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## Complete Summary

#### GUIDELINE TITLE

Practice guidelines for obstetric anesthesia: an updated report by the
American Society of Anesthesiologists Task Force on Obstetric
Anesthesia.

#### BIBLIOGRAPHIC SOURCE(S)

American Society of Anesthesiologists Task Force on Obstetric
Anesthesia. Practice guidelines for obstetric anesthesia: an updated
report by the American Society of Anesthesiologists Task Force on
Obstetric Anesthesia. Anesthesiology 2007 Apr;106(4):843-63.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17413923)

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Society of
Anesthesiologists. Practice guidelines for obstetrical anesthesia: a
report by the American Society of Anesthesiologists Task Force on
Obstetrical Anesthesia. Anesthesiology 1999 Feb;90(2):600-11.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Intrapartum and postpartum pain

**Note**: These guidelines do not address postpartum analgesia for
vaginal delivery, analgesia after tubal ligation, or postoperative
analgesia after general anesthesia (GA) for cesarean delivery.

#### GUIDELINE CATEGORY

Evaluation\
Management

#### CLINICAL SPECIALTY

Anesthesiology\
Obstetrics and Gynecology

#### INTENDED USERS

Patients\
Physicians

#### GUIDELINE OBJECTIVE(S)

To enhance the quality of anesthesia care for obstetric patients,
improve patient safety by reducing the incidence and severity of
anesthesia-related complications, and increase patient satisfaction

#### TARGET POPULATION

Intrapartum and postpartum patients with uncomplicated pregnancies or
with common obstetric problems

**Note**: These guidelines do not apply to patients undergoing surgery
during pregnancy, gynecologic patients, or parturients with chronic
medical disease (e.g., severe cardiac, renal or neurologic disease).

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Perianesthetic evaluation (history and physical examination,
    communication system discussed, intrapartum platelet count, blood
    type and screen or cross-match, perianesthetic recording of fetal
    heart rate)

2.  Aspiration prevention (fasting times for clear liquids and solids
    for labor and delivery, administration of non-particulate antacids,
    histamine \[H~2~\] receptor antagonists, and/or metoclopramide for
    aspiration prophylaxis)

3.  Anesthetic care for labor and delivery (neuraxial techniques with or
    without local anesthetics and/or opioids, continuous infusion
    epidural, single-injection spinal opioids with or without local
    anesthetics, pencil-point spinal needles, combined spinal-epidural
    anesthetics, and patient-controlled epidural analgesia)

4.  Removal of retained placenta (anesthetic choices and nitroglycerin
    for uterine relaxation)

5.  Anesthetic choices for cesarean delivery (spinal, epidural, combined
    spinal-epidural and/or general anesthesia, use of intravenous fluid
    preloading and ephedrine/phenylephrine as supportive care, and
    neuraxial opioids for postoperative analgesia)

6.  Postpartum tubal ligation and anesthetic options

7.  Management of obstetric and anesthetic emergencies (availability of
    management resources for hemorrhagic emergencies, central
    hemodynamic monitoring, equipment for airway emergencies,
    cardiopulmonary resuscitation)

#### MAJOR OUTCOMES CONSIDERED

-   Maternal analgesia

-   Maternal, fetal and neonatal anesthetic complications

-   Maternal, fetal and neonatal obstetric complications

-   Maternal comfort and satisfaction

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases\
Searches of Unpublished Data

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Scientific evidence was derived from aggregated research literature, and
opinion-based evidence was obtained from surveys, open presentations,
and other activities (e.g., Internet posting). For purposes of
literature aggregation, potentially relevant clinical studies were
identified via electronic and manual searches of the literature. The
electronic and manual searches covered a 67-yr period from 1940 through
2006. More than 4,000 citations were initially identified, yielding a
total of 2,986 nonoverlapping articles that addressed topics related to
the evidence linkages. After review of the articles, 2,549 studies did
not provide direct evidence and were subsequently eliminated. A total of
437 articles contained direct linkage-related evidence.

#### NUMBER OF SOURCE DOCUMENTS

437

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

When sufficient numbers of studies are available for evaluation, the
following terms describe the strength of the findings.

