SPRING 1982

*,PRESIDENT'SCOWMN I*Making 08

Anesthesia Availableby Michael H. Plumer, M.D.

The companion article in this issue describes a variety of ways inwhich obstetric anesthesia is being successfully provided incommunity hospitals. The measure of success in all cases is simplythat the anesthesia care provided for obstetric patients is at least asgood as that provided for surgical patients.

These successful practices have in common only one factor - ineach instance, somebody made a personal commitment toproviding good obstetric anesthesia care. Somebody felt thatobstetric anesthesia was no less important than surgical anesthesia,and acted on that feeling, ignoring the conventional excuses whichproclaim obstetric anesthesia an unnecessary luxury, an arcane anddemanding subspecialty, a bothersome nuisance, and a sure roadto financial ruin.

In fact, obstetric anesthesia is a luxury only to those not currentlyin need of it - a group which commonly includes maleanesthesiologists. Obstetric physiology is quite straightforward,techniques of obstetric regional anesthesia are simple, interactionswith patients are seldom depressing, patients are uniformlygrateful, and the practice does pay. Obstetric anesthesia doesn'treally require anything special of those who would provide itexcept commitment. Those who want to provide care will find away to do it.

In many hospitals a few anesthesiologists may feel someobligation to cover obstetrics, but may feel unable to respondunless all their colleagues share their enthusiasm. However, assome of the examples in the article show, it's not always necessaryfor obstetric coverage to be provided by everyone on a hospital'sanesthesia staff. Successful coverage by a portion of the anesthesiastaff is possible and is preferable to no coverage at all. A fewcommitted individuals can make a great difference, even if theircommitment is not uniformly shared.

The financial aspects of obstetric anesthesia coverge are seldomdiscussed in public, much less in print, except to hint that they'redismal. In fact, that need not be so. Many obstetric patients havesome third-party insurance coverage, and the anesthesiologist'sability to care for more than one labor patient simultaneously mayhelp compensate for the disparity between the duration ofanesthesia and the time for which one can actually be paid. Whenobstetric anesthesia is a small part of a diversified anesthesiapractice, an income difference may be scarcely noticeable.However, those for whom obstetric anesthesia constitutes a largeportion of their practice will find that a competitive incomerequires either a busy obstetric service or a hospital subsidy.Obstetricians, hospital administrators, and patients who want toencourage good obstetric anesthesia coverage need to rememberthat adequate obstetric volume greatly facilitates anesthesiacoverage, and they need to encourage consolidation of obstetric

(Continued on page 2)

VOLUME 13, NUMBER 4

OB Anesthesiain theCommunity:Doing It Well

Most teaching centers have reasonably good anesthesiacoverage for their obstetric services. Most community hospitalsdon't. Though SOAP members would agree that anesthesia care forobstetrics should be as readily available assurgical anesthesia care,and as competently provided, that simple objective is so seldomachieved in practice that many question whether it's even practical.Can good obstetric anesthesia care be provided in communityhospitals?

Yes, it can. In selected hospitals of all sizes in all areas of thecountry. obstetric anesthesia care is as good as surgical anesthesiacare or better. I talked to anesthesiologists in a few of thesehospitals in an attempt to discover their secret. I found that there'sno single secret - there are as many solutions to problems ofobstetric coverage as there are hospitals. However, the commonthread which seems to unite all successful attempts at providinggood coverage is personal commitment. In each instance,individuals have agreed that good anesthesia care for obstetrics isimportant and have committed themselves to providing that care.For some, this means sharing obstetric anesthesia coverage as partof a total anesthesia care responsibility; for others, it meansproviding most of the obstetric care which others are unable orunwilling to provide.

The examples which follow illustrate a few of the options forproviding obstetric anesthesia care in the community hospital -enough to show that good care is possible if people care enough toprovide it.

CALIFORNIAFor more than 20 years, this 400-bed hospital in a major

metropolitan center has supported two groups of anesthesiologists- a large group who work only in the operating room, and amuchsmaller group whose practice is confined to the physically separateobstetric suite and its gynecologic surgery unit. Neither group isassisted by nurse anesthetists. The small group of OB/GYNanesthesiologists is there to provide a service which the largergroup was unwilling to provide. Unusually dedicated, workinglonger hours than many of their colleagues in the OR, they aresupported by the hospital with a nominal subsidy for staying in thehospital, and they are supported by the obstetricians withopportunities to provide GYN anesthesia. This hospital has morethan 400deliveries per month, and anesthesiologists are involved inmore than 75% of deliveries - enough volume to support aseparate OB/GYN anesthesia group. To many, this seems the idealsolution to OB coverage in all community hospitals - OBanesthesiologists providing OB anesthesia. Yet few hospitals have

(Continucd on page 2)

SOAPNewsletterPage2

DOING IT WELL(Continued from page 1)enough obstetric volume to support a separate OB anesthesiagroup, and those that do may discover that separate coverage isseldom without problems. The members of this small group havefound that separate OB anesthesia coverage is plagued by tensionbetween the OB anesthesiologists and the others in the hospital, bycontinuing difficulty in recruiting and retaining goodanesthesiologists, by the disparity between hours and income, bythe proprietary feeling of some obstetricians about "their"anesthesiologists, and by simple overwork asa few people strive topre vide 24-hour coverage for a busy service. Separate OBanesthesia coverage may be the best known model, but it may notbe the most practical or the most stable in many circumstances.Other approaches abound.

MASSACHUSETTSLynn is a blue-collar city of 90,000twenty miles from Boston. Lynn

Hospital, a 300-bed general hospital, has the distinction of havingperhaps the country's most pervasive anesthesia coverage for its1100-1500deliveries yearly. Anesthesia for the hospital is providedby a group of 5 nurse anesthetists and 6 anesthesiologists, all of thelatter being former Harvard staff. They are committed to making ananesthesiologist available to obstetrics on request, and they makegreat efforts to do so. Obstetric cases, for example, can delayscheduled OR cases. Anesthesiologists are involved in more than90% of deliveries, and more than 80% have conduction anesthesiafor labor and delivery. Though physicians and nurse anesthetistswork together in the operating room, almost all obstetricanesthesia is provided solely by physicians. The group's founder,Dr. A. Simons, felt an obligation from the start to provide obstetriccov'erage, even though such coverage wasn't the mostremunerative way to spend time. The hospital hasnever provided asubsidy for obstetric coverage. Dr. Simons' group hasgrown now toinclude D,s. Attia, Hepfer, Iskander, Goodwin, and Grojean - allof whom continue the commitment to obstetrics, even though theeconomics of that commitment remain unchanged.

TENNESSEEFor the last 25 years, obstetric anesthesia coverage has been part

of the commitment made by the anesthesiologists at this church-supported 550-bed hospital in a city of 185,000. However, whenobstetric volume dipped as low as20 deliveries per month 10 yearsago, anesthesiologists questioned whether such acommitment waspractical. Unwilling to abandon obstetrics entirely, the hospitalagreed to subsidize the group's efforts to make anesthesiacoverage available for its few deliveries.Obstetric volume has increased in the past decade, but the

hospital still has only 120-140 deliveries per month, and it stillprovides a subsidy for obstetric anesthesia coverage. The group of11 anesthesiologists (and 10 nurse anesthetists who do not coverOB) has now agreed with the hospital to provide a full range oflabor and delivery anesthesia with a physician in the obstetric suitewhenever a patient is in labor. The hospital and theanesthesiologists hope that this expanded coverage will continueto draw obstetric patients there in spite of a neighboring hospital'sepidural service, run by hospital-employed nurse anesthetists.

WISCONSINThere's a different approach to equality of surgical and obstetric

anesthesia care in Janesville, a southern Wisconsin town of 50,000.Three physicians and five nurse anesthetists provide anesthesia inthe 2S0-bed hospital; two of the physicians and all the nurseanesthetists comprise an incorporated group. The nurseanesthetists themselves provide much of the surgical anesthesia,which includes performing their own regional blocks with ananesthesiologist responsible for supervision. The same level of careis provided for the hospital's 1500 deliveries yearly; completecoverage is available for all deliveries, and many of the regionalanesthetics are performed by nurse anesthetists. The hospitalprovides no subsidy. Although one of the physicians is SOAPmember Jay DeVore, who might be expected to encourageobstetric anesthesia, he says that the commitment to obstetriccoverage by nurse anesthetists antedates his arrival in town nearlytwo years ago. The commitment remains strong - nearly 60% ofthe patients who deliver vaginally receive epidural anesthesia forlabor and delivery.

CALIFORNIA

This 400-bed hospital in a suburb of a large metropolitan area hashad a moderately large obstetric volume (usually about 2500deliveries per year) for many years. For most of those years, surgicalanesthesia was provided entirely by physicians. Obstetricanesthesia for other than C-section was provided entirely byhospital-employed nurse anesthetists and by the obstetriciansthemselves. As usual in California, the nurse anesthetists were ableto provide no regional anesthesia; with the decline ofcyclopropane, their anesthetic options became rather limited, andpressure for an expanded anesthesia service grew. One year ago,three anesthesiologists joined the eleven already on the hospitalstaff. These three established an obstetric anesthesia service onwhich a physician is present 24 hours per day, aswell asa hospital-employed nurse anesthetist. The physician provides allanesthesia, though the nurse anesthetist is available to assistwithanesthesia maintenance when the service is busy. Five of theoriginal anesthesiologists were willing to participate in obstetriccoverage once the service was established. Accordingly, thefourteen anesthesiologists, although members of several differentgroups, evolved a unified departmental schedule which providedanesthesiologists for OB and for first and second OR call. Allanesthesiologists take call with the same frequency. Those who willcover OB do so; those who won't, cover OR first call instead.Anesthesiologists are now involved with 60-70% of vaginaldeliveries, with epidural anesthesia provided for about 40% ofdeliveries. No hospital subsidy has been required, and none of theanesthesiologists have required food stamps or public assistance.

OREGONLaGrande is an isolated timber and agricultural town of 12,000in

sparsely-settled eastern Oregon. Thirty new citizens are born eachmonth on the obstetric service of the 72-bed Grande RondeHospital - hardly the setting in which good obstetric anesthesiacoverage is the norm. Yet two of the three anesthesiologists here,Judge Hicks and Tim Gleeson. have committed themselves toobstetric coverage whenever they're available (La Grande is smallenough that if they're anywhere in town, they're available, even ifnot on call). With only two anesthesiologists available for OB and afairly busy surgical schedule, there are times when requests can'tbe answered, but the anesthesiologists do their best to juggle theschedule, delay a case, come in from home, or do whatever isnecessary to cover. They provide epidural anesthesia for about 20percent of vaginal deliveries, and are on hand for all Cesareansections and complicated deliveries. Obstetricians still do somesaddle blocks, and one of the obstetricians sometimes providesepidural anesthesia for his own patients if an anesthesiologist isn'tavailable. The hospital provides no subsidy for obstetric coverage.

These are examples of hospitals where obstetric anesthesia wasconsidered important - and taken care of. I know of others and Ihope there are more besides. Anyone who would like to describe asolution to providing good obstetric anesthesia care is welcome todo so in the pages of the Newsletter. Write the Editor and becomenationally known. •

President's Column (Cont'd from page 1)services where practical. There's simply no reason to expect thatevery small hospital in a metropolitan area can maintain anobstetric service, nor any reason to expect that first-rate obstetricanesthesia coverage can be efficiently arranged when this is thecase.Finally, a question for teachers of obstetric anesthesia ... we've

seen that obstetric anesthesia in the community needs individualswho are committed to making it part of their practice. Is yourprogram producing those individuals? Are you helping those youteach explore ways to provide obstetric anesthesia coveragewithout becoming obstetric anesthesiologists themselves? Are youteaching more teachers who can communicate your enthusiasm?We can expect that obstetric anesthesia care will be as good assurgical anesthesia care only when anesthetists believe thatobstetric anesthesia is part of their practice responsiblity. Are wecommunicating that feeling, and are we helping show thatobstetric anesthesia without obstetric anesthesiologists is entirelypractical? •

LITURATUREUPDATE

by Walter L. Millar, M.D.

lABOR ANALGESIANitrous oxide elimination by the newborn. Mankowitz E, Brock-Utne JG, Downing jW. Anaesthesia 36:1014-1016, 'IY81. (Samplingafter onset of ventilation showed alveolar N,O max 4%)

Double-blind comparison of morphine and bupivacaine forcontinuous epidural analgesia in labor. Writer WDR, James FM,Wheeler AS. Anesthesiology 54: 215-219,1981. (Morphine 0.025%vs bupivacaine 0.25%. Analgesia satisfactory in 2/8 vs 8/8 patients.)

More experience with intrathecal morphine for obstetric analgesia(letter). Mok MS, Tsai SK. Anesthesiology 55:481, 1981.(Unacceptable incidence of side effects: pruritis, vomiting,somnolence, urinary retention. Study aborted.)

Intrathecal injection of morphine for obstetric analgesia. Baraka A,Noveihid R, Hajj S.Anesthesiology 54: 136-140,1981. (1 or 2mg. "Inall parturients, labor pains were completely relieved ... " Incidenceof somnolence, itching, nausea, and inadequate labor was high,and dose-related.)

Epidural fentanyl in labour. Carrie LES,O'Sullivan GM, Seegobin R.Anaesthesia 36: 965-969, 1981. (150-200 mcg reduced mean painscores for 60 minutes.)

Pain relief in labour using epidural pethidine with adrenaline.Perriss BW, Malins AF. Anaesthesia 36: 631-633, 1981. (50 mgmeperidine, 50mcg epi in 10ml saline; excellent analgesia, few sideeffects.)

Shivering during epidural analgesia in women in labor. Webb P]'James FM, Wheeler AS. Anesthesiology 55: 706-707, 1981. (Noeffect of local anesthetic temperature.)

Enflurane analgesia in obstetrics. Abboud TK, Shnider SM, WrightRG, et al. Anesth Analg 60: 133-137,1981. (0.5% in 0, effective andsafe for mother and baby.)

Butcirphanol in obstetrical anesthesia. Maduska AL. AnesthesiolRev 8: 14-17, 1981. (Review: similarities to equianalgesicmeperidine dose more apparent than differences.)

CESAREAN SECTIONGastric fluid pH in patients receiving sodium citrate. Viegas 0],Ravindran RS, Shumacker CA. Anesth Analg 60: 521-523, 1981.(Surgical patients. 0/15 had pH less than 2.5 vs 13/15 controls.)

Epidural anesthesia for cesarean section in diabetic parturients:maternal and neonatal acid-base status and bupivacaineconcentration. Datta S, Brown WU, Ostheimer GW, et al. AnesthAnalg 60: 574-578,1981. ('Maternal hypotension may be related toan increased incidence of neonatal acidosis and a prolonged half-life of bupivacaine. ")

Butorphanol and alphaprodine: a comparison for use in balancedanesthesia in Cesarean section. Abboud TK, Henriksen E.Anesthesiol Rev 8:22-25, 1981. (Not blinded. "The majority of theresults are equivalent for the two drugs. ")

SPINAL OPIATESSpinal action of narcotic analgesics. Kitahata LM, Collins JG.Anesthesiology 54: 153-163,1981. (Review of literature through1979.)

Studies in the primate on the analgetic effects associated withintrathecal actions opiates, alpha-adrenergic agonists andbaclofen. Yaksh TL, Reddy SVR. Anesthesiology 54: 451-467,1981.(These results clearly indicate that a powerful analgesia can be

SOAP Newsletter Page 3

produced by selectively activating adrenergic, opiate, andbaclofenergic receptor systems in the spinal cord. ")

The price of intraspinal narcotic analgesia: basic constraints(editorial). Bromage PRo Anesth Analg 60: 461-463, 1981.(Physicochemical properties of narcotic drugs account for effectsand side effects.)

Serum levels following epidural administration of morphine andcorrelation with relief of post-surgical pain. Weddel S], Ritter RR.Anesthesiology 54: 210-218, 1981. (Serum levels similar to thoseafter 1M; mean analgesia durations 38 (5 mg) and 52 (10 mg)hours.)

Epidural morphine following epidural local anesthesia: effect onventilatory and airway occlusion presure responses to CO,. DoblarDD, Muldoon SM, Abbrecht PH, et al. Anesthesiology 55: 423-428,1981. (Epidural morphine "produces decreased respiratory driveand ... there is a high degree of individual variability in themagnitude and time course of this effect. ")

Peridural meperidine in humans: analgetic responses,pharmacokinetics, and transmission into CSF.Glynn C], Mather LE,Cousins M], et al. Anesthesiology 55: 520-526,1981. (Analgesiarelated to concentration in CSF.)

Postoperative pain relief by epidural morphine. Rawal N, SjostrandU, Dahlstrom B. Anesth Analg 60: 726-731, 1981. ('Excellent"analgesia in 241/286 patients, but 5/13 post-Cesarean section hadno relief.)

Postoperative analgesia in major orthopaedic surgery: epiduraland intrathecal opiates. Barron DW, Strong lE. Anaesthesia 36: 937-941, 1981. (Good results: intrathecal better than epidural,diamorphine better than morphine.)

Postoperative analgesia using epidural methadone administrationby the lumbar route for thoracic pain relief. Welch DB,Hrynaszkiewcz A. Anaesthesia 36: 1051-1054, 1981. (Good effect,few side effects. No controls.)

Spinal narcotics and central nervous system depression. Sidi A,Davidson ]T, Behar M, et al. Anaesthesia 36: 1044-1047,1981. (Casereport and speculation as to mechanism.)

MATERNAL PHYSIOLOGYEpinephrine does not alter human intervillous blood flow duringepidural anesthesia. Albright GA, Jouppila R, Hollmen AI, et al.Anesthesiology 54: 131-135, 1981. (50 mcg epi in 10 ml 2-CP in 12women. MAP decreased significantly but not fBF.)

Parmacokinetics and plasma binding of thiopental. II: studies atCesarean section. Morgan D], Blackman GL, Paull jD, et al.Anesthesiology 54: 474-480, 1981. (Parturients' pharmacokineticparameters differed greatly from nonpregnant controls and onefrom another; plasma binding similar.)

Halothane requirement during pregnancy and lactation in rats.Stroud CD, Nahrwold ML. Anesthesiology 55: 322-323,1981. (MACdecreased 16-19% in pregnancy, returned to control duringlactation although serum progesterone increased.)

Serum potassium levels during and after terbutaline. Hurlbert B],Edelman JD, David K. Anesth Analg 60: 723-725, 1981.(Hypokalemia during infusion, spontaneous correction within 3hours after discontinuance.)

Epidural space pressures during pregnancy. Messih MNA.Anaesthesia 36: 775-782, 1981. (Mean pressure positive duringlabor. Variations did not reflect intrauterine pressure after effectiveanalgesia.)

FETUS AND NEWBORNToxicity and distribution of lidocaine in nonasphyxiated andasphyxiated baboon fetuses. Morishima HO, Covino BG.Anesthesiology 54: 182-186,1981. (Contraction-induced asphyxia(acidosis and hypoxemia) increased CNS and CVS toxicity, tissue-plasma ratios.)

(Continued on page 6)

SOAP Newsletter Page 4

SOAP '82

LOCATION: Grand Teton National Park, WyomingJackson lake lodge

DATES: June 2-6, 1982LAST-MINUTE PHONE NUMBERS:

Jackson lake lodge: (307) 543-2855Meeting registration, general information: Brett Gutsche,

(215) 662-3235Scientific program, abstracts: Tom Joyce, (713) 751-8127Frontier Airlines: 1-800-525-1092

Last Minute Details • • •ABSTRACTS: Too late to submit yours now. Tom Joyce received 84

abstracts for 48 openings, has expanded program to permitpresentation of 56 papers. May appear alopecic at meetingdue to protracted and repetitive hair-tearing.

RECREATION: Plentiful. Details in Brett Gutsche's letter ofMarch 1, and at registration at Jackson lake lodge. Fridayfree for recreation.

CLOTHING: Recommended. If current weather holds, emphasiswill be on styles which are both informal and warm, suitablefor snow. If weather breaks, mosquito-proof clothing maygain acceptability. Coats and ties are optional in diningroom.

SOAP Newsletter Page 5

GENERAL SCHEDULE

DR. JAMES

The second Fredrick W. Hehre, Jr., Memorial Lecture will bepresented at SOAP's 1982meeting by Dr. L.Stanley James,Professorof Pediatrics assigned to Anesthesiology and Professor ofObstetrics and Gynecology at the College of Physicians andSurgeons of Columbia University. Dr. James will discuss recentdevelopments in information about the hypoxic fetus.Though he received his medical training in his native New

Zealand and in Canada, Dr. James has spent most of hisdistinguished professional career at Columbia University, where hebegan as a research assistant with Virginia Apgar in 1955. Hislengthy bibliography is testimony to his continuing interest in fetalphysiology, infant resuscitation, and a variety of related topics.The Hehre Lecture was established by SOAP in 1980 after the

unexpected death of Frederick W. Hehre, Jr., one of SOAP'sfounders. The lectureship established in Dr. Hehre's memory isawarded by the Board of Directors to a person of distinguishedreputation in the field of obstetric anesthesia and perinatology whoexemplifies the qualities of compassion and dedication for whichDr. Hehre is remembered. Not necessarily an annual event, thelecture will be presented whenever the Board of Directors feels asuitably distinguished candidate is at hand. •

L. StanleyJames toDeliverHehreLecture

•

Recreational Free Time2-hour Scientific Session

Registration - Main LobbyComplimentary Continental BreakfastOpen PanelScientific SessionsLuncheon for RegistrantsBoard of Directors MeetingScientific Sessions,What's New in Neonatology

Registration, Main Lobby,Jackson Lake LodgeComplimentary Wine and CheeseReception

SOAP RunContinental Breakfast, Open PanelScientific SessionFrederick Hehre Memorial LectureWhat's New in Obstetric AnesthesiaLuncheonScientific SessionBusiness MeetingCookout BanquetSnowball fight, Mosquito wrestlingEntertainment

Continental BreakfastScientific SessionWhat's New in ObstetricsAdjournment

NOONAFTERNOON

EVENING

10:30 AM

AFTERNOON

MORNING

7-8:30 PM

THURSDAY, JUNE 38-5

7:30-8:30 AM8-8:30 AMMORNING

NOON

WEDNESDAY, JUNE 24-8 PM

FRIDAY, JUNE 4DAYTIME

LATEAFTERNOON

SATURDAY, JUNE 5EARLY

SUNDAY, JUNE 6MORNING

SOAP Newsletter Page 6

LITURATUREUPDATE(Continued from page 3)

Toxicity of lidocaine in adult, newborn, and fetal sheep. MorishimaHO, Pedersen H, Finster M, et al. Anesthesiology 55: 57-61,1981.('Fetal and newborn lambs are no more sensitive to lidocainetoxicity than are adult sheep. ")

The use of a selected ion monitoring technique to study thedisposition of bupivacaine in mother, fetus, and neonate followingepidural anesthesia for Cesarean section. Kuhnert PM, Kuhnert BR,Stitts lM, et al. Anesthesiology 55: 611-617,1981. (Low F/M ratioindicates binding to fetal tissue, not limited placental transfer.)

Atropine and glycopyrrolate: hemodynamic effects and placentaltransfer in the pregnant ewe. Murad SHN, Conklin KA, Tabsh KMA,et al. Anesth Analg 60: 710-714,1981. (Maternal tachycardia withboth, rapid placental transfer with atropine, fetal effects withneither.)

