Appraisal of clinical practice guidelines and consensus statements on obstetric anaesthesia: a systematic review using the AGREE II instrument

Search results

We retrieved 6921 citations, with 6797 being excluded after screening titles and abstracts for not meeting eligibility criteria (figure 1). We thoroughly assessed the remaining 124 citations and excluded 102 as they did not align with our defined criteria. Ultimately, we included 14 guidelines4 16–28 and 8 consensus statements.6–8 29–33

Figure 1
Figure 1

Flow diagram for literature search. AGREE, Appraisal of Guidelines for Research and Evaluation; CBM, Chinese Biomedical Literature Database; CMAD, Chinese Medical Association Database; GIN, Guidelines International Network; NGC, National Guideline Clearinghouse; NICE, National Institute for Health and Care Excellence; SIGN, Scottish Intercollegiate Guidelines Network; TRIP, Turning Research into Practice Database.

Characteristics of included guidelines and consensus statements

A summary of the characteristics of the eligible guidelines and consensus statements is presented in table 1. Fourteen of guidelines4 16–28 and eight consensus statements6–8 29–33 with the latest versions were identified, published from 2014 to 2023, involving 15 national or multi-international organisations predominantly comprising anaesthesiologists or obstetricians and gynaecologists from the USA, UK, Europe and China. Eight documents17 18 22 24 26–28 30 clearly stated being externally reviewed. Eight of these guidelines4 6 16 18 19 21 24 25 included procedures for updating in response to emerging evidence, while only six4 16 19 22 29 32 disclosed their funding body. The focus of these guidelines was primarily on the obstetric patients undergoing vaginal delivery or caesarean delivery (figure 2), with eight documents4 6 8 18 22–25 intended for use by anaesthesiologists or other healthcare providers. Additionally, 10 documents4 17–19 21–23 26 27 33 conducted systematic literature reviews as part of their development process, which 11 documents4 16–18 21 22 24 26 27 32 33 reported the level of evidence supporting recommendations and grading the strength of the guidance recommendations themselves.

Table 1

Characteristics of included guidelines and consensus statements

Figure 2
Figure 2

A summary of the main focus of the included document. AA and OAA, Association of Anesthetists and the Obstetric Anesthetists’ Association; ANNA, American Association of Nurse Anesthesiology; AAGBI, Association of Anesthetists of Great Britain and Ireland; ACOG, American College of Obstetricians and Gynecologists; ASA, American Society of Anesthesiologists; CAA, Chinese Association of Anesthesiology; CHBSA, China Healthy Birth Science Association; ERAS, Enhanced Recovery After Surgery; NICE, National Institute for Health and Care Excellence; OAA, Obstetric Anesthetists’ Association; OG-A-CMA, Obstetrics Group, Anesthesiology Branch of Chinese Medical Association; OG-OG-CMA, Obstetrics Group, Obstetrics and Gynecology Branch of Chinese Medical Association; PROSPECT, Procedure-specific postoperative pain management working group; RcoA, Royal College of Anesthetists; SOAP, Society for Obstetric Anesthesia and Perinatology; SOGC, Society of Obstetricians and Gynecologists of Canada.

Appraisal of guidelines and consensus statements

The standardised AGREE II domain scores for each guidance document are presented in figure 3 and provided in value as online supplemental tables 6 and 7. Mean scores for each AGREE II item can be found in online supplemental table 8. The ICC were above 0.90 (online supplemental table 9). The overall quality of guidance documents varied both between documents across domains and within documents across domains. The ASA guideline published in 20164 had the highest domain scores, with five domains scoring in the upper quartile. This was followed by the guidelines published by the Enhanced Recovery After Surgery Society Recommendations (part2),27 American College of Obstetricians and Gynecologists16 and Royal College of Anesthetists,24 all with four domains scoring above the upper quartile. In total, 81.8% (18 of 22) of the included documents were of excellent quality. Guidance documents received the highest scores for the scope and purpose domain (median 76.4%, IQR 69.4%–79.2%) and the clarity of presentation domain (median 72.2%, IQR 61.1%–80.6%). However, they received the lowest scores for the applicability domain (median 21.9%, IQR 13.5%–27.1%) and the editorial independence domain (median 47.9%, IQR 6.3%–73.2%). No tendency of improvement in the quality score over time was observed.

