Guidelines for the Management of the Obstetrical Patient for the Certified Registered Nurse Anesthetist

 
Certified Registered Nurse Anesthetists (CRNAs) have been the predominant providers of anesthesia services to obstetrical patients.1 CRNAs provide obstetrical anesthesia services with physicians such as obstetricians, family practitioners, and anesthesiologists, and with nurses such as nurse midwives and nurse practitioners.  In recognition of that role, the American Association of Nurse Anesthetists (AANA) advocates establishing clinical guidelines that promote quality patient care.
 

While pregnancy and childbirth are normal physiologic processes, many variables have the potential to complicate overall patient management.2,3  The AANA developed the Guidelines for Anesthesia Management of the Obstetrical Patient4 to 1) promote safe and effective anesthesia care for obstetrical patients, and 2) provide guidance for CRNAs  and healthcare institutions. In the context of these guidelines, anesthesia is the care provided for surgical intervention (i.e., cesarean section), and labor analgesia is the care provided for pain management (i.e., labor epidural).  The AANA Scope and Standards for Nurse Anesthesia Practice5 shall apply to all patients who undergo anesthesia in the obstetrical setting (see appendix).

Guideline 1
The CRNA shall possess the appropriate skills and credentials to initiate and/or manage regional (intrathecal, spinal, epidural or caudal epidural) labor analgesia and anesthesia and general anesthesia for the obstetric patient.
 

Interpretation
The CRNA shall be able to develop and implement a plan of patient care specific to the needs and predispositions of the obstetric patient and based on current anesthesia principles.

Guideline 2
The CRNA shall be aware of fetal status prior to each analgesia/anesthesia intervention.

Interpretation
Fetal status is monitored and documented in the patient’s record.

Guideline 3
The CRNA shall insure that anesthesia equipment is consistent with other anesthetizing locations in the facility.  Emergency airway management equipment and drugs for resuscitation of the neonate shall be available.

Interpretation
Departmental policies should define the anesthesia equipment required to provide high quality anesthesia care to the parturient and the neonate.
 
Guideline 4
The CRNA shall be immediately available, as defined by institutional policy, when analgesia and anesthesia is administered.

Interpretation

During the conduct of a continuous epidural infusion for analgesia, the CRNA must be immediately available to assess the level of analgesia and adjust the plan of care as appropriate.  Following bolus epidural or intrathecal injection for analgesia, the CRNA must be immediately available to assess the level of analgesia until that level has stabilized.

Guideline 5
During the conduct of an anesthetic, a qualified healthcare provider other than the CRNA shall be available in the event neonatal assessment and resuscitation are required.

Interpretation
The primary responsibility of the CRNA is to the patient receiving anesthesia for the obstetrical procedure.

Guideline 6
Initiate, in the event of an emergency, anesthesia care in accordance with institutional policy.

Interpretation
At a minimum, the policy should be congruent with the American College of Obstetrics and Gynecology (ACOG) guidelines.  "Local circumstances must dictate the way in which these guidelines are best interpreted to meet the needs of the particular hospital, community or system.  The nursing, anesthesia, neonatal resuscitation and obstetric personnel should be in the hospital or readily available.  Readily available should be defined by each institution within the context of its resources and geographic location."

Guideline 7
Insure that postanesthesia care for the obstetric patient is consistent with institutional policies.

Interpretation
Departmental policies should define the resources required to provide high-quality postanesthesia care to the parturient.

References
  1. Hawkins J, Gibbs G, Orleans M, Martin-Salvi G, Beaty B. Obstetric anesthesia work force survey, 1981 versus 1992.  Anesthesiology.  1997;87:135-143.
  2. Fiedler M, Shaw B. Obstetric anesthesia. In Nagelhout J, Zaglaniczny K, eds. Nurse Anesthesia. Philadelphia: WB Saunders.1997:292-332.
  3. Santos A, Pederson H, Finster M. Obstetric anesthesia. In: Barash PG et al, eds. Clinical Anesthesia. Philadelphia:  Lippincott-Raven. 1992:1061-1090.
  4. AANA Guidelines for Anesthesia Management of the Obstetrical Patient. In: Professional Practice Manual for the Certified Registered Nurse Anesthetist. Park Ridge, Illinois: American Association of Nurse Anesthetists. 1991.
  5. Scope and Standards for Nurse Anesthesia Practice. American Association of Nurse Anesthetists. Park Ridge, IL: 2012.
  6. American Academy of Pediatrics, American College of Obstetricians and Gynecologists Guidelines for Perinatal Care. 3rd ed. Elk Grove Village, Illinois: American Academy of Pediatrics. 1992.
  7.  
Appendix
Standards for Nurse Anesthesia Practice
These standards are intended to:
  1. Assist the profession in evaluating the quality of care provided by its practitioners.
  2. Provide a common base for practitioners to use in their development of a quality practice.
  3. Assist the public in understanding what to expect from the practitioner.
  4. Support and preserve the basic rights of the patient.
These standards apply to all anesthetizing locations and may be exceeded at any time at the discretion of the CRNA. Although the standards are intended to promote high-quality patient care, they cannot assure specific outcomes. The CRNA should consider the integration of new technologies into current anesthesia practice.
There may be exceptional patient-specific circumstances that require deviation from a standard. The CRNA shall document any deviations from these standards (e.g., emergency cases for which informed consent cannot be obtained, surgical interventions or procedures that invalidate application of a monitoring standard) and state the reason for the deviation on the patient’s anesthesia record.

