t has been a relatively quiet year at the American College of Obstetricians and Gynecologists (ACOG). The optimist in me hopes that this is the start of a long period of mutual respect and teamwork between our societies; the pessimist in me fears that this is the calm before the storm.

Here is what has been happening recently at ACOG as well as some upcoming events. I will divide this article into a few separate sections. First, what has been happening over the past few years (the “good news”), and second, some of the upcoming issues and how they may impact anesthesiologists. Finally I will review recent events as they relate to labor epidural-related infection and what impact ASA and the Centers for Disease Control and Prevention (CDC) might have in developing guidelines for practice in this area.

I. The Good News
The “process” has been working well. After a short period where ACOG or its representatives made comments or published opinions not necessarily in concert with the anesthesiology community, the team spirit has been alive and well, and all relevant or anesthesia-related committee opinions are once again being reviewed by ASA representatives before publication. Several key committee opinions have been produced at the request of ASA members, and all of the new committee opinions attempt to address anesthesiology issues, including “Pain Relief in Labor,” “Obstetric Management of Patients with Spinal Cord Injuries,” “Safety of Lovenox^® in Pregnancy” and “Placenta Accreta.”

Furthermore several other recent advances relating to the ASA/ACOG relationship have been made. First, a joint ASA/ACOG patient education brochure was published this year and is now being distributed to obstetricians across the country. Like the previous ASA brochure, “Planning Your Childbirth” also is available to ASA members through the ASA Publications Department. The ASA logo appears next to the ACOG logo, and, importantly, members of the ASA Committee on Obstetrical Anesthesia were active in helping to write this brochure.

Second, ACOG has continued to support ASA’s position that it is beneficial to have an “Anesthesia Update” lecture at its Annual Clinical Meeting, and the third such lecture will occur at the ACOG Annual Clinical Meeting this May 7-11 in San Francisco, California. It is our hope that eventually this lecture will become a permanent fixture rather than one that is decided upon on a year-by-year basis.

Another example of improved communication between ACOG and ASA is ACOG’s recent support of our position relating to labor nurses being able to assist in the management of epidural infusions. ACOG Committee Opinion number 295 (July 2004) states that “in an effort to allow the maximum number of patients to benefit from neuraxial analgesia, ASA and ACOG believe that labor nurses should not be restricted from participating in the management of pain relief during labor. Under appropriate physician supervision, labor and delivery nursing personnel who have been properly educated and have demonstrated current competence should be able to participate in the management of epidural infusions, including adjusting dosage and discontinuing infusions.”

II. Future Issues
1. Revision of the Joint Statement and Guidelines for Regional Anesthesia in Obstetrics
Guideline 3 of the ASA Guidelines for Regional Anesthesia in Obstetrics currently states, “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.”

ACOG has asked that ASA consider changing the language in this paragraph of the statement as it believes that the current wording is no longer representative of modern practice. The ASA Committee on Obstetrical Anesthesia believes that it is still appropriate for an obstetrician to be the one requesting that a parturient receive neuraxial analgesia and that someone with operative privileges be “available” should a problem occur. This issue will be brought up at a future ACOG meeting and may produce several less-than-perfect outcomes such as ASA changing our position or having a guideline that is no longer endorsed by ACOG.

2. Inclusion of Pediatrics in the “Vaginal Birth After Cesarean (VBAC)” Policy
Last year’s ASA House of Delegates report includes the following paragraph: “Unfortunately, some administrators, insurers and risk managers continue to look to the anesthesiologist to care for not only the mother but, when necessary, also the neonate if no other physician is immediately available. Therefore, we recommend that ASA instruct its Committee on Obstetrical Anesthesia to revisit this issue and liaison with related specialists such as obstetricians, pediatricians and neonatologists to determine if more stringent guidelines should be promulgated to address the need to have an individual, other than the anesthesiologist attending the mother, with the qualifications to resuscitate the severely compromised neonate immediately available when parturients are undergoing VBACs.” This issue has been discussed with ACOG, and the American Academy of Pediatrics has been asked to give its input before a recommendation is made.

