Anaesthesiologists are an integral part of the team managing care for obstetric patients in the maternity units of each medical centre. Delivery suites are very different in Europe depending on the country, and even in the same country, significant differences exist among hospitals and levels of care. In most situations, both the individual health professional and also the system (team, group, department etc.) must be considered when a standard of care is implemented or changed. However, this does not absolve each individual department head, doctor and subspecialist of the responsibility of reaching the minimum standards of care.1 All anaesthesia medical work in the delivery suites must be led and personally supervised by a consultant anaesthesiologist.
The current document is meant as a recommendation for the participation of anaesthesiology departments in the team work of the delivery suite. It is further intended as a document written by professionals for other professionals, with the intention of helping other colleagues to improve and better organise their daily practice.
The current document should be reviewed at 4-year intervals. It covers some of the European Board of Anaesthesiology of the European Union (EU) of Medical Specialists (EBA-UEMS) strategic key areas:
- (1) Area 1: political significance, as this project works through promoting the interest of anaesthesiologists and our professional activities in Europe.
- (2) Area 4: quality assurance of anaesthesia practice and patient safety in Europe, establishing EBA-UEMS as a leading organisation in setting standards and co-ordinating transnational activities of all aspects of anaesthesiology practice.
We expect that the standards set by this group of experts will be particularly helpful for those countries that lack national recommendation documents or guidelines. It is anticipated that these standards may stimulate European countries to collaborate actively in reviewing their own national obstetric care standards.
The foundation for this document is the EBA-UEMS policy ‘Promoting Good Medical Care’ and Anaesthesiology European Training Requirements tailored to anaesthesiology.2
Why are these minimum standards needed?
Maternal mortality and morbidity rates vary widely among different European countries. Substandard anaesthesiology care has been shown to contribute to maternal morbidity and mortality.3
Standards of care also differ significantly between European countries. Professional societies must ensure that the minimum standards of care every woman deserves in Europe are defined, and that these standards can be achieved in all European countries. Access to safe anaesthesiology for essential surgery is a basic human right and should be available to all patients irrespective of their ability to pay.4
Why are these standards different from any other existing document?
Currently, there is no other document in Europe or the EU dedicated to this aspect of anaesthesia care and peripartum care of obstetric patients.
Individual countries are responsible for their medical practice, and may follow general but not specific WHO guidelines for obstetric patients,4,5 and many European countries have written recommendations.6–11
Based on this document, we anticipate that national guidelines will be created or adjusted to meet this minimum level of safety and quality of obstetric care. Equipment and drug availability may be a key factor for anaesthesiologists who are in charge of obstetric patients.
They should follow these minimum standards to build their own units with uniform criteria, to improve maternal safety and quality of care all over Europe.
The current consensus document was created following a methodology based on various revisions of initial proposals, after an unstructured agreement process.
Selection of experts
The experts who contributed to the development of this document are all European key opinion leaders in the fields of obstetric anaesthesiology and patient safety. Our goal was to produce a usable document that can be easily applied in the departments where the authors work, and in other departments in Europe.
The project was proposed to all the participants of the annual EBA-UEMS and European Society of Anaesthesiology (ESA) Obstetric Anaesthesiology Scientific Subcommittee 4 (ESA-SSC4) meetings in 2018.
All members of EBA-UEMS executive and ESA-SSC4 were included, and one more expert who had a heavy editorial input.
Selection of topics to be included in the document
We searched the literature databases (PubMed, Scopus, Embase and Web of Knowledge) and webpages of the main societies of anaesthesiology and medicine for Guidelines and documents focused on obstetric patients: Belgian Association of Regional Anaesthesiology (BARA), French Club d’Anesthésie-Réanimation en Obstétrique (CARO), German Society of Anaesthesiology (DGAI), Obstetric Anaesthetists’ Association (OAA), Sociedad Española de Anestesia y Reanimación (SEDAR), French Society of Anaesthesia and Intensive Care Medicine (SFAR), WHO and other organisations and societies.6–11
A first draft of the document was prepared, selecting 11 main topics of minimum standards which were considered to be of vital importance to be followed in EU countries, and presented at the 2018 Euroanaesthesia congress, the ESA-SSC4 and EBA-UEMS meetings in Copenhagen. These topics affected the following domains:
- (1) Human resources
- (2) Technical equipment
- (3) Pre-operative evaluation
- (4) Initiation of labour analgesia
- (5) Maintenance of labour analgesia
- (6) Conversion of labour epidural analgesia into anaesthesia for caesarean delivery
- (7) Standard management for caesarean delivery
- (8) High-risk obstetric patient management
- (9) Postoperative care
- (10) Maternal cardiac arrest
The experts decided that organisational aspects of acute critical situations would be the initial main focus of this first consensus document. This decision took into consideration that other severe maternal conditions [postpartum haemorrhage (PPH), sepsis, thrombo-embolic disease, pre-eclampsia/eclampsia etc.] would not be discussed in this first version of the document.
Rounds of revisions of the document
The current consensus document was produced by executive members of the EBA-UEMS and also by the members of the ESA Obstetric Anaesthesiology Subcommittee (ESA-SSC4).
Nonexecutive members of both organisations (EBA-UEMS and ESA-SSC4) were approached to collaborate in this project during the 2017 and 2018 Euroanaesthesia meetings, where the project was presented to the attendees of the ESA-SSC4 business meetings. All members of ESA-SSC4 and EBA-UEMS who agreed to participate were invited to give their opinion. Tasks and authorship were shared among authors.