LOCAL ANESTHETIC TECHNIQUEMixtures of local anesthetics are no more toxic than the parentdrugs. De long RH, Bonin lD. Anesthesiology 54: 177-181,1981.(Bupivacaine, lidocaine, chloroprocaine given subcutaneously torats. "Local anesthetic toxicity is essentially additive. ")

Total spinal block after epidural injection into an interspaceadjacent to an inadvertent dural perforation. Hodgkinson R.Anesthesiology 55: 593-595, 1981. (3 cases; SAB or GArecommended for section following dural puncture.)

theSOAPbox

LETTERS FROM MEMBERSTo The Editor:In response to your President's Column "For the Love of It" in

the Fall-Winter 1981-82 SOAP Newsletter, I do not think we needprofessional management. It :s my belief that there are enough ofus amateurs left to continue to run SOAP. I could not edit theNewsletter, but could host the annual meeting. I know it is veryunlikely that SOAP would ever come to Little Rock, but Bob Halland I have talked about co-sponsoring SOAP in Salt Lake City. AsSOAP met in the West in 1981, and will in 1982,1983, and 1984, I'msure it will move east in 1985 (Pittsburgh? Chicago?). Perhaps Boband I could run it in 1986.

Richard B. Clark, M.D.Little Rock, Arkansas

To The Editor:We were rather disappointed in Dr. Millar's misleading summary

of our article "Neonatal effect of prolonged anesthetic inductionfor cesarean section" (Obstet Gynecol 58:331-335, 1981) in hisLiterature Update (SOAP Newsletter, Fall-Winter 1981-82).The gist of the article was the concept of the iII effects of

The components of an effective test dose prior to epidural block.Moore DC, Batra MS. Anesthesiology 55: 693-696, 1981. (15 megepinephrine detects IV; 3 mllocal anesthetic detects SAB.)

Neurologic deficits following epidural or spinal anesthesia. KaneRE.Anesth Analg 60: 150-161,1981. (Review of literature preparedin response to recent case reports involving Nesacaine@.)

Cytotoxicity of local anesthetics (letter). Govier WM. Anesth Analg60: 168-169,1981. (Literature does not indicate chloroprocaine ismore toxic than other local anesthetics.)

Effect of added epinephrine on spinal anesthesia with lidocaine.Chambers WA, Littlewood DC;, Logan MR. Anesth Analg 60: 417-420,1981. ('Little or no clinically useful prolongation.")

Obesity, gravity, and spread of epidural anesthesia. Hodgkinson R,Husain Fl. Anesth Analg 60: 421-424, 1981. (Sitting for 5 minutesfollowing injection reduced spread in obese parturients only.)

Bearing down at the time of delivery and the incidence of spinalheadache in parturients. Ravindran RS,Viegas 0], Tasch MD, et al.Anesth Analg 60: 524-526,1981. (No effect.)

Spread of epidural anesthesia and the lateral position. ApostolouGA, Zarmakoupis PK, Mastrokostopoulos GT. Anesth Analg 60:584-586, 1981. (Dependent side 2 dermotomes higher.)

Subarachnoid injection of autologous blood in dogs isunassociated with neurologic deficits. Ravindran RS, Tasch MD,Baldwin S], et al. Anesth Analg 60: 603-604,1981. (Vide supra.)

Influence of cerebrospinal fluid on epidural pressure. Shah lL.Anaesthesia 36: 627-631,1981. (Epidural pressure positive, close toCSF pressure.) •

prolonged uterine incision delivery interval (UI-D) on fetal well-being both in cases of spinal and general anesthesia.We have not stated that a "good spinal" would have no effect-

that was your statement. One observes severe fetal acidosis and lowApgar scores when the UI-D interval ismore than 180seconds evenwhen hypotension is prevented in spinal anesthesia cases.Your remark on "Boston-style GA" was likewise not appreciated;

if you would have perused the latest obstetric literature, you wouldhave been aware that 50% O2 and 50% N20 is the standard in ourhospital and others at the present time. Hyperventilation in ourgeneral anesthesia series had only a minor influence on neonataloutcome and occurred only in 20% of cases. Prolonged UI-Dinterval was a much more crucial factor.In the future, we ask that you really read an article thoroughly

before you write your editorial pearls, so as to do justice to theauthors.Sanjay Datta, MD.J. Stephen Naulty, MD.Boston, Massachusetts

Dr. Millar replies:I am delighted to see that the "Literature Update" is being read,

but disappointed that I have offended some of the authors of theworks cited, for such was never my intent.

The intent of my remarks about each paper is to summarize theconclusions of the paper as they relate to the title as succinctly aspossible, in a way which might stimulate the reader to actually lookup the article and read it critically and in detail. These requirementsare sometimes conflicting, and I confess that I cannot always dojustice to the author.

I would have found it easier to appreciate and communicate thatthe gist of the article was the concept of the ill effects of prolongeduterine incision delivery interval if the authors had communicatedthis idea somewhere prior to the final paragraph - for instance, inthe title. However, I will accept the responsibility for mymisreading, and I hope that readers will read into my remarks nomore than the spirit of good humor with which they are written .•

LOPPORTUNITIES IA~ a service /0 SOAP members, advertisements for available positions will be printed free

of charge JS space permib. Ads will be deleted after they have been published in four

consecutive issues (one year). A,/vertisers are requested to notify us as soon as positionsare filled. Address all correspondence about ads fa Cathie Miffson. University Hospital.

Department of Anesthesiology. H-770, 225 Dickin~(Jn Sr., San Diego. CA 92103.

NEW YORK Private practice group seeks anesthesiologist;combines OB anesthesia at University-affiliated birthing center(3700 deliveries/year) with anesthesia for ambulatory surgery athospital-operated Surgery Center (5,200 anesthetics/year). Join 4anesthesiologists and 5 CRNA's in this exciting practice. Located inthe heart of Central New York State between the Finger Lakes andthe Adirondacks. Send CV to Jack Egnatinsky, M.D., CNYAnesthesia Group, P.c., 736 Irving Avenue, Syracuse, New York,13210 (315) 470-7828. 1/82

MARYLAND Academic program seeks obstetric anesthesiologistqualified for teaching and investigation to participate in completerevamping of obstetric anesthesia service with new chairman ofOB/GYN. Contact Martin Helrich, M.D., Professor and Chairman,Department of Anesthesiology, Univ. of Maryland Hospital, 22South Greene St., Baltimore, MD 21201. 1/81

CALIFORNIA Private practice OB/GYN anesthesia group inCalifornia seeks additional member. Practice is primarily patientcare, with clinical research and university affiliation readilyavailable. Applicants with fellowship, prior experience, or specialinterest in OB anesthesia encouraged. Reply to SOAP NewsletterBox AA, Dept. of Anesthesia H-770, University Hospital, 225Dickson, San Diego, CA 92103. 1/81

OHIO Director for Division of Obstetric Anesthesia, Departmentof Anesthesiology, University of Cincinnati. Professor or AssociateProfessor depending on experience. Responsible for teaching andpatient care in high-risk obstetric unit, approximately 4500deliveries per year. Research encouraged, facilities available. Sendcurriculum vitae to Phillip O. Bridenbaugh, M.D., Chairman,Department of Anesthesia, University of Cincinnati MedicalCenter, 231 Bethesda Avenue, Room 3507 MSB, Cincinnati, Ohio45267. 9/81

PENNSYVANIA The Department of Anesthesia at PennsylvaniaHospital, a major affiliate of the University of Pennsylvania Schoolof Medicine, has an opening for an individual with primary interestin obstetric anesthesia. Full or part time faculty appointment will becommensurate with experience and qualifications. Minimumrequirements include completion of a 3 or 4 year post graduatetraining program, board certification or eligibility, PA statelicensure or eligibility, and training in obstetric anesthesia. This is avery active patient care and teaching service with 3500deliveries ayear. Research is encouraged. Send curriculum vitae and names of3 references to: Melville Q. Wyche, Jr. M.D., Dept. of Anesthesia,Hospital of Anesthesia, Hospital of The University of Pennsylvanie,3400 Spruce Street, Phila. PA 19104. Affirmative Action/EqualOpportunity Employer. 9/81

WASHINGTON Position available at the University of Washington,Department of Obstetrics and Gynecology, Division of PerinatalMedicine. Applicants must be board certified or board eligible inOB-GYN. Candidates should be either board eligible or boardcertified in Maternal-Fetal Medicine or be board certified inInternal Medicine. The University of Washington is an equalopportunity employer and welcomes applications from women orminority groups. Contact Thomas J. Benedetti, M.D., SearchCommittee Chairman, Dept. of OB-GYN, RH-20, University ofWashington School of Medicine, Seattle, WA 98195. 9/81

SOAP Newsletter Page 7

FELLOWSHIPS

WASHINGTON, D.C. Approved one-year specialty training athigh-risk obstetrical unit - 3000 deliveries per year. Ampleopportunity for clinical experience, teaching, clinical and animalresearch using the chronic maternal-fetal sheep preparation.Contact John B. Craft, Jr., M.D., Director, Obstetric Anesthesia,George Washington University Hospital, 901 23rd Street, N.W.,Wasington, D.C. 20037. (202) 676-3864. 8/80

TEXAS Opportunity for one-year specialty training in high riskobstetric unit with approximately 6500 deliveries per year. Activeclinical research program, aswell as chronic maternal-fetal sheepexperimentation. Faculty position. Reply to Robert Hodgkinson,M.D., Department of Anesthesiology, The University of TexasHealth Science Center at San Antonio, 7703 Floyd Curl Drive, SanAntonio, TX 78284. 8/80

CALIFORNIA One-year OB anesthesia fellowship with rotationthrough three Los Angeles hospitals for clinical experience orresearch opportunity as desired. Contact Kenneth A. Conklin,M.D., Ph.D., Director of Obstetric Anesthesia, UCLA Center forHealth Sciences, Los Angeles, CA 90024. (213)824-6225or (213)825-5021.8/80

CALIFORNIA Immedia\e openings for PGY4 residents in approvedObstetrical Anesthesia Residency at high risk Obstetrical Unit.Ample opportunity for clinical experiences and human research.Contact Therese Abboud, M.D., Associate Professor of Anesthesia,LAC-USC Medical Center, 1200 North State Street, PO Box 12, LosAngeles, CA 90033. (213) 226-3293. 11/80

CALIFORNIA 1-year O.B. anesthesia fellowship for the 1983-84academic year. Clinical experience is in Level 1 Perinatal Centerwith in excess of 4,000 deliveries per year. Opportunity to take partin clinical research program and teaching of medical students.Contact G. M. Bassell, M.D., Director of Obstetric Anesthesia,University of California, Irvine Medical Center. 81A, Orange,California, 92668. 5/82 •

MeetingsWe've HeardAboutMay 20-21, 1982. 10th Annual Perinatal Medicine Conference.Callaway Gardens, Pine Mountain,Georgia. '"A Decade of PerinatalMedicine, Past and Future.'" Speakers Louis Gluck, lohn C.Morrison. For information contact Micki L. SoumaM.D. or A. J.Krautin M.D., Division of Perinatology. The Medical Center. P.O.Box 951, Columbus Georgia 31994 2299.

June 2-6, 1982. SOAP Fourteenth Annual Meeting in Jackson Hole.Wyoming. For registration information contact Brett Gutsche,M.D., Department of Anesthesia, 3400 Spruce Street, Philadelphia,Pennsylvania 19104. For questions about the scientific programcontact Thomas H. Joyce. III, M.D., Department of Anesthesiology,Jefferson Davis Hospital, 1801 Allen Parkway, Houston. Texas 77019.

May 25-28, 1983. SOAP Fifteenth Annual Meeting at the BayshoreInn, Vancouver, British Columbia. Host Graham McMorland.

Spring 1984. SOAP Sixteenth annual Meeting in San Antonio. Texas.Host Bob Hodgkinson.

•

Mail to: Michael H. Plumer, M.D.Editor, SOAP NewsletterDept. of Anesthesia, H-770225 Dickinson St.San Diego, California 92103

Please enter my subscription to the SOAP Newsletter

SOAP Newsletter Page 8

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The SOAP Newsletter IS published quarterly in SanOtego. California. by the Society for Obstetric Anes-thesia and Perinatology. Unless otherwise indicated,opinions expressed are those of the Editor and do no!necessarily represent the consensus of the SocietyAddress correspondence to the Editor at UnIversityHospital. Department of Anesthesiology. H.770. 225Dickinson St.. San Diego. CA 92103. (714) 294-5913or 294-5720EDITOR: Michael H. Plumer. M DEDITORIAL ASSISTANT Cathie MillsonPRODUCTION ProfessIonal Printing Services

SOAP 1981-82BOARD QF DIRECTORS

PresidentSecretary/EditorMichael H. Plumer, M.D.San Diego, California

TreasurerThcmas H. Joyce, M.D.Houston, Texas

Vice PresidentGraham McMorlandVancouver, B.C., Canada

oIrector-at-LargeJohn B. Craft, Jr., M.D.Washington, D.C.

ObstetricsThomas Benedetti, M.D.Seattle, Washington

NeonatologyLawrence Grylack, M.D.Washington, D.C.

Chalnnan. ASA CommiUeeon Obstetrll:al AnesthesiaCharles P. Gibbs, M.D.Gainesville, Florida

SOAP IEWSLETlERUniversity HospitalDepartment of Anesthesiology, H-770225 Dickinson St.San Diego, CA 92103

ADDRESS CORRECTION REQUESTEDRETURN POSTAGE GUARANTEED

ALEX F. F'UE MD3652 CARLETONSAN DIEGO,CA,92106,A/77-81/1983

SOCIETY FOR OBSTETRI~ANESTHESlA .

PERINATO LOGNEWSLETTERVOL 14

VOLUME 14, NUMBER 1SUMMER 1982

-------~SOC!ElY FQ?E<S>ff~;r~R'<;

P~ARs=L~G~IIEWSLETTER*,PRESIDENT'SCOWMN , *

AFTERTHOUGHTS

By Thomas H. Joyce, III, M.D.

My first and happiest task asPresident of SOAP is to convey to allthe members the multiple freely given compliments from manymembers of the Jackson lake lodge staff, who said that of the manymeetings held there, none had friendlier, more understanding (ofcancellations, cranges, etc.), more polite and professionalmembers.Next I should convey to my co-host Brett Gutsche the general

congratulations of the membership. who answered that the bestfeature of this year's meeting was its location and the localarrangements, for which Brett was responsible.Some members have questioned how abstracts were selected for

presentation at this SOAP meeting. The following I hope shall aidthe members' understanding of how abstracts came to be selected:

1. Abstract deadline: 17 AprilMost abstracts arrived 24-26 April

2. Blinded abstracts are sent to 4-6 senior members of SOAP forgrading along American Society of Anesthesiologists' guidelines:80 - should be presented77 - probably should be presented73 - probably should not be presented70 - definitely should not be presented

3. Abstract grades are collected and averaged. Of this year's 84abstracts received, 56 abstracts were presented. All papersreceived an average grade greater than 74. Pediatric andobstetrical papers were graded by at least one neonatologistand one perinatologist.

Future authors are encouraged to follow the following guidelinesto aid those pre;:-aring the annual meeting program.

1. Send an original abstract that is ready for printing. Beware thatsome word processors provide gray, not black, copy.

2. In addition to the original abstract provide the requestednumber of copies blinded as to institution and author(s).

3. Provide a self-addressed stamped envelope to expeditereceiving your notice of acceptance or rejection.

4. Early mailing of abstracts is imperative in this time of slow mailservice - e.g., one abstract with a postmark of April17 arrivedMay 10,4 days after the program went to press. •

WASHINGTON. DC.. CFLEBRA TESwith nighttime fireworks display uponhearing John Cralt will be ho" of 1985 SOAP meeting there.

ObstetricAnesthesiologistsHave a Place in

Community Hospitalsby William C Wright, M.D.

Birth and babies are virtually unparalleled asa means of gettingattention. The media take full advantage of this knowledge in boththeir programming and their commercials. Sometimes they inform,frequently they misinform or confuse, but always they get attention.The impact on the childbearing community is remarkable.Products are bought in excess or for the wrong reasons.Information is absorbed as gospel, though it may be incorrect,incomplete, or irrelevant. The media continue to "milk" thesituation for all that it is worth, significantly affecting theenvironment in which obstetrics is practiced.Equally important in affecting the obstetrical environment.

particularly in community hospitals, has been the ascendency ofthe prepared childbirth instructor as an authority fi~ure. As

Continued Oil page 2

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SOAP Newsletter Page 2

====editorialLOOSE ENDS

by Michael H. Plumer, M.D.

The Newsletter is moving to Seattle after this issue. So is theEditor. After an enjoyable year in private practice helping establishan obstetric a.nesthesia service run by anesthetic generalists in acommunity hospital, I'll return with renewed enthusiasm toteaching obstetric anesthesia.As I prepare to leave SanDiego, I'm particularly aware of the debt

which SOAP and lowe to Larry Saidman and The Department ofAnesthesia at UCSD. Without Dr. Saidman's whole-hearted andgenerous support, I couldn't have managed either the Newsletteror the San Diego Meeting, nor could I have continued to functionasSecretary/Editor during my year in private practice. He may thinkthat obstetric anesthesiologists are peculiar people sometimes, butLarry Saidman is a consistent and vigorous backer of obstetricanesthesia.Leaving SanDiego also means that SOAPwill lose Cathie Millson,

who short-sightedly has chosen to stay with her husband ratherthan follow the Newsletter. For the past four years, Cathie has beenSOAP's one-person executive office, handling the finances of theNewsletter and of the San Diego Meeting, keeping themembership and subscription records, doing much of theorganizing for the San Diego Meeting, serving as the resourceperson whenever anyone needed to contact SOAP, and becomingan irreplaceable friend and colleague to the Editor and his family.We will miss her, and SOAP members will notice her absence.

* *

As I look over the Newsletters of the past year, it occurs to me thatI may have drawn too limited a picture of the roles available tothose with special interest in obstetric anesthesia. I've talked aboutobstetric anesthesiologists in academic medicine, and about thosefew who find a full-time OB anesthesia spot in private practice. But Ireally haven't mentioned another important role - which,ironically, is the role I've played for the past year.Even in hospitals where anesthetic generalists provide the OB

anesthesia, there's a need for one or more individuals with specialinterest or expertise in OB anesthesia to be responsible fororganizing and maintaining the OB anesthesia service. Somebodyneeds to go to committee meetings, pay attention to equipment,organize teaching schedules, and serve as the focal point forcomplaints and suggestions. There's a role in every hospital forpeople with special interest in obstetric anesthesia, even if thosepeople perform no more than their share of OB coverage in ageneral practice.It's impossible to have too many people or too much interest in

obstetric anesthesia, I guess - there will always be a communityrole for those with special interest in obstetric anesthesia. Byextension, more people than only future full-time obstetricanesthesiologists would benefit from additional OB anesthesiaexperience and education.

A Place in the CommunityContinued from page 1

teachers of psychoprophylaxis, childbirth instructors have a role ofunquestionable value, providing patients with an important toolfor handling the discomforts of labor and delivery. Asdisseminators of information about the childbirth process, they arelikewise valuable when their instruction is limited to the areas andlevels of their own personal knowledge. Unfortunately, theseboundaries are too often exceeded. They are exceeded becausethe patient's thirst for knowledge frequently exceeds theinstructor's capability to provide correct answers. This leads to thespread of both misleading and incorrect information, which isoften not appropriately challenged. Many of the questions should

rightfully have been answered by the patients' physicians, butpatients say that their obstetricians are often too rushed to answerquestions. The void thus created is filled by those lesscapable butmore willing. .Whether the ascendency of the childbirth instructor occurred

concurrent to the "women's movement", or as a result of it, isunimportant. The two have become intertwined. As a result, themale-dominated obstetrical profession is regarded as overlyrestrictive, insensitive, and generally suspect.The truth is that there is some validity in that view. Women

increasingly specify the conditions under which they wish to havetheir babies, and their demands generally reflect their level ofknowledge, a level which may be quite variable. When one doctordoes not submit to their wishes, they go to another who will. Theobstetrician who ultimately responds to the patient's demands maynot be responding because he is, in fact, more sensitive or moreknowledgeable, but simply because he is more greedy. I know ofnothing that gets a doctor's attention more quickly than the flow ofdollars out of his pocket. If economically stimulated, theobstetrician who today forbids his patient to have the family poodlepresent for her delivery, may tomorrow require only that the dogbe on a leash.You might wonder what all this has to do with obstetric

anesthesia in the community hospital. One must first understandthat the environment in which the obsteric anesthesiologist worksis different from that of the general surgical anesthesiologist. It isanemotional environment. It is an environment in which what onedoes is sometimes secondary to how it isdone. It isan environmentwhich permits significant non-medical participation. It is anenvironment that can easily get out of control.

STABILIZING INFLUENCEIn order to maintain the control necessary to achieve that still-

desired outcome of a healthy mother and baby, a stabilizinginfluence is necessary. In my opinion, the anesthesiologist is bestqualified to assume this position. Since every innovation ordeviation in obstetrical practice eventually has an impact on theanesthesiologist, it is better that the anesthesiologist be involved atthe inception rather than the culmination. To assume the role ofthe obstetric anesthesiologist as I see it, and have practiced it forover ten years, one must not only be knowledgeable and skillful inanesthesia, but one must be an administrator, educator,sociologist, and psychologist with additional talent in publicrelations.Although most parturients enter the hospital labelled "normal

and healthy", they are strikingly different from non-pregnantpatients similarly labelled. They are susceptible to the samemaladies as the non-pregnant population, but they can have inaddition, an assortment of illnesses unique to pregnancy.Pregnancy also creates certain hazards for the expectant motherwhich are foreign to the non-pregnant population. Finally, theunborn baby who inhabits the parturient's body can not only beaffected by most of what affects the mother, but also can havetotally independent reactions.This is a brief description of the patients with whom both the

obstetrician and obstetric anesthesiologist must work. Theobstetrician has nine months to prepare for his patient, who arrivesin a delivery suite designed, equipped, and administered torespond to all of the obstetrician's needs. However, the patientgenerally arrives asa stranger and a surprise to the anesthesiologist.This need not and should not be the case. As an essential andrespected member of the obstetrical team, the anesthesiologistshould have a seat on every policy-making committee in thedepartment. As there are policies which assure that the obstetricalpatient is well cared for during labor and delivery, so should besimilar policies which provide for every patient to be prepared for asafely administered anesthetic and for supplies and equipment tobe immediately available to achieve this goal. In my experience,constant reinforcement by always being present when decisionsare being made is the only way that anesthesia is not forgotten.Since obstetricians frequently know well in advance of deliveryabout patients who might be complicated or "high-risk", theyshould be conditioned to alert the anesthesiologist as early aspossible to allow the anesthesiologist to be prepared. This can onlyhappen if anesthesia is an integral part of the obstetrician's caseplanning, not an afterthought.

Continued on page 11

WHATSNEWINPERINATO LOGYIN 1982by Thomas]. Benedetti, M.D.

(Ed. Note: This year all three "What's New ... " talks will be printedin the Newsletter. Dr. Conklin's and Dr. Grylack's talks will appearin subsequent issues.)

