Wilkins, Karen K. MD; Greenfield, Mary Lou V. H. MPH, MS; Polley, Linda S. MD; Mhyre, Jill M. MD
Section Editor(s): Wong, Cynthia A.
Cesarean delivery is the most common surgical procedure in the United States.1 In 2006, more than 1.3 million US women required postanesthesia care after cesarean delivery.2 Postanesthesia recovery after cesarean delivery may be complicated by hypotension, airway obstruction, or hemorrhage, among other physiological derangements.
Safe postanesthesia recovery depends on continuous surveillance as well as timely and appropriate interventions to support patients experiencing complications. The American Society of PeriAnesthesia Nurses (ASPAN) defines Standards of Perianesthesia Nursing Practice to help guide postanesthesia care.3,4 These guidelines are intended to assure patient safety and uniform quality of care during postanesthesia recovery in all locations.
Multiple national credentialing organizations and professional associations support the concept that standards should be uniformly applied throughout a care facility. The Joint Commission (JC) requires that patients with comparable needs receive the same standard of care, treatment, and services throughout the hospital.5 The American Society of Anesthesiologists (ASA) Task Force on Postanesthetic Care Guidelines apply to all patients, regardless of the location of their recovery, who are recovering from general anesthesia, neuraxial anesthesia, or moderate to deep sedation.6 A joint statement from the ASA and the American College of Obstetricians and Gynecologists recommends that the equipment, facilities, support personnel, and care provided in the obstetric operating rooms and recovery areas be equivalent to that provided in main surgical areas.* This recommendation was reiterated in the ASA Practice Guidelines for Obstetric Care.7
The Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) standards do not specifically address postanesthesia care.8 With respect to postanesthetic care, the AWHONN textbook, Perinatal Nursing, states that “Comparable care to that which is provided in the main hospital surgical department is recommended by ASA … and [JC] …; however, equivalent care is not required. The special needs of obstetrical patients, their babies and their families must be considered when planning care and designing protocols and practices.”9
The purpose of this study was to identify the current level of recovery care for obstetric patients in North American academic institutions after either general or neuraxial anesthesia for cesarean delivery.
This study was approved by the IRB at the University of Michigan Health System. The names and contact information for the anesthesia department chairs of North American academic institutions were obtained from Internet websites.†‡ The websites for these departments were reviewed and the name and e-mail contact for the obstetric anesthesia directors were obtained. When the name of the obstetric anesthesia director could not be determined from the website, the anesthesia department chair was contacted by e-mail to obtain this information.
An e-mail was sent to the 136 obstetric anesthesia directors of North American academic institutions, with one e-mail address undeliverable, resulting in 135 delivered surveys. The e-mail contained a link to a short electronic survey. The survey was designed by the authors who consulted with a past president of ASPAN and a birthing center nurse manager (both from the University of Michigan Health System) to address key elements of care recommended in relevant ASA and ASPAN policy statements. The survey was reviewed by the authors and study consultants for face validity but was not formally validated. A copy of the survey is available as a Web Appendix (available at www.anesthesia-analgesia.org). The electronic survey directed respondents through a question hierarchy that did not necessarily include all 31 questions. Two weeks later, all nonresponders received a reminder e-mail containing the electronic link. The questions were completed confidentially and anonymously. In all cases, completion of the survey implied consent.
Upon initial review of the data from the first 29 respondents, it was discovered that the electronic question hierarchy failed to direct a subset of responders to complete three key questions regarding delivery center volume. After IRB amendment approval, this error was corrected in the survey. An e-mail letter was sent to the affected responders explaining the error and providing an electronic link to their original survey, which had been reformatted so that the key questions regarding delivery center volume could be answered.
