Belgian Guidelines and Recommendations for Safe Practice in Obstetric Anesthesia

Prepared by the “Working Party on Obstetric Anesthesia 1”
of the Belgian Association for Regional Anesthesia (BARA)

Presented and approved by the members of the BARA on November 16th 2002

Presented, amended and approved by the boards of the Belgian Professional Association of Specialists in Anesthesia and Resuscitation (BPASAR) and the Society of Belgian Anesthesiology and Resuscitation of Belgium (SBAR)

Presented and approved to the members of the BPASAR at their annual meeting on February 8th 2003.

Purpose of the guidelines.

To enhance the quality of obstetric anesthesia.
To increase patient satisfaction.
To reduce the incidence and severity of anesthesia-related complications.

Classification of scientific validity.

A grade is associated with each guideline, recommendation and assertion to indicate scientific validity.

Grade A: Evidence obtained from at least one properly performed meta-analysis or from a properly performed randomized controlled trial.

Grade B: Evidence obtained from well-designed controlled trials without randomisation or from other types of quasi-experimental studies.

Grade C: Evidence obtained from descriptive studies such as comparative studies, correlation studies, case-control studies and retrospective studies.

Grade D: Opinions of respected authorities in the field or reports of expert committees.

These grades will be associated to each guideline and each assertion as required to indicate scientific validity.

Application of the guidelines.

The guidelines take effect two years after the manuscript has been published in Acta Anaesthesiologica Belgica.

Guideline 1: Pre-anesthetic evaluation.

Assessment.( Grade D)
An evaluation of the parturient takes place before any anesthetic or analgesic obstetric procedure. This evaluation is performed by an anesthesiologist, anesthesia resident in training or any other physician of the department of anesthesiology.
- In compliance with the National Order of Physicians rulings, the entire parturients file is available in due time to the attending anesthesiologist.
- If the parturient has no significant medical (ASA Physical Status classification I or II)2 , surgical or obstetrical history, pre-anesthetic evaluation, including a history and physical examination, may be performed just prior to an anesthetic intervention.
- The obstetrician has to inform the anesthesia team as soon as possible if the parturient has a significant medical (ASA Physical Status classification III, IV or V), surgical or obstetrical history.

Laboratory tests.( Grade D)
In the absence of any significant medical (ASA Physical Status classification I or II), surgical or obstetrical history and in the absence of a history of coagulation disorders, no routine laboratory screening tests, even no coagulation tests, are required.
- A new platelet count is not necessary in normal pregnancies if the platelet count is normal during the third trimester of pregnancy.
- In case of Cesarean section, anticipated hemorrhagic complications, or history suggestive of previous allo-immunization, a type and screen is required.

Informed consent. (Grade D)
During the antenatal period, objective information, including benefits and risks, regarding obstetric anesthesia and analgesia is available to parturients. The parturient should be offered the possibility to receive more in depth information from an anesthesiologist.

Guideline 2: Equipment.

A labor and delivery ward includes labor rooms (for the first stage of labor) and delivery rooms (for the second stage of labor). Labor and delivery rooms can be combined.

An operating room is available around the clock for Cesarean sections and obstetric emergencies. It must be possible to deliver the baby within a reasonable time from the decision to perform a Cesarean section. (Grade D)

Labor and/or delivery rooms are equipped with: (Grade D)

- Oxygen wall outlets (at least two in the delivery room).
- Suction.
- Emergency call system to summon an attending physician.
- Adequate lighting.
- Electric power points.

Each labor and delivery room is equipped with electronic fetal heart rate (FHR) monitoring. For maternal monitoring a non-invasive blood pressure monitor is available in each labor and delivery room. A continuous pulse oxymeter and heart rate monitor for maternal monitoring are readily available in the labor and delivery ward. (Grade D)

Any operating room used for Cesarean sections is equipped with the same quality of anesthetic equipment as available in operating rooms as detailed in the most recent Belgian Standards for Patient Safety in Anesthesia 3: this includes appropriate equipment to deal with difficult intubation. (Grade D)

A fully equipped resuscitation cart is readily available on the labor and delivery ward. Uterine displacement equipment, to induce left lateral tilt, is also readily available. (Grade D)

Routine control and maintenance of the technical equipment in the delivery suite is performed similar to that of a standard operating room. (Grade D)

Guideline 3: Sterile technique.

