1. Simpson, Kathleen Rice PhD, RNC, FAAN

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Although in the interests of providing family-centered care we have sometimes treated women with cesarean birth much the same as women having a vaginal birth, there are safety issues specific to this population that require increased vigilance, especially regarding postoperative pain relief measures. After cesarean birth, women should be provided care comparable to other patients having major abdominal surgery.


Patient-controlled analgesia (PCA) pumps and medication administered via epidural catheters postoperatively are commonly used postoperative pain relief options. However, with these options come additional risks. Some patients, such as those with sleep apnea and obesity, are at risk for respiratory depression when using these techniques and need closer monitoring. There should be policies regarding monitoring when PCA medication pumps or opiates via epidural catheter are used, including protocols for patients at high risk for respiratory depression. Maternal deaths after cesarean birth during the postoperative period of patients with sleep apnea and/or obesity have been reported in postpartum rooms where alarms from the pulse oximeter or capnography monitor could not be easily heard by nurses. These deaths could likely have been avoided by closer monitoring.


You wouldn't expect any other patient recovering from major surgery to care for a newborn, and women after cesarean birth should be given the same consideration. After cesarean, patients need assistance with newborn care, especially in the immediate recovery period. They should not be forced to keep their babies in the room if they don't feel up to it and/or a support person is not available to stay with them. Until the new mother recovering from a cesarean is no longer receiving pain relief via PCA pumps or epidural catheters, babies should not be left alone in their arms without nursing personnel or support persons in attendance. These patients can become drowsy while holding their babies. Infant deaths have been reported when mothers fell asleep while holding and/or breastfeeding their babies during the postoperative period and babies were unintentionally suffocated. These tragedies were likely preventable.


As the cesarean birth rate continues to increase, more women will be having a surgical birth. We need to do all we can to keep these mothers and their babies safe while providing effective postoperative pain relief and family-centered care.


Suggestions for Monitoring of Patients with PCA Medication Pumps or Opiate via Epidural Catheter


* Consider using smart pumps that provide end-tidal CO2 monitoring for patients with PCA medication pumps and opiates via epidural catheter for pain relief.


* Establish guidelines for monitoring of patients who are receiving opiates, including frequent assessment of the quality of respirations (not just a rate) and specific signs of oversedation.


* Ensure that resources (personnel and equipment) are available to monitor patients per established guidelines.


* Consider placing patients with sleep apnea and other high-risk conditions for respiratory depression in monitored beds (e.g., monitor specific vital signs at a central station with 24/7 surveillance rather than rely on in-room alarms).


* Use standardized formats for documenting pain control and monitoring values.


* Establish protocols for reversal agents that can be administered without additional physician orders when warranted.


* Ensure that oxygen and naloxone are available when opiates are administered.


* Do not rely on pulse oximetry readings alone to detect opiate toxicity. Use capnography (end-tidal CO2 monitoring) to detect respiratory changes caused by opiates, especially for patients who are at high risk (e.g., patients with sleep apnea, obese patients).


* Ensure that babies of mothers who have cesarean birth are cared for appropriately. Do not leave newborn babies with mothers who are receiving pain relief via PCA pumps or epidural catheters without nursing personnel or support persons in attendance because there is a risk of the mother falling asleep while holding the baby.


Note: Adapted from High alert medication feature: Reducing patient harm from opiates, byInstitute for Safe Medication Practices, 2007, Huntingdon Valley, PA: Author.




Institute for Safe Medication Practices. (2007). High alert medication feature: Reducing patient harm from opiates. Huntingdon Valley, PA: Author. [Context Link]