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.
◊ Reviewed by M. Vercauteren, MD, PhD,
Dept of Anesthesia, Professor,
Antwerp University Hospital,
Belgium
This well conducted survey may raise significant concern. However, it is not a surprise that the quality of post-surgery care for women with caesarean section might be inferior to that for other surgical patients. Too a variable degree negligence of the former may be explained by the high incidence of neuraxial techniques in patients not considered ill and the urge to care for their babies, to start breast feeding as soon as possible, and to meet their families.
The survey was conducted in academic hospitals only, although the concern most probably includes non-academic obstetrical departments as well. Based on an average of 2550 deliveries per hospital and year and an estimated prevalence of caesarean sections of 30% only one cesarean section occurs every 12 hours.
As a consequence in many (even newly built) hospitals, at least in Northern Belgium, caesarean deliveries are preferentially performed in the central operating theatre (except for urgent procedures) where nurses are more familiar with asepsis, surgical procedures and instrumentation while it is considered safer to subsequently transfer these patients to the main surgical post-anesthesia care unit. Even centers performing C-sections in special obstetric operating rooms mostly send patients to the main PACU in which dedicated nurses have more experience in post-anesthetic care, are available at all times, are more likely to be BLS/ACLS certified, and tend to leave their patients less as they have no responsibilities other than postoperative care. The care for the neonate is left to the perinatal nurse. This avoids one nurse being responsible for two patients as it seemed to be the case in 65% of the responding institutions with a special obstetric recovery room. In most surgical recovery rooms, a remote central monitoring, resuscitation equipment, and prepared medication are available. The discussion in the survey whether continuous ECG monitoring is mandatory is not relevant as this does not signify a major effort or cost.
As no such studies have been performed yet, it is unclear whether a decentralisation of surgical delivery and postoperative care is economically beneficial when considering manpower, equipment, transportation, etc.
Finally, an additional argument in favor of a separate recovery unit for C-section patients may be that breast feeding can start very soon after delivery as indicated by the Mother and Baby Friendly Hospital Initiative. However, perinatal nurses have to be aware that, despite the benefit of early breast feeding, postsurgical maternal care prevails.
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