Figure 3
Figure 3

Standardised domain scores for each document. AA and OAA, Association of Anesthetists and the Obstetric Anesthetists’ Association; AAGBI, Association of Anesthetists of Great Britain and Ireland; ACOG, American College of Obstetricians and Gynecologists; ANNA, American Association of Nurse Anesthesiology; ASA, American Society of Anesthesiologists; CAA, Chinese Association of Anesthesiology; CHBSA, China Healthy Birth Science Association; ERAS, Enhanced Recovery After Surgery; NICE, National Institute for Health and Care Excellence; OAA, Obstetric Anesthetists’ Association; OG-A-CMA, Obstetrics Group, Anesthesiology Branch of Chinese Medical Association; OG-OG-CMA, Obstetrics Group, Obstetrics and Gynecology Branch of Chinese Medical Association; PROSPECT, Procedure-specific postoperative pain management working group; RcoA, Royal College of Anesthetists; SOAP, Society for Obstetric Anesthesia and Perinatology; SOGC, Society of Obstetricians and Gynecologists of Canada.

Synthesis of recommendations

Approaches to the perianaesthetic evaluation and preparation

Sixteen documents4 6–8 16–18 21 22 24–26 28 29 31 32 were included in the perianaesthetic evaluation and preparation. Key recommendations are presented in online supplemental table 10. Ten documents4 6–8 16 24 25 28 29 31 provided recommendations for history and physical examination in pregnant individuals, with an emphasis on maternal health, anaesthetic history and relevant obstetric history. Of these, six documents4 6–8 16 25 especially recommended examining the patient’s back when a neuraxial anaesthetic was planned. Eight documents4 6 8 16 25 26 28 29 highlighted the important of communication between obstetric providers, and anaesthesiologists to recognise significant anaesthetic or obstetric risk factors.

Six guidelines4 6 7 16 21 29 referenced in the literature emphasise the important of platelet count in predicting anaesthesia-related complications. Three of these guidelines4 16 21 recommended individualising the platelet count based on a patient’s medical history. Furthermore, five documents4 6 7 21 29 discussed the necessity of blood type and screen or cross-match, with two of them4 21 suggesting that routine test is not essential for healthy and uncomplicated parturient (table 2). Additionally, nine documents4 6–8 16 18 22 25 29 indicated that fetal heart rate patterns should be monitored during the anaesthetic process.

Table 2

Some different recommendations summarised

Eleven documents4 6 17 18 21 24–26 29 31 32 addressed aspiration prevention during delivery. Regarding fasting, five documents4 6 26 31 32 suggested that clear liquids up to 2 hours before anaesthesia induction, and six documents4 6 26 29 31 32 recommended a fasting period of 6–8 hours for solids. The use of antacids, H2-receptor antagonists and metoclopramide were also recommended for aspiration prophylaxis during caesarean delivery.4 6 17 21 24 26 31

Five documents7 8 16 24 25 discussed the use of heparin or low-molecular-weight heparin during the perianaesthesia and post anaesthesia, and the ACOG16 explicitly stated that prophylactic subcutaneous unfractionated heparin at a dosage of 5000 units two times a day did not contraindicate neuraxial techniques, as long as catheter placement or removal more than 4–6 hours since last dose. In the case of intermediate-dose unfractionated heparin (7500–10 000 units) more than 12 hours after the last dose or high-dose unfractionated heparin (total daily dose greater than 20 000 units) more than 24 hours after the last dose with activated partial thromboplastin time, it was deemed low risk to proceed with neuraxial anaesthesia.

Approaches to the anaesthetic care for labour and vaginal delivery

Eight documents4 7 8 16 22 24 25 31 addressed anaesthetic care for labour and vaginal delivery (summarising in online supplemental table 11). Three documents4 7 8 explicitly indicated that neuraxial analgesia could be administrated based on the level of discomfort the parturient, without limitation of cervical dilation. The ASA suggested providing labour neuraxial analgesia for parturient in early labour (ie, cervical dilations of less than 5 cm dilation).4 These documents4 7 8 also recommended to offer neuraxial analgesia on an individualised basis. The ASA also provided recommendations on the administration of neuraxial techniques for patients attempting vaginal birth after previous caesarean delivery, as well as early placement of a neuraxial catheter.4

There were three methods for neuraxial anaesthetic: continuous infusion epidural analgesia (CIEA), combined spinal–epidural analgesia (CSEA) and single-injection spinal. Five documents4 7 8 16 25 covered both CIEA and CSEA and recommended using local anaesthetic, as well as adding opioids. Before a neuraxial procedure, the platelet count was required more than 70*109/L to reduce the risk of haematoma.8 16 25 The puncture location was recommended on L2-3 or L3-4 in China published consensus.7 8 Local anaesthetic including bupivacaine, ropivacaine and levobupivacaine were used with loading dose or maintenance doses. In China, published consensus7 8 recommended using 0.04%–0.125% bupivacaine or 0.0625%–0.15% ropivacaine to initiate analgesia and maintain with 0.05%–0.125% bupivacaine or 0.0625%–0.15% ropivacaine (table 2). The Chinese Associations of Anesthesiology (CAA) consensus also provided recommendations for 0.04%–0.125% levobupivacaine for loading dose and 0.05%–0.125% levobupivacaine for maintenance.8 These two documents suggested that opioids, including fentanyl or sufentanyl, could be injected with local anaesthetic, with recommended loading dose of fentanyl was 0.5–2 µg/mL and 1–2 µg/mL for maintenance, and the loading dose of sufentanyl was 0.2–0.6 µg/mL with maintenance dose 0.3–0.6 µg/mL.7 8 The American Association of Nurse Anesthesiology (ANNA) guideline suggested using 0.0625%–0.125% bupivacaine or 0.08%–0.2% ropivacaine with or without opioids in CIEA.25 In CSEA, opioids and local anaesthetics could be delivered in spinal, with two recommended protocols7 8 16 25: sufentanyl or ropivacaine used singly or in combination. The single dose of sufentanyl was 2.5–7 µg, single dose of ropivacaine was 2.3–3 mg and dose of combined sufentanyl and ropivacaine was 2.5 µg/2.5 mg, respectively.7 8 Another protocol was that fentanyl and bupivacaine were used singly or with combination. The single dose of fentanyl was 15–25 µg, single dose of bupivacaine was 2.0–2.5 mg and dose of combined fentanyl and bupivacaine was 2.5 µg/2.0 mg, respectively.7 8 For CSEA and single-injection spinal, both documents recommended using a small-gauge, non-cutting, pencil point needle to access the subarachnoid space.4 25 Additionally, five documents4 7 8 25 31 provided recommendations for using patient-controlled epidural analgesia for labour analgesia.

Approaches to the anaesthetic care for cesarean delivery

Ten documents4 6 16 18 24 25 27–29 31 covered the anaesthetic care including neuraxial anaesthesia and general anaesthesia for caesarean delivery (summarising in online supplemental table 12). The recommendations for neuraxial anaesthesia including CIEA, single-injection spinal and CSEA were consistent with those for labour and vaginal delivery. Eight of the documents4 6 16 18 24 25 27 28 31 covered CIEA, CSEA and single spinal injection, with four documents6 16 25 28 recommended the use of local anaesthetic with or without opioids. A platelet count more than 70*109/L was recommended to reduce the risk of haematoma.6 16 25 Puncture locations were recommended as follows: L1-2 or L2-3 for CIEA, L3-4 for single injection in spinal and L3-4 in single space for CSEA, while in double space, the puncture location was recommended in T12-L2 or L3-5.6 25 To test the effect of neuraxial anaesthesia, the recommended level of block was T6-4.6 Various local anaesthetic, including lidocaine, bupivacaine, ropivacaine and levobupivacaine, were recommended for use in CIEA. In CAA 2020,6 lidocaine was recommended with 1.5%–2% concentration, bupivacaine with 0.5% and ropivacaine with 0.5%–0.75% (table 2). And 3% chloroprocaine was also recommended. In contrast, ANNA25 recommended lower concentrations, with 0.0625%–0.125% for bupivacaine and 0.08%–0.2% for ropivacaine. For single-injection spinal procedures, the recommended doses were 5–15 mg bupivacaine or 10–20 mg ropivacaine.6 28 To prevent local anaesthetic poisoning, it was recommended that anaesthesiologist withdraw before injection and administer a test dose.6 16 It was also suggested to add epinephrine to local anaesthetic solutions to delay absorption and increase duration of blockade through vasoconstriction of the blood vessels in the area.6 16 Furthermore, the use of a small-gauge, non-cutting, pencil point needle was recommended.4 6 25

