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Problems in obstetric anesthesia
Problems in obstetric anesthesia W. JOSEPH MAY, M.D.* Winston-Salem, North Carolina
THE chief variants in most anesthetic accidents are three in number, namely, the patient's physical status, the anesthetic agent, and the person administering the anesthetic. The great improvement in equipment for the administration of anesthetic agents and the better understanding of the drugs used in anesthesia have eliminated many of the factors involved in anesthetic accidents. The continued occurrence of maternal deaths due to anesthetic accidents should lead one to suspect that the human factors involved are of primary importance. With this supposition in mind the Committee on Maternal Health of the Medical Society of the State of North Carolina conducted a survey of hospitals doing obstetrics in North Carolina in 1960 to determine the adequacy of personnel involved in obstetric anesthesia. The findings of this survey indicate that the greater number of hospitals doing obstetric deliveries in North Carolina have inadequate anesthesia service.
district member of the Committee on Maternal Health of the Medical Society of the State of North Carolina. It should be understood that the primary intent of the survey questionnaire was to determine the physician's attitude about the prevailing practices on the maternity service in his hospital. In addition to the attitude of the physician, certain factual information about the maternity services was secured. Questionnaires were sent to 143 hospitals representing most of the hospitals doing obstetrics in the state. Completed questionnaires were ·returned to the Committee by 101, or 71 per cent, of the total hospitals queried. The hospitals represented 78 per cent of the beds of the total 143 hospitals. The ratio of the hospital beds to the number of deliveries is of importance to the study and is indicated in Table I. There are 38 hospitals with 50 beds or less. The number of deliveries among these hospitals in 1960 varied from a few up to 400 to 600 a year. It is quite significant to note that 38.8 per cent of the total deliveries studied in this survey were done in the small hospitals of 50 beds or under and that a major portion, or 80.5 per cent, are done in hospitals of 150 beds or less. The largest number of deliveries reported by a single hospital was slightly in excess of 2,500& There \vere 5 hospitals having 2,000 or more deliveries a year and six having between 1,500 and 2,000 a year. The first part of the questionnaire concerning obstetric anesthesia was devised to determine in general the qualifications of the personnel available to administer obstetric anesthesia. These data are summarized in Table II.
Material
A questionnaire covering several aspects of hospital maternity services, including anesthesia, was sent to a physician on the hospital staff selected by the appropriate From the Department of Obstetrics and Gynecology of the Bowman Gray School of Medicine of Wake Forest College. Presented by invitation at the Twentysixth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Bal Harbour, Florida, fan. 26-29, 1964. *Chairman, Committee on Maternal Health of the Medical Society of the State of North Carolina.
81
82 May :\m.
Scptemb<'l J 1964 J. Obst. & nyncc.
Table I. Per cent of deliveries according to hospital beds No. of deliveries
0 U .... ~s.~·~-1
J,.l.U.JjiUU(,
beds 0 51 101 15,1 201 251 301 401 601
to to to to to to to to to
Total
50 100 150 200 250 300 400 600 BOO
to
51
101
201
to
251
50
100
to
to
250
300
2.0
3.1
3.1 2.0
9.2
2.0
3.1
6.1
6.1
5.1
9.2
I 301 to I 350 5.1 2.0
7.1
401 to
-------·--------------
601 to
1,001
600
800
4.1 9.2 1.0
6.1 I 1.2
5.1 1.0 1.0
1'7 Q
., 1
14.3
J..l ,J
Total
+
I •"
(%)
38.8 24.4 17.3 5.1 3.1 2.0 5.1 2.0 2.0
4.1 4.1 3.1 2.0 5.1 2.0 2.0 'l'l A
::J.:J,(J " " 0
O:,O::,."T
Table II. Obstetric anesthesia personnel medical Hospitals
%
8
7.9 8.9 8.9 4.9
Medical 1. Board certified anesthesiologist 2. Physician-trained and/or experienced 3. Untrained or inexperienced physician 1 and 2 1 and 3 2 and 3 1, 2 and 3 No medical anesthesia personnel
2 1
2.0
67
66.3
Nurse 1. Nurse anesthetist-registered 2. Registered nurse 1 and 2 No nurse anesthetist
42 18 24 17
41.5 17.8 23.8 16.8
Table II indicates that 18 hospitals, or 17.8 per cent, listed non-Board medical anesthetists. These were found mostly in the small hospitals, less than 400 deliveries, and in the larger hospitals with 1,000 and more deliveries a year. In the smaller hospitals these physicians were usually practicing in the community as general practitioners who gave anesthesia at times for the obstetrical service. The hospitals indicating Board Certified Anesthesiologists available for obstetric anesthesia were all in the hospitals having 1,201 and more deliveries per year. Only one third of the hospitals indicated that they had medical anesthesia personnel. Registered nurse obstetric anesthesia personnel. Table II summarizes the nurse-anesthetist availability to obstetrical delivery
9 9 5
l.D
service. The nurse-anesthetists were on the staff of 65 per cent of the hospitals and there was only nurse-anesthetist coverage in 41 per cent. In 18 per cent of the hospitals a registered on-duty nurse, usually a supervisor or labor floor nurse, gave anesthesia. This is characteristic of hospitals having less than 1,000 deliveries a year. In 16.9 per cent of the hospitals recorded no nurse-anesthetist was available. Availability of formal anesthesia service. Table III is a summary of the response to the question: "Is formal anesthesia coverage actually provided obstetrical patients?" No formal anesthesia service for obstetric patients was indicated in 19.9 per cent of the hospitals. The majority of the hospitals without formal obstetrical anesthesia ser-