Authors were asked independently for their feedback by email on the document at each step of the project. Teleconference meetings were held to discuss controversial topics to facilitate a consensus.
The first draft of the document was sent to all the authors independently. The amendments and suggestions of each expert were implemented in the document, and the next version was sent back to them for a new review. This round of revision was repeated until no more corrections were recommended by any participant.
In case of disagreement or contradiction, the conflicting points were discussed during the in-person meetings of the executive board of EBA-UEMS and the ESA-SSC4, before sending out the next version of the document.
Four in-person meetings were organised during conventions in different European cities to summarise the inputs, to solve conflicted areas and to produce the next version of the draft.
The final version of the document was presented to the EBA-UEMS board during the 2019 ESA Autumn Focus meeting in Rome, where it was approved unanimously.
After this approval, two more internet-based meetings were organised for fine tuning. All the authors participated in these meetings.
To get an overview of the required availability of personnel and analgesic procedures, a survey was launched among current and former members of the ESA Working Group on Obstetric Anaesthesiology (ESA-SSC4).
Good organisation of the personnel of the anaesthetic team is one of the keys to success. Important differences in staffing strategies for maternal care in different centres may be seen, depending on the centre, the level of care and the country.
Staff members with competences and experts in obstetric anaesthesiology (according to European Training Requirements)2 should be immediately available. This means that the anaesthesiologist in charge must be available to attend an emergency within a few minutes (recommendations regarding the response times for a staff member and/or consultant anaesthesiologist in different European countries are shown in Table 1).
Table 1 -
Expected availability to provide an obstetric anaesthetic service in the labour ward according to European national guidelines
||Anaesthesiologists’ availability in the labour suite
||Ideal decision to delivery interval
||Ideal time interval for central neuraxial analgesia availability
||≤ 20 min for category 1 CS
||Should be promptly available
||No specific time limit stated
||Within 5 min
||As soon as safely possible for mother and baby
||Ideally 30 min: within 1 h in exceptional circumstances
||The duty anaesthesiologist should be immediatelya available to attend the obstetric unit 24 h day−1; no other responsibilities outside obstetricsIn all units offering a 24-h epidural service, the duty anaesthesiologist must be resident on site
||≥90% cat-1 CSs should have a DDI ≤ 30 min≥90% cat-2 CSs should have DDI ≤ 75 minPerform category 1 and 2 CS as quickly as possible after making the decision, particularly for category 1Perform category 2 CS in most situations within 75 min of making the decision
||When a 24-h epidural service is offered, the time from the anaesthesiologist's being informed that a woman is requesting an epidural and ready to receive one until attending the mother should not normally exceed 30 minThis period should only exceed 1 h in exceptional circumstances
||According to annual delivery number <1500: 1 anaesthesiologist on call at home or in hospital 1500 to 2000: 1 anaesthesiologist for OB and other surgeries >2000 = 1 anaesthesiologist specific for OB immediately available
||As soon as safely possible for mother and babyStat (red code/UK cat-1) <15 min
||As soon as possible
||No specific time limit stated
||Max 30 min
||No specific time limit standard. PPH or other emergencies, immediately available
||No specific time limit
||No specific time limit stated. As soon as possible
||As soon as safely possible for mother and baby, <15 min (cat-1 CS)
||No specific time limit stated. As soon as possible
||5 to 10 min (depending on the workload in the labour ward)
||20 min in case of active labour
||One anaesthesiologist assigned solely to Labour Suite at all times (specialist or senior trainee)
||Depends on category of CS – crash CS < 15 min; cat-1 CS < 30 min; cat-2 CS < 60 min
||Should attend to the patient within 60 min of being called and if unable to do so seek help
||No specific time
||As soon as possible in cat-1 CS
||As soon as possible
||Within 1 h: no dedicated obstetric anaesthesiologist, but anaesthesiologist on call is responsible for epidural analgesia. In part of the hospitals still done in the holding/recovery area
||Max 30 min
||1 h maximum
||No specific time, but anaesthesiologist is on call in hospital and attends immediately
||No specific time, as soon as possible
||Within 15 min after being called anaesthesiologist should be present in labour suite to start procedure. Most units have dedicated anaesthesiologist for labour and delivery
||Almost all hospitals that have obstetric services (public and private) have anaesthesiologists on call from home
||As soon as possible, no specific time
||No specific time for CS, in case of epidural for labour 30 min
||500 to 1000 deliveries/year in hospital, anaesthesiologist but not dedicated to obstetrics: immediate availability in hospital; 20 min for home call. >1000 deliveries/year, dedicated anaesthesiologist to obstetric service immediately available
||Ideal time interval for decision-delivery 20 min
||Time interval in which central neuraxial analgesia should be available 30 min, but in active labour as soon as possible/immediate
cat, category; CS, caesarean section; DDI, decision to delivery interval; PPH, postpartum haemorrhage.
aImmediately available = able to attend within 5 min or less other than in exceptional circumstances.
One staff member per specific number of deliveries is currently not recommended. The advisable ratio of staff anaesthesiologist to delivery is not defined yet in the EU. Table 1 also presents the recommended availability of an anaesthesiologist to provide obstetric care in many European countries. Such a recommendation may be highly dependent on epidural rate, number of births, risk factors in the obstetric population and so forth. Therefore, we would recommend sufficient staff so that each obstetric patient may receive the standard of care in a timely manner as set up in this recommendation and to take account of emergencies or requests for interventions/neuraxial analgesia occurring at the same time.
