Obstetric Anesthesia ASA Guidelines Flashcards
Perianesthetic Evaluation and Preparation: which fHistory
° focused history
- maternal health 2. anesthetic history,
- a relevant obstetric history,
Perianesthetic evaluation and Preparation : focused physical exam
- baseline blood pressure measurement
- an airway, heart, and lung examination, consistent with the American Society of Anesthesiologists (ASA)
- When a neuraxial anesthetic is planned or placed, examine the patient’s back.
Aim of preoperative assessment
Recognition of significant anesthetic or obstetric risk factors should encourage consultation between the obstetrician and the anesthesiologist.
What is the recommendations on intrapartum Platelet Count?
- A routine platelet count is not necessary in the healthy parturient
- decision to order or
require a platelet count should be individualized and based
on a patient’s history (e.g., preeclampsia with severe features),
physical examination, and clinical signs.
Blood Type and Screen
routine blood cross-match is not necessary for healthy and uncomplicated parturients for vaginal or operative delivery.
The decision whether to order or require a blood type and screen or cross-match should be based on maternal history, anticipated hemorrhagic complications (e.g., placenta accreta in a patient with placenta previa and previous uterine surgery), and local institutional policies.
Perianesthetic Recording of Fetal Heart Rate Patterns
Fetal heart rate patterns should be monitored by a qualif ied individual before and after administration of neuraxial analgesia for labor.
Continuous electronic recording of fetal heart rate patterns may not be necessary in every clinical setting and may not be possible during placement of a neuraxial catheter.**
Aspiration Prevention Clear Liquids during labour and for c/s
The oral intake of moderate amounts of clear liquids may be allowed for uncomplicated laboring patients moderate amounts of
clear liquids up to 2h before induction of anesthesia.
• The uncomplicated patient undergoing elective surgery may have clear liquids up to 2 h before induction of anesthesia.
º Examples of clear liquids include, but are not limited to, water, fruit juices without pulp, carbonated beverages, clear tea, black coffee, and sports drinks.
º The volume of liquid ingested is less important than the presence of particulate matter in the liquid ingested.
• Laboring patients with additional risk factors for aspiration (e.g., morbid obesity, diabetes mellitus, and diff icult airway) or patients at increased risk for operative delivery (e.g., nonreassuring fetal heart rate pattern) may have further restrictions of oral intake, determined on a case-by-case basis.
Recommendations on aspiration prevention with regards to solids?
Solid foods should be avoided in laboring patients.
laboring patients with additional risk factors
for aspiration (e.g., morbid obesity, diabetes mellitus, and
difficult airway) or patients at increased risk for operative
delivery (e.g., nonreassuring fetal heart rate pattern) may
have further restrictions of oral intake, determined on a
case-by-case basis;
• The patient undergoing elective surgery (e.g., scheduled
cesarean delivery or postpartum tubal ligation) should
undergo a fasting period for solids of 6 to 8 h depending
on the type of food ingested (e.g., fat content).###
Antacids, H2-receptor Antagonists, and Metoclopramide
Before surgical procedures (e.g., cesarean delivery and
postpartum tubal ligation), consider the timely admin-
istration of nonparticulate antacids, H2-receptor antago-
nists, and/or metoclopramide for aspiration prophylaxis.
Recommandation on Anesthetic Care for Labor and Vaginal Delivery timing of neuraxialblock ?
• Provide patients in early labor (i.e., less than 5 cm dila-
tion) the option of neuraxial analgesia when this service
is available.
• Offer neuraxial analgesia on an individualized basis
regardless of cervical dilation.
º Reassure patients that the use of neuraxial analgesia
does not increase the incidence of cesarean delivery.
Recommendations on neuraxial block for VBAC?
Offer neuraxial techniques to patients attempting vaginal
birth after previous cesarean delivery
these patients, it is appropriate to consider early
placement of a neuraxial catheter that can be used later for
labor anal
Recommendations on when early insertion of neurexial catheter?
Consider early insertion of a neuraxial catheter for obstet-
ric (e.g., twin gestation or preeclampsia) or anesthetic
indications (e.g., anticipated difficult airway or obesity)
to reduce the need for general anesthesia if an emergent
procedure becomes necessary.
º In these cases, the insertion of a neuraxial catheter may
precede the onset of labor or a patient’s request for
labor analgesia.
Recommendations on CIE?
Continuous epidural infusion 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 concentra-
tion of local anesthetic, improve the quality of analgesia,
and minimize motor block.
Recommandation on analgesic concentrations?