-   *Support*: Meta-analysis of a sufficient number of randomized
    controlled trials\* indicates a statistically significant
    relationship (p \< 0.01) between a clinical intervention and a
    clinical outcome.

-   *Suggest*: Information from case reports and observational studies
    permits inference of a relationship between an intervention and an
    outcome. A meta-analytic assessment of this type of qualitative or
    descriptive information is not conducted.

-   *Equivocal*: Either a meta-analysis has not found significant
    differences among groups or conditions, or there is insufficient
    quantitative information to conduct a meta-analysis and information
    collected from case reports and observational studies does not
    permit inference of a relationship between an intervention and an
    outcome.

\* A prospective nonrandomized controlled trial may be included in a
meta-analysis under certain circumstances if specific statistical
criteria are met.

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

-   *Silent*: No identified studies address the specified relationship
    between an intervention and outcome.

-   *Insufficient*: There are too few published studies to investigate a
    relationship between an intervention and outcome.

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

#### METHODS USED TO ANALYZE THE EVIDENCE

Meta-Analysis\
Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

The scientific assessment of these Guidelines was based on evidence
linkages or statements regarding potential relationships between
clinical interventions and outcomes. The interventions were examined to
assess their impact on a variety of outcomes related to obstetric
anesthesia.

Initially, each pertinent outcome reported in a study was classified as
supporting an evidence linkage, refuting a linkage, or equivocal. The
results were then summarized to obtain a directional assessment for each
evidence linkage before conducting a formal meta-analysis. Literature
pertaining to 11 evidence linkages contained enough studies with
well-defined experimental designs and statistical information sufficient
for meta-analyses. These linkages were (1) nonparticulate antacids
versus no antacids, (2) continuous epidural infusion of local
anesthetics with or without opioids versus parenteral opioids, (3)
induction of epidural analgesia using local anesthetics with opioids
versus equal concentrations of epidural local anesthetics without
opioids, (4) maintenance of epidural infusion of lower concentrations of
local anesthetics with opioids versus higher concentrations of local
anesthetics without opioids, (5) Combined spinal--epidural local
anesthetics with opioids versus epidural local anesthetics with opioids,
(6) PCEA versus continuous infusion epidurals, (7) general anesthesia
versus epidural anesthesia for cesarean delivery, (8) Combined
spinal--epidural anesthesia versus epidural anesthesia for cesarean
delivery, (9) use of pencil-point spinal needles versus cutting-bevel
spinal needles, (10) ephedrine or phenylephrine reduces maternal
hypotension during neuraxial anesthesia, and (11) neuraxial opioids
versus parenteral opioids for postoperative analgesia after neuraxial
anesthesia for cesarean delivery.

General variance-based effect-size estimates or combined probability
tests were obtained for continuous outcome measures, and Mantel-Haenszel
odds ratios were obtained for dichotomous outcome measures. Two combined
probability tests were used as follows: (1) the Fisher combined test,
producing chi-square values based on logarithmic transformations of the
reported P values from the independent studies, and (2) the Stouffer
combined test, providing weighted representation of the studies by
weighting each of the standard normal deviates by the size of the
sample. An odds ratio procedure based on the Mantel-Haenszel method for
combining study results using 2 X 2 tables was used with outcome
frequency information. An acceptable significance level was set at P
\<0.01 (one-tailed). Tests for heterogeneity of the independent studies
were conducted to assure consistency among the study results.
DerSimonian-Laird random-effects odds ratios were obtained when
significant heterogeneity was found (P \<0.01). To control for potential
publishing bias, a \"fail-safe n\" value was calculated. No search for
unpublished studies was conducted, and no reliability tests for locating
research results were done.

Meta-analytic results are reported in table 4 of the original guideline
document. To be accepted as significant findings, Mantel-Haenszel odds
ratios must agree with combined test results whenever both types of data
are assessed. In the absence of Mantel-Haenszel odds ratios, findings
from both the Fisher and weighted Stouffer combined tests must agree
with each other to be acceptable as significant.

