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September 2002
Volume 66 |
Number 9
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SUBSPECIALTY NEWS
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What's New With SOAP?
Joy L. Hawkins, M.D.,
President
Society for Obstetric Anesthesia and Perinatology
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The Society for Obstetric Anesthesia and Perinatology (SOAP)
came into being in 1968 when six anesthesiologists met at
Chicago's O'Hare International Airport to discuss the formation
of an obstetric anesthesia interest group. They were: Robert
D. Bauer, M.D., from University of California-Los Angeles;
Richard B. Clark, M.D., from University of Arkansas at Little
Rock; James O. Elam, M.D., from Chicago Lying-In; James
A. Evans, M.D., from Emory University; Robert F. Hustead,
M.D., from Johns Hopkins; and Bradley E. Smith, M.D., from
University of Miami.
In October 1968, all anesthesiologists known to be interested
in obstetric anesthesia were invited to meet during the
ASA Annual Meeting, and the rest, as they say, is history!
Today, SOAP is a vibrant organization of about 1,100 members
with an active educational program through its annual meeting
and newsletter. Those six anesthesiologists, known as the
founders of SOAP, were honored with the 2002 Distinguished
Service Award at SOAP's Annual Meeting in Hilton Head, South
Carolina.
What issues face us 34 years later? This year at the ASA
2002 Annual Meeting, the SOAP Breakfast Panel will be titled
"Clinical Dilemmas in Obstetric Anesthesia" and
will include discussions about management of the morbidly
obese parturient, anticoagulants, regional anesthesia in
obstetrics and choosing among options for regional analgesia
in labor. The SOAP newsletter publishes a regular "Pro-Con
Forum" in which two members debate "gray areas"
in the subspecialty. Recent controversies have included
whether use of epidural anesthesia for external cephalic
version is useful or appropriate, whether provision of regional
analgesia for labor requires in-house anesthesia coverage,
whether written consent for labor epidurals is necessary,
the timing of postpartum tubal ligations and the role of
the obstetrical nurse in obstetric analgesia. Suggestions
for future topics are welcome!
Separate from clinical controversies are the dilemmas in
practice management that have centered recently on two areas.
These are the guidelines for vaginal birth after cesarean
delivery (VBAC) written by the American College of Obstetricians
and Gynecologists (ACOG) and adopted by the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO) and
the position statement by the Association of Women's Health,
Obstetric and Neonatal Nurses (AWHONN) titled "Role
of the Registered Nurse in the Care of the Pregnant Woman
Receiving Analgesia/Anesthesia by Catheter Techniques."
Both guidelines have significantly impacted staffing requirements
for many anesthesiologists covering labor and delivery units.
ACOG's Statement on VBAC
In 1999, ACOG published a revision of their practice bulletin
"Vaginal Birth After Previous Cesarean Delivery."
The guidelines now state: "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" and that contraindications
to performing VBAC include "inability to perform emergency
cesarean delivery because of unavailable surgeons, anesthesia,
sufficient staff or facility" (italics are mine). Although
ACOG declined to define "immediately available,"
it was assumed by most that this meant in-house coverage
while the woman was in labor. The reality is that many anesthesiologists
in the community cover labor and delivery suites from home,
and the change to in-house coverage for a service that does
not typically allow for reimbursement is a difficult one.
Although many anesthesiologists and obstetricians objected
to the new requirements, ACOG has stood by its guidelines,
noting that this is a patient safety issue and that VBAC
is an elective procedure planned as much as nine months
ahead so alternate arrangements can be made if necessary.
A recent article quantified the risk of uterine rupture
for VBAC versus elective repeat cesarean delivery.1
The relative risk of uterine rupture was 3.3 with spontaneous
onset of labor, 4.9 with induction not using prostaglandins
and 15.6 with induction using prostaglandins. If uterine
rupture occurred, neonatal mortality increased by a factor
of 10. The accompanying editorial closed by saying "…a
patient might ask, 'But doctor, what is the safest thing
for my baby?' Given the findings…my unequivocal answer
is: elective repeated cesarean section."2 JCAHO adopted
ACOG's recommendations into its standards as of January
1, 2001. Some hospitals have chosen not to allow VBACs any
longer, feeling they cannot staff appropriately. Others
offer patients the option of an elective repeat cesarean
delivery or transfer to another hospital where in-house
personnel are available. Anesthesiologists should be involved
in discussions at their hospitals when VBAC guidelines are
decided.