Use dilute concentrations of local anesthetics with opioids
to produce as little motor block as possible
Recommendations on single spinal opioids with/without local anaesthetic?
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
delivery is anticipated.
• If labor duration is anticipated to be longer than the anal-
gesic effects of the spinal drugs chosen, or if there is a rea-
sonable possibility of operative delivery, then consider a
catheter technique instead of a single-injection technique.
• A local anesthetic may be added to a spinal opioid to
increase duration and improve quality of analgesia.
Recommandation on spinal needle?
Use pencil-point spinal needles instead of cutting-bevel
spinal needles to minimize the risk of postdural puncture
headache.
Recommendations on CSE Analgesia.
If labor duration is anticipated to be longer than the
analgesic effects of the spinal drugs chosen, or if there is
a reasonable possibility of operative delivery, then consider a catheter technique instead of a single-injection
technique.
• Combined spinal–epidural techniques may be used to
provide effective and rapid onset of analgesia for labor.
What are the recommendations for Patient-controlled Epidural Analgesia.
Patient-controlled epidural analgesia (PCEA) may be used
to provide an effective and flexible approach for the main-
tenance of labor analgesia.
• The use of PCEA may be preferable to fixed-rate continu-
ous infusion epidural analgesia for administering reduced
dosages of local anesthetics.
• PCEA may be used with or without a background
infusion.
Recommendations on anaesthesia management for retained placenta
In general, there is no preferred anesthetic technique for
removal of retained placenta.
º If an epidural catheter is in place and the patient is hemodynamically stable, consider providing epidural
anesthesia.
• Assess hemodynamic status before administering neuraxial anesthesia.
• Consider aspiration prophylaxis.
• Titrate sedation/analgesia carefully due to the potential risks of respiratory depression and pulmonary aspiration
during the immediate postpartum period.
• In cases involving major maternal hemorrhage with hemodynamic instability, general anesthesia with an endotra-
cheal tube may be considered inpreference to neuraxial
anesthesia.
Recommendations for uterine relaxation for retained placenta removal?
Nitroglycerin may be used as an alternative to terbutaLine sulfate or general endotracheal anesthesia with halogenated agents for uterine relaxation during removal of retained placental tissue.
º Initiating treatment with incremental doses of IV or sublingual (i.e., tablet or metered dose spray) nitroglycerin may be done to sufficiently relax the uterus.
Recommendations on Equipment, Facilities, and Support Personnel for c/s
Equipment, facilities, and support personnel available in
the labor and delivery operating suite should be compa-
rable to those available in the main operating suite.
• Resources for the treatment of potential complications
(e.g., failed intubation, inadequate analgesia/anesthesia,
hypotension, respiratory depression, local anesthetic sys-
temic toxicity, pruritus, and vomiting) should also be
available in the labor and delivery operating suite.
• Appropriate equipment and personnel should be available
to care for obstetric patients recovering from neuraxial or
general anesthesia.
Recommendations on Anesthetic technique General, Epidural, Spinal, or CSE Anesthesia.
The decision to use a particular anesthetic technique for
cesarean delivery should be individualized, based on anes-
thetic, obstetric, or fetal risk factors (e.g., elective vs. emer-
gency), the preferences of the patient, and the judgment
of the anesthesiologist.
º Uterine displacement (usually left displacement)
should be maintained until delivery regardless of the
anesthetic technique used.
• Consider selecting neuraxial techniques in preference to
general anesthesia for most cesarean deliveries.
• If spinal anesthesia is chosen, use pencil-point spinal nee-
dles instead of cutting-bevel spinal needles.
• For urgent cesarean delivery, an indwelling epidural cath-
eter may be used as an alternative to initiation of spinal or
general anesthesia.
• General anesthesia may be the most appropriate choice in
some circumstances (e.g., profound fetal bradycardia, rup-
tured uterus, severe hemorrhage, severe placental abrup-
tion, umbilical cord prolapse, and preterm footling breech).
Preloading and coloading
IV fluid preloading or coloading may be used to reduce
the frequency of maternal hypotension after spinal anes-
thesia for cesarean delivery.
• Do not delay the initiation of spinal anesthesia in order to
administer a fixed volume of IV fluid.
Ephedrine or phenylephrine to treat hypotension?
Either IV ephedrine or phenylephrine may be used for treating hypotension during neuraxial anesthesia.
• In the absence of maternal bradycardia, consider selecting phenylephrine because of improved fetal acid–base status
in uncomplicated pregnancies.
