery. They are intended toencourage quality patient care but cannot guarantee any spe-cific patient outcome. Because the availability of anesthesiaresources may vary, members are responsible for interpretingand establishing the guidelines for their own institutions andpractices. These guidelines are subject to revision from time totime as warranted by the evolution of technology and practice.

19.1 GUIDELINE I

Regional anesthesia should be initiated and maintained onlyin locations in which appropriate resuscitation equipmentand drugs are immediately available to manage procedurallyrelated problems.

Resuscitation equipment should include, but is not limitedto: sources of oxygen and suction, equipment to maintain anairway and perform endotracheal intubation, a means to pro-vide positive pressure ventilation, and drugs and equipment forcardiopulmonary resuscitation.

19.2 GUIDELINE II

Regional anesthesia should be initiated by a physician withappropriate privileges and maintained by or under the medicaldirection1 of such an individual.

Committee of Origin: Obstetrical Anesthesia (Approved by the ASAHouse of Delegates on October 12, 1988, and last amended onOctober 17, 2007)

S. Datta et al., Obstetric Anesthesia Handbook,DOI 10.1007/978-0-387-88602-2,C© Springer Science+Business Media, LLC 2006, 2010

406 APPENDIX A

Physicians should be approved through the institutionalcredentialing process to initiate and direct the maintenanceof obstetric anesthesia and to manage procedurally relatedcomplications.

19.3 GUIDELINE III

Regional anesthesia should not be administered until: (1) thepatient has been examined by a qualified individual2; and (2) aphysician with obstetrical privileges to perform operative vagi-nal or cesarean delivery, who has knowledge of the maternaland fetal status and the progress of labor and who approvesthe initiation of labor anesthesia, is readily available to super-vise the labor and manage any obstetric complications that mayarise.

Under circumstances defined by department protocol, qual-ified personnel may perform the initial pelvic examination. Thephysician responsible for the patient’s obstetrical care shouldbe informed of her status so that a decision can be maderegarding present risk and further management.2

19.4 GUIDELINE IV

An intravenous infusion should be established before the ini-tiation of regional anesthesia and maintained throughout theduration of the regional anesthetic.

19.5 GUIDELINE V

Regional anesthesia for labor and/or vaginal delivery requiresthat the parturient’s vital signs and the fetal heart rate be mon-itored and documented by a qualified individual. Additionalmonitoring appropriate to the clinical condition of the parturi-ent and the fetus should be employed when indicated. whenextensive regional blockade is administered for complicatedvaginal delivery, the standards for basic anesthetic monitoring3

should be applied.

APPENDIX A 407

19.6 GUIDELINE VI

Regional anesthesia for cesarean delivery requires that thestandards for basic anesthetic monitoring3 be applied andthat a physician with privileges in obstetrics be immediatelyavailable.

19.7 GUIDELINE VII

Qualified personnel, other than the anesthesiologist attend-ing the mother, should be immediately available to assumeresponsibility for resuscitation of the newborn.3∼The primaryresponsibility of the anesthesiologist is to provide care to themother. If the anesthesiologist is also requested to provide briefassistance in the care of the newborn, the benefit to the childmust be compared to the risk to the mother.

19.8 GUIDELINE VIII

A physician with appropriate privileges should remain readilyavailable during the regional anesthetic to manage anestheticcomplications until the patient’s postanesthesia condition issatisfactory and stable.

19.9 GUIDELINE IX

All patients recovering from regional anesthesia should receiveappropriate postanesthesia care. following cesarean deliveryand/or extensive regional blockade, the standards for post-anesthesia care4 should be applied.

19.10 GUIDELINE X

There should be a policy to assure the availability in the facil-ity of a physician to manage complications and to providecardiopulmonary resuscitation for patients receiving postanes-thesia care.

408 APPENDIX A

(“Guidelines For Regional Anesthesia in Obstetrics,” approvedby the ASA House of Delegates on October 12, 1988, and lastamended on October 17, 2007, is reprinted with permission ofthe American Society of Anesthesiologists, 520 N. NorthwestHighway, Park Ridge, Illinois 60068-2573.)

19.11 References

1. The Anesthesia Care Team (Approved by ASA House of Delegates10/26/82 and last amended 10/18/2006).

2. American Academy of Pediatrics and American College ofObstetricians and Gynecologists. Guidelines for Perinatal Care, 5thEdition. Elk Grove Village, IL: AAP; Washington, DC: ACOG, 2002.

3. Standards for Basic Anesthetic Monitoring (Approved by ASAHouse of Delegates 10/21/86 and last amended 10/25/2005).

4. Standards for Postanesthesia Care (Approved by ASA House ofDelegates 10/12/88 and last amended 10/27/04).

Appendix B

Practice Guidelines forObstetric Anesthesia

An Updated Report by the AmericanSociety of Anesthesiologists Task Force on

Obstetric Anesthesia1

�Practice guidelines are systematically developed recommenda-tions that assist the practitioner and patient in making decisionsabout health care. These recommendations may be adopted,modified, or rejected according to clinical needs and con-straints and are not intended to replace local institutionalpolicies. In addition, practice guidelines are not intended asstandards or absolute requirements, and their use cannot guar-antee any specific outcome. Practice guidelines are subject torevision as warranted by the evolution of medical knowledge,technology, and practice. They provide basic recommendationsthat are supported by a synthesis and analysis of the current lit-erature, expert opinion, open forum commentary, and clinicalfeasibility data.

This update includes data published since the PracticeGuidelines for Obstetrical Anesthesia were adopted by theAmerican Society of Anesthesiologists in 1998; it also includesdata and recommendations for a wider range of techniquesthan was previously addressed.

Source: “Practice Guidelines for Obstetric Anesthesia.” Anesthesio-logy. 2007;106:843–863. Reprinted with permission from LippincottWilliams & Wilkins.

410 APPENDIX B

19.1 Methodology

19.1.1 A. Definition of Perioperative ObstetricAnesthesia

For the purposes of these Guidelines, obstetric anesthe-sia refers to peripartum anesthetic and analgesic activitiesperformed during labor and vaginal delivery, cesarean delivery,removal of retained placenta, and postpartum tubal ligation.

19.1.2 B. Purposes of the Guidelines

The purposes of these Guidelines are to enhance the qualityof anesthetic care for obstetric patients, improve patient safetyby reducing the incidence and severity of anesthesia-relatedcomplications, and increase patient satisfaction.

19.1.3 C. Focus

These Guidelines focus on the anesthetic management ofpregnant patients during labor, nonoperative delivery, operativedelivery, and selected aspects of postpartum care and analgesia(i.e., neuraxial opioids for postpartum analgesia after neuraxialanesthesia for cesarean delivery). The intended patient popula-tion includes, but is not limited to, intrapartum and postpartumpatients with uncomplicated pregnancies or with commonobstetric problems. The Guidelines do not apply to patientsundergoing surgery during pregnancy, gynecologic patients, orparturients with chronic medical disease (e.g., severe cardiac,renal, or neurologic disease). In addition, these Guidelines donot address (1) postpartum analgesia for vaginal delivery, (2)analgesia after tubal ligation, or (3) postoperative analgesiaafter general anesthesia (GA) for cesarean delivery.

19.1.4 D. Application

These Guidelines are intended for use by anesthesiologists.They also may serve as a resource for other anesthesia providersand healthcare professionals who advise or care for patientswho will receive anesthetic care during labor, delivery, and theimmediate postpartum period.

APPENDIX B 411

19.1.5 E. Task Force Members and Consultants

The American Society of Anesthesiologists (ASA) appointeda Task Force of 11 members to (1) review the publishedevidence, (2) obtain the opinion of a panel of consultantsincluding anesthesiologists and nonanesthesiologist physiciansconcerned with obstetric anesthesia and analgesia, and (3)obtain opinions from practitioners likely to be affected bythe Guidelines. The Task Force included anesthesiologists inboth private and academic practices from various geographicareas of the United States and two consulting methodolo-gists from the ASA Committee on Standards and PracticeParameters.

The Task Force developed the Guidelines by means of aseven-step process. First, they reached consensus on the criteriafor evidence. Second, original published research studies frompeer-reviewed journals relevant to obstetric anesthesia werereviewed. Third, the panel of expert consultants was asked to(1) participate in opinion surveys on the effectiveness of variousperipartum management strategies and (2) review and com-ment on a draft of the Guidelines developed by the Task Force.Fourth, opinions about the Guideline recommendations weresolicited from active members of the ASA who provide obstetricanesthesia. Fifth, the Task Force held open forums at two majornational meetings to solicit input on its draft recommendations.Sixth, the consultants were surveyed to assess their opinionson the feasibility of implementing the Guidelines. Seventh, allavailable information was used to build consensus within theTask Force to finalize the Guidelines.

19.1.6 F. Availability and Strength of Evidence

Preparation of these Guidelines followed a rigorous method-ologic process. To convey the findings in a concise and easy-to-understand fashion, these Guidelines use several descriptiveterms. When sufficient numbers of studies are available forevaluation, the following terms describe the strength of thefindings.

Support: Meta-analysis of a sufficient number of random-ized controlled trials3 indicates a statistically significant

412 APPENDIX B

relationship (P < 0.01) between a clinical intervention anda clinical outcome.

Suggest: Information from case reports and observationalstudies permits inference of a relationship between an inter-vention and an outcome. A meta-analytic assessment ofthis type of qualitative or descriptive information is notconducted.

Equivocal: Either a meta-analysis has not found significantdifferences among groups or conditions, or there is insuf-ficient quantitative information to conduct a meta-analysisand information collected from case reports and observa-tional studies does not permit inference of a relationshipbetween an intervention and an outcome.

The lack of scientific evidence in the literature is described bythe following terms.

Silent: No identified studies address the specified relationshipbetween an intervention and outcome.

Insufficient: There are too few published studies to investigatea relationship between an intervention and outcome.

Inadequate: The available studies cannot be used to assessthe relationship between an intervention and an outcome.These studies either do not meet the criteria for contentas defined in the Focus section of these Guidelines, or donot permit a clear causal interpretation of findings due tomethodologic concerns.

Formal survey information is collected from consultantsand members of the ASA. The following terms describesurvey responses for any specified issue. Responses aresolicited on a five-point scale ranging from 1 (stronglydisagree) to 5 (strongly agree), with a score of 3 being equiv-ocal. Survey responses are summarized based on medianvalues as follows:

Strongly Agree: Median score of 5 (at least 50% of theresponses are 5)

Agree: Median score of 4 (at least 50% of the responses are 4or 4 and 5)

Equivocal: Median score of 3 (at least 50% of the responses are3, or no other response category or combination of similarcategories contain at least 50% of the responses)

APPENDIX B 413

Disagree: Median score of 2 (at least 50% of the responses are2 or 1 and 2)

Strongly Disagree: Median score of 1 (at least 50% of theresponses are 1)

19.1.7 Guidelines

I. Perianesthetic Evaluation

1. History and Physical Examination. Although compara-tive studies are insufficient to evaluate the peripartum impactof conducting a focused history (e.g., reviewing medicalrecords) or a physical examination, the literature reports certainpatient or clinical characteristics that may be associated withobstetric complications. These characteristics include, but arenot limited to, preeclampsia, pregnancy-related hypertensivedisorders, HELLP syndrome, obesity, and diabetes.

The consultants and ASA members both strongly agree that adirected history and physical examination, as well as commu-nication between anesthetic and obstetric providers, reducesmaternal, fetal, and neonatal complications.Recommendations: The anesthesiologist should conduct afocused history and physical examination before providinganesthesia care. This should include, but is not limited to, amaternal health and anesthetic history, a relevant obstetric his-tory, a baseline blood pressure measurement, and an airway,heart, and lung examination, consistent with the ASA “PracticeAdvisory for Preanesthesia Evaluation.”4 When a neuraxialanesthetic is planned or placed, the patient’s back should beexamined.

Recognition of significant anesthetic or obstetric risk fac-tors should encourage consultation between the obstetricianand the anesthesiologist. A communication system should bein place to encourage early and ongoing contact betweenobstetric providers, anesthesiologists, and other members of themultidisciplinary team.2. Intrapartum Platelet Count. The literature is insuffi-cient to assess whether a routine platelet count can predictanesthesia-related complications in uncomplicated parturients.The literature suggests that a platelet count is clinically useful

414 APPENDIX B

for parturients with suspected pregnancy-related hypertensivedisorders, such as preeclampsia or HELLP syndrome, and forother disorders associated with coagulopathy.

The ASA members are equivocal, but the consultants agreethat obtaining a routine intrapartum platelet count does notreduce maternal anesthetic complications. Both the consul-tants and ASA members agree that, for patients with suspectedpreeclampsia, a platelet count reduces maternal anestheticcomplications. The consultants strongly agree and the ASAmembers agree that a platelet count reduces maternal anes-thetic complications for patients with suspected coagulopathy.Recommendations: A specific platelet count predictive ofneuraxial anesthetic complications has not been determined.The anesthesiologist’s decision to order or require a plateletcount should be individualized and based on a patient’s his-tory, physical examination, and clinical signs. A routine plateletcount is not necessary in the healthy parturient.3. Blood Type and Screen. The literature is insufficient todetermine whether obtaining a blood type and screen is associ-ated with fewer maternal anesthetic complications. In addition,the literature is insufficient to determine whether a bloodcross-match is necessary for healthy and uncomplicated par-turients. The consultants and ASA members agree that an intra-partum blood sample should be sent to the blood bank for allparturients.Recommendations: A routine blood cross-match is not nec-essary for healthy and uncomplicated parturients for vaginalor operative delivery. The decision whether to order or requirea blood type and screen, or cross-match, should be based onmaternal history, anticipated hemorrhagic complications (e.g.,placenta accreta in a patient with placenta previa and previousuterine surgery), and local institutional policies.4. Perianesthetic Recording of the Fetal Heart Rate. Theliterature suggests that anesthetic and analgesic agents mayinfluence the fetal heart rate pattern. There is insufficientliterature to demonstrate that perianesthetic recording of thefetal heart rate prevents fetal or neonatal complications. Boththe consultants and ASA members agree, however, that peri-anesthetic recording of the fetal heart rate reduces fetal andneonatal complications.

APPENDIX B 415

Recommendations: The fetal heart rate should be monitoredby a qualified individual before and after administration ofneuraxial analgesia for labor. The Task Force recognizes thatcontinuous electronic recording of the fetal heart rate may notbe necessary in every clinical setting and may not be possibleduring initiation of neuraxial anesthesia.

