Obstetric Anesthesia: Origins and Current Practice

Lisa R. Leffert, M.D., is Chief, Obstetric Anesthesia Division, Vice Chair, Faculty Development, and Associate Professor, Harvard Medical School, Department of Anesthesia, Critical Care & Pain Medicine, Massachusetts General Hospital, Boston.Roulhac D. Toledano, M.D., Ph.D., is Clinical Associate Professor, Department of Anesthesiology, Perioperative Care and Pain Medicine, and Director, Obstetric Anesthesia, New York University Langone Health, Brooklyn.It wasn’t so long ago that physicians in training, obstetricians and surgeons served as ad hoc obstetric anesthesiologists, administering labor analgesia and cesarean delivery anesthesia. In 1845, the surgeon Crawford Long first administered inhalational ether to his own wife for childbirth. The use of chloroform and nitrous oxide for labor analgesia followed, most often administered by trainees under the supervision of surgeons with little to no understanding of aspiration risks. Many of the pioneers of neuraxial techniques were also surgeons: August Bier introduced spinal anesthesia in 1898; Walter Stoeckel and Arthur Läwen applied the then novel single-shot caudal technique to obstetric deliveries in 1901. The Spanish military surgeon Fidel Pagés Miravé introduced the thoracolumbar approach to single-shot epidural anesthesia in 1921; and the Italian surgeon Achille Dogliotti popularized the single-shot epidural technique. It was Manuel Martinez Curbelo, an anesthesiologist, who revolutionized the field in 1947 by introducing the first continuous lumbar epidural technique using a modified silk ureteral catheter to deliver an infusion of local anesthetic for surgical anesthesia.1 In 1953, Virginia Apgar revolutionized the practices of obstetrics, anesthesiology and perinatology by introducing a simple quantitative measure of newborn health, subsequently known as the Apgar score.2 Gradually, as the field of anesthesiology became an independent specialty and the role of anesthesiologists in perioperative care expanded, so too did the role of sub-specialists in our field. In 2011, obstetric anesthesiology joined the ranks of pain, pediatrics, adult cardiothoracic and critical care medicine fellowships to be eligible for accreditation by the Accreditation Council for Graduate Medical Education (ACGME). Cedars-Sinai Medical Center in Los Angeles was the first obstetric anesthesia fellowship program to attain accreditation. Since then, 37 of 49 U.S. programs have become accredited, with a growing number of programs working to meet the rigorous ACGME standards. Eighty eight obstetric anesthesia fellowship positions are currently offered, most of which will be filled through the SF Match program. More broadly, obstetric anesthesiologists, who routinely care for the increasingly complex obstetric population, are specifically trained to manage the more challenging clinical scenarios that commonly arise on the labor and delivery unit. Required rotations for the obstetric anesthesia fellowship include the labor and delivery unit, maternal fetal medicine and neonatology rotations, and blocks of dedicated research time. Many incoming obstetric anesthesia fellows will also have opportunities to train in surgical, medical and cardiac intensive care units; regional anesthesia services; blood banks; and point-of-care ultrasonography. All will participate in simulation and quality improvement programs. As our subspecialty continues to evolve, plans are now under way to apply to the American Board of Anesthesiology (ABA) for obstetric anesthesia subspecialty certification. A growing body of literature suggests improved clinical care when obstetric anesthesiologists are involved.3 There are multiple reasons for the superiority of neuraxial rather than general anesthesia for cesarean delivery, including decreased risks of anesthesia-related complications (such as inadvertent intraoperative awareness and fetal depression associated with emergent general anesthesia) and optimal opioid-sparing postoperative analgesia.4–8 Multiple studies and a meta-analysis have reported a lower rate of general (versus neuraxial) anesthesia for unplanned cesarean delivery when an obstetric anesthesiologist provides care.3,9–12 One proposed explanation is that obstetric anesthesiologists are vigilant for the signs of dysfunctional epidural catheters (such as an increasing number of boluses during labor) and are more likely than their generalist colleagues to address these shortcomings prior to cesarean delivery. More broadly, obstetric anesthesiologists, who routinely care for the increasingly complex obstetric population, are specifically trained to manage the more challenging clinical scenarios that commonly arise on the labor and delivery unit.13 They are also more likely to be facile at initiating neuraxial blockade in the lateral position14 and may be more comfortable performing neuraxial techniques in parturients with comorbidities (e.g., thrombo-cytopenia) and for cases with anticipated massive blood loss (e.g., placenta accreta).15Obstetric anesthesiologists are also leaders in interdisciplinary simulation,16 health services research17 and hospital administration18,19 and have been major contributors to the development and implementation of the National Maternal Patient Safety Bundles. The American College of Obstetricians and Gynecologists (ACOG) has recently codified the need for specialized obstetric anesthesia qualifications in its Maternal Levels of Care Designation.20 Level III-subspecialty care and Level IV-regional perinatal health care centers caring for higher-acuity obstetric patients must have a board-certified anesthesiologist (Level III) with obstetric anesthesia fellowship training or extensive experience in obstetric anesthesia (Level IV) physically present at all times.20 But not everyone wants to be a dedicated obstetric anesthesiologist – or needs to be. The Society for Obstetric Anesthesia and Perinatology (SOAP) provides a wealth of information to guide non-specialists in our field. Our annual meetings feature opportunities to work together “Raising the Standard for Each Woman Everywhere” (Halifax2020) through interdisciplinary panels, plenary lectures with other anesthesia and obstetric professional associations, hands-on workshops, and an expanded clinical track. The SOAP Center of Excellence initiative sets benchmarks to improve the standard of care nationally by outlining optimal levels of emergency preparedness, expert staffing, cesarean and labor analgesia care, and patient safety protocols (soap.org/grants/center-of-excellence). Hospitals that have attained this prestigious designation to date include 39 academic and private practices, both within and outside the United States. In the second round of applications, 25 additional centers have applied for this designation. The networking and sharing of best practices continue throughout the year through social media and the SOAP website (soap.org), where you can find the following tools relevant to your practice: interdisciplinary consensus statements on enhanced recovery after cesarean delivery; monitoring for respiratory depression after neuraxial morphine; anesthetic management of peripartum patients receiving anti-thrombotic agents; and a forthcoming consensus statement on management of neuraxial anesthesia in thrombocytopenic parturients. The website also offers guides to obstetric simulation, virtual grand rounds on high-yield obstetric anesthesia topics and links to national initiatives. So, whether you pursue an obstetric anesthesia fellowship or join one or all the many SOAP-sponsored events, you will find a community of anesthesiologists bound together by a common goal – Raising the Standard for Each Woman Everywhere (Halifax2020).