To perform a central neural blockade, the parturient is prepared with an antiseptic solution that should be left to dry for at least two minutes. (Grade A)
Antiseptic solutions should not be present on the regional anesthesia tray. (Grade D)

All injectable solutions are identified by a skilled professional and are aspirated from the original bottle in a sterile manner. (Grade B)

The anesthesiologist wears a new facemask and a cap (Grade B), washes his/her hands with antiseptic solution or soap (Grade A) and wears sterile gloves. (Grade D)
Sterile drapes delineate a sterile field. (Grade D)
It is recommended that the nurse, midwife or any other skilled person helping the anesthesiologist wears a mask and a cap. (Grade B)

It is a recommended option to use disposable equipment only. (Grade D)

Guideline 4: Anesthetic staffing and availability.

Obstetric anesthesia is performed by an anesthesiologist.
Specialists in training are supervised by such a person according to their level of training and proficiency. (Grade D)

Regional analgesia.
Following initiation of regional analgesia an anesthesiologist remains available for at least 30 minutes. (Grade D)
- After initiation of labor analgesia or after administration of subsequent top-ups, the anesthesiologist stays in the near proximity of the parturients until she is relieved from her pain, maternal vital parameters are stable and fetal heart rate remains reassuring.
- In case of continuous infusion or Patient Controlled Epidural Analgesia (PCEA), the parturient is visited and checked hourly. This task can be delegated to a skilled person (including midwife) having experience in labor analgesia. During these visits the state of the blockade and quality of analgesia are assessed and recorded on the parturients charts.
- Visiting the parturient only when called is insufficient.
Moving the parturient to the operating theatre to initiate labor analgesia is discouraged. (Grade D)

Only strategies to relieve maternal pain initiated by the anesthesiologist are his/her responsibility. When epidural analgesia is initiated, additional forms of labor pain relief are only started following order of the attending anesthesiologist. (Grade D)

Cesarean section.
To be ready for a urgent Cesarean section, at any time, an anesthesiologist and appropriate staffing is readily available to allow delivery of the foetus within a reasonable time from being called. (Grade D)
For Cesarean section the same standards and guidelines should be applied as those existing for any operative procedure under anesthesia as detailed in the most recent Belgian Standards for Patient Safety in Anesthesia 4. (Grade D)

Emergency.
When, in case of an emergency maternal or fetal problem, the anesthesiologist is already involved in another procedure, then he/she will designate a skilled person who will ensure the surveillance of one of the two patients to the exclusion of any other activity during his/her absence. This surveillance remains the sole responsibility of the anesthesiologist in charge of the patient. (Grade D)

Guideline 5: Midwifery tasks.

Analgesia.
Midwives and anesthesiologists should agree a hospital policy for maintenance of epidural analgesia and publish it as a written procedure defining the anesthesia care acts that can be delegated to the midwives. This text is regularly updated and must be available to all concerned. (Grade D)

Midwives assist the anesthesiologist in preparing and performing the block. Midwives provide continuous care and monitoring of mother and foetus, during the central neural blockade. (Grade D)
Midwives and obstetricians remain responsible for monitoring foetal well-being prior, during and after initiation of the regional block. (Grade D)
- The midwife monitors maternal blood pressure and heart rate as well as fetal heart rate prior to and after initiation of regional analgesia.
- It is part of specific midwife expertise to monitor the course of analgesia including assessment of the spread and quality of analgesia, detection of adverse reactions and initiation of their treatment according to existing protocols; monitor the vital signs of both the parturient and foetus; perform hourly assessment of the sensory and motor block and determination of the upper sensory level.
- Clear individualised medical prescriptions are included in the patient’s file, which contains orders to the midwife.

