The Perinatal Birth Environment: Communication Strategies and Processes for Adherence to a Standardized Guideline in Women Undergoing Second-Stage Labor With Epidural Anesthesia.

Key to any perinatal safety initiative is buy-in and strong leadership from obstetric and pediatric providers, advanced practice nurses, and labor and delivery nurses in collaboration with ancillary staff. In the fall of 2007, executives of a large Midwestern hospital system created the Zero Birth Injury Initiative. This multidisciplinary group sought to eliminate birth injury using the Institute of Healthcare Improvement Perinatal Bundles. Concurrently, the team implemented a standardized second-stage labor guideline for women who choose epidural analgesia for pain management to continue the work of eliminating birth injuries in second-stage labor. The purpose of this article was to describe the process of the modification and adaptation of a standardized second-stage labor guideline, as well as adherence rates of these guidelines into clinical practice. Prior to implementation, a Web-based needs assessment survey of providers was conducted. Most (77% of 180 respondents) believed there was a need for an evidence-based guideline to manage the second stage of labor. The guideline was implemented at 5 community hospitals and 1 academic health center. Data were prospectively collected during a 3-month period for adherence assessment at 1 community hospital and 1 academic health center. Providers adhered to the guideline in about 57% of births. Of patients whose provider followed the guideline, 75% of women were encouraged to delay pushing compared with only 28% of patients delayed pushing when the provider did not follow the guideline.

The rapid sequence spinal for category 1 caesarean section: anaesthetic trainee knowledge and practice.

Rapid sequence induction of general anaesthesia (GA) is the fastest anaesthetic technique in a category-1 caesarean section (C1CS) for foetal distress. Recently rapid sequence spinal anaesthesia (RSS) has been explored as a technique to avoid the potential risks of GA in such cases. Out of hours, trainee anaesthetists are often required to provide anaesthesia for these emergencies. We surveyed their practices when performing a RSS. The aim of a RSS is to rapidly and safely achieve anaesthesia for C1CS, while optimising foetal oxygenation and preparing for possible GA. It requires anaesthetic skill, team work and communication. Many trainees understood the principles of the RSS, however, a significant number did not. Practice varied widely and no trainee had received any formal RSS training. Training for junior anaesthetists and those working in obstetric theatres, in the conduct of the RSS is crucial, to ensure safe practice, avoid delays in delivery and safely avoid the risks associated with GA in the C1CS.

Case report: anesthetic management of acute fatty liver of pregnancy in the postpartum period.

Acute fatty liver of pregnancy (AFLP) is a potentially fatal metabolic disorder that manifests during the third trimester. Early diagnosis, termination of pregnancy, and treatment of complications associated with AFLP significantly reduce maternal morbidity and mortality. While most cases of AFLP occur before delivery, some may occur after vaginal delivery. Anesthesia providers should have a high level of suspicion for AFLP in a patient with altered mental status and elevated liver function test results in the postpartum period. Anesthetic implications include early recognition of liver dysfunction and aggressive resuscitation and treatment of hypoglycemia, disseminated intravascular coagulopathy, and other associated complications and reduction or avoidance of medications with substantial hepatic metabolism. This is a case report describing the management of a woman with AFLP in whom acute liver failure rapidly developed after a vaginal delivery with epidural analgesia at a small overseas hospital.

Anesthetic management of an obstetric patient with Charcot-Marie-Tooth disease: a case study.

Additional documentation of regional anesthesia in patients with Charcot-Marie-Tooth disease (CMT) is needed to guide practitioners and patients in exploring appropriate options for anesthesia and analgesia management. This case report describes the successful use of a combined spinal-epidural technique for labor progressing to cesarean delivery in a patient with CMT. Previous similar case reports were reviewed and an extensive literature search was conducted to organize the limited body of research regarding use of regional anesthesia in patients with CMT. Opinions regarding regional anesthesia in patients with neuromuscular diseases such as CMT are often contradictory and based on theory rather than documented practice. This case report confirms what seems to be the developing consensus in anesthesia that regional management is a safe alternative to general anesthesia in these patients. Considering that CMT is among the most common of hereditary neuromuscular diseases, it seems valid to establish a more research-driven recommendation for practice.

A survey of obstetric perianesthesia care unit standards.