Interobserver agreement among Task Force members and two methodologists
was established by interrater reliability testing. Agreement levels
using a kappa statistic for two-rater agreement pairs were as follows:
(1) type of study design, kappa = 0.83--0.94; (2) type of analysis,
kappa = 0.71--0.93; (3) evidence linkage assignment, kappa = 0.87--1.00;
and (4) literature inclusion for database, kappa = 0.74--1.00.
Three-rater chance-corrected agreement values were (1) study design, Sav
= 0.884, Var (Sav) = 0.004; (2) type of analysis, Sav = 0.805, Var (Sav)
= 0.009; (3) linkage assignment, Sav = 0.911, Var (Sav) = 0.002; and (4)
literature database inclusion, Sav = 0.660, Var (Sav) = 0.024. These
values represent moderate to high levels of agreement.

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The American Society of Anesthesiologists (ASA) appointed a Task Force
of 11 members to (1) review the published evidence, (2) obtain the
opinion of a panel of consultants including anesthesiologists and
nonanesthesiologist physicians concerned with obstetric anesthesia and
analgesia, and (3) obtain opinions from practitioners likely to be
affected by the Guidelines. The Task Force included anesthesiologists in
both private and academic practices from various geographic areas of the
United States and two consulting methodologists from the American
Society of Anesthesiologists Committee on Standards and Practice
Parameters.

The Task Force developed the Guidelines by means of a seven-step
process. First, they reached consensus on the criteria for evidence.
Second, original published research studies from peer-reviewed journals
relevant to obstetric anesthesia were reviewed. Third, the panel of
expert consultants was asked to (1) participate in opinion surveys on
the effectiveness of various peripartum management strategies and (2)
review and comment on a draft of the Guidelines developed by the Task
Force. Fourth, opinions about the Guideline recommendations were
solicited from active members of the American Society of
Anesthesiologists who provide obstetric anesthesia. Fifth, the Task
Force held open forums at two major national meetings (International
Anesthesia Research Society, 80th Clinical and Scientific Congress and
Society of Obstetric Anesthesia and Perinatology 38th Annual Meeting) to
solicit input on its draft recommendations. Sixth, the consultants were
surveyed to assess their opinions on the feasibility of implementing the
Guidelines. Seventh, all available information was used to build
consensus within the Task Force to finalize the Guidelines (appendix 1
of the original guideline document).

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review\
Internal Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Consensus was obtained from multiple sources, including (1) survey
opinion from consultants who were selected based on their knowledge or
expertise in obstetric anesthesia or maternal and fetal medicine, (2)
survey opinions solicited from active members of the American Society of
Anesthesiologists (ASA), (3) testimony from attendees of publicly held
open forums at two national anesthesia meetings, (4) Internet
commentary, and (5) Task Force opinion and interpretation. The survey
rate of return was 75% (n = 76 of 102) for the consultants, and 2,326
surveys were received from active American Society of Anesthesiologists
members. Results of the surveys are reported in tables 5 and 6 and in
the text of the Guidelines.

The guidelines were submitted for publication October 31, 2006, accepted
for publication October 31, 2006, and were approved by the House of
Delegates on October 18, 2006.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

I.  **[Perianesthetic Evaluation]{.underline}**

    -   Conduct a focused history and physical examination before
        providing 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 encourage early and
        ongoing contact between obstetric providers, anesthesiologists,
        and other members of the multidisciplinary team

    -   Order or require a platelet count based on a patient\'s history,
        physical examination, and clinical signs; a routine intrapartum
        platelet count is not necessary in the healthy parturient

    -   Order or require an intrapartum blood type and screen or
        cross-match 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; a routine blood cross-match is not necessary for
        *healthy and uncomplicated* parturients

    -   The fetal heart rate should be monitored by a qualified
        individual before and after administration of neuraxial
        analgesia for labor; *continuous* electronic recording of the
        fetal heart rate may not be necessary in every clinical setting
        and may not be possible during initiation of neuraxial
        anesthesia

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II. **[Aspiration Prophylaxis]{.underline}**

    -   Oral intake of modest amounts of clear liquids may be allowed
        for uncomplicated laboring patients

    -   The uncomplicated patient undergoing elective cesarean delivery
        may have modest amounts of clear liquids up to 2 hours before
        induction of anesthesia

    -   The volume of liquid ingested is less important than the
        presence of particulate matter in the liquid ingested

