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]).
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.
1. DeFrances C, Hall M. 2005 National hospital discharge survey. Advance data from vital and health statistics; No 385. Hyattsville, MD: National Center for Health Statistics, 2007
2. Hamilton BE, Martin JA, Ventura SJ. Births: preliminary data for 2006. Hyattsville, MD: National Vital Statistics Reports, 2007
3. 2006–2008 Standards of Perinanesthesia Nursing Practice. Cherry Hill, NJ: The American Society of PeriAnesthesia Nurses, 2006
4. 2008–2010 Standards of Perinanesthesia Nursing Practice. Cherry Hill, NJ: The American Society of PeriAnesthesia Nurses, 2008
5. Comprehensive Accreditation Manual for Hospitals: the Official Handbook. Oakbrook Terrace, IL: The Joint Commission on Accreditation of Healthcare Organization, Joint Commission Resources, 2008:LD-12
6. Practice guidelines for postanesthetic care: a report by the American Society of Anesthesiologists Task Force on Postanesthetic Care. Anesthesiology 2002;96:742–52
7. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 2007;106:843–63
8. Standards for Professional Nursing Practice in the Care of Women and Newborns. 6th ed. Washington, DC: AWHONN, 2003
9. Simpson K. Labor and birth. In: Simpson K, Creehan P, eds. Perinatal Nursing. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2008
10. Resta RG. Changing demographics of advanced maternal age (AMA) and the impact on the predicted incidence of Down syndrome in the United States: implications for prenatal screening and genetic counseling. Am J Med Genet A 2005;133A:31–6
11. Martin JA, Hamilton BE, Sutton PD, Ventur SJ, Menacker F, Kirmeyer S, Munson ML. Births: final data for 2005. Hyattsville, MD: National Vital Statistics Reports, 2007
12. Flegal KM, Carroll MD, Ogden CL, Johnson CL. Prevalence and trends in obesity among US adults, 1999–2000. JAMA 2002;288:1723–7
13. Optimal Goals for Anesthesia Care in Obstetrics: Standards, Guidelines and Statements. American Society of Anesthesiologists, 2007:63–5
14. Callaghan WM, Berg CJ. Pregnancy-related mortality among women aged 35 years and older, United States, 1991–1997. Obstet Gynecol 2003;102:1015–21
15. Luke B, Brown MB. Contemporary risks of maternal morbidity and adverse outcomes with increasing maternal age and plurality. Fertil Steril 2007;88:283–93
16. Goffman D, Madden RC, Harrison EA, Merkatz IR, Chazotte C. Predictors of maternal mortality and near-miss maternal morbidity. J Perinatol 2007;27:597–601
17. Samuels-Kalow ME, Funai EF, Buhimschi C, Norwitz E, Perrin M, Calderon-Margalit R, Deutsch L, Paltiel O, Friedlander Y, Manor O, Harlap S. Prepregnancy body mass index, hypertensive disorders of pregnancy, and long-term maternal mortality. Am J Obstet Gynecol 2007;197:490 e1–e6
18. MacKay AP, Berg CJ, King JC, Duran C, Chang J. Pregnancy related mortality among women with multifetal pregnancies. Obstet Gynecol 2006;107:563–8
19. Day MC, Barton JR, O’Brien JM, Istwan NB, Sibai BM. The effect of fetal number on the development of hypertensive conditions of pregnancy. Obstet Gynecol 2005;106:927–31
20. Walker MC, Murphy KE, Pan S, Yang Q, Wen SW. Adverse maternal outcomes in multifetal pregnancies. BJOG 2004;111:1294–6
21. Mhyre JM, Riesner MN, Polley LS, Naughton NN. A series of anesthesia-related maternal deaths in Michigan, 1985–2003. Anesthesiology 2007;106:1096–104
22. Lewis G. The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mother’s Lives: Reviewing Maternal Deaths to Make Motherhood Safer–2003–2005. London:CEMACH, 2007
23. Asai T, Koga K, Vaughan RS. Respiratory complications associated with tracheal intubation and extubation. Br J Anaesth 1998;80:767–75
24. Hines R, Barash PG, Watrous G, O’Connor T. Complications occurring in the postanesthesia care unit: a survey. Anesth Analg 1992;74:503–9
25. Peskett MJ. Clinical indicators and other complications in the recovery room or postanaesthetic care unit. Anaesthesia 1999;54:1143–9
