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Anesthesia
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HE woman about to become a mother or with a new-born infant upon her bosom, shouId be the object of trembfing care and sympathy wherever she bears her tender burden, or stretches her aching limbs. The very outcast of the streets has pity upon her sister in degradation, when the sea1 of promised maternity is impressed upon her. The remorseIess vengeance of the Iaw brought down upon its victims by a machinery as sure as destiny, is arrested in its faI1 at a word which reveaIs her transient claim for mercy. The soIemn prayer of the Iiturgy singIes out her sorrows from the muItipIied triaIs of life, to pIead for her in her hour of peri1. God forbid that any member of the profession to which she trusts her Iife, doubly precious at that eventful period, shouId hazard it negIigentIy, unadvisedly or seIfishIy. OLIVER
WENDELL
HOLMES
3rd of the Series
ANESTHESIA CHARLES
A.
GORDON,
M.D.
Emeritus Professor of Obstetrics and Gynecology, State University of New York, State University Medical Center at New York ALEXANDER
H.
ROSENTHAL,
M.D.
AND
JAMES
L.
O’LEARY,
M.D.
Associate Obstetrician and Gynecologist, St. Catberine’s Hospital
Assistant Professor of Clinical Obstetrics and Gynecology, State University oj New York, State University Medical Center at New York
Brooklyn, New York
T
HE importance of anesthesia as a cause of materna1 death is not wideIy appreciated. There is good reason for this. If anesthesia is mentioned on a certificate of death, it is not tabuIated by the statistician even though death is stated to have been due to the toxic action of the anesthetic itseIf or to aspiration asphyxia. It just disappears from view. In no case reported here was the cause of death assigned to anesthesia, but to another cause. The actual frequency of death from anesthesia cannot be discovered unIess by examination of case records. If parturition should be compIicated by toxemia, tuberculosis or heart disease, for example, poor choice of anesthetic or a casual attitude toward its administration wiII contribute materiaIIy to the materna1 death rate. And every physician knows, or shouId know, that anesthesia pIays an impprtant part in death foIIowing long Iabor and diflicuh or muItipIe operative procedures. However, that anesthesia in the absence of these compIications
is dangerous is not so we11 appreciated. our purpose to make this plain.
It is
* * * * CASE I. A twenty-three year oId primipara was admitted to the hospital shortIy after dinner. She had been in Iabor for about two hours. Uterine contractions occurred reguIarIy every ten minutes but they were not hard. The patient was given an enema and put to bed. No sedative was administered. ShortIy afterward Iabor became very active. Within the hour the membranes ruptured and she was found to be fuIIy diIated and ready for deIivery. .Her obstetrician was caIIed and she was rushed to the delivery room. Administration of gas, oxygen anesthesia was begun at once as the caput was crowning. The patient vomited so the mask was removed. When she cried out again with pain, anesthesia was resumed. She vomited again, became deepIy cyanosed and ceased breathing. ArtificiaI respiration was tried and the head
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of the tabIe Iowered. After death a Iive baby was deIivered with outlet forceps. The patient had been in the deIivery room about five minutes. At necropsy the trachea and Iarge bronchi were found fiIIed with Iarge food particles. Large pleura1 petechiae were present. The Iungs showed marked congestion, edema and mucopuruIent exudate in the bronchi and bronchioles. Questions. (I) Might this patient have vomited even if she were not given an anesthetic? (2) ShouId she have had an anesthetic and, if so, was the anesthetic properIy administered? Of course the patient may have Answers. vomited without anesthesia. Vomiting occurs frequentIy in the second stage of Iabor but not as a ruIe so close to its concIusion. The anesthetic intended to reIieve pain deprived her of life. The deep inspiration which may carry vomitus into the bronchia tree occurs most frequentIy during induction. During a brief critica period the vomiting center is stimuIated by the anesthetic agent at a time when cough and IaryngeaI reffexes are aboIished. Prevention of vomiting depends upon carrying the patient rapidIy through the second stage and into the first pIane of the third stage of anesthesia. If vomiting shouId occur, anesthesia shouId be stopped at once. The obstetrician shouId instruct his patient not to eat at home if she thinks that labor has begun. Food during Iabor increases the hazard of de1iver.y under genera1 anesthesia. The physica and emotiona stress of Iabor stops gastric peristaIsis so that food may remain in the stomach for many hours. Vomiting is dangerous. The margin of safety with nitrous oxide is wide provided the anesthetist is aIert to the dangers of the second stage. However, this may be said of kny inhaIation anesthetic. The onIy disadvantage of nitrous oxide is anoxia which was not a factor in this case. Infiltration of the perineum with 0.5 per cent novocain wouId have been perfect for spontaneous delivery or episiotomy and cIearIy the anesthetic of choice.
**** CASE II. After fourteen hours of good Iabor a thirty year oId primipara was deIivered February,
1951
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spontaneously under Iight open mask ether given during uterine contractions. Anesthesia was satisfactory. When anesthesia was resumed for perinea1 repair, she struggIed vioIentIy and tried to vomit but was prevented from doing so by crowding anesthesia. SuddenIy she stopped breathing and her face and neck became deepIy cyanosed. Respiration was re-estabhshed with a mechanica respirator and the perineum was repaired without anesthesia. Cyanosis deepened, bIoody froth appeared on her Iips and breathing, which had been shaIIow for some time, ceased. AI1 efforts at resuscitation faiIed. At necropsy food particIes were found in the trachea1 bifurcation. Questions. (I) When did the patient vomit? (2) WouId continuous anesthesia for deIivery and repair have been better than a second induction? Answers. The anesthetist thought that he had prevented vomiting, but it is cIear that he had not. Repeated attempts at vomiting whiIe the breath is heId are very dangerous. During attempts to vomit the jaws may be heId so tightIy cIosed that the mouth cannot be opened by the anesthetist. Vomitus fiIIs the pharynx and is sucked into the Iungs at the first inspiration. Anesthesia shouId not be pushed at this point, nor shouId the mask be strapped or buckIed over the patient’s mouth. As a matter of fact the presence of food in the stomach shouId be suspected if induction is difficult or if Iarge amounts of anesthetic are required. If coughing or retching shouId occur, the presence of food or ffuid shouId be assumed. The stomach shouId then be emptied or another form of anesthesia substituted. Since induction is dangerous once shouId be enough. Why tempt fate twice? A second anesthetic adds to the risk. The time interva1 between deIivery and perinea1 repair wiI1 not be considerabIe if the delivery room is we11organized and the third stage of Iabor well managed.
