Care of obstetric patients during the immediate postanesthesia period.

STUDY OBJECTIVE: To determine the level of care available to obstetric patients during the immediate postanesthesia period. DESIGN: Mail and telephone survey of members of anesthesia departments in Michigan. SETTING: All Michigan hospitals with licensed obstetric beds. PATIENTS: Patients recovering from general or major regional anesthesia following an operative delivery. INTERVENTIONS: The factors determining patient care were the physical suitability of the recovery site, skills and experience of personnel providing care in postanesthesia care units (PACUs), and adjustments in care patterns by anesthesia personnel. MEASUREMENTS AND MAIN RESULTS: Most obstetric PACUs are staffed by labor and delivery nurses whose assignment to the unit is only part of their overall patient care responsibilities within the labor and delivery area (88.2% of hospitals with more than 2,000 annual births and performing cesarean deliveries in the obstetric suite; 92.3% of hospitals with 500 to 1,999 annual births and performing cesarean deliveries in the obstetric suite). Obstetric PACUs in the remaining hospitals in either group are staffed by dedicated nurses who are permanently assigned to these units. Preparation of labor and delivery nurses for PACU duties varies greatly, but 60.0% of hospitals with more than 2,000 annual births and 30.8% of hospitals with 500 to 1,999 annual births provide no special training. Concern about the level of expertise available in obstetric PACUs staffed by labor and delivery nurses was expressed by almost every respondent and has led to a practice pattern followed by most anesthesia personnel of transferring patient care responsibility only after patients have regained consciousness, cardiovascular stability, and ventilatory adequacy. Several institutions also allow anesthesia personnel to summon nurses from the surgical PACU or to transfer patients to alternate recovery sites, such as the surgical PACU or the intensive care unit (ICU). CONCLUSIONS: In many obstetric PACUs, the level of expertise of personnel needs to be upgraded to ensure the safety of patients recovering from general or major regional anesthesia and to comply with existing care standards.

What obstetricians should know about anesthesia care standards.

In recent years the American Society of Anesthesiologists (ASA) has adopted several practice standards that relate directly to the practice of obstetric anesthesia. In addition, the American College of Obstetricians and Gynecologists and ASA defined, in a joint statement, both organizations' views on optimal goals for anesthesia care in obstetrics. Ostensibly, those documents and a number of others promulgated by the two professional organizations enhance the safety of patient care. Knowledge of the documents is equally important to the obstetrician and the anesthesiologist since care rendered to the parturient by the two specialists is closely intertwined, and so are their respective fates in case of legal action.

Quality assurance in a large American perinatal center.

The obstetric service of Hutzel Hospital in Detroit, Michigan is responsible for approximately 7,300 deliveries annually. To monitor the quality and appropriateness of patient care, recognize and pursue opportunities for improving care, and resolve identified problems in the obstetric service as well as other clinical areas, the hospital developed a quality assurance (QA) program. The application of clinical indicators represents the principal method by which relevant QA information is obtained. These indicators are designed to identify problems in patient care. The obstetric/gynecologic QA committee analyzes the results of this indicator-based review process as well as other information (appropriateness of surgery, drug usage, transfusions, utilization of hospital resources, etc.) and reports its findings to the full staff of the Department on a monthly basis. If necessary, actions are taken to correct problems. They include lectures, individual counselling, development of guidelines, addition of personnel and/or equipment, and indicated disciplinary actions. These remedial measures have led to improvements in clinical care such as, for example, a more appropriate usage of antibiotics and oxytocin, and stricter adherence to guidelines. More important, however, are the intangible changes in practice patterns that have occurred in that physicians and other members of the health care team tend to render care with an added degree of diligence and circumspection because of their awareness that an effective monitoring process exists.

Anesthesia-related maternal mortality in Michigan, 1972 to 1984.

We reviewed maternal deaths in the state of Michigan occurring from 1972 through 1984. There were 15 maternal deaths in which anesthesia was considered the primary cause and 4 deaths in which anesthesia was a contributory factor. Complications of regional anesthesia were the main cause of death during the early part of the period, whereas the inability to accomplish endotracheal intubation emerged as the principal cause of death in recent years. Eleven of the 15 patients had undergone cesarean section. Obesity was a risk factor in 12 patients, in an equal number of patients the risk factor was the emergent nature of the operation, and hypertensive disease was a risk factor in eight. Thirteen of the 15 deaths occurred in black patients.

