ASA October 2003 Newsletter

There are approximately 4 million births in the United States each year, and nearly 60 percent of these women will receive neuraxial analgesia during labor and delivery. Obstetric (OB) anesthesia is almost always administered in a location that is “off-site” from the hospital’s main operating room suite. At times merely yards away, although more often in an entirely different building, obstetric anesthesia is more, far more, than just anesthesia administered in a remote locale. Obstetric anesthesiologists are presented with unique challenges and special circumstances that differ in meaningful ways from typical anesthetic practices in the main operating room (O.R.) setting. In this article, I will summarize some of the introductory comments I deliver every month to the new residents rotating on the obstetric anesthesia service at my hospital.

A Special Event
First and foremost, obstetric anesthesiologists must always remember that we are welcomed into one of the most special, intimate, private events in a woman’s life. Most people who present to the main operating room for general surgical procedures would probably rather not be there at all, not have the procedure and when all is concluded, would be perfectly happy to forget the entire experience. Not so in OB. Childbirth is an event that most women will remember as a sentinel event in their lives, commensurate with marriage, an important graduation or other similar milestones. The dignity and importance of this event is one of the special perks that makes the practice of obstetric anesthesia a privilege unrivaled by most circumstances encountered in the surgical O.R.

Not Like the Main O.R.
Unlike the general O.R., we rarely use sedatives or hypnotics in OB. One reason is concern about placental transfer and subsequent fetal heart rate abnormalities or neonatal depression. In addition the avoidance of parenteral central nervous system depressants and exclusive reliance on the effectiveness of regional blocks allows for an awake, alert, cooperative mother who can fully participate in her delivery. Subtle consequences of this for the OB anesthesiologist include the fact that our patients are acutely aware of events and conversations and comments that occur around them. Thus the interpersonal skills and tact of the anesthesiologist are challenged in ways seldom encountered in the main O.R. Moreover unlike the circumstances in the main O.R., we frequently perform anesthetics in the presence of other nonmedical people. Who ever heard of a spouse coming into the operating room to observe their loved one’s cholecystectomy? Yet in OB, this is a part of our daily routine. The ability to provide analgesia and anesthesia in the presence of one or more family members or other assorted support personnel is one of the challenges of obstetric anesthesia. A few reported examples of the potential difficulties that can occur include spurious blood pressure results owing to a husband leaning on the cuff during a cesarean delivery¹; a fainting husband who suffers a fractured skull during a fall to the floor while observing his wife receive an epidural²; or the sister who, due to some inadvertent under-the-drapes fumbling, wears a pulse oximeter on her own finger for the duration of her sibling’s cesarean! (from personal communications with David J. Birnbach, M.D.)

The practice of employing a “doula” for emotional and physical support during labor is something with which obstetric anesthesiologists must become familiar. Although far more common among patients attempting a natural childbirth, the use of doulas is becoming increasingly common in some areas of the country and is entirely compatible with the use of epidural analgesia — the “epi-doula,” as I like to call them. A full discussion of doulas and their interactions with obstetric anesthesiologists has been published in a prior edition of the ASA NEWSLETTER.³

In addition to the presence of the father and others, the obstetric anesthesiologist must always be mindful of an additional patient — the baby. Many of our anesthetics can, either directly or indirectly, affect the fetus. Blood pressure changes owing to sympathetic block or caval compression, vasopressor use, systemic absorption of anesthetic drugs and even intravenous fluid administration can have effects on uterine tone, contraction pattern and the apparent well-being of the fetus.

Unlike the general O.R., most (but by no means all) of our patients in obstetrics are alert, conscious, healthy women having healthy babies. In fact most of our patients who have mild or even severe medical or obstetric complications of pregnancy are still largely alert and conscious, and worried. This may seem like a small thing, but it is not. “Schmoozing” with pregnant patients and their partners during labor and birth requires communication skills that are accurate and effective as well as calm and reassuring.

It requires knowledge of the particular concerns and fears of a laboring woman, such as concerns about body habitus and image changes, concerns about loss of dignity during childbirth, concerns about the well-being of the infant and respect for confidentiality with regard to sensitive issues. For example understanding that discussing a patient’s prior obstetric history in front of the partner may, in some cases, be much more than simply a moment of embarrassment or even a violation of federally mandated privacy rules, such as the woman with three prior pregnancy terminations whose husband believes she is now pregnant for the first time.