* * * * CASE III. A twenty year oId primipara was admitted to the hospita1 in active labor. Within two hours she was ready for deIivery and Iight ether anesthesia was begun. She took it we11 but contractions decreased in frequency and strength and it became neces-
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sary to deIiver her with Iow forceps. Anesthesia was continued for episiotomy and deEvery. The pIacenta was expressed without dificuIty and the patient was returned to her bed. Soon afterward she vomited a Iarge amount of fluid and undigested food, but at no time was there any sign of respiratory distress. Her bIood pressure was 120/80 and the puIse rate IOO. A IittIe Iater cyanosis was noticed. RestIessness increased and breathing became noisy. Death occurred shortIy after a smaI1 quantity of ffuid was removed through a bronchoscope. At necropsy the trachea and main bronchi were congested and many of the Iarger bronchi contained fluid. No food particIes were seen. The Iower Iobe of the right Iung showed beginning consoIidation. Questions. (I) Were the symptoms due to aspiration? (2) How couId this death have been prevented? Answers. In a11 probability aspiration occurred during the period of emergence as the patient passed from the third stage of anesthesia to the second, the same critica IeveI as of induction. The patient shouId not have been returned to bed unti1 conscious. At any rate she shouId have been watched more cIoseIy during the period of recovery. She might have been turned on her side so as to favor escape of vomitus from her mouth. The period of emergence is much Ionger after ether anesthesia than after nitrous oxide. HyperventiIation with CO2 wiII shorten this period. Finding pathology in the right Iung and particuIarIy in the Iower Iobe is fairIy good evidence that aspiration took pIace. It is not necessary to find food to prove the diagnosis. Aspirated Auid is more apt to gravitate to the right Iung and particuIarIy to the Iower Iobe because of the course of the right bronchus. **** CASE IV. A thirty year oId patient who had been delivered of a Iive baby by high forceps was admitted to the hospita1 at term earIy in Iabor in her second pregnancy. After thirteen hours of Iabor, with membranes ruptured eight hours, the cervix was found fuIIy diIated, with the vertex in Ieft occipitoposterior position stiI1 unengaged. Cesarean section was decided upon and operation was begun at 2 P.M. under gas, oxygen and ether
sequence. At 2:3g P.M. just after delivery of the baby the patient vomited Iarge quantities of food aIthough she had had no food during the tweIve hours she had been in the hospita1. A resident bronchoscopist who was immediateIy avaiIabIe was abIe to remove a considerabIe amount of food particIes from the Iarynx but the patient was pronounced dead after five minutes after vomiting. At post mortem it was found that a11 food particIes had been removed. Questions. (I) Was the anesthetic we11 seIected? (2) Why did vomiting occur in the middIe of the operation? (3) After tweIve hours in the hospita1 without food cannot one assume that the stomach is empty? (3) Is bronchoscopy good treatment? Answers. InhaIation anesthetics are not idea1 for cesarean section if onIy because they a11 pass the pIacenta1 barrier and add to our anxiety for the safety of the baby. Uterine atony, hemorrhage and shock occur more often under genera1 anesthesia, particuIarIy ether, than with IocaI anesthesia or spina1. Nitrous oxide induction may be more dificuIt for cesarean section than for vagina1 deIivery. Once seIf-restraint has been aboIished in the second stage of anesthesia, fear and anxiety for herseIf and the baby may cause the patient to vomit or thrash about, sIowing induction and adding to the hazards of aspiration and hypoxia. Cesarean section may not be compared with the pIanned surgery of the gynecoIogist. Operation may not be begun unti1 the surgica1 pIane of ether anesthesia is we11 established. Often marked increase in bronchia secretion, sIow emergence and troubIesome vomiting add to the risk. The anesthetist, even though expert, may try so hard to carry the patient IightIy in the interest of the baby, that the anesthetic IeveI is Iowered and the patient drifts back into the second stage. That is what happened in this case. After tweIve hours in the hospita1 one may assume that the patient’s stomach is empty unIess she has been in Iabor. In that event it shouId be assumed that the stomach may not be empty and vomiting shouId be induced. A smaI1 gIass of mustard water wiI1 be easier on the patient and much more effective than gastric Iavage. Apparatus for suction shouId be in readiness. The head end of the operating tabIe shouId be American
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lower than the foot. Bronchoscopy may be cIearIy indicated, yet as a ruIe it wiII be ineffective or too Iate. * * * * CASE v. A twenty-seven year oId primipara had an assisted breech deIivery after twentytwo hours of Iabor. Delivery took very IittIe more than one-haIf hour. Ether anesthesia with open mask was we11taken and no vomiting occurred. It was thought that anesthesia had to be deep for use of Piper’s forceps. During labor she had been given seconal, 3 gr., on the night of admission, morphine, $4 gr., eight hours before deIivery and morphine, 34 gr., two hours before. Deep cyanosis and Iabored breathing with harsh unproductive cough were observed twelve hours Iater. After administration of oxygen the patient improved greatly. However, ten hours Iater she again became dyspneic and cyanotic and the puIse rate rose to 144. BronchiaI breathing was noted in both Iower lobes of the Iungs with a few moist raIes, but x-ray of the chest was negative. Death occurred four hours Iater.
