Category A.

Randomized controlled trials report comparative findings between clinical interventions for specified outcomes. Statistically significant ( P < 0.01) outcomes are designated as either beneficial (B) or harmful (H) for the patient; statistically nonsignificant findings are designated as equivocal (E).

• 
  

  Level 1: The literature contains a sufficient number of RCTs to conduct meta-analysis, ^c

  
  

  c All meta-analyses are conducted by the ASA methodology group. Meta-analyses from other sources are reviewed but not included as evidence in this document.

  and meta-analytic findings from these aggregated studies are reported as evidence.
  
  
  
• 
  

  Level 2: The literature contains multiple RCTs, but the number of RCTs is not sufficient to conduct a viable meta-analysis for the purpose of these updated guidelines. Findings from these RCTs are reported separately as evidence.

  
  
• 
  

  Level 3: The literature contains a single RCT, and findings are reported as evidence.

Category B.

Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relations among clinical interventions and clinical outcomes. Inferred findings are given a directional designation of beneficial (B), harmful (H), or equivocal (E). For studies that report statistical findings, the threshold for significance is a P value of less than 0.01.

• 
  

  Level 1: The literature contains observational comparisons (e.g., cohort and case-control research designs) with comparative statistics between clinical interventions for a specified clinical outcome.

  
  
• 
  

  Level 2: The literature contains noncomparative observational studies with associative statistics (e.g., relative risk, correlation, or sensitivity/specificity).

  
  
• 
  

  Level 3: The literature contains noncomparative observational studies with descriptive statistics (e.g., frequencies and percentages).

  
  
• 
  

  Level 4: The literature contains case reports.

Insufficient literature.

The lack of sufficient scientific evidence in the literature may occur when the evidence is either unavailable (i.e., no pertinent studies found) or inadequate. Inadequate literature cannot be used to assess relations among clinical interventions and outcomes because a clear interpretation of findings is not obtained due to methodologic concerns (e.g., confounding of study design or implementation), or the study does not meet the criteria for content as defined in the “Focus” of the guidelines.

Category A: Expert opinion.

Survey responses from Task Force-appointed expert consultants are reported in summary form in the text, with a complete listing of the consultant survey responses reported in Appendix 2 .

Category B: Membership opinion.

Survey responses from active ASA members are reported in summary form in the text, with a complete listing of ASA member survey responses reported in Appendix 2 .

Survey responses from expert and membership sources are recorded using a 5-point scale and summarized based on median values. ^d

d When an equal number of categorically distinct responses are obtained, the median value is determined by calculating the arithmetic mean of the two middle values. Ties are calculated by a predetermined formula.

• 
  

  Strongly Agree: Median score of 5 (at least 50% of the responses are 5)

  
  
• 
  

  Agree: Median score of 4 (at least 50% of the responses are 4 or 4 and 5)

  
  
• 
  

  Equivocal: Median score of 3 (at least 50% of the responses are 3, or no other response category or combination of similar categories contain at least 50% of the responses)

  
  
• 
  

  Disagree: Median score of 2 (at least 50% of responses are 2 or 1 and 2)

  
  
• 
  

  Strongly Disagree: Median score of 1 (at least 50% of responses are 1)

Category C: Informal opinion.

Open-forum testimony obtained during the development of these guidelines, Internet-based comments, letters, and editorials are all informally evaluated and discussed during the formulation of guideline recommendations. When warranted, the Task Force may add educational information or cautionary notes based on this information.

Literature findings.

Although it is a well-accepted clinical practice to review medical records and conduct a physical examination, comparative studies are insufficient to directly evaluate the impact of these practices. Studies with observational findings suggest that certain patient or clinical characteristics (e.g., hypertensive disorders of pregnancy such as preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome, obesity, and diabetes mellitus) may be associated with obstetric complications ( Category B2/B3-H evidence ).

Survey findings.

The consultants and ASA members both strongly agree (l) to conduct a focused history and physical examination before providing anesthesia care and (2) that a communication system should be in place to encourage early and ongoing contact between obstetric providers, anesthesiologists, and other members of the multidisciplinary team.

Literature findings.

The literature is insufficient to assess whether a routine platelet count can predict anesthesia-related complications in uncomplicated parturients. An observational study reported that platelet count and fibrinogen values are associated with the frequency of postpartum hemorrhage ( Category B2 evidence ). Other observational studies and case reports suggest that a platelet count may be useful for diagnosing hypertensive disorders of pregnancy, such as preeclampsia; hemolysis, elevated liver enzymes, and low platelet count syndrome; and other conditions associated with coagulopathy ( Category B3/B4-B evidence ).