Additionally, eight documents4 6 16 21 24 25 29 31 provided recommendations on general anaesthesia for caesarean delivery. According to the ASA,4 general anaesthesia may be the most appropriate choice in cases of profound fetal bradycardia, ruptured uterus, severe haemorrhage, severe placental abruption, umbilical cord prolapse and preterm footling breech. Other documents16 25 recommended the use of general anaesthesia if neuraxial anaesthesia placement was unsuccessful. Induction delivery was recommended within 10 min, with specific intravenous anaesthetics. CAA6 detailly recommended intravenous anaesthetics including thiopental sodium (4–5 mg/kg), propofol (1.5–2.5 mg/kg), etomidate (0.2–0.3 mg/kg) and ketamine (0.5–1 mg/kg) as induction agents. Fentanyl (2–5 µg/kg), sufentanyl (0.2–0.5 µg/kg) and remifentanil (4 ng/kg for target) were commonly applied in the general anaesthesia. Succinylcholine (1–1.5 mg/kg) or rocuronium (0.6–1.2 mg/kg) was used as a muscle relaxant.

Approaches to the monitoring of obstetric and anaesthetic or intraoperative or postoperative pain management

To mitigate postcaesarean delivery pain, nine documents16 17 19 21 23 25 31–33 provided recommendations for the management of intraoperative or postoperative pain (summarising in online supplemental table 13). Six of these documents16 19 21 25 31–33 recommended the administration of intrathecal morphine 50–150 µg or epidural 1–3 mg for analgesia. Two documents19 21 also suggested the use of epidural diamorphine (2–3 mg or 2.5–5 mg) for analgesia. ANNA25 recommended hydromorphone 75–150 µg in intrathecal administration as well. When morphine was used in neuraxial block, four documents21 25 29 33 suggested monitoring respiratory frequency and modality. The Society of Obstetric Anesthesia and Perinatology33 explicitly stated that using morphine less than 0.15 mg or epidural morphine less than 3 mg in healthy parturient would pose low risk, and recommended monitoring respiratory rate and sedation measurement every 2 hours for 12 hours postoperatively. However, in high-risk circumstances such as cardiopulmonary or neurological comorbidity, obesity (body mass index ≥40 kg/m2), obstructive sleep apnoea, chronic opioid use or abuse, and hypertension, or who was administrated with magnesium, as well as high doses of morphine (morphine greater than 0.15 mg or epidural morphine greater than 3 mg), more intensive monitoring (respiratory rate and sedation assessments were monitored for every 1 hour for first 12 hours, every 2 hour for 12–24 hours) and additional modalities such as pulse oximetry and capnography were suggested (table 2). To minimise systemic opioids utilisation, eight documents16 17 19 21 25 31–33 recommended the administration of non-steroidal anti-inflammatory drug for postoperative pain. Two guidelines19 25 suggested a single dose of intravenous dexamethasone for analgesia. Local anaesthetic infiltration for the wound after caesarean delivery was recommended by six documents,16 17 19 25 31 32 and continuous local anaesthetic infusion with the wound was recommended by three documents.16 19 31 Nerve blocks, including transversus abdominis plane block and erector spinae plane block, for improving postcaesarean delivery pain was recommended by five documents.16 17 19 31 32 Patient-controlled intravenous analgesia used for pain management after caesarean was recommended by four documents.16 19 21 31 Regarding obstetric neuraxial block, the Association of Anesthetists and the Obstetric Anesthetists’ Association (AA and OAA)20 stated that straight-leg raising was used for neurological monitoring, and if a maternal was unable to straight-leg raise at 4 hours from the last dose of epidural/spinal local anaesthetic, neurological injury required be investigated.