Questions. (I) Did this patient have ether pneumonia? (2) What part did sedatives pIay in this case? (3) Was diagnosis possibIe? (4) Must anesthesia be deep for use of Piper’s forceps? Answers. Ether pneumonia as a diagnosis had better be forgotten. This patient had ateIectasis due to obstruction of a bronchus and diminished puImonary ventiIation. The causative factors were Iong Iabor, spIinting of the diaphragm due to pain, decreased puImonary excursions and possibIy anaIgesia and ether anesthesia. The anesthetic, however, appears to have been we11 taken. At any rate there is no record of great stimuIation of the bronchia secretion. Barbiturates Iike a11 hypnotics and sedatives do depress respiration, yet it is unIikeIy that secona1 given so long before delivery pIayed an important part. Morphine depresses the respiratory center, the cough reflex and the ceIIuIar respiratory mechanism. It is not wise to use it within four hours of deIivery. The earIier the diagnosis of ateIectasIs is made the better. If after operation or deIivery, no matter what the anesthetic and occasionaIIy when no anesthetic at a11 has been adminFebruary,
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istered, coughing, increased pulse and respiratory rate and signs of oxygen want are observed, ateIectasis is the IikeIy cause. A keen look at the patient’s chest shouId show asymetric movement and narrowing of the rib spaces. X-ray may not be concIusive unti1 much Iater. Deep anesthesia is unnecessary when Piper’s forceps are appIied to the feta1 head in the peIvic excavation. ObviousIy the depth and duration of anesthesia add to maternal risk. * * * * CASE VI. This patient was twenty-six years of age, para IV. After tweIve hours of Iabor cesarean section under gas oxygen ether anesthesia was performed for disproportion. The operating time was one hour. There was no undue hemorrhage and the patient took the anesthetic weI1. At the concIusion of the operation the anesthetist reported the patient’s puIse couId not be feIt and that systoIic bIood pressure was unobtainabIe. She was thought to be in shock. She was transfused with plasma and bIood, improved somewhat and was taken to her room. Cyanosis and dyspnea were then observed. With coughing, rapid puIse and rapid respiration ateIectasis was beIieved to be present, but on auscuItation and percussion chest signs were inconcIusive. One-haIf hour Iater the patient had a chiI1 and was put into an oxygen tent. Dyspnea and cyanosis steadiIy became worse and she died five hours after operation. Necropsy showed massive ateIectasis invoIving the entire Iower Iobes of the right and Ieft lungs, nearIy a11of the upper Iobe of the Ieft Iung and two-thirds of the upper Iobe of the right Iung. Genera1 puImonary edema was present and the smaIIer bronchioIes were fiIIed with watery fluid. CASE VII. This patient was forty years of age, para x1. After a Iabor of thirty hours during which two doses of phenobarbita1, 3 gr. each, three doses of scopaIamine, Pi5 0 gr. each, and one dose of morphine, s/4 gr., were administered, a frank breech was broken up and deIivered under ether anesthesia. The procedure took thirty minutes and no untoward symptoms were observed. An hour Iater the patient’s puIse rose to 130 and respirations to 38. Cyanosis appeared and graduaIIy deepened. No breath sounds couId be heard in the Iower Iobe of the right lung. Coughing was frequent with blood-
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streaked sputum. The puIse became thready and more rapid, rising to 140. Breathing became more Iabored and moist raIes were heard over the entire chest. Death occurred eighteen hours postpartum. Treatment incIuded morphine, atropine and oxygen. Questions. (I) What caused the puImonary comphcation? Sedation? (2) How might it have been prevented? (3) How may the diagnosis be made before death? (4) What is the best treatment? Answers. It is diffIcuIt to be sure about its safety when sedation has been heavy. It is often impossibIe to predict the effect of a combination of sedative drugs. Barbiturates depress the meduIIary respiratory center onIy when used in Iarge doses. Morphine is a continuous depressant of respiration even in smaI1 doses. A multipara with frank breech presentation shouId get but IittIe sedation. If she is bIessed with good uterine contractions, so much the better, for she wiI1 need them in the second stage. If contractions are poor, they should be augmented by continuous intravenous pituitary stimuIation. Good Iabor shouId not be discouraged. Many obstetricians wouId have performed cesarean section dn this patient. AteIectasis occurs when access of air to the Iung or any part of it is prevented. Absorption of the air remaining resuIts in coIIapse of the alveoIi. It may resuIt from obstruction of a bronchus by bronchia secretion, aspiration of stomach or nasopharyngea1 content. Loss of IaryngeaI and cough reflexes under anesthesia make aspiration into the tracheobronchia1 tree easy. Oversedation, profound anesthesia, Iong operations, spIinting of the diaphragm and compression of the Iower lobes of the Iungs a11 contribute to decreased puImonary ventiIation. AteIectasis may occur under any form of anesthesia. Its not infrequent occurrence under spina anesthesia may be attributed to hypoventiIation due to change in diaphragmatic action or intercosta1 paralysis. The earlier ateIectasis is recognized the better. Signs of oxygen want Iike increased puIse and respiration rate and cyanosis are inevitabte. Coughing and Iabored breathing are common. Asymetric movement of the chest is diagnostic. On the affected side it wiII move less or not at a11 and narrowing and retraction of the rib spaces wiII be seen. Shift of the
mediastinum to the affected side with shift of apex beat and cardiac borders wiII be noted when actua1 shrinkage of the Iung occurs. Not until then wiI1 x-ray be diagnostic. Percussion and auscuItation may not be reIied upon for earIy diagnosis. Shock which foIIows massive puImonary coIIapse is possibIy due to mechanica shift interference with the great vesseIs of the mediastinum. Many factors in prevention have been indicated. During emergence from anesthesia the patient shouId be watched carefully, turned on her side and encouraged to breathe deepIy or cough. HyperventiIation with 3 per cent COZ and 9s per cent oxygen is vaIuabIe. In the Iater stage of infection and pneumonitis treatment by an internist wiI1 be indicated. * * * * CASE VIII. A primigravida, aged twentytwo years, was admitted to the hospita1 in active labor. Her chest was negative, bIood pressure rzo/80 and her prenata1 course had been uneventfu1. The feta1 heart tones were good, the vertex deep in right occipitoanterior position, the cervix diIated one finger, and regular uterine contractions occurred every five minutes. One hour Iater with the cervix dilated three fingers and the vertex just below the spines cauda1 anesthesia was instituted. In the next hour the cervix diIated fuIIy and the vertex came on the perineum. The patient was awake and cooperative, heIping to move herseIf from her bed to ‘the stretcher and then to the deIivery tabIe. Just prior to deIivery when asked to Iift her hips she faiIed to respond. On investigation it was noted that she had stopped breathing; apex beat and puIse were unobtainabIe. ArtificiaI respiration, intracardiac adrenaIin, intravenous coramine and oxygen were given. There was no response. WhiIe these procedures were going on she was debvered of a Iive baby by Iow forceps and episiotomy. The infant, weighing 6 pounds, 8 ounces required but sIight resuscitation. The tota amount of metycaine solution used was 45 cc. There was no diff&Ity with its administration. At necropsy inactive rheumatic heart disease involving the mitraI vaIve was found. Chemical examination of the spinal fluid showed concentration of metycaine 2.9 mg. per cc.
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Questions. (I) If mitra1 disease had been recognized, would caudaI anesthesia have been contraindicated? (2) Was heart disease the cause of death? Answers. CaudaI anesthesia is not contraindicated for delivery of patients with cardiac disease. On the contrary, it appears to have merit. Like a11 anesthetics it has potentia1 dangers. The amount of anesthetic for caudal anesthesia is much necessary greater than for spinal anesthesia. If it shouId be inadvertentjy injected into the spina canal or make its way there, death wil1 ensue. That is what happened in this case, probabIy when the patient helped to move herself from the stretcher to the deIivery table. * * * * CASE IX. Cesarean section was eIected in a patient thirty years of age who had had two earIy spontaneous abortions previousIy. For spina anesthesia IOO mg. of procaine were injected into the subarachnoid space at the IeveI of the third Iumbar vertebra. Immediate difFicuIty with respiration occurred just as soon as the patient was returned to the recIining position. Respiration soon ceased. ArtificiaI respiration, carbogen and finaIIy adrenaIin into the heart faiIed to revive her. AbdominaI deIivery after death did not save the fetus. CASE x. A primigravida, aged twenty-five years, was admitted to the hospita1 in the thirty-ninth week of pregnancy. Cesarean section had been planned because the peIvic measurements were smaI1 and the fetus appeared to be Iarge. She was not in Iabor. Under spina anesthesia using ISO mg. of procaine a Iive baby weighing 6 pounds, 1 ounces was deIivered by cIassica1 cesarean section. Sudden death occurred twenty-five minutes after administration of the spina anesthetic. Questions. (I) Is spina anesthesia safe for cesarean section? (2) What treatment shouId he carried out if respiratory faiIure or circulatory coIIapse shouId occur? (3) What is the safest anesthetic for cesarean section? Answers. In neither case was there good reason to eIect cesarean section. Procaine, ISO mg. at one dose, shouId be a thing of the past. Not onIy is IOO mg. an unnecessarily large dose, but aIso given in the same way it is decidedIy dangerous.