Volume 90
Number 1
vice were those with small maternity services. One glaring exception was in a hospital with 1,200 deliveries per year and it was indicated that anesthesia was available but was provided by the floor nurse. Of significance is that one hospital indicated the Jack of service until 2 years ago at which time death from anesthesia brought prompt correction. Another 23 per cent of the hospitals apparently provide anesthetic service only on occasions and 58 per cent of the hospitals provide anesthesia service on a usual or always basis. Obstetric anesthesia administered by physicians. The number of hospitals that provide obstetrical anesthesia given by a physi.. cian is indicated by Table IV. It summarizes the answers to the question: "In your opinion what percentage of obstetric patients receive anesthesia from Board Anesthesiologist, physician trained, or experienced or attending obstetrician?" The physiciananesthetists in Table IV are predominantly associated with small obstetric services. A sizable number of hospitals, 54 per cent, the sums of lines 3, 5, 6, and 7, indicate that the attending obstetrician gave his own anesthesia. The record indicated that this was in the form of local, caudal, or spinal and, in some cases, a preference was stated for this type of anesthesia whether an anesthetist was available or not. Obstetric anesthesia administered by registered nurses. Data similar to that in Table IV for nurse-anesthetists providing obstetric anesthesia, are summarized in Table V. Twenty hospitals used only graduate nurses who were on regular hospital duty such as labor floor nurse, night supervisor, etc. An additional 9 per cent used licensed practical nurses and nurse's aides. One large hospital indicated that aides gave 15 per cent of the anesthesia, approximately 300 obstetrical anesthetics a year. The data indicated that Board Certified Anesthesiologist provided only occasional obstetrical anesthesia, probably for only the most complicated cases. The Board Anesthesiologist gave anesthesia in 14 hospitals and in 12 of these the amount was considered to be less than 5 per cent
Problems in obstetric anesthesia
83
and usually 1 per cent or less. Physicians other than Board Certified Anesthesiologists gave anesthesia in 12 per cent of these hospitals predominantly at the level of 5 per cent. On the other hand, the obstetrician gave anesthesia to their patients in 53 per cent of the hospitals and at all levels of frequency. Of interest is the fact that in 53.6 per cent of the hospitals nurse-anesthetists were either not available or provided only occasional service for obstetrical patients. Their services were used at a higher rate only in the hospitals having more than 1,000 deiiveries a year. Anesthesia service was provided by on-duty almost entirely in the hospitals with less than 1,000 deliveries a year, although there were some glaring exceptions. In 25 per cent of the hospitals 50 to 100 per cent of the anesthesia was given by an on-duty nurse. Table V indicates that 8.9 per cent of the hospitals used licensed practical nurses or nurse's aides. The percentage of anesthesia given by this personnel was stated in only 3 cases: one large hospital listed 15 per cent and 2 small hospitals listed 20 per cent and 85 per cent of the anesthesia was administered by practical nurses and aides "on call," respectively. Place of standby for "on call" obstetrical anesthesia nersonnel. A resnonse to the auestion: "Where do these anesthetists stand by when on call?" is found in Table VI. The "standby" location of persons responsible for giving anesthesia presented a complicated problem. The question was interpreted loosely and multiple items were checked. If among the multiple answers labor floor was indicated as one of the "standby" locations, it was so recorded to the exclusion of all other places marked. In the hospital was next in priority. If the answer was marked as some place outside the hospital, the record was so labeled. It is recognized that this makes the results much more favorable than they probably are. Even though the on-duty nurse who gave the anesthesia was usually on the labor floor, 56 per cent of the hospitals permitted "stand&
•
•
84 May
\m .
Table III. Formal anesthesia service ---------· -··(/D
---~----
Hospitals Always available n ... ~n., available Seldom available Never available ~0~~ . .
,
-----
25
24.7 32.7 22.7
3:>
23 20
19.9 ~-·--~-
Table IV. Obstetrical anesthesia medical doctor
o/o
2
2.0
7 40 2 7 5
6.9 39.6 2.0 6.9 4.9 3.0
2. Physician-trained or experienced 3. Attending obstetrician 1 and 2 1 and 3 2 and 3 1, 2 and 3
3
Table V. Obstetrical anesthesia nurse Hospitals 1. Nurse
anesthetist~registered
30 20
')Q.,
2. Nurse graduate 3. Licensed practical nurse and others 1 and 2 1, 2 and 3 No nurse coverage
9 23 2 17
8.9 22.8 2.0 16.8
,._.J,I
19.9
Table VI. Place of standby for obstetrical anesthesia personnel Hospitals Labor floor Hospital Not in hospital No anesthetists
11 21 57 11
vice was inadequate. Fifty-five and fivetenths per cent felt that their service was adequate. The answers were equally divided among the small and large services. Since the smaller services used untrained personnel to a large extent, there is some indication that the respondents may not really recognize good anesthesia service in some instances. Comment
Hospitals 1. Board anesthesiologist
Septemb,., 1. 196+ .J. Ohst. & f ;yiH'C.
