Critical Care in Obstetrics: Golden Hour Guidelines

Maternal Critical Care

The American Society of Anesthesiologists recommends that if maternal cardiac arrest occurs, circulation should be restored within 4 minutes before proceeding to perimortem cesarean delivery 1, 2, 3
The American Society of Anesthesiologists suggests initiating standard ACLS protocols immediately, maintaining left uterine displacement throughout resuscitation, and beginning hysterotomy if maternal circulation is not restored within 4 minutes 1, 2, 4, 5
Basic and advanced life-support equipment must be immediately available in the operative area of all labor and delivery units, including pulse oximeter, qualitative carbon dioxide detector, and basic airway management equipment 1, 2, 4, 5

The American Society of Anesthesiologists recommends inserting a neuraxial catheter early for anticipated difficult deliveries or obstructed labor to avoid the need for general anesthesia during a crisis 1, 2, 3
Neuraxial techniques should be selected over general anesthesia for most cesarean deliveries, including urgent cases, unless there are specific contraindications such as profound fetal bradycardia or ruptured uterus 1, 2
Phenylephrine is recommended as the first-line vasopressor for neuraxial anesthesia-induced hypotension, unless maternal bradycardia is present 1, 2

The American Society of Anesthesiologists recommends that uncomplicated laboring patients may consume modest amounts of clear liquids, but solid foods must be avoided 4, 5, 6
Clear liquids are permitted up to 2 hours before anesthesia induction for elective cesarean delivery, while solid foods require 6-8 hours fasting depending on fat content 1, 2, 4, 5, 6
Aspiration prophylaxis, including non-particulate antacids, H₂ receptor antagonists, and/or metoclopramide, should be administered before all surgical procedures 2, 4, 5

Strict fluid balance should be limited to 60-80 mL/hour during labor in preeclamptic patients to prevent pulmonary edema 6
Fluid volumes should be adjusted proportionally to patient stature in patients with skeletal dysplasia, as volume of distribution correlates with height 3, 6

The American Society of Anesthesiologists emphasizes the importance of not underestimating the physiological changes of pregnancy that complicate airway management during emergency cesarean delivery 3
A preformulated difficult airway strategy should be in place, including immediate mask ventilation with cricoid pressure or supraglottic airway device if intubation fails, and creation of a surgical airway if ventilation is impossible 4, 5
Perimortem cesarean delivery should not be delayed beyond 4 minutes of maternal cardiac arrest 1, 2, 4, 5