Beginning with the 1950s, obstetric anesthesia has made remarkable strides: emergence as a subspecialty, foundation of a society and institution of a multitude of clinical improvements. Obstetric anesthesia developed as a subspecialty because of concern for the well-being of the mother.

Accordingly, in 1958, ASA established a Committee on Maternal Welfare to achieve better communication and closer cooperation with the American College of Obstetricians and Gynecologists (ACOG). A liaison between the two organizations was initiated in 1963 and led that same year to the publication of a manuscript on "Pain Relief in Labor and Childbirth," prepared by ASA and distributed by ACOG. Standards for obstetric analgesia/anesthesia and infant resuscitation were formulated in 1964 and included in the ACOG Manual of Standards.¹

At this time, anesthesia-related maternal mortality was declining steadily, attributable primarily to the "number of qualified individuals who administer anesthesia."² Consequently, in 1966, the ASA committee was appropriately renamed Committee on Obstetrical Anesthesia to join fetal-neonatal concerns with those of the mother. Further accomplishments of this committee included a survey on Residency Training in Obstetric Anesthesia³ as well as academic conferences and clinical workshops, often in cooperation with ACOG. The ASA Committee on Obstetrical Anesthesia also played a major role in the ACOG Technical Bulletin titled "Obstetrical Analgesia and Anesthesia." The introductory sentences of the revised bulletin read:

"Pain relief during labor and delivery is an important aspect of modern obstetrics. It consists of more than providing personal comfort to the mother; it is a necessary part of good obstetric practice."

The second paragraph is a quotation from the Accreditation Manual of Hospitals (Joint Commission on Accreditation of Hospitals, March 1971) and states:

"Obstetric anesthesia must be considered as emergency anesthesia demanding a competence of personnel and availability of equipment similar to or greater than that required for elective procedures."

Organizing a Society With Special Interest in Peripartum Period

As the recognition of the value of expert obstetric anesthesiologists increased, the roster of specialists started to grow. Soon, the need to discuss common problems became evident, leading to the foundation of an informal society. The first meeting in 1969 attracted more than 50 physicians with special interest in maternal and/or neonatal well-being who chose to name the new organization the "Society for Obstetric Anesthesia and Perinatology" (SOAP). The Society was formally organized at its third meeting in 1971. The Organization and Bylaws then stated that:

"The Society does not seek corporate status nor legal identity ... The purpose of the organization is to provide a forum for discussion of problems unique to the peripartum period. This includes clinical practice of medicine, basic research, practical business and public health aspects of this important phase of life ... Any physician or scientist particularly interested in the problems of the perinatal period may become a member of the organization."

The Society has continued to grow steadily with its membership reaching 1,200 in 1997. From the onset, SOAP has featured an annual meeting as well as a quarterly newsletter. The meetings have had planned scientific sessions. Formal presentations and reviews of "What Is New in Obstetrics," "What Is New in Neonatology" and "What Is New in Obstetric Anesthesia" have been delivered by experts in these fields. The newsletters contain scientific articles, research columns, committee reports as well as a news box.

In 1988, the Obstetric Anesthesia and Perinatology Endowment Fund (OAPEF) was established. The fund allows SOAP to award one or two grants for research annually in the specialty. Research findings resulting from the investigations are presented at the following SOAP meeting. In addition, through the generous support of industry, SOAP has instituted a Traveling Scholar Program that arranges for obstetric anesthesiologists from underdeveloped countries to attend the annual meeting and spend one week in a major U.S. medical center hosted by a SOAP member.

Clinical improvements in the management of obstetric analgesia/anesthesia within the last five decades have included new equipment (e.g., pencil-point spinal needles) and new drugs (e.g., ropivacaine); none has been more impressive than those leading to a "new look" in childbirth, that of "family-oriented" obstetrics. Prior to this event, most vaginal deliveries and preceding labor periods were conducted either with no pain relief or under twilight sleep, the combination of morphine and scopolamine.

Eventually, the potential hazard to mother and/or fetus of both methods was recognized. The adverse effect of untreated pain was confirmed experimentally in pregnant ewes; a brief, minor stress such as a bout of loud noise, movement of personnel or application to the skin of mild electric stimulation decreased uterine blood flow secondary to release of norepinephrine.⁴ Maternal hyperventilation, often a reaction to pain, was shown to harm the fetus in two ways: 1) by the development of an oxygen debt in the mother and 2) by a shift of her hemoglobin-oxygen dissociation curve to the left, i.e., in the baby's disfavor. The sequelae of twilight sleep were even more pertinent. In addition to the potential of producing neonatal narcotic depression, the drug combination rendered the parturients amnesic and incoherent. Although screaming with every contraction, the women were unaware of their plight as were their husbands who, banned from the labor-delivery area, were pacing up and down in a distant room.⁶ (This author clearly remembers a young lady who climbed over the bedrail, delivered the baby on the floor and did not realize for the next 24 hours that she had become a mother.)

Anesthesia, frequently indicated to maintain the uncontrollable parturient in lithotomy position, was generally provided by nonanesthesiologists administering nitrous oxide, open drop ether or chloroform. For complicated cases, an anesthesiologist was summoned from the operating room. Infant resuscitation was then undertaken by the anesthesiologist/anesthetist present in the delivery room; the specialty of neonatology had not yet been conceived.