United States of America standards12 may not be applicable in the EU.
Trained assistants to the anaesthesiologist must be available for labour analgesia, caesarean delivery and also for crisis situations.
In small hospitals, an emergency plan for patient transfer should be available for sick mothers and high-risk patients.
Training and simulation for critical situations should be progressively implemented in all hospitals for all staff of anaesthesiology departments.
Delivery suites and operating rooms should be ideally on the same floor level. The lists of drugs and equipment presented in Tables 2 and 3 are a recommended minimum standard, and may be more extensive in some centres, depending on local protocols and the obstetric patient characteristics in each centre. When sick mothers or high-risk obstetric patients are managed, these lists have to be adapted and probably expanded to include more advanced facilities. Some delivery suites have an integrated operating room and in other delivery suites the operating room may be far away, even on another floor.
Table 2 -
Emergency drugs and equipment in delivery suites
||AtropineEpinephrineNaloxone20% lipid emulsion (local anaesthetic toxicity protocol available)Recommended: Magnesium sulphate, calcium, ephedrine, phenylephrine (when high-risk parturients are managed) or local alternativesLabetalol and/or hydralazineNicardipine and/or urapidil are also options
||Guedel airway sizes 3 and 4Macintosh laryngoscopeEndotracheal tube/s, size 7.0 or smallerLaryngeal mask airway (with suction) or 2nd-generation supraglottic airwayAutoinflatable resuscitation bagFace maskIntubating introducerVideolaryngoscopea
||Always plugged and checked regularly (include check-list chart)
||Available in delivery suiteAt least 15 l min−1 flowmeterHumidified high flow nasal oxygena
||Remember wedge or manual displacement of the uterus to relieve aortocaval compression
|Facilities for standard (and invasive) monitoring in OR
||Invasive blood pressure monitoringaCentral venous line availabilitya
|This availability may be different depending on delivery suite location in each centre and how far it is from the operating room
OR, operating room.
Table 3 -
Available drugs in delivery suites/operating rooms
||Midazolam and/or diazepam
||Magnesium sulphate, hydralazine, labetalol (depending on local availability), nicardipinea
|Vasopressors and others
||Ephedrine, phenylephrine, norepinephrine, epinephrine, atropine (differences depending on local availability)Epinephrine and atropine and any α-agonist are mandatory
||Cephazoline, ampicillin, ceftriaxone, clindamycin, gentamicin (penicillin allergy protocol)
||Lidocaine (1 and 2%)Ropivacaine or bupivacaine for spinal (hyperbaric and isobaric) and epidural anaesthesia (differences depending on local availability)
|Intravenous general anaesthetics
||Propofol or thiopentone, and ketamine or etomidatea
||Fentanyl, sufentanil, remifentanil, morphine (some not available in every country) (preservative-free morphine is needed if for spinal or epidural use)
||Paracetamol, NSAIDs (differences in local availability)
||Oxytocin, ergometrine, misoprostol, sulprostoneOther 2nd-line drugs depending on local protocol (local protocol recommended)
||Tranexamic acidFFP, fibrinogen concentrates and/or cryoprecipitate availabilityLocal protocol for massive haemorrhage with immediate availability of blood is advisable (O-negative blood immediately available in case of massive haemorrhage)
|Other drugs (recommendation)
||Sugammadex (at least 16 mg kg−1 for immediate reversal of NMBs)Intralipid and LAST protocolDantrolene in hospitala
FFP, fresh frozen plasma; LAST, local anaesthetics systemic toxicity; NMB, neuromuscular blocker.
In the delivery suite
Resuscitation equipment should be available whenever a neuraxial block is performed or maintained13. Syringe labelling is strongly recommended. Maternal monitoring should be available.
Written local protocols/algorithms are recommended for emergency resuscitation [high neuraxial block, intravenous local anaesthetic overdose, eclampsia, PPH and cardiopulmonary resuscitation (CPR)].14
Generic recommendations: patient safety resources were recently published by the EBA-UEMS Taskforce for patient safety.15 National resources that take into account local situations are available on the ESA website (http://www.esahq.org/patient-safety/patient-safety/protocols/national-protocols).
All such institutions should have protocols and the necessary facilities for managing the following (Helsinki Declaration on patient safety recommended protocols).
- (1) Pre-operative assessment and preparation
- (2) Checking equipment and drugs
- (3) Syringe labelling
- (4) Difficult/failed intubation
- (5) Malignant hyperthermia
- (6) Anaphylaxis
- (7) Local anaesthetic toxicity
- (8) Massive haemorrhage
- (9) Infection control
- (10) Postoperative care including pain relief
In Table 2, we describe a list of emergency medication and equipment that we recommend should be available in delivery suites. These specific requirements should be checked against the equipment considered necessary to adhere to the Emergency Quick Reference guide of the ESA/EBA Task Force on Patient Safety.15
In obstetric operating rooms
The central message is that operating rooms dedicated to obstetrics should have the same standards as regular operating rooms.16
- (1) Monitoring [ECG, blood pressure (BP), pulse oximeter, capnograph, gas analyser, temperature monitoring]
- (2) Invasive BP monitoring possibilities
- (3) Anaesthesiology machine
- (4) Intubation and difficult intubation trolley
- (5) Drugs (international standards) and use of the International Standardisation Organisation standard-coloured medication labels17 and all the specific drugs needed for obstetric patients
- (6) Warming devices (forced air warming systems, resistance heating etc.)
