David J. Birnbach, M.D., Chair
Committee on Obstetrical Anesthesia

The ASA Committee on Obstetrical Anesthesia has been working on several projects in conjunction with ASA, the Society for Obstetric Anesthesia and Perinatology (SOAP) and the American College of Obstetricians and Gynecologists (ACOG). While many of these works are still in progress, this article highlights the accomplishments made since the last NEWSLETTER update as well as review some of the committee’s current activities.

Practice Guidelines for Obstetric Anesthesia
This report of evidence-based guidelines, which went into effect in January 1999, was developed by an ASA task force chaired by Joy L. Hawkins, M.D. The aim of these guidelines was “to enhance the quality of anesthesia care for obstetric patients, reduce the incidence and severity of anesthesia-related complications and increase patient satisfaction.” The guidelines have had a major impact on the current practice of obstetric anesthesia and are widely quoted and used frequently in clinical practice. The following subjects were included in the guidelines: perianesthetic evaluation, intrapartum platelet count, blood type and screen, perianesthetic recording of the fetal heart rate, nothing-by-mouth policies, anesthesia care for labor (including a review of epidural analgesia, use of continuous infusions, spinal opioids, combined spinal-epidural techniques and the impact of epidural on the progress of labor), monitored standby anesthesia for complicated vaginal delivery, removal of retained placenta, anesthesia choices for cesarean delivery, postpartum tubal ligations and management of obstetric complications. These guidelines are available on the ASA Web site, were published in Anesthesiology (1999; 90:600-611), and also have been published in other journals for the benefit of our obstetric colleagues.

Guidelines for Regional Anesthesia in Obstetrics
These guidelines, last amended in 2000, have been widely published and have improved patient safety. The eight guidelines related to use of regional anesthesia or analgesia to the parturient provide direction for the practitioner. Many anesthesiologists who practice in private practices where the obstetrician does call from home have asked ASA about recommendations regarding availability of obstetricians prior to placement of a neuraxial block. Guideline III states that “Regional anesthesia should not be administered until: 1) The patient has been examined by a qualified individual; and 2) A physician with obstetrical privileges to perform operative vaginal or cesarean delivery, who has knowledge of the maternal and fetal status and the progress of labor and who approves the initiation of labor anesthesia, is readily available to supervise the labor and manage any obstetric complications that may arise.” The definition of “readily available” must be made by each individual institution.

Optimal Goals for Anesthesia Care in Obstetrics
This joint statement from ASA and ACOG reviews several areas of concern to both specialties. The question of the time to prepare for a cesarean delivery (“decision-to-incision time”), an area of great concern, is addressed in this document. As previously recommended by ACOG, anesthesia and surgical personnel must be available to permit the start of a cesarean delivery within 30 minutes of the decision to perform the procedure. This time line, however, is not appropriate for cases of vaginal birth after cesarean (VBAC) where staff must be “immediately available.” The “Optimal Goals” statement is available on the ASA Web site at <www.ASAhq.org/publicationsAndServices/standards/24.html>. The most recent ACOG committee opinion regarding VBAC (No. 271, April 2002) is available from ACOG and discusses the increased risk of uterine rupture during VBAC attempts when prostaglandin cervical ripening agents are used. Because the issue of VBAC has become so controversial, we have asked ACOG Vice-President of Practice Activities Stanley Zinberg, M.D., to write a few words about why ACOG so strongly believes that an anesthesiologist and obstetrician need to be “immediately” available for a trial of labor following cesarean section. His comments follow:

“The American College of Obstetricians and Gynecologists continue to emphasize the need for those institutions offering VBAC to have the facilities and personnel, including obstetric, anesthesia and nursing personnel, immediately available to perform emergency cesarean delivery when conducting a trial of labor for women with a prior uterine scar. The operational definition of “immediately available” personnel and facilities remains the purview of each local institution, and the College strongly encourages these institutions to make the necessary resources available for eligible patients.

The risk of uterine rupture, with potential dire consequences for both mother and infant, is approximately 1 percent in VBAC patients. In contrast to other obstetric emergencies, VBAC is a completely elective procedure that allows for reasonable precautions in assuming this small but significant risk. Patient outcomes may benefit from the immediate availability of a physician who can perform c-sections. In addition, uterine rupture is often accompanied by legal action no matter what the clinical outcome or how excellent the clinical care. Defendant physicians and hospital are in a better position from a liability perspective if the physicians were present at the time of the complication.

The College recognizes the implications such immediate availability has for smaller hospitals, for the practice patterns of obstetricians and anesthesiologists and for the incidence of VBAC in general. But while recognizing the possible difficulties this position may generate, this stand is taken in the interest of women’s health and patient safety. The VBAC issue will be monitored continuously, and should information develop that contradicts ACOG’s current approach, change could certainly be effected.”