Anesthesia.
If midwifes have to assist on a routine basis Cesarean sections, they must be trained to help the anesthesiologist in administering regional and general anesthesia for that procedure. During surgery the midwifery staff should be available to help or assist the anesthesiologist. Supervising a parturient in the early postoperative phase and evaluating discharge criteria to the ward are also part of the normal tasks delegated to the midwife. (Grade D)

Education of midwifes.
Pain is naturally a part of childbirth. Analgesia is its modern counterpart. The raison d’être of midwifery is to accompany childbirth. Therefore understanding the mechanisms and treatment of pain, and their practice, is part of modern midwifery. Obstetric anesthesia and analgesia must be part of their formal education, training, and continuous postgraduate education. Midwives assist anesthesiologists on a regular basis in order to ensure maintenance of their competence. (Grade D)
Quality of anesthesia care on an obstetric service is monitored on a regular basis and the guidelines concerning the midwife’s acts, involving anesthesia care, are regularly evaluated and updated. (Grade D)

Guideline 6: Monitoring of mother and foetus during regional labor analgesia.

Before initiation of regional analgesia.
Prior to the initiation of the regional block, fetal heart rate should be recorded by a midwife or an obstetrician. This recording is examined and found satisfactory by midwife or obstetrician.
An intravenous infusion is initiated prior to initiation of regional analgesia.
Maternal blood pressure and heart rate are measured and recorded at least once less than 30 minutes before establishing analgesia. (Grade D)

While performing the neuraxial blockade, fetal heart rate monitoring may be interrupted providing midwife or obstetrician agree. (Grade D)

After initiation of regional analgesia.
Maternal vital signs (at least blood pressure and heart rate) are monitored non-invasively and recorded at least every 5 minutes for at least 30 minutes and until these parameters are stable.
Fetal heart rate is monitored and recorded continuously for at least 30 minutes following the start of regional blockade. (Grade D)
A skilled person (obstetrician or midwife) monitors the fetal heart rate either in the labor room (if central monitoring is absent) or in the labor and delivery area (if central monitoring is present). (Grade D)
The lateral position is encouraged during labor.

Maintenance of analgesia.
If an epidural continuous infusion or patient controlled epidural analgesia is used, vital signs (hemodynamics and consciousness) are monitored and recorded hourly.
If analgesia is maintained by intermittent top-ups, maternal vital signs (at least blood pressure and heart rate) are monitored non-invasively and recorded at least every 5 minutes for 30 minutes after the top-up. Fetal heart rate is recorded continuously for at least 30 minutes following the bolus top-up. (Grade D)
A skilled person (obstetrician or midwife) monitors the fetal heart rate either in the labor room (if central monitoring is absent) or in the labor and delivery area (if central monitoring is present). (Grade D)

Guideline 7: Monitoring during anesthesia for Cesarean section.

Maternal monitoring.
Maternal monitoring during anesthesia for Cesarean section is similar to that advised for any surgical procedure by the Belgian Standards for Patient Safety in Anesthesia 5 (3). (Grade D)
During Cesarean section, a 30º or more (left) lateral tilt is the rule. (Grade B).

Guideline 8: Ambulation.

Epidural analgesia does not contraindicate maternal ambulation during labor provided certain rules are followed.
ASA I and II parturients, which do not require continuous FHR monitoring, can be allowed to ambulate. Other parturients can be allowed to be mobile provided fetal heart rate can be continuously monitored by telemetry. (Grade D)
If ambulation is allowed, the mother should not leave the labour and delivery ward.
Whilst ambulation the mother must be accompanied by a responsible adult (partner, family, midwife, etc…) (Grade D)
Ambulation can be allowed if the following conditions are met: (Grade D)

a. Fetal heart rate monitoring is reassuring during the first 30 minutes after initiation of analgesia.
b. The parturients ability to be mobile is assessed by the midwife or anesthesiologist based on a protocol which has been pre-decided on by the anesthesia department.
c. Midwives and obstetricians do not object to ambulation in this specific patient.
Ambulation is contraindicated during the second stage of labor. (Grade D)

Guideline 9: Fluid intake, NPO-policy and aspiration prophylaxis.

