Key Guidelines Recap
  • AWHONN Issues New Practice Guideline for OB Pain Management

    A new evidenced-based clinical practice guideline has been released by the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) that provides guidance for assessment and management of the woman and her fetus, including an assessment of pain relief, side effects, and potential adverse effects of medications.

    Some of their enumerated research priorities include support person presence during regional analgesia/anesthesia administration, patient positioning, remifentanil administration protocols and monitoring devices, management of inhaled nitrous oxide, intrapartum pain management for the opioid dependent woman, and fetal effects for chronic exposure to opioid replacement therapies.

    Also included in the document, recently published in the journal Nursing for Women’s Health, are interventions directed at minimizing side effects and adverse reactions associated with analgesia and anesthesia and facilitating labor progress.

    The document’s development was spearheaded by (AWHONN) whose 7-member 2020 Analgesia and Anesthesia in the Intrapartum Period Evidence-Based Clinical Practice Guideline Revision Science Team included AANA’s Cheryl Parker, DNP, CRNA, RNC-OB, Director of the Program of Nurse Anesthesia at University of Louisville.  The authors write that Dr. Parker “was selected for her expertise as an obstetric anesthesia care provider and a member of the American Association of Nurse Anesthetists (AANA) and the Society for Obstetric Anesthesia and Perinatology.”

    ‘An informational resource’

    The guideline, intended as an informational resource for nursing practice, provides evidence-based approaches to:

    • Identify safety principles for maternal analgesia/anesthesia in the intrapartum period.
    • Describe the nursing role during the administration of pharmacologic interventions during labor, including analgesics, regional analgesia/anesthesia, remifentanil, and inhaled nitrous oxide.
    • Promote safe staffing patterns for the woman choosing analgesia/anesthesia in labor.
    • Use evidence to recommend routine nursing assessments and interventions for maternal and fetal response to analgesics/anesthetics in labor.
    • Evaluate specific needs of special populations receiving pharmacologic interventions during labor.

    While the guideline does not define a standard of care, notes AWHONN, nor is intended to dictate an exclusive course of management, it “presents general methods and techniques of practice that AWHONN believes to be currently and widely viewed as acceptable, based on current research and recognized authorities.”

    Be sure to also review AANA’s “Analgesia and Anesthesia for the Obstetric Patient” Practice Guidelines.

    Intended patients and settings

    The authors note that the focus of the guideline is on women for whom vaginal birth is intended and is applicable in acute care and birthing center settings which have the capability and resources necessary to provide, monitor, and manage the care of laboring women receiving analgesia or anesthesia.

    They add that the guideline is intended for use in populations of women for whom obstetric analgesia or anesthesia is planned via a process of informed decision making and who have no identified contraindication to the chosen form of pain management.

    Expanded content and search range

    All team members participated in video teleconferences to determine the content and search terms and to support an extensive literature review, evaluation, and scoring.  Dr. Parker and her colleagues on the science team elected to expand the original Nursing Care and Management of the Woman Receiving Analgesia/Anesthesia in Labor to include analgesics, remifentanil patient-controlled analgesia (PCA), and inhaled nitrous oxide.

    Several topic-specific electronic database searches and manual searches were conducted to identify relevant literature.  Specifically, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, Scopus, and the Cochrane Library were searched for journal articles published in English between 2010 and 2019 primarily in developed countries.

    Review, scoring, and consensus

    In sections divided by search terms, 3,071 abstracts were reviewed and considered by at least two science team members.  Additional articles, including selected literature published before 2010 and some published after the original literature search was completed, were retrieved and scored based on knowledge of seminal works and as new topics or gaps in the literature were identified.

    A total of 773 articles were read and scored.  Consensus on the rating of evidence was obtained by at least two science team members before an article could be included as supporting rationale for the clinical practice recommendations in the Guideline.  Quantitative literature was scored using the quality-of-evidence-rating.  Qualitative literature was scored using the evaluation and scoring tool.

    Draft sections of key topics of focus, including pertinent clinical practice recommendations accompanied by referenced rationale statements, were created and reviewed by two team members.  Individual and group videoconference meetings were held to further review, refine, and obtain consensus for all clinical practice recommendations and supportive rationale statements.  In addition, all science team members reviewed and discussed the complete draft Guideline prior to external review.

    The quality of quantitative evidence supporting clinical practice recommendations was determined by team consensus using a revised scale that included a combination of the U.S. Preventive Services Task Force Guide to Clinical Preventive Services (1996) quality-of-evidence rating scale and additional scoring schemas to further delineate meta-analysis and systematic review studies.

    More to explore

    Despite the Team’s comprehensive 60-page guideline, they conclude with the imperative for further research and continued organizational collaboration.

    “The advancement of obstetric anesthesia practice has had an important impact on maternal satisfaction in labor and birth,” the authors write.  “However, gaps in practice still exist.  In order to provide safe analgesia/anesthesia care, standardized recommendations are needed. Future research should be well coordinated by national organizations to continue to advance the science in the care of laboring women.”

    Find “Analgesia and Anesthesia in the lntrapartum Period Evidence-Based Clinical Practice Guideline.” Nurs Womens Health. 2020 Feb;24(1):e1-e60., at this link: