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October 2000
Volume 64 |
Number 10
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SUBSPECIALTY NEWS
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| Society for
Obstetric Anesthesia and Perinatology: A New Life |
Alan
C. Santos, M.D., President
Society for Obstetric Anesthesia and Perinatology
It has now been approximately 30
years since a small group of prominent obstetric anesthesiologists
founded the Society for Obstetric Anesthesia and Perinatology
(SOAP). Even then, these obstetric anesthesiologists perceived
a need for a professional organization and forum to enhance clinical
anesthesia care for women during the peripartum period and to
promote scholarly activities and education in obstetric anesthesiology.
Since then, SOAP has grown from a handful of diehard obstetric
anesthesiologists to a group of more than 1,000 members, predominantly
from North America but also from Europe, Africa, Latin America,
Asia and Australia. SOAP is primarily now an organization of anesthesiologists
interested in obstetric anesthesia, but we are indeed very fortunate
to have obstetricians and neonatalogists as members as well.
A central part of SOAP's mission is the education of anesthesiologists
and other health care professionals in the comprehensive anesthetic
and pain management of women during pregnancy and the puerperium.
To accomplish this, SOAP sponsors a fully accredited, four-day
meeting every spring that has become an international forum for
discussion of all aspects of obstetric anesthesiology and related
disciplines. It is noteworthy that over 50 percent of SOAP's members
attend the annual meeting. The content and format of the annual
meeting are diverse enough to meet the needs of the anesthesiologist
practicing exclusively obstetric anesthesia as well as the needs
of the infrequent practitioner of obstetric anesthesia. The format
of the annual meeting includes traditional scientific presentations
of research work, small-group problem-based case discussion, lively
debates of new and controversial topics, panels dealing with practice
management and economics, as well as keynote lectures. The abstracts
of research work presented at the annual meeting are published
in a stand-alone supplement to Anesthesiology, the official journal
of the Society, and circulated to more than 45,000 subscribers
worldwide. The next annual meeting will take place on April 25-28,
2001, in San Diego, California, and promises to be the most diverse
and exciting ever. With the American Society of Regional Anesthesia
and Pain Medicine, SOAP co-sponsors a winter meeting on obstetric
and regional anesthesia. The upcoming meeting will be held on
February 18-23, 2001, in Steamboat Springs, Colorado.
| "A Central Part of SOAP's mission is
the education of anesthesiologists and other health care professionals
in the comprehensive anesthetic and pain management of women
during pregnancy and the puerperium." |
SOAP publishes a quarterly newsletter that includes educational
articles and pro/con position statements on new and controversial
topics. Its Web site provides members and others with easy access
to Society events. The Web site also has a discussion center where
many topics regarding clinical practice, economics and health
care policy are discussed. An exciting feature of this forum is
that laypersons can also initiate discussion of topics that would
not necessarily be thought of by health care professionals but
which are nonetheless of extreme interest to patients.
Performance-based credentialing of health care professionals
is inevitable in the future. SOAP is particularly interested in
working with ASA to develop accurate and meaningful credentialing
criteria for obstetric anesthesia.
SOAP, in partnership with ASA, has significantly enhanced the
anesthesia care of women during pregnancy and childbirth. Through
education of anesthesiologists and obstetricians, we have witnessed
a decrease in the maternal case fatality rate related to anesthesia
from 4.3 fatalities per million livebirths in 1979-81 to 1.7 maternal
deaths per million live births in 1988-90.1
This has been accomplished through education of anesthesiologists
and obstetricians (aided by the American College of Obstetricians
and Gynecologists [ACOG]) regarding the specific hazards of general
anesthesia in pregnant women, particularly in emergency situations.
Education and advances in regional anesthesia have made it an
extremely safe option for pregnant women. This has been the result
of guidelines, use of appropriate test doses, fractionation of
the induction dose of drugs where applicable, and heightened vigilance
and monitoring.