II. Aspiration Prevention

1. Clear Liquids. There is insufficient published evidenceto draw conclusions about the relationship between fastingtimes for clear liquids and the risk of emesis/reflux or pul-monary aspiration during labor. The consultants and ASAmembers both agree that oral intake of clear liquids duringlabor improves maternal comfort and satisfaction. Although theASA members are equivocal, the consultants agree that oralintake of clear liquids during labor does not increase maternalcomplications.Recommendations: The oral intake of modest amounts ofclear liquids may be allowed for uncomplicated labor-ing patients. The uncomplicated patient undergoing electivecesarean delivery may have modest amounts of clear liquidsup to 2 h before induction of anesthesia. Examples of clear liq-uids include, but are not limited to, water, fruit juices withoutpulp, carbonated beverages, clear tea, black coffee, and sportsdrinks.5 The volume of liquid ingested is less important than thepresence of particulate matter in the liquid ingested. However,patients with additional risk factors for aspiration (e.g., morbidobesity, diabetes, difficult airway) or patients at increased riskfor operative delivery (e.g., nonreassuring fetal heart rate pat-tern) may have further restrictions of oral intake, determined ona case-by-case basis.2. Solids. A specific fasting time for solids that is predictiveof maternal anesthetic complications has not been determined.There is insufficient published evidence to address the safety ofany particular fasting period for solids in obstetric patients. Theconsultants and ASA members both agree that the oral intakeof solids during labor increases maternal complications. Theyboth strongly agree that patients undergoing either electivecesarean delivery or postpartum tubal ligation should undergo

416 APPENDIX B

a fasting period of 6–8 h depending on the type of food ingested(e.g., fat content).5 The Task Force recognizes that in laboringpatients the timing of delivery is uncertain; therefore, compli-ance with a predetermined fasting period before nonelectivesurgical procedures is not always possible.Recommendations: Solid foods should be avoided in laboringpatients. The patient undergoing elective surgery (e.g., sched-uled cesarean delivery or postpartum tubal ligation) shouldundergo a fasting period for solids of 6–8 h depending on thetype of food ingested (e.g., fat content).5

3. Antacids, H2 Receptor Antagonists, and Metoclopramide.The literature does not sufficiently examine the relationshipbetween reduced gastric acidity and the frequency of eme-sis, pulmonary aspiration, morbidity, or mortality in obstetricpatients who have aspirated gastric contents. Published evi-dence supports the efficacy of preoperative nonparticulateantacids (e.g., sodium citrate, sodium bicarbonate) in decreas-ing gastric acidity during the peripartum period. However,the literature is insufficient to examine the impact of non-particulate antacids on gastric volume. The literature suggeststhat H2 receptor antagonists are effective in decreasing gastricacidity in obstetric patients and supports the efficacy of meto-clopramide in reducing peripartum nausea and vomiting. Theconsultants and ASA members agree that the administration ofa nonparticulate antacid before operative procedures reducesmaternal complications.Recommendations: Before surgical procedures (i.e., cesareandelivery, postpartum tubal ligation), practitioners should con-sider the timely administration of nonparticulate antacids, H2receptor antagonists, and/or metoclopramide for aspirationprophylaxis.

III. Anesthetic Care for Labor and Vaginal Delivery

1. Overview. Not all women require anesthetic care duringlabor or delivery. For women who request pain relief for laborand/or delivery, there are many effective analgesic techniquesavailable. Maternal request represents sufficient justificationfor pain relief. In addition, maternal medical and obstetric

APPENDIX B 417

conditions may warrant the provision of neuraxial techniquesto improve maternal and neonatal outcome.

The choice of analgesic technique depends on the medi-cal status of the patient, progress of labor, and resources at thefacility. When sufficient resources (e.g., anesthesia and nursingstaff) are available, neuraxial catheter techniques should be oneof the analgesic options offered. The choice of a specific neu-raxial block should be individualized and based on anestheticrisk factors, obstetric risk factors, patient preferences, progressof labor, and resources at the facility.

When neuraxial catheter techniques are used for analgesiaduring labor or vaginal delivery, the primary goal is to provideadequate maternal analgesia with minimal motor block (e.g.,achieved with the administration of local anesthetics at lowconcentrations with or without opioids).

When a neuraxial technique is chosen, appropriateresources for the treatment of complications (e.g., hypotension,systemic toxicity, high spinal anesthesia) should be available.If an opioid is added, treatments for related complications(e.g., pruritus, nausea, respiratory depression) should be avail-able. An intravenous infusion should be established beforethe initiation of neuraxial analgesia or anesthesia and main-tained throughout the duration of the neuraxial analgesic oranesthetic. However, administration of a fixed volume of intra-venous fluid is not required before neuraxial analgesia isinitiated.2. Timing of Neuraxial Analgesia and Outcome of Labor.Meta-analysis of the literature determined that the timing ofneuraxial analgesia does not affect the frequency of cesareandelivery. The literature also suggests that other delivery out-comes (i.e., spontaneous or instrumented) are also unaffected.The consultants strongly agree and the ASA members agreethat early initiation of epidural analgesia (i.e., at cervical dila-tions of less than 5 cm vs. equal to or greater than 5 cm)improves analgesia. They both disagree that motor block ormaternal, fetal, or neonatal side effects are increased by earlyadministration.Recommendations: Patients in early labor (i.e., 5 cm dilation)should be given the option of neuraxial analgesia when this ser-vice is available. Neuraxial analgesia should not be withheld

418 APPENDIX B

on the basis of achieving an arbitrary cervical dilation, andshould be offered on an individualized basis. Patients may bereassured that the use of neuraxial analgesia does not increasethe incidence of cesarean delivery.3. Neuraxial Analgesia and Trial of Labor after PreviousCesarean Delivery. Nonrandomized comparative studies sug-gest that epidural analgesia may be used in a trial of labor forprevious cesarean delivery patients without adversely affectingthe incidence of vaginal delivery. Randomized comparisonsof epidural vs. other anesthetic techniques were not found.The consultants and ASA members agree that neuraxial tech-niques improve the likelihood of vaginal delivery for patientsattempting vaginal birth after cesarean delivery.Recommendations: Neuraxial techniques should be offered topatients attempting vaginal birth after previous cesarean deliv-ery. For these patients, it is also appropriate to consider earlyplacement of a neuraxial catheter that can be used later forlabor analgesia, or for anesthesia in the event of operativedelivery.4. Early Insertion of a Spinal or Epidural Catheter forComplicated Parturients. The literature is insufficient toassess whether, when caring for the complicated parturient, theearly insertion of a spinal or epidural catheter, with later admin-istration of analgesia, improves maternal or neonatal outcomes.The consultants and ASA members agree that early insertionof a spinal or epidural catheter for complicated parturientsreduces maternal complications.Recommendations: Early insertion of a spinal or epiduralcatheter for obstetric (e.g., twin gestation or preeclampsia) oranesthetic indications (e.g., anticipated difficult airway or obe-sity) should be considered to reduce the need for GA if anemergent procedure becomes necessary. In these cases, theinsertion of a spinal or epidural catheter may precede the onsetof labor or a patient’s request for labor analgesia.5. Continuous Infusion Epidural Analgesia. CIE Comparedwith Parenteral Opioids. The literature suggests that the useof continuous infusion epidural (CIE) local anesthetics with orwithout opioids provides greater quality of analgesia comparedwith parenteral (i.e., intravenous or intramuscular) opioids. Theconsultants and ASA members strongly agree that CIE local

APPENDIX B 419

anesthetics with or without opioids provide improved analgesiacompared with parenteral opioids. Meta-analysis of the liter-ature indicates that there is a longer duration of labor, withan average duration of 24 min for the second stage, and alower frequency of spontaneous vaginal delivery when con-tinuous epidural local anesthetics are administered comparedwith intravenous opioids.

Meta-analysis of the literature determined that there are nodifferences in the frequency of cesarean delivery. Neither theconsultants nor ASA members agree that CIE local anestheticscompared with parenteral opioids significantly (1) increase theduration of labor, (2) decrease the chance of spontaneous deliv-ery, (3) increase maternal side effects, or (4) increase fetal andneonatal side effects.6. CIE Compared with Single-injection Spinal. There isinsufficient literature to assess the analgesic efficacy of CIElocal anesthetics with or without opioids compared to single-injection spinal opioids with or without local anesthetics.The consultants are equivocal, but the ASA members agreethat CIE local anesthetics improve analgesia compared withsingle-injection spinal opioids; both the consultants and ASAmembers are equivocal regarding the frequency of motor block.The consultants are equivocal, but the ASA members disagreethat the use of CIE compared with single-injection spinal opi-oids increases the duration of labor. They both disagree thatCIE local anesthetics with or without opioids compared tosingle-injection spinal opioids with or without local anestheticsdecreases the likelihood of spontaneous delivery or increasesmaternal, fetal, or neonatal side effects.7. CIE with and without Opioids. The literature supports theinduction of analgesia using epidural local anesthetics com-bined with opioids compared with equal concentrations ofepidural local anesthetics without opioids for improved qual-ity and longer duration of analgesia. The consultants stronglyagree and the ASA members agree that the addition of opi-oids to epidural local anesthetics improves analgesia; theyboth disagree that fetal or neonatal side effects are increased.The consultants disagree, but the ASA members are equivocalregarding whether the addition of opioids increases maternalside effects.

420 APPENDIX B

The literature is insufficient to determine whether induc-tion of analgesia using local anesthetics with opioids comparedwith higher concentrations of epidural local anesthetics with-out opioids provides improved quality or duration of analgesia.The consultants and ASA members are equivocal regardingimproved analgesia, and they both disagree that maternal, fetal,or neonatal side effects are increased using lower concentra-tions of epidural local anesthetics with opioids.

For maintenance of analgesia, the literature suggests thatthere are no differences in the analgesic efficacy of lowconcentrations of epidural local anesthetics with opioids com-pared with higher concentrations of epidural local anestheticswithout opioids. The Task Force notes that the addition of anopioid to a local anesthetic infusion allows an even lower con-centration of local anesthetic for providing equally effectiveanalgesia. However, the literature is insufficient to examinewhether a bupivacaine infusion concentration of less thanor equal to 0.125% with an opioid provides comparable orimproved analgesia compared with a bupivacaine concentra-tion greater than 0.125% without an opioid6. Meta-analysis ofthe literature determined that low concentrations of epidurallocal anesthetics with opioids compared with higher con-centrations of epidural local anesthetics without opioids areassociated with reduced motor block. No differences in theduration of labor, mode of delivery, or neonatal outcomesare found when epidural local anesthetics with opioids arecompared with epidural local anesthetics without opioids. Theliterature is insufficient to determine the effects of epidural localanesthetics with opioids on other maternal outcomes (e.g.,hypotension, nausea, pruritus, respiratory depression, urinaryretention).

The consultants and ASA members both agree that mainte-nance of epidural analgesia using low concentrations of localanesthetics with opioids provides improved analgesia com-pared with higher concentrations of local anesthetics withoutopioids. The consultants agree, but the ASA members areequivocal regarding the improved likelihood of spontaneousdelivery when lower concentrations of local anesthetics withopioids are used. The consultants strongly agree and the ASAmembers agree that motor block is reduced. They agree that

APPENDIX B 421

maternal side effects are reduced with this drug combination.They are both equivocal regarding a reduction in fetal andneonatal side effects.Recommendations: The selected analgesic/anesthetic tech-nique should reflect patient needs and preferences, practitionerpreferences or skills, and available resources. The continuousepidural infusion technique may be used for effective analgesiafor labor and delivery. When a continuous epidural infusion oflocal anesthetic is selected, an opioid may be added to reducethe concentration of local anesthetic, improve the quality ofanalgesia, and minimize motor block.

Adequate analgesia for uncomplicated labor and deliveryshould be administered with the secondary goal of producingas little motor block as possible by using dilute concentrationsof local anesthetics with opioids. The lowest concentration oflocal anesthetic infusion that provides adequate maternal anal-gesia and satisfaction should be administered. For example,an infusion concentration greater than 0.125% bupivacaine isunnecessary for labor analgesia in most patients.8. Single-injection Spinal Opioids with or without LocalAnesthetics. The literature suggests that spinal opioids withor without local anesthetics provide effective analgesia duringlabor without altering the incidence of neonatal complications.There is insufficient literature to compare spinal opioids withparenteral opioids. There is also insufficient literature to com-pare single-injection spinal opioids with local anesthetics vs.single-injection spinal opioids without local anesthetics.

The consultants strongly agree and the ASA members agreethat spinal opioids provide improved analgesia compared withparenteral opioids. They both disagree that, compared withparenteral opioids, spinal opioids increase the duration oflabor, decrease the chance of spontaneous delivery, or increasefetal and neonatal side effects. The consultants are equivocal,but the ASA members disagree that maternal side effects areincreased with spinal opioids.

Compared with spinal opioids without local anesthetics, theconsultants and ASA members both agree that spinal opioidswith local anesthetics provide improved analgesia. They bothdisagree that the chance of spontaneous delivery is decreasedand that fetal and neonatal side effects are increased. They are

422 APPENDIX B

both equivocal regarding an increase in maternal side effects.However, they both agree that motor block is increased whenlocal anesthetics are added to spinal opioids. Finally, the con-sultants disagree, but the ASA members are equivocal regardingan increase in the duration of labor.Recommendations: Single-injection spinal opioids with orwithout local anesthetics may be used to provide effective,although time-limited, analgesia for labor when spontaneousvaginal delivery is anticipated. If labor is expected to last longerthan the analgesic effects of the spinal drugs chosen or if thereis a good possibility of operative delivery, a catheter techniqueinstead of a single-injection technique should be considered.A local anesthetic may be added to a spinal opioid to increaseduration and improve quality of analgesia. The Task Force notesthat the rapid onset of analgesia provided by single-injectionspinal techniques may be advantageous for selected patients(e.g., those in advanced labor).9. Pencil-point Spinal Needles. The literature supports theuse of pencil-point spinal needles compared with cutting-bevelspinal needles to reduce the frequency of post-dural punctureheadache. The consultants and ASA members both stronglyagree that the use of pencil-point spinal needles reducesmaternal complications.Recommendations: Pencil-point spinal needles should beused instead of cutting-bevel spinal needles to minimize therisk of post-dural puncture headache.10. Combined Spinal-Epidural Analgesia. The literature sup-ports a faster onset time and equivalent analgesia with com-bined spinal-epidural (CSE) local anesthetics with opioids vs.epidural local anesthetics with opioids. The literature is equiv-ocal regarding the impact of CSE vs. epidural local anestheticswith opioids on maternal satisfaction with analgesia, modeof delivery, hypotension, motor block, nausea, fetal heart ratechanges, and Apgar scores. Meta-analysis of the literature indi-cates that the frequency of pruritus is increased with CSE.The consultants and ASA members both agree that CSE localanesthetics with opioids provide improved early analgesiacompared with epidural local anesthetics with opioids. Theyare equivocal regarding the impact of CSE with opioids onoverall analgesic efficacy, duration of labor, and motor block.