% 10.9 20.8 56.4 10.9
by" personnel to be outside the hospital. The hospital having less than 1,000 deliveries tended to have "standby" outside the
hospital more frequently than the larger services. Adequacy of anesthesia service. In answer to the question: "Is anesthesia service adequate?" 44.5 per cent of the physicians felt that their hospital obstetric anesthesia ser-
Dr. F. Bayard Carter in his Presidential Address before the South Atlantic Association of Obstetricians and Gynecologists 10 years ago stated: "Anesthesiology is a specialty so important and vital to us that \Ve should hear at stated intervals the progress it has made. We should adopt the progressive methods and precautions it advocates." A review of the Proceedings of this Association in the American Journal of Obstetrics and Gynecology reveals that this is the first formal recall of this subject since that time. The data contained in this report along with other evidence indicate that Dr. Carter's statement of 10 years ago was a timely one and that a serious reflection on the matter of obstetrical anesthesia is due. Twenty-six of the first 1,000 maternal deaths reported in North Carolina by the Committee on Maternal Health between 1946 and 1951 were due primarily to anesthetic accidents. Twenty-nine of the second 1,000 maternal deaths reported from 1951 to 1956 were due to the same cause. There is no way of assessing the number of postpartum deaths from hemorrhage due to uterine atony which was secondary to obstetrical anesthesia or the morbidity resulting from aspiration and other complications in patients who did not die but nearly died because of anesthetic accidents. These figures are a source of grave concern since there vvas no improvement in L~e maternal mortality from anesthetic accidents during a period of time when much improvement was taking place in the field of anesthesiology. The psychological and emotional makeup of American women seem to put increasing demands upon the obstetrician for a
Volume 90 Number i
pain-free labor and delivery. The increased use of anesthesia for obstetrical delivery has been accompanied by a marked increase in the demand for more personnel who are properly trained in anesthetic techniques. The data revealed in this paper indicated that nearly a fifth of our hospitals doing obstetric deliveries have no formal anesthetic service and that less than a third of the anesthesia administered is given by registered nurse-anesthetists or trained physicians. It would appear that the demand for proper anesthesia coverage has greatly exceeded the provisions for it. The safety of inhalation anesthesia depends primarily on the judgment, skill, a....Tld experience of the anesthetist. Many of the agents used have been unnecessarily maligned because of faulty administration. Hingson pointed out that special techniques used in obstetrical anesthesia are greatly limited by the untrained nurse-anesthetist or physician-anesthetist. The range of techniques which are safe in anesthesia must be necessarily limited by the limitations of the personnel administering the anesthesia. Any good technique may be acceptable when administered by a competent anesthetist. He expresses the opinion that every inhalation anesthesia should be accompanied by 40 per cent oxygen and that no spinal or regional anesthesia should be administered by the obstetrician unless the patient is to be monitored for blood pressure, pulse and respirations, and anesthesia levels by a competent person for this purpose. If such wise advice is to be followed in the delivery room where anesthesia is concerned, it is quite apparent there must be a great curtailment of the anesthesia which is improperly given by inadequately experienced personnel in the interest of both the mother and the fetus. \Vith 41.5 per cent of the physicians doing obstetrical deliveries in North Carolina feeling that their hospital anesthesia service is inadequate, we as obstetricians should make a serious assessment of the attitudes toward obstetrical anesthesia service. These data for accepting inadequate anesthesia service for
Problems m obstetric anesthesia
85
obstetrical suites indicts the physician practicing obstetrics. The hospital administration stands indicted for putting the economics of such importance as obstetrical anesthesia ahead of the safety of the mothers and babies who suffer from any lack of competent service. The anesthesiologist is also indicted for failing to encourage the regular and adequate anesthesia coverage for obstetrical services. The government and private health insurance plans are indicted for not providing adequate compensation for medical anesthesia service. Conclusions 1. Obstetrical anesthesia in most hospitals in North Carolina is very much neglected. 2. The demand for trained obstetrical anesthesia personnel far exceeds the supply or the availability which is even more important. 3. The attitude of the physicians practieing obstetrics tO\\Tard obstetrical anesthesia should become more positive and demands be made for more personnel if complicated anesthetic techniques are to be used. 4. Where competent anesthetists are not available techniques must be tailored within the range of safety for the anesthesia service available. Summary
A survey of 101 hospitals in North Carolina representing 78 per cent of all of the hospitals doing obstetrics in the state indicate that 80 per cent of the deliveries in l'~orth Carolina are done in hospitals of less than 150 beds and in these small hospitals the adequacy of quality of the anesthesia service provided for the parturient mother is of dreadfully inferior quality when one considers the ideal quality of anesthesia service for obstetric delivery service. The author wishes to acknowledge with grateful appreciation the services of Dr. james F. Donnelly, Director, Personal Hygiene Section of the North Carolina State Department of Public Health, for tabulating the data selected in this survey and used in this paper.
86 May
S•·plt'mbcr l, 196+ o\m, ]. Ob<>t. & Gynec.