Survey findings.

The consultants and ASA members strongly agree that the anesthesiologist’s decision to order or require a platelet count should be individualized and based on a patient’s history (e.g., preeclampsia with severe features), physical examination, and clinical signs.

Literature findings.

The literature is insufficient to determine whether obtaining a blood type and screen is associated with fewer maternal anesthetic complications. In addition, the literature is insufficient to determine whether a blood cross-match is necessary for healthy and uncomplicated parturients.

Survey findings.

The ASA members agree and the consultants strongly agree that (1) a routine blood cross-match is not necessary for healthy and uncomplicated parturients for vaginal or operative delivery and (2) the decision whether to order or require a blood type and screen or cross-match should be based on maternal history, anticipated hemorrhagic complications (e.g., placenta accreta in a patient with placenta previa and previous uterine surgery), and local institutional policies.

Literature findings.

Studies with observational findings and case reports indicate that fetal heart rate patterns may change after the administration of neuraxial anesthetics ( Category B3/B4 evidence ).

Survey findings.

The consultants and ASA members strongly agree that fetal heart rate patterns should be monitored by a qualified individual before and after administration of neuraxial analgesia for labor.

Literature findings.

There is insufficient published literature to examine the relation between fasting times for clear liquids and the risk of emesis/reflux or pulmonary aspiration during labor.

Survey findings.

ASA members agree and the consultants strongly agree that (l) oral intake of moderate amounts of clear liquids may be allowed for uncomplicated laboring patients and (2) the uncomplicated patient undergoing elective surgery (e.g., scheduled cesarean delivery or postpartum tubal ligation) may have moderate amounts of clear liquids up to 2 h before induction of anesthesia.

Literature findings.

A specific fasting time for solids that is predictive of maternal anesthetic complications has not been determined. There is insufficient published literature to address the safety of any particular fasting period for solids in obstetric patients.

Survey findings.

The consultants and ASA members strongly agree that (l) the patient undergoing elective surgery (e.g., scheduled cesarean delivery or postpartum tubal ligation) should undergo a fasting period for solids of 6 to 8 h depending on the type of food ingested (e.g., fat content); (2) laboring patients with additional risk factors for aspiration (e.g., morbid obesity, diabetes mellitus, and difficult airway) or patients at increased risk for operative delivery (e.g., nonreassuring fetal heart rate pattern) may have further restrictions of oral intake, determined on a case-by-case basis; and (3) solid foods should be avoided in laboring patients.

Literature findings.

Randomized controlled trials indicate that preoperative nonparticulate antacids (e.g., sodium citrate and sodium bicarbonate) are associated with higher gastric pH values during the peripartum period ( Category A2-B evidence ) and are equivocal regarding gastric volume ( Category A2-E evidence ). Randomized placebo-controlled trials indicate that H ₂ -receptor antagonists are associated with higher gastric pH values in obstetric patients ( Category A2-B evidence ) and are equivocal regarding gastric volume ( Category A2-E evidence ). Randomized placebo-controlled trials indicate that metoclopramide is associated with reduced peripartum nausea and vomiting ( Category A2-B evidence ). Literature is not available that examines the relation between reduced gastric acidity and the frequency of pulmonary aspiration, emesis, morbidity, or mortality in obstetric patients who have aspirated gastric contents.

Survey findings.

The consultants and ASA members both agree that before surgical procedures (e.g., cesarean delivery or postpartum tubal ligation), consider the timely administration of nonparticulate antacids, H ₂ -rcceptor antagonists, and/or metoclopramide for aspiration prophylaxis.

Literature findings.

Meta-analyses of RCTs report equivocal findings for spontaneous, instrumented, and cesarean delivery when comparing early administration (i.e., cervical dilations of less than 4 or 5 cm) with late administration (i.e., cervical dilations of greater than 4 or 5 cm) of epidural analgesia ( Category A1-E evidence ). An RCT comparing cervical dilations of less than 2 cm with greater than or equal to 2 cm also reports equivocal findings ( Category A3-E evidence ). Finally, RCTs comparing early versus late combined spinal-epidural (CSE) analgesia administration report equivocal findings for cesarean, instrumented, and spontaneous delivery ( Category A2-E evidence ).

Survey findings.