APPENDIX B 423

The consultants and ASA members both disagree that CSEincreases the risk of fetal or neonatal side effects. The consul-tants disagree, but the ASA members are equivocal regardingwhether CSE increases the incidence of maternal side effects.Recommendations: Combined spinal-epidural techniquesmay be used to provide effective and rapid onset of analgesiafor labor.11. Patient-controlled Epidural Analgesia. The literature sup-ports the efficacy of patient-controlled epidural analgesia(PCEA) vs. CIE in providing equivalent analgesia with reduceddrug consumption. Meta-analysis of the literature indicates thatthe duration of labor is longer with PCEA compared with CIE forthe first stage (e.g., an average of 36 min) but not the secondstage of labor. Meta-analysis of the literature also determinedthat mode of delivery, frequency of motor block, and Apgarscores are equivalent when PCEA administration is comparedwith CIE. The literature supports greater analgesic efficacy forPCEA with a background infusion compared with PCEA with-out a background infusion; meta-analysis of the literature alsoindicates no differences in the mode of delivery or frequencyof motor block. The consultants and ASA members agree thatPCEA compared with CIE improves analgesia and reduces theneed for anesthetic interventions; they also agree that PCEAimproves maternal satisfaction. The consultants and ASA mem-bers are equivocal regarding a reduction in motor block, anincreased likelihood of spontaneous delivery, or a decrease inmaternal side effects with PCEA compared with CIE. They bothagree that PCEA with a background infusion improves anal-gesia, improves maternal satisfaction, and reduces the needfor anesthetic intervention. The ASA members are equivo-cal, but the consultants disagree that a background infusiondecreases the chance of spontaneous delivery or increasesmaternal side effects. The consultants and ASA members areequivocal regarding the effect of a background infusion on theincidence of motor block.Recommendations: Patient-controlled epidural analgesiamay be used to provide an effective and flexible approachfor the maintenance of labor analgesia. The Task Force notesthat the use of PCEA may be preferable to fixed-rate CIE forproviding fewer anesthetic interventions and reduced dosages

424 APPENDIX B

of local anesthetics. PCEA may be used with or without abackground infusion.

IV. Removal of Retained Placenta

1. Anesthetic Techniques. The literature is insufficient toassess whether a particular type of anesthetic is more effectivethan another for removal of retained placenta. The consultantsstrongly agree and the ASA members agree that, if a functioningepidural catheter is in place and the patient is hemodynami-cally stable, epidural anesthesia is the preferred technique forthe removal of retained placenta. The consultants and ASAmembers both agree that, in cases involving major maternalhemorrhage, GA is preferred over neuraxial anesthesia.Recommendations: The Task Force notes that, in general,there is no preferred anesthetic technique for removal ofretained placenta. However, if an epidural catheter is in placeand the patient is hemodynamically stable, epidural anes-thesia is preferable. Hemodynamic status should be assessedbefore administering neuraxial anesthesia. Aspiration prophy-laxis should be considered. Sedation/analgesia should betitrated carefully due to the potential risks of respiratory depres-sion and pulmonary aspiration during the immediate postpar-tum period. In cases involving major maternal hemorrhage,GA with an endotracheal tube may be preferable to neuraxialanesthesia.2. Uterine Relaxation. The literature suggests that nitroglyc-erin is effective for uterine relaxation during the removal ofretained placenta. The consultants and ASA members bothagree that the administration of nitroglycerin for uterine relax-ation improves success in removing a retained placenta.Recommendations: Nitroglycerin may be used as an alterna-tive to terbutaline sulfate or general endotracheal anesthesiawith halogenated agents for uterine relaxation during removalof retained placental tissue. Initiating treatment with incremen-tal doses of intravenous or sublingual (i.e., metered dose spray)nitroglycerin may relax the uterus sufficiently while minimizingpotential complications (e.g., hypotension).

APPENDIX B 425

V. Anesthetic Choices for Cesarean Delivery

1. Equipment, Facilities, and Support Personnel. The litera-ture is insufficient to evaluate the benefit of providing equip-ment, facilities and support personnel in the labor and deliveryoperating suite comparable to that available in the main oper-ating suite. The consultants and ASA members strongly agreethat the available equipment, facilities, and support personnelshould be comparable.Recommendations: Equipment, facilities, and support per-sonnel available in the labor and delivery operating suiteshould be comparable to those available in the main operatingsuite. Resources for the treatment of potential complications(e.g., failed intubation, inadequate analgesia, hypotension, res-piratory depression, pruritus, vomiting) should also be availablein the labor and delivery operating suite. Appropriate equip-ment and personnel should be available to care for obstetricpatients recovering from major neuraxial anesthesia or GA.2. General, Epidural, Spinal, or Combined Spinal–EpiduralAnesthesia. The literature suggests that induction-to-deliverytimes for GA are lower compared with epidural or spinal anes-thesia and that a higher frequency of maternal hypotensionmay be associated with epidural or spinal techniques. Meta-analysis of the literature found that Apgar scores at 1 and 5 minare lower for GA compared with epidural anesthesia and sug-gests that Apgar scores are lower for GA vs. spinal anesthesia.The literature is equivocal regarding differences in umbilicalartery pH values when GA is compared with epidural or spinalanesthesia.

The consultants and ASA members agree that GA reducesthe time to skin incision when compared with either epiduralor spinal anesthesia; they also agree that GA increases mater-nal complications. The consultants are equivocal and the ASAmembers agree that GA increases fetal and neonatal compli-cations. The consultants and ASA members both agree thatepidural anesthesia increases the time to skin incision anddecreases the quality of anesthesia compared with spinal anes-thesia. They both disagree that epidural anesthesia increasesmaternal complications.

426 APPENDIX B

When spinal anesthesia is compared with epidural anes-thesia, meta-analysis of the literature found that induction-to-delivery times are shorter for spinal anesthesia. The literatureis equivocal regarding hypotension, umbilical pH values, andApgar scores. The consultants and ASA members agree thatepidural anesthesia increases time to skin incision and reducesthe quality of anesthesia when compared with spinal anes-thesia. They both disagree that epidural anesthesia increasesmaternal complications.

When CSE is compared with epidural anesthesia, metaanal-ysis of the literature found no differences in the frequency ofhypotension or in 1-min Apgar scores; the literature is insuf-ficient to evaluate outcomes associated with the use of CSEcompared with spinal anesthesia. The consultants and ASAmembers agree that CSE anesthesia improves anesthesia andreduces time to skin incision when compared with epiduralanesthesia. The ASA members are equivocal, but the con-sultants disagree that maternal side effects are reduced. Theconsultants and ASA members both disagree that CSE improvesanesthesia compared with spinal anesthesia. The ASA mem-bers are equivocal, but the consultants disagree that maternalside effects are reduced. The consultants strongly agree and theASA members agree that CSE compared with spinal anesthe-sia increases flexibility of prolonged procedures, and they bothagree that the time to skin incision is increased.Recommendations: The decision to use a particular anes-thetic technique for cesarean delivery should be individualized,based on several factors. These include anesthetic, obstet-ric, or fetal risk factors (e.g., elective vs. emergency), thepreferences of the patient, and the judgment of the anes-thesiologist. Neuraxial techniques are preferred to GA formost cesarean deliveries. An indwelling epidural catheter mayprovide equivalent onset of anesthesia compared with initiationof spinal anesthesia for urgent cesarean delivery. If spinal anes-thesia is chosen, pencil-point spinal needles should be usedinstead of cutting-bevel spinal needles. However, GA may bethe most appropriate choice in some circumstances (e.g., pro-found fetal bradycardia, ruptured uterus, severe hemorrhage,severe placental abruption). Uterine displacement (usually left

APPENDIX B 427

displacement) should be maintained until delivery regardless ofthe anesthetic technique used.3. Intravenous Fluid Preloading. The literature supports andthe consultants and ASA members agree that intravenousfluid preloading for spinal anesthesia reduces the frequencyof maternal hypotension when compared with no fluidpreloading.Recommendations: Intravenous fluid preloading may be usedto reduce the frequency of maternal hypotension after spinalanesthesia for cesarean delivery. Although fluid preloadingreduces the frequency of maternal hypotension, initiation ofspinal anesthesia should not be delayed to administer a fixedvolume of intravenous fluid.4. Ephedrine or Phenylephrine. The literature supports theadministration of ephedrine and suggests that phenylephrineis effective in reducing maternal hypotension during neurax-ial anesthesia for cesarean delivery. The literature is equivocalregarding the relative frequency of patients with breakthroughhypotension when infusions of ephedrine are compared withphenylephrine; however, lower umbilical cord pH values arereported after ephedrine administration. The consultants agreeand the ASA members strongly agree that ephedrine is accept-able for treating hypotension during neuraxial anesthesia. Theconsultants strongly agree and the ASA members agree thatphenylephrine is an acceptable agent for the treatment ofhypotension.Recommendations: Intravenous ephedrine and phenyle-phrine are both acceptable drugs for treating hypotensionduring neuraxial anesthesia. In the absence of maternal brady-cardia, phenylephrine may be preferable because of improvedfetal acid–base status in uncomplicated pregnancies.5. Neuraxial Opioids for Postoperative Analgesia. Forimproved postoperative analgesia after cesarean delivery dur-ing epidural anesthesia, the literature supports the use of epidu-ral opioids compared with intermittent injections of intravenousor intramuscular opioids. However, a higher frequency ofpruritus was found with epidural opioids. The literature is insuf-ficient to evaluate the impact of epidural opioids comparedwith intravenous PCA. In addition, the literature is insufficient

428 APPENDIX B

to evaluate spinal opioids compared with parenteral opioids.The consultants strongly agree and the ASA members agree thatneuraxial opioids for postoperative analgesia improve analgesiaand maternal satisfaction.Recommendations: For postoperative analgesia after neurax-ial anesthesia for cesarean delivery, neuraxial opioids arepreferred over intermittent injections of parenteral opioids.

VI. Postpartum Tubal Ligation

There is insufficient literature to evaluate the benefits ofneuraxial anesthesia compared with GA for postpartum tuballigation. In addition, the literature is insufficient to evaluate theimpact of the timing of a postpartum tubal ligation on maternaloutcome. The consultants and ASA members both agree thatneuraxial anesthesia for postpartum tubal ligation reduces com-plications compared with GA. The ASA members are equivocalbut the consultants agree that a postpartum tubal ligation within8 h of delivery does not increase maternal complications.Recommendations: For postpartum tubal ligation, the patientshould have no oral intake of solid foods within 6–8 h of thesurgery, depending on the type of food ingested (e.g., fat con-tent). Aspiration prophylaxis should be considered. Both thetiming of the procedure and the decision to use a particu-lar anesthetic technique (i.e., neuraxial vs. general) should beindividualized, based on anesthetic risk factors, obstetric riskfactors (e.g., blood loss), and patient preferences. However,neuraxial techniques are preferred to GA for most postpartumtubal ligations. The anesthesiologist should be aware that gas-tric emptying will be delayed in patients who have receivedopioids during labor, and that an epidural catheter placedfor labor may be more likely to fail with longer postdeliverytime intervals. If a postpartum tubal ligation is to be per-formed before the patient is discharged from the hospital, theprocedure should not be attempted at a time when it mightcompromise other aspects of patient care on the labor anddelivery unit.

APPENDIX B 429

VII. Management of Obstetric and AnestheticEmergencies

1. Resources for Management of Hemorrhagic Emergencies.Observational studies and case reports suggest that the avail-ability of resources for hemorrhagic emergencies may beassociated with reduced maternal complications. The consul-tants and ASA members both strongly agree that the availabilityof resources for managing hemorrhagic emergencies reducesmaternal complications.Recommendations: Institutions providing obstetric careshould have resources available to manage hemorrhagic emer-gencies (Table B-1). In an emergency, the use of type-specificor O-negative blood is acceptable. In cases of intractablehemorrhage when banked blood is not available or the patientrefuses banked blood, intraoperative cell-salvage should beconsidered if available.

Table B–1. Suggested Resources for ObstetricHemorrhagic Emergencies

• Large-bore intravenous catheters• Fluid warmer• Forced-air body warmer• Availability of blood bank resources• Equipment for infusing intravenous fluids and blood

products rapidly. Examples include, but are not limited to,hand-squeezed fluid chambers, hand-inflated pressurebags, and automatic infusion devices

The items listed represent suggestions. The items should be cus-tomized to meet the specific needs, preferences, and skills of thepractitioner and health-care facility.

2. Central Invasive Hemodynamic Monitoring. There is insuf-ficient literature to examine whether pulmonary artery catheter-ization is associated with improved maternal, fetal, or neonataloutcomes in patients with pregnancy-related hypertensive dis-orders. The literature is silent regarding the management ofobstetric patients with central venous catheterization alone.The consultants and ASA members agree that the routine use

430 APPENDIX B

of central venous or pulmonary artery catheterization doesnot reduce maternal complications in severely preeclampticpatients.Recommendations: The decision to perform invasive hemo-dynamic monitoring should be individualized and based onclinical indications that include the patient’s medical historyand cardiovascular risk factors. The Task Force recognizes thatnot all practitioners have access to resources for use of centralvenous or pulmonary artery catheters in obstetric units.3. Equipment for Management of Airway Emergencies. Casereports suggest that the availability of equipment for themanagement of airway emergencies may be associated withreduced maternal, fetal, and neonatal complications. Theconsultants and ASA members both strongly agree that theimmediate availability of equipment for the management ofairway emergencies reduces maternal, fetal, and neonatalcomplications.Recommendations: Labor and delivery units should havepersonnel and equipment readily available to manage air-way emergencies, to include a pulse oximeter and qualitativecarbon dioxide detector, consistent with the ASA PracticeGuidelines for Management of the Difficult Airway7. Basicairway management equipment should be immediately avail-able during the provision of neuraxial analgesia (Table B-2).

Table B–2. Suggested Resources for AirwayManagement during Initial Provision of Neuraxial

Anesthesia

• Laryngoscope and assorted blades• Endotracheal tubes, with stylets• Oxygen source• Suction source with tubing and catheters• Self-inflating bag and mask for positive-pressure

ventilation• Medications for blood pressure support, muscle

relaxation, and hypnosis• Qualitative carbon dioxide detector• Pulse oximeter

The items listed represent suggestions. The items should be cus-tomized to meet the specific needs, preferences, and skills of thepractitioner and healthcare facility.

APPENDIX B 431

Table B–3. Suggested Contents of a Portable StorageUnit for Difficult Airway Management for Cesarean

Delivery Rooms

Rigid laryngoscope blades of alternate design and size fromthose routinely used• Laryngeal mask airway• Endotracheal tubes of assorted size• Endotracheal tube guides. Examples include, but are not

limited to, semirigid stylets with or without a hollowcore for jet ventilation, light wands, and forcepsdesigned to manipulate the distal portion of theendotracheal tube

• Retrograde intubation equipment• At least one device suitable for emergency nonsurgical

airway ventilation. Examples include, but are not limitedto, a hollow jet ventilation stylet with a transtracheal jetventilator, and a supraglottic airway device (e.g.,Combitube R©, Intubating LMA [FastrachTM])

• Fiberoptic intubation equipment• Equipment suitable for emergency surgical airway access

(e.g., cricothyrotomy)• An exhaled carbon dioxide detector• Topical anesthetics and vasoconstrictors

The items listed represent suggestions. The items should be cus-tomized to meet the specific needs, preferences, and skills of thepractitioner and healthcare facility.Adapted from Practice guidelines for management of the difficult air-way: An updated report by the American Society of AnesthesiologistsTask Force on Management of the Difficult Airway. Anesthesiology.2003;98:1269–1277.