The statistical analysis was designed to explore the level of recovery care for obstetric patients in academic institutions after general or neuraxial anesthesia for operative delivery. Univariate statistics (frequency counts, percentages, medians, means, standard deviations, ranges) were used to characterize survey results. Bivariate analyses were used to explore relationships between perceived quality of care and variables, such as delivery census, staffing patterns, staff education, and resuscitation certification; specifically, the χ2 goodness of fit test for proportions, the Pearson χ2 test, or the Fisher’s exact test was used, as appropriate. A P value of 0.05 indicated a relationship for future study. All data were analyzed using SAS 9.1.2 (SAS Institute, Cary, NC).
Seventy-Four of 135 Distributed Surveys were Completed, Representing a 55% Response Rate
Respondents had completed a median number of 18 yr since residency (range, 2–34), and 81% (54 of 67) spent at least 50% of their clinical time in obstetrics. The geographic locations of survey recipients and respondents are shown in Table 1. There was no statistically significant difference in geographic distribution between responders and survey recipients. The median number of deliveries per year was 2550 (interquartile range [IQR] 2000, 4000), the median proportion of cesarean deliveries per year was 30% (IQR 26%, 33%), and the median proportion of cesarean deliveries completed under general anesthesia was 5% (IQR 4%, 8%) (60 responses).
Ninety-seven percent of institutions (72 of 74) performed cesarean deliveries in an obstetric surgery suite. Most institutions recovered postcesarean patients in an obstetric perianesthesia care unit (PACU) or a labor, delivery, and recovery room (LDR) after both neuraxial (97% [72 of 74]) and general anesthesia (96% [71 of 74]) (Table 2).
Most institutions reported that perinatal nurses provide postanesthesia nursing care for patients recovering from cesarean deliveries performed under either neuraxial or general anesthesia (Table 3). In 12% of institutions (8 of 68), dedicated PACU nurses work along side, or in place of, perinatal nurses. In one institution, patients recover from neuraxial anesthesia in a LDR staffed by perinatal nurses and from general anesthesia in a general surgical PACU. Nurse-to-patient ratios for patients recovering from cesarean deliveries are shown in Table 4. The minimum educational requirements for postanesthesia nursing care providers are presented in Table 5. Forty-five percent of institutions do not require any training specific to postanesthesia nursing care; however, 92% of institutions (57 of 62) require either Basic Life Support (BLS) certification, Advanced Cardiac Life Support (ACLS) certification, or some form of postanesthesia recovery training.
Eighty-four percent of institutions (56 of 67) have at least one dedicated anesthesia provider (anesthesiologist or nurse anesthetist) who has no other patient care responsibilities and who is assigned to the obstetric unit 24 h a day. In all responding institutions, (67) attending anesthesiologists assigned to the obstetric unit performed in-house (in-hospital) call.
Recovery nurses in all reporting institutions monitor vital signs and support patient comfort as part of routine postoperative care. In 79% of institutions (54 of 68), nurses providing recovery care after general anesthesia assume additional responsibilities, including normal newborn care, breastfeeding support, or care for additional obstetric or neonatal patients (Table 6). Physiological variables routinely monitored after neuraxial and general anesthesia for cesarean delivery are shown in Table 7.
Potential Interruptions of Care
A number of situations may require the postanesthesia nurse to move to a position that is out of direct vision from the patient (Table 8). In 63% of institutions (45 of 72), the nurse leaves the bedside to obtain medications, monitoring equipment or equipment to start an additional IV line. In 11% of institutions, the nurse leaves the patient to complete case charting and documentation. In the event of a cardiopulmonary arrest, a facemask and an Ambu bag or other device to deliver positive pressure ventilation are available in the same room as the patient in approximately 85% of centers (Table 9).
Formal discharge criteria have been established in 93% of responding institutions (63 of 68). Either an anesthesiologist assisted in developing these discharge criteria (n = 59) or the respondent did not know who had developed the discharge criteria (n = 4). Other personnel who helped to develop recovery area discharge criteria included an obstetrician (in 29% of responding institutions in which the respondent knew who had developed the criteria [17 of 59]), a perinatal nurse (37% [22 of 59]), a dedicated PACU nurse (14% [8 of 59]), and a nurse manager (54% [32 of 59]).