Discussion DR. D. LERoY CRANDELL, Winston-Salem, North Carolina. Obstetrical analgesia and anesthesia serves as a common meeting ground for the general practitioner, obstetrician, and anesthesiologist. In recent years, it has received relatively greater emphasis due to the reduction in maternal mortality resulting from toxemia, infection and hemorrhage. The medical profession is beginning to accept its obligation to furnish the obstetrical patient with the best anesthesiological service available. Dr. May's paper emphasizes the important fact that anesthesia always involves at least
No real purpose is served .in discussing the methods of obstetrical analgesia and anesthesia unless a corresponding effort is made to encourage the application of these methods with the best judgment and greatest skiii. It is important to realize that drugs used to produce analgesia may be administered by several routes. The most controllable route is by the inhalational method. The concentration of the drug can be changed from moment to moment while maintaining adequate alveolar ventilation. Inadequate pulmonary ventilation of the mother may enhance birth asphyxia and potentiate the effect of analgesic and sedative drugs on the baby. Hypoten-
three variables: the patient, the agent and tech-
sion or the use of vasopressors to correct hypo-
nique chosen, and the anesthetist. By far the most important variable is the anesthetist. The administration of safe obstetrical anesthesia depends on his knowledge, experience and skill. Frequently, too much emphasis is placed on specific anesthetic agents and techniques in maternal mortality reports without mention of the qualifications of the anesthetists. A recent survey has shown that in North Carolina, 31 per cent
tension may reduce uterine blood flow and further enhance birth asphyxia. Spinal and epidural anesthesia may be analogous to deep general anesthesia in that the higher the level of anesthesia the greater the circulatory and respiratory depression. It should be emphasized that drug therapy is a poor substitute for a good patient-physician relationship. The employment of psychotherapeutic measures
of the hospitals have no qualified anesthetist to
may greatly contribute in allaying fear and ap-
administer anesthesia for even surgical operations let alone obstetrical deliveries. This same survey also revealed that 46 per cent of the anesthesia in the United States is administered by unqualified nurses and physicians and that 2 per cent of the anesthesia is administered by persons who are neither registered nurses nor physicians. Is this deplorable situation caused entirely by the problem of supply and demand of qualified anesthetists or in part by an attempt by the hospital administration to economize at the patient's expense? The realization that obstetrical anesthesia is often a complex therapeutic procedure must replace the archaic belief that it is a simple task to be relegated to the most inexperienced person in the delivery room. The ease with which a needle can be inserted into the lumbar subarachnoid space for spinal anesthesia or into a vein for the administration of Pentothal or the simplicity of dropping ether on a mask subjects these techniques to use by unqualified individuals to the detriment of the patient. There is no one method of anesthesia that is best for all obstetrical patients. The varied methods of general and conduction anesthesia have their specific indications and contraindications. The routine use of one method of pain relief to the exclusion of other> is haphazard therapeutics.
prehension and relieving pain. This will reduce the requirements for analgesic and sedative drugs. The provision of better anesthesia for the obstetrical patient in the smaller communities where good anesthesiological service is not available is best accomplished by the encouragement of general practitioners to undertake formalized training in obstetrical anesthesia and then to devote part of their time to its practice. Only by improving the quality of the anesthetist can a substantial reduction in maternal mortality and morbidity due to anesthesia be realized. DR. }EssE CALDWELL, Gastonia, North Carolina. This report is important but it does not describe the obstetric anesthesia experience in the hospitals of North Carolina. It concerns the opinions of practitioners on the services and is valuable for the interpretation of the attitude of these practitioners. The main point seems to be that satisfactory anesthetic techniques must be devised for occasions when competent anesthetists are not available. However, as suggested, if techniques are developed within the range of safety for the available anesthesia service then ipso facto competent anesthetists are available for this type of anesthesia. In a time when we are concerned with providing a physician to attend every labor, the thought of also providing a physician-anesthetist
Volume 90 Number 1
is fantastic. Trained anesthetists are simply not available for every parturient woman and programs to provide them have not been successful. When comparison is made with the elaborate preparation and control of patients for surgicai anesthesia and considering the conditions that surround labor and delivery, accidents from obstetrical anesthesia are somehow remarkably rare. In the future, complicated inhalation and regional anesthesia in obstetrics may be replaced, as experience accumulates with agents to be administered intravenously. DR. MAY (Closing). As a practicing obstetrician, I am happy to know that the anesthesiologist does recognize the problems involved in obstetric anesthesia as expressed in the remarks by Dr. Crandell. Dr. Caldwell in his discussion implies that physician anesthetists are suggested for obstetrical anesthesia by the data presented in my paper. On the contrary, this is a plea for more trained anesthetic personnel at all professional levels. He also notes a remarkably low incidence of accidents from obstetrical anesthesia. It is my contention that no anesthesia is necessary in many instances and is particularly
Problems m obstetric anesthesia
87
preferable to a poorly administered anesthetic by untrained personnel. It is pointed out by Dr. Crandell that inhalation techniques offer the most controllable route of administration of agents providing anaigesia and anesthesia for labor and delivery. The intravenous route suggested by Dr. Caldwell would increase the risk to both mother and fetus since, once given there is no control of anesthesia levels. My philosophy on the subject of maternal deaths from obstetric anesthesia was best expressed by Dr. James F. Donnelly, a former Chairman of the Committee on Maternal Welfare of the Medical Society of the State of North Carolina. He said that many of the women who have died as a result of obstetrical anesthesia would have been better off to have had an unattended labor by the roadside, never having reached the hospital. He further pointed out that no woman ever died of the pains of childbirth. There is no room for maternal deaths from the administration of anesthesia when one considers the ideal approach to the safe conduct of labor and delivery. I am not prepared to accept any effort aimed at anything less than the ideal.