In addition, portable equipment for difficult airway manage-ment should be readily available in the operative area of laborand delivery units (Table B-3). The anesthesiologist shouldhave a preformulated strategy for intubation of the difficultairway. When tracheal intubation has failed, ventilation withmask and cricoid pressure, or with a laryngeal mask airway orsupraglottic airway device (e.g., Combitube R©, Intubating LMA[FastrachTM]) should be considered for maintaining an airwayand ventilating the lungs. If it is not possible to ventilate orawaken the patient, an airway should be created surgically.4. Cardiopulmonary Resuscitation. The literature is insuffi-cient to evaluate the efficacy of cardiopulmonary resuscitation

432 APPENDIX B

in the obstetric patient during labor and delivery. In cases ofcardiac arrest, the American Heart Association has stated that4–5 min is the maximum time rescuers will have to deter-mine whether the arrest can be reversed by Basic Life Supportand Advanced Cardiac Life Support interventions.8 Delivery ofthe fetus may improve cardiopulmonary resuscitation of themother by relieving aortocaval compression. The AmericanHeart Association further notes that “the best survival rate forinfants 24–25 weeks in gestation occurs when the delivery ofthe infant occurs no more than 5 min after the mother’s heartstops beating. This typically requires that the provider beginthe hysterotomy about 4 min after cardiac arrest.”8 The consul-tants and ASA members both strongly agree that the immediateavailability of basic and advanced life-support equipment in thelabor and delivery suite reduces maternal, fetal, and neonatalcomplications.Recommendations: Basic and advanced life-support equip-ment should be immediately available in the operative areaof labor and delivery units. If cardiac arrest occurs duringlabor and delivery, standard resuscitative measures shouldbe initiated. In addition, uterine displacement (usually leftdisplacement) should be maintained. If maternal circulationis not restored within 4 min, cesarean delivery should beperformed by the obstetrics team.

VIII. Perianesthetic Evaluation

• Conduct a focused history and physical examination beforeproviding anesthesia care– Maternal health and anesthetic history– Relevant obstetric history– Airway and heart and lung examination– Baseline blood pressure measurement– Back examination when neuraxial anesthesia is planned

or placed• A communication system should be in place to encour-

age early and ongoing contact between obstetric providers,anesthesiologists, and other members of the multidisci-plinary team

APPENDIX B 433

• Order or require a platelet count based on a patient’s his-tory, physical examination, and clinical signs; a routineintrapartum platelet count is not necessary in the healthyparturient

• Order or require an intrapartum blood type and screen orcrossmatch based on maternal history, anticipated hemor-rhagic complications (e.g., placenta accreta in a patient withplacenta previa and previous uterine surgery), and localinstitutional policies; a routine blood cross-match is notnecessary for healthy and uncomplicated parturients

• The fetal heart rate should be monitored by a qualifiedindividual before and after administration of neuraxial anal-gesia for labor; continuous electronic recording of the fetalheart rate may not be necessary in every clinical settingand may not be possible during initiation of neuraxialanesthesia

IX. Aspiration Prophylaxis

• Oral intake of modest amounts of clear liquids may beallowed for uncomplicated laboring patients

• The uncomplicated patient undergoing elective cesareandelivery may have modest amounts of clear liquids up to2 h before induction of anesthesia

• The volume of liquid ingested is less important than thepresence of particulate matter in the liquid ingested

• Patients with additional risk factors for aspiration (e.g.,morbid obesity, diabetes, difficult airway) or patients atincreased risk for operative delivery (e.g., nonreassuring fetalheart rate pattern) may have further restrictions of oral intake,determined on a case-by-case basis

• Solid foods should be avoided in laboring patients• Patients undergoing elective surgery (e.g., scheduled

cesarean delivery or postpartum tubal ligation) shouldundergo a fasting period for solids of 6–8 h depending onthe type of food ingested (e.g., fat content)

• Before surgical procedures (i.e., cesarean delivery, post-partum tubal ligation), practitioners should consider timely

434 APPENDIX B

administration of nonparticulate antacids, H2 receptorantagonists, and/or metoclopramide for aspiration prophy-laxis

X. Anesthetic Care for Labor and Delivery

Neuraxial Techniques: Availability of Resources.• When neuraxial techniques that include local anesthetics

are chosen, appropriate resources for the treatment of com-plications (e.g., hypotension, systemic toxicity, high spinalanesthesia) should be available

• If an opioid is added, treatments for related complications(e.g., pruritus, nausea, respiratory depression) should beavailable

• An intravenous infusion should be established before theinitiation of neuraxial analgesia or anesthesia and main-tained throughout the duration of the neuraxial analgesic oranesthetic

• Administration of a fixed volume of intravenous fluid is notrequired before neuraxial analgesia is initiated

Timing of Neuraxial Analgesia and Outcome of Labor.• Neuraxial analgesia should not be withheld on the basis

of achieving an arbitrary cervical dilation, and should beoffered on an individualized basis when this service isavailable

• Patients may be reassured that the use of neuraxial analgesiadoes not increase the incidence of cesarean delivery

Neuraxial Analgesia and Trial of Labor after Previous CesareanDelivery.• Neuraxial techniques should be offered to patients attempt-

ing vaginal birth after previous cesarean delivery• For these patients, it is also appropriate to consider early

placement of a neuraxial catheter that can be used later forlabor analgesia or for anesthesia in the event of operativedelivery.

Early Insertion of Spinal or Epidural Catheter for ComplicatedParturients.• Early insertion of a spinal or epidural catheter for obstet-

ric (e.g., twin gestation or preeclampsia) or anestheticindications (e.g., anticipated difficult airway or obesity)

APPENDIX B 435

should be considered to reduce the need for general anes-thesia if an emergent procedure becomes necessary• In these cases, the insertion of a spinal or epidural

catheter may precede the onset of labor or a patient’srequest for labor analgesia

Continuous Infusion Epidural (CIE) Analgesia.• The selected analgesic/anesthetic technique should reflect

patient needs and preferences, practitioner preferences orskills, and available resources

• CIE may be used for effective analgesia for labor and delivery• When a continuous epidural infusion of local anesthetic is

selected, an opioid may be added to reduce the concen-tration of local anesthetic, improve the quality of analgesia,and minimize motor block

• Adequate analgesia for uncomplicated labor and deliv-ery should be administered with the secondary goal ofproducing as little motor block as possible by using diluteconcentrations of local anesthetics with opioids

• The lowest concentration of local anesthetic infusionthat provides adequate maternal analgesia and satisfactionshould be administered

Single-injection Spinal Opioids with or without LocalAnesthetics.• Single-injection spinal opioids with or without local anes-

thetics may be used to provide effective, although time-limited, analgesia for labor when spontaneous vaginal deliv-ery is anticipated

• If labor is expected to last longer than the analgesic effectsof the spinal drugs chosen or if there is a good possibility ofoperative delivery, a catheter technique instead of a single-injection technique should be considered

• A local anesthetic may be added to a spinal opioid toincrease duration and improve quality of analgesia

Pencil-point Spinal Needles.• Pencil-point spinal needles should be used instead of

cutting-bevel spinal needles to minimize the risk of post-dural puncture headache

Combined Spinal-Epidural (CSE) Anesthetics.CSE techniques may be used to provide effective and rapid

analgesia for labor

436 APPENDIX B

Patient-controlled Epidural Analgesia (PCEA).• PCEA may be used to provide an effective and flexible

approach for the maintenance of labor analgesia• PCEA may be preferable to CIE for providing fewer anes-

thetic interventions, reduced dosages of local anesthetics,and less motor blockade than fixed-rate continuous epiduralinfusions

• PCEA may be used with or without a background infusion

XI. Removal of Retained Placenta

• In general, there is no preferred anesthetic technique forremoval of retained placenta– If an epidural catheter is in place and the patient is hemo-

dynamically stable, epidural anesthesia is preferable• Hemodynamic status should be assessed before administer-

ing neuraxial anesthesia• Aspiration prophylaxis should be considered• Sedation/analgesia should be titrated carefully due to the

potential risks of respiratory depression and pulmonaryaspiration during the immediate postpartum period

• In cases involving major maternal hemorrhage, generalanesthesia with an endotracheal tube may be preferable toneuraxial anesthesia

• Nitroglycerin may be used as an alternative to terbutalinesulfate or general endotracheal anesthesia with halogenatedagents for uterine relaxation during removal of retainedplacental tissue– Initiating treatment with incremental doses of intravenous

or sublingual (i.e., metered dose spray) nitroglycerin mayrelax the uterus sufficiently while minimizing potentialcomplications (e.g., hypotension)

XII. Anesthetic Choices for Cesarean Delivery

• Equipment, facilities, and support personnel available in thelabor and delivery operating suite should be comparable tothose available in the main operating suite

APPENDIX B 437

– Resources for the treatment of potential complications(e.g., failed intubation, inadequate analgesia, hypoten-sion, respiratory depression, pruritus, vomiting) should beavailable in the labor and delivery operating suite

– Appropriate equipment and personnel should be avail-able to care for obstetric patients recovering from majorneuraxial or general anesthesia

• The decision to use a particular anesthetic technique shouldbe individualized based on anesthetic, obstetric, or fetal riskfactors (e.g., elective vs. emergency), the preferences of thepatient, and the judgment of the anesthesiologist– Neuraxial techniques are preferred to general anesthesia

for most cesarean deliveries• An indwelling epidural catheter may provide equivalent

onset of anesthesia compared with initiation of spinal anes-thesia for urgent cesarean delivery

• If spinal anesthesia is chosen, pencil-point spinal needlesshould be used instead of cutting-bevel spinal needles

• General anesthesia may be the most appropriate choicein some circumstances (e.g., profound fetal bradycar-dia, ruptured uterus, severe hemorrhage, severe placentalabruption)

• Uterine displacement (usually left displacement) shouldbe maintained until delivery regardless of the anesthetictechnique used

• Intravenous fluid preloading may be used to reduce the fre-quency of maternal hypotension after spinal anesthesia forcesarean delivery

• Initiation of spinal anesthesia should not be delayed toadminister a fixed volume of intravenous fluid

• Intravenous ephedrine and phenylephrine are both accept-able drugs for treating hypotension during neuraxialanesthesia– In the absence of maternal bradycardia, phenylephrine

may be preferable because of improved fetal acid–basestatus in uncomplicated pregnancies

• For postoperative analgesia after neuraxial anesthesia forcesarean delivery, neuraxial opioids are preferred over inter-mittent injections of parenteral opioids

438 APPENDIX B

XIII. Postpartum Tubal Ligation

• For postpartum tubal ligation, the patient should haveno oral intake of solid foods within 6–8 h of thesurgery, depending on the type of food ingested (e.g., fatcontent)

• Aspiration prophylaxis should be considered• Both the timing of the procedure and the decision to use

a particular anesthetic technique (i.e., neuraxial vs. gen-eral) should be individualized, based on anesthetic riskfactors, obstetric risk factors (e.g., blood loss), and patientpreferences

• Neuraxial techniques are preferred to general anesthesia formost postpartum tubal ligations– Be aware that gastric emptying will be delayed in patients

who have received opioids during labor and that anepidural catheter placed for labor may be more likely tofail with longer postdelivery time intervals

• If a postpartum tubal ligation is to be performed before thepatient is discharged from the hospital, the procedure shouldnot be attempted at a time when it might compromise otheraspects of patient care on the labor and delivery unit

XIV. Management of Obstetric and AnestheticEmergencies

• Institutions providing obstetric care should have resourcesavailable to manage hemorrhagic emergencies– In an emergency, the use of type-specific or O negative

blood is acceptable– In cases of intractable hemorrhage when banked blood is

not available or the patient refuses banked blood, intra-operative cell-salvage should be considered if available

– The decision to perform invasive hemodynamic moni-toring should be individualized and based on clinicalindications that include the patient’s medical history andcardiovascular risk factors

• Labor and delivery units should have personnel and equip-ment readily available to manage airway emergencies, toinclude a pulse oximeter and qualitative carbon dioxide

APPENDIX B 439

detector, consistent with the ASA Practice Guidelines forManagement of the Difficult Airway– Basic airway management equipment should be immedi-

ately available during the provision of neuraxial analgesia– Portable equipment for difficult airway management

should be readily available in the operative area of laborand delivery units

– The anesthesiologist should have a preformulated strategyfor intubation of the difficult airway

– When tracheal intubation has failed, ventilation withmask and cricoid pressure, or with a laryngeal mask air-way or supraglottic airway device (e.g., Combitube R©,Intubating LMA [FastrachTM]) should be considered formaintaining an airway and ventilating the lungs

– If it is not possible to ventilate or awaken the patient, anairway should be created surgically

• Basic and advanced life-support equipment should beimmediately available in the operative area of labor anddelivery units

• If cardiac arrest occurs during labor and delivery, standardresuscitative measures should be initiated– Uterine displacement (usually left displacement) should

be maintained– If maternal circulation is not restored within 4 min,

cesarean delivery should be performed by the obstetricsteam

19.2 Methods and Analyses

The scientific assessment of these Guidelines was based on evi-dence linkages or statements regarding potential relationshipsbetween clinical interventions and outcomes. The interventionslisted below were examined to assess their impact on a varietyof outcomes related to obstetric anesthesia.9

1. Perianesthetic Evaluationi. A directed history and physical examinationii. Communication between anesthetic and obstetric

providers

440 APPENDIX B

iii. A routine intrapartum platelet count does not reducematernal anesthetic complications

iv. For suspected preeclampsia or coagulopathy an intra-partum platelet count

v. An intrapartum blood type and screen for all parturi-ents reduces maternal complications

vi. For healthy and uncomplicated parturients, a bloodcross-match is unnecessary

vii. Perianesthetic recording of the fetal heart rate reducesfetal and neonatal complications

2. Aspiration Prophylaxis in the Obstetric Patienti. Oral intake of clear liquids during labor improves

patient comfort and satisfaction but does not increasematernal complications

ii. Oral intake of solids during labor increases maternalcomplications

iii. A fasting period for solids of 6–8 h before an electivecesarean reduces maternal complications

iv. Nonparticulate antacids vs. no antacids before opera-tive procedures (excluding operative vaginal delivery)reduces maternal complications

3. Anesthetic Care for Labor and Deliveryi. Neuraxial techniques

a. Prophylactic spinal or epidural catheter insertion forcomplicated parturients reduces maternal compli-cations

b. Continuous epidural infusion of local anestheticswith or without opioids vs. parenteral opioids

c. Continuous epidural infusion of local anestheticswith or without opioids vs. spinal opioids with orwithout local anesthetics

d. Induction of epidural analgesia using local anes-thetics with opioids vs. equal concentrations ofepidural local anesthetics without opioids

e. Induction of epidural analgesia using local anes-thetics with opioids vs. higher concentrations ofepidural local anesthetics without opioids

f. Maintenance of epidural infusion of lower con-centrations of local anesthetics with opioids vs.