3. Clarification of the VBAC Policy
This ACOG policy needs to be clarified, especially as it relates to the definition of the phrase “immediately available.” This continues to be the single most commonly questioned issue for anesthesiologists who contact the Committee on Obstetrical Anesthesia. In some scenarios, obstetricians have defined “immediately available” for VBAC as 30 minutes, and in other instances, the hospitals have required an anesthesiologist to be present on the labor floor even if no other cases are occurring (and occasionally in hospitals where the obstetrician is not available). Until now ACOG has not clarified its definition of “immediately available” other than saying that “immediately means immediately” and that it is a “local decision.” Perhaps further clarification will be possible in the future.

4. Use of Epidural Analgesia in Early Labor
A potential new ACOG committee opinion may need to be considered regarding the use of early epidural analgesia in labor based on recently published data. A 2000 ACOG task force on cesareans suggested that one of the factors involved with the increasing cesarean rates involved placement of epidurals in early labor. Based on strong opposition from ASA, ACOG released a committee opinion in 2002 stating, “Various studies report conflicting data with regard to the level of risk of cesarean delivery for nulliparous women who receive epidural analgesia before 5 cm of cervical dilatation. As a result, some institutions are requiring that laboring women reach 4-5 cm of dilatation before receiving epidural analgesia. The American College of Obstetricians and Gynecologists wishes to reaffirm the opinion published jointly with the American Society of Anesthesiologists 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.” Recent literature, however, including a landmark study by Wong et al. published in the February 17, 2005, New England Journal of Medicine, provides evidence that early epidurals do not cause increased cesareans. It is my hope that at some point in the future, ACOG will revisit this issue and update its committee opinion.

III. Infection Following Neuraxial Analgesia in Labor
ACOG informed ASA that it had received reports of several recent cases of maternal mortality due to infections in parturients who received neuraxial blocks and asked that this be reviewed by ASA and discussed with CDC. Though there is no central repository to be able to specifically know either the numerator or denominator, there do appear to be more anecdotal reports of catheter-related morbidity and mortality related to epidural or spinal abscess and meningitis. While these cases might suggest that the number of epidural/spinal infections appears to be increasing, there is no definitive data to support this conclusion.

Preliminary discussions with CDC have occurred, and at this point, it has been suggested that, as a first step, ASA should attempt to evaluate this issue in greater detail. It is clear that more information is necessary before definitive conclusions or guidelines can be proposed. Although there is a plethora of information and guidelines regarding placement of many different varieties of intravascular catheters, there is no such information regarding neuraxial catheters. Since there are currently no standards or guidelines for antisepsis relating to initiating epidurals or spinals in any patient (obstetrics or nonobstetrics), this may have a large impact on the practice of anesthesiology.

What guidelines exist elsewhere? Some foreign countries require that a hat and mask be worn by anesthesiologists placing epidurals or that hands be washed (or the most extreme case, that anesthesiologists wear surgical gowns). Why are the cases in obstetrics getting more press? There are lots of possible reasons. First, these cases may be more sensationalistic or more likely to result in a lawsuit. They also may be more likely to get published if submitted to an anesthesiology journal. In addition, while anesthesiologists performing neuraxial blocks for surgery are forced to wear a hat and mask because they are in the operating room, the same cannot be said for labor epidurals when these blocks are performed in a standard room on the labor and delivery floor.

Furthermore there appears to be no standard regarding disinfecting the skin of the back prior to epidural placement. Most U.S. anesthesiologists use povidone iodine (PI), and most of those using PI prefer single-use bottles or packets rather than multiuse bottles. Some, though, use two swabs, some three; some let it dry while others wipe it off; and some continue to use multiuse bottles of PI. Some anesthesiologists use alcohol alone, some use alcohol plus PI, and some use other agents such as DuraPrep™. Still others in the United States (and most Europeans) use chlorhexidine.

What is next? We need more information, and if any of you has any ideas about how this should be handled (or firsthand knowledge of cases that involve infection following neuraxial blockade), please let me know. The best way to reach me is via e-mail at <dbirnbach@med.miami.edu>.

I believe that we as a Society would probably benefit from guidelines (especially ones that are written by us as opposed to CDC). Before that can happen, however, more information and a better method of collecting data about these cases will be necessary. Who should take the lead, ASA or CDC? I believe that ASA and its subspecialty representatives are best equipped to follow this up but that CDC should be used as a valuable resource.

David J. Birnbach, M.D., is Professor and Executive Vice-Chair, Department of Anesthesiology, Miller School of Medicine, University of Miami, Miami, Florida.