February,
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SpinaI anesthesia has no effect whatever on the baby, bIood Ioss is minima1 and immediate postoperative recovery is exceIIent. Other than safety, what more couId one desire? Except in a few cIinics, however, it has not found favor with obstetricians even though those experienced in its use had apparentIy Iessened its danger. Continuous or fractiona spina anesthesia greatIy reduces the risk due to the amount of the drug used and is receiving a steadily increasing measure of approva1 from obstetricians Iong opposed to administration of any spina anesthetic; yet since as Iittle as $0 mg. has caused sudden death, smaIIer amounts shouId be cautiousIy injected unti1 the anesthetic IeveI becomes satisfactory; 35 to 30 mg. of procaine may be sufficient, particuIarIy if segmenta bIock is used. Everyday it becomes more cIear that. an alert, we11 trained anesthetist is a necessity in every hospita1 where obstetrics is prac ticed. At the moment this does not appear to be practicabIe everywhere. The safety of spina anesthesia is immeasurably enhanced when administered by an expert who knows how to do it and how to cope with any emergency which may arise. It is hardIy safe otherwise. Administration of oxygen as soon as anesthesia has begun is heIpfu1 since the importance of oxygen transport is obvious. In the event of respiratory depression the bag on the anesthesia machine shouId be compressed with each inspiration of the patient. If breathing shouId stop compIeteIy, time must not be Iost for if oxygen does not get to the brain for three or four minutes the patient wiI1 surely die. It is a waste of precious time to Iisten to the chest with a stethoscope. The oropharynx shouId be aspirated and an oropharyngea1 airway introduced at once. A tightIy fitted mask shouId be appIied and the jaw supported in the forward position. A breathing machine is not essential. Positive pulmonary ventiIation must be carried on by rhythmic pressure on the anesthetic bag at about 20 to 30 mm. of Hg at the rate of sixty times a minute. The Iungs must be we11 inflated and we11 deflated during this period of forced respiration and mechanica breathing should go on unti1 respiration is resumed. ManuaI methods of artificia1 respiration are unsatisfactory. Respiratory stimulants should not be administered nor any oxygen mixture
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containing COZ, nor shouId the inexpert Iose vaIuabIe time trying to pass an endotrachea1 tube. Routine use of $0 to 75 mg. of ephedrine intramuscuIarIy a few minutes before induction of spina anesthesia is good prophyIaxis for circuIatory depression. Continuous intravenous drip of neosynephrine, 5 mg., in 500 cc. of norma saIine provides for fine contro1 and rapid administration if bIood pressure shouId faI1 suddenIy. If cardiac asystole shouId foIIow respiratory failure, oxygen transport wiI1 not be possibIe. A sIightIy bent 3- to $-inch needIe may be passed into the right auricIe through the third right intercosta1 space cIose to the sternum downward toward the midIine. If a11 this shouId fai1, cardiac massage may stiI1 save the patient’s Iife. If the abdomen has not been opened for cesarean section, the boId obstetrician wiI1 make an incision in the fourth interspace from sternum to posterior axiIIary line, retract the ribs or cut the Costa1 cartiIages and massage the heart. The obstetrician wiI1 not find appea1 to this dreadfu1 court of Iast resort necessary if his spina anesthesia is we11 considered and in good hands. AI1 inhaIation anesthetics pass through the placenta and so endanger the baby. The dangers of induction are variabIe, yet they of are aIways present. The disadvantages voIatiIe anesthetics may be briefly stated. Ether wiI1 not pIease the patient. In the surgica1 pIane it interferes with uterine contraction immediateIy after deIivery of the baby and pIacenta and increases blood 10s~. SaIivation and bronchia secretions are markedIy increased favoring postoperative ateIectasis. Gas, oxygen and ether sequence is more pIeasant and safe if oxygen is given in suff~cient concentration to prevent anoxia. ReAex excitabiIity is apt to be high, so smooth induction may not be possibIe. CycIopropane, easiIy the most potent of anesthetic gases, perhaps shouId not be seIected if onIy because of its. high potency. It shouId be administered not onIy by a trained
anesthetist but aIso by one famiIiar with its dangers. AIthough induction is rapid, cycIopropane wiI1 not give deep reIaxation without deep third stage anesthesia. Cardiac irreguIarities not infrequentIy occur and the margin of safety is narrow. The baby is far more prone to deveIop asphyxia with nitrous oxide. Chioroform is dangerous. Easy to take, induction is rapid, but steady sIowing of the heart action with depth of anesthesia may resuIt in cardiac standstiI1. Its use for more than fifteen minutes may result in Iiver damage. Anesthesia for cesarean section carries a doubIe burden-mother and baby. It shouId be effective, of course, for reIief of pain, but first of all it shouId be safe. LocaI anesthesia is cIearIy the safest anesthetic and it can be made very satisfactory, yet it wiI1 not be found suitabIe for every patient nor for every obstetrician for that matter. It may be effective from beginning to end of the operation. If it shouId not be, intravenous sodium pentothaI@ drip 0.2 per cent wiI1 carry the patient through satisfactoriIy and safeIy. AnaIgesia and anesthesia for peIvic deIivery are no Iess important than for cesarean section. AnaIgesics may be used safeIy if administered with caution. As the patient approaches deIivery, nitrous oxide and oxygen may be given with each contraction. Episiotomy and low forceps can be easiIy and satisfactoriIy accompIished under IocaI anesthesia. Pudenda1 bIock, in expert hands, is exceIIent for deIivery from mid-peIvis. LocaI anesthesia approaches the ideaI. That onIy genera1 anesthesia wiI1 be found suitabIe for some patients we fuIIy recognize. AIthough there is increasing interest in natura1 chiIdbirth, most women ask that Iabor be shortened and the pains Iessened. A woman does not need to take a series of Iessons and exercises to Iose her fear of chiIdbirth. If she has confidence that her obstetrician wiI1 give her the best possibIe care, she wiI1 be happy. An obstetrician who does not inspire confidence and deserve it is not worth his saIt.