APPENDIX B 441

higher concentrations of local anesthetics withoutopioids (e.g., bupivacaine concentrations < 0.125%with opioids vs. concentrations > 0.125% withoutopioids)

g. Single-injection spinal opioids with or without localanesthetics vs. parenteral opioids

h. Single-injection spinal opioids with local anesthet-ics vs. spinal opioids without local anesthetics

ii. Combined spinal-epidural (CSE) techniquesa. CSE local anesthetics with opioids vs. epidural local

anesthetics with opioidsiii. Patient-controlled epidural analgesia (PCEA)

a. PCEA vs. continuous infusion epiduralsb. PCEA with a background infusion vs. PCEA without

a background infusioniv. Neuraxial analgesia, timing of initiation, and progress

of labora. Administering epidural analgesia at cervical dila-

tions of < 5 cm (vs. > 5 cm)b. Neuraxial techniques for patients attempting vagi-

nal birth after previous cesarean delivery4. Removal of Retained Placenta

i. If an epidural catheter is in situ and the patient is hemo-dynamically stable, epidural anesthesia is preferredover general or spinal anesthesia to improve the successat removing retained placenta

ii. In cases involving major maternal hemorrhage, gen-eral anesthesia is preferred over neuraxial anesthesia toreduce maternal complications

iii. Administration of nitroglycerin for uterine relaxationimproves success at removing retained placenta

5. Anesthetic Choices for Cesarean Deliveryi. Equipment, facilities, and support personnel available

in the labor and delivery suite should be comparableto that available in the main operating suite

ii. General anesthesia vs. epidural anesthesiaiii. General anesthesia vs. spinal anesthesiaiv. Epidural anesthesia vs. spinal anesthesiav. CSE anesthesia vs. epidural anesthesia

442 APPENDIX B

vi. CSE anesthesia vs. spinal anesthesiavii. Use of pencil-point spinal needles vs. cutting-bevel

spinal needles reduces maternal complicationsviii. Intravenous fluid preloading vs. no intravenous fluid

preloading for spinal anesthesia reduces maternalhypotension

ix. Ephedrine or phenylephrine reduces maternalhypotension during neuraxial anesthesia

x. Neuraxial opioids vs. parenteral opioids for postoper-ative analgesia after neuraxial anesthesia for cesareandelivery

6. Postpartum Tubal Ligationi. Neuraxial anesthesia vs. general anesthesia

ii. A postpartum tubal ligation within 8 h of delivery doesnot increase maternal complications

7. Management of Complicationsi. Availability of resources for management of hemor-

rhagic emergenciesii. Immediate availability of equipment for management of

airway emergenciesiii. Immediate availability of basic and advanced life-

support equipment in the labor and delivery suiteiv. Invasive hemodynamic monitoring for severely

preeclamptic patientsScientific evidence was derived from aggregated research

literature, and opinion-based evidence was obtained from sur-veys, open presentations, and other activities (e.g., Internetposting). For purposes of literature aggregation, potentially rel-evant clinical studies were identified via electronic and manualsearches of the literature. The electronic and manual searchescovered a 67-year period from 1940 through 2006. More than4,000 citations were initially identified, yielding a total of 2,986nonoverlapping articles that addressed topics related to theevidence linkages. After review of the articles, 2,549 studiesdid not provide direct evidence and were subsequently elim-inated. A total of 437 articles contained direct linkage-relatedevidence.

Initially, each pertinent outcome reported in a study wasclassified as supporting an evidence linkage, refuting a linkage,or equivocal. The results were then summarized to obtain a

APPENDIX B 443

directional assessment for each evidence linkage before con-ducting a formal meta-analysis. Literature pertaining to 11evidence linkages contained enough studies with well-definedexperimental designs and statistical information sufficient formeta-analyses. These linkages were (1) nonparticulate antacidsvs. no antacids, (2) continuous epidural infusion of local anes-thetics with or without opioids vs. parenteral opioids, (3)induction of epidural analgesia using local anesthetics withopioids vs. equal concentrations of epidural local anestheticswithout opioids, (4) maintenance of epidural infusion of lowerconcentrations of local anesthetics with opioids vs. higherconcentrations of local anesthetics without opioids, (5) CSElocal anesthetics with opioids vs. epidural local anestheticswith opioids, (6) PCEA vs. continuous infusion epidurals, (7)general anesthesia vs. epidural anesthesia for cesarean deliv-ery, (8) CSE anesthesia vs. epidural anesthesia for cesareandelivery, (9) use of pencil-point spinal needles vs. cutting-bevelspinal needles, (10) ephedrine or phenylephrine reduces mater-nal hypotension during neuraxial anesthesia, and (11) neuraxialopioids vs. parenteral opioids for postoperative analgesia afterneuraxial anesthesia for cesarean delivery.

General variance-based effect-size estimates or combinedprobability tests were obtained for continuous outcome mea-sures, and Mantel-Haenszel odds ratios were obtained fordichotomous outcome measures. Two combined probabilitytests were used as follows: (1) the Fisher combined test, pro-ducing chi-square values based on logarithmic transformationsof the reported P values from the independent studies, and(2) the Stouffer combined test, providing weighted representa-tion of the studies by weighting each of the standard normaldeviates by the size of the sample. An odds ratio proce-dure based on the Mantel-Haenszel method for combiningstudy results using 2 × 2 tables was used with outcome fre-quency information. An acceptable significance level was setat P < 0.01 (one-tailed). Tests for heterogeneity of the inde-pendent studies were conducted to assure consistency amongthe study results. DerSimonian-Laird random-effects odds ratioswere obtained when significant heterogeneity was found(P < 0.01). To control for potential publishing bias, a “fail-safen” value was calculated. No search for unpublished studies was

444 APPENDIX B

conducted, and no reliability tests for locating research resultswere done.

Meta-analytic results are reported in Table B-4 (see orig-inal report in Anesthesiology 2007; 106:856–857). To beaccepted as significant findings, Mantel-Haenszel odds ratiosmust agree with combined test results whenever both typesof data are assessed. In the absence of Mantel-Haenszel oddsratios, findings from both the Fisher and weighted Stouffer com-bined tests must agree with each other to be acceptable assignificant.

Interobserver agreement among Task Force members andtwo methodologists was established by interrater reliability test-ing. Agreement levels using a k statistic for two-rater agreementpairs were as follows: (1) type of study design, k = 0.83–0.94;(2) type of analysis, k = 0.71–0.93; (3) evidence linkage assign-ment, k = 0.87–1.00; and (4) literature inclusion for database,k = 0.74–1.00. Three-rater chance-corrected agreement valueswere (1) study design, Sav = 0.884, Var (Sav) = 0.004; (2)type of analysis, Sav = 0.805, Var (Sav) = 0.009; (3) linkageassignment, Sav = 0.911, Var (Sav) = 0.002; and (4) litera-ture database inclusion, Sav = 0.660, Var (Sav) = 0.024. Thesevalues represent moderate to high levels of agreement.

Consensus was obtained from multiple sources, including(1) survey opinion from consultants who were selected basedon their knowledge or expertise in obstetric anesthesia ormaternal and fetal medicine, (2) survey opinions solicited fromactive members of the ASA, (3) testimony from attendees ofpublicly held open forums at two national anesthesia meetings,(4) Internet commentary, and (5) Task Force opinion and inter-pretation. The survey rate of return was 75% (n = 76 of 102) forthe consultants, and 2,326 surveys were received from activeASA members. Results of the surveys are reported in Tables B-5and B-6 and in the text of the Guidelines (see original report inAnesthesiology 2007;106:858–863).

The consultants were asked to indicate which, if any, of theevidence linkages would change their clinical practices if theGuidelines were instituted. The rate of return was 35% (n= 36).The percent of responding consultants expecting no changeassociated with each linkage were as follows: perianestheticevaluation – 97%; aspiration prophylaxis – 83%; anesthetic

APPENDIX B 445

care for labor and delivery – 89%; removal of retained pla-centa – 97%; anesthetic choices for cesarean delivery – 97%;postpartum tubal ligation – 97%; and management of com-plications – 94%. Ninety-seven percent of the respondentsindicated that the Guidelines would have no effect on theamount of time spent on a typical case. One respondent indi-cated that there would be an increase of 5 min in the amount oftime spent on a typical case with the implementation of theseGuidelines.

19.3 References

1. Developed by the American Society of Anesthesiologists TaskForce on Obstetric Anesthesia: Joy L. Hawkins, M.D. (Chair),Denver, Colorado; James F. Arens, M.D., Houston, Texas; BrendaA 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, NewYork; and Kathryn J. Zuspan, M.D., Stillwater, Minnesota.

2. International Anesthesia Research Society, 80th Clinical andScientific Congress,San Francisco, California, March 25, 2006;and Society of Obstetric Anesthesia and Perinatology 38th AnnualMeeting, Hollywood, Florida, April 29, 2006.

3. A prospective nonrandomized controlled trial may be included ina metaanalysis under certain circumstances if specific statisticalcriteria are met.

4. American Society of Anesthesiologists Task Force onPreanesthesia Evaluation: Practice advisory for preanesthesiaevaluation. ANESTHESIOLOGY 2002;96:485–496.

5. American Society of Anesthesiologists Task Force on PreoperativeFasting: Practice guidelines for preoperative fasting and the use ofpharmacologic agents to reduce the risk of pulmonary aspiration.ANESTHESIOLOGY 1999;90:896–905.

6. References to bupivacaine are included for illustrative purposesonly, and because bupivacaine is the most extensively studiedlocal anesthetic for continuous infusion epidural analgesia. TheTask Force recognizes that other local anesthetics are appropriatefor continuous infusion epidural analgesia.

446 APPENDIX B

7. American Society of Anesthesiologists Task Force on Managementof the Difficult Airway: Practice guidelines for managementof the difficult airway: An updated report. Anesthesiology.2003;98:1269–1277.

8. 2005 American Heart Association guidelines for cardiopulmonaryresuscitationand emergency cardiovascular care. Circulation2005;112(suppl):IV1–IV203.

9. Unless otherwise specified, outcomes for the listed interven-tions refer to the reduction of maternal, fetal, and neonatalcomplications.

10. Additional outcomes include improved analgesia, analgesic use,maternal comfort, and satisfaction

Appendix COptimal Goals for

Anesthesia Care inObstetrics

�This joint statement from the American Society ofAnesthesiologists (ASA) and the American College ofObstetricians and Gynecologists (ACOG) has been designed toaddress issues of concern to both specialties. Good obstetriccare requires the availability of qualified personnel andequipment to administer general or regional anesthesia bothelectively and emergently. The extent and degree to whichanesthesia services are available varies widely among hospi-tals. However, for any hospital providing obstetric care, certainoptimal anesthesia goals should be sought. These include:1. Availability of a licensed practitioner who is credentialed to

administer an appropriate anesthetic whenever necessary.For many women, regional anesthesia (epidural, spinal, orcombined spinal epidural) will be the most appropriateanesthetic.

2. Availability of a licensed practitioner who is credentialedto maintain support of vital functions in any obstetricemergency.

3. Availability of anesthesia and surgical personnel to permitthe start of a cesarean delivery within 30 min of the decisionto perform the procedure.

4. Immediate availability of appropriate facilities and per-sonnel, including obstetric anesthesia, nursing personnel,and a physician capable of monitoring labor and perform-ing cesarean delivery, including an emergency cesareandelivery in cases of vaginal birth after cesarean delivery

Committee of Origin: Obstetrical Anesthesia (Approved by the ASAHouse of Delegates on October 17, 2007, and last amended onOctober 22, 2008)

448 APPENDIX C

(VBAC).1 The definition of immediately available person-nel and facilities remains a local decision based on eachinstitution’s available resources and geographic location.

5. Appointment of a qualified anesthesiologist to be responsi-ble for all anesthetics administered. There are many obstet-ric units where obstetricians or obstetrician-supervisednurse anesthetists administer labor anesthetics. The admin-istration of general or regional anesthesia requires bothmedical judgment and technical skills. Thus, a physi-cian with privileges in anesthesiology should be readilyavailable.Persons administering or supervising obstetric anesthesia

should be qualified to manage the infrequent but occasion-ally life-threatening complications of major regional anesthesiasuch as respiratory and cardiovascular failure, toxic localanesthetic convulsions, or vomiting and aspiration. Masteringand retaining the skills and knowledge necessary to managethese complications require adequate training and frequentapplication.

To ensure the safest and most effective anesthesia for obstet-ric patients, the Director of Anesthesia Services, with theapproval of the medical staff, should develop and enforce writ-ten policies regarding provision of obstetric anesthesia. Theseinclude:1. A qualified physician with obstetric privileges to perform

operative vaginal or cesarean delivery should be read-ily available during administration of anesthesia. Readilyavailable should be defined by each institution within thecontext of its resources and geographic location. Regionaland/or general anesthesia should not be administered untilthe patient has been examined and the fetal status andprogress of labor evaluated by a qualified individual. Aphysician with obstetric privileges who concurs with thepatient’s management and has knowledge of the mater-nal and fetal status and the progress of labor should bereadily available to deal with any obstetric complicationsthat may arise. A physician with obstetric privileges shouldbe responsible for midwifery backup in hospital settingsthat utilize certified nurse midwives/certified midwives asobstetric providers.

APPENDIX C 449

2. Availability of equipment, facilities, and support personnelequal to that provided in the surgical suite. This shouldinclude the availability of a properly equipped and staffedrecovery room capable of receiving and caring for allpatients recovering from major regional or general anes-thesia. Birthing facilities, when used for analgesia or anes-thesia, must be appropriately equipped to provide safeanesthetic care during labor and delivery or postanesthesiarecovery care.

3. Personnel, other than the surgical team, should be imme-diately available to assume responsibility for resuscitationof the depressed newborn. The surgeon and anesthesi-ologist are responsible for the mother and may not beable to leave her to care for the newborn, even when aregional anesthetic is functioning adequately. Individualsqualified to perform neonatal resuscitation shoulddemonstrate:3.1. Proficiency in rapid and accurate evaluation of the

newborn condition, including Apgar scoring.3.2. Knowledge of the pathogenesis of a depressed new-

born (acidosis, drugs, hypovolemia, trauma, anoma-lies, and infection), as well as specific indications forresuscitation.

3.3. Proficiency in newborn airway management, laryn-goscopy, endotracheal intubations, suctioning of air-ways, artificial ventilation, cardiac massage, andmaintenance of thermal stability.

In larger maternity units and those functioning as high-riskcenters, 24-hour in-house anesthesia, obstetric and neonatalspecialists are usually necessary. Preferably, the obstetric anes-thesia services should be directed by an anesthesiologist withspecial training or experience in obstetric anesthesia. Theseunits will also frequently require the availability of more sophis-ticated monitoring equipment and specially trained nursingpersonnel.

A survey jointly sponsored by ASA and ACOG found thatmany hospitals in the United States have not yet achievedthe goals mentioned previously. Deficiencies were most evi-dent in smaller delivery units. Some small delivery units arenecessary because of geographic considerations. Currently,

450 APPENDIX C

approximately 34% of hospitals providing obstetric care havefewer than 500 deliveries per year.2 Providing comprehensivecare for obstetric patients in these small units is extremely inef-ficient, not cost-effective and frequently impossible. Thus, thefollowing recommendations are made:1. Whenever possible, small units should consolidate.2. When geographic factors require the existence of smaller

units, these units should be part of a well-establishedregional perinatal system.The availability of the appropriate personnel to assist in the

management of a variety of obstetric problems is a necessaryfeature of good obstetric care. The presence of a pediatricianor other trained physician at a high-risk cesarean delivery tocare for the newborn or the availability of an anesthesiolo-gist during active labor and delivery when VBAC is attemptedand at a breech or multifetal delivery are examples. Frequently,these physicians spend a considerable amount of time standingby for the possibility that their services may be needed emer-gently, but may ultimately not be required to perform the tasksfor which they are present. Reasonable compensation for thesestandby services is justifiable and necessary.