- (7) Rapid infusion system
Antepartum and pre-operative anaesthetic evaluation
Local systems should be encouraged and implemented to give written patient information and written patient consent when needed, on analgesia and anaesthesia options for every woman.
Every obstetric patient should complete a bleeding-risk assessment questionnaire.18
Pre-operative platelet count is not necessary in low-risk obstetric patients if they have an uneventful bleeding history.6,12
Platelet count should by requested on an individual basis, and at least one determination of platelet count should be performed in the third trimester.
Initiation of labour analgesia
Aseptic technique is strongly recommended, and the existing guidelines provide details on how to perform it: it should be highlighted that the use of 0.5% alcoholic chlorhexidine is advised for skin preparation.19
The room where the epidural catheter is inserted must be safe in terms of resuscitation equipment availability and sterile technique facilities.
Oral intake should follow local policy and local protocols should be available in every unit.
Identify obstetric patients high risk for aspiration or for emergency operation (obese, vaginal birth after caesarean delivery, use of opioids, diabetes, twins etc.).
Neuraxial analgesia should be available on request by obstetric patients in the absence of a contraindication.
- (1) Early epidural catheters are advised in high-risk patients.20,21
- (2) Not every high-risk obstetric patient is eligible for an epidural catheter; for example, obstetric patients under anticoagulation are high-risk obstetric patients. Safety intervals must be respected before any neuraxial technique22,23 and appropriate alternatives in terms of analgesic efficacy should be at hand for these patients.
- (3) Epidural or combined spinal epidural are both techniques which are standard for labour pain (selected cases for continuous spinal). At the moment, dural puncture epidural cannot be recommended as a standard technique.
- (4) Every neuraxial block for labour should be documented, as well as incidents (e.g. accidental dural puncture or need to resite the epidural). The use of a sheet or chart for labour analgesia is recommended (paper or electronic data recording) as a part of each patient's file.
- (5) Monitoring apparatus should be available for noninvasive BP, ECG and pulse oximetry. It is suggested that BP monitoring should be measured and recorded every 5 min during the first 20 min after the initiation of epidural analgesia.
- (6) The optimal extent of epidural analgesia depends on the woman's preference and can vary very widely among hospitals and countries. The primary aim is to provide adequate analgesia while avoiding motor weakness, thus ensuring that the mother is able to push. This can be achieved best using dilute concentrations of local anaesthetics (lower concentration than bupivacaine 0.1% or ropivacaine) in conjunction with lipophilic opioids.
Maintenance of labour epidural analgesia
Epidural catheters should be clearly identified (yellow labels if possible, to reach standardisation in Europe) to avoid errors in medication administration. Some countries have different connections to avoid wrong-routeTM drug administration (non-Luer connection, e.g. NRFit).21
- (1) Every top-up should be documented in a chart or electronic record.
- (2) Available modes for epidural analgesia are manual boluses, continuous infusion, patient-controlled epidural analgesia (PCEA), programmed intermittent epidural boluses (PIEB) or combinations of some of these modes.
- (3) It is highly recommended to use low-dose/low-concentration epidural analgesia (lower than bupivacaine 0.1% or ropivacaine and lipophilic opioids).
- (4) The use of PCEA/PIEB is recommended, when available, as these regimens are associated with better maternal and obstetric outcomes in terms of analgesia and mode of delivery due to better local anaesthetic diffusion than relying solely on a continuous application. PIEB may provide more uniform administration into the epidural space and ensure a more homogeneous block due to the rapid administration of the local anaesthetics.
- (5) Obstetric patients should be under periodic surveillance by the anaesthesiologist, looking for signs of catheter migration (intrathecal, subdural or intravascular) and under the midwives’ and/or nurses’ direct and continuous surveillance, even though under the responsibility of an anaesthesiologist.
- (6) In case of a need for top-up, safety measures should be taken to avoid intravascular or intrathecal injection.
- (7) If an accidental dural puncture took place during labour epidural analgesia, a local protocol is advised. This protocol should apply to labour analgesia management and possible caesarean delivery. The objective is to avoid a high-level block due to an epidural top-up.
We encourage the use of a local protocol to manage epidural failure and conversion of labour analgesia into caesarean delivery anaesthesia, according to existing recommendations.24–26 This includes early recognition and an algorithm to manage epidural failure.
Signs of local anaesthetic systemic toxicity should be actively sought, to identify and manage complications.
Conversion of labour epidural analgesia into epidural anaesthesiology for caesarean delivery
Caesarean delivery should be performed under neuraxial anaesthesia whenever possible.27,28
In case of emergency caesarean delivery (categories 1 to 3),27 we advise administration of an epidural top-up using the fastest acting epidural solution (mixture) available (especially if category 1 caesarean delivery).
For safety reasons, it is advisable to aspirate the epidural catheter before the top-up.
Top-up doses for caesarean delivery may be administered in the delivery suites, when CPR facilities are available and an immediate caesarean delivery can be performed. If the top-up is given in the labour suite or started within the labour suite, which may help to establish adequate anaesthesiology in a timely manner, obstetric patients should remain monitored and/or under direct surveillance of the anaesthesiologist after the top-up for caesarean delivery and during transfer to the operating room.
After the top-up and before the start of caesarean delivery, the presence of a motor block and adequate sensory level of neuraxial blockade should be checked (with cold and pin-prick). This will aid identification of an inadequate block.
The optimal level for comfortable caesarean delivery is T4, although T6 is also suitable to begin the procedure.26
In case of intra-operative pain, a local protocol is advised, including emergency and safe general anaesthesiology induction strategies.