THE chief variants in most anesthetic accidents are three in number, namely, the patient's physical status, the anesthetic agent, and the person administering the anesthetic. The great improvement in equipment for the administration of anesthetic agents and the better understanding of the drugs used in anesthesia have eliminated many of the factors involved in anesthetic accidents. The continued occurrence of maternal deaths due to anesthetic accidents should lead one to suspect that the human factors involved are of primary importance. With this supposition in mind the Committee on Maternal Health of the Medical Society of the State of North Carolina conducted a survey of hospitals doing obstetrics in North Carolina in 1960 to determine the adequacy of personnel involved in obstetric anesthesia. The findings of this survey indicate that the greater number of hospitals doing obstetric deliveries in North Carolina have inadequate anesthesia service.
district member of the Committee on Maternal Health of the Medical Society of the State of North Carolina. It should be understood that the primary intent of the survey questionnaire was to determine the physician's attitude about the prevailing practices on the maternity service in his hospital. In addition to the attitude of the physician, certain factual information about the maternity services was secured. Questionnaires were sent to 143 hospitals representing most of the hospitals doing obstetrics in the state. Completed questionnaires were ·returned to the Committee by 101, or 71 per cent, of the total hospitals queried. The hospitals represented 78 per cent of the beds of the total 143 hospitals. The ratio of the hospital beds to the number of deliveries is of importance to the study and is indicated in Table I. There are 38 hospitals with 50 beds or less. The number of deliveries among these hospitals in 1960 varied from a few up to 400 to 600 a year. It is quite significant to note that 38.8 per cent of the total deliveries studied in this survey were done in the small hospitals of 50 beds or under and that a major portion, or 80.5 per cent, are done in hospitals of 150 beds or less. The largest number of deliveries reported by a single hospital was slightly in excess of 2,500& There \vere 5 hospitals having 2,000 or more deliveries a year and six having between 1,500 and 2,000 a year. The first part of the questionnaire concerning obstetric anesthesia was devised to determine in general the qualifications of the personnel available to administer obstetric anesthesia. These data are summarized in Table II.
Material
A questionnaire covering several aspects of hospital maternity services, including anesthesia, was sent to a physician on the hospital staff selected by the appropriate From the Department of Obstetrics and Gynecology of the Bowman Gray School of Medicine of Wake Forest College. Presented by invitation at the Twentysixth Annual Meeting of the South Atlantic Association of Obstetricians and Gynecologists, Bal Harbour, Florida, fan. 26-29, 1964. *Chairman, Committee on Maternal Health of the Medical Society of the State of North Carolina.
81
82 May :\m.
Scptemb<'l J 1964 J. Obst. & nyncc.
Table I. Per cent of deliveries according to hospital beds No. of deliveries
0 U .... ~s.~·~-1
J,.l.U.JjiUU(,
beds 0 51 101 15,1 201 251 301 401 601
to to to to to to to to to
Total
50 100 150 200 250 300 400 600 BOO
to
51
101
201
to
251
50
100
to
to
250
300
2.0
3.1
3.1 2.0
9.2
2.0
3.1
6.1
6.1
5.1
9.2
I 301 to I 350 5.1 2.0
7.1
401 to
-------·--------------
601 to
1,001
600
800
4.1 9.2 1.0
6.1 I 1.2
5.1 1.0 1.0
1'7 Q
., 1
14.3
J..l ,J
Total
+
I •"
(%)
38.8 24.4 17.3 5.1 3.1 2.0 5.1 2.0 2.0
4.1 4.1 3.1 2.0 5.1 2.0 2.0 'l'l A
::J.:J,(J " " 0
O:,O::,."T
Table II. Obstetric anesthesia personnel medical Hospitals
%
8
7.9 8.9 8.9 4.9
Medical 1. Board certified anesthesiologist 2. Physician-trained and/or experienced 3. Untrained or inexperienced physician 1 and 2 1 and 3 2 and 3 1, 2 and 3 No medical anesthesia personnel
2 1
2.0
67
66.3
Nurse 1. Nurse anesthetist-registered 2. Registered nurse 1 and 2 No nurse anesthetist
42 18 24 17
41.5 17.8 23.8 16.8
Table II indicates that 18 hospitals, or 17.8 per cent, listed non-Board medical anesthetists. These were found mostly in the small hospitals, less than 400 deliveries, and in the larger hospitals with 1,000 and more deliveries a year. In the smaller hospitals these physicians were usually practicing in the community as general practitioners who gave anesthesia at times for the obstetrical service. The hospitals indicating Board Certified Anesthesiologists available for obstetric anesthesia were all in the hospitals having 1,201 and more deliveries per year. Only one third of the hospitals indicated that they had medical anesthesia personnel. Registered nurse obstetric anesthesia personnel. Table II summarizes the nurse-anesthetist availability to obstetrical delivery
9 9 5
l.D
service. The nurse-anesthetists were on the staff of 65 per cent of the hospitals and there was only nurse-anesthetist coverage in 41 per cent. In 18 per cent of the hospitals a registered on-duty nurse, usually a supervisor or labor floor nurse, gave anesthesia. This is characteristic of hospitals having less than 1,000 deliveries a year. In 16.9 per cent of the hospitals recorded no nurse-anesthetist was available. Availability of formal anesthesia service. Table III is a summary of the response to the question: "Is formal anesthesia coverage actually provided obstetrical patients?" No formal anesthesia service for obstetric patients was indicated in 19.9 per cent of the hospitals. The majority of the hospitals without formal obstetrical anesthesia ser-