The recent year was marked by manynew and exciting advances in perinatalmedicine. This past year saw a numberof publications relating to in utero fetaltreatment and surgery, which areprobably the opening salvos of adramatic and exciting new field inperinatal medicine.Birnholtz and Frigoletto described a

case of early-onset fetal hydrocephalus DR. BENEDETIIin which repeated encephalocentesesto decompress the fetal head were done with the aid of real-timeultrasound. The infant, delivered at 34 weeks, unfortunately hadabsence of the corpus callosum. The infant also had Becker'smuscular dystrophy, a family history of which had beenoverlooked. Despite the poor outcome in this infant, the technicalfeasibility of encephalocentesis in the neonate was demonstrated.More recently, investigators at the University of Colorado havesuccessfully placed in utero one-way shunt valves in these infants.The second area of in utero fetal treatment and surgery involved

fetuses with urinary tract malformations. Harrison and co-workersat the University of California, San Francisco, were able to identifywhich infants with urinary tract malformations could be salvagedby in utero treatment. Patients with good kidney function, asevidenced by normal amniotic fluid volume and demonstration ofbladder filling with maternal furosemide administration, in generalhave good outcome. Patients with oligohydramnios ordeteriorating fetal renal function were demonstrated to benefitfrom intervention, which could include early delivery or in uterodecompression. The same group reported a case of fetalexteriorization and correction of hydronephrosis with bilateralcutaneous ureterostomies. The fetus was then replaced in utero,the uterus and abdomen were closed, and with vigorous maternaltreatment the pregnancy was prolonged 10 additional weeks.When delivered at 35 weeks, however, the fetus showed Potter'stype 4 cystic dysplasia and irreversible renal damage due to severeobstruction. This casemarked the first time ahuman fetus had beenexteriorized and then replaced in the mother's uterus, in which thepregnancy was then prolonged significantly with both maternaland fetal survival. This work would appear to open the door forfurther in utero fetal surgery if the ethical and moral considerationscan be adequately addressed.

FETALHYDROPS

Kleinman and co-workers reported use of fetalechocardiography in evaluation of fetuses with non-immunehydrops. They found that they could identify the etiology of all 13cases they investigated. Ten of the fetuses had cardiovascularabnormalities which resulted in heart failure; three had non-cardiac causes of hydrops. In nearly all of the cases a lesion orcondition which increased right atrial pressure led to right sidedheart failure in the fetus. Of most interest was one patient withheart failure secondary to supraventricular tachycardia. Thoughthe heart rate was in the normal fetal range of 140-160 beats perminute, an atrial rate which was twice as fast would not have beenappreciated had it not been for the M mode echocardiogram. Thismode of investigation would appear to offer an exciting new toolfor the identification and possible treatment of fetal hydrops, acondition which has previously been frustrating for the

SOAP Newsletter Page 3

obstetrician and pediatrician.Van Dorsten and co-workers performed a randomized control

trial of external cephalic version with tocolysis in late pregnancy. Ina low risk group of patients, version was successful inapproximately 70% of attempts. Nearly all of these patients beganlabor with a vertex presentation. In the control group, only 18%converted spontaneously to vertex presentation. Transient fetalheart rate abnormalities were noted during version attempt in 1/3of all patients. Fetal heart rate abnormalities were present duringattempted version in 2/3 of ? unsuccessful attempts. Only one caseof fetal maternal hemmorhage occurred in the 51 attemptedexternal versions. They concluded that version could be successfulin 70% of low risk patients, but their article carefully defines whichpatients should be excluded from attempted versions.Manning and co-workers used real-time B-scanning in nearly

1200 high-risk patients to evaluate fetal breathing movements,gross fetal body movements, fetal tone, qualitative amniotic fluidvolume, and the non-stress test. They were able to develop abiophysical score which resembled an in utero Apgar score. Theprospective use ot this test in high risk pregnancies resulted in avery low perinatal mortality rate, and allowed identification of 13ofthe 19 possible identifiable congenital anomalies. This test wouldappear to have an advantage when the oxytocin challenge test orthe non-stress test is abnormal and a further evaluation of fetalwell-being is desired.

DIABETES

Jovanovic and co-workers reported a series of 52 consecutiveinsulin dependent diabetics who were managed according to astrict protocol, which included thrice daily insulin administrationand strict glucose control. They kept the fasting blood sugarbetween 55 and 65 mg%, the mean blood glucose in the 80-90mg%range, and the one-hour post-prandial glucose below 140 mg%.Glucose was monitored before and after each meal. Their datashowed a dramatic reduction in the hemoglobin A lC level, adramatic reduction in the mean amplitude of glycemic excursion,and a dramatic fall in the mean blood glucose. The meangestational age at delivery was 39weeks, and there were virtually noneonatal complications and no perinatal mortality. In addition,there were no instances of pregnancy-induced hypertension in thepatients.O'Brien and co-workers demonstrated that accurate fetal

gestational age in the second trimester can be determined by fetalfemur length measurements. This should provide another meansby which to date pregnancies correctly, a valuable supplement toother fetal growth measurements.The first report of the collaborative group on antenatal steroid

therapy was published in 1981. This double-blind collaborativerandomized trial was ini.tiated in 1976 to evaluate maternaldexamethasone administration asamethod of preventing neonatalrespiratory distress syndrome. Five centers enrolled nearly 700patients at risk for premature delivery. The study showed areduction in respiratory distress syndrome in steroid-treatedsubjects, from 18%to 12.6%. However, the differences were mainlydue to effects in singleton female infants. There was no treatmenteffect in male infants. There also was no apparent treatment effectin caucasian patients. It was disappointing to note that, despitereduction in incidence of respiratory distress syndrome, there wasno effect on neonatal mortality. Therapy did not reduce theincidence of respiratory distress syndrome in patients withpreeclampsia. In fact, those patients had a higher incidence ofrespiratory distress syndrome than the non-preeclamptic patients.

PREVIOUS SECTION

Benedetti and others reported a prospective trial of vaginaldelivery after previous cesarean section for non-recurrent cause. Ina trial of 89 patients with previous cesarean sections for breech,fetal distress, preeclampsia, and placenta previa, 82%accomplishedvaginal delivery. Oxytocin was used in 20% of patients withoutadverse maternal or fetal effects. Examination of the scar in allpatients showed incomplete scar dehiscence in 4 percent.However, there were no uterine ruptures and no maternal or fetaladverse effects.

Continued on page 12

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SOAP Newsleher Page 4

theSOAPbox

LETTERS FROM MEMBERSDB Coverage

in the General HospitalTo The Editor:

Having read "Making OB Anesthesia Available", (SOAPNewsletter 13(4), Spring 1982) I would like to describe our coverageof obstetric anesthesia. I feel our group can show just what can bedone to provide obstetric anesthesia.

First, a description of the hospital in our community and of o.urgroup. The only hospital in the area is a 450 bed commu~ltyhospital. Approximately 1500 deliveries occur each year, for whichabout 90% receive anesthesia. We are the only group ofanesthesiologists. There are nine doctors and four nurses in thisgroup. Only six doctors work on any given day; two are always onvacation, and one is off from previous night duty. The nurses workonly in the OR, from 7:00 A.M. until 3:00 P.M., where seven roomsof anesthesia are provided. One physician during the day coverslabor and Delivery, sees In-and-Out patients,. consults, andprovides lunch relief. He also provides. ba~k-up coverag~ to thefirst-call physician, should he be occupied In the OR at night.Approximately 90% of our OB anesthesia isepidural. We start the

epidural, with subsequent top-up doses given by the OB nurses.Only those nurses who have taken our course and passed an examare allowed to top up an epidural. Someone is always available forany problem which might occur. The anesthesiologist is alsopresent for the delivery, unless the obstetrician is in a hurry.So far this is not extraordinary. What I feel is unique follows.In an effort to inform our patients of our service, to rid us of the

label of hospital-based physicians, and to improve collections, wehave for the past year rented a small office where we see prenatalpatients. The patients are given instructions by their obstetricians tosee us prior to their delivery. When they arrive, our secretary hasthem fill out a history and physical form, a financial responsibilitystatement, and an anesthesia consent form. They then watch a 10minute film that describes the choices of pain relief during laborand delivery. The patients are encouraged to make arrangementsto discuss any question they might have with an anesthesiologist.One physican goes to the office Monday through Thursday from3:00 until 5:00 for the pre-anesthetic evaluation with the patients.Ten to twelve patients are seen each day.There is no obligation to the patients. Those who intend natural

childbirth are encouraged to do so. However, many will needanesthesia at some time during consultation. There is a flat fee forvaginal deliveries. Those patients without insurance areencouraged to pre-pay. Those who do pre-pay receive a 15%discount, with the money held in escrow ?hould they not needanesthesia. If they do not receive an anesthetic, the money isrefunded.The information the patient provides, together with the

physician's notes and consent form, are photocopied and theoriginal is filed in the labor and Delivery department of thehospital. Since all pertinent information has been obtained and alldiscussions completed in the office, all the anesthesiologist has todo is say hello and pop in the epidural.

Even though this requires additional time and expense, we feelthis should benefit our group. It allows the patient to be educatedabout anesthesia. They see us as physicians in the traditionaldoctor-patient setting. It provides good public relations, clears anymisunderstandings, and allows us to contact the patient's physici4n

in advance should any difficulties be anticipated.Recently, we began seeing patients scheduled for In-and-Out

surgery. The recent 20120 TV program on anesthesia mishaps hasgenerated a lot of interest about anesthesia. Our office providesthe perfect setting to discuss their concerns.Good OB care can be provided without much effort. We make a

comfortable salary without excessive patient charges and still getten weeks vacation each year.Our ultimate goal is to have a place where we can see all elective

cases, house our computer-billing operation, do nerve blocks andultimately, out-patient anesthesia.Those who would like a sample of the forms and literature given

to the patients can write me at P.O. 3295, Winchester, VA 22601.

John J, Marino, M.D.Winchester, Virginia

... and in the Specialty HospitalTo the Editor:

I was reading your editorial in the SOAP Newsletter (Volume 13,Number 4) on anesthesia coverage in the community and I wantedto share our experience here atWoman's Hospital with the readers.

Baton Rouge is a city of approximately 250,000 inhabitants.Before 1968 there were two community hospitals which catered toall the OB's in town. However, the obstetricians thought that theywere not being treated fairly and they committed themselves toopening a hospital just for obstetricians. It was in 1968 that"Woman's Hospital" was born, funded largely by the obstetriciansand the general public.Now this 135-bed hospital is the only OB/GYN hospital in the

city, and it averages 7,300 deliveries and 6,000 GYN procedures peryear. We have a corporation of six M.D.'s who, alone with twelveCRNA's, provide 24-hour/day 365 day/year in-house anesthesiacoverage. It was the commitment of these obstetricians and theconsolidation of their resources which started an all-OB/GYNhospital.I wish this could be done in other cities where there are two,

three, four, or even five different hospitals catering to deliveries.In lafayette, louisiana, fifty miles from Baton Rouge, there is a newwoman's hospital in the offing to provide obstetricians with anexclusive place to work. labor and delivery need the same kind ofcoverage as surgery, and this is one way to do it.

Deepak MehrotraBaton Rouge, Louisiana

Johnson ~ Johnson isBullish about AnesthesiaEver wonder why patients assimilate so much confused and

inaccurate information about pain relief in childbirth? It's probablybecause so much is available.Johnson and Johnson has begun to distribute a slick magazine

entitled Pre-Parent Advisor, billed as "the first in a series of threecontrolled-circulation magazines to be published annuallyaddressing the concerns of expectant and new parents."The first issue includes four interviews with patients who tell

"What Is labor Really Like" (patients who had experiencedDemerol/local, pudendal, Demerol/saddle, or Seconal/local forrepair), as well as a sidebar feature telling "The Facts of labor."From these "facts" patients learn that an epidural block is "aninjection into the space between the spinal cord and the dura (theouter membrane surrounding the spinal cord)." They also learnthat a spinal block is "a single injection into the spinal canal thatnumbs feeling from the waist to the knees; usually administeredwithin one hour of birth; requires mother to remain prone foreight hours after delivery to avoid a severe headache" and that asaddle block, in contrast, is "a 'little spinal' used just before birth."Well, the publishers do admit in the fine print that information in

the magazine "is not a substitute for personal medical, psychiatric,or psychological advice .. ." Nor for accurate facts, it would appear.•

SOAP Newsletter Page 5

OLD BUSINESS

As a first item of business, the Board of Directors considerednominations for the Hehre Lectureship in 1983. Furthernominations can be considered as they al'l€ received from themembership, and a decision will be made this summer aboutwhether and to whom to offer the lectureship.Last year the Board of Directors considered the issue of whether

SOAP should be professionally managed by a permanent executivesecretary. A decision on that question had been deferred until thisyear, as we gathered additional information. This year, Boardmembers felt that they and other SOAP members have apparentlybeen satisfied to date with our system of amateur management andvolunteer meeting hosts established fourteen years ago. The Boardof Directors are aware that the supply of amateur managers,editors, and volunteer hosts may be exhausted at some point, butfelt that was not yet a problem. The Board decided not to give thisissue further consideration until problems with the current systembecome more apparent.

NEW BUSINESS

Dr. Plumer presented a Newsletter financial report as follows:

VIRGINIA SLOAN alld KA THY MILLSON discw.' wh"rher allkl" chains wi/lbf' r('/('a~(>din time for evening meal.

INCOMEBalance from previous yearSubscriptionActive members 1981Sale mailing list x 2

Total

$4256.002066.002515.00200.009037.00

EXPENSEUCSD ReimbursementPublishingComputerBulk Postage

Total

$822.002712.00156.00140.003830.00

MINUTES

EX-TREASURER'SREPORT

Continued

BRETT GlJTSCHE k""(,, alH/iDvisual eXI'"m", down ill maralhDn 4.,/ay_~tint a~ projPcfioni'it.

Dr. Plumer reported that the Newsletter account showed asurplus of $5207, to which will be added a $2000 reserve from the1981 meeting and the membership dues from the 1982 meeting.This additional "padding" may be important as the Newslettermoves from San Diego to Seattle and establishes itself there.Seeking wider distribution of news about SOAP and its activities,

the Board of Directors approved mailing copies of the Newsletterto all chiefs of anesthesiology residency programs, all chiefs ofmaternal-fetal medicine programs, and all chiefs of neonatologyprograms. The Board also gave its tacit approval to the practice ofentering individual names on the mailing list at the request ofindividual SOAP members.Dr. Plumer announced that he will be joining the Department of

Anesthesiology at the University of Washington this summer andannounced his willingness to continue as Newsletter editor. Itappears that the Newsletter will move to Seattle this summer.

$3794.00700.00

10316.006637.00885.002515.0024847.00

Printing, etc.HonorariaEntertainmentHotelUCSD ReimbursementNewsletter

Total

MINUTES

$23045.008375.00605.002148.0034173.00

Minutes of theBoard of Di rectors Meeti ng

Dr. Plumer reported that the 1981meeting generated asurplus of$9326, of which $2000 was reserved for a Newsletter emergencyfund and $7326 was forwarded to Brett Gutsche for 1982 meetingexpenses.

INCOMERegistration & BanquetContributionsMiscellaneousFrom 1980 SOAP

Total

Dr. Plumer in his role as ex-treasurer presented the followingaccounting of expenses from the 1981 SOAP meeting:

EXPENSE

Minutes of the previous meeting had been published in theSummer 1981 Newsletter, and were accepted as printed.

The Board of Directors met at a luncheon meeting on Thursday,June 3, 1982.

SOAP Newsletter Page 6

MEMBERSHIP

The Board dealt again with the issue of nonmembers who vote atSOAP business meetings, and decided at least to remind membersof the constitutional provisions which state that membership islimited to physicians or scientists (as defined by the Board ofDirectors) and that only active members are permitted to vote atbusiness meetings.

LEO CARMEN HAKaLA - "anise trapper, mountaineer, and indigenousnative" - describes life-style at SOAP Banquet, aided by wife, child inbuckskin (and Pampers).

Minutes of theAnnual Business Meeting

The SocietY's annual business meeting was held on Saturdayafternoon, June 5, 1982, with Dr. Michael Plumer presiding.

MINUTES

Minutes of the previous meeting were approved asprinted in theSummer 1981 Newsletter.

BOARD OF DIRECTORS' REPORT

Dr. Plumer read the report of the Board of Directors' meeting,which was accepted without comment.

EXCITEMENT BUILDS during a float trip on the Snake River as each bendreveals more scenic beauty.

OLD BUSINESS

The assembled memership expressed its joint appreciation toDrs. Gutsche and Joyce for the conduct of the 1982 meeting.Graham McMoriand, host of the 1983 meeting, announced that

he is eagerly soliciting all suggestions which pertain to conduct ofthe Vancouver meeting, He emphasized that he will review allevaluation sheets from the 1982 meeting, but would appreciateadditional suggestions as well. Suggestions can be sent directly to

Dr. Graham McMorlandDepartment of AnaesthesiaGrace Hospital4490 Oak SI.Vancouver, B.C. V6H 3V5

NEW BUSINESS

Richard Clark was selected as director-at-Iarge to replace JohnCraft, whose term had expired.Nominations for the 1985 meeting site were as follows:

Washington, D.C. - John CraftPittsbu rgh - Ezzat Abou leishSalt lake City - Richard Clark/Bob HallMadison, Wisconsin - Jay DeVore

Members voted overwhelmingly in favor of holding the 1985meeting in Washington, D.C., with John Craft as host.At the close of the meeting, the presidency passed to Tom Joyce,

who presented Dr. Plumer a plaque to commemorate his just-completed year as president. •

URSUS HORRIBIUS DEVORIS as seen at SOAP banquee

INDIAN MEETS MOUNTAINEER as Raji Asrani introduces Hakala child tomarvels of flashlight.

SOAP RUNNERS shiver as Barry Corke describes the courses.

SOAP Newsletter Page 7

. and stampede' past Alex Pue's ever-present camera at the starring whistle.

SOAP's FASTEST(Runners)Four-Mile Run WOMEN (younger)

WOMENMary BaysingerCarol Sepkoski

Valerie Wassill Virginia Williams

MEN (under 40) WOMEN (young)John Finley 29:22 Dolly AlbrightJim Southwick 30:00 Helen FriedmanRichard Rottman 31:40

MEN (under 40)MEN (over 40) Fred SpielmanJim Farina 31:00 Stuart GutscheBarry Corke 31:46 Theodore CheekKen Fairhurst 33:17

MEN (over 40)Short Two-Mile Run Jack Scanlon

Turhan DoguWOMEN (youngest) Sol Shnider

Ann Joyce 17:10

17:2617:3618:14

21:2021 :50

13 4514201445

1627164717 00 OVER-FORTY WINNER Jim Farina is helped gently to the speaker's stand to

receive 4-mile trophy from Jude Morrison.

Review of a FewAbstracts from the 1982 Meeting

LOCAL ANESTHETICS

by Walter L. Mil/ar, M.D.

SOAP members presented and discussed fifty-six "works-in-progress", more or less, during the four meeting days in JacksonHole. A sampling of these studies is presented here. Failure tomention a paper may indicate only that the reviewer wassomnolent or inattentive rather than that any paper lacked merit.Mention in the Newsletter does not imply that any form of peerreview has occurred.

lidocaine is again becoming a f-o"'usehold word in obstetricsuites, and several groups of investigators presented worksinvolving this once familiar drug.

The neurobehavioral effects of lidocaine were investigated bytwo groups. Abboud, Sarkis, Blikian, and Varakian (LAC-USCMedical Center, Los Angeles) assessed22 infants at 2 and 24 hoursof age by the Early Neonatal Neurobehavorial Scale after theirmothers received 423 + 40 mg epidural lidocaine for labor andvaginal delivery. No significant differences from an unmedicatedcontrol group were noted.

Continued

SOAP Newsletter Page 8

Kileff, James, Dewan, Floyd and DiFazio(Bowman Gray and University of Virginia)compared ENNS scores, acid-base data,and drug levels in infants born of motherswho had received either lidocaine orbupivacaine for cesarean section. Thelidocaine dose was 586+ 105mg. Only onesignificant difference appeared - ahigher score in sucking response at 24hours in the lidocaine group.

The relationship of labor pain to theendorphin system was further exploredby Abboud, Shnider, et al. (LAC-USC andUCSF), who injected 0.5 and 1.0 mg mor-phine sulfate in hyperbaric solutionintrathecally inl aboring patients. Intrath-ecal morphine provided good labor anal-gesia, no obvious fetal effects, but a highincidence of maternal side effects.

DR. KILEFFASPIRATION PNEUMONITIS

DR. SHNIDER

TOM JOYCE sits calmly astride his mount at the start of a horseback ride.Moments later the horse will start with a jerk, causing him to dismountrapidly,

FETUSAND NEWBORN

Grylack, Chu, and Scanlon (Columbia DR. ABOULIESHHospital for Women and GeorgetownUniversity) investigated the effect of alter-ations in maternal intravenous fluid onperinatal glucose and sodium homeosta- r.tis. Maternal IV infusion of 1000 cc D5Wover 60 or 150 minutes compared to 1000cc Ringer's lactate produced maternaland fetal hyponatremia, hyperglycemia,and hyperinsulinemia and a greater inci-dence of neonatal hypoglycemia.

Plumer and Millar (Grossmont DistrictHospital and UCSD) surveyed U.S. anes- DR. GRYLACKthesiology training programs to assessthestatus of OB anesthesia teaching.Although the vast majority of current resi-dents in training are exposed to an OBanesthesia rotation, deficiencies seriousenough to limit the value of these rota-tions were detected in about half. •

EDUCATION

Uram, Abouleish, McKenzie, Phitya-korn,Tantisiara, and Uy (University ofPittsburgh) attempted to determine theoptimum delivery/surgery interval tominimize the risk of aspiration duringpostpartum tubal ligation. Having mea-sured gastric volume and pH after induc-tion of general anesthesia in 40 patients,the authors concluded that there was norelationship of risk to delivery/surgeryinterval, duration of labor, weight, orpostpartum food ingestion.

DR. FINLEY

DR. SURESH

DR. KUHNERT

DR. DONCHIN.

The effect of aminophylline on uterineblood flow in sheep was presented byDonchin and Caton (University of Florida-,Gainesville). Maintenance infusion of 1mg/kg/hr produced no change in hemo-dynamics or blood flow, although theloading infusion produced a small butdetectable decrease in uterine bloodflow.

LABOR ANALGESIA

MATERNAL PHYSIOLOGY

Finley, Harper, Hameroff, Corke, andSchearer (University of Arizona) likewisedemonstrated a decrease in serum beta-endorphin post-epidural, but found thatlevels rose again i,n the second stage oflabor.

Suresh, Nelson, Steinsland, and Nelson(UTMB, Galveston) demonstrated thatVerapamil inhibited the vasoconstrictorresponse of norepinephrine in humanuterine arteries in vitro, and obliteratedthe vasoconstrictor response to potas-sium. The authors speculate that calciumchannel blockers might be therapeuti-cally useful in preeclampsia.

The effect of epidural analgesia onplasma levels of endorphins was investi-gated by two groups. Abboud, Sarkis,Goebelsmann, Hung, and Henriksen(LAC-USC) assayed beta-endorphin inserum of laboring patients before andafter epidural analgesia, laboring patientsbefore and after epidural saline, and non-pregnant volunteers. Serum beta-endorphine was significantly higher inlaboring patients than in non-pregnantcontrols before as well as after analgesia.However; levels decreased by 50% afterlocal anesthesia, with no change notedafter epidural saline.