Caesarean delivery should be categorised according to the level of emergency (Lucas classification is advised).27
Pre-operative fasting guidelines (clear liquids, nonclear liquids and solids) should be written and followed, and may be omitted in emergency caesarean delivery.
Obstetric patients in labour (with or without epidural analgesia) should be advised not to take solids if there is any possibility of caesarean delivery. It should be noted that every parturient may possibly require intrapartum caesarean delivery.
Aspiration prophylaxis has been recommended for many years and is still recommended by many guidelines.
- (1) In case of difficult airway, oxygenation and ventilation of the patient have utmost priority.
- (2) Mask ventilation must be attempted if tracheal intubation and rescue laryngeal mask airway have failed.29
- (3) For caesarean delivery, the time that the patient is under general anaesthesia before delivery should be minimised. Local strategies should be developed to achieve this goal.
- (4) In most countries, there is an agreement for the use of prophylactic antibiotics before the start of caesarean delivery.
- (5) For elective caesarean delivery, we recommend regional anaesthesia techniques (spinal or combined spinal epidural).
- (6) Small-bore pencil point needles are advised for spinal techniques.
- (7) Opioid use: intrathecal fentanyl/sufentanil and/or intrathecal morphine should be used (maximal recommended doses should be acknowledged when selecting doses).
- (8) The use of oxytocic drugs should be guided by a local protocol, considering that the ED90 of oxytocin is not higher than 5 IU, even for emergency caesarean delivery.28,30
- (9) Women with PPH more than 500 ml (vaginal delivery) or more than 1000 ml (caesarean delivery) should be identified as having PPH and treated aggressively.
High-risk obstetric patient management
Early detection and treatment of high-risk obstetric patients and sick mothers are essential to avoid severe complications of pregnancy.
- (1) High-risk obstetric patients should ideally be referred for delivery in a centre with suitable expertise. Tertiary-level hospitals have highly specialised staff and technical equipment – for example, cardiology, ICU, specialised imaging units and clinical services highly differentiated by function. They may also have teaching activities and their sizes range from 300 to 1500 beds. They are often called ‘National Hospital’, ‘Central Hospital’, ‘Academic Hospital’, ‘Teaching Hospital’ or ‘University Hospital’.31
- (2) Specialised antepartum and pre-operative evaluation and care may be required for high-risk mothers.
- (3) Information for high-risk mothers: it is recommended to inform sick mothers and high-risk patients of the dangers and optimally refer them to a tertiary hospital for optimal care.
- (4) It is recommended to institute an early contact system with tertiary hospital teams for sick mothers and high-risk patients.
- (5) There should be a system to flag up and refer high-risk obstetric patients.
- (6) Immediate pre-operative platelet count should be performed in case of suspected or confirmed pre-eclampsia, HELLP (Haemolysis, Elevated Liver enzyme levels and Low Platelet levels) syndrome, gestational thrombocytopenia, coagulation abnormality and so on.
- (7) Recommended early consultation of an anaesthesiologist for sick or ‘high-risk’ obstetric patients is desirable as early as possible during pregnancy or even before according to specific guidelines.32
Criteria for sick mothers and high-risk obstetric patients that need to be addressed for the pre-operative evaluation are shown in Table 4.
Table 4 -
Indications for consultation with anaesthesiologist before or during third trimester of pregnancy
||Congenital cardiac diseases (corrected or not)CardiomyopathyValvular diseaseRhythm abnormalitiesPacemaker or defibrillatorPregestation hypertensionAortic diseases (e.g. Marfan)
||ThrombocytopeniaCoagulation abnormalities (acquired or congenital)Current anticoagulant therapyJehovah's witness
|Spinal and neuromuscular conditions
||Anatomical abnormalities or previous spinal surgeryPrior spinal cord injuryCNS problems (intracerebral or spinal cord mass, aneurysm, fistula, Chiari, ventriculoperitoneal valves)EpilepsyMyopathiesPrevious neurosurgery
|Hepatic or renal disease
||Chronic renal insufficiencyHepatitis or cirrhosis
||Anticipated difficult airwayOSAMorbid obesityPrevious failed blockMalignant hyperthermia (personal or family history)Local anaesthetic allergyLatex allergy or previous anaphylactic shockAdvanced maternal agePredictable complex obstetric cases (accreta, EXIT procedure etc.)
||Moderate or severe asthma or COPD
||Previous solid organ transplant
CNS, central nervous system; COPD, chronic obstructive pulmonary disease; EXIT, ex-utero intrapartum treatment; OSA, obstructive sleep apnoea.
It is important to identify patients at high risk for PPH before delivery, especially in case of previous PPH, placental abnormalities, repeated caesarean delivery or current anticoagulant therapy.
- (1) A PPH protocol should be available at all centres. If a local protocol is not available, it is recommended to adopt a protocol published by one of the national or international societies.
- (2) Large-bore intravenous cannulae are needed early in PPH. In emergency situations, intra-osseous placement may be needed.
- (3) Dilutional coagulopathy and hypothermia should be avoided.
- (4) Antifibrinolytic drugs should be considered as soon as possible especially in PPH due to placental abruption, placenta praevia, HELLP syndrome or amniotic fluid embolism.
- (5) Visco-elastic tests can be helpful to guide transfusion of blood products.
- (6) Teamwork and early expert staff involvement are helpful and strongly recommended.