The consultants and ASA members strongly agree to (1) provide patients in early labor (i.e., less than 5 cm dilation) the option of neuraxial analgesia when this service is available; (2) offer neuraxial analgesia on an individualized basis; and (3) not withhold neuraxial analgesia on the basis of achieving an arbitrary cervical dilation.

Literature findings.

Nonrandomized comparative studies are equivocal regarding mode of delivery, duration of labor, and adverse outcomes when epidural analgesia is used in a trial of labor for previous cesarean delivery patients ( Category B1-E evidence ).

Survey findings.

The consultants and ASA members strongly agree (1) to offer neuraxial techniques to patients attempting vaginal birth after previous cesarean delivery and (2) that for these patients, it is appropriate to consider early placement of a neuraxial catheter that can be used later for labor analgesia or for anesthesia in the event of operative delivery.

Analgesia/anesthetic techniques.

Considerations for analgesic/anesthetic techniques include (l) early insertion of a neuraxial (i.e., spinal or epidural) catheter for complicated parturients, (2) continuous infusion epidural (CIE) analgesia, (3) epidural local anesthetics combined with opioids, (4) higher versus lower concentrations of local anesthetics, (5) single-injection spinal opioids with or without local anesthetics, (6) pencil-point spinal needles, (7) CSE analgesia, and (8) patient-controlled epidural analgesia (PCEA).

Literature findings.

The literature is insufficient to assess whether, when caring for the complicated parturient, the early insertion of a neuraxial catheter, with immediate or later administration of analgesia, improves maternal or neonatal outcomes.

Survey findings.

The consultants and ASA members strongly agree to consider early insertion of a neuraxial catheter for obstetric (e.g., twin gestation or preeclampsia) or anesthetic indications (e.g., anticipated difficult airway or obesity) to reduce the need for GA if an emergent procedure becomes necessary.

Literature findings.

Randomized controlled trials indicate that CIE local anesthetics are associated with reduced maternal pain and discomfort compared with single-shot IV opioids during labor ( Category A2-B evidence ). The literature is insufficient to evaluate CIE compared with continuous infusion of IV opioids. An RCT reports greater pain relief during labor for CIE when compared with intramuscular opioids ( Category A3-B evidence ), with equivocal findings for duration of labor and mode of delivery ( Category A3-E evidence ). A nonrandomized comparative study reports equivocal findings for duration of labor and mode of delivery when CIE local anesthetics are compared with single-injection spinal opioids ( Category B1-E evidence ).

Survey findings.

The consultants and ASA members strongly agree that (1) continuous epidural infusion may be used for effective analgesia for labor and delivery, and (2) when a continuous epidural infusion of local anesthetic is selected, an opioid may be added.

Literature findings.

Meta-analyses of RCTs report improved analgesic quality when comparing epidural local anesthetics combined with opioids versus equal concentrations of epidural local anesthetics without opioids ( Category A1-B evidence ). Findings were equivocal for frequency of spontaneous delivery, hypotension, pruritus, and 1-min Apgar scores ( Category A1-E evidence ).

Randomized controlled trials are equivocal for analgesic efficacy and duration of labor when continuous epidural infusion of low concentrations of local anesthetics with opioids are compared with higher concentrations of local anesthetics without opioids for maintenance of analgesia ( Category A2-E evidence ). Meta-analyses of RCTs are also equivocal regarding spontaneous delivery and neonatal Apgar scores when continuous epidural infusion of low concentrations of local anesthetics with opioids are compared with higher concentrations of local anesthetics without opioids ( Category A1-E evidence ). A lower frequency of motor block was found for lower concentrations of local anesthetics ( Category A1-B evidence ). ^{, k}

k The Task Force notes that the addition of an opioid to a local anesthetic infusion allows an even lower concentration of local anesthetic for providing equally effective analgesia.

Survey findings.

The consultants and ASA members strongly agree to use dilute concentrations of local anesthetics with opioids to produce as little motor block as possible.

Literature findings.

An RCT reports a longer duration of analgesia when a spinal opioid is compared with an IV opioid ( Category A1-B evidence ). Nonrandomized comparisons are equivocal for duration of labor, mode of delivery, and other adverse outcomes such as nausea, vomiting, headache, and pruritus ( Category B1-E evidence ). The literature is not sufficient to compare single-injection spinal opioids with local anesthetics versus single-injection spinal opioids without local anesthetics.

Survey findings.

