October 2000
Volume 64 |
Number 10
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| AWHOON Guidelines
and Obstetric Anesthesia Practice |
James P. McMichael,
M.D.
Committee on Anesthesia Care Team
The
Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN)
is the specialty society that represents nurses who care for patients
for whom anesthesiologists provide care in the labor and delivery
suite. It began as the Nurses Association of the American College
of Obstetricians and Gynecologists (NAACOG). As the current name
indicates, AWHONN sees as its constituency nurses involved in
all aspects of women's health care needs.
Anesthesiologists provide care to women
throughout their lives, but obstetric anesthesiologists' involvement
with women and their families during pregnancy and the peripartum
period provides an opportunity for more personal contact and visibility
than in most other aspects of the practice of anesthesiology.
While anesthesiologists interact with nurses in a variety of areas
in the hospital, the relationship with and dependence on the obstetrics
(OB) nurse during labor and delivery is perhaps more intense than
in any other patient care area. Mutual understanding, trust and
respect are essential as both groups of professionals provide
care at this very special time in the lives of women.
Many medical specialty societies, including
ASA, have published various standards, guidelines, protocols or
practice parameters. ASA has published guidelines for anesthesia
care provided to the pregnant patient, including Standards for
Conduction Anesthesia in Obstetrics (1988), Guidelines for Regional
Anesthesia in Obstetrics (1990) and Practice Guidelines for Obstetrical
Anesthesia approved in 1998 by the ASA House of Delegates. 1
Standards and guidelines are also common
in nursing; AWHONN has published its own Standards and Guidelines,
the most recent version being the 5th edition, 1998. (Neither
ASA nor the Society for Obstetric Anesthesia and Perinatology
was involved in the development of this document.) General statements
found in this publication include: These Standards and Guidelines
summarize the nursing profession's best judgment and optimal practice
based on current research and clinical practice. AWHONN believes
that these guidelines will be helpful for all nurses engaged in
the functions described. However, as with most or all such standards,
certain qualifications should be borne in mind. AWHONN states
that these Standards and Guidelines:
- articulate general guidelines; additional
considerations or procedures may be warranted for particular
patients or settings;
- represent optimal practice; full compliance
may not be possible at all times with all patients in all
settings, although optimal practice should be strived for;
- are but one source of guidance. Nurses
also must act in accordance with law, institutional rules
and procedures and established interprofessional arrangements
concerning the division of duties;
- are intended to serve as a guide for
optimal practice.
They are not designed to establish the
required standard of care for legal liability, licensure, discipline,
ethical matters or for reimbursement or payment for services,
which are determined according to other bodies of rules; may change
in response to changes in research and practice.
What are the issues in the AWHONN guidelines
that are of particular interest to anesthesiologists? The main
concerns of anesthesiologists providing care to women in labor
are found in the "Guidelines for Perioperative and Perianalgesia/Anesthesia
Care of the Pregnant Woman" in the section titled "Epidural
Anesthesia/Analgesia for Labor and Vaginal Birth" (which
is currently being reviewed by AWHONN). The specific issues that
have caused concern for obstetric anesthesiologists are found
in item six, page 33 of the 1998 AWHONN guidelines:
"Catheter dosing includes the
rebolus of an epidural catheter by manual syringe injection,
the continuous infusion of pharmacologic agents via continuous
pump infusion, and increasing the rate of the continuous pump
infusions. Catheter dosing is performed only by a licensed anesthesia
provider. The perinatal nurse may replace empty infusion syringes
or infusion bags (for continuous pump therapy) with premeasured,
prepackaged solutions; stop the infusion in an anesthetic emergency"
These guidelines may not be as problematic
for OB services that have a volume sufficient to justify a 24-hour
in-hospital service as they may be for smaller OB services that
cannot support an anesthesiologist dedicated to labor and delivery.
However, there certainly are (or were) OB anesthesia services
that provided safe and effective care to obstetric patients utilizing
practices that are at odds with the tenets of the AWHONN guidelines.
The disclaimers quoted above allow for
additional considerations, established interprofessional arrangements
and [these] are not designed to establish the required standard
of care for legal liability, [and] licensure. However, it appears
that some state boards of nursing, as well as many hospital nursing
departments, have adopted the AWHONN guidelines as policy. When
asked about this, the AWHONN executive director stated that "it
is within the purview of individual state boards to adopt any
association's guidelines or recommendations," and it is the
prerogative of health care facilities to evaluate AWHONN's guidelines
relative to their patient populations, the risks inherent in the
administration of anesthetic agents in labor, and the validated
competence of nursing personnel to adjust doses of anesthetic/analgesic
agents. [However] AWHONN maintains the recommendation that catheter
dosing of the patient during labor and birth should be performed
only by a licensed anesthesia provider." In July of this
year, AWHONN reported that their position on nurse bolusing of
a defined volume of a dilute concentration [of a local anesthetic
and a narcotic] will be reviewed in early 2001.
It is of interest to note that AWHONN has
made no mention of the use of patient-controlled epidural analgesia
(PCEA). The use of this technique has not been widespread for
the patient in labor, but for a variety of reasons, it may be
on the increase. AWHONN is developing a position on the monitoring
needs of the woman in labor receiving pain management by PCEA.
Patient safety and quality care is of primary
importance to both anesthesiologists and labor and delivery nurses.
Before any nurse can be involved in the care of patients who have
indwelling epidural catheters for pain management, be it for postoperative
pain or for the management of the pain associated with labor and
delivery, the proper "educational infrastructure" must
be in place. Anesthesiologists caring for women during labor and
delivery must be involved in the development of institutional
nursing education programs and must continuously monitor the effectiveness
of those educational efforts. With appropriate education and ongoing
evaluation of nursing practices, there should be no reason to
set universal limits on the involvement of nurses caring for women
having neuraxial analgesia for labor.
| "Before
any nurse can be involved in the care of patients...the proper
'educational infrastructure' must be in place." |
Just as there are significant and serious
concerns about having enough anesthesiologists and other members
of the anesthesia care team to meet the anesthesia needs in the
United States, the same worries are found in the nursing community.
AWHONN is concerned about the nationwide escalating nursing shortage
on the provision of safe patient care and is trying to factor
this into the discussion of its Standards and Guidelines.
ASA, through the Committee on Anesthesia
Care Team, has established a formal liaison with AWHONN. It is
hoped that through this relationship, nursing practice standards
can be developed that will allow for timely and safe interventions
involving neuraxial techniques by obstetric nurses.
For those practices that are or might be
affected by AWHONN's position, strategies for reacting to or adapting
to these guidelines may include:
1. Review of existing literature –
where are the near misses or bad outcomes?
2. Education, including monitoring and measuring the effects of
existing policies concerning different classes of drugs administered
by OB nurses.
3. Negotiation
4. Compromise – appeal to common sense
5. Consideration of the use of patient-controlled epidural analgesia
(PCEA)
6. Live with them (but don’t abandon items 1-5).
Reference:
1. Practice guidelines
for obstetrical anesthesia: A report by the American Society of
Anesthesiologists Task Force on Obstetrical Anesthesia. Anesthesiology.
1999; 90:600-611.
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James
P. McMichael, M.D., is a Partner in the Capitol Anesthesiology
Association, Seton Medical Center, Brackenridge Hospital,
Austin, Texas. |
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