A variety of other mechanisms have been suggested toincrease the availability and quality of anesthesia services inobstetrics. Improved hospital design, to place labor and deliv-ery suites closer to the operating rooms, would allow forsafer and more efficient anesthesia care, including supervisionof nurse anesthetists. Anesthesia equipment in the labor anddelivery area must be comparable to that in the operating room.

Finally, good interpersonal relations between obstetriciansand anesthesiologists are important. Joint meetings betweenthe two departments should be encouraged. Anesthesiologistsshould recognize the special needs and concerns of the obste-trician and obstetricians should recognize the anesthesiologistas a consultant in the management of pain and life-supportmeasures. Both should recognize the need to provide high-quality care for all patients.

“Optimal Goals for Anesthesia Care in Obstetrics,”approved by the ASA House of Delegates on October 17, 2007and last amended on October 22, 2008, is reprinted with per-mission of the American Society of Anesthesiologists, 520 N.Northwest Highway, Park Ridge, Illinois 60068-2573.

APPENDIX C 451

19.1 References

1. Vaginal birth after previous cesarean delivery. ACOG PracticeBulletin No. 54. American College of Obstetricians andGynecologists. Obstet Gynecol. 2004;104:203–212.

2. Bucklin BA, Hawkins JL, Anderson JR, et al. Obstetric anes-thesia workforce survey: twenty-year update. Anesthesiology.2005;103:645–653.

Index�

AAbruptio placentae, 307–309

anesthetic management, 309blood transfusion, 308classification, 308diagnostic testing, 308differential diagnosis, 309and drug addiction, 309compared to placenta

previa, 309Abscess, epidural, 141Accidental intravascular injec-

tion, epidural complications,132–133

Acidosis, fetal. See Fetal acidosisAcupuncture, labor pain

management, 88–89Addiction, maternal, 285–286

and abruptio placentae,307–308

alcohol, 286amphetamine use, 286cocaine use, 286

Adhesive arachnoiditis, epiduralcomplication, 141

AIDS. See HIV/AIDSAir embolism, epidural anesthe-

sia for cesareansection, 216

Airway managementgeneral anesthesia for cesarean

delivery, 207–208general anesthesia for obese

parturients, 295neonate, 238–239portable unit, contents, 431

Alcohol abuse, anesthesiaoptions, 286

Alfentanil, placental transferproblem, 120

American Society ofAnesthesiologists (ASA)

anesthesia care, optimal goals,447–450

regional anesthesia, guidelines,405–407

Amnestic agents, labor painmanagement, 102

Amniocentesis, fetal distressdiagnosis, 346

Amniotic fluid embolismclinical signs, 335differential diagnosis, 335

Amphetamine abuse, anesthesiaoptions, 286

Amphetamines, drug/anestheticinteractions, 46

Anterior spinal artery syndrome,epidural complication, 141

Antiasthmatic drugs,drug/anesthetic interactions,46–47

Antibiotics, drug/anestheticinteractions, 42

Anticholinergic drugsaspiration, prevention of, 202drug/anesthetic

interactions, 48Anticoagulant therapy, during

pregnancy, 281Antidepressants, drug/anesthetic

interactions, 48–49

454 Index

Antiepileptic drugs,drug/anesthetic interactions,42–44

Antifungal drugs, drug/anestheticinteractions, 52

Antihypertensive drugs, uteropla-cental blood flow decrease,74–75

Antipsychotic drugs,drug/anesthetic interactions,47

Aortocaval compression,uteroplacental blood flowdecrease, 69

Apgar scoresand induction-delivery

interval, 214and meperidine, 96neonatal resuscitation based

on, 236–238and nitrous oxide, 213scoring system, 239

Arterial line monitoring, 324Artificial insemination. See In

vitro fertilizationAspiration. See Maternal

aspirationAsthma, 265–267

cesarean section, 266epidural anesthesia, 266induction agents, 267inhalation agents, 267premedication

precautions, 266spinal anesthesia, 266

Atropineasthmatic parturients, 267and baseline variability, 169and fetal tachycardia, 62

Autoimmune diseaseHIV/AIDS, 289rheumatoid arthritis, 283–284systemic lupus erythematosus,

284–285

BBackache, epidural complication,

134Background infusion, epidural

anesthesia, 119Barbiturates

and baseline variability, 167disuse, 100teratogenic effects, 370

Baseline heart rate, fetalmonitoring, 167–168

Baseline variabilityaffecting factors, 169fetal monitoring, 169short and long-term, 169

Benign intracranial hypertension,273–274

Benzodiazepines, and labor painmanagement, 100

Beta-blockersand fetal bradycardia, 45side effects, 45as tocolytic agents, 338uteroplacental blood flow

decrease, 75Beta-mimetic drugs

drug/anesthetic interactions,53–54

and fetal tachycardia, 168and maternal pulmonary

edema, 341uteroplacental blood flow

decrease, 75See also Tocolytic drugs

Bicarbonate solutionadded to local anesthetic,

21, 58neonatal resuscitation,

244, 245solutions/amounts, 58

Biophysical profilefetal activities, 164monitoring of, 164

Index 455

Bladder dysfunction, epiduralcomplication, 139

Bleeding, excessive. SeeHemorrhage

Blood clotting,thromboelastography(TEG), 327

Blood components, compositionof, 349–350

Blood patches, 130–131contraindications, 126and eclampsia, 333procedures for use, 130–131

Blood pressurechange in pregnancy, 4elevated. See Hypertension

Blood-related disorders. SeeHematological disorders

Blood transfusionabruptio placentae, 307–308placenta previa, 304–307uterine rupture, 313

Blood urea nitrogen (BUN),changes in pregnancy, 9

Blood volumechange in pregnancy, 1–2increase and drug

administration, 32–33Bradycardia, fetal. See Fetal

bradycardiaBrain tumors, 273–274

cesarean delivery, 275–276epidural anesthesia, 273intracranial pressure, drainage,

273Breastfeeding, epidural analgesia

and, 157Breasts

change in pregnancy, 12and intubation difficulty, 12

Breathing, neonatal eval-uation/assistance,242

Breech presentation, 344

anesthesia options, 344cesarean delivery, 344

Brown fat, fetalthermoregulation, 236

Buffering capacity, infants ofdiabetic mothers, 253

Bupivacainecardiovascular complications,

23, 197–199cesarean section, 114–115,

186–187, 189, 266combined spinal/epidural

(CSE), 124, 200for complete block, 121–123epidural usage, 114shortened effectiveness with

chloroprocaine, 57spinal anesthesia, 190subarachnoid usage, 115for tubal ligation, 362

Butorphanolanalgesic dosage, 102spinal anesthesia, cesarean

section, 189Butyrophenones, drug/anesthetic

interactions, 48

CCalcium-channel blockers

drug/anesthetic interactions,43, 54

uteroplacental blood flowdecrease, 75

Carbon dioxideadded to local anesthetic, 58respiratory gas exchange, 68

Cardiac disease, 259–265acquired conditions, 259anesthesia management,

260–265anticoagulant therapy, 260cesarean section, 259congenital conditions, 260

456 Index

Cardiac disease (cont.)hypotension prevention,

261–262stress management, 270

Cardiac massageneonate, 243thumb technique, 243two-finger technique, 243

Cardiac outputchange in labor/delivery, 260change in pregnancy, 3, 260fetus, 325

Cardiopulmonary resuscitation,431–432

Cardiovascular complicationsbupivacaine, 197–199management of, 201

Cardiovascular systemfetus, 232–235maternal, 3–4, 261toxicity of local anesthetic,

23–24Catecholamines

amphetamine depletion, 286biosynthesis/metabolism of, 50epidural and increase of, 254

Catheter, broken, 133Cauda equina syndrome,

epidural complication, 139Caudal anesthesia,

technique, 142Cell saver technique, 307Central nervous system

changes in pregnancy, 10–11HIV/AIDS complications, 289toxicity of local anesthetic,

22–23Central nervous system depres-

sants, drug/anestheticinteractions, 48

Central nervous system stim-ulants, drug/anestheticinteractions, 46

Central venous pressure (CVP)monitoring, 325

Cerebral hemorrhage, 270anesthetic management,

270–271and eclampsia, 270types of, 271

Cesarean deliveryanesthetic choice, practice

guidelines, 425–428asthmatic parturients, 266brain tumors, parturients with,

274–275breech presentation, 344cardiac cases, 260–261cocaine addicted

parturients, 287combined spinal/epidural

(CSE), 200epidural anesthesia, 154,

193–200for fetal distress, 344general anesthesia, 201–215genital herpes, women

with, 288incision-delivery interval,

neonatal effects, 214local anesthetics,

195–196, 272multiple sclerosis, agents

for, 271myasthenia gravis, parturient

with, 274paraplegic women, 270and placenta previa, 304postoperative pain relief,

217–218premature delivery, 270renal disorders, parturients

with, 276–277sickle cell disease, parturients

with, 280spinal anesthesia, 180–192

Index 457

vaginal birth after, uterinerupture, 313–314

See also specific anesthesiamethods

Chlordiazepoxide, teratogeniceffects, 373

Chloroprocaineallergic reactions, 57cesarean delivery, 193, 287neurological complications,

197–199Choanal atresia

clinical signs, 245treatment of, 245

Cimetidineaspiration, prevention, 202asthmatic women,

avoiding, 266Cleft palate, Pierre Robin

syndrome, 246Clonidine, cesarean delivery, 191Cocaine

drug/anestheticinteractions, 46

teratogenic effects, 373uteroplacental blood flow

decrease, 72Cocaine addiction, 286

anesthesia options, 286obstetric problems, 288

Colloidal oncotic pressure, andbeta-mimetic therapy, 340

Combined spinal/epidural (CSE)advantages of, 200cesarean delivery, 201drugs used, 123, 200side effects, 125technique, 124–125, 200–201

Complications. See Epiduralanesthesia complications;High-risk pregnancy

Congenital abnormalities.See Teratogenic effects,anesthesia

Continuous epidural infusion(CEI)

advantages of, 119versus patient-controlled,

119–120Contractions. See Uterine

contractionsContraction stress test, 165Corticosteroids, drug/anesthetic

interactions, 47Curare, surgery during

pregnancy, 378Cystic fibrosis, 267–268

anesthesia option, 267

DDantrolene, malignant hyper-

thermia prophylaxis,294

Deathfetal, intrauterine, 348–349maternal. See Maternal

mortality/morbidityDense motor block, correction

of, 122Desflurane

inhalation trials, 104neonatal effects, 214situations for use, 72for uterine manipulation, 104

Diabetes mellitus, 251–258cesarean section, anesthesia

for, 254complications in pregnancy,

251diabetic ketoacidosis, 251fetal acidosis, 254–255labor/delivery pain

management, 254uteroplacental blood flow

decrease, 70, 252Diacetylmorphine, teratogenic

effects, 373

458 Index

Diaphragmatic hernia, 246–247clinical signs, 246treatment of, 246–247

Diazepamneonatal effects, 101teratogenic effects, 363uteroplacental blood flow

decrease, 71Disseminated intravascular

coagulation, 278anesthesia management,

277–278fetal death, 348pathophysiology, 278

Dissociative drugs, labor painmanagement, 101–102

Diureticsintracranial pressure

reduction, 273pulmonary edema

treatment, 341Dopamine, neonatal

resuscitation, 245Droperidol, nausea/vomiting

treatment, 185Drug/anesthetics interactions

amphetamines, 46antibiotics, 42antiepileptic drugs, 42–44anti-fungal drugs, 52beta-mimetic drugs, 53–54butyrophenones, 48calcium channel blockers, 54cocaine, 46corticosteroids, 47enzyme induction, 44ergot alkaloids, 56–57histamine receptor

blockers, 47hypotensive drugs, 55lithium carbonate, 51magnesium sulfate, 53, 319monoamine oxidase inhibitors

(MAOIs), 49–51

muscle relaxants, 42, 319narcotics, 58oxytocin, 55phenothiazine, 48prostaglandin, 57prostaglandin inhibitors, 54serotonin reuptake inhibitors

(SSRIs), 51–52sympathomimetic drugs,

44–45, 46–47thioxanthenes, 48–49tricyclic antidepressants,

48–49xanthine derivatives, 46–47

Dural punctureincidence of, 127prevention, 131steps to take, 134

Dural puncture headache,128–131

incidence of, 127therapeutic blood patches,

129–131treatment of, 128–131

EEarly decelerations, fetal heart

rate, 170–172Eclampsia, 333

and cerebral hemorrhage, 270magnesium sulfate treatment,

334risk factors, 333

Edrophonium chloride,myasthenia gravisdiagnosis, 276

Elimination of drugs, fetal, 35Embolism, 334–336

amniotic fluid, 334thrombotic, 334venous air, 335–336

Endocrine disordershyperthyroidism, 258

Index 459

pheochromocytoma, 259Enflurane

mixtures, 104with nitrous oxide, 213

Entonox, mixtures/delivery,103–104

Enzyme inductioncauses of, 44drug/anesthetic

interactions, 44Ephedrine

and fetal tachycardia, 125maternal hypotension

treatment, 181, 345surgery during pregnancy, 429uteroplacental blood flow

decrease, 73Epidural analgesia on labor and

infant, effects ofcharacteristics of patients

requesting, 152effect on maternal temperature

and newborn, 155–156epidural analgesia and

breastfeeding, 157epidural analgesia and

progress of labor, 151cesarean delivery, 154duration of labor, 153initiation of block, 152–153instrumental vaginal delivery(forceps, vacuum), 153–154methodological difficulties,152patient satisfaction andneonatal outcome, 155

Epidural anesthesia, 109–121asthmatic parturients, 265background infusion, 112brain tumor, parturient

with, 273cardiac patients, 259cocaine addicted patients,

289

combined spinal/epidural(CSE), 200–201

common problems, 193–194complications of. See Epidural

anesthesia complicationscontraindications, 194cystic fibrosis parturients, 267epidural space, anatomy of,

109–110and fetal distress, 344fetal effects, 113fetal monitoring, 169high-risk pregnancy, 254local anesthetic, loading

dose, 194multiple gestation, 345multiple sclerosis, 271myasthenia gravis, parturients

with, 274paraplegic women, 270patient-controlled versus

continuous, 119–120patient monitoring, 126and placenta previa, 304–305practice guidelines, 413–415prehydration, 182and progress of labor, 151–152renal disorders, parturients

with, 277rheumatoid arthritis,

parturients with, 283segmental block, 111sickle cell disease, parturients

with, 280test dose, 116time of onset, 116tubal ligation, postpartum,

362–363and uterine rupture, 313vaginal birth after

cesarean, 313wearing off and pushing, 121

Epidural anesthesia, cesareandelivery, 193–200

460 Index

Epidural anesthesia (cont.)advantages of, 193air embolism, 216–217cardiovascular effects, 193contraindications, 194dural puncture, 194rate of cesarean delivery, 180shivering, 194compared to spinal, 109technique, 200–201