Although the labor and delivery unit is largely a happy place, the obstetric anesthesiologist also must be able to handle the often devastating circumstances surrounding the administration of anesthesia to a patient who has experienced a fetal demise. I frequently tell my residents that success as an obstetric anesthesiologist cannot be measured by how rapidly and effectively one can place an epidural (although this is certainly of great importance) but rather how effectively one can meet the interpersonal communication requirements of the labor and delivery unit.

Consumer Interest
Again, unlike the general O.R., many obstetric patients arrive with a variety of preconceived notions (unfortunately often misguided and inaccurate) about anesthesia for childbirth. More so than virtually any other anesthetic subspecialty, our patients are subjected to a wide and diverse array of opinions about anesthesia, usually from nonanesthesia-related sources such as childbirth classes, books, magazines, the Internet and friends. A quick tour of the pregnancy section of any major book or magazine store will convince even the most casual observer that consumer interest in pain relief during labor is unrivaled by any other branch of anesthesiology practice. Much of what is written is not entirely favorable to the use of regional analgesia during labor. It behooves the obstetric anesthesiologist to be aware of what the lay press is writing and what our patients are reading so we can answer our patients’ questions and address their concerns with knowledge and confidence.

A Word About Natural Childbirth
Not all women experiencing vaginal delivery want or need an anesthetic. Some women do not receive regional analgesia simply due to the lack of availability of an anesthesia provider or, rarely, a medical or anatomic contraindication to a regional technique. Others do not receive regional analgesia due to a planned and calculated desire to experience “natural childbirth” (NCB). Patients attempting NCB are often off our radar screens, they don’t bother us, and we don’t bother them. I am strongly committed to respectfully supporting a woman’s informed right to choose nonmedicated childbirth if she so desires.

We also need to be aware of a variety of issues unique to the NCB population, however. The frequent use of complementary and alternative therapies in obstetrics may be of importance with regard to drug interactions.⁴ The NCB patient who eventually “converts” to receiving regional analgesia (something that could occur for a wide variety of reasons) may, despite superb pain relief, still not be satisfied with her overall experience.⁵ An understanding of the myriad reasons why a woman might desire NCB is important for the obstetric anesthesiologist to effectively counsel and interact with these patients. Finally the NCB patient may still have medical or anatomic issues (e.g., difficult airway, obesity) of importance should emergent anesthesia, especially general anesthesia, be required. In the interest of patient safety, close communication between us and our obstetric, midwifery and nursing colleagues is critical for early identification and consultation, and possibly early anesthetic intervention, in patients with such concerns.

In conclusion, obstetric anesthesiology is far more than simply placing a needle in the right space in someone’s back and giving the right drugs to relieve pain. A resident who judges the success of his or her obstetric anesthesia rotation by how many epidurals he or she performs is missing the point. Obstetric anesthesiology requires superb interpersonal skills and an intimate understanding of a highly consumer-oriented practice. The stresses and challenges of obstetric anesthesiology practice can be intense and differ in a variety of ways from the stresses of general O.R. anesthesia. Nonetheless the personal and professional satisfaction is tremendous. How many general O.R.-based anesthesiologists regularly have their pictures taken for their patients’ family photo albums?

References:

1. Healzer JM, Pearl RG. Husband-induced hypotension. Anesthesiology. 1995; 82:323.

2. DeVore JS, Asrani R. Paternal fractured skull as a complication of obstetric anesthesia. Anesthesiology. 1978; 48:386.

3. Camann W. Doulas — Who are they and how might they affect obstetric anesthesia practices? ASA Newsl. 2000; 64(10):11-12.

4. Hepner DH, Harnett MJ, Segal S, et al. Herbal medicine use in parturients. Anesth Analg. 2002; 94:690-693.

5. Kannan S, Jamison RM, Datta S. Maternal satisfaction and pain control in women electing natural childbirth. Reg Anesth Pain Med. 2001; 26:468-472.

William Camann, M.D., is Associate Professor of Anesthesiology, Harvard Medical School, and Director of Obstetric Anesthesiology, Brigham and Women’s Hospital, Boston, Massachusetts. He is Vice-President of the Society for Obstetric Anesthesia and Perinatology.

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