American Journal of Surgery
HE woman about to become a mother or with a new-born infant upon her bosom, shouId be the object of trembfing care and sympathy wherever she bears her tender burden, or stretches her aching limbs. The very outcast of the streets has pity upon her sister in degradation, when the sea1 of promised maternity is impressed upon her. The remorseIess vengeance of the Iaw brought down upon its victims by a machinery as sure as destiny, is arrested in its faI1 at a word which reveaIs her transient claim for mercy. The soIemn prayer of the Iiturgy singIes out her sorrows from the muItipIied triaIs of life, to pIead for her in her hour of peri1. God forbid that any member of the profession to which she trusts her Iife, doubly precious at that eventful period, shouId hazard it negIigentIy, unadvisedly or seIfishIy. OLIVER
WENDELL
HOLMES
3rd of the Series
ANESTHESIA CHARLES
A.
GORDON,
M.D.
Emeritus Professor of Obstetrics and Gynecology, State University of New York, State University Medical Center at New York ALEXANDER
H.
ROSENTHAL,
M.D.
AND
JAMES
L.
O’LEARY,
M.D.
Associate Obstetrician and Gynecologist, St. Catberine’s Hospital
Assistant Professor of Clinical Obstetrics and Gynecology, State University oj New York, State University Medical Center at New York
Brooklyn, New York
T
HE importance of anesthesia as a cause of materna1 death is not wideIy appreciated. There is good reason for this. If anesthesia is mentioned on a certificate of death, it is not tabuIated by the statistician even though death is stated to have been due to the toxic action of the anesthetic itseIf or to aspiration asphyxia. It just disappears from view. In no case reported here was the cause of death assigned to anesthesia, but to another cause. The actual frequency of death from anesthesia cannot be discovered unIess by examination of case records. If parturition should be compIicated by toxemia, tuberculosis or heart disease, for example, poor choice of anesthetic or a casual attitude toward its administration wiII contribute materiaIIy to the materna1 death rate. And every physician knows, or shouId know, that anesthesia pIays an impprtant part in death foIIowing long Iabor and diflicuh or muItipIe operative procedures. However, that anesthesia in the absence of these compIications
is dangerous is not so we11 appreciated. our purpose to make this plain.
It is
* * * * CASE I. A twenty-three year oId primipara was admitted to the hospital shortIy after dinner. She had been in Iabor for about two hours. Uterine contractions occurred reguIarIy every ten minutes but they were not hard. The patient was given an enema and put to bed. No sedative was administered. ShortIy afterward Iabor became very active. Within the hour the membranes ruptured and she was found to be fuIIy diIated and ready for deIivery. .Her obstetrician was caIIed and she was rushed to the delivery room. Administration of gas, oxygen anesthesia was begun at once as the caput was crowning. The patient vomited so the mask was removed. When she cried out again with pain, anesthesia was resumed. She vomited again, became deepIy cyanosed and ceased breathing. ArtificiaI respiration was tried and the head
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of the tabIe Iowered. After death a Iive baby was deIivered with outlet forceps. The patient had been in the deIivery room about five minutes. At necropsy the trachea and Iarge bronchi were found fiIIed with Iarge food particles. Large pleura1 petechiae were present. The Iungs showed marked congestion, edema and mucopuruIent exudate in the bronchi and bronchioles. Questions. (I) Might this patient have vomited even if she were not given an anesthetic? (2) ShouId she have had an anesthetic and, if so, was the anesthetic properIy administered? Of course the patient may have Answers. vomited without anesthesia. Vomiting occurs frequentIy in the second stage of Iabor but not as a ruIe so close to its concIusion. The anesthetic intended to reIieve pain deprived her of life. The deep inspiration which may carry vomitus into the bronchia tree occurs most frequentIy during induction. During a brief critica period the vomiting center is stimuIated by the anesthetic agent at a time when cough and IaryngeaI reffexes are aboIished. Prevention of vomiting depends upon carrying the patient rapidIy through the second stage and into the first pIane of the third stage of anesthesia. If vomiting shouId occur, anesthesia shouId be stopped at once. The obstetrician shouId instruct his patient not to eat at home if she thinks that labor has begun. Food during Iabor increases the hazard of de1iver.y under genera1 anesthesia. The physica and emotiona stress of Iabor stops gastric peristaIsis so that food may remain in the stomach for many hours. Vomiting is dangerous. The margin of safety with nitrous oxide is wide provided the anesthetist is aIert to the dangers of the second stage. However, this may be said of kny inhaIation anesthetic. The onIy disadvantage of nitrous oxide is anoxia which was not a factor in this case. Infiltration of the perineum with 0.5 per cent novocain wouId have been perfect for spontaneous delivery or episiotomy and cIearIy the anesthetic of choice.
**** CASE II. After fourteen hours of good Iabor a thirty year oId primipara was deIivered February,
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spontaneously under Iight open mask ether given during uterine contractions. Anesthesia was satisfactory. When anesthesia was resumed for perinea1 repair, she struggIed vioIentIy and tried to vomit but was prevented from doing so by crowding anesthesia. SuddenIy she stopped breathing and her face and neck became deepIy cyanosed. Respiration was re-estabhshed with a mechanica respirator and the perineum was repaired without anesthesia. Cyanosis deepened, bIoody froth appeared on her Iips and breathing, which had been shaIIow for some time, ceased. AI1 efforts at resuscitation faiIed. At necropsy food particIes were found in the trachea1 bifurcation. Questions. (I) When did the patient vomit? (2) WouId continuous anesthesia for deIivery and repair have been better than a second induction? Answers. The anesthetist thought that he had prevented vomiting, but it is cIear that he had not. Repeated attempts at vomiting whiIe the breath is heId are very dangerous. During attempts to vomit the jaws may be heId so tightIy cIosed that the mouth cannot be opened by the anesthetist. Vomitus fiIIs the pharynx and is sucked into the Iungs at the first inspiration. Anesthesia shouId not be pushed at this point, nor shouId the mask be strapped or buckIed over the patient’s mouth. As a matter of fact the presence of food in the stomach shouId be suspected if induction is difficult or if Iarge amounts of anesthetic are required. If coughing or retching shouId occur, the presence of food or ffuid shouId be assumed. The stomach shouId then be emptied or another form of anesthesia substituted. Since induction is dangerous once shouId be enough. Why tempt fate twice? A second anesthetic adds to the risk. The time interva1 between deIivery and perinea1 repair wiI1 not be considerabIe if the delivery room is we11organized and the third stage of Iabor well managed.