Epidural anesthesiacomplications, 194

abscess, 141accidental intravascular

injection, 132adhesive arachnoiditis, 141anterior spinal artery

syndrome, 141backache, 134bladder dysfunction, 139broken catheter, 133cardiovascular toxicity, 133cauda equina syndrome, 139dural puncture, 127–128headache, 193hematoma, 141Horner’s syndrome, 133massive anesthesia, 132methemoglobinemia, 133nerve root trauma, 140neurological complications,

197–198paresthesia, 127prolonged neural blockade,

138–139shivering, 133subdural injection, 132transient neurological

symptoms (TNS), 140Epidural space

anatomical features, 109–110complications. See Dural

punctureEpilepsy

antiepileptic drugs/anestheticinteractions, 42–44

drugs to avoid, 274Epinephrine

added to local anesthetic, 20,32, 73, 154, 190

cesarean delivery, 123combined spinal/epidural

(CSE), 125in neonatal resuscitation, 242in test dose, 115uterine blood flow

reduction, 73and uterine contraction, 166uteroplacental blood flow

decrease, 73Esmolol, uteroplacental blood

flow decrease, 75Ethanol, as tocolytic

agent, 338Etidocaine, cardiovascular

system toxicity, 23Etomidate

as induction agent, 71, 265uteroplacental blood flow

decrease, 71Ex-utero intrapartum treatment

(EXIT), 379anesthetics, use of, 377fetal monitoring, 377

FFactor V Leiden mutation,

281–283Fasting, maternal, 415–416Fatty liver of pregnancy,

differential diagnosis, 332Fentanyl

cesarean delivery, 99, 188combined spinal/epidural

(CSE), 124, 166epidural usage, 112

Index 461

spinal anesthesia, cesareandelivery, 191

subarachnoid usage, 190Fetal acidosis

fetal scalp pH sampling, 176and maternal diabetes, 255and maternal hyperventilation,

7, 68, 209and maternal hypotension,

181, 254mechanisms of, 68, 255

Fetal bradycardiacauses of, 168–169combined spinal/epidural

(CSE) complication, 70mechanisms of, 125

Fetal distress, 346–348diagnosis, 347management of, 347–348maternal factors, 346placental causes, 346See also Neonatal resuscitation

Fetal heart ratechange in pregnancy, 3–4decelerations, types of,

170–172fetal, normal rate, 168fetal bradycardia, 168fetal tachycardia, 168monitoring. See Fetal

monitoringFetal lung maturity, assessment

measures, 165Fetal monitoring, 163–177

baseline heart rate, 167–169baseline variability, 169–170biophysical evaluation, 164contraction stress test, 165with epidural, 194ex-utero intrapartum treatment

(EXIT), 379fetal scalp pH sampling, 176heart rate decelerations,

170–175

nonstress test, 164–165oxytocin challenge test, 165surgery during pregnancy, 377tocodynamometer, 167

Fetusarrhythmias, treatment of, 58cardiovascular system, 26,

232–235ex-utero intrapartum treatment

(EXIT), 379intrauterine death, 348–349intrauterine surgery, 379respiratory gas exchange, 66respiratory system, 235and teratogenic agents.

See Teratogenic effects,anethesia

thermoregulation, 236Fetus and anesthetic

administrationdistribution of drugs, 36drug/anesthetic

interactions, 58elimination of drugs, 35and liver, 37metabolism of drugs, 35regional anesthesia effects, 151shunting of fetal circulation,

37–38umbilical vein blood

dilution, 37uptake of drugs, 35See also Teratogenic effects,

anesthesiaForceps delivery

cardiac cases, 135and cerebral

hemorrhage, 270and epidural, 111

GGallbladder, changes in

pregnancy, 9

462 Index

Gastric contentsaspiration and cesarean

delivery, 335fasting, 365tubal ligation, postpartum, 365

Gastric suction, 241Gastrointestinal system, change

in pregnancy, 7–9General anesthesia

and abruptio placentae, 307cardiac problems, 259hematological disorder,

parturients with, 278–279high-risk pregnancy, 296in vitro fertilization, 388multiple gestation, 345obese women, 296and placenta previa, 304and retained placenta, 310tubal ligation, postpartum,

362–362and uterine inversion,

311–312General anesthesia, cesarean

delivery, 201–216advantages of, 200airway management, 202–207maternal aspiration, 202–203maternal awareness, 215neonatal effects, 215preoxygenation procedure,

202compared to regional

anesthesia, 207–208technique, 208

Genital herpes, 288–289anesthesia options, 289–290cesarean delivery, 288obstetric management, 288

Gestational hypertension, 314GIFT procedure, anesthesia

options, 390Glossoptosis, Pierre Robin

syndrome, 246

Glucose tolerance test, fetaldistress diagnosis, 344

Glycopyrrolateaspiration, prevention, 202asthmatic parturients, 267

Gonadotropin-releasing,hormone, in vitrofertilization, 388

Gravid hysterectomyand placenta previa, 308and uterine rupture, 313

HHalothane

asthmatic parturients, 267with nitrous oxide, 213uteroplacental blood flow

decrease, 72Headache. See Dural puncture

headacheHeartburn, causes, 7Heart rate

fetus. See Fetal heart rateneonate, evaluation of, 238

HELLP syndromeanesthetic management, 332clinical signs, 332differential diagnosis, 332

Hematological disorders,278–279

factor V Leiden mutation, 281general anesthesia, 277–278hypercoaguable states,

281–283idiopathic thrombocytopenia,

280sickle cell disease, 280

Hematoma, epidural, 141Hemolytic-uremic syndrome,

differential diagnosis, 332Hemorrhage

abruptio placentae, 307–308and alcohol abuse, 286

Index 463

cerebral, 270emergency management,

practice guidelines,429–432

intraventricular, neonatal, 244lacerations, 310–311placenta previa, 304–305retained placenta, 310–311uterine inversion, 311–312uterine rupture, 313

Heparin therapy, and spinal cordinjuries, 281

Herpes, genital. See Genitalherpes

Herpes simplex, as complicationof morphine, 288

High-risk pregnancyabruptio placentae, 307–308addiction, maternal, 285asthma, 265–266brain tumors, 273–274breech presentation, 344cardiac disease, 259–265cerebral hemorrhage, 270cystic fibrosis, 267–268defined, 304diabetes mellitus, 251–258disseminated intravascular

coagulation, 278eclampsia, 333embolism, 334–336epidural anesthesia, 254epilepsy, 274factor V Leiden mutation, 281fetal distress, 346–348general anesthesia, 266–267genital herpes, 288–289HIV/AIDS, 289hypercoaguable states, 281hyperthyroidism, 258intrauterine fetal death,

348–349malignant hyperthermia,

293–294

multiple gestation, 345–346multiple sclerosis, 271–272myasthenia gravis, 274–276obesity, 294–295paraplegia, 269–270pheochromocytoma, 259placenta previa, 304–305psychiatric disorders, 291–293renal disorders, 276–277retained placenta, 310–311rheumatoid arthritis, 283–284sickle cell disease, 280subarachnoid block, 311–312systemic lupus erythematosus,

284–285uterine inversion, 311–312uterine rupture, 313

HIV/AIDS, 289anesthesia risks, 291anesthesiologist precautions,

291Horner’s syndrome, epidural

complication, 133–134Hydralazine

drug/anestheticinteractions, 55

pre-eclamptic women, 329uteroplacental blood flow

decrease, 74Hydromorphone, teratogenic

effects, 366Hyperbilirubinemia, and

premature delivery, 337Hypercarbia, and teratogenicity,

374Hypercoaguable states, 281Hypertension

categories of, 315defined, 315pregnancy-induced, 315

Hyperthyroidism, 258anesthesia to avoid, 258

Hyperventilation. See Maternalhyperventilation

464 Index

Hypnosis, labor painmanagement, 86

Hypoglycemia, and prematuredelivery, 337

Hypotension. See Maternalhypotension

Hypotensive drugs,drug/anestheticinteractions, 55

Hypovolemiauteroplacental blood flow

decrease, 71volume expanders, use of,

243–244Hypoxia

Apgar score, 253and teratogenicity, 373

IIndomethacin, as tocolytic

agent, 75Induction agents

asthmatic parturients, 266uteroplacental blood flow

decrease, 70–71, 273Infections, and pulmonary

edema, 324Infectious disease

genital herpes, 288–289HIV/AIDs, 289–291

Inhalation anesthetics, 374–376agents used, 374asthmatic women, 266drug/anesthetic

interactions, 48intrauterine surgery, 379for manipulation of uterus, 104mask, problems of, 103mixtures/procedure, 103neonatal effects, 294and retained placenta,

310–311teratogenic effects, 374

twin births, 345and uterine inversion, 310uteroplacental blood flow

decrease, 71–72Innovar, disuse, 102Instrumental vaginal deliv-

ery (forceps, vacuum),153–154

Intermittent technique, completeblock, 118

Intracranial hemorrhage, andpremature delivery, 343

Intracranial pressure, reductionmethods, 334

Intraocular pressure, changes inpregnancy, 12

Intrauterine fetal death, 348–349anesthesia options, 348causes of, 348–349

Intrauterine surgery, 379–381anesthetics, 376–37and preterm labor, 381tocolytic drugs, 281

Intravascular injection, epiduralcomplication, 194

Invasive monitoring,pre-eclampsia, 325–326,342

In vitro fertilizationanesthesia options, 389–392complications of, 394GIFT procedure, 391oocytes transfer, 388ovarian down regulation, 388ovarian hypertimulation

syndrome (OHSS),394–395

ultrasound-guided transvaginaloocyte retrieval, 392–394

Ischemic cerebral damage, andpremature delivery, 337

Isofluraneasthmatic parturients, 266with nitrous oxide, 214

Index 465

uteroplacental blood flowdecrease, 71

KKetamine

analgesic dosage, 101asthmatic parturients, 255as induction agent, 71, 211negative maternal effects, 101uteroplacental blood flow

decrease, 71Ketoacidosis, diabetic, 251

LLabetalol, pre-eclamptic

parturients, 331Labor and delivery

cardiac output in, 260epidural, effects of, 155–156pain of. See Labor pain; Labor

pain managementstages of, 81uterine activity assessment,

166See also Uterine contractions

Labor painfirst stage of labor, 81pain pathways (diagram), 82pain scores comparison, 83second stage of labor, 81

Labor pain managementacupuncture, 88–89diabetic parturients, 142epidural anesthesia, 109–121hypnosis, 86Lamaze method, 87Leboyer technique, 88lumbar sympathetic block, 142natural childbirth, 87paracervical block, 142–143pudendal block, 142–143spinal anesthesia, 180–181

systemic medications, 95–104transcutaneous electrical nerve

stimulation (TENS), 89–90Lamaze method, labor pain

management, 87Laparoscopic surgery

during pregnancy, 377in vitro fertilization, 388

Laryngoscopy, airway man-agement, obese women,241–242

Late decelerations, fetal heartrate, 174–175

Leboyer technique, labor painmanagement, 88

Lecithin/sphingomyelin ratio(US), fetal lung maturity,166

Levobupivacainebenefits of, 24cardiovascular system

toxicity, 23cesarean delivery, 193

Lidocainecardiovascular system

toxicity, 23cesarean delivery, 271spinal anesthesia, cesarean

delivery, 190for tubal ligation, 362uteroplacental blood flow

decrease, 72Lipid solubility

local anesthetic potency, 18and placental transfer, 33and protein binding, 33

Lithium carbonate,drug/anestheticinteractions, 51

Local anestheticsbicarbonation/carbonation of,

21, 58cesarean delivery, 180–181,

263

466 Index

Local anesthetics (cont.)chemical classification, 16combinations of, 21–22drug/anesthetic interactions,

57–58ester anesthetics, allergic

reactions, 57lipid solubility effects, 17loading dose with

epidural, 118pKa, 17pregnancy, effects on, 22protein binding and

duration, 17site of administration and

onset, 19teratogenic effects, 371uteroplacental blood flow

decrease, 73–73vasoconstrictor agents added

to, 20and vasodilation, 19volume/concentration, effects

of, 19warming of, 22

Lordosis, causes of, 12Lumbar sympathetic block,

142–143Lungs, fetus at time of delivery,

431–432

MMagnesium sulfate

drug/anestheticinteractions, 53

for eclampsia, 319surgery during pregnancy, 378uteroplacental blood flow

decrease, 75Malignant hyperthermia,

293–294anesthesia options, 293–294clinical signs, 293

Massive analgesia, epiduralcomplication, 132

Maternal anestheticadministration, 32–36

effects on fetus. See Fetus andanesthetic administration

free drug concentration,affecting factors, 35

maternal pH, 33metabolism of drugs, 34–35with other drugs. See

Drug/anestheticsinteractions

pKa, 33placental transfer, 33–34and plasma volume, 32protein binding, 33

Maternal aspirationand general anesthesia, 201prevention, 201

Maternal hyperventilationfetal acidosis, 68, 209and general anesthesia,

207–208during labor, 7

Maternal hypotensionand cocaine addiction, 287and fetal acidosis, 181management of, 181, 258, 305prophylactic agents, 182–183and spinal anesthesia for

cesarean delivery, 181Maternal mortality/morbidity

anesthesia-related morbidity,399–402

causes of death, 399direct/indirect mortality

rates, 399Maternal physiology

blood volume changes, 2breasts, 12cardiovascular changes, 341gastrointestinal system, 7–9musculoskeletal system, 12

Index 467

nervous system, 10–11ocular system, 12renal system, 9, 276–278respiratory system changes,

5–7Maternal temperature and

newborn, epidural analgesiaeffect on, 155–156

McGill pain questionnaire, 83Meconium, aspiration

syndrome, 247Meperidine, 96–98

Apgar scores, low, 96–97cesarean delivery, 190epidural usage, 131and neonatal respiratory

depression, 96for shivering, 133spinal anesthesia, cesarean

delivery, 190teratogenic effects, 373for tubal ligation, 363

Mepivacaine, uteroplacentalblood flow decrease, 72

Metabolism of drugs, byplacenta, 34–35

Methemoglobinemia, epiduralcomplication, 133

Methohexital, uteroplacentalblood flow decrease, 71

Methoxyflurane, with nitrousoxide, 214

Methylxanthines, as tocolyticagent, 339

Metoclopramideaspiration, prevention, 201nausea/vomiting treatment,

185, 191for tubal ligation, 362

Micrognathia, Pierre Robinsyndrome, 246

Midazolam, amnestic effect, 101Molecular weight, and placental

transfer, 34

Monoamine oxidase inhibitors(MAOIs), drug/anestheticinteractions, 49–51

Morphinecesarean delivery pain relief,

120, 189combined spinal/epidural

(CSE), 166epidural side effects, 120epidural usage, 120and genital herpes

infections, 288routes of administration, 96spinal anesthesia, cesarean

delivery, 189subarachnoid usage, 189for twilight sleep, 102

Multiple gestation, 345–346anesthesia options, 343and cardiac output, 340triplets/quadruplets, 345–346twins, 345

Multiple sclerosis, 271–272cesarean section, 272epidural anesthesia, 271postpartum relapse, 271