The consultants and ASA members agree that single-injection spinal opioids with or without local anesthetics may be used to provide effective, although time-limited, analgesia for labor when spontaneous vaginal delivery is anticipated. The ASA members agree and the consultants strongly agree that a local anesthetic may be added to a spinal opioid to increase duration and improve quality of analgesia.

Literature findings.

Meta-analysis of RCTs indicate that the use of pencil-point spinal needles reduces the frequency of postdural puncture headache when compared with cutting-bevel spinal needles ( Category A1-B evidence ).

Survey findings.

The consultants and ASA members strongly agree to use pencil-point spinal needles instead of cutting-bevel spinal needles to minimize the risk of postdural puncture headache.

Literature findings.

Meta-analyses of RCTs report improved analgesia and a faster onset time ( Category A2-B evidence ) when CSE local anesthetics with opioids are compared with epidural local anesthetics with opioids, with equivocal findings for maternal satisfaction with analgesia, mode of delivery, hypotension, pruritus, and 1-min Apgar scores ( Category A1-E evidence ). Meta-analysis of RCTs report an increased frequency of motor block with CSE ( Category A1-H evidence ).

Survey findings.

The consultants and ASA members strongly agree that (1) if labor is expected to last longer than the analgesic effects of the spinal drugs chosen, or if there is a good possibility of operative delivery, then consider a catheter technique instead of a single-injection technique and (2) CSE techniques may be used to provide effective and rapid onset of analgesia for labor.

Literature findings.

Meta-analysis of RCTs report reduced analgesic consumption ( Category A1-B evidence ) when PCEA is compared with CIE. Meta-analysis of RCTs report equivocal findings for duration of labor, mode of delivery, motor block, and 1- and 5-min Apgar scores when PCEA is compared with CIE ( Category A1-E evidence ). Meta-analysis of RCTs indicate greater analgesic efficacy for PCEA with a background infusion compared with PCEA without a background infusion ( Category A1-B evidence ) and is equivocal regarding mode of delivery and frequency of motor block ( Category A1-E evidence ).

Survey findings.

The consultants and ASA members strongly agree that (l) PCEA may be used to provide an effective and flexible approach for the maintenance of labor analgesia and (2) the use of PCEA may be preferable to fixed-rate CIE for providing fewer anesthetic interventions and reducing dosages of local anesthetics. The consultants and ASA members agree that PCEA may be used with or without a background infusion.

Early insertion of a neuraxial catheter for complicated parturients

• •
  

  Consider early insertion of a neuraxial catheter for obstetric (e.g., twin gestation or preeclampsia) or anesthetic indications (e.g., anticipated difficult airway or obesity) to reduce the need for GA if an emergent procedure becomes necessary.

  
  
  
  
  • •
    

    In these cases, the insertion of a neuraxial catheter may precede the onset of labor or a patient’s request for labor analgesia.

  
  

CIE analgesia

• •
  

  Continuous epidural infusion may be used for effective analgesia for labor and delivery.

  
  
• •
  

  When a continuous epidural infusion of local anesthetic is selected, an opioid may be added to reduce the concentration of local anesthetic, improve the quality of analgesia, and minimize the motor block.

Analgesic concentrations

• •
  

  Use dilute concentrations of local anesthetics with opioids to produce as little motor block as possible.

Single-injection spinal opioids with or without local anesthetics

• •
  

  Single-injection spinal opioids with or without local anesthetics may be used to provide effective, although time-limited, analgesia for labor when spontaneous vaginal delivery is anticipated.

  
  
• •
  

  If labor duration is anticipated to be longer than the analgesic effects of the spinal drugs chosen, or if there is a reasonable possibility of operative delivery, then consider a catheter technique instead of a single-injection technique.

  
  
• •
  

  A local anesthetic may be added to a spinal opioid to increase duration and improve quality of analgesia.

Pencil-point spinal needles

• •
  

  Use pencil-point spinal needles instead of cutting-bevel spinal needles to minimize the risk of postdural puncture headache.

CSE analgesia

• •
  

  If labor duration is anticipated to be longer than the analgesic effects of the spinal drugs chosen, or if there is a reasonable possibility of operative delivery, then consider a catheter technique instead of a single-injection technique.

  
  
• •
  

  CSE techniques may be used to provide effective and rapid onset of analgesia for labor.

Patient-controlled epidural analgesia

• •
  

  Patient-controlled epidural analgesia may be used to provide an effective and flexible approach for the maintenance of labor analgesia.