Volume 90
Number 1
vice were those with small maternity services. One glaring exception was in a hospital with 1,200 deliveries per year and it was indicated that anesthesia was available but was provided by the floor nurse. Of significance is that one hospital indicated the Jack of service until 2 years ago at which time death from anesthesia brought prompt correction. Another 23 per cent of the hospitals apparently provide anesthetic service only on occasions and 58 per cent of the hospitals provide anesthesia service on a usual or always basis. Obstetric anesthesia administered by physicians. The number of hospitals that provide obstetrical anesthesia given by a physi.. cian is indicated by Table IV. It summarizes the answers to the question: "In your opinion what percentage of obstetric patients receive anesthesia from Board Anesthesiologist, physician trained, or experienced or attending obstetrician?" The physiciananesthetists in Table IV are predominantly associated with small obstetric services. A sizable number of hospitals, 54 per cent, the sums of lines 3, 5, 6, and 7, indicate that the attending obstetrician gave his own anesthesia. The record indicated that this was in the form of local, caudal, or spinal and, in some cases, a preference was stated for this type of anesthesia whether an anesthetist was available or not. Obstetric anesthesia administered by registered nurses. Data similar to that in Table IV for nurse-anesthetists providing obstetric anesthesia, are summarized in Table V. Twenty hospitals used only graduate nurses who were on regular hospital duty such as labor floor nurse, night supervisor, etc. An additional 9 per cent used licensed practical nurses and nurse's aides. One large hospital indicated that aides gave 15 per cent of the anesthesia, approximately 300 obstetrical anesthetics a year. The data indicated that Board Certified Anesthesiologist provided only occasional obstetrical anesthesia, probably for only the most complicated cases. The Board Anesthesiologist gave anesthesia in 14 hospitals and in 12 of these the amount was considered to be less than 5 per cent
Problems in obstetric anesthesia
83
and usually 1 per cent or less. Physicians other than Board Certified Anesthesiologists gave anesthesia in 12 per cent of these hospitals predominantly at the level of 5 per cent. On the other hand, the obstetrician gave anesthesia to their patients in 53 per cent of the hospitals and at all levels of frequency. Of interest is the fact that in 53.6 per cent of the hospitals nurse-anesthetists were either not available or provided only occasional service for obstetrical patients. Their services were used at a higher rate only in the hospitals having more than 1,000 deiiveries a year. Anesthesia service was provided by on-duty almost entirely in the hospitals with less than 1,000 deliveries a year, although there were some glaring exceptions. In 25 per cent of the hospitals 50 to 100 per cent of the anesthesia was given by an on-duty nurse. Table V indicates that 8.9 per cent of the hospitals used licensed practical nurses or nurse's aides. The percentage of anesthesia given by this personnel was stated in only 3 cases: one large hospital listed 15 per cent and 2 small hospitals listed 20 per cent and 85 per cent of the anesthesia was administered by practical nurses and aides "on call," respectively. Place of standby for "on call" obstetrical anesthesia nersonnel. A resnonse to the auestion: "Where do these anesthetists stand by when on call?" is found in Table VI. The "standby" location of persons responsible for giving anesthesia presented a complicated problem. The question was interpreted loosely and multiple items were checked. If among the multiple answers labor floor was indicated as one of the "standby" locations, it was so recorded to the exclusion of all other places marked. In the hospital was next in priority. If the answer was marked as some place outside the hospital, the record was so labeled. It is recognized that this makes the results much more favorable than they probably are. Even though the on-duty nurse who gave the anesthesia was usually on the labor floor, 56 per cent of the hospitals permitted "stand&
•
•
84 May
\m .
Table III. Formal anesthesia service ---------· -··(/D
---~----
Hospitals Always available n ... ~n., available Seldom available Never available ~0~~ . .
,
-----
25
24.7 32.7 22.7
3:>
23 20
19.9 ~-·--~-
Table IV. Obstetrical anesthesia medical doctor
o/o
2
2.0
7 40 2 7 5
6.9 39.6 2.0 6.9 4.9 3.0
2. Physician-trained or experienced 3. Attending obstetrician 1 and 2 1 and 3 2 and 3 1, 2 and 3
3
Table V. Obstetrical anesthesia nurse Hospitals 1. Nurse
anesthetist~registered
30 20
')Q.,
2. Nurse graduate 3. Licensed practical nurse and others 1 and 2 1, 2 and 3 No nurse coverage
9 23 2 17
8.9 22.8 2.0 16.8
,._.J,I
19.9
Table VI. Place of standby for obstetrical anesthesia personnel Hospitals Labor floor Hospital Not in hospital No anesthetists
11 21 57 11
vice was inadequate. Fifty-five and fivetenths per cent felt that their service was adequate. The answers were equally divided among the small and large services. Since the smaller services used untrained personnel to a large extent, there is some indication that the respondents may not really recognize good anesthesia service in some instances. Comment
Hospitals 1. Board anesthesiologist
Septemb,., 1. 196+ .J. Ohst. & f ;yiH'C.