* * * * CASE III. A twenty year oId primipara was admitted to the hospita1 in active labor. Within two hours she was ready for deIivery and Iight ether anesthesia was begun. She took it we11 but contractions decreased in frequency and strength and it became neces-
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sary to deIiver her with Iow forceps. Anesthesia was continued for episiotomy and deEvery. The pIacenta was expressed without dificuIty and the patient was returned to her bed. Soon afterward she vomited a Iarge amount of fluid and undigested food, but at no time was there any sign of respiratory distress. Her bIood pressure was 120/80 and the puIse rate IOO. A IittIe Iater cyanosis was noticed. RestIessness increased and breathing became noisy. Death occurred shortIy after a smaI1 quantity of ffuid was removed through a bronchoscope. At necropsy the trachea and main bronchi were congested and many of the Iarger bronchi contained fluid. No food particIes were seen. The Iower Iobe of the right Iung showed beginning consoIidation. Questions. (I) Were the symptoms due to aspiration? (2) How couId this death have been prevented? Answers. In a11 probability aspiration occurred during the period of emergence as the patient passed from the third stage of anesthesia to the second, the same critica IeveI as of induction. The patient shouId not have been returned to bed unti1 conscious. At any rate she shouId have been watched more cIoseIy during the period of recovery. She might have been turned on her side so as to favor escape of vomitus from her mouth. The period of emergence is much Ionger after ether anesthesia than after nitrous oxide. HyperventiIation with CO2 wiII shorten this period. Finding pathology in the right Iung and particuIarIy in the Iower Iobe is fairIy good evidence that aspiration took pIace. It is not necessary to find food to prove the diagnosis. Aspirated Auid is more apt to gravitate to the right Iung and particuIarIy to the Iower Iobe because of the course of the right bronchus. **** CASE IV. A thirty year oId patient who had been delivered of a Iive baby by high forceps was admitted to the hospita1 at term earIy in Iabor in her second pregnancy. After thirteen hours of Iabor, with membranes ruptured eight hours, the cervix was found fuIIy diIated, with the vertex in Ieft occipitoposterior position stiI1 unengaged. Cesarean section was decided upon and operation was begun at 2 P.M. under gas, oxygen and ether
sequence. At 2:3g P.M. just after delivery of the baby the patient vomited Iarge quantities of food aIthough she had had no food during the tweIve hours she had been in the hospita1. A resident bronchoscopist who was immediateIy avaiIabIe was abIe to remove a considerabIe amount of food particIes from the Iarynx but the patient was pronounced dead after five minutes after vomiting. At post mortem it was found that a11 food particIes had been removed. Questions. (I) Was the anesthetic we11 seIected? (2) Why did vomiting occur in the middIe of the operation? (3) After tweIve hours in the hospita1 without food cannot one assume that the stomach is empty? (3) Is bronchoscopy good treatment? Answers. InhaIation anesthetics are not idea1 for cesarean section if onIy because they a11 pass the pIacenta1 barrier and add to our anxiety for the safety of the baby. Uterine atony, hemorrhage and shock occur more often under genera1 anesthesia, particuIarIy ether, than with IocaI anesthesia or spina1. Nitrous oxide induction may be more dificuIt for cesarean section than for vagina1 deIivery. Once seIf-restraint has been aboIished in the second stage of anesthesia, fear and anxiety for herseIf and the baby may cause the patient to vomit or thrash about, sIowing induction and adding to the hazards of aspiration and hypoxia. Cesarean section may not be compared with the pIanned surgery of the gynecoIogist. Operation may not be begun unti1 the surgica1 pIane of ether anesthesia is we11 established. Often marked increase in bronchia secretion, sIow emergence and troubIesome vomiting add to the risk. The anesthetist, even though expert, may try so hard to carry the patient IightIy in the interest of the baby, that the anesthetic IeveI is Iowered and the patient drifts back into the second stage. That is what happened in this case. After tweIve hours in the hospita1 one may assume that the patient’s stomach is empty unIess she has been in Iabor. In that event it shouId be assumed that the stomach may not be empty and vomiting shouId be induced. A smaI1 gIass of mustard water wiI1 be easier on the patient and much more effective than gastric Iavage. Apparatus for suction shouId be in readiness. The head end of the operating tabIe shouId be American
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lower than the foot. Bronchoscopy may be cIearIy indicated, yet as a ruIe it wiII be ineffective or too Iate. * * * * CASE v. A twenty-seven year oId primipara had an assisted breech deIivery after twentytwo hours of Iabor. Delivery took very IittIe more than one-haIf hour. Ether anesthesia with open mask was we11taken and no vomiting occurred. It was thought that anesthesia had to be deep for use of Piper’s forceps. During labor she had been given seconal, 3 gr., on the night of admission, morphine, $4 gr., eight hours before deIivery and morphine, 34 gr., two hours before. Deep cyanosis and Iabored breathing with harsh unproductive cough were observed twelve hours Iater. After administration of oxygen the patient improved greatly. However, ten hours Iater she again became dyspneic and cyanotic and the puIse rate rose to 144. BronchiaI breathing was noted in both Iower lobes of the Iungs with a few moist raIes, but x-ray of the chest was negative. Death occurred four hours Iater.
