Routine maternal electrocardiogram (ECG) monitoring in the obstetric postanesthesia care unit (PACU) for healthy women following cesarean birth is not the standard of care, nor should it be. This isn't to say there isn't a need for monitoring cardiac rate and rhythm for all women, or that ECG monitoring isn't indicated for selected women with preexisting medical conditions or complications of pregnancy, surgery, or anesthesia. My opinion opposing routine ECG monitoring is supported by many professional organizations, professional journals, textbooks, hospital policies, and expert practitioners.
The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN, 1998), the American Society of Anesthesiologists (ASA, 1994), the American Society of PeriAnesthesia Nurses (ASPAN, 2000), and the Joint Commission on Accreditation of Healthcare Organization (JCAHO, 2002) do not require routine ECG monitoring in the obstetric PACU. Standards and guidelines from all of these organizations are in agreement that the mother recovering from obstetric anesthesia should have careful monitoring of oxygenation, ventilation, circulation, and temperature. Pulse oximetry monitoring is required as a method of quantitative assessment of oxygenation following anesthesia.
This discussion about routine ECG monitoring in the PACU should not be confused with opinions about care for women experiencing obstetric regional anesthesia or analgesia used for labor and vaginal birth. PACU care and postpartum recovery care are two different standards (O'Brien-Abel, Reinke, Warner, & Nelson, 1994). The anesthesia provider is responsible for determining whether the condition of the mother warrants PACU or routine obstetric postpartum recovery care. Once it is determined that the mother requires PACU care, she should be continually observed and monitored by methods appropriate to her medical condition (ASA, 1994;ASPAN, 2000;AWHONN, 1998;JCAHO, 2002).
Pulse oximetry provides an assessment of maternal cardiac rhythm, pulse, and perfusion. The pulse oximeter waveform indicates quality of perfusion, and the constant audible tone indicates rate and rhythm. This nominal amount of technology combined with a noninvasive hemodynamic assessment can safely and effectively provide the same level of care as routine ECG monitoring. Assessment of skin color and condition, mental status, urine output, blood pressure, and pulse are all very valuable assessment parameters of a noninvasive hemodynamic assessment. Comparable care and/or equivalent care should not be confused with identical technology. Use of routine ECG monitoring in the nonobstetric PACU does not dictate ECG monitoring in an obstetric PACU.
Anesthesia levels are at their peak during the intraoperative period, and maximal cardiac output occurs in the first few minutes after delivery of the placenta. Thus, we can expect that any ECG disturbances would occur intraoperatively while the mother's ECG complex is being monitored by a qualified anesthesia care provider. After a stable intraoperative experience, routine ECG monitoring in the PACU is simply not required. In my 20+ years of practice at a tertiary care facility (with 6,500-10,000 births/year), I have cared for many women requiring critical care. I know that ECG monitoring complicates both the high-touch care required for women following cesarean birth, and interaction between the mother and the baby. Of course, every effort is made to minimize this interference when ECG monitoring is in place, but I cannot support the use of this technology when it is not absolutely necessary. I'm pleased the professional organizations share my opinion. I would hate to see more "routine" technology added to what should be a healthy life event, especially when there is no evidence that it would enhance perinatal nursing care or improve outcomes for new mothers.
No professional or regulatory organizations require ECG monitoring in OB PACU.
References