Great strides have also been made in regional analgesia for labor
and vaginal delivery. In the early 1990s, as a result of a limited
prospective randomized trial that suggested that epidural analgesia
may increase the risk of cesarean delivery in nulliparous women,
there was some concern about the use of regional anesthesia for
labor and vaginal delivery, particularly if initiated before the
active phase of labor.2 However, through
education and refinement of epidural techniques, the use of ultra-low
concentrations of bupivacaine in combination with a lipid-soluble
opioid has become widespread. This newer epidural technique has
been demonstrated in multiple studies, including a National Institutes
of Health meta-analysis, not to increase the risk of cesarean
delivery in nulliparous or parous women. 3-6
The introduction of combined spinal-epidural analgesia offers
yet another alternative for fast, effective and safe pain relief,
particularly for women who might wish to ambulate during labor.7
ACOG Paper Discourages Epidurals Before 4-5 cm Dilation
Nonetheless, there are still some who would attempt to limit
the options available to women for effective pain relief during
the early stages of labor. In late August, ACOG released the findings
of a task force convened to investigate once again the increasing
cesarean delivery rates in the United States .8
Despite substantial and credible evidence to the contrary, one
of the task force conclusions was that when feasible, obstetric
practitioners should delay the administration of epidural anesthesia
in nulliparous women until the cervical dilation reaches at least
4-5 cm. Practitioners should recommend using other forms of analgesia
instead of an epidural prior to cervical dilation of 4-5 cm. 8
Unfortunately, an obstetric anesthesiologist was not included
as a consultant on the task force. As a result, the literature
cited by the task force was not as complete as it could have been,
and the studies cited were no longer applicable to contemporary
practice by the time ACOG published this document. Also, the task
force did not distinguish the various epidural techniques used
in the studies. For instance, studies using relatively higher
concentrations of local anesthetic than is routine in contemporary
practice, and showing an increase in cesarean delivery, were apparently
weighted the same as studies using ultra-low-dose bupivacaine,
which showed no difference in cesarean delivery rates between
epidural and parenteral analgesia.2,5
The logic used by the task force at times appears disingenuous.
On the one hand, they use a study with a 2-percent cesarean section
rate in the nonepidural group to support their conclusion that
epidural analgesia increases the risk of cesarean section; in
a subsequent paragraph, they question the results of a larger
study (one using better methodology and showing that epidural
analgesia does not increase the risk of cesarean section) simply
because the cesarean section rate is approximately 4 percent and
not able to be generalized! 2,5
The most alarming recommendation is that institutions and practitioners
with high case-mix adjusted rates of cesarean delivery in nulliparous
women with term singleton fetuses with vertex presentation should
be reviewed to determine how many of these patients received an
epidural when cervical dilation was less than 4 cm. In my view,
ACOG has put their practitioners in an impossible position between
government/third-party payers and their patients. Nowhere else
in medicine would an institution or practitioner be at risk of
scrutiny for providing analgesia that has been shown to be safe
and superior to other modalities in its relief of pain during
labor. Both SOAP and ASA will be working together in the months
ahead to resolve these issues in a way that preserves a woman's
access to safe and effective pain relief during labor.
The last 30 years have witnessed unparalleled advances in obstetrics
and anesthesia. SOAP and ASA will need to continue education of
practitioners, develop guidelines and stimulate scholarship so
that obstetric anesthesia continues to be a safe and effective
option for women in the future.
References:
1. Hawkins JL, Koonin LM, Palmer SK, Gibbs CP.
Anesthesia-related deaths during obstetric delivery in the United
States, 1979-1990. Anesthesiology. 1997; 86:277-284.
2. Thorp JA, Hu DH, Albin RM, et al. The effect
of intrapartum analgesia on nulliparous labor: A randomized, controlled,
prospective trial. Am J Obstet Gynecol. 1993; 169:851-858.
3. Halpern SH, Leighton BL, Ohlsson A, et al.
Effect of epidural vs. parenteral opioid analgesia on the progress
of labor: A meta-analysis. JAMA. 1998; 280:2105-2110.
4. Zhang J, Klebanoff MA, DerSimonian R. Epidural
analgesia in association with duration of labor and mode of delivery:
A quantitative review. Am J Obstet Gynecol. 1999; 180:970-977.
5. Sharma SK, Sidawi JE, Ramin SM, et al. Cesarean
delivery: A randomized trial of epidural versus patient-controlled
meperidine analgesia during labor. Anesthesiology. 1997; 87:487-494.
6. Chestnut DH, McGrath JM, Vincent RD, et al.
Does early administration of epidural analgesia affect obstetric
outcome in nulliparous women who are in spontaneous labor? Anesthesiology.
1994; 80:1201-1208.
7. Nageotte MP, Larson D, Rumney PJ, et al. Epidural
analgesia compared with combined spinal-epidural analgesia during
labor in nulliparous women. N Engl J Med. 1997; 337:1715-1719.
8. American College of Obstetricians and Gynecologists.
Task Force on Cesarean Delivery Rates. Washington, DC; August
2000.
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Alan
C. Santos, M.D., is Associate Director of Anesthesiology,
St. Luke's-Roosevelt Hospital Center, New York, New York. |
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