Questions. (I) Did this patient have ether pneumonia? (2) What part did sedatives pIay in this case? (3) Was diagnosis possibIe? (4) Must anesthesia be deep for use of Piper’s forceps? Answers. Ether pneumonia as a diagnosis had better be forgotten. This patient had ateIectasis due to obstruction of a bronchus and diminished puImonary ventiIation. The causative factors were Iong Iabor, spIinting of the diaphragm due to pain, decreased puImonary excursions and possibIy anaIgesia and ether anesthesia. The anesthetic, however, appears to have been we11 taken. At any rate there is no record of great stimuIation of the bronchia secretion. Barbiturates Iike a11 hypnotics and sedatives do depress respiration, yet it is unIikeIy that secona1 given so long before delivery pIayed an important part. Morphine depresses the respiratory center, the cough reflex and the ceIIuIar respiratory mechanism. It is not wise to use it within four hours of deIivery. The earIier the diagnosis of ateIectasIs is made the better. If after operation or deIivery, no matter what the anesthetic and occasionaIIy when no anesthetic at a11 has been adminFebruary,
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istered, coughing, increased pulse and respiratory rate and signs of oxygen want are observed, ateIectasis is the IikeIy cause. A keen look at the patient’s chest shouId show asymetric movement and narrowing of the rib spaces. X-ray may not be concIusive unti1 much Iater. Deep anesthesia is unnecessary when Piper’s forceps are appIied to the feta1 head in the peIvic excavation. ObviousIy the depth and duration of anesthesia add to maternal risk. * * * * CASE VI. This patient was twenty-six years of age, para IV. After tweIve hours of Iabor cesarean section under gas oxygen ether anesthesia was performed for disproportion. The operating time was one hour. There was no undue hemorrhage and the patient took the anesthetic weI1. At the concIusion of the operation the anesthetist reported the patient’s puIse couId not be feIt and that systoIic bIood pressure was unobtainabIe. She was thought to be in shock. She was transfused with plasma and bIood, improved somewhat and was taken to her room. Cyanosis and dyspnea were then observed. With coughing, rapid puIse and rapid respiration ateIectasis was beIieved to be present, but on auscuItation and percussion chest signs were inconcIusive. One-haIf hour Iater the patient had a chiI1 and was put into an oxygen tent. Dyspnea and cyanosis steadiIy became worse and she died five hours after operation. Necropsy showed massive ateIectasis invoIving the entire Iower Iobes of the right and Ieft lungs, nearIy a11of the upper Iobe of the Ieft Iung and two-thirds of the upper Iobe of the right Iung. Genera1 puImonary edema was present and the smaIIer bronchioIes were fiIIed with watery fluid. CASE VII. This patient was forty years of age, para x1. After a Iabor of thirty hours during which two doses of phenobarbita1, 3 gr. each, three doses of scopaIamine, Pi5 0 gr. each, and one dose of morphine, s/4 gr., were administered, a frank breech was broken up and deIivered under ether anesthesia. The procedure took thirty minutes and no untoward symptoms were observed. An hour Iater the patient’s puIse rose to 130 and respirations to 38. Cyanosis appeared and graduaIIy deepened. No breath sounds couId be heard in the Iower Iobe of the right lung. Coughing was frequent with blood-
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streaked sputum. The puIse became thready and more rapid, rising to 140. Breathing became more Iabored and moist raIes were heard over the entire chest. Death occurred eighteen hours postpartum. Treatment incIuded morphine, atropine and oxygen. Questions. (I) What caused the puImonary comphcation? Sedation? (2) How might it have been prevented? (3) How may the diagnosis be made before death? (4) What is the best treatment? Answers. It is diffIcuIt to be sure about its safety when sedation has been heavy. It is often impossibIe to predict the effect of a combination of sedative drugs. Barbiturates depress the meduIIary respiratory center onIy when used in Iarge doses. Morphine is a continuous depressant of respiration even in smaI1 doses. A multipara with frank breech presentation shouId get but IittIe sedation. If she is bIessed with good uterine contractions, so much the better, for she wiI1 need them in the second stage. If contractions are poor, they should be augmented by continuous intravenous pituitary stimuIation. Good Iabor shouId not be discouraged. Many obstetricians wouId have performed cesarean section dn this patient. AteIectasis occurs when access of air to the Iung or any part of it is prevented. Absorption of the air remaining resuIts in coIIapse of the alveoIi. It may resuIt from obstruction of a bronchus by bronchia secretion, aspiration of stomach or nasopharyngea1 content. Loss of IaryngeaI and cough reflexes under anesthesia make aspiration into the tracheobronchia1 tree easy. Oversedation, profound anesthesia, Iong operations, spIinting of the diaphragm and compression of the Iower lobes of the Iungs a11 contribute to decreased puImonary ventiIation. AteIectasis may occur under any form of anesthesia. Its not infrequent occurrence under spina anesthesia may be attributed to hypoventiIation due to change in diaphragmatic action or intercosta1 paralysis. The earlier ateIectasis is recognized the better. Signs of oxygen want Iike increased puIse and respiration rate and cyanosis are inevitabte. Coughing and Iabored breathing are common. Asymetric movement of the chest is diagnostic. On the affected side it wiII move less or not at a11 and narrowing and retraction of the rib spaces wiII be seen. Shift of the
mediastinum to the affected side with shift of apex beat and cardiac borders wiII be noted when actua1 shrinkage of the Iung occurs. Not until then wiI1 x-ray be diagnostic. Percussion and auscuItation may not be reIied upon for earIy diagnosis. Shock which foIIows massive puImonary coIIapse is possibIy due to mechanica shift interference with the great vesseIs of the mediastinum. Many factors in prevention have been indicated. During emergence from anesthesia the patient shouId be watched carefully, turned on her side and encouraged to breathe deepIy or cough. HyperventiIation with 3 per cent COZ and 9s per cent oxygen is vaIuabIe. In the Iater stage of infection and pneumonitis treatment by an internist wiI1 be indicated. * * * * CASE VIII. A primigravida, aged twentytwo years, was admitted to the hospita1 in active labor. Her chest was negative, bIood pressure rzo/80 and her prenata1 course had been uneventfu1. The feta1 heart tones were good, the vertex deep in right occipitoanterior position, the cervix diIated one finger, and regular uterine contractions occurred every five minutes. One hour Iater with the cervix dilated three fingers and the vertex just below the spines cauda1 anesthesia was instituted. In the next hour the cervix diIated fuIIy and the vertex came on the perineum. The patient was awake and cooperative, heIping to move herseIf from her bed to ‘the stretcher and then to the deIivery tabIe. Just prior to deIivery when asked to Iift her hips she faiIed to respond. On investigation it was noted that she had stopped breathing; apex beat and puIse were unobtainabIe. ArtificiaI respiration, intracardiac adrenaIin, intravenous coramine and oxygen were given. There was no response. WhiIe these procedures were going on she was debvered of a Iive baby by Iow forceps and episiotomy. The infant, weighing 6 pounds, 8 ounces required but sIight resuscitation. The tota amount of metycaine solution used was 45 cc. There was no diff&Ity with its administration. At necropsy inactive rheumatic heart disease involving the mitraI vaIve was found. Chemical examination of the spinal fluid showed concentration of metycaine 2.9 mg. per cc.
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Questions. (I) If mitra1 disease had been recognized, would caudaI anesthesia have been contraindicated? (2) Was heart disease the cause of death? Answers. CaudaI anesthesia is not contraindicated for delivery of patients with cardiac disease. On the contrary, it appears to have merit. Like a11 anesthetics it has potentia1 dangers. The amount of anesthetic for caudal anesthesia is much necessary greater than for spinal anesthesia. If it shouId be inadvertentjy injected into the spina canal or make its way there, death wil1 ensue. That is what happened in this case, probabIy when the patient helped to move herself from the stretcher to the deIivery table. * * * * CASE IX. Cesarean section was eIected in a patient thirty years of age who had had two earIy spontaneous abortions previousIy. For spina anesthesia IOO mg. of procaine were injected into the subarachnoid space at the IeveI of the third Iumbar vertebra. Immediate difFicuIty with respiration occurred just as soon as the patient was returned to the recIining position. Respiration soon ceased. ArtificiaI respiration, carbogen and finaIIy adrenaIin into the heart faiIed to revive her. AbdominaI deIivery after death did not save the fetus. CASE x. A primigravida, aged twenty-five years, was admitted to the hospita1 in the thirty-ninth week of pregnancy. Cesarean section had been planned because the peIvic measurements were smaI1 and the fetus appeared to be Iarge. She was not in Iabor. Under spina anesthesia using ISO mg. of procaine a Iive baby weighing 6 pounds, 1 ounces was deIivered by cIassica1 cesarean section. Sudden death occurred twenty-five minutes after administration of the spina anesthetic. Questions. (I) Is spina anesthesia safe for cesarean section? (2) What treatment shouId he carried out if respiratory faiIure or circulatory coIIapse shouId occur? (3) What is the safest anesthetic for cesarean section? Answers. In neither case was there good reason to eIect cesarean section. Procaine, ISO mg. at one dose, shouId be a thing of the past. Not onIy is IOO mg. an unnecessarily large dose, but aIso given in the same way it is decidedIy dangerous.