- (7) Patients should remain under observation, at least for a few hours, looking for bleeding and/or complications secondary to transfusion, and thromboprophylaxis should be considered soon after the end of the haemorrhagic episode.
Obstetric patients with severe hypertension
- (1) Offer pharmacological treatment to all obstetric patients and measure BP every 15 to 30 min until BP is less than 160/110 mmHg.
- (2) In obstetric patients with gestational hypertension who have given birth, measure BP frequently until the 5th postpartum day and continue antihypertensive treatment if required.
- (3) Inform obstetric patients that the duration of their postnatal antihypertensive treatment may be long and requires medical surveillance.
- (1) All healthcare professionals should be aware of the symptoms and signs of maternal sepsis and critical illness and of the rapid, potentially lethal course of severe sepsis and septic shock.
- (2) Suspicion of significant sepsis should trigger an urgent referral to secondary care.
- (3) Clinical signs suggestive of sepsis include one or more of the following: pyrexia, hypothermia, tachycardia, tachypnoea, hypoxaemia, hypotension, oliguria, impaired consciousness and failure to respond to treatment.
- (4) These signs, including pyrexia, may not always be present and are not necessarily related to the severity of sepsis. Regular observations of all vital signs (including temperature, pulse rate, BP and respiratory rate) may be recorded on a Modified Early Obstetric Warning Score (MEOWS) chart or by using electronic records with appropriate alarm settings.33
Obstetric patients after a caesarean section or after an instrumental delivery should be carefully monitored.
All patients should be monitored by qualified professionals until recovery. Patients with haemodynamic, respiratory or neurological instability should be transferred to a high-dependency unit or ICU.
Postoperative monitoring should follow similar principles to intra-operative monitoring.
- (1) Continuous clinical observation is advised (observation of oxygenation, airway, breathing, circulation and measurement of the patient's pain score, and uterine contraction and amount of postpartum bleeding).
- (2) Use of a pulse oximeter and intermittent BP monitoring are recommended.4,18
- (3) Use of other monitoring (e.g. temperature or urine output) may also be indicated, depending on the patient and on surgical factors.
A tool is intended to guide clinical judgement, but not to replace it. The MEOWS is used widely in the United Kingdom and recommended by different scientific societies. Alternative protocols and automated alarm thresholds implemented in monitoring systems may help to achieve the aim of a safe recovery.34,35
- (1) The intention of the MEOWS is to improve recognition of obstetric patients at risk of clinical deterioration and facilitate early intervention, allowing an earlier recognition of conditions that can contribute to maternal morbidity and mortality.
- (2) The parameters commonly included in the MEOWS are heart rate, respiratory rate, BP and level of consciousness (Table 5).34
- (3) Other parameters (pain score, lochia characteristics and urine output) are sometimes included, either in the score or recorded on the chart.
- (4) Physiological parameters are recorded and scored. The colour prompts are green for a low score, amber for medium and red for high scores. These colour codes reflect how abnormal the value is compared with normal pregnancy physiology, and also indicate how rapidly action is needed.
Table 5 -
Modified Early Obstetric Warning Score parameters33
||Normal Green values
|Respiratory rate (breaths min−1)
||10 to 20
||21 to 30
||<10 or >30
|Oxygen saturation (%)
||96 to 100
||36.0 to 37.4
||35 to 36 or 37.5 to 38
||<35 or >38
||100 to 139
||140 to 180 or 90 to 100
||>180 or <90
||50 to 89
||90 to 100
|Heart rate (bpm)
||50 to 99
||100 to 120 or 40 to 50
||>120 or <40
The use of MEOWS facilitates communication and provides an expectation and auditable standard for response by the medical team to deterioration in a pregnant woman's physiology.
Depending on the MEOWS score, an algorithm will advise calling midwives, obstetricians or an emergency phone number (recommended standardisation of emergency call 2222).36
Levels of maternal care may be different among European countries, depending on the organisation of each country's healthcare system. These levels of maternal care should be defined in each country. The American College of Obstetricians and Gynecologists defined levels of maternal care for the United States in 2015 from birth centres to level IV,37 but this classification is not a standard in the EU. The WHO also has its own classification, although not specifically dedicated to obstetrics.4
The use of strategies for communication and handover among the members of the team is highly recommended.
Cardiac arrest and cardiopulmonary resuscitation
Cardiac arrest in pregnancy is rare, but every department should be prepared for it.38
Early recognition and intervention with effective chest compressions and airway management are crucial for improving outcomes for the mother and foetus and consideration must be given to caesarean delivery depending on the gestational age.
Possible causes of cardiac arrest should be considered, including the following:
- (1) Anaesthetic causes
- (2) Bleeding
- (3) Cardiovascular
- (4) Drugs
- (5) Embolism
- (6) Fever
- (7) General nonobstetric causes
- (8) Hypertension
Advanced cardiac life support protocols are suitable for pregnant patients.
Perimortem caesarean delivery should be performed soon (less than 5 min) after the diagnosis of cardiac arrest, in the place where the cardiac arrest was recognised, when cardiac arrest has been witnessed. However, regardless of foetal viability and gestational age, perimortem caesarean delivery should be considered if the uterus is large enough to cause aortocaval compression.
Left lateral displacement of the uterus is recommended during CPR.
Equipment as recommended38 for cardiac arrest in pregnancy should be available for immediate perimortem caesarean delivery (scalpel blade, packing and umbilical cord clip).