Kuhnert, Kuhnert, Phillipson, andRosen (Cleveland Metropolitan GeneralHospital/Case Western Reserve) investi-gated lidocaine elimination in infants ofmothers who had received lidocaineepidural analgesia. Lidocaine was clearedsomewhat more slowly in pre-term thanterm infants, although MEGX clearancewas similar; conversion of lidocaine toMEGX was slower in the pre-term babies.Renal excretion was similar in term andpre-term infants.

ABC's 20/20 Tacklesthe Perils of Anesthesia(Ed. Note: Older readers may remember how ABC News broughtclarity and understanding to the cesarean section controversy withits 20/20 segment in 1978 by suggesting that fetal monitoring wasdangerous and unnecessary, that cesarean sections were oftenperformed for reasons of convenience or greed, and thatanesthetics used with childbirth caused children to lose IQ points.

On April 22, 1982, ABC News undertook to discuss the perils ofanesthesia - as many of you now know from the questions yourpatients are asking. The entire text of that segment is reproducedwith permission, though it loses something without the heart-rending pictures.)

Dr. WALT WARD: If you're going to go into anesthesia, you aregoing on a long trip, and you should not do it if you can avoid it inany way.ANNOUNCER: General anesthesia - safe most of the time, butthere are dangers - from human error, carelessness and a criticalshortage of anesthesiologists. This year, 6,000 patients will die orsuffer brain damage. Tom Jarriel looks at the risks you may takewhen you go into "The Deep Sleep."HUGH DOWNS: Up front tonight, the danger you least expect.Every year, 17 million of us have surgery of some kind. Now, mostpatients go into surgery worrying about the surgical procedure andthe ailment, but they give little thought to what most doctors.andnurses will tell you they fear most during surgery - theadministering of general anesthesia. And here with a report on thedangers of this deep sleep is Tom Jarriel. Tom?TOM JARRiEl: Hugh, the medical statistics are imprecise, but it isgenerally accepted that accidents experienced by patients undergeneral anesthesia kill or critically injure up to 6,000 people a year.And many, many more experience serious side effects which gototally unreported, such asparalysis, cardiac arrest, or liver damage.let us stress, most patients are going to come through all right; butwe had no trouble at all finding case after case of the tragicconsequences of anethesia accidents.Mrs. SAllY McGETRICK: He laughingly said, "I really don't like tohave anesthesia, because I'm always afraid I might not wake up."That came back to me so hauntingly. Yet I don't think he really wasconsidering the risks - it was just the idea of being undersomebody else's control and not your own.JARRIEL (voice-over): But John McGetrick did go under generalanesthesia for a routine ear operation. His premonition tragicallybecame reality.Mrs. McGETRICK: To see a very vital, exuberant man struck downfor something so simple, I have not been able to come to grips withyet.JARRIEL (voice-over): At age eight, Patrick O'Rourke was stillwetting the bed. His surgery was a 15-minute procedure, but doneunder general anesthesia. This is Patrick today at age 12; his mind isthat of an infant.Mrs. ELAINE O'ROURKE: The surgeon kept telling us that withGod's help, he'll be all right. That isn't what happened. That's whatthey told us - he'll be all right.JARRiEl (voice-over): A construction accident left David Hodgewith a sliver of metal in his eye. The operation to remove itsucceeded, but the patient died.Mrs. BRENDA. HODGE: He did not know he was allergic toanesthesia. He had never been given any.JARRIEL (voice-over): The people you have just seen were tragicvictims of a danger they never knew existed - mistakes inadministering anesthesia. (on camera) When you enter surgery,you put your life in the hands of two people: the surgeon and theperson who administers the gas,the anesthesiologist, who puts youinto a deep sleep, keeps you there throughout the operation, andthen must bring you back.Dr. WALT WARD, physician-attorney: Don't do it if you can avoid it.You're not playing around with something that innocuous. Ifyou're going to go into anesthesia, you are going on a long trip, andyou should not do it if you can avoid it in any way.

SOAP Newsletter Page 9

Dr. Ell BROWN, anesthesiologist: There is no such thing asaminoranesthetic.JARRiEl: (voice-over): Dr. Eli Brown, chairman of anesthesiology atSinai Hospital in Detroit, showed us how general anesthesia isdonein a routine gall bladder operation.Dr. BROWN: (to patient): Take a deep breath-JARRiEl (voice-over): Sodium Penthothal is injected, to inducesleep.Dr. BROWN (to patient): This may make you feel a little bit sleepy,it's going to make you feel good, okay?JARRiEl (voice-over): Most patients think Sodium Pentothal is all ittakes; in fact, it's only the begnning. A muscle relaxant is injected,which paralyzes the entire body system.Dr. BROWN: The patient has now stopped breathing -JARRiEl (voice-over): A breathing tube to the lurigs is immediatelyconnected through a mask to a mixutre of gases- oxygen, to keepthe patient alive, and nitrous oxide, to keep the patient asleep. Thepatient's life is now entirely in the hands of the anesthesiologist.Dr. BROWN: We literally have to breathe for the patient during thatentire period.JARRIEL(voice-over): The patient's breathing is now turned over toa mechanical ventilator. It is up to this machine to act asthe patient'slungs. There is little margin for error; with genefal anesthesia, ittake less than five minutes before a mistake can result in death orirreversible brain damage. When the anesthesia is administeredproperly -Dr. BROWN (to patient): Can you open your eyes, sweetheart?JARRIEL (voice-over): - the outcome is predictable.Dr. BROWN (to patient): Open your eyes, sweetheart, everything'sfine.Dr. WARD: This is a very, very serious business they're about.They're, as we said, putting people down near death, and thenbringing them back. And that's the problem sometimes, is bringingthem back.JARRiEl (voice-over): This year alone, asmany as6,000 people willdie or join the living dead because of accidents in anesthesia -accidents many doctors say are preventable. 20120's investigationof operating room accidents has found three significant problemsthat make anesthesia unnecessarily dangerous.Problem #1: Human error - it is the job of the anesthesiologist to

catch even the smallest change in the patient's vital signs. In a longoperation, that can mean hours of nonstop monitoring. Theprimary cause of anesthesia accidents - human error - amomentof inner tension, a careless mistake.Dr. WARD: From my own experience, I would say that probably 80to 90 percent of these terrible incidents could have been avoidedwith proper attention.JARRiEl (voice-over): It's up to these machines to act asasafety netfor the anesthesiologist, by sounding alarms. If the patient's oxygenis cut off for any reason - (alarm bell sounds), machines can makethe critical difference.D. SUSAN DORSCHE, anesthesiologist: Depending on what the .problem is-JARRiEl (voice-over): Dr. Susan Dorsch showed us how a simplewarning device called an oxygen analyzer can prevent ananesthesia accident.Dr. DORSCH: If we have a situation where no oxygen is going tothe patient, this will alarm you, this will alert you, by this veryirritating noise, that something is wrong and corrective actionneeds to be taken immediately.JARRiEl (voice-over): The problem: These safety devices are notmandatory. Although an oxygen analyzer costs less than $700, oneout of four hosptials does not have this backup safety device. (oncamera) Martha Jefferson Hosoital didn't have one when JohnMcGetrick checked himself in for a routine operation. That wasnearly two years ago, and he hasn't gone home since.Mrs. McGETRICK: I drove him to the doctor's office that morning,and that still stands out in my mind. I dropped him off, and he was ingood spirits and looking forward to having the surgery and gettingup, because he was coming home the next day. Well, he didn'tcome home.JARRIEL (voice-over): Sally McGetrick discovered why when shegot a call from the surgeon. There had been an accident.Mrs. McGETRICK: He said he was having a little trouble wakingJohn up. And I said, "You're frightening me." And there was noreply, and I said, "I'll be right down." And I got down to thehospital, and the surgeon came in and he told me right away what

Continued

SOAP Newsletter Page 10

had happened: The oxygen had been turned off instead of thenitrous oxide.JARRiEl: How is it possible to accidentally turn off the oxygen?Dr. DORSCH: If an anesthesiologist, say, at the end of a case,wishing to waken his patient up, lighten the anesthetic, would turnoff the nitrous oxide and be giving the patient pure oxygen.However, should he be distracted, perhaps thinking about the nextcase, writing on his chart, talking to someone, could equally wellturn off the oxygen - in which case pure nitrous oxide would begoing to the patient, and the patient would be receiving no oxygen.This would be a very common, and very serious problem.JARRiEl (voice-over): When it happened to John McGetrick, therewas no alarm to alert the anesthesiologist that she had turned offthe oxygen. By the time anyone noticed, it was too late. Home forJohn is now a rehabilitation center in Phoenix, Arizona, 2,000 milesfrom his six children. John McGetrick is somewhere in a twilightzone, too damaged to ever recover, yet very much alive. (to Mrs.McGetrick) Since this case, now you've learned more about it, howdo you feel knowing that just for a couple of hundred dollars inequipment this may have been prevented?Mrs. McGETRICK: That's right. It appalls me and sickens me, and ithurts.JARRiEl (voice-over): Problem #2: A manpower shortage. In themedical field, almost every speciality has a surplus of doctorsexcept anesthesia. Because it is not considered a glamor speciality,anesthesia attracts only 4 out of 100 doctors. It is not enough tomeet the growing demands of surgery - not in places like Mobile,Alabama. Doctors here say the shortage has made it simplyimpossible for every patient to have an anesthesiologist present inthe operating room. (on camera) The solution: Highly trainednurses make up the manpower difference. But nurses are notdoctors, and in times of crisis that difference has had tragic results.

(voice-over) A series of deaths in the late '70s raised questonsabout Mobile's solution to the manpower shortage. It wassupposed to work like this: Doctors supervised nurses, who in turnadministered the anesthesia. If the nurse got into trouble, thedoctor was to be immediately available. But when David Hodgehad complications under anesthesia, the supervising doctor wasassigned to another hospital. (to Robert Cunningham) In the caseof David Hodge, where was the doctor when the nurse got intotrouble?ROBERT CUNNINGHAM, attorney: The public record on that casewill reveal that Mr. Hodge was being operated on at the Spring HillMemorial Hospital in one part of town. When the nurse developeda problem that she couldn't handle, she had to call the supervisinganesthesiologist, who was at the /VIobile Infirmary in another partof the city. He had to then leave a patient in that hospital, get in hiscar, and drive across town to the Spring Hill Memorial Hospital. Bythe time he arrived, it was too late - Mr. Hodge had suffered braindamage.JARRiEl (voice-over): For nine months, David Hodge remained in acoma.Mrs. HODGE: His heart stopped, I think it was three times, and theybrought him back. And then finally wejust took all the machines offof him, and just - we took them off that morning, and he died thatnight.JARRiEl: In the cases brought to your attention, how many of thepatients knew that it would be a nurse, not a doctor, who would beadministering anesthesia?Mr. CUNNINGHAM: Not one of them knew it. Everyone of themassumed, as most people do, that a doctor would be handling thatpart of the procedure.JARRiEl (voice-over): But 30 percent of the hospitals in this countrydon't have a physician anesthesiologist on staff. The anesthesia, likein Mobile, is administered by a registered nurse with two years ofspecial training. With proper supervision, doctors say, nurses areperfectly capable of doing the job, but even nurses can't make upthe manpower difference. A nurse anesthetist, who asked us toconceal her identity, told 20/20 how patients are sometimes leftalone under anesthesia.ANONYMOUS NURSE: There is a hospital in New York City, wherethere are two anesthesia people covering five operating rooms.JARRIEL: Run that by me again. You have five patients, all in theoperating room, all under whose care?NURSE: Under two people's care.JARRIEL: And how do they do that?NURSE: Well, they run quickly and pray a lot.

JARRiEl (voice-over): The manpower shortage in the field ofanesthesiology is expected to be around until 1990.Problem #3: an uninformed public: Most people know very little

about anesthesia - what questions to ask, what equipment isavailable, could a safer local anesthesia be injected.Dr. LOUIS BLANCATO, president, American Society ofAnesthesiologists: Our feeling in this particular thing is. there maybe minor surgical procedures. but there is no anesthesia that isminor. Anesthesia is always major. One of the things we're trying toget across is: The patient should know who their anesthesiologist is,what he can do, and be able to discuss things with him.JARRiEl (voice-over): But Patrick O'Rourke's parents didn't meettheir son's anesthesiologist until after the accident occurred. Thesehome movies show the healthy youngster at age eight. at Christmastime - playing, growing, his entire life ahead of him. He needed aminor operation to correct a bedwetting problem - a procedurewhich could have been done with a simple injection in the doctor'soffice. His parents were told it would be better to have the surgerydone in the hospital, under general anesthesia. Just before surgerywas the last time the O'Rourkes saw their son healthy.Mrs. O'ROURKE: We kissed him good-bye, told him not to beafraid, everything would be fine, not to worry, you'll get presentsafterwards, and he was all excited over that.DONALD O'ROURKE: He was very nervous, but he didn't want tolet it on. He was joking, fooling around. That's the way Patrick was.THERAPIST: (at therapy session): Can you open your big blue

eyes?JARRiEl (voice-over): There was an anesthesia accident which leftPatrick in a dull coma. The anxious parents to this day don't knowhow the anesthesiologist failed to notice when their son's heartstopped beating.Mrs. O'ROURKE: They told us nothing at all, and they neverprepared us. When I went in, Patrick was there, and he was on atable, and he was blue, and he had all these tubes and he was on aresuscitator, and it was terrible, I mean, it was really terrible.JARRiEl (voice-over): Like most people, the O'Rourkes were notaware of what should have taken place after they checked their soninto the hospital. (to O'Rourkes) Did they say before the operation;did they explain to you about anesthesia risk?Mrs. O'ROURKE: No.JARRiEl: Procedures, the need to meet the anesthesiologist?Mrs. O'ROURKE: No.JARRiEl: The need for the anesthesiologist to see and understandyour son and his condition?Mrs. O'ROURKE: No.JARRiEl: You knew nothing about the danger?Mrs. O'ROURKE: No.JARRiEl (voice-over): Today, four years later, his eyes hardlyrespond to the brilliant lights. His hearing barely reacts to the loudbuzzer noises on his therapy board.JARRIEL (voice-over): The shock of Patrick's condition has cuasedhis sister Christy to undergo a different kind of therapy.CHRISTY O'ROURKE (to Patrick): Don't get scared.

Mrs. O'ROURKE: Sometimes she's very sad, she cries herself tosleep at night. She goes weekly to a psychiatrist. He was alwaysthere defending her; now she has to defend him.THERAPIST: You see that, Pat?

JARRiEl (voice-over): And anesthesia must take impacts bothemotionally and financially. It costs $85,000 a year for Patrick's care.It takes around the clock nurses, and the help of 100 volunteers tokeep Patrick from curling into a tight ball with muscle contractions.THERAPIST: Very good, Pat.

Mrs. O'ROURKE: When these doctors made that mistake with ourson, it was like taking a gun and killing him, because they just aboutdid kill him. In fact, they did kill him and they brought him back tolife, and they gave him back to us without any feeling oranything.Mr. O'ROURKE: If perhaps my son was hit by a car out in the street,it would be a tragic situation. But to put your son in the hands ofpeople who you trust, and have something like this happen, it's-it's not the same.HUGH DOWNS: What a tragedy. Tom, what could any of us do toreduce this kind of risk?JARRiEl: Several very basic points: First of all, try to avoidunnecessary surgery. Try to avoid general anesthesia - a far lessdangerous local, where the patient stays awake, is usually anoption. Personally meet your anesthesiologist well before theoperation, and ask a lot of questions. Even that will reduce the risk.•

A Place in the CommunityCantinued fram page 2Mast haspitals have case review canferences where difficult

cases, "high-risk"cases, and C-sectians are discussed ~t r~gularintervals. Active participatian in these canferences IS, In myapinian, imperative for the abstetric anesthesialagist. This servestwa functians. First, the anesthesialagist gains a better understand-ing af abstetrical prablems and haw they are managed. Secand, theabstetrician learns to. utilize the anesthesialagist as a medicalcansultant and partner in achieving the gaad autcame which heand his patient desire. Since the anethesialagist is legallyrespansible far the effects af anesthetic manipulatians an matherand fetus, the anesthesialagist needs a clear understanding afmaternal-fetal physialagy, as well as a reasanable facility atinterpreting fetal manitar traci~gs. It i.s nat ~nusual. farabstetricians to. cansult me when interpreting manltar tracings,since they knaw that I see mare af them than they do.. A mutualrespect develaps from an understanding af each ather's prablems.This relatianship becames very valuable when dealing with thehaspital as well as patients. The haspital administratar who. isreluctant to. purchase a certain piece af equipment ar provide acertain canvenience requested by the abstetric anesthesialagist,may became mare amenable when the abstetrician agrees that theitem is essential far patient care.Mast haspitals lacate abstetrical patients separately fram

medical and surgical patients, partly because they are classified as"narmal" and "healthy". Accardingly, palicies and pravisians farpatient care, equipment maintenance, and supplies may be morerelaxed. The results for the abstetric patient may be care which fallsbe law standards set elsewhere in the hospital. As a canstantpresence in the labar and delivery suite, the abstetricanesthesialagist tends to. be the mast reliable observer af qualitycantral, ane who. can assume the respansibility far initiatingchange and maintaining quality cantrol.

PATIENT EDUCATOR

Patient education, in my experience, isane af the major activitiesin which the abstetrical anesthesialagist shauld be involved. I havementianed previausly that misinformatian abaunds in thecammunity. In respanse to. this, my assaciatesand I have addressedprenatal graups at aur haspital twice a manth for the last ten yearsan the tapic af abstetric anesthesia. We discuss the reasans for thepain af labar and delivery, and the techniques which are availablefar handling the discamfart. Included in the presentation are slideswhich demanstrate the techniques that we use. After thepresentation, we have a questian and answer periad, at which timewe allaw the cauples to exhaust their questians. We even waitaround after the pragram far peaple who. might wish to ask aquestion privately. Often they will inquire abautthings which theyhave seen an television ar read in a magazine. Sametimes they askabaut informatian which they have been taught by their preparedchildbirth instructars. Whatever the question, we try to. answer ithanestly and objectively.Patients are enarmausly respansive and appreciative af this

effart. When evaluating aur haspital after delivery, the prenatalanesthesia lectures are among the mast highly praised services.From the anesthesialagist's stand paint, these patients aredecidedly mare relaxed and caaperative than are the patients who.have nat attended the prenatalleclUres. In fact, the lectures havebecome so popular that patients planning to. deliver at otherhospitals frequently come to. aur haspital to. attend the lectures.Finally, since there may be no appartunity to. effectively discussanesthesia with patients when they enter in labar, the prenatalanesthesia lecture is a goad faith effart at informed consent.I previausly mentianed that the parturient is susceptible to all of

the physical maladies af the non-pregnant papulatian while beingprone to. same which are unique to pregnancy. This is also.true ofematianal prablems. Patients enter the haspital with differentcapabilities for handling labar, delivery, ar an awake c-sectian.Sametimes the abstetric anesthesialagist must literally "tame thesavage beast". This is a unique situatian which requires a uniquekind af patience and compassion. Such a situatian should not behandled by an anesthesialagist who. must give periadic coverage toabstetric anesthesialagy even thaugh he is indifferent to. it, or mayeven dislike it. This wauld be an injustice to. the patient and theanesthesialagist, and bath will likely have a miserable experience.

SOAP Newsletter Page 11

Obstetric anesthesia is best practiced by an anesthesiolagist who.has a particular fandness for it. I have gane to. same length to.shawthat it is different fram general surgical anesthesia. It daesn'trequire better anesthesialagists, but it daes need anesthesiolagistswith a different kind af cammitment and adifferent attitude. I haveseldam had camplaints abaut the fact that we make lessmaney fartime invalved when I have warked with anesthesialagists who. likeabstetric anesthesia. On the ather hand, it has been a frequentcomplaint when I have had generalists working with me. In fact, thegeneralists Quite aften felt taken advantage af and wished to. giveless service. Trading call, or getting autsiders to. caver their OB call,became a camman accurance and it warked to. the detriment afabstetric anesthesia. Patient and physician camplaints increasedand the wark laad decreased. Obstetricians stated that they wauldrather their patients do. withaut anesthesia than be expased to. ananesthesialagist whase unhappiness abaut praviding servicesshowed in the way patients were handled.

TEAM MEMBER

Establishing and participating in educational programs takestime, but it elevates the quality af care provided by all who areinvalved. The ultimate beneficiary is the patient, but theenvironment in which the rales af all the participants are fullyunderstaod is a more appreciative enviranment. This appreciatianusually leads to. greater respect, greater utilizatian, and ultimatelybetter callectians far the anesthesialagist. The time necessary to. bea full participating member af the perinatal team is usually difficultfor the generalist, who. may be busy in the aperating raam duringthe haurs when caferences and administrative meetings take place.On the ather hand, schedules for specialty graups can be

arranged so. as to include free time which can allaw suchparticipatian. Since patients deliver thraughaut the twenty-faurhaurs af the day, at aur haspital we take twa 24-haur ratations perweek and have every fourth week free. This concentrates workingtime while maximizing free time. All members of the group haveample time to participate in departmental activities and patienteducation, and plenty of time to recuperate from the call schedule.I cannot deny that certain skills which the generalist uses

frequently may get far lessfrequent use by the specialist in obstetricanesthesia. This is a definite sacrifice but I feel that the benefits areworth it. As I have already said, abstetricians must be taught tonotify anesthesiolagists early af patients who might have problems.This allows the anesthesiologist to make necessary preparations,obtain needed consultations, or arrange for apprapriate assistance.If a patient is admitted unexpectedly and requires a technique withwhich the abstetric anesthesiologist is not fully familiar, a secondanesthesiologist who. is more familiar with the technique should becalled to assist. I have many times seen surgeons call far autsideassistance while in the middle of surgery. There is nothing wrongwith the anesthesiolgist doing likewise.From a practical standpoint, every hospital that is delivering

babies does not have a patient valume sufficient to accomodate aspecialty graup in obstetric anesthesia. In my opinion, hospitals incommunities with valumes of fewer than 200 deliveries per monthprobably shouldn't be delivering babies, since they can neithersuppart an obstetric anesthesia group, nor can they support otherservices which are cansistent with today's standar~ of perinatalcare. The patient who delivers at such a hospital should not,however, be deprived of anesthesia services. As in most other areasof medicine, when a specialty service cannot be provided, thegeneralist should provide the service.

REGIONAL CENTERS

Much progress has been made over the past ten years, both inobstetrics and obstetric anesthesia. Regionalizatian, even amongcommunity hospitals, has been the trend. The regional perinatalcenter provides all of the services which the expectant mother andthe unborn baby might need. Having been involved in thedevelopment of such a center, and having been consulted onseveral others, I believe that the first step is the establishment offull-time, in-house obstetric anesthesia. Patient volume generallyfollows the availability of anesthesia.Obstetricians like the convenience of anesthesia, and patients

are reassured by the option of pain relief, if they need it. Initially.the anesthesia can be provided on a rotational basis by the existinggeneral surgical anesthesiologists, but assoon as the obstetric casevolume is sufficient to support an obstetric anesthesia group,

Continued

SOAP NewsleUer Page 12

perhaps supplemented by short GYN or outpatient procedures,such a group should be formed.The criteria for choosing obstetric anesthesiologists should be no

less stringent than those for general surgical anesthesiologists. Theyshould be residency trained anesthesiologists capable of anestheticmanagement according to current standards of practice.Additionally, they should have qualities which respond to theunique needs of the obstetric patient. They should have more thanan occasional interest in obstetric anesthesia-they should likeobstetric anesthesia. Other areas of medicine may be practicedwithout having a particular fondness for them, but one cannot givethe type of commitment and service that obstetric anesthesia needsif one does not like it.I have described the role of the obstetric anesthesiologist as I see

it and have experienced it. I feel that it requires not only ananesthetic specialist, but a special person. We are dealing with ourmost prized resource-our future generations. The job is'preserving this resource at its highest potential. It is a privilege toparticipate in one of the few true milestones of a lifetime, and affecthow it is remembered.