    -   Patients with additional risk factors for aspiration (e.g.,
        morbid obesity, diabetes, 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

    -   Solid foods should be avoided in laboring patients

    -   Patients undergoing elective surgery (e.g., scheduled cesarean
        delivery or postpartum tubal ligation) should undergo a fasting
        period for solids of 6--8 hours depending on the type of food
        ingested (e.g., fat content)

    -   Before surgical procedures (i.e., cesarean delivery, postpartum
        tubal ligation), practitioners should consider timely
        administration of nonparticulate antacids, histamine (H~2~)
        receptor antagonists, and/or metoclopramide for aspiration
        prophylaxis

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III. **[Anesthetic Care for Labor and Delivery]{.underline}**

> **Neuraxial Techniques: Availability of Resources**

-   When neuraxial techniques that include local anesthetics are chosen,
    appropriate resources 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 available

-   An intravenous infusion should be established before the initiation
    of neuraxial analgesia or anesthesia and maintained throughout the
    duration of the neuraxial analgesic or anesthetic

-   Administration of a fixed volume of intravenous fluid is not
    required 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 be offered on an
    individualized basis when this service is available

-   Patients may be reassured that the use of neuraxial analgesia does
    not increase the incidence of cesarean delivery

> **Neuraxial Analgesia and Trial of Labor after Previous Cesarean
> Delivery**

-   Neuraxial techniques should be offered to patients attempting
    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 for labor
    analgesia or for anesthesia in the event of operative delivery

> **Early Insertion of Spinal or Epidural Catheter for Complicated
> Parturients**

-   Early insertion of a spinal or epidural catheter for obstetric
    (e.g., twin gestation or preeclampsia) or anesthetic indications
    (e.g., anticipated difficult airway or obesity) should be considered
    to reduce the need for general anesthesia 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\'s request for labor
        analgesia

> **Continuous Infusion Epidural (CIE) Analgesia**

-   The selected analgesic/anesthetic technique should reflect patient
    needs and preferences, practitioner preferences or skills, and
    available resources

-   Continuous infusion epidural 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 concentration of local
    anesthetic, improve the quality of analgesia, and minimize motor
    block

-   Adequate analgesia for uncomplicated labor and delivery should be
    administered with the secondary goal of producing as little motor
    block as possible by using dilute concentrations of local
    anesthetics with opioids

-   The lowest concentration of local anesthetic infusion that provides
    adequate maternal analgesia and satisfaction should be administered

> **Single-injection Spinal Opioids with or without Local Anesthetics**

-   Single-injection spinal opioids with or without local anesthetics
    may be used to provide effective, although time-limited, analgesia
    for labor when spontaneous vaginal delivery is anticipated

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

-   A local anesthetic may be added to a spinal opioid to increase
    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

> **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 continuous infusion epidural for providing
    fewer anesthetic interventions, reduced dosages of local
    anesthetics, and less motor blockade than fixed-rate continuous
    epidural infusions

-   PCEA may be used with or without a background infusion

IV. **[Removal of Retained Placenta]{.underline}**

    -   In general, there is no preferred anesthetic technique for
        removal of retained placenta

        -   If an epidural catheter is in place and the patient is
            hemodynamically stable, epidural anesthesia is preferable

    -   Hemodynamic status should be assessed before administering
        neuraxial anesthesia

    -   Aspiration prophylaxis should be considered

    -   Sedation/analgesia should be titrated carefully due to the
        potential risks of respiratory depression and pulmonary
        aspiration during the immediate postpartum period

    -   In cases involving major maternal hemorrhage, general anesthesia
        with an endotracheal tube may be preferable to neuraxial
        anesthesia

    -   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

        -   Initiating treatment with incremental doses of intravenous
            or sublingual (i.e., metered dose spray) nitroglycerin may
            relax the uterus sufficiently while minimizing potential
            complications (e.g., hypotension)

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V.  **[Anesthetic Choices for Cesarean Delivery]{.underline}**

    -   Equipment, facilities, and support personnel available in the
        labor and delivery operating suite should be comparable to those
        available in the main operating suite

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

        -   Appropriate equipment and personnel should be available to
            care for obstetric patients recovering from major neuraxial
            or general anesthesia