The development and publication of minimum standards documents have proved to be beneficial for safety of practice in many other medical domains. We believe that defining standards of practice in obstetric anaesthesiology in Europe is important to further develop the idea of safer health care for obstetric patients. We encourage the ESA and EU countries to follow and monitor these new European recommendations, to reach a higher level of care for our obstetric patients and a better uniformity of care among different countries and hospitals.
This first version of the minimum standards in obstetric anaesthesiology is based on the best currently available evidence. There are several noteworthy limitations. First, by design, the document focuses on the most burning issues concerning safety of obstetric patients. For this reason, there are topics that have not been addressed in this first document. Future iterations will address these, as detailed above, for example, sepsis and pre-eclampsia management strategies. However, we have highlighted the need for all units to have management protocols. Another limitation is that not all the recommendations can be supported by evidence, as it is lacking in some areas. However, we believe that the experts supporting this project have sufficient scientific and clinical background in obstetrics to make these recommendations acceptable to any anaesthesiologists who practise obstetric anaesthesia.
Other guidelines differ from ours. That of the American Society of Anesthesiologists’ (ASA) task force12 is mainly a document based on ASA members’ responses to a survey; the results of the survey were analysed and recommendations were elaborated focusing on scientific levels of evidence. The OAA/Association of Anaesthetists of Great Britain and Ireland document10 was produced by members of the boards of these institutions and covers many aspects of practical organisation of obstetric departments. These two guidelines focus mainly on single countries, and their countries’ health system characteristics underlie many of the recommendations. Also BARA, CARO and SEDAR6–8 recommendations respond to the needs of a single country. The WHO document,5 while it has an international perspective, is mainly focused on normal birth and developing countries, with a strong focus on obstetric rather than obstetric anaesthesia aspects. One of our biggest strengths is that our document is conceived by experts with different points of view from several European countries and with the objective of raising minimum standards in very different environments in Europe.
Since medical science and knowledge are in constant evolution, these standards should be updated every 4 years: this will allow implementation of new strategies, treatments and techniques to maternal care, following scientific and technique advances, and encourage countries to reach high standards of quality and safety.
Acknowledgements relating to this article
Assistance with the study: we would like to thank all the members of the European Society of Anaesthesiology Scientific Subcommittee 4 who attended business meetings, and gave support and ideas for the development of this project; all EBA-UEMS delegates who have contributed with positive and constructive criticism; and Dr Carmel Abela and Dr Brian Kinirons, President and Honorary Secretary of EBA-UEMS, who first listened to this idea and believed in it from the first minute.
Financial support and sponsorship: none.
Conflicts of interest: none.
1. Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ
2. UEMS Anaesthesiology Section and Board. Training requirements for the specialty of anaesthesiology, pain and intensive care medicine; European standards of postgraduate medical specialist training. 2018; ##DeleteExtraTag##https://www.uems.eu/data/assets/pdf_file/0004/44428/UEMS-42013.44418-European-Training-Requirements-Anaesthesiology.pdf
. [Accessed 12 May 2020].
3. Cantwell R, Clutton-Brock T, Cooper G, et al. Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006–2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG
2011; 118: (Suppl 1): 1–203.
4. Gelb AW, Morriss WW, Johnson W, et al. International Standards for a Safe Practice of Anesthesia W. World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) international standards for a safe practice of anesthesia. Can J Anaesth
5. World Health Organization. WHO recommendations: intrapartum care for a positive childbirth experience. 2018; ##DeleteExtraTag##https://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/
. [Accessed 12 May 2020].
6. Van De Velde M, Vercauteren M, Stockman W, et al. Recommendations and guidelines for obstetric anesthesia in Belgium. Acta Anaesthesiol Belg
7. Elsevier Masson, Chassard D. Club d’anesthésie-réanimation obstétricale. Protocoles en anesthésie et analgésie obstétricales publié sous l’égide du Club d’anesthésie-réanimation obstétricale, CARO [coordonné par Dominique Chassard]. 2018; 1 vol. (XIII-229).
8. Sección de Obstetricia de la SEDAR. Actualización de los protocolos asistenciales de la Sección de Anestesia Obstétrica de la SEDAR. 2nd ed2016; ##DeleteExtraTag##https://www.sedar.es/images/site/GuiasClinicas/2017-protocolos_SEDAR-2012%C2012%AA_edpdf.pdf
. [Accessed 12 May 2020].
9. Ducloy-Bouthors AS, Tourres J, Malinovsky JM. Organization of the obstetric anaesthesia and reanimation. Anesth Reanim
10. Association of Anaesthetists of Great Britain & Ireland, Obstetric Anaesthetists’ Association. OAA/AAGBI guidelines for obstetric anaesthetic services. 2013; ##DeleteExtraTag##https://anaesthetists.org/Portals/0/PDFs/Guidelines%20PDFs/Guideline_obstetric_anaesthetic_services_2013_final.pdf?ver=2018-2007-2011-163755-163693&ver=162018-163707-163711-163755-163693
. [Accessed 12 May 2020].
11. Working group of the scientific medical societies. Obstetric analgesia and anesthesia. 2020. https://wwwawmforg/uploads/tx_szleitlinien/001-038l_S1_Die-geburtshilfliche-Analgesie-und-Anaesthesie_2020-03pdf
. [Accessed 17 May 2020].
12. [No authors listed]. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on obstetric anesthesia and the society for obstetric anesthesia and perinatology. Anesthesiology
13. Whitaker D, Brattebo G, Trenkler S, et al. The European Board of Anaesthesiology recommendations for safe medication practice: First update. Eur J Anaesthesiol
14. Mellin-Olsen J, Staender S, Whitaker DK, et al. The Helsinki Declaration on patient safety in anaesthesiology. Eur J Anaesthesiol
15. Staender S, Fairley-Smith A, Bratteboe G, et al. Emergency quick reference guide. ESA/EBA Taskforce for patient safety
. [Accessed 12 May 2020].