(Ed. Note: Dr. Wright is a staff anesthesiologist at Cedars-SinaiMedical Center in Los Angeles. He presented this address in theforum on controversial topics at (he meeting of the CaliforniaSociety of Anesthesiologists, June 13, 1982. I asked his permission toprint it because I felt it added fin important dimension to the rathernarrow views presented in the President's Column over the pastyear.) •What'sNew ...Continued from page 3

Lavin and co-workers reviewed all the published studies ofvaginal delivery after prior cesarean section, concluding that trial oflabor after cesarean section for a non-recurrent cause hasapproximately 75-80% chance of accomplishing vaginal delivery.Patients whose previous cesarean section was performed forcephalopelvic disproportion or failure to progress had only a 30-35% chance of accomplishing successful vaginal delivery. In theirreview of more than 3,000 vaginal deliveries, there were noinstances of maternal mortality associated with either uterinerupture or scar dehiscence. Perinatal mortality due to uterinerupture or scar dehiscence is approximately 1 in 1000,which is nodifferent from the expected intrapartum death rate in any patientduring labor. The issue of the type of anesthesia to use duringattempted vaginal trial is still unresolved. However, the one studyin the literature which addresses this issue shows that if cesareansections are done for the clinical symptoms of uterine rupture(lower abdominal pain during labor), 95% of such operations willbe done needlessly. It seems, therefore, that epidural analgesia forvaginal trial is appropriate.Lloyd and co-workers reported on the incidence of fetal-

maternal hemorrhage in a series of 1,200 consecutively monitoredRh-negative women delivered of Rh-positive infants. They foundfetal erythrocytes in the mother's blood in 15% immediatelypostpartum. In 1% of patients at least 15 ml of circulating fetalerythorcytes were found, which would exceed the neutralizingabilities of the standard dose of RHOgam. On the basisof this study,it probably will become standard practice to perform Kleiheur-Betke monitoring of all Rh-negative women postpartum to insurethat an adequate dose of RHOgam is given.Sibai and co-workers studied intravenous magnesium sulfate

showing that the standard 4 gram loading dose and 1 gram per hourdid not achieve a magnesium sulfate level of at least 5 mg% in themajority of patients. Even 2 grams per hour did not uniformly resultin a level greater than 5 mg%. In addition, they presented a list of 13patients who suffered an eclamptic seizure despite magnesiumsulfate therapy. The majority of these patients were treated with 1gram per hour of magnesium sulfate, and had magnesium levelsbelow 5 mg%.

MATERNAL MORTALITY

Rubin and co-w?rkers examined the issue of maternal mortalityafter cesarean section In Georgia. They found that, with the use ofvital records alone, approximately 30-40% of the maternalmortalities were unreported. They matched the live birthcertificates with the death certificates in Georgia, and found 45%more maternal mortalities than were reported in vital records. In-depth .analysis of t~ese cases showed that maternal mortality inGeorgia was approximately 19 per 100,000 live born deliveries. Themortality rate for vaginal delivery was 10 per 100,000; that ofcesarean section was 105 per 100,000. Approximately half of thesecesarean section maternal mortalities were attributed to theoperation per se, and the other half were attributable to severematernal disease present before the operation.We have recently uncovered similar data in the state of

Washington, showing a significant under-reporting of maternalmortality by the use of vital records alone. If the states ofWashington and Georgia are characteristic of the other states in theunion, perhaps the maternal mortality has not been falling rapidlyasmany of us have th~ught, but may actually be stable or perhapseven rISing. These statistics from this paper are quite disturbing inlight of the recent rapid rise of cesarean section in the UnitedStates. If one assumes that maternal mortality attributable tocesarean section is 1 in 2000 to 1 in 5000, then every 5% increase inthe. cesarean section rate results in approximately 50 to 75additional maternal mortalities in the United States every year.

REFERENCES

Fetal Therapy and Diagnosis

1. Barclay WR. et al: The ethics of in utero surgery. JAMA 246: 1550,1981.

2. Birnholz Jc. et al: The antenatal treatment of hydrocephalus. NEJM 303:1021,1981.

3. Harrison MR, et al: Management of the fetus with a urinary tractmalformation. lAMA 246:635, 1981.

4. Harrison MR. et al: Fetal surgery for congenital hydronephrosis. NEIM306: 591, 1982.

5. Kleinman CS, et al: Fetal echocadiography for evaluation of in uterocongestive heart failure. NEIM 306: 569,1982.

6. Van Dorsten, et al: Randomized control trial of external cephalicversion with tocolysis in late pregnancy. Am I Obstet Gynecol141: 417,1981.

7. Manning FA,et al: Fetal biophysical profile scoring: A prospective studyin 1,184 high risk patients. Am J Obstet Gynecol140: 289,1981.

8. Jovanovic L, et al: Effect of euglycemia on the outcome of pregnancy inInsulin-dependent diabetic women a compared with normal controlsubjects. Am J Med 71: 921,1981.

9. O'Brien GD, et al: Assessment of gestational age in second trimester byreal time ultrasound measurement of femur length. Am J ObstetGynecol 139: 540, 1981.

10. Collaborative Group on Antenatal Steroid Therapy: Effect of antenataldexamethasone administration on the prevention of respiratory distresssyndrome. Am J Obstet Gynecol 141: 276,1981.

Maternal Therapy

1. Sibai BM, et al: Reassessment of intravenous MgSO; therapy inpreeclampsia-eclampsia. Obstet Gynecol 57: 199, 1981.

2. Lloyd LK, et al: Intrapartum fetomaternal bleeding in Rh-negativewomen. Obstet Gynecol 56: 285,1980.

3. Benedetti Tj, et al: Vaginal delivery after previous cesarean section for anon-recurrent cause. Am J Obstet Gynecol142: 358,1982.

4. Lavin]p, et al: Vaginal delivery in patients with a prior cesarean section.Obstet Gynecol 59: 135, 1982.

5. Rubin G: Maternal death after cesarean section in Georgia. Am J ObstetGynecol 139: 681, 1981. •

LOPPORTUN ITIESlAs a service to SOAP members. advertisements (or available positions will be printed free

of charge as space permits. Ads wifl be deleted after ,hey have been published;n four

consecutive issues (one year). Advertisers are recluestecl to notify us as :won as positionsare filled. Address all correspondence about ads to Cathie MiJhon. University Hospital.

Department of Anesthesiology, H-770, 225 Dickinson SI" San Diego, CA 92103.

NEW YORK Private practice group seeks anesthesiologist;combines OB anesthesia at University-affiliated birthing center(3700 deliveries/year) with anesthesia for ambulatory surgery athospital-operated Surgery Center (5,200 anesthetics/year). Join 4anesthesiologists and 5 CRNA's in this exciting practice. located inthe heart of Central New York State between the Finger lakes andthe Adirondacks. Send CV to Jack Egnatinsky, M.D., CNYAnesthesia Group, P.e., 736 Irving Avenue, Syracuse, New York,13210 (315) 470-7828. 1/82

MARYLAND Academic program seeks obstetric anesthesiologistqualified for teaching and investigation to participate in completerevamping of obstetric anesthesia service with new chairman ofOB/GYN. Contact Martin Helrich, M.D., Professor and Chairman,Department of Anesthesiology, Univ. of Maryland Hospital, 22South Greene St., Baltimore, MD 21201. 1/81

OHIO Director for Division of Obstetric Anesthesia, Departmentof Anesthesiology, University of Cincinnati. Professor or AssociateProfessor depending on experience. Responsible for teaching andpatient care in high-risk obstetric unit, approximately 4500deliveries per year. Research encouraged, facilities available. Sendcurriculum vitae to Phillip O. Bridenbaugh, M.D., Chairman,Department of Anesthesia, University of Cincinnati MedicalCenter, 231 Bethesda Avenue, Room 3507 MSB, Cincinnati, Ohio45267. 9/81

PENNSYVANIA The Department of Anesthesia at PennsylvaniaHospital, a major affiliate of the University of Pennsylvania Schoolof Medicine, has an opening for an individual with primary interestin obstetric anesthesia. Full or part time faculty appointment will becommensurate with experience and qualifications. Minimumrequirements include completion of a 3 or 4 year post graduatetraining program, board certification or eligibility, PA statelicensure or eligibility, and training in obstetric anesthesia. This is avery active patient care and teaching service with 3500deliveries ayear, Research is encouraged. Send curriculum vitae and names of3 references to: Melville Q. Wyche, Jr. M.D., Dept. of Anesthesia,Hospital of Anesthesia, Hospital of The University of Pennsylvanie,3400 Spruce Street, Phila. PA 19104. Affirmative Action/EqualOpportunity Employer. 9/81

WASHINGTON Position available at the University of Washington,Department of Obstetrics and Gynecology, Division of PerinatalMedicine. Applicants must be board certified or board eligible inOB-GYN. Candidates should be either board eligible or boardcertified in Maternal-Fetal Medicine or be board certified inInternal Medicine. The University of Washington is an equalopportunity employer and welcomes applications from women orminority groups. Contact Thomas J. Benedetti, M.D., SearchCommittee Chairman, Dept. of OB-GYN, RH-20, University ofWashington School of Medicine, Seattle, WA 98195. 9/81

TENNESSEEMedical Center with 600 Adult and 100 pediatric beds,has need for BEor BC Pediatric Anesthesiologist. Excellent practiceopportunity with over 14,000 procedures per year. If interestedplease send complete CV to: D. l. Bramlett, 1 East NorthwestHighway, Suite 102, Palatine, Il60067 or call collect (312)991-4070,7/82

SOAP Nl'wsll'ltl'r Pagl' 13

FELLOWSHIPS

WASHINGTON, D.C. Approved one-year specialty training athigh-risk obstetrical unit - 3000 deliveries per year. Ampleopportunity for clinical experience, teaching, clinical and animalresearch using the chronic maternal-fetal sheep preparation.Contact John B. Craft, Jr., M.D., Director, Obstetric Anesthesia,George Washington University Hospital, 901 23rd Street, N.W.,Wasington, D.e. 20037. (202) 676-3864. 8/80

TEXAS Opportunity for onp--year specialty training in high riskobstetric unit with approximately 6500 deliveries per year. Activeclinical research program, aswell as chronic maternal-fetal sheepexperimentation. Faculty position. Reply to Robert Hodgkinson,M.D., Department of Anesthesiology, The University of TexasHealth Science Center at San Antonio, 7703 Floyd Curl Drive, SanAntonio, TX 78284. 8/80

CALIFORNIA One-year OB anesthesia fellowship with rotationthrough three los Angeles hospitals for clinical experience orresearch opportunity as desired. Contact Kenneth A. Conklin,M.D,. Ph.D., Director of Obstetric Anesthesia, UCLA Center forHealth Sciences, los Angeles, CA 90024. (213)824-6225or (213)825-5021.8/80

CALIFORNIA Immediate openings for PGY4 residents in approvedObstetrical Anesthesia Residency at high risk Obstetrical Unit.Ample opportunity for clinical experiences and human research,Contact Therese Abboud, M.D., Associate Professor of Anesthesia,lAC-USC Medical Center, 1200 North State Street, PO Box 12, losAngeles, CA 90033. (213) 226-3293. 11/80

CALIFORNIA 1-year O.B. anesthesia fellowship for the 1983-84academic year. Clinical experience is in level 1 Perinatal Centerwith in excess of 4,000 deliveries per year. Opportunity to take partin clinical research program and teaching of medical students.Contact G. M. Bassell, M.D., Director of Obstetric Anesthesia,University of California, Irvine Medical Center, 81A, Orange,California, 92668. 5/82 •

MeetingsWe've HeardAboutMay 25-28, 1983. SOAP Fifteenth Annual Meeting at the BayshoreInn, Vancouver, British Columbia, Host Graham McMoriand.

Spring 1984. SOAP Sixteenth Annual Meeting in San Antonio.Texas, Host Bob Hodgkinson,

Spring 1985. SOAP Seventeenth Annual Meeting in Washington.D.e. Host John Craft.

•

SOAP Newsletter Page 14

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The SOAP Newsietter is published quarterly in SanDiego. Caltlornia. by the Society for Obstetric Anes-theSia and Perinatology. Unless otherwise Indicated.opinIons expressed are those of the Editor and do notnecessanly represent the consensus of the SocIetyAddress correspondence to the EdItor at UnIVersItyHospital. Department of Anesthesiology. H-770. 225D'ck,nson St. San D,egu. CA 92103 (714/ 294-5913or 294.5720EDITOR M,chael H. Plum~r. MD.EDITORIAL ASSISTANT: Cathie Mill,onPRODUCTION ProfeSSIonal Pnnting Services

SOAP 1982-83BOARD OF DIRECTORS

SOAP IIEWSLETTERUniversity HospitalDepartment of Anesthesiology. H-770225 Dickinson St.San Diego, CA 92103

ADDRESS CORRECTION REQUESTEDRETURN POSTAGE GUARANTEED

BULK RATEU.S. POSTAGE

PAIDSAN DIEGO. CAPERMIT NO. 1919

PresidentThomas H. Joyce III. M.D.Houston. Texas

TreasurerGraham McMorland. M.B .. Ch.BVancouver. B.C .. Canada

Vice PresidentRobert Hodgkinson. M.D.San Antonio. Texas

Secretary/EditorMichael H. Plumer. M.D.San Diego. California

Director-at-LargeRichard B Clark. M.D.Little Rock. Arkansas

Director: ObstetricsThomas Benedetti. M.D.Seattle. Washington

Director: NeonatologyLawrence Grylack. M.D.Washington. D.C

Chairman. ASA CommilleeCharles P Gibbs. MD.Gainesville. Florida

i~I...FX F. F'Ur: hI:!3(~)~:j2 CtIF~I...ET()NSAN DIEGO,CA,92106,,~/?7 ....B2/ 19B~:j

Continued on Page 10

FALL 1982

SOAP 1983:Vancouver, B.C.Abstracts due March 15

\'.',~:'~k</~..

Vancouver's Kitsilano Beach may be accessible to SOAP membersduring 1983 meeting. At any rate, it makes a nice picture.

Adapted from G. H. McMorJand, MB, ChB.

SOAP's 15th annual meeting will be held in Vancouver, B.C., atthe Westin Bayshore Hotel from Wednesday through Saturday,May 25-28, 1983. Registration material will go out with the januaryNewsletter. Please note that we plan to call for abstracts by March15, 1983. If we can get the abstracts in by that date, we should beable to notify people of their acceptance or rejection and of thetime of presentation well ahead of the meeting date.Our SOAP meeting ends on the Saturday of the Memorial Day

weekend. Because some people may wish to combine the SOAPmeeting with a vacation in this area, we have obtained assurancefrom the hotel that they will extend the convention rate for twodays before and two after the meeting. Vancouver is quite easy toreach. The Vancouver International Airport is served by most ma-jor airlines; for those wishing to travel by car, we do have goodpaved highways after you cross the 49th parallel. For those SOAPmembers who happen to be named Gutsche, there is a Trans-Canada train which originates in Montreal and Toronto.While we do not know what the currency exchange rate will be

next May, at present the U.S. dollar is worth $1.23 in Canada. Thisis important to remember when converting local prices (such ashotel and ~estaurant prices) into U.S. currency. Some people haveinquired from us about pre- and post-convention tours such asboat cruises to Alaska, visits to the Canadian Rockies, and trips toVictoria. I understand that the shipping lines generally start theirAlaska cruises about the end of Mayor the first week of june. Alocal travel agent has suggested to me that any SOAP memberswishing to embark on one of these cruises would be well advisedto make arrangements through their own local travel agents. Thisis because, with the fall-off in business due to the economic reces-sion, some of the lines have subsidized air fares to and from Van-

VOLUME 14, NUMBER 2

couver. So anyone planning such a cruise may just possibly beable to effect some sort of reduction in their air fare. Whether thiswill be true again next year is questionable at this stage.If there are questions about the meeting that need to be

answered in advance of publicity, please contact me directly inthe Department of Anaesthesiology, Grace Hospital, 4490 OakStreet, Vancouver, B.C., Canada V6H 3V5.

•*IPRESIDENT'SCOWMN , *OBSTETRICANESTHESIA- WHO?

by Thomas H. joyce, III, M.D.

"Obstetric anesthesia - why?" was a question for the 1970's."Obstetric anesthesia - who?" is the question for the 1980's. "TheExperts Opine" surveyed five SOAP members: Doctors jayDeVore, Brett Gutsche, Frank james, Gerard Ostheimer, andMichael Plumer.' All five physicians' crystal balls forecast anincreasingly important role of the nurse anesthetist in theobstetric anesthesia health care team.The President of the American Society of Anesthesiologists in

his year-end summation notes that physician responsibilities arebeing fragmented by a host of paramedical personnel. He furthernotes that, in his opinion, regional anesthesia is the practice ofmedicine and, hence, should not be performed by paramedicalpersonnel. This view is often emphatically echoed by ASAmembers, who say in the next breath that they have not set foot inOB since they were residents.Thus a dichotomy exists which states that regional anesthesia, in

particular epidural block, protects mother and fetus from thedanger of aspiration and other effects of the emotional andphysical stress of labor; however, regional anesthesia can be per-formed only by anesthesiologists who will not enter a deliverysuite.The increase in medical school graduates plus the GEMENAC

report should increase the number of anesthesiologists comingout of the pipeline. If residency programs continue to improvethe time and teaching of the subspecialty of obstetric anesthesia,the interest of these new anesthesiologists in obstetricanesthesia as a full-time or part-time practice will depend uponthe economic principle that a paid-for service, or the demandtherefor, will attract physicians to this marketplace. The specialtyof obstetrics must demand the same quality of care and reim-bursement for anesthesia for the obstetric patient as for thegynecologic patient. Neonatology support is also absolutely es-sential to attain this goal.

SOAP Newsletter Page 2

theSOAPbox

LETTERS FROM MEMBERS

Ed. note: A senior SOAP member privately expressed to me somedismay that John Marino's letter describing OB anesthesiacoverage in a general hospital (SOAP Newsletter, Summer 1982)didn't regard the practice of having obstetric nurses give epiduraltop-up doses as extraordinary. This senior SOAPer suggested that Iask Diane Biehl to comment on this practice, since she has beeninvolved in the controversy in Canada. Dr. Biehl's reply follows.

To The Editor:I am writing in response to your letter about the advisability of

obstetrical nurses injecting epidurals for patients during labour.Thi~ i~. a .difficult qu~stion to. answer because of the greatvarrabillty In resources In obstetrrcal units. Therefore, I don't thinkfixed rules are possible. Perhaps I can outline what we do in ourunit and use this as a framework for discussing this problem.The St. Boniface Hospital obstetrical department is considered a

high-risk unit which delivers 3,000 patients yearly. Twenty-five tothirty percent of the patients who deliver vaginally do so withepidural anaesthesia. The epidural catheters are placed by staffanaesthesiologists or residents and the first injection is done bythem. After the effectiveness of the epidural is established, writtenorders are left on the chart for the nurses to do top-up injections.-:he nurses who do the top-ups of the epidurals are specially

trained obst~trrcal nurs~s who have taken an extensive trainingand arrentation course In our obstetrical unit. These nurses arealso responsible for fetal monitoring, insertion of spiral electrodesand intra-uterine pressure catheters, and scalp sampling.To get back to the epidurals, these nurses use a strict protocol

for injection of the epidurals. The nurses do not give the perinealdoses but rather the anaesthesiologist does this when the patientIS In the delivery room. He or she remains with the patient untilthe completion of the third stage.The nurses during their orientation are given two to three

seminars concerning the possible complications of epidurals dur-ing labour. They are also instructed on the proper treatment andmanagement of these complications. In any situation where bloodor fluid is aspirated from the catheter they are instructed not to in-ject any local anaesthetic, not even a test dose, but rather to callthe anaesthesiologist or his resident.We have an anaesthesiologist on call 24 hours a day, seven days

a week on the obstetrical unit. This anaesthesiologist has no otherresponsibilities except the obstetrical unit. The remuneration forthis is by a sessional fee (this is Canada, remember). Theanaesthesiologist assumes the responsibility for the epidurals eventhough the nurses may be doing the top-up doses.This arrangement has been in place in St. Boniface since 1969.

When I came on staff in 1977 I had great reservation about nursesdoing the top-up doses, but after a rather intense period ofmonitoring the results I could find no problems with it. In fact inour audits ",:,e do slightly better than the literature reports onepidurals. Since 1969 there have been no total spinals and noIntravascular injection by nurses. In fact, we have had twocatheters penetrate the dura since 1977 and in both instances theproblem was detected by the nurse during aspiration on thecatheter. Since 1969 there have been over 10,000epidurals used inlabour in our unit without a major complication. Therefore in ourunit this arrangement works particularly well.

,..

The key to anyone injecting epidural catheters safely is that theyare able to detect problems - both major and minor. I think thatnurses can be trained to detect problems as well as housestaff orfully qualified physicians. Given the shortage of anaesthesiologistson th~s.continent I think it is only practical to consider the option~f tralm.ng nu~ses to perform these t~sks. As well, many complica-tions With epidurals occur not durmg the injection but severalmin~tes later. Unless the anaesthesiologist is going to stay by thebedSide for 20-30 minutes following each injection he must stillrel.y on. th.e nurse attending the patient to detect problems. I dothmk It IS necessary for an anaesthesiologist to be readilyavailable at all times to handly any emergencies should they oc-cur.From the above I am sure you can see that I am prepa-red to ac-

cept the idea of nurses topping up epidurals. I must say, however,that I do know of incidents where problems - serious ones - haveoccurred. In both cases nurses were doing top-ups but without ananaesthesiologist being present in the labour suite. In one of thesesituations the mother died. Obviously such a tragic outcome can-not be condoned, but after both caseswere reviewed it was ap-parent that the nurses had not received any instructions concern-ing possi?le complications and as I have said the anaesthesiologistwas not In the labour suite. This kind of situation can only beaVOided by the anaesthesiologist becoming very actively involvedIn not only caring for patients but in teaching the other membersof the perinatal team what we are about in our administering ofanaesthesia to our patients.We have done a pretty good job of selling epidurals to both

patients and obstetricians - therefore the responsibility rests withus to see that they are administered safely and effectively. We mayhave others assist us in this but ultimately the responsibility restsWith us and we can never afford to take this lightly.