It must be kept in mind that ALL pregnant women from the second trimester on are at risk of inhaling gastric contents and thus aspiration. (Grade B and D)

Labor.
Clear liquids 6 can be consumed during labor in uncomplicated patients. (Grade B)
When the parturient is in active first stage labor solid foods and non-clear liquids are not allowed. (Grade D)

Cesarean section.
Before elective Cesarean section clear liquids can be consumed until two hours prior to the start of anesthesia. (Grade B)
Solid food or non-clear liquids should be banned for at least six hours before an elective Cesarean section. (Grade D)
Aspiration prophylaxis is mandatory for elective and emergency Cesarean section. (Grade B)

Guideline 10: Cesarean section.

Choice of anesthetic technique.
Unless there are contraindications, regional anesthesia is the recommended option for elective Cesarean section. (Grade B)
The decision to use general anesthesia or a regional technique should be individualized based on anaesthetic, obstetric (e.g. elective versus urgent) and fetal risk factors and the preferences of the patient. General anesthesia is not induced until the surgeon is scrubbed and ready. (Grade D)

Availability.
The time interval between the decision to perform an urgent caesarean section and the delivery of the baby should be reasonable provided the anesthesiologist is informed as early as possible following the decision to perform an operative delivery. (Grade D)

Antibiotics.
Prophylactic antibiotics are the issue of a hospital policy which should be agreed on by obstetricians and anesthesiologists. They can be administered during elective or emergent Cesarean section. (grade A).

Operating room.
The location for elective and urgent caesarean section is dependent from hospital to hospital.
In any case the room should be fully equipped to the standards described for operating theatres in the Belgian Standards for Patient Safety in Anesthesia 7. Operating department or midwifery staff trained to assist the anesthesiologist should be available throughout the procedure. A fully equipped and staffed recovery area is necessary. (Grade D)
A 30° or more left lateral tilt is maintained during Cesarean section. (Grade D)

Paternal presence – Multimedia.
The presence of an accompanying person and the use of multimedia recordings depends on the individual hospital policy. (Grade D)
During elective Cesarean delivery under regional anesthesia paternal presence should be allowed, provided the obstetrician agrees. (Grade D)

Guideline 11: Maternal and neonatal resuscitation.

Maternal resuscitation.
Whenever present, the anesthesiologist directs maternal resuscitation in a shared effort with the obstetric team. (Grade D)

Neonatal resuscitation.
Neonatal resuscitation is the responsibility of the paediatrician whenever his/her presence during delivery is legally mandatory. If the anesthesiologist judges that the mother requires immediate care, he/she cannot be held responsible for the neonate. He/she may, based on individual judgement, assist briefly in neonatal resuscitation, only after having weighed the benefit of the newborn against the risk to the mother and only when the care for the mother has been transferred to a skilled person who will perform this task to the exclusion of any other. (Grade D)

Guideline 12: High-risk pregnancies.

High-risk pregnancies include all pregnancies, which fall in one of the following categories: (Grade D)

a. Hypertension, more in particular preeclampsia.
b. Preterm labor.
c. Preterm rupture of membranes.
d. Maternal associated disease resulting in ASA class status III or IV.
e. Antepartum obstetric haemorrhage.
f. Fetal growth restriction.
g. Twin or multiple pregnancy.
h. Breech delivery.
i. Vaginal delivery after previous Cesarean section.
j. Any conditions which increases the likelihood of a (semi-) urgent Cesarean section.
k. Any conditions which complicate the safe institution of a regional block (anticoagulation, previous back surgery, etc…), any conditions which can be associated with problematic tracheal intubation or any disease associated with increased sensitivity to any drug.
l. Chorioamnionitis.

The anesthesiologist should be informed immediately after admission of a high risk parturient.
The anesthesiologist, obstetrician, midwife and paediatrician establish a concerted plan of action. Communication is of supreme importance. A multidisciplinary approach is essential. (Grade D)

It is advisable to establish regional analgesia early in the course of labor in the absence of contraindications. (Grade D)

Centers caring for high-risk pregnancies (Maternal Intensive Care units (MIC)) should feature facilities to establish prolonged neonatal care and maternal intensive care. It is a recommended option that at least one anesthesiologist acquires experience in obstetric anesthesia. Invasive monitoring equipment is available in the delivery suite whenever potentially unstable parturients are present. (Grade D)
High risk pregnancies can only be managed by an anesthesiologist or an in-training anesthesiologists under direct supervision of an anesthesiologist. (Grade D).