Approaches to the adverse events during obstetric anaesthesia

Twelve documents4 6 8 16–18 21 25 27 30–32 provided recommendations for preventing the hypotension during obstetric anaesthesia (summarising in online supplemental table 14). Eleven documents4 6 8 16–18 21 25 27 30 31 advised on using 500–1000 mL volume expansion with crystals or colloids, as well as seven documents4 6 8 21 25 30 31 recommended using left uterine displacement once the maternal was positioned supine for surgery to reduce inferior vena cava compression. Vasopressor management during neuraxial anaesthesia was recommended by 10 documents,4 6 8 16 17 21 25 30–32 with vasoactive drugs such as phenylephrine, metaraminol, noradrenalin and ephedrine. Phenylephrine with 20–50 µg/min or 0.25–0.5 µg/kg/min was recommended by nine documents.4 6 8 16 17 25 30–32 Ephedrine 2–15 mg intravenous was recommended by six documents6 8 16 17 30 31 (table 2). The Association of Anesthetists of Great Britain and Ireland30 recommended that metaraminol with 0.5 mg/mL could be used to mediate blood pressure. CAA6 also recommended that noradrenalin 4–6 µg or 0.08 µg/kg/min was useful for preventing hypotension. The target of blood pressure was to maintain systolic arterial pressure greater than 90% and avoid a decrease to <80% baseline.21 30 For maternal with pre-eclampsia, two documents6 30 advised that vasopressor infusion should not be prophylactically used.

Six documents8 16 23–25 28 provided recommendations for inadequate neuraxial anaesthesia, and three guidelines23 25 28 suggested assessing other causes of pain, evaluating the catheter site, and reassessing the sensory block level. For rescuing inadequate anaesthesia, four documents16 23 25 28 provided recommendations including administrating a second neuraxial technique or extending the neuraxial technique, repeating boluses of fast-acting opioids (fentanyl 25–50 µg, alfentanil 250–500 µg) or ketamine (10 mg boluses), and if necessary, recommending general anaesthesia.

Unintentional dural puncture would lead to postdural puncture headache (PDPH). AANA25 provided recommendations on using small, non-cutting spinal needle or placing intrathecal catheter for preventing PDPH. Treatment options for PDPH included epidural blood patch, adequate hydration, multimodal analgesia, caffeine, sumatriptan, gabapentin and sphenopalatine ganglion block.

Approaches to the management of obstetric and anaesthetic emergencies

Four documents4 6 24 25 provided recommendations for managing haemorrhagic emergencies, with three of them4 6 25 consistently recommending the use of large bore intravenous catheters (summarising in online supplemental table 15). The ASA4 and ANNA25 suggested the implementation of a massive transfusion protocol. Additionally, the ASA4 recommended the availability of blood bank resource, fluid warmer, forced-air body warmer and equipment for rapid infusion of intravenous fluids and blood products.

Seven documents4 6 16 18 21 24 25 addressed airway emergency in obstetric anaesthesia, with three of them4 16 25 recommending the availability of personnel and equipment, such as laryngoscope with assorted blades and endotracheal tubes with stylets. In cases where tracheal intubation fails, the use of emergency procedures such as cricothyrotomy was advised. Access to oxygen source and suction source with tubing were also recommended.4 21 25 The ASA provided specific recommendations for medications to support blood pressure, muscle relaxation and hypnosis.4

Three documents4 24 25 covered cardiopulmonary resuscitation, with both the ASA4 and ANNA25 recommending the availability of basic and advanced life-support equipment during cardiac arrest. It was also recommended to maintain uterine left displacement during cardiac arrest. If circulation was not restored within 4–5 min, two guidelines suggested performing a caesarean section.4 24 25

Six documents4 16 21 24 25 28 addressed emergency caesarean delivery, with the National Institute for Health and Care Excellence21 providing specific recommendations for the time of unplanned and emergency caesarean births when there is a threat to the life of the woman or fetus, within 30 min. The use of neuraxial anaesthesia and general anaesthesia was recommended for emergency caesarean delivery.16 21 28

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