Diane Biehl, M.D.Winnipeg, Manitoba

COMMUNITY OB ANESTHESIA

To The Editor:

let me take this opportunity commend you for the columns youhave made available to the readers of the SOAP Newsletter.I particularly enjoyed your remarks relating to obstetric

anesthesia by the general anesthesiologist appearing severalmonths ago. It certainly is consistent with my own opinion aboutthe responsibilities for obstetric patients which should be as-sumed by the anesthesiologist practicing in smaller hospitals. Un-fortunately, such anesthesiologists frequently allow their con-Siderations of those responsibilities to deteriorate into economics.This leads me to tell you a bit about our own practice at PomeradoHospital in Poway and our pride in having made a commitment toobstetric anesthesia.This is a dist~ict hospital with a capacity of 130 beds. The delivery

loadls approximately 800 per year, but a rate which has graduallycontinued to grow since the hospital first opened five years ago.We are very proud of the fact that we made a commitment toobstetric anesthesia from day one at the hospital. With a smalldelivery load we find it is not necessary for an anesthesiologist tobe constantly present, but through close communication with themedical and nursing staff and by virtue of the fact that most of thesix anesthesiologists live within five to eight minutes of thehospital, we are easily available. Constant availability is the keyword, of course. To achieve that end, each of the sixanesthesiologists has obstetrics as his/her sole responsibility for a24 hour period. Most deliveries are currently accomplished usingone of the "natural" methods and pudendal block, but the use ofepidural anesthesia is gradually growing. Speaking from a verypersonal point of view, I find obstetric anesthesia to be one ofthe most satisfying aspects of my practice for reasons that are wellknown to those anesthesiologists including obstetric anesthesiain their practice. I thought you might be interested in knowinghow we get thiS done In our "country hospitaL"

John S. Hattox, M.D.San Diego, California

Ed note: Dr. Hattox was President of the AS.A in 1980.

WHAT'S NEWIN OBSTETRICANESTHESIA:1982

by Kenneth A. Conklin, M.D., Ph.D.UCLA Center for The Health Sciences

INADVERTENCE

Anesthesia textbooks and journal articles have commonly usedthe word inadvertent when referring to anesthetic complicationssuch as subarachnoid or intravascular injection of localanesthetics. Although the author generally intends the word todenote unexpected, unanticipated, or untoward, its unequivocaldefinition implies careless disregard. As suggested by LegalPerspectives ;n Anesthesia (Vol. 2, No.1, Jan.lFeb. 1982), unlessthe concept of negligence and fault is intended, the wordinadvertent should be avoided in our medical writing and hospitalrecords.

BUPIVACAINE CARDIOTOXICITYThe controversy about cardiotoxicity of bupivacaine and

etidocaine was introduced to most anesthesiologists by Dr.Albright's editorial in 1979 (Anesthesiology 51:285, 1979). Mooreet al. (Anesthesiology 56:230, 1982) recently reported 5 cases ofseizures following intravascular injection of bupivacaine. Allpatients exhibited significant acidosis following the seizures;however, none developed signs of cardiac toxicity. These authorspostulate that toxicity, when it occurs, is due to delay in propertreatment of hypoxia and acidosis and is not directly related to thelocal anesthetic.Animal models have been used in an attempt to resolve this

controversy. Using anesthetized ventilated dogs, Liu et a/. (AnesthAnalg 61:317, 1982) found the cardiovascular to central nervoussystem toxicity ratio in the absence of acidosis and hypoxia to be4:1 for bupivacaine, etidocaine, mepivacaine, and prilocaine. Theyconcluded that these local anesthetics all have the same margin ofsafety for producing cardiotoxicity. Other studies, however,produced different results. Lightly anesthetized cats were givenbupivacaine, etidocaine, or lidocaine and allowed to seize while PO 2and pH were maintained in the normal range (de Jong et al.:Anesth Analg 61:3, 1982). Those receiving bupivacaine oretidocaine developed nodal and ventricular arrhythmias, whereasequiconvulsant doses of lidocaine were without effect on thecardiac rhythm.Other factors may also contribute to the cardiac effects of

bupivacaine and etidocaine. As shown by Avery et al.(Anesthesiology 55:A164, 1981), hyperkalemia increases the car-diovascular toxicity of bupivacaine, but not of lidocaine. Ofinterest is that succinylcholine increases serum potassium, andsuccinycholine has been used in many resuscitative efforts after abupivacaine-induced seizure. Although the effect of suc-cinylcholine alone is not great, when combined with acidosiswhich also causes hyperkalemia, the elevation of potassium mayenhance the cardiac effects of bupivacaine.In summary, cases reports and some animal studies suggest that

these highly lipid-soluble and protein-bound local anesthetics(bupivacaine and etidocaine) may have an effed on the myocar-dium not seen with other agents. Although untreated hypoxia andacidosis occuring with a seizure will surely lead to cardiac arrest,this would be true regardless of the local anesthetic used (and itdoesn't seem as if we have had as many reported casesof cardiacarrest or prolonged resuscitations following lidocaine-inducedseizures). Therefore, when using bupivacaine or etidocaine forregional anesthesia, it seems prudent to administer the doseincrementally instead of all at once.

SOAP Newsletter Page 3

CHLOROPROCAINE NEUROTOXICITYOur attention was once again focused on the controversy of

chloroprocaine neurotoxicity by the report of 5 cases ofneurological deficit following use of this drug (Moore et al.Anesth Analg 61:155, 1982). The authors feel that these casessup-port the suggestion of a unique toxicity of chloroprocaine, aconcern initiated for many anesthesiologists by two articles ap-pearing in 1980 (Ravindran et al. Anesth Angal 59:447, 1980;Reisner et al. Anesth Analg 59:452, 1980). This concern was one ofthe topics of primary interest at a meeting entitled "TheAnesthesiology Triad in Obstetrics: Mother-Fetus-Physician"(Meeting reports Anesthesiology 56:335, 1982; Carron Reg Anesth6:159, 1981). Discussed at this meeting was a review by Dr. Scally(prepared for the FDA) of reported cases of neurologic sequelaefollowing use of chloroprocaine for epidural anesthesia. Whenthe incidence of sequelae following chloroprocaine was com-pared to that with other local anesthetics, Dr. Scally concludedchloroprocaine was not clearly more offensive than the otheragents.With the hope of resolving the controversy, many investigators

have attempted to determine the neurotoxicity of chloroprocainein animals. Ravindran et al. (Anesth Analg 61:279,1982) evaluatedthe effects of subarachnoid injection of chloroprocaine,bupivacaine, normal saline, or a low pH solution (because of theconcern for the low pH of chloroprocaine solutions) in dogs.Thirty-five percent of the animals receiving chloroprocainedevelped paralysis, but none of the animals in the other groups.Although other studies (many reported at the SOAP meeting) withdogs, monkeys, sheep have failed to show selective toxicity ofchloroprocaine, we are still left without an explanation for theresults of Ravindran et al.In summary, although neither the clinical incidence nor the

animal data necessarily support the contention thatchloroprocaine is overly or uniquely toxic, cases of neurologicaldeficit after intended epidural use of this drug have un-questionably occurred. Whether or not chloroprocaine is directlyresponsible, the controversy has emphasized the need to exercisecaution with epidural administration of this (aswell as other) localanesthetics.

PREVENTING ASPIRATION PNEUMONIAOur continued search for agents to reduce morbidity and mor-

tality from aspiration has resulted in several publications concern-ing oral and parenteral agents for reducing gastric volume andacidity. The agents with greatest promise are the H2-receptor an-tagonists and the clear antacids.Cimetidine is the most extensively studied H2- antagonist, and is

effective in reducing both gastric volume and acidity. It is withouteffect on gastro-esophageal sphincter tone (barrier pressures) orgastric emptying. Johnston et al. (Anaesthesia 32:26, 1982)demonstrated the effectiveness of cimetidine administered priorto c-section. One to three hours following a 400 mg oral dose,gastric pH was uniformly greater than 2.5, and gastric volume wassignificantly less than in control patients (10 ml vs. 42 mil. Noadverse effects of cimetidine on maternal or neonatal well-beingwere noted.Cimetidine is also effective for elevating gastric pH of patients

during labor (Johnston et al. Anaesthesia 37:33, 1982). A 400 mgloading dose followed by 200 mg every 2 hours resulted in agastric pH of greater than 2.5 in 96% of parturients. Gastricvolume, however, was greater (35 mil than when the drug wasused as a single oral dose prior to c-section (see above), a resultnot unexpected with multiple oral doses. Apgar scores, generalactivity, and feeding behavior of neonates were normal in all casesstudied.Cimetidine, like all drugs administered to the parturient, crosses

the placenta. Following its administration, the fetal/maternal ratiogradually rises, reaching its maximum of 0.84 at 2 hours (Howe etal. Anaesthesia 36:321, 1981). This slow rise in fetal/maternal ratiois not surprising due to the polar, hydrophilic nature of the drug.Several studies have demonstrated the effectiveness of clear an-

tacids (citrate) for reducing risk of aspiration pneumonitis. Fifteenml of sodium citrate given to patients prior to elective surgeryuniformly producted a gastric pH of greater than 2.5 (Viegas et al.Anesth Analg 60:521, 1982). Gibbs et al. (Anesthesiology 55:A311,1981)also reported the effects of 30 ml of sodium citrate on gastric

Continued

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volume and pH in patients for elective c-section. Gastric samplestaken immediately after induction of general anesthesia and priorto extubation were all above pH 2.5.

Sodium citrate appears to be safer than the particulate antacids,as shown by Eyler et a/. (Anesth Analg 61:288, 1982). These authorsinvestigated the effects of aspiration of normal saline, HCIneutralized with Mylanta, HCI alone, and HCI neutralized withBicitra (sodium citrate plus citric acid) in rabbits. Compared to acontrol, significant differences in gross pathology were observedonly in the animals receiving Mylanta plus HCI or HCI alone. Theonly significant microscopic changes were seen in the animalsreceiving Mylanta plus HCI. Deterioration of arterial blood gases(PO 2) were observed in all animals, although the changes weremost prolonged in those receiving Mylanta plus HCI.~t what point during gestation should we consider the pregnant

patient to be at increased risk of aspiration? Gastric volume andacidicty in early pregnancy (less than 20 weeks) are no differentthan in non-pregnant patients (Cohen and Wyner. Anesthesiology53:5306, 1980). Reduction of lower esophageal sphincter tonerelative to gastric pressure (barrier pressure) might increase thelikelihood of aspiration, and this situation has been demonstratedin pregnant patients who complain of heartburn (Brock-Utne eta/. Br J Anaesth 53:381, 1981). If we assume that the barrier pres-sure is important in preventing aspiration, we should take care notto reduce it pharmacologically with intravenous administration ofeither atropine or glycopyrrolate (Cotton and Smith. Br J Anaesth53:875, 1981). We may also be able to reduce aspiration risk bypharmacologically increasing the barrier pressure by administra-tion of metoclopramide (Cotton and Smith. Br J Anaesth 53:869,1981). These authors also demonstrated that if metoclopramide isadministered with atropine, the barrier-pressure-Iowering effectof the latter drug predominates.

A final note of caution with the use of all the drugs mentioned isthat their maternal, fetal, and neonatal safety should be deter-mined before their general acceptance for use in the parturient.After acute administration, cimetidine does reduce hepatic bloodflow and hepatic drug metabolism, and has been associated withhypotension and arrhythmias in chronically ill patients. Some feelthese effects may be observed in healthy patients aswell. Adverseeffects after chronic administration (skin rash, diarrhea,gynecomastia, granulocytopenia, neurologic changes) areprobably of less concern when cimetidine is used in obstetrics.Metoclopramide has not been clearly demonstrated to be safe inobstetrics.

PREECLAMPSIAWe continued to find support for volume expansion and

epidural anesthesia for management of preeclampsia. Joyce andLoon (Anesthesiology 55:A313, 1981) demonstrated that 25 per-cent albumin raises central venous pressure, increases urine out-put, and reduces diastolic blood pressure in results similar tothose previously reported with administration of crystalloid solu-tions or crystalloid plus colloid. (Joyce et a/. Anesthesiology51:5297, 1979).

Epidural anesthesia has also been shown to increase intervillousblood flow in parturients with severe preeclampsia when 10 ml0.25% . bupi~acaine was administered during labor followinghydration With 500 cc of balanced salt solution (Jouppila et a/.Obstet Gynecol 59:158, 1982). These authors observed a 77 per-cent Increase in intervillous blood flow compared to thatmeasured by 133Xe technique before initiating the block.However, since 500 ml of crystalloid may not be adequate forhydration of severely preeclamptic parturients, it may be ofinterest to deter.mine the benefits of regional analgesia plus op-timal hydration In these patients.

THIOPENTAL PHARMACOKINETICSMany of us learned that thiopental is metabolized at the rate of

15-25 percent per hour (half life of 2.5-4.0 hours). Recent studies,however, have reevaluated the pharmacokinetics of this qrug byextending the data collection period, and have found that theelimination half-life in surgical patients is much longer. Theelimination half-life of thiopental has also been evaluated inpatients for elective c-section (Morgan et a/. Anesthesiology54:474, 1981). Whereas in their companion study (Morgan et a/.Anesthesiology 54:468, 1981) the elimination half-life in surgicalpatients was 11.5 hours, the elimination half-life in pregnant sub-

jects was 26 hours. Although this extended half-life may be of littleImportance when a single induction dose is given, if multipledoses are used we may expect to see an extended recovery timepost-partum.

SPREAD OF LOCAL ANESTHETICSeveral factors have been evaluated in the spread of local

anesthetics in the epidural space - e.g. obesity, gravity, uterinecontractions, and volume and concentration of local anesthetic.

Using 8 ml of 2 percent chloroprocaine to provide laboranalgesia, Sivakumaran et a/. (Anesth Analg 61 :127, 1982)demonstrated that injecting during a contraction did not increasethe spread. Patients in one group received the initial dose at thebeginning of a contraction and a top-up dose between contrac-tions. A second group received the doses in the reverse order.Analgesia (covering 16-17 segments) was the same in all instances.

Obesity has previously been shown (Hodgkinson and Husain.Anesth Analg 59:89, 1980) to be positively correlated withcephalad spread of epidural anesthesia. The same authors recentlyconfirmed this finding (Anesth Analg 60:421, 1981) and found thatincreased spread in obese patients could be limited by the sittingpOSItion, a phenomenon not observed in lean patients.

Rolbin et a/. (Canad Anesth Soc J 28:431,1981), using either 12ml of 0.25 percent bupivacaine or 6 ml of 0.5 percent bupivacaine,found that superior analgesia was obtained with the larger volumeand lower concentration, and also that analgesia was improved ifthe patient was turned from side to side instead of being main-tained only on one side.

NITROPRUSSIDE IN PREGNANCYAt times were are in need of a direct-acting vasodilator for a

pregnant patient during anesthesia. One such agent is sodiumnitroprusside, which strt:rcturally consists of a nitroso group and 5cyanides co-ordinately bound to iron. However, the rapid placen-tal transfer of nitroprusside (and cyanide) and the probable slowrate of detoxification of cyanide in the neonate raise concerns aboutfetal and neonatal toxicity. Fetal toxicity was demonstrated byNaulty et a/. (Am J Obstet Gynecol 139:708, 1981) when they in-fused nitroprusside for 1hour in 8 pregnant ewes. In 5 animals,tachyphylaxis to nitroprusside occured, and was associated withthe expected rise in maternal and fetal cyanide levels. The ewes inthis group received a mean nitroprusside dose of 25 mcg/kg/min.The fetuses died within 30 minutes after nitroprusside was discon-tinued, and the ewes died somewhat later. The remaining 3animals (receiving less than 1 mcg/kg/min) exhibited a normalblood pressure response to nitroprusside and did not haveelevated cyanirJe levels. No adverse effects were observed in theewes, the fetuses, or the neonatal lambs.

Although nitroprusside may be toxic when administered for aprolonged period of time and when tachyphylaxis and highcyanide levels are observed, short-term use or use of low dosesmay be safe. Rigg and McDonogh (Br J Anesth 53:985, 1981)reported the safe use of nitroprusside in 2 pregnant patients (20weeks gestation) to provide controlled hypotension duringsurgery for cerebral aneurysm. Both patients recovered anddelivered normal infants at term. Another study alsodemonstrated that limited amounts of nitroprusside (2.3 mcg/kg/min) safely controlled norepinephrine-induced hypertension inpregnant ewes for 50 minutes (Ellis et a/. Anesthesiology 55:A302,1981).Although we cannot say that SNP is safe in all circumstances,judicious use of this agent may be beneficial for selected patientsduring gestation or at the time of delivery.

•

Alex Pue, SOAP's semi-official photographer, has recent-ly finished work on a commercially available 50-minute"professional" videotape presentation abo'ut obstetricanesthesia which is intended for use in prenatal education. Ifyou'd like to explore making this material available in yourarea, contact Alex F. Pue, M.D., 3652 Carleton, San Diego,California 92106.

WHATS NEWIN NEONATOLOGY

IN 1982by Lawrence Grylack, M.D.

Columbia Hospital For WomenWashington, D.C.

RESPIRATORY

As usual, the respiratory system leads the hit parade in terms ofnumbers of papers published. Looking at prevention ofrespiratory distress syndrome, Papageorgiou evaluated our oldfriends betamethasone and found the drug to be effective in the27-34 week gestational range, more so in females than males. (1)Interestingly, they found that rupture of membranes did not addsignificantly to the effect of the drug and the mode of delivery ofthe baby had no effect on outcome, if pulmonary maturity hadbeen achieved by the time of delivery. Johnson also demonstrateda decrease in mortality in the 27-29 week GA group and a decreasein morbidity (asmeasured by hospital costs) in the betamethasonetreated group. (2) As we might expect, prolongation of gestationin treated and untreated groups was related to reduction of mor-bidity in a linear fashion. Finally, MacArthur provided us with a 4-year follow-up study showing no differences in developmentbetween betamethasone-treated and control groups. (3)Moving on to etiology of respiratory disease, Rossstudied racial

and environmental influences on fetal lung maturation by com-paring South African blacks, Ethiopian blacks, and Americanwhites and blacks. (4) Americans showed no differences betweenraces; however, the South Africans had the slowest maturation,and the Ethiopians had the fastest. In addition, cigarette smokingwas associated with accelerated lung maturity. There were a cou-ple of interesting studies which evaluated pulmonary function inmature newborns in relationship to mode of delivery. Boondemonstrated significantly increased thoracic gas volumes,decreased pulmonary resistance, and increased lung compliancein babies born vaginally when compared to those born by section.(5) Compliance was worst in those born by emergency section. Alldifferences disappeared by 72 hours of age and all were attributedto unresvolved lung fluid. Vyas showed intrathoracic pressure andvolume to be similar in babies born by section and vaginally, butexpiratory and delivery pressures were less after section. (6)On the diagnostic front, the skin surface PC02 monitor con-

tinued to be evaluated and was found to be useful in the sick new-born except in casesof hypotensive shock, according to Brunstler.(7) Pulmonary cytology obtained by tracheal aspirate was furtherstudied by Merritt. (8) This remains a useful adjunct to clinical andradiological criteria for the classification of respiratory distresssyndrome and bronchopulmonary dysplasia. One of our mostcommon acute complications in newborn respiratory disease isthat of pneumothorax. Goldberg demonstrated that there was arise in arterial blood pressure in 70 percent of babies withpneumothorax and that this rise occurred an average of 48minutes prior to thoracentesis, followed by a fall to baselinewithin 20 minutes after treatment. (9) In addition, 57 percent ofthese patients had heart rate and pulse pressure increases prior tothoracentesis.Regarding treatment modalities, there continue to be

numerous investigations on what is the best way to ventilate anewborn. I will mention a few pertinent findings. Of interest to allof us who are involved in delivery room care, Vyas examinedphysiologic responses to prolonged slow-rise inflation in theresuscitation of the asphyxiated newborn. (10) In one group initialinflation pressure was maintained for 5 seconds in comparison toslow inflation over 3 to 5 seconds. Both methods produced alarger tidal volume than the conventional one-second squarewave inflation; however, the prolonged 5-second square wave

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was more efficient than the slow inflation in establishing openingpressure. In another important perinatal respiratory disease,Truog produced experimental meconium aspiration in animalsand demonstrated that immediate post-aspiration application ofpositive end expiratory pressure resulted in decreasing thepulmonary shunt without creating areas of low ventilation-perfusion ratios. (11) The net result was improved gas exchange.The addition of tolazoline (an adenergic blocker) did not help inthis situation.Another facet of respirator therapy which you heard about two

years ago at this meeting was high frequency oscillatory ventila-tion. Marchak demonstrated a significant improvement in ox-ygenation during respiratory distress syndrome with this ventilatorin comparison to conventional intermittent positive pressure ven-tilation therapy. (12) De Lamos reviewed the current status of thismodality and pointed out that ventilatory distribution is efficientand there is a significant decrease in distal airway pressure;however, oxygenation improvement is relatively less efficient interms of mean airway pressure required, and there may be anincreased left-to-right shunt. (13) He feels that the chief indicationfor its use is in pulmonary interstitial emphysema. The high fre-quency oscillatory ventilator is not currently available for routineuse. Looking at the tail end of ventilator use, figuratively andchronologically, Spitzer discovered that post-extubation atelec-tasis occurred significantly less often after orotracheal intubationthan after nasotracheal intubation. (14)Research on surfactant replacement therapy has continued with

effervescent enthusiasm. Schneider found no significant dif-ference between human and rabbit surfactant in the rabbit model.(15) Clyman demonstrated an increased shunt through the ductusarteriosus after surfactant replacement by decreasing pulmonaryvascular resistance. (16) Notter pointed out that there is still uncer-tainty about the critical components of pulmonary surfactant invivo. (17) It is possible that the majority of clinical trials in thefuture will involve replacement with a complex rather than simplesurfactant mixture. In addition to the problems of mixture com-position, other potential problems include sterility of the mixture,temperature stability, optimal delivery route, method of replace-ment, time course of therapy, and the effects of this exogenousmaterial on endogenous surfactant, and pulmonary vascular andfluid dynamics.As with any medical problem, we look at those patients who

may suffer beyond the acute period. Weinstein (18) demonstratedincreased 02 consumption in infants with bronchopulmonarydysplasia and Werthammer (19) found that sudden infant deathsyndrome was 7 times more frequent in LBW babies with chroniclung disease compared with controls. Finally, Stahlman providedus with a 3 to 11 year follow-up of those who had hyalinemembrane disease during the 1960's and discovered that only 5 to10 percent of survivors had lung fibrosis and abnormal pulmonaryfunction tests. (20)

CARDIOVASCULAR

Knowing that a good set of lungs is worthless without a goodpump and vessel collection, we focus on the cardiovascularsystem. Just after everybody has memorized the last nomogramsfor blood pressure (BP), a new set of standards for BP during thefirst 12 hours of life has been provided by Vermold. (21) The chiefrelevance is that for the newborn less than 1000gm, the norms arelower than previously thought and therefore hypotension mayhave been overdiagnosed. In turn, investigators have looked atthe effects of volume expansion. Laptook looked at the effects ofc:fferent rates of plasmanate infusion upon brain flow afterasphyxia and hypotension in newborn pigs by comparing rates of15 ml/kg in 3 min., 15 ml/kg in 30 min., or no infusion at all. (22)There was sustained decrease in BP and brain blood flow after noinfusion. In contrast, BP and brain blood flow improved equallyafter both rates of infusion. As expected, there were regional dif-ferences in the brain, with the brain stem getting the greatestflow, cerebellum less, and cerebrum least. In another study,Goddard-Finegold (23) demonstrated intraventricular hemor-rhage after volume expansion for hypotension in newbornbeagles.The patent ductus arteriosus remains an important clinical

concern in the newborn, especially one who is sick and LBW.Perlman showed that the patent ductus arteriosus affects cerebral

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blood flow in a way that potentiates germinal matrix andintraventricular hemorrhage. (24) In further analysis of in-domethacin treatment for ductal closure, Merritt showed that ad-ministration at 2 days of age was superior to use at 7 days of age interms of decreasing 02 requirement and incidence ofbronchopulmonary dysplasia. (25) Betkerul reassured us by show-ing that although indomenthacin decreased urine production,there was no significant decrease in glomerular filtration rate. (26)One of the most fascinating aspects of perinatal medicine is the

cardiovascular transition. ]acobstein compared babies born afterelective cesearean section with those born vaginally and foundechocardiographic evidence of increased pulmonary vascularresistance in the CIS babies during thp first 3 hours of life. (27)Thiscould create a greater risk for persistent fetal circulation, knownalso as persistent pulmonary hypertension. Murphy found that ifthis problem existed primarily on an anatomical basis, namely ex-tension of muscle into the small pulmonary arteries, then theprognosis for survival was very poor. (28) On the other hand, ifpersistent fetal circualtion is primarily on a physiologic basis,Drummond reported that hyperventilation-induced respiratoryalkalosis and infusion of tolazoline (an adrenergic blocker)produced a favorable response in a majority of patients. (29) Onthe horizon lurk the prostaglandins: Soifler showed that PGD2reversed induced pulmonary hypertension in newborn lambs. (30)Finally, in an area of significant mutual interest, Brazy reported

on the newborn manifestations of severe maternal hypertensionin less than 36 week gestations. (31) When compared withcontrols, these babies had lower birthweights, head cir-cumferences, Apgar scores, platelet and white cell counts. Theyalso had a greater incidence of delayed cardiopulmonarygastrointestinal hypomotility. These latter cardiovascular,neuromuscular and gastrointentinal problems may have beenrelated to maternal medication.