BACKGROUND: Although obstetric patients are generally healthy, population risk is increasing because of increases in maternal age, obesity, and rates of multifetal pregnancies, and complications may occur in the immediate postoperative period. In this study, we sought to identify the current level of recovery care for obstetric patients in North American academic institutions after either general or major neuraxial anesthesia for cesarean delivery. METHODS: A survey of obstetric anesthesia recovery practices was delivered electronically to 135 obstetric anesthesiology directors of North American academic institutions from June to October, 2007. Surveys were completed electronically and anonymously. RESULTS: The response rate was 54.8% (74 of 135). Respondents reported a median of 2550 deliveries per year (interquartile range [IQR] 2000, 4000), with 30% delivered by cesarean delivery (IQR 25.5%, 32.5%) and 5% of cesarean deliveries performed under general anesthesia (IQR 4%, 8%). Most institutions recovered postcesarean patients in either an obstetric perianesthesia care unit or a labor, delivery, and recovery room. Recovery care was staffed solely by perinatal nurses, rather than dedicated perianesthesia care unit nurses in most institutions. Forty-five percent (28 of 62) of institutions had no specific postanesthesia recovery training for nursing staff providing postcesarean care for patients recovering from neuraxial or general anesthesia. Forty-three percent (29 of 67) of respondents rated the recovery care provided to cesarean delivery patients as lower quality than care given to general surgical patients. Respondents who relied solely on perinatal nurses to provide postanesthesia care were most likely to perceive that postanesthetic care for cesarean delivery was of lower quality than that given to general surgery patients (P = 0.008). CONCLUSIONS: Guidelines put forth by the American Society of Anesthesiologists Task Force on Postanesthetic Care and the American Society of PeriAnesthesia Nurses apply to all postoperative patients regardless of their recovery locations. Results from this survey suggest that the level of care provided for postanesthesia recovery from cesarean delivery in North American academic institutions may not meet these guidelines.

Complications in obstetric anesthesia: nursing's role to anticipate, recognize, and respond.

Anesthetic complications require immediate recognition and intervention. With the many options and high anesthesia rates among laboring women, today's perinatal nurses need education not only in the choices of anesthesia but also in the complications that can result from these choices. Most orientation programs briefly discuss the subject, leaving the amount of information and training insufficient for the nurses to feel confident in their understanding of the complications and competent to respond. This educational need could also extend to experienced staff who lack current knowledge and appropriate competence in responding to obstetric anesthesia emergencies. The purpose of this article is to address the major complications of obstetric anesthesia and how nurses need to respond, with the goal of improving patient safety in these rare but high-risk situations. Recommendations in didactic content are presented to assist hospital educators in achieving this goal.

Evidence-based anesthesia: fever of unknown origin in parturients and neuraxial anesthesia.

The safety of neuraxial analgesia in febrile patients is controversial. We performed an evidenced-based project in an effort to establish a guideline for our active obstetric clinical practice. Neuraxial anesthesia is generally safe for parturients, and complications are rare; however, serious adverse outcomes can result. Because of the devastating nature of the morbidity, the decision to proceed with a neuraxial anesthetic in the face of infection may be contentious. Fever and sepsis are considered relative contraindications to regional anesthesia; however, epidural anesthesia is a superior method of management of pain during labor. One must also consider that 30% to 40% of patients with chorioamnionitis require cesarean delivery. Because of the increased morbidity and mortality of general anesthesia in this population, it may be reasonable to proceed with regional anesthesia. Based on a review of the literature, it is difficult to estimate the risk of an infrequently occurring event. We recommend evaluation of each individual to determine the risks and benefits of the anesthetic. However, it is prudent to administer antibiotics before the regional anesthetic and adhere to strict aseptic technique. Postprocedure monitoring is essential for early detection and treatment of complications.

Knowledge to action: implementing a guideline for second stage labor.

PURPOSE: To quantify practice changes associated with implementing a clinical practice guideline for the second stage of labor in term nulliparous women with epidural anesthesia and to describe the lessons learned about knowledge translation. The main clinical practice guideline recommendation was waiting up to 2 hours before pushing after full dilatation. DESIGN AND METHODS: Pre- and post-evaluation of clinical outcomes and knowledge translation strategies associated with implementing the second stage of labor clinical practice guideline at two birthing units within a large teaching hospital. RESULTS: The implementation of the clinical practice guideline resulted in a significant increase in median waiting time before pushing of 33 minutes at Site 1. This change was also reflected in the twofold increase in the proportion of women waiting longer than 120 minutes before pushing at this site. There was no change in waiting time at Site 2. The duration of the second stage did not change significantly at either site. The median pushing time decreased at both sites but was only statistically significant at Site 1. CLINICAL IMPLICATIONS: Bringing about practice change in obstetrics is complex. The measured change in this study was less than we expected. Greater success might have been achieved by enhancing feedback to care providers and more frequent audits of practice. We need to better understand the subtle influences in attitude and culture that prevented successful implementation in one site. For units considering a similar process, we recommend a commensurately greater level of presence in the units to encourage compliance with the clinical practice guideline in order to achieve the desired level of practice change.

