Christopher F. Ciliberto, MD
New York, NY
The need for a dedicated anesthesiologist to cover the labor room changes with the times. An analysis of the obstetric work force in 1981 revealed that most analgesia was provided by nurse anesthetists working independently or by obstetricians themselves 1. Only a small percentage was performed by anesthesiologists, primarily because of the unpredictable nature of the service and unreliable payment for labor analgesia. Availability of anesthesia services was therefore low and many women had no access to regional analgesia at all. By 1992, a survey of the obstetric work force by Hawkins showed a change in obstetric practice, with a decrease in the number of hospitals (especially those with fewer than 500 beds) delivering obstetric care 2. The shift of obstetric care to larger facilities acts as a two-fold advantage to the anesthesiologist; it increases the number of deliveries in one location and increases the probability of an existing anesthesiology presence by the mere nature of it being at a larger institution. In 1998, Dunbar reported 3 that the lack of epidural service in rural Washington and Montana hospitals limited the obstetric practices at these institutions. The increase in the number of patients at individual institutions, and increasing patient desire for and acceptance of labor analgesia has led to the increased use of regional analgesia and anesthesia overall.
A service with a dedicated provider leads to multiple benefits for both patients and the group of providers. The commitment to provide continuous, consistent obstetric anesthesia and analgesia coverage leads almost automatically to the development of increasing expertise in the area. In any service, the level of care is improved by consistent coverage because an individual or individuals doing obstetric anesthesia on a regular basis become more proficient in the most common techniques, and more familiar with obstetric common problems. He or she also has a greater interaction with the obstetric staff, which allows for anticipation of practice style and knowledge of pertinent issues for both services. The practice of obstetric anesthesia as a whole becomes safer, in that there is a greater utilization of regional analgesia and therefore anesthesia at the time of cesarean section. Hawkins showed that the use of general anesthesia was associated with a higher mortality for cesarean section than that of the use of regional techniques 4. A dedicated in house individual also is more available to treat a complication after analgesia (both spinal and epidural) happens anywhere from 10 to 40 minutes after the initiation 5,6. Some of these complications are easily treated and others may be missed if specific monitoring is not in place. The American Society of Anesthesiologists has guidelines for the practice of regional anesthesia in the labor and delivery area which include presence during the administration of any regional anesthetic or analgesic using local anesthetics. In our institution (academic practice) another benefit to a dedicated provider or group is the concentration and focus in obstetric anesthesia that we are able to provide to the residents. Teaching and research efforts are better concentrated when a group is dedicated to one specific area of specialization.
Other than straightforward shortages in manpower, the major obstacle to in-house coverage has been financial. In recent years the use of regional anesthesia in labor has increased. With increased patient awareness more and more insurance companies and HMOs have been forced to cover these analgesics in an effort to maintain subscribers. Certain states, through the lobbying of the physicians, are now reimbursing at a somewhat higher rate than previously for their Medicaid patients. It is important that we not take the position that labor analgesia is only necessary during "business" hours, then HMOs and insurance carriers are very likely to say they are not necessary at all and reimbursement will cease altogether. There is also the issue of our CRNA colleagues who will be more than willing to pick up this pool of patients if they are able to practice independently of physician guidance; to a degree we should be looking to protect our turf.
It seems to me that in the ever-changing medical atmosphere in which we find ourselves at the dawning of a new millennium, capturing the greatest number of patients is only to our advantage. The way to do that is to be able to provide the services that they are requesting. At the same time we need to be able to provide these services as safely as possible to ensure the best possible care, and protect against unnecessary medico legal entanglements. While there exists ASA Guidelines for the safe administration of analgesia and anesthesia to women in labor we should adhere to them as much as possible. If we are able to provide excellent care and increase our caseload we can satisfy what should be our main objectives, to 1) grant relief of the pain of labor, and 2) make a living at it.
References