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October 2000
Volume 64 |
Number 10
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| Obstetric Anesthesia:
Recent Guidelines for Our Availability to the Labor Floor |
Marianna P. Crowley,
M.D., Chair
Committee on Obstetrical Anesthesia
How quickly should an anesthesiologist be able to respond to
an obstetric emergency? Can the anesthesiologist cover the labor
floor from home, five minutes away? How about 20 minutes away?
Can the anesthesiologist cover the general operating room suite
and the labor floor as well?
ASA frequently receives questions such as these concerning anesthesia
staffing for obstetrics. There are no specific answers to such
questions, as each must be individualized for the local situation
and resources. However, ASA, the American College of Obstetricians
and Gynecologists (ACOG) and the American Academy of Pediatrics
(AAP) have published documents that provide some guidance. In
addition, the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) has published standards for response time
for obstetric emergencies. Recently, ACOG published the Practice
Bulletin on Vaginal Birth After Previous Cesarean Section that
included new guidelines for staffing for vaginal birth after cesarean
section (VBAC). It understandably generated concern among anesthesiologists.
| "The
30-minute rule states that for an institution to offer obstetric
care, it should be capable of performing a cesarean section
within 30 minutes of the decision to do so." |
In October 1998, ACOG published its Practice Bulletin #2, Vaginal
Birth After Previous Cesarean Delivery. In the bulletin, ACOG
stated that a trial of labor for patients with a prior uterine
scar should only be offered at institutions capable of performing
an immediate emergency cesarean section. Much discussion followed
among anesthesiologists, obstetricians and hospital administrators,
partially because the language that defined this new standard
for availability of personnel was somewhat confusing. The document
was revised and reissued with the same title in July 1999 as Practice
Bulletin #5, and more clearly stated the recommendation above.1
In order to understand the implications for anesthesiologists,
it is worth looking at the history of the guidelines for staffing
for institutions that offer obstetric care. In the late 1980s,
ACOG, ASA and AAP agreed to the "30-minute rule" that
defines the term readily available as it refers to staffing. After
years of discussion and some argument, the 30-minute rule was
put into print in a joint statement between ASA and ACOG titled
"Optimal Goals for Anesthesia Care in Obstetrics," approved
by the ASA House of Delegates in 1988. It appeared as well in
a joint ACOG/AAP publication titled "Guidelines for Perinatal
Care."2 The 30-minute rule states that for
an institution to offer obstetric care, it should be capable of
performing a cesarean section within 30 minutes of making the
decision. Somewhere along the line, the 30-minute rule was included
in JCAHO standards for accreditation under its standards for anesthesia
care. In Guidelines for Perinatal Care, ACOG and AAP went on to
say that there were some obstetric emergencies that would require
a more expeditious response, such as hemorrhage from placenta
previa, placental abruption and uterine rupture. There was recognition
that some institutions were incapable of maintaining 24-hour,
in-hospital physician and facility staffing for emergency care.
The 30-minute rule provided such facilities a guide for staffing
and help when deciding whether obstetric care could be reasonably
provided.
The new immediately available guideline is not a departure from
the 30-minute rule. It is meant to address a specific elective
clinical situation. In its Practice Bulletin, ACOG has said that
for an obstetrician to offer a trial of labor to a patient who
has had a previous cesarean section, one of the resources that
should be available is the capability of the institution to perform
an immediate cesarean section. Specifically, in addition to obstetric
criteria for offering VBAC, Practice Bulletin #5 lists selection
criteria useful in identifying candidates for VBAC...Physician
immediately available throughout active labor capable of monitoring
labor and performing an emergency cesarean delivery...availability
of anesthesia and personnel for emergency cesarean delivery.1
It further states as a recommendation that "Because uterine
rupture may be catastrophic, VBAC should be attempted in institutions
equipped to respond to emergencies with physicians immediately
available to provide emergency care."1
The primary reason for this recommendation is a result of recent
studies reporting that the incidence of uterine rupture in VBAC
labors is approximately 1 percent with maternal and/or neonatal
morbidity or mortality of 10 to 25 percent. Uterine rupture may
be catastrophic and accompanied by massive hemorrhage which needs
to be recognized and dealt with quickly. Elective repeat cesarean
section is a safe alternative if adequate resources to deal with
complications are unavailable.
Anesthesiologists across the country have wrestled with compliance
with ACOG's recommendation, especially in those institutions without
24-hour, in-house anesthesia staffing dedicated to the labor floor.
At one extreme, a small community hospital with two anesthesiologists
on staff and located 120 miles from a larger medical center cannot
provide in-house anesthesia coverage for obstetrics or anything
else. Patients who have had a prior cesarean section may be faced
with a choice between elective repeat cesarean section and a two-hour
drive while in labor. Another extreme might involve a 500-bed
academic institution where the one anesthesiologist in house at
night covers both the main operating room and the labor floor.
This hypothetical situation might see an anesthesiologist needing
backup support in the hospital while giving anesthesia for an
appendectomy, when at the same time a patient attempts VBAC in
active labor. An anesthesiologist may need to provide standby
coverage for actively laboring patients attempting VBAC. There
will certainly be situations in which the hospital's resources
are insufficient to continue to offer patients an attempt at VBAC.
This possibility was considered as ACOG made its recommendations
in its VBAC Practice Bulletin. Reimbursement for such service
is a difficult issue under negotiation in many institutions.
ACOG's position is that these difficult staffing decisions in
response to the VBAC Practice Bulletin must be made on a local
level. The statements on anesthesia staffing coming from ASA,
ACOG and AAP are in the form of recommendations and guidelines
rather than standards. There has been no minute value placed on
the term "immediate availability" nor is there likely
to be, at least by ACOG or ASA.
On the other hand, JCAHO has published its new standards for
accreditation that will take effect in 2001. Under "Standards
for Sedation and Anesthesia Care," JCAHO now writes the following:
"In organizations providing labor services for patients seeking
vaginal birth after previous cesarean delivery, appropriate facilities
and personnel, including obstetric anesthesia and nursing personnel,
are immediately available to perform emergency cesarean delivery
when conducting a trial of labor for women with a prior uterine
scar."3
In hospitals where the discussion about staffing for VBAC coverage
has until now been primarily at the level of care providers, it
will soon involve hospital administrators at the highest levels;
there will likely be fewer hospitals offering VBAC. It will be
important for anesthesiologists to be at the table at each institution
as negotiations on this issue take place.
References:
1. American College of Obstetricians and Gynecologists.
Vaginal birth after previous cesarean delivery. Practice Bulletin
#5. July 1999.
2. American Academy of Pediatrics and American
College of Obstetricians and Gynecologists. Guidelines for Perinatal
Care. 4th ed. Elk Grove Village, IL: AAP; Washington, DC: ACOG:
1997.
3. Joint Commission on Accreditation of Healthcare
Organizations. Standards Revisions for 2001. CAMH: Comprehensive
Accreditation Manual for Hospitals. Standards and Intents for
Sedation and Anesthesia Care. Intent of TX 2.1 Sedation and Anesthesia
Care. Oakbrook Terrace, IL: JCAHO, 2001.
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Marianna
P. Crowley, M.D., is Chief of Obstetric Anesthesia, Massachusetts
General Hospital, Harvard Medical School, Boston |
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