    -   The decision to use a particular anesthetic technique should be
        individualized based on anesthetic, obstetric, or fetal risk
        factors (e.g., elective vs. emergency), the preferences of the
        patient, 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 anesthesia for
        urgent cesarean delivery

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

    -   General anesthesia may be the most appropriate choice in some
        circumstances (e.g., profound fetal bradycardia, ruptured
        uterus, severe hemorrhage, severe placental abruption)

    -   Uterine displacement (usually left displacement) should be
        maintained until delivery regardless of the anesthetic technique
        used

    -   Intravenous fluid preloading may be used to reduce the frequency
        of maternal hypotension after spinal anesthesia for cesarean
        delivery

    -   Initiation of spinal anesthesia should not be delayed to
        administer a fixed volume of intravenous fluid

    -   Intravenous ephedrine and phenylephrine are both acceptable
        drugs for treating hypotension during neuraxial anesthesia

        -   In the absence of maternal bradycardia, phenylephrine may be
            preferable because of improved fetal acid-base status in
            uncomplicated pregnancies

    -   For postoperative analgesia after neuraxial anesthesia for
        cesarean delivery, neuraxial opioids are preferred over
        intermittent injections of parenteral opioids

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VI. **[Postpartum Tubal Ligation]{.underline}**

    -   For postpartum tubal ligation, the patient should have no oral
        intake of solid foods within 6--8 hours of the surgery,
        depending on the type of food ingested (e.g., fat content)

    -   Aspiration prophylaxis should be considered

    -   Both the timing of the procedure and the decision to use a
        particular anesthetic technique (i.e., neuraxial vs. general)
        should be individualized, based on anesthetic risk factors,
        obstetric risk factors (e.g., blood loss), and patient
        preferences

    -   Neuraxial techniques are preferred to general anesthesia for
        most postpartum tubal ligations

        -   Be aware that gastric emptying will be delayed in patients
            who have received opioids during labor and that an epidural
            catheter placed for labor may be more likely to fail with
            longer postdelivery time intervals

    -   If a postpartum tubal ligation is to be performed before the
        patient is discharged from the hospital, the procedure should
        not be attempted at a time when it might compromise other
        aspects of patient care on the labor and delivery unit

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VII. **[Management of Obstetric and Anesthetic
     Emergencies]{.underline}**

     -   Institutions providing obstetric care should have resources
         available 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,
             intraoperative cell-salvage should be considered if
             available

         -   The decision to perform invasive hemodynamic monitoring
             should be individualized and based on clinical indications
             that include the patient\'s medical history and
             cardiovascular risk factors

     -   Labor and delivery units should have personnel and equipment
         readily available to manage airway emergencies, to include a
         pulse oximeter and qualitative carbon dioxide detector,
         consistent with the American Society of Anesthesiologists (ASA)
         Practice Guidelines for Management of the Difficult Airway

         -   Basic airway management equipment should be immediately
             available during the provision of neuraxial analgesia

         -   Portable equipment for difficult airway management should
             be readily available in the operative area of labor and
             delivery units

         -   The anesthesiologist should have a preformulated strategy
             for intubation of the difficult airway

         -   When tracheal intubation has failed, ventilation with mask
             and cricoid pressure, or with a laryngeal mask airway or
             supraglottic airway device (e.g., Combitube^®^, Intubating
             laryngeal mask airway (LMA) \[Fastrach™\]) should be
             considered for maintaining an airway and ventilating the
             lungs

         -   If it is not possible to ventilate or awaken the patient,
             an airway should be created surgically

     -   Basic and advanced life-support equipment should be immediately
         available in the operative area of labor and delivery units

     -   If cardiac arrest occurs during labor and delivery, standard
         resuscitative measures should be initiated

         -   Uterine displacement (usually left displacement) should be
             maintained

         -   If maternal circulation is not restored within 4 minutes,
             cesarean delivery should be performed by the obstetrics
             team

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

Scientific evidence was derived from aggregated research literature, and
opinion-based evidence was obtained from surveys, and other activities
(e.g., Internet postings).