26. Ford JB, Roberts CL, Bell JC, Algert CS, Morris JM. Postpartum haemorrhage occurrence and recurrence: a population-based study. Med J Aust 2007;187:391–3
27. Bucklin BA, Hawkins JL, Anderson JR, Ullrich FA. Obstetric anesthesia workforce survey: twenty-year update. Anesthesiology 2005;103:645–53
28. Endler GC, Bhatia RK. Care of obstetric patients during the immediate postanesthesia period. J Clin Anesth 1991;3:117–24
29. Walker E, Moore P. Obstetric recovery practice: a survey of UK obstetric anaesthetists. Int J Obstet Anesth 2005;14:193–9
30. Resource 3: patient classification/recommended staffing guidelines. 2006–2008 Standards of Perinanesthesia Nursing Practice. Cherry Hill, NJ: The American Society of PeriAnesthesia Nurses, 2006:61–2
31. Resource 2: patient classification/recommended staffing guidelines. 2008–2010 Standards of Perinanesthesia Nursing Practice. Cherry Hill, NJ: The American Society of PeriAnesthesia Nurses, 2008:59–61
32. Standard III: staffing and personnel management. 2006–2008 Standards of Perinanesthesia Nursing Practice. Cherry Hill, NJ: The American Society of PeriAnesthesia Nurses, 2006:14
33. Standard III: staffing and personnel management. 2008–2010 Standards of Perinanesthesia Nursing Practice. Cherry Hill, NJ: The American Society of PeriAnesthesia Nurses, 2008:14
34. Resource 13: recommended competencies for the perianesthesia nurse. 2006–2008 Standards of Perinanesthesia Nursing Practice. Cherry Hill, NJ: The American Society of PeriAnesthesia Nurses, 2006:88–9
35. Resource 12: recommended competencies for the perianesthesia nurse. 2008–2010 Standards of Perinanesthesia Nursing Practice. Cherry Hill, NJ: The American Society of PeriAnesthesia Nurses, 2008:89–90
36. O’Brien-Abel N, Reinke C, Warner P, Nelson C. Obstetric postanesthesia nursing: a staff education program. J Perinat Neonatal Nurs 1994;8:17–32
37. Appendix K. In: Simpson K, Creehan P, eds. Competence Validation for Perinatal Care Providers. Philadelphia: Lippincott, 1998:288–9
38. Dane FC, Russell-Lindgren KS, Parish DC, Durham MD, Brown TD. In-hospital resuscitation: association between ACLS training and survival to discharge. Resuscitation 2000;47:83–7
39. Luppi CJ. Should ECG monitoring during the postanesthesia period be the standard of care for all women who have cesarean birth? MCN Am J Matern Child Nurs 2002;27:211
40. A position statement on minimum staffing in phase I PACU. 2006–2008 Standards of Perinanesthesia Nursing Practice. Cherry Hill, NJ: The American Society of PeriAnesthesia Nurses, 2006:100
41. Position statement 4: a position statement on minimum staffing in Phase I PACU. 2008–2010 Standards of Perinanesthesia Nursing Practice. Cherry Hill, NJ: The American Society of PeriAnesthesia Nurses, 2008:103
42. Resource 5: equipment for preanesthesia/day of surgery Phase, PACU Phase I, Phase II, and extended observation. 2006–2008 Standards of Perinanesthesia Nursing Practice. Cherry Hill, NJ: The American Society of PeriAnesthesia Nurses, 2006:68–71
43. Resource 4: recommended equipment for preanesthesia/day of surgery phase, PACU I, PACU II, and extended observation. 2008–2010 Standards of Perinanesthesia Nursing Practice. Cherry Hill, NJ: The American Society of PeriAnesthesia Nurses, 2008:68–71
*American Society of Anesthesiologists. Optimal goals for anesthesia care in obstetrics. In: ASA standards, guidelines and statements. October 2007. Available at: http://www2.asahq.org/publications/p-106-asa-standards-guidelines-and-statements.aspx, accessed on December 5, 2008.
†http://www.aapd-saac.org/membersalpha.php, accessed on November 14, 2008.
‡http://www.cas.ca/members/sign_in/related_organizations/default.asp?load=university, accessed on August 1, 2008.
§American Society of Anesthesiologists. Standards for postanesthesia care. In: ASA standards, guidelines and statements. October 2007. Available at: http://www2.asahq.org/publications/p-106-asa-standards-guidelines-and-statements.aspx, accessed on December 4, 2008.