  
  
• •
  

  The use of PCEA may be preferable to fixed-rate CIE for administering reduced dosages of local anesthetics.

  
  
• •
  

  PCEA may be used with or without a background infusion.

Literature findings.

The literature is insufficient to assess whether a particular anesthetic technique is more effective than another for removal of retained placenta.

Survey findings.

The consultants and ASA members strongly agree (l) that the hemodynamic status should be assessed before administering neuraxial anesthesia and (2) if an epidural catheter is in place and the patient is hemodynamically stable, consider providing epidural anesthesia. The consultants and ASA members agree to consider aspiration prophylaxis. The consultants and ASA members strongly agree that (1) titration of sedation/analgesia should be performed carefully due to the potential risks of respiratory depression and pulmonary aspiration during the immediate postpartum period and (2) in cases involving major maternal hemorrhage with hemodynamic instability, GA with an endotracheal tube may be considered in preference to neuraxial anesthesia.

Literature findings.

Randomized controlled trials comparing IV or sublingual nitroglycerin with placebo for the purpose of uterine relaxation report inconsistent findings for the successful removal of retained placenta ( Category A2-E evidence ). Observational studies and case reports indicate successful uterine relaxation and successful placental removal after IV or sublingual nitroglycerin administration ( Category B3/B4 evidence ).

Survey findings.

The ASA members agree and the consultants strongly agree that nitroglycerin may be used as an alternative to terbutaline sulfate or general endotracheal anesthesia with halogenated agents for uterine relaxation during removal of retained placental tissue.

Literature findings.

The literature is insufficient to evaluate the benefit of providing equipment, facilities, and support personnel in the labor and delivery operating suite comparable to that available in the main operating suite.

Survey findings.

The consultants and ASA members strongly agree that (l) equipment, facilities, and support personnel available in the labor and delivery operating suite should be comparable to those available in the main operating suite; (2) resources for the treatment of potential complications (e.g., failed intubation, inadequate anesthesia, hypotension, respiratory depression, local anesthetic systemic toxicity, pruritus, and vomiting) should also be available in the labor and delivery operating suite; and (3) appropriate equipment and personnel should be available to care for obstetric patients recovering from major neuraxial or GA.

Literature findings.

Randomized controlled trials report higher Apgar scores at 1 and 5 min for epidural anesthesia when compared with GA ( Category A2-B evidence ) and equivocal findings for umbilical artery pH values ( Category A2-E evidence ). When spinal anesthesia is compared with GA, RCTs report equivocal findings for 1- and 5-min Apgar scores and umbilical artery pH values ( Category A1-E evidence ). RCTs also are equivocal regarding total time in the operating room when epidural or spinal anesthesia is compared with GA ( Category A2-E evidence ).

When spinal anesthesia is compared with epidural anesthesia, RCTs are equivocal regarding induction-to-delivery times, hypotension, umbilical pH values, and Apgar scores ( Category A2-E evidence ).

When CSE is compared with epidural anesthesia, RCTs report equivocal findings for the frequency of hypo­tension and for 1-min Apgar scores ( Category A2-E evidence ). RCTs report equivocal findings for delivery times, time in the operating room, hypotension, and l- and 5-min Apgar scores when CSE is compared with spinal anesthesia ( Category A2-E evidence ).

Survey findings.

The consultants and ASA members strongly agree that (1) the decision to use a particular anesthetic technique for cesarean delivery should be individualized, based on anesthetic, obstetric, or fetal risk factors (e.g., elective versus emergency), the preferences of the patient, and the judgment of the anesthesiologist; (2) uterine displacement (usually left displacement) should be maintained until delivery regardless of the anesthetic technique used; (3) consider selecting neuraxial techniques in preference to GA for most cesarean deliveries; (4) if spinal anesthesia is chosen, use pencil-point spinal needles instead of cutting-bevel spinal needles; (5) for urgent cesarean delivery, an indwelling epidural catheter may be used as an alternative to initiation of spinal anesthesia; and (6) GA may be the most appropriate choice in some circumstances (e.g., profound fetal bradycardia, ruptured uterus, severe hemorrhage, severe placental abruption, umbilical cord prolapse, and preterm footling breech).

Literature findings.

Randomized controlled trial findings are inconsistent regarding the frequency of maternal hypotension when IV fluid preloading or coloading for spinal anesthesia is compared with no fluids ( Category A2-E evidence ). Meta-analyses of RCTs are equivocal for maternal hypotension when IV fluid preloading is compared with coloading ( Category A2-E evidence ).