16. World Health Organization. WHO guidelines for safe surgery: safe surgery saves lives. 2009; ##DeleteExtraTag##http://whqlibdoc.who.int/publications/2009/9789241598552_eng.pdf?ua=1
. [Accessed 12 May 2020].
17. ISO Standard. ISO/DIS 26825: anaesthetic and respiratory equipment – user-applied labels for syringes containing drugs used during anaesthesiology – colours, design and performance. 2019; ##DeleteExtraTag##https://www.iso.org/standard/76678.html
. [Accessed 12 May 2020].
18. Pfanner G, Schaden E. Perioperative Gerinnung der ÖGARI zum Thema: management der peripartalen Blutung. 2019; ##DeleteExtraTag##https://www.oegari.at/web_files/cms_daten/agpg-pph-management-2019-v2011_2011.pdf
. [Accessed 12 May 2020].
19. Campbell JP, Plaat F, Checketts MR, et al. Safety guideline: skin antisepsis for central neuraxial blockade. Anaesthesia
20. Knight M, Bunch K, Tuffnell D, et al. MBRRACE-UK: saving lives, improving mothers’ care: lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014–16. 2018; ##DeleteExtraTag##https://www.npeu.ox.ac.uk/downloads/files/mbrrace-uk/reports/MBRRACE-UK%20Maternal%20Report%202018%202020-%202020Web%202020Version.pdf
. [Accessed 12 May 2020].
21. Association of Anaesthetists of Great Britain and Ireland, Royal College of Anaesthetists, Obstetric Anaesthetists’ Association, Regional Anaesthesiology UK, Association of Paediatric Anaesthetists of Great Britain and Ireland, Royal College of Anaesthetists Patient Liaison Group. The introduction of new neuraxial connectors into the NHS. 2011; ##DeleteExtraTag##https://www.rcoa.ac.uk/system/files/PUB-NeuraxialConnectors.pdf
. [Accessed 12 May 2020].
22. Gogarten W, Vandermeulen E, Van Aken H, et al. Regional anaesthesiology and antithrombotic agents: recommendations of the European Society of Anaesthesiology. Eur J Anaesthesiol
23. Leffert L, Butwick A, Carvalho B, et al. The Society for Obstetric Anesthesia and Perinatology consensus statement on the anesthetic management of pregnant and postpartum women receiving thromboprophylaxis or higher dose anticoagulants. Anesth Analg
25. Guasch E, Iannuccelli F, Brogly N, et al. Failed epidural for labor: what now? Minerva Anestesiol
26. Desai N, Gardner A, Carvalho B. Labor epidural analgesia to cesarean section anesthetic conversion failure: a national survey. Anesthesiol Res Pract
27. Lucas DN, Yentis SM, Kinsella SM, et al. Urgency of caesarean section: a new classification. J R Soc Med
28. Kinsella M. Section 8: Obstetrics. Royal College of Anaesthetists: Raising the Standard: a compendium of audit recipes. 3rd ed2012; ##DeleteExtraTag##https://www.rcoa.ac.uk/system/files/CSQ-ARB2012-SEC2018.pdf
. [Accessed 12 May 2020].
29. Devroe S, Van de Velde M, Rex S. General anesthesia for caesarean section. Curr Opin Anaesthesiol
30. Lavoie A, McCarthy RJ, Wong CA. The ED90 of prophylactic oxytocin infusion after delivery of the placenta during cesarean delivery in laboring compared with nonlaboring women: an up-down sequential allocation dose-response study. Anesth Analg
31. World Health Organization. Referral hospitals. 2006. https://www.who.int/management/facility/ReferralDefinitions.pdf
. [Accessed 19 January 2020].
32. Regitz-Zagrosek V, Roos-Hesselink JW, Bauersachs J, et al. 2018 ESC guidelines for the management of cardiovascular diseases during pregnancy. Eur Heart J
33. Royal College of Obstetricians and Gynaecologists. Bacterial sepsis in pregnancy. RCOG green – top guideline. 2012; No. 64a: https://www.rcog.org.uk/globalassets/documents/guidelines/gtg_64a.pdf
. [Accessed 12 May 2020].
34. Singh S, McGlennan A, England A, et al. A validation study of the CEMACH recommended Modified Early Obstetric Warning System (MEOWS). Anaesthesia
35. Royal College of Anaesthetists, Royal College of Obstetricians and Gynaecologists, Royal College of Midwives, Intensive Care Society, The Faculty Of Intensive Care Medicine, Obstetric Anaesthetists Association. Care of the critically ill woman in childbirth; enhanced maternal care. 2018; ##DeleteExtraTag##https://www.rcoa.ac.uk/system/files/EMC-Guidelines2018.pdf
. [Accessed 12 May 2020].
36. Whitaker DK. Establishing a standard ‘Cardiac Arrest Call’ telephone number for all hospitals in Europe-2222. Resuscitation
37. Kilpatrick SJ, Menard MK, Zahn CM, et al. Obstetric care consensus #9: levels of maternal care: (replaces Obstetric Care Consensus Number 2, February 2015). Am J Obstet Gynecol
38. Kikuchi J, Deering S. Cardiac arrest in pregnancy. Semin Perinatol