Anesthesia for the Patient With Severe Pregnancy Induced Hypertension
A task force of the National Institutes of Health evaluated the controversial issue of the obstetric and anesthetic management of the preeclamptic patient, and because of our liaison with ACOG, an anesthesiologist was asked to participate. The final document (Am J Ob Gyn. 2000; 183:S1-22) is a broad review and includes a section that evaluates and supports the use of neuraxial techniques in these patients.

AWHONN
As many of you know, the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) published a position statement in 2001 suggesting that nonanesthetist registered nurses should not be involved in the management of epidural catheters or epidural infusions. Despite numerous efforts by many individuals, ASA and SOAP have been unsuccessful in attempts to change the opinions of AWHONN leadership concerning this issue. The ASA Committee on Obstetrical Anesthesia has joined with the Committee on Pain Medicine to write a statement on the role of registered nurses in the management of continuous regional analgesia. This statement was approved by the ASA House of Delegates on October 16, 2002, and can be found on the ASA Web site.* In addition, correspondence between our societies and AWHONN can be read on the SOAP Web page <www.SOAP.org> under “Inside SOAP.” Many ASA members have contacted ASA regarding this ongoing issue. In the meantime, one possible solution that will help in many cases is the initiation of patient-controlled epidural analgesia so that a lower concentration of local anesthetic is used and a patient can give herself a limited number of “top-ups” when necessary.

“Fetal Distress”
In 1988, ACOG recommended that the term “fetal distress” be abandoned (Committee Opinion No. 197) and recently voiced its concern about the continued use of the term as an antepartum or intrapartum diagnosis. The ACOG Committee on Obstetric Practice has reaffirmed that the term “fetal distress” is imprecise and nonspecific and has asked that the anesthesiology community be made aware that this term should not be used. The committee has suggested that the term be replaced with “nonreassuring fetal status” followed by a further description of findings (e.g., due to fetal bradycardia, late decelerations, etc.). Of note to anesthesiologists, the ACOG Committee Opinion No. 197 states that “performing a cesarean delivery for a nonreassuring fetal heart rate pattern does not necessarily preclude the use of regional anesthesia.”

Patient Education
Both ASA and ACOG independently publish a patient education brochure regarding labor analgesia, ASA’s “Planning Your Childbirth” and ACOG’s “Pain Relief During Labor and Delivery.” These two organizations are currently working out the details to jointly distribute one brochure approved by both specialties. If these negotiations are successful, this effort will have several benefits. First, we can guarantee that the information in the brochure regarding anesthesia and analgesia is accurate. Second, the brochure will have the seals of both societies and thus will improve anesthesiologist visibility and get information regarding anesthesia into the hands of many more patients than at present. Last, it once again helps to improve relationships between our societies so that anesthesiologists will have a better working relationship with obstetricians. As an example of this improved relationship, ACOG has decided to have an update on labor analgesia given by an anesthesiologist as a refresher course-type lecture at its annual meeting.

Neuraxial Analgesia/Cesarean Delivery Rates
A task force report published in 2000 suggested that one of the possible causes for the increased cesarean delivery rates in the United States was the increasing rate of labor epidurals. The message was misinterpreted, and some obstetricians believed that they should withhold epidural analgesia or delay it. The ACOG Committee on Obstetric Practice reiterated its support of allowing any parturient who requests analgesia to receive it. In the “Practice Bulletin on Obstetric Analgesia and Anesthesia,” published in July 2002, ACOG once again states that “labor results in severe pain for many women. There is no other circumstance in which it is considered acceptable for a person to experience untreated severe pain, amenable to safe intervention while under a physician’s care.” Furthermore, in a recently published Committee Opinion (Int J Gynaecol Obstet. 2002; 77:297-8), ACOG states: “The American College of Obstetricians and Gynecologists wishes to reaffirm the opinion published jointly with ASA that while under a physician’s care, in the absence of a medical contraindication, maternal request is a sufficient medical indication for pain relief during labor. Decisions regarding analgesia should be coordinated among the obstetrician, the anesthesiologist, the patient and support personnel.”

During the past year, ASA and the Committee on Obstetrical Anesthesia have received more than 100 e-mails, telephone calls, letters and faxes with inquiries regarding obstetric anesthesia practice. We hope that this review will answer some of your questions about the work of the Committee on Obstetrical Anesthesia. If you have a question or concerns, please drop me a line at <dbirnbach@miami.edu>.

^* The American Medical Association House of Delegates voted last month to adopt ASA’s position that “in order to provide optimum patient care, it is essential that registered nurses participate in the management of analgesic modalities.”

David J. Birnbach, M.D., is Professor, Executive Vice-Chair and Associate Director, Institute for Women’s Health, University of Florida School of Medicine, Miami, Florida.