% 10.9 20.8 56.4 10.9
by" personnel to be outside the hospital. The hospital having less than 1,000 deliveries tended to have "standby" outside the
hospital more frequently than the larger services. Adequacy of anesthesia service. In answer to the question: "Is anesthesia service adequate?" 44.5 per cent of the physicians felt that their hospital obstetric anesthesia ser-
Dr. F. Bayard Carter in his Presidential Address before the South Atlantic Association of Obstetricians and Gynecologists 10 years ago stated: "Anesthesiology is a specialty so important and vital to us that \Ve should hear at stated intervals the progress it has made. We should adopt the progressive methods and precautions it advocates." A review of the Proceedings of this Association in the American Journal of Obstetrics and Gynecology reveals that this is the first formal recall of this subject since that time. The data contained in this report along with other evidence indicate that Dr. Carter's statement of 10 years ago was a timely one and that a serious reflection on the matter of obstetrical anesthesia is due. Twenty-six of the first 1,000 maternal deaths reported in North Carolina by the Committee on Maternal Health between 1946 and 1951 were due primarily to anesthetic accidents. Twenty-nine of the second 1,000 maternal deaths reported from 1951 to 1956 were due to the same cause. There is no way of assessing the number of postpartum deaths from hemorrhage due to uterine atony which was secondary to obstetrical anesthesia or the morbidity resulting from aspiration and other complications in patients who did not die but nearly died because of anesthetic accidents. These figures are a source of grave concern since there vvas no improvement in L~e maternal mortality from anesthetic accidents during a period of time when much improvement was taking place in the field of anesthesiology. The psychological and emotional makeup of American women seem to put increasing demands upon the obstetrician for a
Volume 90 Number i
pain-free labor and delivery. The increased use of anesthesia for obstetrical delivery has been accompanied by a marked increase in the demand for more personnel who are properly trained in anesthetic techniques. The data revealed in this paper indicated that nearly a fifth of our hospitals doing obstetric deliveries have no formal anesthetic service and that less than a third of the anesthesia administered is given by registered nurse-anesthetists or trained physicians. It would appear that the demand for proper anesthesia coverage has greatly exceeded the provisions for it. The safety of inhalation anesthesia depends primarily on the judgment, skill, a....Tld experience of the anesthetist. Many of the agents used have been unnecessarily maligned because of faulty administration. Hingson pointed out that special techniques used in obstetrical anesthesia are greatly limited by the untrained nurse-anesthetist or physician-anesthetist. The range of techniques which are safe in anesthesia must be necessarily limited by the limitations of the personnel administering the anesthesia. Any good technique may be acceptable when administered by a competent anesthetist. He expresses the opinion that every inhalation anesthesia should be accompanied by 40 per cent oxygen and that no spinal or regional anesthesia should be administered by the obstetrician unless the patient is to be monitored for blood pressure, pulse and respirations, and anesthesia levels by a competent person for this purpose. If such wise advice is to be followed in the delivery room where anesthesia is concerned, it is quite apparent there must be a great curtailment of the anesthesia which is improperly given by inadequately experienced personnel in the interest of both the mother and the fetus. \Vith 41.5 per cent of the physicians doing obstetrical deliveries in North Carolina feeling that their hospital anesthesia service is inadequate, we as obstetricians should make a serious assessment of the attitudes toward obstetrical anesthesia service. These data for accepting inadequate anesthesia service for
Problems m obstetric anesthesia
85
obstetrical suites indicts the physician practicing obstetrics. The hospital administration stands indicted for putting the economics of such importance as obstetrical anesthesia ahead of the safety of the mothers and babies who suffer from any lack of competent service. The anesthesiologist is also indicted for failing to encourage the regular and adequate anesthesia coverage for obstetrical services. The government and private health insurance plans are indicted for not providing adequate compensation for medical anesthesia service. Conclusions 1. Obstetrical anesthesia in most hospitals in North Carolina is very much neglected. 2. The demand for trained obstetrical anesthesia personnel far exceeds the supply or the availability which is even more important. 3. The attitude of the physicians practieing obstetrics tO\\Tard obstetrical anesthesia should become more positive and demands be made for more personnel if complicated anesthetic techniques are to be used. 4. Where competent anesthetists are not available techniques must be tailored within the range of safety for the anesthesia service available. Summary
A survey of 101 hospitals in North Carolina representing 78 per cent of all of the hospitals doing obstetrics in the state indicate that 80 per cent of the deliveries in l'~orth Carolina are done in hospitals of less than 150 beds and in these small hospitals the adequacy of quality of the anesthesia service provided for the parturient mother is of dreadfully inferior quality when one considers the ideal quality of anesthesia service for obstetric delivery service. The author wishes to acknowledge with grateful appreciation the services of Dr. james F. Donnelly, Director, Personal Hygiene Section of the North Carolina State Department of Public Health, for tabulating the data selected in this survey and used in this paper.
86 May
S•·plt'mbcr l, 196+ o\m, ]. Ob<>t. & Gynec.
