Understanding Each Other’s Priorities: Anesthesiologists Versus Gynecologists on Fetal Distress

"Hi, are you on call? We urgently need to do a cesarean section," said the gynecologist. "Where is the patient and what's the indication?" the anesthesiologist answered back with a question. "I am the junior resident and i am not very sure about the patient details, but it's fetal distress. We are moving the patient and reaching in 10 minutes," the gynecologist blurted back. By the next 5 minutes, the patient is in the OT. "Do we have time for a spinal?" "No". "Why do you guys rush in the last minute?" the anesthesiologist asked while struggling with setting up the operation room and thereafter pre-oxygenating the patient. This scenario sounds so familiar. Doesn't it? Fetal distress, a critical obstetrics challenge, generally demands immediate intervention from gynecologists, anesthesiologists, and pediatricians. All the members of the team head toward the same goal of a safe outcome; however, differences in training, priorities, and perspectives can lead to differences in interpretations and management strategies. Anesthesiologists are primarily concerned with the mother's medical issues, vital parameters, airway management, and fetal well-being. Their main focus is on administering appropriate anesthesia, monitoring, and ensuring that she remains comfortable and stable during delivery. Rapid decision-making is required from them. Gynecologists, on the other hand, are concerned with both mother and baby as complications in any of them will not be accepted by the family. They are responsible for recognizing signs of fetal distress, and deciding whether interventions such as emergency cesarean are necessary. Their primary concern is the safe delivery of the baby, minimizing risks to both the mother and the fetus. It is recommended that the "decision to delivery" should be done within 30 minutes;[1] however, the common concurrence for the surgery is sometimes lacking, most commonly due to the communication barriers.[2] Despite any difference in the perspectives, complications of cesarean sections or failed intubation cannot be tolerated by any member of the team.[3-5] This editorial explores the differences between the understanding of anesthesiologists and gynecologists and also impresses upon the importance of communication and collaboration to minimize complications in the fetal outcome. Let us start with the concerns of gynecologists. Gynecologists are mainly focused on maternal-fetal medicine with a deep understanding of obstetric physiology and pathology. Though multiple objective parameters are available for decision-making, it is difficult to determine the timing for surgery. This still needs continuous efforts to improve clinical practice and contribute to our understanding of the variability of strategies and decision-making processes in intrapartum care. When fetal distress is suspected, gynecologists must quickly decide whether to wait or proceed with a cesarean section. They balance the risks of continued labor against the potential complications of surgical intervention. The gynecologist's first detection and diagnosis tool is fetal heart rate monitoring using cardiotocography (CTG). They interpret CTG tracings to identify abnormal patterns such as late decelerations, variable decelerations, and bradycardia as potential signs of fetal hypoxia or acidosis.[6] CTG has its limitations,[7] and it is high time to seek new integrative methods to associate cardiotocography with continuous monitoring of the fetal status. Invasive monitoring such as discontinuous fetal blood analysis (FBA) using blood from the fetal scalp can be used to accurately assess the severity of the fetal distress; however, such invasive monitors will require epidural analgesia, and too much movement by the expectant mother can cause inadvertent injury to the fetus while sampling.[8] In addition to this medical concern, there is a medicolegal angle to it. To minimize liability and ensure that all possible measures are taken to protect the fetus, there is a more aggressive approach to surgical intervention. Years of experience of practice as a gynecologist becomes one of the most important factors in such decision-making. It is also prudent to know the difference between emergency and urgency, in other words, the classification of cesarean sections. Royal College of Obstetrics and Gynecology has given a four-category classification [Table 1] of the urgency of cesarean sections, from category I as "emergency with immediate threat" to category IV as "elective." Maximum emergency cesarean sections fall under category II, which is "urgent with a fetal or maternal compromise that is not immediately life-threatening." The surgery in this category should be done within 75 minutes; however, that needs more research. While discussing, the anesthesiologist can be told about the category of this cesarean section clearly to understand the urgency and possibility of giving neuraxial blockade.[9]Table 1: RCOG 2010 classification of cesarean sectionRCOG Classification of cesarean section [Table 1][10] Coming to an anesthesiologist's perspective, anesthesiologists may approach the diagnosis of fetal distress with a slightly different lens, considering the maternal hemodynamic status and overall clinical context. They are often involved in interpreting the broader clinical picture, which includes maternal factors that could contribute to apparent fetal distress, such as hypotension or the effects of medications. While general anesthesia (GA) can be administered rapidly, it carries risks such as difficult airway management and potential maternal aspiration. Neuraxial anesthesia, if feasible, is often preferred for its maternal safety profile but requires adequate time for administration and effect.[11,12] This dual focus can sometimes lead to more conservative interpretations of fetal distress, especially if maternal safety could be compromised by hasty interventions. The difference in perception between anesthesiologists and gynecologists can be minimized in the following ways. Regular interdisciplinary meetings, joint training sessions, and the use of shared protocols can enhance mutual understanding and streamline decision-making processes. Joint simulation drills for obstetric emergencies, including scenarios of fetal distress, can improve team dynamics and readiness.[13] These simulations can also help to understand each other's priorities and concerns. Even low-fidelity mannequins are sufficient for practice in low-resource settings.[14-16] All parturients admitted in the labor room should have a basic airway assessment. Once active labor is documented, strict fasting/clear fluid ingestion guidelines should be initiated with intravenous fluids whenever required in case of prolonged labor. The use of prokinetics and proton pump inhibitors should be ensured if required. Early warning signs such as changes in fetal heart rate, decreased fetal movement, abruptio placentae, placenta previa, and meconium-stained amniotic fluid leak should be documented and communicated to the anesthesia team. In conclusion, navigating divergent perspectives judiciously between anesthesiologists and gynecologists on fetal distress and urgent cesarean sections is crucial for ensuring optimal outcomes during childbirth. Both specialties bring unique expertise and viewpoints to the table, which can sometimes lead to differing opinions on the best course of action. Frequent simulation exercises, official joint meetings interspersed with social get-togethers, and a no-blame-game approach can go a long way to solve this perpetual differing standpoint.