Summary of Recommendations
Perianesthetic Evaluation and Preparation
History and Physical Examination
- This should include, but is not limited to, a maternal health and anesthetic history, a relevant obstetric history, a baseline blood pressure measurement, and an airway, heart, and lung examination, consistent with the American Society of Anesthesiologists (ASA) “Practice Advisory for Preanesthesia Evaluation.”
- When a neuraxial anesthetic is planned or placed, examine the patient’s back.
- Recognition of significant anesthetic or obstetric risk factors should encourage consultation between the obstetrician and the anesthesiologist.
Intrapartum Platelet Count
- A routine platelet count is not necessary in the healthy parturient.
Blood Type and Screen
Perianesthetic Recording of Fetal Heart Rate Patterns
- Continuous electronic recording of fetal heart rate patterns may not be necessary in every clinical setting and may not be possible during placement of a neuraxial catheter.
- The oral intake of moderate amounts of clear liquids may be allowed for uncomplicated laboring patients.
- Examples of clear liquids include, but are not limited to, water, fruit juices without pulp, carbonated beverages, clear tea, black coffee, and sports drinks.
- The volume of liquid ingested is less important than the presence of particulate matter in the liquid ingested.
Antacids, H2-receptor Antagonists, and Metoclopramide
Anesthetic Care for Labor and Delivery
Timing of Neuraxial Analgesia and Outcome of Labor
- Reassure patients that the use of neuraxial analgesia does not increase the incidence of cesarean delivery.
Neuraxial Analgesia and Trial of Labor after Prior Cesarean Delivery
Early Insertion of a Neuraxial (i.e., Spinal or Epidural) Catheter for Complicated Parturients
- In these cases, the insertion of a neuraxial catheter may precede the onset of labor or a patient’s request for labor analgesia.
Continuous Infusion Epidural Analgesia
Single-injection Spinal Opioids with or without Local Anesthetics
Pencil-point Spinal Needles
Combined Spinal–Epidural Analgesia
Patient-controlled Epidural Analgesia
Removal of Retained Placenta
- If an epidural catheter is in place and the patient is hemodynamically stable, consider providing epidural anesthesia.
Nitroglycerin for Uterine Relaxation
- Initiating treatment with incremental doses of IV or sublingual (i.e., tablet or metered dose spray) nitroglycerin may be done to sufficiently relax the uterus.
Anesthetic Care for Cesarean Delivery
Equipment, Facilities, and Support Personnel
General, Epidural, Spinal, or Combined Spinal–Epidural Anesthesia
- Uterine displacement (usually left displacement) should be maintained until delivery regardless of the anesthetic technique used.
IV Fluid Preloading or Coloading
Ephedrine or Phenylephrine
Neuraxial Opioids for Postoperative Analgesia
Postpartum Tubal Ligation
- Be aware that gastric emptying will be delayed in patients who have received opioids during labor.
- Be aware that an epidural catheter placed for labor may be more likely to fail with longer postdelivery time intervals.
- If a postpartum tubal ligation is to be performed before the patient is discharged from the hospital, do not attempt the procedure at a time when it might compromise other aspects of patient care on the labor and delivery unit.
Management of Obstetric and Anesthetic Emergencies
Resources for Management of Hemorrhagic Emergencies
- In an emergency, type-specific or O-negative blood is acceptable.
- In cases of intractable hemorrhage, when banked blood is not available or the patient refuses banked blood, consider intraoperative cell salvage if available.
Equipment for Management of Airway Emergencie
- Basic airway management equipment should be immediately available during the provision of neuraxial analgesia.
- Portable equipment for difficult airway management should be readily available in the operative area of labor and delivery units.
- A preformulated strategy for intubation of the difficult airway should be in place.
- When tracheal intubation has failed, consider ventilation with mask and cricoid pressure or with a supraglottic airway device (e.g., laryngeal mask airway, intubating laryngeal mask airway, and laryngeal tube) for maintaining an airway and ventilating the lungs.
- If it is not possible to ventilate or awaken the patient, a surgical airway should be performed.
- Uterine displacement (usually left displacement) should be maintained.
- If maternal circulation is not restored within 4 min, cesarean delivery should be performed by the obstetrics team.
February 1, 2016
External Publication Status
Country of Publication
Enhance the quality of anesthetic care for obstetric patients, improve patient safety by reducing the incidence and severity of anesthesia-related complications, and increase patient satisfaction.
Target Patient Population
Patients with uncomplicated pregnancies or with common obstetric problems
Target Provider Population
Health Care Settings
Hospital, Operating and recovery room, Outpatient
Nurse, nurse practitioner, physician, physician assistant
D013513 - Obstetric Surgical Procedures, D000773 - Anesthesia, Obstetrical, D016362 - Analgesia, Obstetrical, D009774 - Obstetrics
Peripartum, Obstetric Anesthesia, intrapartum anesthesia
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 2016;124(2):270-300.