AWHONN's Nursing Guidelines for Labor Epidurals
AWHONN revised its nursing guidelines on epidural analgesia
for labor in 2001, stating that nonanesthetist registered
nurses should not increase or decrease the rate of an epidural
infusion or start one that has been stopped, bolus an epidural
catheter from the pump or by other methods, or manipulate
patient-controlled epidural (PCEA) doses. Earlier this year,
ASA President Barry M. Glazer, M.D., and SOAP President
Valerie A. Arkoosh, M.D., jointly wrote a letter to the
president of AWHONN, which is available on the SOAP Web
site at http://www.soap.org/AWHONN.iphtml.
They make three very important points:
1. Infusion adjustment of a properly placed epidural
catheter can be performed safely within defined parameters.
Labor nurses adjust other "dangerous" medications
such as oxytocin and magnesium once they have received training.
In many other settings (postanesthesia care unit, intensive
care unit and postsurgical), nurses adjust epidural infusions
under a physician's written order, and there are no data
to suggest that this practice is unsafe. Labor nurses are
capable of the same level of care.
2. The current practice of using dilute solutions for
labor epidural infusions makes overdosing nearly impossible.
The local anesthetic and opioid concentrations used in current
practice are so dilute, the risks to patients are minimal
even if catheter migration occurs. Intravenous migration
would cause inadequate pain relief rather than any toxic
manifestations, and subarachnoid migration would cause increasing
motor block rather than hemodynamic compromise. The nurse
would then contact the anesthesiologist to evaluate the
patient for pain or excessive motor block.
3. To underutilize all reasonable resources in the delivery
of care will mean that ultimately it will be laboring women
who lose the most. Nonphysician providers are used increasingly
throughout medicine once training and parameters have been
provided. The shortage of anesthesiology providers and the
increasing demand for labor analgesia mean there is an insufficient
workforce to provide all laboring women the care they request.
ASA and SOAP believe that labor nurses should be active
participants in all aspects of their patients' obstetric
care, including pain relief.
Reports of hospitals discontinuing their labor epidural
services because nurses have stopped adjusting epidurals,
despite a patient-specific physician order, has prompted
the California Society of Anesthesiologists to partner with
California ACOG to issue a joint letter to AWHONN urging
them to revise their position statement and providing a
suggested revision. SOAP and ASA will continue to try to
work with AWHONN so pain relief in labor can be managed
as a partnership.*
The mission of the Society is to promote excellence in
research and practice of obstetric anesthesiology and perinatology.
Through its annual meeting, newsletters and Web site, the
mission continues to be addressed and improvements in health
care for pregnant women continue to be made.
References:
1. Lydon-Rochelle M, Holt VL, Easterling
TR, Martin DP. Risk of uterine rupture during labor among
women with a prior cesarean delivery. N Engl J Med. 2001;
345:3-8. 2. Greene MF. Vaginal delivery after cesarean section
– Is the risk acceptable? N Engl J Med. 2001; 345:54-55.
*A statement written jointly by the ASA committees on Pain
Medicine and Obstetrical Anesthesia titled "Statement
on the Role of Registered Nurses in the Management of Continuous
Regional Analgesia," was presented to the ASA Board of
Directors at its meeting last month. The statement outlines
several duties that can be done safely by registered nurses
if they follow a patient-specific protocol written by a qualified
physician. The actions of the Board will go to the House of
Delegates in October for approval, disapproval or referral.
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Joy
L. Hawkins, M.D., is Professor of Anesthesiology and
Director of Obstetric Anesthesia, University of Colorado
School of Medicine, Denver, Colorado. |
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