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November 2001
Volume 65 |
Number 11
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SUBSPECIALTY
NEWS
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| SOAP Working Hard to Resolve
Labor Issues |
Valerie A. Arkoosh, M.D., Committee
on Obstetric Anesthesia
President, Society for Obstetric Anesthesia and Perinatology
The mission of the Society for Obstetric Anesthesia and Perinatology
(SOAP) includes the education of anesthesiologists and other health
care professionals in the comprehensive anesthetic and pain management
of women during pregnancy and the puerperium. Toward this end, SOAP
directs significant resources to the planning and implementation
of our Annual Meeting. SOAP 2002 will be held in Hilton Head, South
Carolina, May 1-5, 2002, and will offer something for both the occasional
and routine practitioner of obstetric anesthesia. Meeting planners
Gary Vasdev, M.D., and Joy L. Hawkins, M.D., will offer several
new educational opportunities including an optional Neonatal Advanced
Life Support certification course and an optional Hands-On Airway
Management Course. Abstract submission will be online, with the
Web site going live on November 1, 2001, and abstracts will be due
in January 2002. In order to formally recognize the importance of
education to our Society, the 2002 meeting will be the first opportunity
to compete for the new SOAP Research in Education Award. The criteria
for this award, as well as Annual Meeting information and registration,
can be found on the SOAP Web site at <www.SOAP.org>.
The practice of obstetric anesthesia continues to face challenges
on several fronts. Two areas in particular stand out. Questions
persist from several constituencies as to the safety of neuraxial
labor analgesia and its impact on obstetric and neonatal outcome,
and the Association of Women’s Health, Obstetric and Neonatal
Nurses (AWHONN) newest guidelines continue to substantially limit
the ability of perinatal nurses to assist anesthesiologists in
managing epidural infusions in any way.
Last spring, several SOAP members were invited to attend a symposium
sponsored by the Maternity Center Association (MCA) and the New
York Academy of Medicine and titled, “The Nature and Management
of Labor Pain, An Evidence-Based Symposium.” The MCA is a
not-for-profit organization founded in 1918 whose stated mission
is to improve the quality of maternity care in the United States
through innovative woman- and family-centered approaches to maternity
care. MCA is involved in prenatal care, childbirth education,
nurse-midwifery education and care in out-of-hospital birth centers.
The objectives of the symposium included making accurate information
about labor pain and methods to relieve it easily available to
relevant health care professionals, childbearing women and the
general public; to improve women’s access to a choice of
reasonably safe and effective pharmacological and non-pharmacological
methods for pain relief during labor and assure that women receive
full information on all methods of labor pain relief available
in their place of birth; and to identify gaps in our knowledge
base and develop research priorities. Obstetricians, nurse midwives,
childbirth educators, pediatricians, epidemiologists and public
health researchers attended the meeting. A unique aspect of this
meeting was that all presentations were put in paper format and
submitted for peer review prior to the meeting. These papers were
critiqued and the presentations modified accordingly. Lawrence
J. Saidman, M.D., (former editor-in-chief of Anesthesiology) was
the reviewer representing anesthesiology. The quality of presentations
was quite high. SOAP was well-represented by Donald Caton, M.D.,
Barbara L. Leighton, M.D., and Mark A. Rosen, M.D., each of whom
spoke on various aspects of labor analgesia. There was minimal
to no debate that epidural analgesia is the safest and best form
of labor analgesia for women with any sort of complicated delivery
or significant co-existing medical problem. The real issue for
many of the attendees was that for healthy women with normal pregnancies
and labors, the increasing predominance of epidural analgesia
has resulted in decreased availability of alternative techniques
(jacuzzis, birthing balls, Doulas, etc.). For those women who
truly want an un-medicated labor, these alternatives are increasingly
scarce. Although some participants were clearly antiepidural,
I had the sense that the majority were more interested in assuring
the continued availability of nonpharmacologic options. Despite
an unusually high quality of science around the presentations
and the predominance of positive data about neuraxial labor analgesia
from prospective, randomized trials, it is this author’s
opinion that emotion continues to hold sway over many of those
who participated. Thus, these issues are likely to be with us
for many years to come. The proceedings from this symposium are
scheduled for publication in a supplement to the American Journal
of Obstetrics and Gynecology in early 2002.
AWHONN published guidelines in 1998 limiting the role that perinatal
nurses could have in assisting an anesthesia care provider with
an epidural infusion. Those guidelines were in conflict with the
established practice patterns of many anesthesia groups. AWHONN
stated that they would review the guidelines in early 2001. The
new position paper can be found at:
www.awhonn.org/sitemap/ebg/Cardiovascular_Health_
Backroun/positionstatements/Epidural/epidural.html.
The following are contained in the new position statement: nonanesthetist
registered nurses should not:
• rebolus an epidural either by injecting medication into
the catheter or increasing the rate of a continuous infusion;
• increase/decrease the rate of a continuous infusion;
re-initiate an infusion once it has been stopped;
• manipulate patient-controlled epidural analgesia doses
or dosage intervals;
• be responsible for obtaining informed consent for analgesia/anesthesia
procedures (The nurse, however, may witness the patient signature
for informed consent prior to analgesia/anesthesia administration.)
ASA’s Committee on Anesthesia Care Team continues to attempt
constructive dialogue with AWHONN. Should this position statement
impact your practice — stress that these are guidelines,
not standards of care. Education is our best recourse.
SOAP looks forward to addressing these and future challenges
by stimulating and supporting education and research in the field
of obstetric anesthesia.
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Valerie A. Arkoosh,
M.D., is Pr ofessor and Chair, Department of Anesthesiology
and Professor of Obstetrics and Gynecology, MCP Hahnemann
University, Philadelphia, Pennsylvania. |
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