Obstetric Anesthesia: It’s Not Just About Epidurals!

he Society for Obstetric Anesthesia and Perinatology (SOAP) is a subspecialty organization of ASA whose mission is to promote excellence in research and the practice of obstetric anesthesiology. SOAP is an active society, and obstetric anesthesiology issues are some of the most frequently encountered questions among ASA members. What are some of the current issues that the specialty of obstetric anesthesiology has encountered?

What Can SOAP Do for You? The society has many resources that a practicing anesthesiologist may find useful. On our homepage <www.soap.org>, one can utilize a feedback option that allows one to submit any question to the SOAP office. These questions are initially screened by Lawrence C. Tsen, M.D., our society’s secretary, and then answered by either Dr. Tsen or in consultation with other appropriate persons within the SOAP Board of Directors and various committees. Some of the more frequent questions include issues related to “policy” or “guidelines.” For example, what should one do with regard to fetal monitoring in the pregnant patient undergoing nonobstetric surgery? What should patients be allowed to eat or drink during labor? What constitutes appropriate fasting guidelines before elective cesarean delivery? When is the appropriate time and anesthetic technique for a postpartum tubal ligation? And there are many more! If you have a question about obstetric anesthesiology, SOAP can find an answer for you!

Additional resources include publication of a “What’s New in Obstetric Anesthesia” article annually in both Anesthesiology¹ and the International Journal of Obstetric Anesthesia.² These comprehensive reviews, always written by an expert in obstetric anesthesiology, provide an up-to-date summary of the recent literature that influences our practice.

At present, a task force has been assembled to revise the ASA “Practice Guidelines for Obstetric Anesthesia” <www.ASAhq.org/publicationsAndServices/obguide.html>. This document, first introduced in 1999, will provide practitioners with guidelines to help with many of the more common and even uncommon clinical situations that arise. The foundation for the guidelines is always evidence-based to as great a degree as possible, and the input of expert consultants is utilized from both within and outside the specialty of anesthesiology. Moreover SOAP and ASA place tremendous value on the input of our members. Hence, as part of the process for the practice parameters revision, we will hold open forums at various national meetings, and we welcome and actively encourage all interested ASA members to contribute.

Integration With Other Specialties: Obstetric anesthesiology has become a mature and respected subspecialty in the arena of the care of the pregnant patient. Obstetric anesthesiologists now regularly appear as faculty speakers and panelists at national meetings of the American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine and the North American Society of Obstetric Medicine (NASOM). It is now de rigeur that obstetric anesthesiologists are included in all aspects of the multidisciplinary care and management of the high-risk pregnant patient. SOAP’s annual meeting now will regularly feature an “obstetric medicine” specialist to deliver a lecture on what is new in that specialty; the inaugural lecture was given last year by NASOM President Raymond Powrie, M.D., and met with enthusiastic and positive reviews.

Controversies Continue: One of the most interesting aspects of obstetric anesthesiology is the passion created by the various controversial topics related to pain relief during labor. Over the last decade, there has been no more controversial topic than the effect of regional analgesia on the progress and outcome of labor. It has now been shown to a reasonable degree of certainty that regional analgesia may be “associated with,” but does not “cause,” a higher rate of cesarean deliveries due to failure to progress in labor. An additional wrinkle was addressed in an important randomized, controlled trial published in the February 17, 2005 issue of the New England Journal of Medicine, wherein it was shown that early institution of regional analgesia, compared to later in labor, does not necessarily lead to an increased incidence of cesarean delivery.³ This study received widespread media attention in many national newspapers, magazines and television. The principal author of the study, Cynthia A. Wong, M.D., from Northwestern University in Chicago, and myself as author of an editorial⁴ that accompanied the article, were interviewed on the “Today” show to discuss the implications of this study. This segment, which aired February 17, 2005, was the recipient of the 2005 ASA Media Award for television, presented at the ASA Annual Meeting in Atlanta last October.

Considering that a very common methodology for billing labor analgesia services includes a ceiling on allowable time units, the Wong study may have implications for the economics of obstetric anesthesiology. If, as a result of the study, labor analgesia is initiated earlier, the duration of anesthetic care increases and the fraction of physician time recognized under time unit ceilings falls. Put another way, early analgesia may increase service demands without a corresponding expansion of payable units. Readers can be sure that both SOAP and the ASA Committee on Economics will be watching this issue closely.

The next SOAP Annual Meeting will take place on April 26-30, 2006, in Hollywood, Florida. Details are available at <www.soap.org>. We hope to see a large crowd!


References:
1. Tsen LC. Gerard W. Ostheimer. What’s New in Obstetric Anesthesia. Lecture. Anesthesiology. 2005; 102(3):672-679.
2. Tsen LC. What’s new and novel in obstetric anesthesia? Int J Obstet Anesth. 2005; 14(2):126-146.
3. Wong CA, Scavone BM, Peaceman AM, et.al. The risk of cesarean delivery with neuraxial analgesia given early vs. late in labor. N Engl J Med. 2005; 352:655-665.
4. Camann WR. Pain relief in labor. N Engl J Med. 2005; 352:718-720.

William R. Camann, M.D., is Associate Professor of Anesthesia, Harvard Medical School and Director of Obstetric Anesthesia, Brigham and Women’s Hospital, Boston, Massachusetts.