Discussion DR. D. LERoY CRANDELL, Winston-Salem, North Carolina. Obstetrical analgesia and anesthesia serves as a common meeting ground for the general practitioner, obstetrician, and anesthesiologist. In recent years, it has received relatively greater emphasis due to the reduction in maternal mortality resulting from toxemia, infection and hemorrhage. The medical profession is beginning to accept its obligation to furnish the obstetrical patient with the best anesthesiological service available. Dr. May's paper emphasizes the important fact that anesthesia always involves at least
No real purpose is served .in discussing the methods of obstetrical analgesia and anesthesia unless a corresponding effort is made to encourage the application of these methods with the best judgment and greatest skiii. It is important to realize that drugs used to produce analgesia may be administered by several routes. The most controllable route is by the inhalational method. The concentration of the drug can be changed from moment to moment while maintaining adequate alveolar ventilation. Inadequate pulmonary ventilation of the mother may enhance birth asphyxia and potentiate the effect of analgesic and sedative drugs on the baby. Hypoten-
three variables: the patient, the agent and tech-
sion or the use of vasopressors to correct hypo-
nique chosen, and the anesthetist. By far the most important variable is the anesthetist. The administration of safe obstetrical anesthesia depends on his knowledge, experience and skill. Frequently, too much emphasis is placed on specific anesthetic agents and techniques in maternal mortality reports without mention of the qualifications of the anesthetists. A recent survey has shown that in North Carolina, 31 per cent
tension may reduce uterine blood flow and further enhance birth asphyxia. Spinal and epidural anesthesia may be analogous to deep general anesthesia in that the higher the level of anesthesia the greater the circulatory and respiratory depression. It should be emphasized that drug therapy is a poor substitute for a good patient-physician relationship. The employment of psychotherapeutic measures
of the hospitals have no qualified anesthetist to
may greatly contribute in allaying fear and ap-
administer anesthesia for even surgical operations let alone obstetrical deliveries. This same survey also revealed that 46 per cent of the anesthesia in the United States is administered by unqualified nurses and physicians and that 2 per cent of the anesthesia is administered by persons who are neither registered nurses nor physicians. Is this deplorable situation caused entirely by the problem of supply and demand of qualified anesthetists or in part by an attempt by the hospital administration to economize at the patient's expense? The realization that obstetrical anesthesia is often a complex therapeutic procedure must replace the archaic belief that it is a simple task to be relegated to the most inexperienced person in the delivery room. The ease with which a needle can be inserted into the lumbar subarachnoid space for spinal anesthesia or into a vein for the administration of Pentothal or the simplicity of dropping ether on a mask subjects these techniques to use by unqualified individuals to the detriment of the patient. There is no one method of anesthesia that is best for all obstetrical patients. The varied methods of general and conduction anesthesia have their specific indications and contraindications. The routine use of one method of pain relief to the exclusion of other> is haphazard therapeutics.
prehension and relieving pain. This will reduce the requirements for analgesic and sedative drugs. The provision of better anesthesia for the obstetrical patient in the smaller communities where good anesthesiological service is not available is best accomplished by the encouragement of general practitioners to undertake formalized training in obstetrical anesthesia and then to devote part of their time to its practice. Only by improving the quality of the anesthetist can a substantial reduction in maternal mortality and morbidity due to anesthesia be realized. DR. }EssE CALDWELL, Gastonia, North Carolina. This report is important but it does not describe the obstetric anesthesia experience in the hospitals of North Carolina. It concerns the opinions of practitioners on the services and is valuable for the interpretation of the attitude of these practitioners. The main point seems to be that satisfactory anesthetic techniques must be devised for occasions when competent anesthetists are not available. However, as suggested, if techniques are developed within the range of safety for the available anesthesia service then ipso facto competent anesthetists are available for this type of anesthesia. In a time when we are concerned with providing a physician to attend every labor, the thought of also providing a physician-anesthetist
Volume 90 Number 1
is fantastic. Trained anesthetists are simply not available for every parturient woman and programs to provide them have not been successful. When comparison is made with the elaborate preparation and control of patients for surgicai anesthesia and considering the conditions that surround labor and delivery, accidents from obstetrical anesthesia are somehow remarkably rare. In the future, complicated inhalation and regional anesthesia in obstetrics may be replaced, as experience accumulates with agents to be administered intravenously. DR. MAY (Closing). As a practicing obstetrician, I am happy to know that the anesthesiologist does recognize the problems involved in obstetric anesthesia as expressed in the remarks by Dr. Crandell. Dr. Caldwell in his discussion implies that physician anesthetists are suggested for obstetrical anesthesia by the data presented in my paper. On the contrary, this is a plea for more trained anesthetic personnel at all professional levels. He also notes a remarkably low incidence of accidents from obstetrical anesthesia. It is my contention that no anesthesia is necessary in many instances and is particularly
Problems m obstetric anesthesia
87
preferable to a poorly administered anesthetic by untrained personnel. It is pointed out by Dr. Crandell that inhalation techniques offer the most controllable route of administration of agents providing anaigesia and anesthesia for labor and delivery. The intravenous route suggested by Dr. Caldwell would increase the risk to both mother and fetus since, once given there is no control of anesthesia levels. My philosophy on the subject of maternal deaths from obstetric anesthesia was best expressed by Dr. James F. Donnelly, a former Chairman of the Committee on Maternal Welfare of the Medical Society of the State of North Carolina. He said that many of the women who have died as a result of obstetrical anesthesia would have been better off to have had an unattended labor by the roadside, never having reached the hospital. He further pointed out that no woman ever died of the pains of childbirth. There is no room for maternal deaths from the administration of anesthesia when one considers the ideal approach to the safe conduct of labor and delivery. I am not prepared to accept any effort aimed at anything less than the ideal.