An anesthetic management protocol should be established for each type of high-risk pregnancy by the anesthesia department. It is advised to write down an individual anesthetic plan as soon as possible and preferably well in advance of the delivery. (Grade D)

References.

References related to classification of scientific validity.
1. Pedersen T, Moller AM. How to use evidence-based medicine in anesthesiology. Acta Anaesth Scand 2001; 45, 267 – 274.
2. Benhamou D, Mercier FJ, Dounas M. Hospital policy for prevention of infection after neuraxial blocks in obstetrics. Int J Obstet Anesth 2002; 11, 265 – 269.

References related to guideline 1.
1. American Society of Anesthesiologists (ASA) Task Force on Obstetrical Anesthesia. Practice Guidelines for Obstetrical Anesthesia. Anesthesiology 1999; 90, 600 – 611.
2. The Association of Anaesthetists of Great Britain and Ireland and the Obstetric Anaesthetists Association. Guidelines for Obstetric Anaesthesia Services. 1998.

References related to guideline 2.
1. The Belgian Anesthesia Patient Safety Steering Committee. Belgian Standards for Patient Safety in Anesthesia. Acta Anaesthesiologica Belgica 2001; 52, 2, 173 – 180.
2. ASA House of Delegates 1988, last amended 2000. Guidelines for Regional Anesthesia in Obstetrics. www.asahq.org/standards/11.
3. OAA working party 1995. Recommended minimum standards for obstetric anaesthesia services.
4. Joint Statement by the ASA and American College of Obstetricians (ACOG). Optimal goals for anesthesia care in obstetrics. Appendix C, p. 679. Anesthesia for Obstetrics, editors Hughes, Levinson and Rosen.
5. American Society of Anesthesiologists (ASA) Task Force on Obstetrical Anesthesia. Practice Guidelines for Obstetrical Anesthesia. Anesthesiology 1999; 90, 600 – 611.
6. The Association of Anaesthetists of Great Britain and Ireland and the Obstetric Anaesthetists Association. Guidelines for Obstetric Anaesthesia Services. 1998.

References related to guideline 3.
1. Benhamou D, Mercier FJ, Dounas M. Hospital policy for prevention of infection after neuraxial blocks in obstetrics. Int J Obstet Anesth 2002; 11, 265 – 269.

References related to guideline 4.
1. The Belgian Anesthesia Patient Safety Steering Committee. Belgian Standards for Patient Safety in Anesthesia. Acta Anaesthesiologica Belgica 2001; 52, 2, 173 – 180.
2. Joint Statement by the ASA and American College of Obstetricians (ACOG). Optimal goals for anesthesia care in obstetrics. Appendix C, p. 679. Anesthesia for Obstetrics, editors Hughes, Levinson and Rosen.
3. OAA working party 1995. Recommended minimum standards for obstetric anaesthesia services.

References related to guideline 5.
1. OAA working party 1995. Recommended minimum standards for obstetric anaesthesia services.
2. Joint Statement by the ASA and American College of Obstetricians (ACOG). Optimal goals for anesthesia care in obstetrics. Appendix C, p. 679. Anesthesia for Obstetrics, editors Hughes, Levinson and Rosen.

References related to guideline 6.
1. ASA House of Delegates 1988, last amended 2000. Guidelines for Regional Anesthesia in Obstetrics. www.asahq.org/standards/11.
2. OAA working party 1995. Recommended minimum standards for obstetric anaesthesia services.
3. The Association of Anaesthetists of Great Britain and Ireland and the Obstetric Anaesthetists Association. Guidelines for Obstetric Anaesthesia Services. 1998.

References related to guideline 7.
1. The Belgian Anesthesia Patient Safety Steering Committee. Belgian Standards for Patient Safety in Anesthesia. Acta Anaesthesiologica Belgica 2001; 52, 2, 173 – 180.
2. OAA working party 1995. Recommended minimum standards for obstetric anaesthesia services.

References related to guideline 8.
1. Plaat F. Ambulatory analgesia in labour. Chapter 7, p. 101 – 111, in Textbook of Obstetric Anaesthesia, editors Collis R, Plaat F, Urquhart J.

