Safety, Not “Sharing,” Must Guide Visitor Policies for Cesarean Surgery

By Andrew Geller, M.D.

By Keynote ContributorDr. Andrew Geller, M.D.Assistant professor anesthesiologist,
Cedars-Sinai Medical Center, Los Angeles, CA

Giving birth is one of life’s most exciting events – one that many women want to experience with family members and capture on video. But the desire to share the delivery with others has resulted, in some cases, in a crowded delivery room of supportive (and occasionally fainting) observers.

For the most part, this is a vast improvement over an era in which Father and extended family were relegated to the waiting room to pace until a nurse showed up with the newborn baby. But in the case of cesarean section surgery, both planned and in emergency situations, too many visitors in the operating room may be counterproductive, and may even compromise patient care.

A new survey of anesthesiologists, presented last month at the American Society of Anesthesiologists meeting, shows that about 70% believe that having more than one visitor (doula, friend, parent, adoptive/surrogate parent, translator, or other) in the operating room during a cesarean section surgery makes it more difficult to care for the patient.

Anesthesiologists are at the center of this surgical procedure, where they play a leadership role in setting the visitor guidelines.  The findings from this research will help to inform policies regarding visitors in the OR – and reinforce the importance of limiting visitors in order to protect patient safety.

There are numerous reasons that extraneous visitors may be a concern. All ORs are already anxiety provoking, stressful, high-risk environments; the birth process is emotionally charged, and an invasive procedure involving a vulnerable baby creates additional commotion and risk. Cesareans pose extra challenges with an individual who is awake during the procedure, social visitors, and multiple “patients” (mom, baby, and the potential of a hysterical observer or “fainter”). These factors can interfere with the physician’s attention, and delay medical intervention and function decreasing patient safety.

According to the survey results, the majority (70%) of anesthesiologists felt that more than one visitor during cesarean section surgery made it more difficult to care for the patient, and 68% felt that more than one visitor interfered with the ability to care for the patient. Alarmingly, more than 90% of the anesthesiologists felt that more than one visitor interfered with anesthesia workflow: almost half (49%) responded that it caused mild interference, 35% said it caused moderate interference, and 8% said that it caused severe interference with their workflow. Specifically, the respondents cited increased stress, distraction and noise. A remarkable 86% expressed concern that having an extra person in the OR would “interfere with my access to medications/IV sites/monitors/anesthesia machines.”

At the conclusion of the survey, respondents were asked whether the risks outweigh benefits of having a second visitor. 63% said yes. 59% noted that their preferred “maximum visitors” is one individual, while 29% capped the number at two.

Given these unequivocal survey results and the stated risk of interference with patient care, one might assume that most facilities and/or organizations would have written policies regarding the number of allowable visitors. But only about half of respondents (51%) said that they had a written policy regarding the number of visitors allowed in the OR during C sections. Most of the decisions about including or excluding visitors are made by anesthesiologists (58%) – more so than obstetricians (28%), nurses (9%), or “all of the above” (26%) – thus these results should provide helpful data for anesthesiologists in crafting safety-based visitor policies moving forward.

Because anesthesiologists are primarily decision-makers regarding visitors in the OR, they must insist that patient care and safety take precedence over the desire to include loved ones or document the birth. This study suggests that limiting visitors in the OR to one individual (spouse/significant other/support person) may be the standard, while exceptions could be made in cases based on the need for a translator, doula or other with the express permission of the patient, anesthesiologist and obstetrician. Of course, any written policy must include a provision to remove individuals who exhibit disruptive behavior, unsafe practices, or evidence of communicable disease; or in any situation when the treating physician believes it is in the patient’s best interest to limit all visitation.

This important new research can help inform the development of written visitor policies, and anesthesiologists should take the lead in their design. Under new accountable care delivery models, patient satisfaction is related to payments, and hospitals are competing for patients. These dynamics may add pressure on anesthesiologists, other medical professionals, and even hospitals to allow extra visitors to appeal to patient satisfaction sentiments. But armed with evidence that excess visitors may adversely impact patient care, anesthesiologists will be well-equipped to stand firm in their commitment to the care and safety of mothers and their babies.

About Dr Geller

Andrew Geller, M.D., an assistant professor anesthesiologist at Cedars-Sinai Medical Center, Los Angeles, CA, serves as a member of the Legislative and Practice Affairs Division of the California Society of Anesthesiologists and Education Committee Member of the Society for Obstetric Anesthesia and Perinatology.