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Obstetric Regional Analgesia Practice Guidelines
Canadian Anaesthesiologists' Society, 1999

These consensus-based guidelines for obstetric regional analgesia practice in Canada were prepared by a committee of the Canadian Anesthesiologists’ Society (CAS) Obstetric Section and approved in 1999 by the CAS Committee on Standards of Practice and CAS Board of Governors.

Anesthesia services to parturients include Obstetric Analgesia for labour and uncomplicated deliveries, and Obstetric Anesthesia for complicated or operative deliveries. All guidelines regarding provision of anesthesia for other diagnostic or therapeutic procedures also apply to provision of Obstetric Anesthesia. These Guidelines for Obstetrical Regional Analgesia pertain to epidural and spinal analgesia during labour. The term "regional analgesia" includes epidural, spinal, and combined spinal-epidural analgesia.

These Guidelines will be reviewed by the Canadian Anesthesologists' Society Obstetric Section every three years and updated as indicated. Each hospital may wish to develop additional guidelines or policies for specific situations where regional labour analgesia is provided.

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INITIATION OF REGIONAL LABOUR ANALGESIA

1. Prior to introducing Obstetrical Regional Analgesia, hospitals should have appropriate monitoring protocols in place. These protocols should specify requirements for both maternal and fetal monitoring, including the frequency of monitoring. In addition, protocols should clearly state how common problems and emergencies should be managed, and who to contact if assistance is required.

2. Obstetric Regional Analgesia should only be provided by physicians with training, licensure and hospital privileges to provide these services. This includes trainees with appropriate supervision.

3. Regional analgesia should only be initiated and maintained in locations where appropriate resuscitation equipment and drugs are immediately available.4. Informed consent should be obtained and documented in the medical record.

4. Informed consent should be obtained and documented in the medical record.

5. Intravenous access must be established prior to initiating regional analgesia. The intravenous access should be maintained as long as regional analgesia is utilised.

6. The anesthesiologist should be immediately available until analgesia is established and the patient’s vital signs demonstrate a stable pattern.

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MAINTENANCE OF REGIONAL LABOUR ANALGESIA

1. Continuous infusion of low dose (diluted) epidural local anesthetics with or without adjuncts are associated with a very low incidence of significant complications. Consequently, it is not necessary for an anesthesiologist to remain physically present or immediately available during maintenance of continuous epidural infusion analgesia provided:

• there are appropriate protocols for management of patients receiving epidural analgesia ; and

• the anesthesiologist can be contacted for advice and direction.

2. The safety of patient controlled epidural analgesia (PCEA) using low dose (diluted) local anesthetics with or without adjuncts is comparable to low dose continuous infusion epidural analgesia. Consequently, it is not necessary for an anesthesiologist to remain physically present or immediately available during maintenance of PCEA provided:

• there are appropriate protocols for management of patients receiving PCEA; and

• the anesthesiologist can be contacted for purpose of advice and direction.

3. Bolus doses of local anesthetics through an epidural catheter, or through a catheter or needle presumed to be in the epidural space, can cause immediate, life-threatening complications. For this reason, when a bolus dose of local anesthetic is injected through an epidural catheter (except during PCEA), an anesthesiologist must be available to intervene appropriately should any complications occur.

The intent of the phrase "available to intervene appropriately" is that individual Departments of Anesthesiology should establish their own policies regarding the availability of an anesthesiologist to manage any complications of regional analgesia. Each Department should consider the possible risks of bolus injection of local anesthetics and the methods of dealing with emergency situations in developing these policies.

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ORAL INTAKE DURING LABOUR

Gastric emptying of solids is delayed during labour. Opioid analgesics may further delay gastric emptying. Therefore, parturients should not eat solid foods once they are in established labour. In contrast to solid food, clear liquids are relatively rapidly emptied from the stomach and absorbed in the proximal small bowel, even during labour. Therefore, hospitals should develop protocols regarding the ingestion of clear liquids for women in established labour.

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