References related to guideline 9.
1. Simpson KH, Stakes AF, Miller M. Pregnancy delays paracetamol absorption and gastric emptying in patients undergoing surgery. Brit J Anaesth 1988; 60, 24 – 27.
2. Wong CA, Loffredi M, Ganchiff JN, Zhao J, Wang Z, Avram MJ. Gastric emptying of water in term pregnancy. Anesthesiology 2002; 96, 1395 – 1400.
3. Colman RD, Frank M, Loughnan BA, Cohen DG, Cattermole R. Use of IM ranitidine for the prophylaxis of aspiration pneumonitis in obstetrics. Brit j Anaesth 1988; 61, 7201.

References related to guideline 10.
1. Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesia-related deaths during obstetric delivery in the United States, 1979 – 1990. Anesthesiology 1997; 86, 277 – 284.
2. The Belgian Anesthesia Patient Safety Steering Committee. Belgian Standards for Patient Safety in Anesthesia. Acta Anaesthesiologica Belgica 2001; 52, 2, 173 – 180.
3. OAA working party 1995. Recommended minimum standards for obstetric anaesthesia services.
4. American Society of Anesthesiologists (ASA) Task Force on Obstetrical Anesthesia. Practice Guidelines for Obstetrical Anesthesia. Anesthesiology 1999; 90, 600 – 611.
5. Joint Statement by the ASA and American College of Obstetricians (ACOG). Optimal goals for anesthesia care in obstetrics. Appendix C, p. 679. Anesthesia for Obstetrics, editors Hughes, Levinson and Rosen.
6. The Association of Anaesthetists of Great Britain and Ireland and the Obstetric Anaesthetists Association. Guidelines for Obstetric Anaesthesia Services. 1998.

References related to guideline 11.
1. Joint Statement by the ASA and American College of Obstetricians (ACOG). Optimal goals for anesthesia care in obstetrics. Appendix C, p. 679. Anesthesia for Obstetrics, editors Hughes, Levinson and Rosen.

References related to guideline 12.
1. Joint Statement by the ASA and American College of Obstetricians (ACOG). Optimal goals for anesthesia care in obstetrics. Appendix C, p. 679. Anesthesia for Obstetrics, editors Hughes, Levinson and Rosen.

Notes

1 Working party on obstetric anesthesia of the BARA:
Prof. Dr. Brichant, Dr. Bruskin, Dr. De Swaef, Dr. Gautier, Dr. Lechat, Dr. Roelants, Dr. Soetens, Prof. Dr. Van de Velde, Dr. Van Houwe, Prof. Dr. Vercauteren.
Coordination and editorial work: Prof. Dr. Van de Velde – Prof. Dr. Vercauteren.

2 ASA Physical Status classification: ASA I: healthy patient; ASA II: mild systemic disease – no functional limitations; ASA III: severe systemic disease – definite functional limitations; ASA IV: severe systemic disease that is a constant threat to life; ASA V: moribund patient not expected to survive 24 hours with or without surgery or treatment.

3 Belgian Standards for Patient Safety in Anesthesia; The Belgian Anesthesia Patient Safety Steering Committee, Acta Anaesthesiologica Belgica 2001; 52, 2, 173 – 180.

4 Belgian Standards for Patient Safety in Anesthesia; The Belgian Anesthesia Patient Safety Steering Committee, Acta Anaesthesiologica Belgica 2001; 52, 2, 173 – 180.

5 Belgian Standards for Patient Safety in Anesthesia; The Belgian Anesthesia Patient Safety Steering Committee, Acta Anaesthesiologica Belgica 2001; 52, 2, 173 – 180.

6 Clear liquids are all liquids which do not contain solid material. Clear liquids are water, tea, pulp-free fruit juice, carbonated drinks, sport drinks. The following drinks are NOT considered to be clear liquids: milk, pulp-containing fruit juice and alcoholic beverages.

7 Belgian Standards for Patient Safety in Anesthesia; The Belgian Anesthesia Patient Safety Steering Committee, Acta Anaesthesiologica Belgica 2001; 52, 2, 173 – 180.