Grace Lim, M.D., M.S.; Francesca L. Facco, M.D., M.S.; Naveen Nathan, M.D.; Jonathan H. Waters, M.D.; Cynthia A. Wong, M.D.; et al
Anesthesiology 7 2018, Vol.129, 192-215.
OBSTETRIC anesthesiology has historically bridged multiple disciplines including obstetrics, maternal-fetal medicine, neonatology, general surgery, and anesthesiology. Virginia Apgar, a surgeon turned obstetric anesthesiologist, is best known for her namesake neonatal assessment scoring system. She is widely credited for early advances in neonatology. Her contributions exemplify how obstetric anesthesiologists sought answers to scientific questions about anesthetic effects on the mother, fetus, and neonate. Early investigations focused on the use of volatile agents for labor anesthesia, shifted to opioids and amnestics, and then to neuraxial techniques. Studies focused on the effects of these interventions on labor and the newborn.
The “birth” of obstetric anesthesia began with the introduction of ether labor analgesia by obstetrician James Young Simpson in 1847.1 While Simpson publicized this intervention as effective and innovative, he expressed reservations about its unknown effects on labor and the fetus. The medical community expressed concerns about safety and toxicity. Women’s rights to request and receive labor pain relief was controversial—religious mores of the nineteenth century viewed pain, including labor pain, as divine punishment, and interference was considered sinful.2 Ultimately, the clinical use of ether and chloroform for labor analgesia was not driven by the scientific community, but by a shift in the social attitudes of patients who demanded it, persuaded by public rhetoric from feminist advocates.2 In the early twentieth century, “twilight sleep,” a combination of morphine and scopolamine, became common, but was ultimately abandoned due to its depressant effects on the neonate. In the mid-twentieth century, general anesthesia for cesarean delivery gave rise to airway complications, including failed tracheal intubations, maternal aspiration, and Mendelsohn syndrome (aspiration pneumonitis).3 Anesthesiologists began focusing their efforts on reducing anesthesia-related adverse maternal and neonatal outcomes, including airway-associated morbidity and mortality. As a result, neuraxial labor anesthesia became increasingly used by the 1980s, although it was simultaneously feared to be a risk factor for cesarean delivery.4 Fortunately, most concerns were resolved by rigorous research, and by refining regional anesthesia approaches.5 Advances that led to reductions in anesthesia-related maternal morbidity and mortality included the use of an epidural test dose, incremental epidural injection of local anesthetic, elimination of bupivacaine 0.75% for epidural anesthesia, and lipid emulsion therapy for local anesthetic systemic toxicity. Past and ongoing research in obstetric anesthesiology has contributed to a substantial reduction of anesthesia-related maternal mortality. Read More