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate anesthesia care for obstetric patients by reducing the
incidence and severity of anesthesia-related complications and
increasing patient satisfaction

#### POTENTIAL HARMS

-   Maternal complications related to epidural or spinal local
    anesthetics include hypotension, systemic toxicity, high spinal
    anesthesia, motor block, and post-dural puncture headache

-   Maternal complications related to epidural or spinal opioids include
    pruritus, nausea and respiratory depression

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

Practice guidelines are systematically developed recommendations that
assist the practitioner and patient in making decisions about health
care. These recommendations may be adopted, modified, or rejected
according to clinical needs and constraints and are not intended to
replace local institutional policies. In addition, practice guidelines
are not intended as standards or absolute requirements, and their use
cannot guarantee any specific outcome. Practice guidelines are subject
to revision as warranted by the evolution of medical knowledge,
technology, and practice. They provide basic recommendations that are
supported by a synthesis and analysis of the current literature, expert
opinion, open forum commentary, and clinical feasibility data.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

#### IMPLEMENTATION TOOLS

Patient Resources

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

American Society of Anesthesiologists Task Force on Obstetric
Anesthesia. Practice guidelines for obstetric anesthesia: an updated
report by the American Society of Anesthesiologists Task Force on
Obstetric Anesthesia. Anesthesiology 2007 Apr;106(4):843-63.
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=17413923)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

1999 (revised 2007 Apr)

#### GUIDELINE DEVELOPER(S)

American Society of Anesthesiologists - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Society of Anesthesiologists

#### GUIDELINE COMMITTEE

Task Force on Obstetrical Anesthesia

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Task Force Members*: Joy L. Hawkins, MD (*Chair*), Denver, Colorado;
James F. Arens, MD, Houston, Texas; Brenda A Bucklin, MD, Denver,
Colorado; Richard T. Connis, PhD, Woodinville, Washington; Patricia A.
Dailey, MD, Hillsborough, California; David R. Gambling, MBBS, San
Diego, California; David G. Nickinovich, PhD, Bellevue, Washington;
Linda S. Polley, MD, Ann Arbor, Michigan; Lawrence C. Tsen, MD, Boston,
Massachusetts; David J. Wlody, MD, Brooklyn, New York; Kathryn J.
Zuspan, MD, Stillwater, Minnesota

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: American Society of
Anesthesiologists. Practice guidelines for obstetrical anesthesia: a
report by the American Society of Anesthesiologists Task Force on
Obstetrical Anesthesia. Anesthesiology 1999 Feb;90(2):600-11.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [Anesthesiology Journal Web
site](http://www.anesthesiology.org/pt/re/anes/asapractice.htm;jsessionid=GydWzG8K24g9Pp2pD423pSTrWBTLNTRWDf2RgnNgQlhWr0DLrLMl!-1734750035!-949856144!8091!-1).

Print copies: Available from the American Society of Anesthesiologists,
520 N. Northwest Highway, Park Ridge, IL 60068-2573.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

The following is available:

-   Planning your childbirth: pain relief during labor and delivery.

Available from the [American Society of Anesthesiologists Web
site](http://www2.asahq.org/publications/pc-143-8-planning-your-childbirth-pain-relief-during-labor-and-delivery.aspx).

Please note: This patient information is intended to provide health
professionals with information to share with their patients to help them
better understand their health and their diagnosed disorders. By
providing access to this patient information, it is not the intention of
NGC to provide specific medical advice for particular patients. Rather
we urge patients and their representatives to review this material and
then to consult with a licensed health professional for evaluation of
treatment options suitable for them as well as for diagnosis and answers
to their personal medical questions. This patient information has been
derived and prepared from a guideline for health care professionals
included on NGC by the authors or publishers of that original guideline.
The patient information is not reviewed by NGC to establish whether or
not it accurately reflects the original guideline\'s content.

#### NGC STATUS

This summary was completed by ECRI on May 31, 1999. The information was
verified by the guideline developer on July 14, 1999. This NGC summary
was updated by ECRI Institute on June 26, 2007. The updated information
was verified by the guideline developer on July 5, 2007.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline that is copyrighted
by the American Society of Anesthesiologists.

### DISCLAIMER

#### NGC DISCLAIMER

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Date Modified: 11/3/2008