Survey findings.

The consultants and ASA members agree that IV fluid preloading may be used to reduce the frequency of maternal hypotension after spinal anesthesia for cesarean delivery. The ASA members agree and the consultants strongly agree that, although fluid preloading reduces the frequency of maternal hypotension, it does not delay the initiation of spinal anesthesia in order to administer a fixed volume of IV fluid.

Literature findings.

Meta-analysis of double-blind placebo-controlled RCTs report reduced maternal hypotension during anesthesia for cesarean delivery when IV ephedrine is administered compared with placebo ( Category A1-B evidence ). RCTs are equivocal for hypotension when intramuscular ephedrine is compared with placebo ( Category A2-E evidence ). RCTs comparing phenylephrine with placebo report a lower frequency of hypotension when higher dosages of phenylephrine are administered ( Category A2-B evidence ) and equivocal findings when lower dosages are administered ( Category A2-E evidence ). Meta-analysis of double-blind RCTs report lower frequencies of patients with hypotension when infusions of phenylephrine are compared with ephedrine ( Category A1-B evidence ) ; higher umbilical artery pH values are reported for phenylephrine when compared with ephedrine ( Category A1-H evidence ).

Survey findings.

The consultants and ASA members strongly agree that IV ephedrine and phenylephrine both may be used for treating hypotension during neuraxial anesthesia.

Literature findings.

Randomized controlled trials comparing epidural opioids with intermittent injections of IV or intramuscular opioids report improved postoperative analgesia for epidural opioids after cesarean delivery ( Category A2-B evidence ) ; meta-analysis of RCTs reports equivocal findings for nausea, vomiting, and pruritus ( Category A1-E evidence ). RCTs report improved postoperative analgesia when PCEA is compared with IV patient-controlled analgesia ( Category A2-B evidence ) with equivocal findings for nausea, vomiting, pruritus, and sedation ( Category A2-E evidence ).

Survey findings.

The consultants and ASA members strongly agree that for postoperative analgesia after neuraxial anesthesia for cesarean delivery, selecting neuraxial opioids rather than intermittent injections of parenteral opioids should be considered.

Literature findings.

The literature is insufficient to evaluate the benefits of neuraxial anesthesia compared with GA for postpartum tubal ligation. In addition, the literature is insufficient to evaluate the impact of the timing of a postpartum tubal ligation on maternal outcome.

Survey findings.

The consultants and ASA members strongly agree (l) that before postpartum tubal ligation, the patient should have no oral intake of solid foods within 6 to 8 h of the surgery, depending on the type of food ingested (e.g., fat content), and (2) that both the timing of the procedure and the decision to use a particular anesthetic technique (i.e., neuraxial versus general) should be individualized based on anesthetic risk factors, obstetric risk factors (e.g., blood loss), and patient preferences. The ASA members agree and the consultants strongly agree to consider selecting neuraxial techniques in preference to GA for most postpartum tubal ligations.

Survey findings.

The consultants and ASA members strongly agree that institutions providing obstetric care should have resources available to manage hemorrhagic emergencies.

Survey findings.

The consultants and ASA members strongly agree that labor and delivery units should have personnel and equipment readily available to manage airway emergencies consistent with the ASA Practice Guidelines for Management of the Difficult Airway, to include a pulse oximeter and carbon dioxide detector.

Literature findings.

The literature is insufficient to evaluate the efficacy of cardiopulmonary resuscitation in the obstetric patient during labor and delivery. In cases of cardiac arrest, the American Heart Association has stated that 4 to 5 min is the maximum time rescuers will have to determine whether the arrest can be reversed by Basic Life Support and Advanced Cardiac Life Support interventions. ^m Delivery of the fetus may improve cardiopulmonary resuscitation of the mother by relieving aortocaval compression. The American Heart Association further notes that the best survival rate for infants more than 24 to 25 weeks in gestation occurs when the delivery of the infant occurs no more than 5 min after the mother’s heart stops beating.

Survey findings.

The consultants and ASA members strongly agree that (1) basic and advanced life-support equipment should be immediately available in the operative area of labor and delivery units, and (2) if cardiac arrest occurs during labor and delivery, to initiate standard resuscitative measures with accommodations for pregnancy such as left uterine displacement and preparing for delivery of the fetus.