Quality of Care
When asked to compare the quality of anesthetic recovery care provided to cesarean delivery patients with the care given to general surgical patients, 3% of respondents reported better quality (2 of 67), 54% reported the same quality (36 of 67), 39% reported lower quality (26 of 67), and 4% reported cause for concern (3 of 67). Respondents who relied solely on perinatal nurses to provide postanesthesia care were more likely to indicate that their perceived postanesthetic care for cesarean delivery was of lower quality or cause for concern compared with that given to general surgery patients (Fisher’s exact test, P = 0.008).
Although obstetric patients are generally healthy, advanced maternal age, obesity, and multifetal pregnancy1,10–12 may increase risk for complications, including cesarean delivery, postpartum hemorrhage, pregnancy-associated hypertension, and maternal death.6,13–20 Anesthesia-related maternal deaths from airway obstruction, hypoventilation, and hemorrhage have been reported during postanesthesia recovery from both general and neuraxial anesthesia.21,22 The incidence of airway obstruction in the nonobstetric PACU has been reported between 4% and 7%23,24; the rate of respiratory arrest in one study was 0.05%.25 Postpartum maternal hemorrhage complicates approximately 4% of cesarean deliveries.26 Hemorrhage may lead to maternal death or major morbidity if recognition or management is delayed.21,22 An additional concern is that general anesthesia for obstetric surgery is becoming less frequent,27 decreasing the opportunities for perinatal nurses to maintain skills in postgeneral anesthesia care.
Prior surveys have suggested that there may be opportunities for improvement in obstetric PACUs. In a 1991 survey of Michigan hospitals,28 67% of responders rated the level of patient care in their obstetric PACU as “cause for concern.” A 2005 survey conducted in the United Kingdom concluded there was often a disparity between obstetric recovery practice and the recommended guidelines published by the Association of Anesthetists of Great Britain and Ireland (AAGBI).29 For example, although AAGBI guidelines state that all recovery staff should be trained in BLS, only 54% of nondedicated recovery staff were certified in BLS.29
A comparison between our survey results and ASPAN standards points to several areas in which routine obstetric PACU care seems to differ from current standards. Phase I postanesthesia care focuses on providing a transition from a totally anesthetized state to one requiring less acute interventions.30,31 ASPAN Standard III recommends that one nurse competent in Phase I postanesthesia care be responsible for the direct care of the patient.32,33 ASPAN′s recommended competencies for the perianesthesia nurse include BLS, ACLS, airway management, and electocardiograph (ECG) interpretation, among other competencies.34,35 Postanesthesia competence checklists for perinatal nurses have been published36,37 but do not seem to be widely adopted in obstetric PACUs.
Almost 20% of institutions require neither BLS nor ACLS certification. It is difficult to conceive of a care system in which nursing staff could rely on other personnel to perform BLS while awaiting the arrival of a resuscitation team. Therefore, in our opinion, BLS certification is almost certainly warranted.
The requirement for ACLS certification is controversial. According to the AWHONN text book, Perinatal Nursing, “An ACLS course is not required for obstetrical nurses providing perioperative care as long as a team with these skills is available to respond to provide emergent care for an obstetrical patient if needed within a timely manner.”9 In contrast, ASPAN recommends that for adult patients, the “… perianesthesia nurse providing Phase I level of care will maintain a current ACLS … provider status …”32,33 Among other benefits, ACLS certification increases a caregiver’s ability to evaluate abnormal cardiac rhythms. Based on one study, patients with a malignant rhythm identified by an ACLS-certified nurse were four times more likely to survive than patients discovered by a nurse without ACLS training.38
In the nursing literature, some authors have questioned the value of ECG monitoring in the obstetric PACU.9,39 According to the ASA postanesthesia guidelines, “… there are certain categories of patients or procedures for which routine electrocardiographic monitoring may not be necessary.”6 However, “… electrocardiographic monitors should be immediately available.”6 ECG interpretation can be problematic in obstetric PACUs in which nurses are not ACLS certified. It is possible that some centers provide alternative training in ECG monitoring or use telemetry services to monitor the ECG rhythms remotely.