Muscle relaxantsdrug/anesthetic

interactions, 49myasthenia gravis

parturients, 276surgery during pregnancy, 377

Musculoskeletal system, changein pregnancy, 12

Myasthenia gravis, 274–276cesarean delivery, 275–276epidural anesthesia, 275neonatal, 276problems related to, 274

NNalbuphine

analgesic dosage, 102

468 Index

Nalbuphine (cont.)spinal/epidural side effects

treatment, 125Naloxone, neonatal resuscitation,

244, 245Narcotics

cardiac cases, 261drug/anesthetic interactions,

48, 49, 58labor pain management, 87teratogenic effects, 370

Nasal passage abnormality,choanal atresia, 245

Natural childbirth, labor painmanagement, 87

Nausea/vomiting, spinal anes-thesia for cesarean delivery,184–185

Neonatal resuscitationairway management, 240–241Apgar score-based

intervention, 238–239aspiration syndrome, 247breathing, evaluation and

assistance, 242cardiac massage, 232–235choanal atresia, 245diaphragmatic hernia,

246–247equipment for, 238fetal factors related to, 237heart rate evaluation, 232intraventricular

hemorrhage, 244maternal factors related to, 237medications used, 245Pierre Robin syndrome, 245pneumothorax, 247steps in delivery room

(flowchart), 240tracheal anomalies, 246tracheoesophageal fistula, 246volume expanders, 243–244

Neonate and anesthesia effects

barbiturates, 100cesarean incision-delivery

interval, 213general anesthesia, 209–210inhalation agents, 214and maternal

oxygenation, 213meperidine, 96naloxone, 244neuromuscular blockers, 212

Neostigmine, and fetalbradycardia, 169

Neo-Synephrine. SeePhenylephrine

Neurological disordersbrain tumors, 273cerebral hemorrhage, 270epilepsy, 274multiple sclerosis, 271–272myasthenia gravis, 274paraplegia, 269

Nervous system, change inpregnancy, 10–11

Neurological complicationschloroprocaine, 197–199obstetric-related, 135–138regional anesthesia-related,

138–141Neuromuscular blockers. See

Muscle relaxantsNifedipine, pre-eclamptic

patients, 331Nitroglycerin

drug/anestheticinteractions, 55

outcome criteria, 310and retained placenta, 310twin births, 345and uterine inversion, 310uteroplacental blood flow

decrease, 74Nitroprusside

drug/anestheticinteractions, 55

Index 469

uteroplacental blood flowdecrease, 74

Nitrous oxideDNA synthesis disruption, 374neonatal effects, 215teratogenic effects, 376–377

Nonstress test, 164–165Norepinephrine, added to local

anesthetic, 20

OObesity, 294–296

anesthesia options, 296–297obstetric problems, 295–296

Obstetrical anesthesia, practiceguidelines, 409

Ocular system, change inpregnancy, 12

Oliguria, management of, 314Ovarian hyperstimulation

syndrome (OHSS), 394Ovulation, inducing, in vitro

fertilization, 388Oxygenation

for fetal distress, 346neonatal effects, 242pre-general anesthesia,

212, 280Oxygen dissociation curve, 67Oxygen transport, diabetes and

impairment, 252Oxytocin

discontinuing, and fetaldistress, 344

drug/anesthetic interactions,55–56

Oxytocin challengetest, 165

PPain of labor and delivery, pain

score of labor pain, 81–84

Pancuronium, surgery duringpregnancy, 380

Paracervical block, technique,142–143, 360

Paraplegia, 269–270cesarean delivery, 270epidural anesthesia, 270mass reflex syndrome, 269

Paresthesia, epiduralcomplication, 127

Patchy block, correction of,122–123

Patient-controlled analgesia(PCA)

post-cesarean delivery, 217postoperative pain relief, 217

Patient monitoringepidural anesthesia, 126fetus. See Fetal monitoring

Perinatal pharmacologyeffects on fetus, 35–37See also Fetus and anesthetic

administration; Maternalanesthetic administration;Placental drug transfer

Peripheral nervous system,changes in pregnancy,10–11

Phenobarbital, 42Phenothiazines, 100

and baseline variability, 169drug/anesthetic

interactions, 47Phenylephrine

added to local anesthetic, 20maternal hypotension

treatment, 185surgery during pregnancy, 377

Phenytoin, 275Pheochromocytoma

anesthesia management, 259pre-labor treatment, 259

Phospholipids, and fetal lungmaturity, 165–166

470 Index

pH, maternal, and placentaltransfer, 33

Pierre Robin syndromeclinical signs, 246treatment of, 246

pKalocal anesthetic onset

speed, 17and placental transfer, 33

Placentaproblems and fetal

distress, 346removal of, 424retained, 310–311

Placenta accreta, 305Placenta increta, 305Placenta percreta, 305Placental transfer, 33–34

antiepileptic drugs, 42–44area of transfer, 34diffusion distance, 34diffusion equation for, 34and maternal pH, 35metabolism of drugs, 35molecular weight, 34and pKa, 33–34protein binding, 33

Placenta previa, 304–307bleeding and anesthetic

management, 305blood transfusions, 307categories of, 304–305differential diagnosis, 309not bleeding and anesthetic

management, 306–307compared to placentae

abruptio, 307–309regional versus general

anesthesia, 306Plasma cholinesterase, changes

in pregnancy, 8Plasma volume

change in pregnancy, 1–2and distribution of drugs, 32

Pneumothoraxclinical signs, 247treatment of, 247

Pregnancyphysical changes. See Maternal

physiologysurgery during. See Surgery

during pregnancySee also High-risk pregnancy

Prolonged decelerations, 174Prolonged neural blockade,

epidural complication, 138Promethazine, and baseline

variability, 100Propofol, as induction agent,

71, 212uteroplacental blood flow

decrease, 71Propranolol, and fetal

bradycardia, 169Prostaglandin, drug/anesthetic

interactions, 54Prostaglandin inhibitors

drug/anestheticinteractions, 57

prostaglandin synthetaseinhibitors, 339

Protein bindingand lipid solubility, 34–35local anesthetic

duration, 17and placental transfer, 33

Pruritus, combined,spinal/epidural (CSE)complication, 125

Psychiatric disorders, 291–293classification of, 292drug/anesthesia interactions,

292–293Psychoanalgesia, labor pain

management, 87Psychotropic drugs,

drug/anestheticinteractions, 48

Index 471

Pudendal block, technique,142–143

Pulmonary arterial (PA) linemonitoring, 325

Pulmonary edemacauses of, 340–341treatment of, 342

Quadruplets, deliverycomplications, 345

RRanitidine

aspiration, prevention, 202asthmatic parturients, avoiding,

255Regional anesthesia

advantages of, 306American Society of

Anesthesiologists guidelines,409–412

caudal anesthesia, 142epidural anesthesia, 151–153fetal effects, 175lumbar sympathetic block, 142neonatal effects, sources

of, 127paracervical block, 142and placenta previa, 308pudendal block, 142–143spinal anesthesia, 180–192and uterine contractions,

166–167See also specific methods

Remifentanil, 99–100advantage of, 100analgesic dosage, 100

Renal disorders, 276–278epidural anesthesia, 277pre-delivery factors, 277

Renal systemchange in pregnancy, 9fetal, and anesthetic

administration, 35

and pre-eclampsia, 276Respiratory problems, maternal

asthma, 265–267cystic fibrosis, 267–268

Respiratory problems, neonatecombined spinal/epidural

(CSE) complication,200–201

and premature delivery, 336See also Neonatal resuscitation

Respiratory systemchange in pregnancy, 5–6fetus at time of delivery, 372

Retained placenta, 310–311anesthetic methods, 312severe bleeding, steps to

take, 310Rheumatoid arthritis

anesthesia difficulties,281–283

epidural anesthesia, 283Ropivacaine

benefits of, 24cardiac patients, 265cardiovascular system toxicity,

23–24cesarean delivery, 194

SScopolamine

spinal/epidural side effectstreatment, 125

for twilight sleep, 102Segmental block

dosage, 181limitations of, 181

Seroflurane, inhalation trials,104

Serotonin reuptake inhibitors(SSRIs)

drug/anesthetic interactions,51–52

serotonin syndrome, 52

472 Index

Sevofluraneasthmatic patients, 267neonatal effects, 215situations for use, 72for uterine manipulation, 104

Shiveringepidural complication,

155, 194reduction of, 193

Sickle cell diseasecesarean delivery, 280epidural anesthesia, 280obstetric risks, 280

Sinusoidal pattern,decelerations, 174

Sodium bicarbonate. SeeBicarbonate solution

Sodium citrate, aspiration,prevention, 202

Spinal anesthesiaasthmatic patients, 266combined spinal/epidural

(CSE), 200–201diabetic patients, 251multiple gestation, 345obese patients, 296premature delivery, 377tubal ligation, postpartum,

362–366in vitro fertilization, 387See also Spinal opiates

Spinal anesthesia, cesareandelivery, 179–218advantages of, 180–181contraindications, 192diabetic patients, 256drugs used, 190compared to epidural,

200–201headache, 186–188and maternal hypotension,

181–182nausea/vomiting, 184–186technique, 186–187

Spontaneous abortion, anesthesiaexposure, 371

Stroke volume, change inpregnancy, 3–4

Subarachnoid blockhigh-risk pregnancy, 306and retained placenta,

310–311Subarachnoid hemorrhage, 270Subdural injection

epidural complication, 132features of, 132

Substance abusers. SeeAddiction, maternal

Succinylcholineasthmatic patients, 269drug interactions, 332for tubal ligation, 362–366

Suctiongastric, 241neonatal airway, 240–242

Sufentanilcesarean delivery, 115combined spinal/epidural

(CSE), 113, 124epidural usage, 112for shivering, 133spinal anesthesia, cesarean

delivery, 125Supine hypotensive

syndrome, 346Surfactant, fetal lungs, 236Surgery during pregnancy

anesthesia options, 378causes of, 370fetal monitoring, 380incidence of, 371intrauterine surgery, 379–381laparoscopic, 378–379patient monitoring, 378preoperative

medications, 378tocodynamometry/tocolytic

drugs, 378

Index 473

See also Teratogenic effects,anesthesia

Sympathectomy, uteroplacentalblood flow decrease, 69

Sympathomimetic drugsdrug/anesthetic interactions,

45–46, 48, 49and fetal tachycardia, 168

Systemic lupus erythematosus,284–285

anesthesia options, 286obstetric complications, 286

Systemic medicationsbenzodiazepines, 100–101butorphanol, 102fetanyl, 98–99inhalation analgesia, 103–104ketamine, 101–102meperidine, 96–98morphine, 96nalbuphine, 102–103phenothiazines, 100remifentanil, 99–100scopolamine, 102

TTachycardia, fetal, causes of, 168Teratogenic effects, anesthesia

acute exposure, 371chronic fetal exposure,

371–372halogenated anesthetics, 375hyperbaric oxygen, 374local anesthetics, 373muscle relaxants, 373narcotics, 373nitrous oxide, 374–376sedative/hypnotics, 372–373

Test dose, epidural anesthesia,115–118

Thebaine, teratogeniceffects, 373

Thermoregulation, fetus, 236

Thiopentalfetal effects, 37, 211pre-eclamptic patients, 329for tubal ligation, 365uteroplacental blood flow

decrease, 70–71Thioxanthenes, drug/anesthetic

interactions, 48Thrombocytopenia, and cocaine

addiction, 287Thromboelastography (TEG),

pre-eclampsia clottingparameter, 327

Thrombotic embolism,treatment, 335

Thrombotic thrombocyticpurpura, differentialdiagnosis, 332

Thumb technique, cardiacmassage, 243

Tocodynamometrylimitations of, 167surgery during pregnancy, 377

Tocolytic drugsbeta-blockers, 340drug/anesthetic interactions,

53–54ethanol, 338intrauterine surgery, 379–381methylxanthines, 339premature delivery

management, 377prostaglandin synthetase

inhibitors, 339and pulmonary edema,

340–341uteroplacental blood flow

decrease, 75See also Beta-mimetic drugs

Tracheal anomalies, neonatalresuscitation, 246

Tranquilizerslabor pain management, 100teratogenic effects, 373

474 Index

Transcutaneous electrical nervestimulation (TENS), laborpain management, 89–90

Transient neurological symptoms(TNS), 140

Trichlorethylene, with nitrousoxide, 213–214

Tricyclic antidepressants,drug/anesthetic interactions,48–49

Trimethaphandrug/anesthetic

interactions, 55pre-eclamptic patients, 328

Triplets, delivery complications,343–344

Tubal ligation, postpartumadvantages of, 362epidural anesthesia, 363–364gastric emptying, 345general anesthesia, 365–366optimal time, 363practice guidelines, 411spinal anesthesia, 364–365

Twilight sleep, drug combinationfor, 102

Twins, anesthesiaoptions, 345

Two-finger technique, cardiacmassage, 243

UUltrasound, fetal distress

diagnosis, 347Ultrasound-guided transvaginal

oocyte retrieval, anesthesiaoptions, 392–394

Umbilical cord compression, andvariable decelerations, 344

Umbilical veinfetal circulation, 33–37route for volume expanders,

243–244

Umbilical vein/maternal vein(UV/MV) ratio, and localanesthetic, 18, 33

Uterine blood flowequation for, 65reduced, and epinephrine, 73

Uterine contractionscontraction stress test, 165epidural effects, 153epinephrine effects, 153uteroplacental blood flow

decrease, 69Uterine inversion, anesthesia

management, 311–312Uterine manipulation, inhalation

anesthetics, use of, 104Uterine rupture, 313

anesthesia management,313–314

common cause, 313and gravid hysterectomy, 313

Uteroplacental blood flowgas exchange mechanisms,

66–68oxygen dissociation curve, 67uterine blood flow, equation

for, 65uterine blood flow velocity, 66

Uteroplacental blood flowdecrease

antihypertensive agents, 74–75beta-adrenergic blockers, 75diabetes mellitus, 70, 251epidural/subarachnoid

opiates, 75epinephrine, 73induction agents, 70–71, 211inhalation agents, 71–72local anesthetics, 72–73mean maternal artery

pressure, 69postmature pregnancy, 70and pre-eclampsia, 70tocolytic drugs, 75

Index 475

uterine contractions, 69vasopressors, 73–74

Uteroplacental insufficiency, andlate decelerations, 165

Uteroplacental perfusion, andepidural anesthesia, 344

Uterotonic drugsdrug/anesthetic interactions,

55–57surgery during pregnancy, 377

VValproic acid, antibiotics, 42–44Variable decelerations, fetal heart

rate, 165, 172–174Vasoactive substances, and

pre-eclampsia cautions, 316Vasodilation, and local

anesthetic, 19Vasopressors

maternal hypotensionprophylaxis, 181–182

uteroplacental blood flowdecrease, 73–74

Vecuroniumasthmatic patients, 269surgery during pregnancy,

377Venous air embolism

causes, 335clinical signs, 335treatment, 337

Verapamil, uteroplacental, bloodflow decrease, 75

Volume expanders, indicatorsfor, 243–244

Von Willebrand disease,classification of, 281

XXanthine derivatives,

drug/anesthetic interactions,46

ZZIFT technique, anesthesia,

options, 393