The picture began to change with the introduction of continuous regional analgesia/anesthesia into obstetrics. Although single injection blocks were already employed (spinal blocks since 1900, caudal blocks since 1909, lumbar extradural blocks since 1938), they were given solely for the period of parturition. In contrast, continuous techniques (spinal introduced in 1940, caudal in 1942, lumbar extradural in 1949), permitted the expectant father to become a true partner in the birth process.⁷

Initially, men were allowed only in the labor room. Some time later, they could also be present during uncomplicated vaginal delivery and eventually during cesarean section. At the onset, a few fathers fainted in the delivery room, placing an added burden on the anesthesiologist. (This author recalls a handsome young man sitting in a chair to my left while attending his wife's vaginal delivery, who fell unconscious onto my shoulder leaving me no choice but to secure him with my left arm while continuing to administer nitrous oxide analgesia with the right.) Since then, however, childbirth education has eliminated the uncertainty and reduced the anxiety associated with childbirth.

A second important development in this time span was the return of spinal anesthesia to obstetrics, the first regional technique employed for childbirth. Its effect was early on described by the young Swiss obstetrician⁸who initiated its use: "The impression gained from the medullary narcosis in parturients is remarkable. Loss of sensation to pain with maintained mobility and unclouded sensorium is most unusual." The method remained popular for both vaginal and abdominal deliveries until the late 1950s, when lumbar extradural anesthesia took over as the preferred regional technique. The presumed advantages of the extradural method first included lack of a potential dural puncture headache and, second, ability to employ separate blockade of the differing segments involved in the two stages of labor, thereby reducing the dose of local drug as well as the extent of motor and sympathetic blockade. The disadvantages of slow onset of action and relatively large doses of drug were ignored.

Because of the delayed onset, it became the edict of the 1970s to perform general anesthesia for all emergency cesarean sections. In turn, this led to an unacceptable increase in maternal mortality from intubation difficulty and/or aspiration of gastric contents.⁹ Fortunately, two later reports demonstrated advantages of spinal anesthesia for both mother and fetus. A review of 442 cases of the technique in gravid women led to the conclusion that "spinal block was particularly valuable when anesthesia was required urgently in the labour and delivery suite and may even be regarded as the anaesthetic of choice in such circumstances."¹⁰

A comparison of fetal and neonatal blood-gas data showed faster recovery of depressed fetal values when the emergency delivery took place under spinal or extradural block as compared to general anesthesia, and the one-minute Apgar scores were significantly (p <0.01) better in the former group.¹¹ Spinal block has had a further rebirth since use of the new pencil-point needles has decreased the incidence of post-dural puncture headaches, and the addition of narcotic to a smaller dose of local anesthetic has lessened the magnitude of motor and sympathetic involvement.

In conclusion, the last five decades have witnessed impressive strides in obstetric anesthesia, not only as a clinical practice, but also as a family experience.

References:

1. Marx GF. Obstetric anesthesia organizations in the United States. Anesthesiology. 1974; 41:308-310.
2. Klein DM, Clahr J. Factors in the decline of maternal mortality. JAMA. 1958; 168:237-242.
3. SM. Training in obstetric anesthesia in the United States. Am J Obstet Gynecol. 1965; 93:243-252.
4. Shnider SM, Wright RG, Levinson G, Roizen MF, et al. Uterine blood flow and plasma norepinephrine changes during maternal stress in the pregnant ewe. Anesthesiology. 1979; 50:524-527.
5. Bassell GM, Marx GF. Optimization of fetal oxygenation. Internat J Obstet Anaesth. 1995; 4:238-243.
6. Levinson G, Shnider SM. Systemic Medication for Labor and Delivery. In: Anesthesia for Obstetrics, 3rd ed. Shnider SM, Levinson G. eds. Baltimore: Williams & Wilkins, 1993:128-129.
7. Marx GF. Die historische Entwicklung der geburtshilflichen Anaesthesie. Anaesthesist. 1987; 10:537-540.
8. Kreis O. Ueber Medullarnarkose bei Gebärenden. Ctrbl Gynäk 1900; 28:724-729.
9. Bassell GM, Marx GF. Anesthesia-Related Maternal Mortality. In: Anesthesia for Obstetrics, 3rd ed. Shnider SM, Levinson G. eds. Baltimore: Williams & Wilkins, 1993:458-460.
10. Brownridge P. Spinal anaesthesia revisited: An evaluation of subarachnoid block in obstetrics. Anaesth Intens Care. 1984; 12:334-342.
11. Marx GF, Luykx WM, Cohen S. Fetal-neonatal status following caesarean section for fetal distress. Br J Anaesth. 1984; 56:1009-1013.

Gertie F. Marx, M.D., is Professor Emeritus at Albert Einstein College of Medicine, Bronx, New York. She received the ASA Distinguished Service Award in 1988.

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FEATURES

Celebrating 150 Years of Modern OB Anesthesia

• Management of Childbirth Pain Before Anesthesia
  
  
• Fanny Longfellow and Nathan Keep
  
  
• Analgesia in Labor Becomes Respectable: The Role of John Snow
  
  
• 'To Give Birth Without Pain!' The First Cases of Mesmeric Pain Relief for Obstetrics
  
  
• 150 Years of Obstetric Anesthesia: A Pictorial Overview
  
  
• And What About the Baby? Virginia Apgar and the Apgar Score
  
  
• Obstetric Anesthesia: The Last Five Decades
  
  
• John J. Bonica Makes Obstetric Anesthesia an Academic Concern
  
  

ARTICLES

• Breaking Down the Barriers to Pain Management
  
  
• Practice Options: Considerations in Setting Up an Office-Based Anesthesia Practice

DEPARTMENTS

• To the Membership
  
• Washington Report
  
• Practice Management
  
• Residents' Review
  
• ASA News
  
• Letters to the Editor
  
• FAER Report
  

The views expressed herein are those of the authors and do not necessarily represent or reflect the views, policies or actions of the American Society of Anesthesiologists.

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