According to the ASPAN staffing guidelines, there should be a ratio of one nurse to two patients (who are conscious, stable, and free from complications) during Phase I recovery.30,31 AWHONN, in its official textbook, agrees that “… when the recovery nurse is [also] responsible for the newborn, the 1:2 care limit is met.”9 If interpreting a mother and her neonate as two distinct patients, 10% of responding institutions in our survey fail to satisfy this staffing standard.
The ASA standards for postanesthesia care state that the “… patient’s condition shall be evaluated continually in the PACU.”§ According to the AWHONN textbook, Perinatal Nursing, “… in settings where the postoperative patient returns to an LDR … after surgery, the perinatal nurse remains at the bedside until … the patient is stable and discharged from postanesthesia care.”9 During this period, “she shall be continually observed and monitored by methods appropriate to her medical condition.”9,36 To ensure continuous observation, ASPAN recommends that two registered nurses, one competent in Phase I postanesthesia nursing, should remain in the room where the patient is receiving Phase I level of care.30,31,40,41 In the interest of patient privacy and because of low surgical volume, obstetric patients frequently recover in isolation. The requirement for a second nurse effectively increases the nurse-to-patient ratio to two nurses for each woman. Such a high nursing ratio may not be practical given the current shortage of registered nurses. Alternative systems can ensure that at least one nurse competent in Phase I postanesthesia care is able to stay with the patient throughout the postanesthesia recovery period. For example, medications and equipment can be stored at the bedside or delivered to the nurse upon request; case charting and documentation can be completed at the bedside. Such systems appear lacking in many of the surveyed centers (Table 8).
In a list of resuscitation equipment for Phase I level of care, ASPAN recommends that each “… patient bedside will be equipped with … various types and sizes of artificial airways, various means of oxygen delivery, constant, and intermittent suction …” among other resources.42,43 Our survey found that suction was not located in the same room in more than 40% of centers. A facemask and Ambu bag were not in the same room in approximately 15% of centers.
There are several limitations to this study. The sample size is small, the response rate was low, and the survey examined academic centers only. The responding institutions were geographically representative of the US but not of Canada. Despite the anonymous nature of the survey there is the potential for responder bias. Some of the data could be “best guess” answers if the obstetric division director did not know the details about nursing training requirements. A higher quality study would either survey nursing administrators or examine actual clinical policy rather than understood policy, or both. Finally, the survey excluded a variety of topics, including airway management, malignant hyperthermia, training in ECG interpretation, telemetry for remote ECG monitoring, the number of nurses required to stay in the same room with the patient during Phase I recovery, and the actual distance to resuscitation equipment.
In addition to these specific limitations, a more fundamental concern is that perianesthesia nursing standards are primarily based on expert and consensus opinion. Recent case series have included maternal deaths from postanesthesia airway obstruction or postpartum hemorrhage21,22; however, a robust implementation of ASPAN standards may or may not prevent such deaths in the future.
Postanesthesia recovery from cesarean delivery is unique in that general anesthesia is rare, patients are typically healthy, a neonate and family members are usually present, attachment and breastfeeding are additional goals, surgical volume is limited, women often recover in isolation, and care is provided primarily by perinatal nurses. Given these unique challenges, a careful reconciliation between ASPAN standards and obstetric postanesthesia care is required. In our opinion, future efforts to enhance patient safety during obstetric postanesthesia recovery should rigorously define the optimal postanesthesia curriculum for perinatal nurses, establish a requirement for BLS certification, evaluate the role of ACLS certification, evaluate the costs and benefits of continuous ECG monitoring by qualified personnel, and establish environmental and staffing solutions to ensure continuous bedside monitoring during the obstetric postanesthesia recovery.
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