Suspected amniotic fluid embolism following amniotomy: a case report.

Amniotic fluid embolism (AFE), also referred to as anaphylactoid syndrome of pregnancy, is a rare obstetric emergency that may manifest itself at any time during pregnancy. AFE is believed to occur when the constituents of amniotic fluid enter the maternal circulation, leading to varying degrees of multiorgan compromise. AFE was first described in 1926, gaining widespread recognition in 1941. This article describes the pathogenesis of AFE, including theories of its immunological mediation available in the literature. The most current diagnostic and treatment modalities are discussed, including several novel therapies. A case report of a 40-year-old parturient who suffered probable AFE following amniotomy, with the development of cardiopulmonary compromise, neurologic involvement, fetal distress, and coagulopathy, is outlined. The patient survived emergency cesarean delivery and hysterectomy with no residual physiologic deficits.

Anesthesia staffing and anesthetic complications during cesarean delivery: a retrospective analysis.

BACKGROUND: Obstetrical anesthesia services may be provided by Certified Registered Nurse Anesthetists (CRNAs), anesthesiologists, or a combination of the two providers. Research is needed to assist hospitals and anesthesia groups in making cost-effective staffing choices. OBJECTIVES: To identify differences in the rates of anesthetic complications in hospitals whose obstetrical anesthesia is provided solely by CRNAs compared to hospitals with only anesthesiologists. METHODS: Washington State hospital discharge data were obtained from 1993 to 2004 for all cesarean sections, and were merged with a survey of hospital obstetrical anesthesia staffing. Anesthetic complications were identified via International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Resulting rates were risk-adjusted using regression analysis. RESULTS: Hospitals with CRNA-only staffing had a lower rate of anesthetic complications than those with anesthesiologist staffing (0.58% vs. 0.76%, p=.0006). However, after regression analysis, this difference was not significant (odds ratio for CRNA vs. anesthesiologist complications: 1.046 to 1, 95% confidence interval 0.649-1.658, p=.85). DISCUSSION: There is no difference in rates of complications between the two types of staffing models. As a result, hospitals and anesthesiology groups may safely examine other variables, such as provider availability and costs, when staffing for obstetrical anesthesia. Further study is needed to validate the use of ICD-9-CM codes for anesthesia complications as an indicator of quality.

Labor epidural anesthetics comparing loss of resistance with air versus saline: does the choice matter?

This study examined whether air or saline, used for the loss-of-resistance (LOR) technique, resulted in a difference in pain relief or adverse events for laboring parturients. Previous studies had mixed findings regarding the onset of analgesia and subsequent pain relief. Research questions were as follows: Is there difference in analgesic onset for patients receiving air vs saline during the LOR technique? Do women receiving the air method for LOR experience any difference in the quality of pain relief from that of women receiving saline? Is there any difference in the incidence of analgesic distribution or segmental pain relief in women receiving the air vs the saline method? Is there any difference in the incidence of adverse effects in women receiving air vs saline during the LOR technique? This was an experimental, prospective study with 50 women. Subjects were randomized to receive air or saline. The visual analogue scale was used to measure pain. A dermatome level recorded the spread of analgesia. No significant differences were found between groups for onset or quality of analgesia. There was a significant increase in the number of subjects who experienced segmental blocks after receiving air during the LOR technique.

Lower epidural anesthesia use associated with labor support by student nurse doulas: implications for intrapartal nursing practice.

Interventions of baccalaureate nursing students, trained as doulas, were examined for their association with epidural anesthetic use. Doulas, trained to support laboring mothers, are associated with shorter labors and fewer medical interventions. Data from a convenience sample of 89 vaginal births attended between 1999 and 2002 were analyzed. Analysis showed an association of lower epidural use with increased complementary doula interventions (.62 OR, P=.003) and an association of higher epidural use with longer labors (1.22 OR, P=.004). No significant association was found between epidural use and parity, income, education and type of health care provider. These findings support previous research of decreased analgesia use by doula-supported women and suggest benefits of the interventions by student nurse doulas. Students trained in providing low-tech supportive care may change the environment for intrapartum nursing practice. Institutional changes may be required to allow greater opportunity for intrapartal nurses to provide support to laboring women.