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SpinaI anesthesia has no effect whatever on the baby, bIood Ioss is minima1 and immediate postoperative recovery is exceIIent. Other than safety, what more couId one desire? Except in a few cIinics, however, it has not found favor with obstetricians even though those experienced in its use had apparentIy Iessened its danger. Continuous or fractiona spina anesthesia greatIy reduces the risk due to the amount of the drug used and is receiving a steadily increasing measure of approva1 from obstetricians Iong opposed to administration of any spina anesthetic; yet since as Iittle as $0 mg. has caused sudden death, smaIIer amounts shouId be cautiousIy injected unti1 the anesthetic IeveI becomes satisfactory; 35 to 30 mg. of procaine may be sufficient, particuIarIy if segmenta bIock is used. Everyday it becomes more cIear that. an alert, we11 trained anesthetist is a necessity in every hospita1 where obstetrics is prac ticed. At the moment this does not appear to be practicabIe everywhere. The safety of spina anesthesia is immeasurably enhanced when administered by an expert who knows how to do it and how to cope with any emergency which may arise. It is hardIy safe otherwise. Administration of oxygen as soon as anesthesia has begun is heIpfu1 since the importance of oxygen transport is obvious. In the event of respiratory depression the bag on the anesthesia machine shouId be compressed with each inspiration of the patient. If breathing shouId stop compIeteIy, time must not be Iost for if oxygen does not get to the brain for three or four minutes the patient wiI1 surely die. It is a waste of precious time to Iisten to the chest with a stethoscope. The oropharynx shouId be aspirated and an oropharyngea1 airway introduced at once. A tightIy fitted mask shouId be appIied and the jaw supported in the forward position. A breathing machine is not essential. Positive pulmonary ventiIation must be carried on by rhythmic pressure on the anesthetic bag at about 20 to 30 mm. of Hg at the rate of sixty times a minute. The Iungs must be we11 inflated and we11 deflated during this period of forced respiration and mechanica breathing should go on unti1 respiration is resumed. ManuaI methods of artificia1 respiration are unsatisfactory. Respiratory stimulants should not be administered nor any oxygen mixture
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containing COZ, nor shouId the inexpert Iose vaIuabIe time trying to pass an endotrachea1 tube. Routine use of $0 to 75 mg. of ephedrine intramuscuIarIy a few minutes before induction of spina anesthesia is good prophyIaxis for circuIatory depression. Continuous intravenous drip of neosynephrine, 5 mg., in 500 cc. of norma saIine provides for fine contro1 and rapid administration if bIood pressure shouId faI1 suddenIy. If cardiac asystole shouId foIIow respiratory failure, oxygen transport wiI1 not be possibIe. A sIightIy bent 3- to $-inch needIe may be passed into the right auricIe through the third right intercosta1 space cIose to the sternum downward toward the midIine. If a11 this shouId fai1, cardiac massage may stiI1 save the patient’s Iife. If the abdomen has not been opened for cesarean section, the boId obstetrician wiI1 make an incision in the fourth interspace from sternum to posterior axiIIary line, retract the ribs or cut the Costa1 cartiIages and massage the heart. The obstetrician wiI1 not find appea1 to this dreadfu1 court of Iast resort necessary if his spina anesthesia is we11 considered and in good hands. AI1 inhaIation anesthetics pass through the placenta and so endanger the baby. The dangers of induction are variabIe, yet they of are aIways present. The disadvantages voIatiIe anesthetics may be briefly stated. Ether wiI1 not pIease the patient. In the surgica1 pIane it interferes with uterine contraction immediateIy after deIivery of the baby and pIacenta and increases blood 10s~. SaIivation and bronchia secretions are markedIy increased favoring postoperative ateIectasis. Gas, oxygen and ether sequence is more pIeasant and safe if oxygen is given in suff~cient concentration to prevent anoxia. ReAex excitabiIity is apt to be high, so smooth induction may not be possibIe. CycIopropane, easiIy the most potent of anesthetic gases, perhaps shouId not be seIected if onIy because of its. high potency. It shouId be administered not onIy by a trained
anesthetist but aIso by one famiIiar with its dangers. AIthough induction is rapid, cycIopropane wiI1 not give deep reIaxation without deep third stage anesthesia. Cardiac irreguIarities not infrequentIy occur and the margin of safety is narrow. The baby is far more prone to deveIop asphyxia with nitrous oxide. Chioroform is dangerous. Easy to take, induction is rapid, but steady sIowing of the heart action with depth of anesthesia may resuIt in cardiac standstiI1. Its use for more than fifteen minutes may result in Iiver damage. Anesthesia for cesarean section carries a doubIe burden-mother and baby. It shouId be effective, of course, for reIief of pain, but first of all it shouId be safe. LocaI anesthesia is cIearIy the safest anesthetic and it can be made very satisfactory, yet it wiI1 not be found suitabIe for every patient nor for every obstetrician for that matter. It may be effective from beginning to end of the operation. If it shouId not be, intravenous sodium pentothaI@ drip 0.2 per cent wiI1 carry the patient through satisfactoriIy and safeIy. AnaIgesia and anesthesia for peIvic deIivery are no Iess important than for cesarean section. AnaIgesics may be used safeIy if administered with caution. As the patient approaches deIivery, nitrous oxide and oxygen may be given with each contraction. Episiotomy and low forceps can be easiIy and satisfactoriIy accompIished under IocaI anesthesia. Pudenda1 bIock, in expert hands, is exceIIent for deIivery from mid-peIvis. LocaI anesthesia approaches the ideaI. That onIy genera1 anesthesia wiI1 be found suitabIe for some patients we fuIIy recognize. AIthough there is increasing interest in natura1 chiIdbirth, most women ask that Iabor be shortened and the pains Iessened. A woman does not need to take a series of Iessons and exercises to Iose her fear of chiIdbirth. If she has confidence that her obstetrician wiI1 give her the best possibIe care, she wiI1 be happy. An obstetrician who does not inspire confidence and deserve it is not worth his saIt.
American Journal of Surgery