GASTROINTESTINAL

Now, I'll move on to one of my favorite research areas, the GItract. An important cause of morbidity and mortality continues tobe necrotizing enterocolitis. In an epidemiologic study, Liegmanreported no identifiable risk factors which clearly distinguishedaffected patients from controls. (32) Interestingly, the enterocolitisgroup tended to have more married mothers, a greater incidenceof abruptio placentae, and a lesser incidence of respiratorydistress syndrome. One of the infectious factors though to be as-sociated with this disease has been the Clostridia species ofbacteria. However, reports during the last year fail to define asignificant relationship between Clostridia colonization of the GItract and enteric illness. (33, 34)Once a baby does get necrotizing enterocolitis or other serious

bowel disease, intestinal perforation and pneumoperitoneumbecome frequent occurrences. Several reports dealt with how tobest diagnose the presence and etiology of this problem. Themost simple finding was that of meconium-stained urine, aspointed out by Karna. (35) The most novel approach was reportedby Cohen who used Metrizamide, a radiographic isotonic contrastagent, in order to rule out GI perforation. (36)Moving onto solid ground, the liver, we have been told by

French that subcapsular hemorrhage of the liver had been under-diagnosed in the newborn. (37) In a retrospective post-mortemanalysis, 15 percent of babies were affected. The hemorrhage oc-curred most commonly in premature males with history ofgestational and labor and delivery problems, umblical venouscatheter placement, and endotracheal or thoracotomy tubeusage. As we would expect, hypovolemic shock was the mostcommon presenting sign.Staying with the biliary system, there have been some promising

reports. Clustering of cases of extrahepatic biliary atresia has beenreported in specific geographic areas, suggesting that there maybe an identifiable environmental, preventable etiology. (38)Furthermore, early diagnosis can lead to successful biliaryreconstruction in most patients. (39)

NUTRITION

One of the major functions of the GI tract and one of myfavorite recreational endeavors is nutrition. The literature con-

tinues to be filled with studies which analyzed breast milk andvarious milk formulas in every imaginable way. On the wholebreast feeding still appears to be the pediatrician's choice. It isvery interesting that differences between milk of term and pre-term mothers have been found. Pre-term milk has a greatercontration of protein and electrolytes, which is usually adequateto meet the baby's needs. (40) An important finding was that freshmilk from pre-term mothers was superior to pooled milk inproviding general nutrition, aswell as fat absorption and nitrogenretention. (41) Other studies demonstrated various relativebenefits to the baby who is breast fed. It was found that breastfeeding delayed introduction of food solids and protected againstlater obesity when compared to controls. (42) Evaluation of breastfeeding in a developing country found this to be associated withincreased physical growth, sensory motor development andresistance to infection. (43) Regarding choice of formula in theLBW baby, standard milk-based formula was found to be superiorto a soy-based formula. (44) From the maternal perspective, it isreassuring to find that mothers who had not breast fed their sickor small newborns initially could re-establish lactation up to 5manths post-partum. (45) In addition, post-partum amenorrheawas directly related to the duration and frequency of breastfeeding.(46) In one study, an average 16 1/2 months of durationand 4 1/2 times daily breast feeding led to an average 12 1/2months of post-partum amenorrhea. One of the major assets incurrent neonatal care is the ability to nourish a sick babyparenterally. Recent studies continue to shed light on thismodality. Investigators have further delineated the amounts ofspecific nutrients and the appropriate combinations of thesenutrients necessary to meet metabolic needs and promotegrowth. For example, Zlotkin showed that if you provide at least70 calories/kg/d, then the infusion of 3 grams of protein/kg/d willduplicate intrauterine nitrogen accretion rates. (47) Other workershave demonstrated modifications of lipid and carbohydrate solu-tions which have led to greater tolerance of these substances. (48,49) On the other hand, studies continue to warn of potentialhazards, especially in regard to lipid infusion. (50, 51) In particular,lipids need to be used with caution in patients with infedion,pulmonary disease, and biliary disease.

BILIRUBIN

As the subject of bilrubin lies somewhere between the redblood cell and the GI tract, that's where I've put it in this discus-sion. The major message this year is that kernicterus remainsunpredictable. First of all, Turkel found that kernicterus mayrepresent more than one type of abnormality in the brain. (52)Furthermore, and contrary to some previously held belief, Levinedemonstrated that kernicterus was produced in the animal modelby passage of albumin-bound bilirubin, not free bilirubin, acrossthe blood-brain barrier. (53) Attempts continue to be made in cor-relating levels of bilirubin and levels of bound and unboundbilirubin in the human newborn with kernicterus. (54) Unfor-tunately, there remains nothing close to a linear relationship ofcause and effect in these areas. What is becoming evident is thatsuch factors as hypertonicity, hypothermia, acidosis, hypoxia,sepsis, and hypoglycemia may be powerful influences in makingthe blood-brain barrier more permeable to bilirubin.Regarding the actual measurement of serum bilirubin,

Schreiner reported a wide inter-laboratory variability, e.g., for amean bilirubin of 18.1 mg percent results ranged from 10.9 to 24.0.(55) We have also received further evaluations of the tran-scutaneous bilirubinometer. At this point, it seems to be a usefulscreening device for healthy term newborns; (56, 57) however,there still appears to be a lack of accuracy and precision inrelationship to the baby's original skin color. (58) As you can see,there remains a broad ground for further research and debate inthe field of bilirubinology.

HEMATOLOGY

One of the main topics of interest in neonatal hematology isalways polycythemia and/or hyperviscosity. One of the commoncauses of neonatal polycythemia is chronic intrauterine hypoxia,although other acute changes in hemodynamic balance betweenfetus and placenta may also produce it. Ramamurthy found thatumbilical venous hematocrit or viscosity provided better correla-

tion with symptoms than capillary or peripheral venous samples.(59) An Hct greater than G3 correlated strongly with hyper-viscosity. Goldberg looked at the effects of partial exchange tran-sfusion in this syndrome in relationship to neurobehavioral out-come. (GO)Treated babies showed a more rapid improvement intheir neurobehavioral scores during the first 2 to 3 weeks, but at 8months there was no difference between treated patients andcontrols. Black reported a high incidence of maternal pre-eclampsia and neonatal hypoglycemia in newborns with hyper-viscosity. (Gl) She also reported a higher incidence of abnormaldevelopment follow-up at 1 to 3 years in comparison to normalnewborns. The problem in this field of study remains one of dif-ferentiating the effects of the hyperviscosity itself from theasphyxia that caused it or the hypoglycemia which accompaniedit. In turn, the decision of whether to do an exchange transfusionis still hotly debated.

Speaking of exchange transfusions, they have often been usedas a mode of therapy in disseminated intravascular coagulation(DIC). Gross compared exchange, with a second group thatreceived fresh frozen plasma and platelets, and a 3rd group thatreceived no therapy. (G2)There were no differences in outcome.The significant factor in the study was that hypotensive shock waspresent in 85 percent of cases and that correction of the underly-ing process in DIC is the most important therapy.

Finally, since smoking continues to be a hot topic in medicine, Iwill mention a study by Bureau on carboxyhemoglobin in cordblood with a history of smoking during labor. (G3) It was foundthat the fetus had a 2 to 3 fold higher carboxyhemoglobin levelthan the mother. The cord blood level increased as smoking wasdone closer to delivery, and carboxyhemoglobin impaired fetal O2transport.

INFECTIOUS DISEASE

One of the main challenges in the area of perinatal infectiousdisease is the prevention and treatment of beta-hemolytic group Bstreptococcus sepsis. Based on a study of prenatal vaginalcolonization and antibiotic treatment, Allardice recommendedscreening and treatment in labor because of decreased coloniza-tion and infection in the newborns of the treated group. (G4)Sincethis approach often meets with recurrence of colonization andantibiotic side effects, more attention has been focused on the im-mune aspects of the disease. Based on the finding that low level oftype-specific antibody seems to correlate with the risk of infec-tion, investigators have attempted to devise a method of passiveimmunity. Santos demonstrated increased survival in rats with ex-perimental GBS infection after the use of a modified immuneserum globulin containing type-specific antibody. (G5) This as-sumes greater importance in light of reports which indicate thatearly antibiotic treatment of congenitally infected newborns maynot be significantly successful. that penicillin tolerance can occurin recurrent infection, and that birthweight specific mortality fromthis disease has not changed significantly. (66, 67)

The viruses which continue to receive a lot of attention arecytomegalovirus and herpes simplex. There had been furtherdocumentation of CMV transmission to the newborn from thegenitourinary tract of the mother, (68) from breast milk, (68) andfrom blood transfusions. (G9) Diagnosis of congenital CMV infec-tion is based partially on finding specific IgM antibodies in cordblood. Furthermore, Griffiths reports that the presence ofrheumatoid factor and an elevated total level of IgM along withthe specific IgM have prognostic significance. (70) An importantprognnstic factor in congenital infection centers on whether themother had a primary or secondary infection. (71) Primary CMVinfection in the mother is more likely to cause a serious infectionin the baby. Epidemiologically, primary infections duringpregnancy are more common in upper socioeconomic groups.The major report this year on herpes simplex was a negative one.Arvin reported a majority of cases with disseminated herpessimplex and/or encephalitis occurred without previous iden-tifiable mucocutaneous lesions in the newborn. (72)

I can't leave the topic of infectious disease without saying that,as usual, the literature is filled with 5-year review of organismswe've forgotten and new foolproof permutations and combina-tions of physical signs and laboratory tests for the early dignosis ofnewborn sepsis.

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METABOLIC

The category of metabolism usually represents a conglomera-tion of smaller subsets which are lumped together forconvenience.

The consensus about optimal thermal environment for lowbirthweight babies is that incubators are better than radiantwarmers, and plastic blankets are better than other types of heatshields.

Turning to one organ that is important in metabolic control,namely the thyroid gland, Brown reported that congenitalhypothyroidism is six times more frequent in Caucasians than inblack population. (73) Looking at low T4 levels in pre matures,investigators found no differences between babies with orwithout respiratory distress, (74) and that these low levels spon-taneously increase with maturity. On the high side of thyroidfunction we are reminded that the newborn of a mother withGraves' disease can die or have serious morbidity from problemssuch as hypertension. (75)

Switching to a truly multidisciplinary subject I will mention thatSwanstrom investigated the metabolic effects of obstetric regionalanalgesia and asphyxia in the newborn during the first 2 hours oflife. (76) First of all, there was an increased incidence of hyper-and hypoglycemia in babies with a history of perinatal asphyxiaand regional analgesia. Regarding lipid metabolism, newbornglycerol and free fatty acid levels increased earlier in controls thanin those with history of analgesia. Furthermore, analgesia ap-parently blunted the postnatal increase in beta-hydroxy-butyrateseen in controls. Regarding oxygenation and acid-base balance,regional analgesia did not induce any major changes, assumingthe absence of asphyxia. However, there was an associationbetween hyperglycemia, fetal distress, and postnatal metabolicacidosis.

The only thing I want to say about calcium is that rapid infusionof IV calcium to the hypocalcemic newborn is not effective insustaining a desirable calcium level. (77) Furthermore this type oftherapy is associated with increases in blood pressure and heartrate which are not desirable unless used for cardiac resuscitation.(78)

A report by Stevenson on fetal macrosomia reminds us that verybig babies may be abnormal and so may be their mothers. (79) Thissituation deserves further evaluation from the obstetric stand-point of abnormalities in such areas as glucose homeostasis. Final-ly, who sweats in the nursery besides nurses and doctors?Prematures earlier than 36 weeks don't sweat after birth, but willdo so within 2 weeks, starting with the forehead. (80)

PHARMACOLOGY

The American Academy of Pediatrics provided a committeereview on the subject of Psychotropic Drugs in Pregnancy andLactation. (81) The main message was that these drugs should beused as indicated in the mother with the knowledge that mostcross the placenta and enter into breast milk. Therefore, potentialeffects can occur in fetus and newborn. Lithium is the only com-monly used drug in this category which absolutely contrain-dicated during gestation and lactation.

Looking at a pharmacologic agent used commonly in theprepartum period, MgS04 was studied for its neurobehavioral ef-fects on the newborn by Rashch. (82) Impairment ofneuromuscular transmission was present and neurobehavioral dif-ferences were found between treated toxemics compared withnon-treated toxemics and normals. Mean cord Mg was 4.15 mgpercent in the treated group compared with 1.5 in non-treatedcontrols.

A brief word about the use of digoxin in LBW newborns withpatent ductus arteriosus and congestive heart failure; a 50 percentrate of drug complication has been reported. (83)

A common drug group used in newborns with apnea is themethylxanthines, specifically aminophylline and caffeine. Recentstudies confirm the increased half-life of the drugs in the new-born, and the potential hyperglycemic and hyperinsulinemic sideeffects. (84. 85) (Don't give your patients too much coffee duringlabor.)

Finally, Lachner reminds us of the need for drug replacementfollowing exchange transfusion and gives us a formula for doing it.

SOAP Newslelter Page 8

(86) This aspect of pharmacologic management can sometime beoverlooked.

OPTHALMOLOGYOne of the most worrisome morbidities of prematurity is that of

retinopathy of prematurity, or retrolental fibroplasia. In her re-cent commentary, Phelps discusses the actual and projected in-cidence of this disease. (87) There are approximately 2100 babiesper year with serious retrolental fibroplasia disease, about 25 per-cent of whom become blind. The risk increases with decreasingbirthweight. She projects an incidence of 30 percent seriousdisease with 8 percent blindness in babies less than one kgbirthweight. Only 1/10 that incidence :~ expected in babiesbetween 1000 and 1500 grams. Looking at one facet of etiology,Sacks described a significant relationship between transfusion ofadult blood to babies and retinopathy; (88) this relationship wasmaximal with increasing duration of 02 environment greater than40 percent, but was minimized with good control of partial pres-sure of O2 in the baby's blood.

Getting back to the delivery room, there has been continuedsupport for the Academy of Pediatrics opinion that silver nitratetreatment of the eyes in the delivery room can be delayed in orderto promote parental-infant bonding. However, it is also pointedout by Butterfield that AgN03 application probably does not ac-tively interfere with this process. (89)

CONGENITAL ABNORMALITIESOne of the most difficult areas of perinatal meqicine in terms of

medical and emotional aspects is that of congenital anomalies.During the last year spina bifida has been examined from a fewstandpoints. Based on 233,000 births in the New York areabetween 1965 and 1979, Stein reports a linear decrease inmeningomyelocoele, without a similar one in anencephaly orhydrocephalus. (90) Regarding prevention, Smithells reports therole of prenatal vitamin supplementation with folic acid inpatients at risk for meningomyelocoele based on comparison ofoutcome in supplemented and control groups. (91) Continuing onan optimistic note, Leonard provides a prognostic perspective bysummarizing recent reports. (92) There has been 80-95 percentsurvival of babies with meingomyelocoele, with a great majorityhaving normal IQ and being able to stand with braces or otherdevices by 1-2 years of age.

Still in the area of CNS anomalies, occipital encephalocoele hasbeen associated with early gestational hyperthermia, specificallymothers who had a temperature more than 1.5 degrees abovenormal at 20-28 days gestation. (93)

As in the past, this year's literature does not lack for newsyndromes. In addition, we continue to see new methods ofprenatal diagnosis reported.

A most fascinating report about congenital anomalies was byJorgenson who looked into the mouths of 2258babies and found ahigh frequency of minor anomalies. (94) Finally, consider this:children identified as having had the fetal alcohol syndrome havean increased incidence of speech and language deficits. (95)(Whether this is based on an abnormality of brain structure andfunction or simply an imitation of their parents' elocution remainsopen to debate.)

CENTRAL NERVOUS SYSTEMGetting to the meat of the matter, what's been happening in the

newborn's brain? Periventricular/intraventricular hemorrhage isone event that's occurring with considerable frequency, especial-ly in the very low birthweight newborn, and a number of studieshave been devoted to it. It has become evident that a majority ofthese hemorrhages can be identified during the first day of life. Intrying to delineate obstetric risk factors, Lebed found that therewas a high association with breech presentation regardless ofmode of delivery. (96) Other perinatal factors reported by Clark tohave increased risk for hemorrhage include birth outside andpostnatal transport to a perinatal center. (97) In addition, hemor-rhage was associated with less prenatal betamethasone, fewerblood gases,more bicarbonate and IV fluid bolus infusions than incontrols. This is another vote in favor of maternal transport, asop-posed to neonatal transport.

In the diagnostic area, a familiar name Dubowitz has reap-peared to provide us with physical examination correlates ofintraventricular hemorrhage (IVHl. (98) Confirmation of thediagnosis in the viable newborn appears to be well done by realtime ultrasound. Since this is portable and non-invasive, it isgradually replacing CT scan for routine diagnosis. The main newareas of research in IVH are centering around analysis of cerebralblood flow and intracranial pressure relationships. (99-103) Interms of sequelae of intra-ventricular hemorrhage, the most com-mon findings are those of unlateral or bilateral hydrocephalus,with potential compression of brain tissue. Lesscommonly, bloodgoes into the brain parenchyma itself, leading to cyst formationand/or dissolution of tissue. Recent data continue to confirm theassociation between IVH and abnormal mental and motordevelopment; however, it remains impossible to make specificpredictions in individual patients.

Seizures in the newborn may be associated with perinatalasphyxia and intraventricular hemorrhage, among other causes.Coen found that continuous monitoring of the EEG followingperinatal asphixia maximizes the diagnosis of seizures when com-pared to physical examination alone. (105)Goldberg reported thatrhythmic fluctuation of vital signs and transcutaneous P02 levelsstrongly suggested seizure activity in the artificially paralyzednewborn on the respirator. (106) As with intraventricular hemor-rhage, brain scanning of asphyxiated newborns provides onlyvariable predictive accuracy of development at 18 months of age.(107) Looking at the less dramatic issue of CNS maturation inprematures, there has been anatomical evidence of neuronalmaturation delay when compared to term infants of the samepostconceptional age.(108) Clincially speaking, one facet ofmaturation examined has been visual fixation. This has beenobserved as early as 30 weeks gestation and gradually increaseswith increasing postnatal age and periods of awakeness. (109)

To conclude my CNS dissection on a shrill note, Golub has got-ten back to basics by analyzing the newborn's cry. (110) Notablefindings included instability of the glottis in hyperbilirubinemia.Other vocal abnormalities were associated with subsequent riskfor sudden infant death syndrome.

SURVIVAL AND DEVELOPMENTThe final question to be considered is who survives and in what

condition? An issue which has challenged us for years is that of therelationship of perinatal asphyxia and developmental outcome.To this end Nelson continued to analyze the National Col-laborative Perinatal Project data. (111) Of babies with Apgars of 0-3 at 10, 15 or 20 minutes, 12 percent of survivors had cerebral palsy(CP) and mental retardation, whereas 80 percent had no majorhandicap at school age. Conversely, 55 percent of all children withCP had Apgars of 7 to 10 at 1 minute and 73 percent had thesescores at 5 minutes. Therefore, although perinatal asphyxia asmeasured by Apgars increased the risk of CP, it did not predict itin a majority of cases.

In the very low birthweight (VLBW) group, there continues tobe a decreasing mortality rate with perinatal asphyxia being themain correlate of mortality. Reports on developmental morbidityof VLBW prematures continue to provide a wide range of results,going from a low of 13 percent abnormality in one study to a highof 49 percent in another with other results in between. (112-117)My interpretation is that the overall incidence of developmentalmorbidity in the original birth population has graduallydecreased; however, because the total number of survivors hasincreased, then the prevalence or total number of abnormal sur-vivors has remained the same or increased. Statistically, the mostpowerful predictors of abnormal development in the VLBW groupare small head size at birth, perinatal asphyxia, and lowsocioeconomic status.

Regarding babies who suffered intrauterine growth retardation,they continue to be at greater risk for less physical growth duringchildhood. (118) The same factors are important in predicting out-come as in the rest of the LBW group. In particular, Harveyreported that if head growth slowed before 26 weeks gestation,then that had a significant negative effect on cognitive and motordevelopment. (119)

Well, I'm out of space and I have to see some patients. That wasthe year that was in neonatology. Thank you for your interest.