Standard I

Perform and document a thorough preanesthesia assessment and evaluation.

Standard II
Obtain and document informed consent for the planned anesthetic intervention from the patient or legal guardian, or verify that informed consent has been obtained and documented by a qualified professional.

Standard III

Formulate a patient-specific plan for anesthesia care.

Standard IV

Implement and adjust the anesthesia care plan based on the patient’s physiologic status. Continuously assess the patient’s response to the anesthetic, surgical intervention, or procedure. Intervene as required to maintain the patient in optimal physiologic condition. 

Standard V

Monitor, evaluate, and document the patient’s physiologic condition as appropriate for the type of anesthesia and specific patient needs. When any physiological monitoring device is used, variable pitch and threshold alarms shall be turned on and audible. The CRNA should attend to the patient continuously until the responsibility of care has been accepted by another anesthesia professional.
  1. Oxygenation
    Continuously monitor oxygenation by clinical observation and pulse oximetry. If indicated, continually monitor oxygenation by arterial blood gas analysis.
  2. Ventilation
    Continuously monitor ventilation. Verify intubation of the trachea or placement of other artificial airway devices by auscultation, chest excursion, and confirmation of expired carbon dioxide. Use ventilatory pressure monitors as indicated. Continuously monitor end-tidal carbon dioxide during controlled or assisted ventilation and any anesthesia or sedation technique requiring artificial airway support. During moderate or deep sedation, continuously monitor for the presence of expired carbon dioxide.
  3. Cardiovascular
    Continuously monitor cardiovascular status via electrocardiogram. Perform auscultation of heart sounds as needed. Evaluate and document blood pressure and heart rate at least every five minutes.
  4. Thermoregulation
    When clinically significant changes in body temperature are intended, anticipated, or suspected, monitor body temperature in order to facilitate the maintenance of normothermia.
  5. Neuromuscular
    When neuromuscular blocking agents are administered, monitor neuromuscular response to assess depth of blockade and degree of recovery.
  6. Positioning
    Monitor and assess patient positioning and protective measures, except for those aspects that are performed exclusively by one or more other providers.
Interpretation
Continuous clinical observation and vigilance are the basis of safe anesthesia care. Consistent with the CRNA’s professional judgment, additional means of monitoring the patient’s status may be used depending on the needs of the patient, the anesthesia being administered, or the surgical technique or procedure being performed.
Standard VI
Document pertinent anesthesia-related information on the patient’s medical record in an accurate, complete, legible, and timely manner.
 
Standard VII
Evaluate the patient’s status and determine when it is safe to transfer the responsibility of care. Accurately report the patient’s condition, including all essential information, and transfer the responsibility of care to another qualified healthcare provider in a manner that assures continuity of care and patient safety.
 
Standard VIII
Adhere to appropriate safety precautions as established within the practice setting to minimize the risks of fire, explosion, electrical shock and equipment malfunction. Based on the patient, surgical intervention or procedure, ensure that the equipment reasonably expected to be necessary for the administration of anesthesia has been checked for proper functionality and document compliance. When the patient is ventilated by an automatic mechanical ventilator, monitor the integrity of the breathing system with a device capable of detecting a disconnection by emitting an audible alarm. When the breathing system of an anesthesia machine is being used to deliver oxygen, the CRNA should monitor inspired oxygen concentration continuously with an oxygen analyzer with a low concentration audible alarm turned on and in use.
 
Standard IX
Verify that infection control policies and procedures for personnel and equipment exist within the practice setting. Adhere to infection control policies and procedures as established within the practice setting to minimize the risk of infection to the patient, the CRNA, and other healthcare providers.
 
Standard X
Participate in the ongoing review and evaluation of anesthesia care to assess quality and appropriateness.
 
Standard XI
Respect and maintain the basic rights of patients.
  
 

The AANA Board of Directors adopted "Guidelines for the Management of the Obstetrical Patient for the Certified Registered Nurse Anesthetist" at the 1998 Preconvention Board Meeting.  The guidelines became effective January 1, 1999. Revised by the AANA Board of Directors January 2013.