PIP: A review of all maternal deaths occurring in Michigan in 1972-84 uncovered 15 deaths in which anesthesia was considered the primary cause and an additional 4 deaths in which anesthesia was a contributory factor. Overall, anesthesia-related deaths contributed 6.9% of the direct maternal mortality in the state during the period under review. The mean age of the 15 women was 24 years (range, 16-34 years). 13 of the 15 deaths involved black women, resulting in an anesthesia-related mortality rate of 4.26/100,000 live births for blacks compared to only 0.14/100,000 among whites. The causes of deaths attributable to anesthesia were pulmonary complications in 1 case, cardiac complications in 9 cases, central nervous system complications in 2 cases, and reactions to spinal or lumbar puncture in 3 cases. Complications of regional anesthesia were the main cause of death during the early part of the study period, while the inability to accomplish endotracheal intubation has been the principal cause in recent years. 11 women had undergone cesarean section. Risk factors included obesity in 12 cases, the emergent nature of the operation in 12 cases, and hypertensive disease in 8 cases. All 3 of these risk factors were present in 40% of the women who died, at least 2 were present in 80%, and at least 1 was present in 93%. Specific steps recommended to reduce the incidence of anesthesia-related maternal mortality include the use of regional anesthesia where indicated, development of a plan to deal with airway problems, use of up-to-date equipment and monitoring instruments, and use of antacids.

Effect of general anesthesia on fertilization and cleavage of human oocytes in vitro.

To determine whether anesthesia affects in vitro fertilization (IVF), the authors examined 3 1/2 years' experience with IVF. Anesthesia length significantly predicted fertilization and cleavage at stage 0 of stepwise multiple logistic regression analysis, but not at the final step. Oocyte grade, retrieval order, and a quadratic term for grade remained significant for fertilization; cleavage, order, the interaction of order and grade, and the quadratic term for grade remained significant. Order correlated with anesthesia (r = 0.675, P less than 0.001). Also inherent in order are CO2 pneumoperitoneum, increased prolactin, decreased gonadotropins, ovarian trauma, and time. First oocytes of equivalent grade from contralateral ovaries were compared. Fertilization rates were equivalent, but significantly fewer mature oocytes from the second ovary cleaved. Anesthetic agents and CO2 appear to adversely affect fertilization and cleavage in vitro.

Follicular fluid concentrations of thiopental and thiamylal during laparoscopy for oocyte retrieval.

Because access into ovarian tissue of drugs used during anesthesia may be potentially harmful to the oocyte and/or follicular structure, we measured concentrations of thiopental (n = 15) and thiamylal (n = 9) in follicular fluid (FF) aspirates of 24 patients who underwent laparoscopic oocyte retrieval. In both groups, measurable amounts of the respective drug were found in all FF aspirates. Within individual patients, plasma concentrations of both drugs declined during the period of sampling between initial and final follicular aspiration. The mean plasma drug concentration was 7.99 +/- 3.97 micrograms/ml in the thiamylal group and 4.13 +/- 0.90 micrograms/ml in the thiopental group. Mean drug concentrations in FF were similar in both groups (thiopental 1.62 +/- 0.61 micrograms/ml; thiamylal 1.67 +/- 0.83 micrograms/ml). The mean FF/plasma concentration ratio during the sampling period was greater in the thiopental group (0.41 +/- 0.19) as compared with the thiamylal group (0.22 +/- 0.14). Several steps in the clinical management of these patients can be taken to reduce exposure of oocytes to drugs used during anesthesia.

Use of spinal anesthesia in laparoscopy for in vitro fertilization.

Regional anesthesia, in selected cases, is a useful alternative method of providing anesthesia for the retrieval of oocytes when general anesthesia is not indicated. We report our experience in managing anesthesia in four patients in whom we used a subarachnoid block. Ova were obtained in three patients, and two became pregnant and delivered healthy full-term infants. Although the high pregnancy rate was noted with delight, it is clearly a statistical happenstance. It would be interesting, however, to carry out prospective studies to determine whether a relationship between the incidence of pregnancy and anesthetic method might exist.

Conduction anesthesia in obstetrics and its effects upon fetus and newborn.

The use of conduction anesthesia has made childbearing a vastly more pleasant experience for the mother and certainly made the practice of obstetrics safer and easier. However, its safety to the fetus and newborn, once unquestioned, has become the subject of much study and concern in recent years. It is the purpose of this article to examine the fetal effects of local anesthetic agents and review some of these agents as well as the regional techniques most commonly employed in the perinatal period with respect to their fetal and maternal safety.

Gastric perforation during pelvic laparoscopy.

Gastric perforation is one of the recognized hazards of pelvic laparoscopy. Two such instances of perforation are presented and the role of gastric distention in causing this complication is examined. This article also reviews the literature and outlines the measures which can be taken to prevent and treat this complication.