1. A. N. Papageorgiou, et al: Pediatrics 67: 614, 19812. D. E. johnson, et al: Pediatrics 68: 633, 19813. 8. A. MacArthur, et al: Pediatrict 68: 638, 19814. 5. Ross et al: Pediatrics 68: 790, 19815. P. W. Boon, et al: }. Pediarr 98: 812, 19816. H Vyas, er al: j. Pediatr 99: 787, 19817. I Brunstler, et al: j. Pediatr 100: 454, 19828. T. A. Merritt, et al: j. Pediatr 98: 949, 19819. R. N. Goldberg: Pediatrics 68: 775, 198110. H. Vyas, et al: j. Pediatr 99: 635, 198111. W. E. Truog, et al: j. Pediatr 100: 284, 198212. B. E. Marchak, et al: j. Pediatr 99: 287, 198113. R. A. deLemos, et al: Pediatrics 69: 240, 198214. A. R. Spirzer, et al: }. Pediatr 100: 806, 198215. H. A. Schneider, er al: j. Pediatr, 100: 619, 198216. R. I. Clyma, et al: }. Pediatr 100: 101, 198217. R. H. Notter, et al: Podiatrics 68: 781, 198118. M. R. Weinstein, et al: Ij. Pediatr 99: 958, 198119. j Werthammer, et al: Pediatrics 69: 301, 198220. M Stahlman, et al: Pediatrics 69: 572, 198221. H. T. Versmold, et al: Pediatrics 67: 607, 198122. A Laptook, et al: j. Pediarr 100: 791, 198223. j. Goddard-Finegold, et al: j. Pediatr 100: 796, 198224. }. Perlman, et al: j. Pediatr 99: 767, 198125. T. A. Merritt, er al: j. Pediarr 99: 281, 198126. M. V. Betkerur, et al: Pediarrics 68: 99, 198127. M. D. jacobstein, er al: pediatrics 69: 374, 198228. j. D. Murphy, et al: j. Pediatr 98: %2, 198129. W. H. Drummond, et al: j. Pediatr 98: 603, 198130. 5. j. Soifler, et al: }. Pediatr 100: 265, 198231. j. E. Brazy, et al: }. Pediatr 100: 265, 198232. R. M. Kliegman, et al: }. Pediatr 100: 440, 198233. 5. T. Donta, et al: j. Pediatr 100: 431, 198234. R. j. Shererz, et al: j. Pediarr 100: 435, 198235. P. Kama, et al: j. Pediatr 100: 804, 198236. M. D. Cohen, et al: Pediatrics 69: 587, 198237. C. E. French, et al: Pediatrics 69: 204, 198238. A. D. Strickland, et al: j. Pediatr 100: 749, 198239. R. P. AIrman: Pediatrics 68: 896, 198140. 5. j. Gross, et al: Pediarrics 68: 490, 198141. 5. A. Atkinson, et al: j. Pediatr 99: 617, 198142. M. 5. Kramer, et al: j. Pediatr 98: 883, 198143. H. B. Young, et al: Pediarrics 69: 169, 198244. }. P. Shenai, et al: Pediatrics 67: 631, 198245. C. L. Bose, et al: Pediarrics 67: 565, 198146. E. O. Ojoleitimi: Pediarrics 69: 164, 198247. 5. H. llotkin, er al: }. Pediatr 99: 115, 198148. R. Dhanireddy, et al: j. Pediatr 98: 617, 198149. }. W. Sparks, er al: }. Pediatr 100: 255, 198250. D. English, et al: j. Pediarr 99: 913, 198151. D. D. Black, er al: j. Pediatr 99: 445, 198152. S. B. Turkel, et al: Pediatrics 69: 267, 198253. R. L. Levine, er al: Pediarrics 69: 255, 198254. D. A. Ritter, et al:Pediatrics 69: 260, 198255. R. L. Schreiner, et al: Pediatrics 69: 277, 198256. T. Hegvi: Pediatrics 69: 124, 198257. R. R. Engel: Pediatrics 69: 126, 198158. R. f. Hannemann, ef al: Pediatrics 69: 707, 198259. R. S. Ramamurrhy, et al: Pediarrics 68: 168, 198160 K. Goldberg, et al: Pediatrics 69: 419, 198261. \". D. Black et al: Pediarrics 69: 426, 198262. 5.]. Gross, et al: ]. Pediarr 100: 445, 198263. M. A. Bureau, et al: Pediatrics 69: 371, 19826.. ]. G. Allardice: Am. }. Obsrer, Gynec, 142: 617, 198265. j. I. Santos, et al: }. Pediarr 99: 873, 198166. S. P. Pvati, et al: }. Pediatr 98: 625, 198167. }. D. Siegel, et al: j. Pediarr 99: 920, 198168. S. Stagno, et al: Pediatrics 68: 322, 198169. S. C. Sandler, et al: Pediatrics 69: 650, 198270. P. D. Grilliths, er al: Pediatrics 69: 544, 198271. S. Stagna, el a/: N Eng j Med 306: 945, 198272. A. M. Arvin, et al: ]. Pediafr 100: 775, 198273. A. l. Brown, et al: j. Pediarr 99: 934, 1981N A. H. Klein, et al: j. Pediarrv 98: 818, 198175. E. Eason, et al: }. Pediafr 100: 766, 198276. S. Swanstrom, er al: Acta Pedialr Scand 70.: " 1981

D. R. Brown. et al: j. Pediatr 100: 777, 198278. D.]. 5alsburev, et al: Pediatrics 69: 51" 198279. D. K. Slevenson, et al: }. Pediafr 100: 515, 198280. \, A. Harpin, el al: }. Pediatr 100: 272, 198281. Committee on Drugs: Ped/Jules 69: 241, 198282 D, K, Ra;ch. ef al: }. Pediafr 100' 272, 198283. G. L. Johnson, e1 al:Pediatrics 69: 463, 19828.+ \\1. D. Parsons, er al: I. Pediarr 98: 640.. 198185. C Srinivasan, el al: }. Peuialr 98: 815, 19818b, T. E. lackner: I. Periiafr 100: 811. 19828;' D. L. Phelps: Pedialrics 67: 924, 198188 L. M. 5dcb, ('1 al: Pediatrics 68: 770, 198189 P. M, ButferilelJ, et at: Pedialrio 67: 737, 198190 S, C. Slein, ('t .'II: Pediatrics 69: 571, 1982YI R. \'\1. 5mithf'I/~: Pedialric" 69: 498, 19829.3. C O. /.(~onJrd, pI al: P('dialrics 68: 1]6, 19819; ,,\:. L. Fi:-.her, pI .11: Pf'diJlrin 68: 480, 19819-4. P. I. Jorcpn,orJ, el al: Pedia/rio 69: 577, 1982Y5 S. low I;, ('I at: PpdrJrno 68: 474, 198141). ,\1. R. /.('/)"(/, pI J/: Am. J. Obiter. (;vnec. 142' 851, 1982lj-: c. F. Clark, et .11: ,. Pl'JsJtr 99: 625, 1981Y8. I. 1\1. S. Du1Juwilz: J. Pedialr 99: 127, 198'1

SOAP Newsletter Page 9

99. A. Hill, et al: Pediatrics 68: 623, 1981100. L. R. Ment, el af: Pedialrics 68: 763, 1981101. A. Hill, et al: Pediatrict 69: 4, 1982102. T. Raju, et a/: j. Pediatr 100: 139, 1982103. H. 5. Bada, el al: j, Pediatr 100: 291, 1982104. S. Shankaran, et at: /. Pediatr 100:469, 1982105. P. W. Coen, et al: j. Pediatr 100: 628, 1982106. R. N. Goldberg, et al: Pedialrics 69: 583, 1982107. P. M. Fitzhardinge, el al: j. Pediatr 100: 476, 1982108, S. Takashima, et al: Periiarrics 69: 33, 1982109. M. Hack, el al: Pediatrics 68: 87, 1981110, H. L. Golub, el al: Pediatrics 69: 197, 1982111, K. B. Nelson, et a/: Pedialrics 68: 36, 1982112. j. M. Driscoll, el al: Pediarrics 69: 21, 1982113. H. Knobloch, et al: Pediatrics 69: 285, 1982114. S. B. Britron, el al: /. Pediatr 99: 937, 1981115, 5, Saigal, ef al: j. Pediatr 100: 606, 1982116. S. P. Horwood, et al: Pediatrics 69: 613. 1982117, R. S. Cohen, el al: Pediatrics 69: 621, 1982118, j. A. low, el al: Am. j. Obstet Gynec. 142: 670, 1982119. D. Harvey, et a/: Pediatrics 69: 2%, 1982

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MeetingsWe've HeardAboutDecember 1-5, 1982. Seventh Caribbean Symposium inAnesthesiology and Related Fields. Faculty includes Abouleish,Gibbs, and Colon-Morales. Sponsored by the Department ofAnesthesiology, Teacher's Hospital, San Juan, Puerto Rico, andPuerto Rico Society of Anesthesiologists, For information write:Seventh Carribean Symposium, GPO Box 4547, San Juan, PuertoRico. Attention: Miguel Colon-Morales, M.D.

January 3D-February 4, 1983. Tenth Neonatal and InfantRespiratory Symposium, The Marriott Mark Resort, Vail,Colorado. Sponsored by the Department of Anesthesiology, OhioState University. Contact Ohio State University Hospital, Dept. ofAnesthesiology, 410 W, 10th Ave., Columbus, Ohio 43210. Phone(614) 421-8487.

February 13-18, 1983. Eleventh Obstetric Anesthesia Conference,Maui and Oahu, Hawaii. Sponsored by the Department ofAnesthesiology, Ohio State University. Contact Ohio StateUniversity Hospital, Department of Anesthesiology, 410 W. 10thAve., Columbus, Ohio 43210, Phone (614) 421-8487.

March 2-4, 1983. International Symposium on the SurfactantSystem of the Lung. Rome, Italy. International Faculty. ContactFondazione Giovanni Lorenzini, Via Monte Napoleone, 23, 20121Milano, Italy.

March 10-13, 1983. Anesthesia for the High Risk Mother, Fetus,and Newborn. Golden Gateway Holiday Inn, San Francisco. Con-tact Sol M. Shnider, M.D., University of California San Francisco,M-1498, San Francisco, California 94143.

March 12-18, 1983. Fourth Space Age Monitoring Conference, St.Moritz, Switzerland. Sponsored by Department ofAnesthesiology, Ohio State University. Contact the Ohio StateUniversity Hospitals, Department of Anesthesiology, 410 W. 10thAve., Columbus, Ohio 43210. Phone (614) 421-8487.

March 19-26, 1983.Third Conference on Intensive Care Medicine,Wengen, Switzerland. Sponsored by Department ofAnesthesiology, Ohio State University. Contact the Ohio StateUniversity Hospitals, Department of Anesthesiology, 410 W. 10thAve., Columbus, Ohio 43210. Phone (614) 421-8487.

March 27, 1983. John S. McDonald returns as Visiting Professor.Sponsored by Department of Anesthesiology, Ohio State Univer-

sity. Continued

SOAP Newsletter Page 10

April 6-9, 1983. Second European Congress of ObstetricAnaesthesia and Analgesia, Rome, Italy. Contact Professor E. V.Cosmi, Via G Marchi 3, 00161 Rome, Italy.

May 25-28, 1983. SOAP 15th Annual Meeting at the Bayshore Inn,Vancouver, B.C. Host Graham McMoriand, Grace Hospital,Department of Anaesthesiology, 4490Oak Street, Vancouver, B.C.V6H 3V5.

Spring 1984. SOAP 16th Annual Meeting in San Antonio, Texas.Host Bob Hodgkinson.

Spring 1985.SOAP 17th Annual Meeting in Washington, D.C. HostJohn Craft.

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OBSTETRIC ANESTHESIA-WHOlContinued From Page One

No foreseeable increase in this nation's residency program willstaff these units. Consolidation of obstetric units is slow due toboth lay and medical politics. Smaller units (40-100 deliveries permonth) will continue to exist. Who will staff these units?Do we agree with Dr. J. Jacoby's purported statement that if

society is to receive its best return for medical dollars spent,then ... a mother and her fetus with 150-year life span (should)receive top priority?Since 1973, I have observed the role of the subspecialty-trained

nurse anesthetist using regional anesthesia in a level 3 obstetricunit. Physician consultation and/or supervision demanded by theCRNA's was readily available. During this period at the Universityof Cincinnati, no major anesthetic complications were noted. Allcomplicated obstetric cases had appropriate consultation andsupervision. This is in no way mitigated against the known poten-tial complications of regional anesthetic techniques or the localanesthetic agents themselves, but rather emphasized the role ofthe anesthesia health-care team. If invasive techniques (i.e., drugs,inhalational agents, regional anesthetics) are to be used inobstetrics; if the specialty of anesthesia continues to promote, de-fend, and demonstrate maternal and fetal advantages of regionalanesthesia for pain relief in labor; then regional anesthetic techni-ques must be made available to all rather than a select few.The only forseeable way to begin implementation of such a goal

is the active training, retraining, and recruitment of more CRNAanesthetists in regional anesthesia and, in particular, in thesubspecialty of obstetric anesthesia. If this is to occur successful-ly and safely, the physician-anesthesiologist cannot be allowed todeny that the obstetric unit exists. Physician-anesthesiologistdirection and implementation of anesthetizing policies in theobstetric suite (already a responsibility as I read JCAH) mustbecome reality.The challenge of the 1980's to this society of perinatal specialists

(obstetricians, anesthesiologists, and neonatologists) is to insistand ensure that relative to anesthesia, the statement in the 1970JCAH guidelines, "The anesthesia personnel and equipment inthe maternity unit shall be equivalent to that provided theemergency patient in the operating room suites" is indeed fact.2

REFERENCES:

1. The Experts Opine. Survey of Anesthesiology 26: 252-255, 1982.

2. Joyce TH. Foreword, Symposium on Obstetric Anesthesia andAnalgesia. Clinics in Perinatology, W.B. Saunders Company, Phila-delphia, PA, 1982.

ANIMAL RESEARCHERS

Would you like a session at this year's SOAPmeeting in which to discuss models and methods?Want to hear Cleveland Amory debate Sol Shnider?Tell Graham McMoriand, and he'll try to coordinatesuch a session (outside the regularly scheduled ses-sions). His address appears elsewhere in this issue.

MAILING LISTSAVAILABLE-FOR A PRICE

Complete SOAP mailing lists, including active members, News-letter subscribers, and persons listed by request (chiefs ofanesthesiology, neonatology, and maternal-fetal medicineprograms) are available to SOAP members who need to publicizemeetings or communicate with the membership. As the Societydoes incur some expense each time in printing the list (computertime, label cost), we will need to pass that expense along to listusers. Therefore, copies of the SOAP mailing list printed on gum-med labels will be available to professional non-commercial usersfor $25 each except when used for society business, when SOAPwill foot the bill.The SOAP mailing list also remains available to commercial

users. Commercial users may "rent" the list for a one-time use indistributing a communication deemed likely by theSecretary/Editor to be of interest to SOAP members. The Societycharges a substantial fee for this commercial use of the mailing list,and the income helps pay for part of the cost of maintaining anup-to-date mailing list.Requests for copies of the mailing list for professional or com-

mercial use should be directed to the Secretary/Editor.

CHECK YOUR MAILING LABELThe SOAP Newsletter has moved to Seattle, and the mailing list

has moved to a new computer. Please take a moment to seewhether your name and address are (still) correct. Also, pleasecheck the information on the first line of the label.The first letter indicates your medical specialty (A -

anesthesiologist; 0 -obstetrician; P - pediatrician; K - other). Thenumbers in the middle indicate by year the SOAP meetings wethink you have attended. The last number in the line indicates theyear in which your Newsletter subscription or entitlement will ex-pire (with the Spring issue). If your label saysREQ, you are receiv-ing the Newsletter because someone in the Society wanted you toknow what we are doing and didn't figure you'd pay to know(chiefs of training programs, foreign lur;ninaries, governmentfunctionaries, and the Editor's mother, for example).Please force us to correct all information; call or write the

editorial office at once.

MISSING YOUR NEWSLETTER?

If you've missed some back issues of the Newsletter, wehave plenty. Ask, and they shall be given unto you. Justsend a note to the editorial office in Seattle.Incidentally, the two main reasons why people miss

copies are 1) lethargy and carelessness in your ownhospital's mail room, and 2) failure to tell us of a change ofaddress.

SOAP NewsleUer Page 11

lOPPORTUNITIES 1As a service to SOAP members, advertisements for available positions will be printed

free of charge as space permits. Ads will be deleted after they have been published

in four consecutive issues (one year). Advertisers are requested to notify us as soon

as positions are filted. Address all correspondence about ads to Hilda Kapusy,Department of Anesthesiology, RN-10, University of Washington, Seallle, WA 98195.Phone (206) 543-4070.

WASHINGTON Position available at the University of Washington,Department of Obstetrics and Gynecology, Division of PerinatalMedicine. Applicants must be board certified or board eligible inOB-GYN. Candidates should be either board eligible or boardcertified in Maternal-Fetal Medicine or be board certified inInternal Medicine. The University of Washington is an equalopportunity employer and welcomes applications from women orminority groups, Contact Thomas J. Benedetti, M.D., SearchCommittee Chairman, Dept. of OB-GYN, RH-20, University ofWashington School of Medicine, Seattle, WA 98195. 9/81

FELLOWSHIPS

CALIFORNIA l-year O.B. anesthesia fellowship for the 1983-84academic year. Clinical experience is in Levell Perinatal Centerwith in excess of 4.000 deliveries per year. Opportunity to take partin clinical research program and teaching of medical students.Contact G. M. Bassell, M.D .. Director of Obstetric Anesthesia,University of Califorria, Irvine Medical Center, 81A, Orange,California. 92668. 5/82

TEXAS Opportunity for one-year specialty tralntng in high riskobstetric unit with approximately 6500 deliveries per year. Activeclinical research program, as well as chronic maternal-fetal sheepexperimentation. Faculty position. Reply to Robert Hodgkinson,M.D., Department of Anesthesiology, The University of Texashealth Science Center at San Antonio, 7703 Floyd Curl Drive, SanAntonio, TX 78284. 8/80

WASHINGTON Potential one or two year fellowship programcombining research, teaching, and clinical experience on high-risk referral obstetric unit. Program could be individualized to leadtoward academic obstetric anesthesia or toward leadership in com-munity obstetric anesthesia practice. Contact Michael H, Plumer,M.D., Department of Anesthesiology RN-l0, University of Wash-ington, Seattle, Washington 98195. (206) 543-4070,10/82

WASHINGTON, D.C. Approved one-year specialty training athigh-risk obstetrical unit - 3000 deliveries per year. Ampleopportunity for clinical experience, teaching, clinical and animalresearch using the chronic maternal-fetal sheep preparation.Contact John B. Craft, Jr., M.D., Director, Obstetric Anesthesia,George Washington University Hospital, 901 23rd Street, N.W.,Wasington, D.C. 20037. (202) 676-3864. 8/80

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FLAKESSOAP

CALIFORNIA One-year OB anesthesia fellowship with rotationthrough three Los Angeles hospitals for clinical experience orresearch opportunity as desired. Contact Kenneth A. Conklin,M.D., Ph.D., Director of Obstetric Anesthesia, UCLA Center forHealth Sciences, Los Angeles, CA 90024. (213) 824-6225or (213)825-

5021.8/80 <" i2\\.1'~~26CALIFORNIA Immediate openings for PGY4 resiBe'nts in approvedObstetrical Anesthesia Residency at high risk Obstetrical Unit.Ample opportunity for clinical experiences and human research.Contact Therese Abboud; M.D., Associate Professor of Anesthesia,LAC-USC Medical Center, 1200 North State Street, PO Box 12, LosAngeles, CA 90033. (213) 226-3293.11/80

PENNSYVANIA The Department of Anesthesia at PennsylvaniaHospital, a major affiliate of the University of Pennsylvania Schoolof Medicine, has an opening for an individual with primary interestin obstetric anesthesia. Full or part time faculty appointment will becommensurate with experience and qualifications. Minimumrequirements include completion of a 3 or 4 year post graduatetraining program, board certification or eligibility, PA statelicensure or eligibility, and training in obstetric anesthesia. This is avery active patient care and teaching service with 3500deliveries ayear. Research is encouraged. Send curriculum vitae and names of3 references to: Melville Q. Wyche, Jr. M.D., Dept. of Anesthesia,Hospital of Anesthesia, Hospital of The University of Pennsylvania,3400 Spruce Street, Phila. PA 19104. Affirmative Action/EqualOpportunity Employer. 9/81

TENNESSEEUniversity of Tennessee Center for the HealthSciences, Department of Anesthesiology, is seeking board cer-tified anesthesiologist to serve as Professor and Chief ofObstetric Anesthesia Division. Position requires extra ex-perience and/or training in obstetric anesthesia, qualifying anindividual for a division leader. Anti<;ipate development of fullscale programs of research, patient care, and education in thefield of obstetric anesthesia. Interested applicants should write:Robert S. Crumrine, M.D., Chairman, Dept. of Anesthesiology,UTCHS, 848 Adams Avenue, Memphis, TN 38103. 10/82

OHIO Director for Division of Obstetric Anesthesia, Departmentof Anesthesiology, University of Cincinnati. Professor or AssociateProfessor depending on experience. Responsible for teaching andpatient care in high-risk obstetric unit, approximately 4500deliveries per year. Research encouraged, facilities available, Sendcurriculum vitae to Phillip O. Bridenbaugh, M,D., Chairman,Department of Anesthesia, University of Cincinnati MedicalCenter, 231 Bethesda Avenue, Room 3507 MSB, Cincinnati, Ohio45267. 9/81

PENNSYLVANIA Academic obstetric anesthesiologist needed;capable teacher with clinical/laboratory research ability requiredfor Magee-Womens Hospital, University of Pittsburgh. 10,000deliveries per year. Contact: Ray McKenzie, M,D., Chief ofAnesthesiology and Professor of Anesthesia, Forbes and HalketStreet, Pittsburgh, PA 15213. Phone (412) 647-4260, 10/82

NEW YORK Private practice group seeks anesthesiologist;combines OB anesthesia at University-affiliated birthing center(3700 deliveries/year) with anesthesia for ambulatory surgery athospital-operated Surgery Center (5,200 anesthetics/year). Join 4anesthesiologists and 5 CRNA's in this exciting practice. Located inthe heart of Central New York State between the Finger Lakes andthe Adirondacks. Send CV to Jack Egnatinsky, M.D., CNYAnesthesia Group, P.c., 736 Irving Avenue, Syracuse, New York,13210 (315) 470-7828. 1/82

TENNESSEEMedical Center with 600 Adult and 100 pediatric beds,has need for BEor BC Pediatric Anesthesiologist. Excellent practiceopportunity with over 14.000 procedures per year. If interestedplease send complete CV to: D. L. Bramlett. 1 East NorthwestHighway. Suite 102. Palatine. IL 60067 or call collect (312) 991-4070.7/82

Ezzat Abouliesh, long a fixture at Magee Women's Hospital inPittsburgh, has apparently despaired of inducing SOAP to cometo Pittsburgh for a meeting. He's moving to Houston.

Karen Gould, finding time heavy on her hands since the SOAPNewsletter left Boston, has committed matrimony.

Mail to: Michael H. Plumer, M.D.Editor, SOAP, NewsletterDept. of Anesthesia, RN-10University of Washington, School of MedicineSeattle, Washington 98195

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The SOAP Newslener is published quarterly in Seanle,Washington by the Society of Obstetric Anesthesia andPerinatology. Unless otherwise indicated, opinions expres-sed are thos of the Editor and do not necessarily representthe consensus of the Society. Address correspondence tothe Editor at Department of Anesthesiology, RN-lO, Univer-sity of Washington School of Medicine, Seanle, WA 98195(206) 543-4070

EDITOR: Michael H. Plumer. M.D.

EDITORIAL ASSISTANT: Hilda Kapusy

SOAP 1982-83BOARD OF DIRECTORS

PresidentThomas H. Joyce II, M.D.Houston, Texas

TreasurerGraham McMorland, M.B., Ch.B.Vancouver, B.C., Canada

Vice PresidentRobert Hodgkinson, M.D.San Antonio, Texas

Secretary/EditorMichael H. Plumer, M.D.Seattle, Washington

Director-at-LargeRichard B. Clark, M.D.Little Rock, Arkansas

Director: ObstetricsThomas Benedetti, M.D.Seattle, Washington

Director: NeonatologyLawrence Grylack, M.D.Washington, D.C.

Chairman, ASA Committeeon Obstetrical AnesthesiaCharles P. Gibbs, M.D.Gainesville, Florida

SOAP IEWSI.ETlBDepartment of Anesthesiology, RN-10University of WashingtonSchool of MedicineSeattle, WA 98195

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