Controversies in Obstetric Anesthesia and Analgesia.

Abstract

The majority of obstetric patients are healthy. However, with the increase in obesity and metabolic syndrome, advanced maternal age, and often suboptimal prenatal care, many parturients have medical comorbidities that are not recognized before labor.Among the general surgical population, patients are evaluated preoperatively by an anesthesiologist or internist to optimize medical management before a planned surgery. Obstetric patients, however, may experience labor with limited or no previous medical attention. They can present with pathology, such as severe blood pressure elevation, lower extremity swelling (which may be normal, a clot, or the effect of heart failure), untreated asthma, or abnormal placental implantation placing them at risk for hemorrhage. These issues during labor are often concurrent with a nonreassuring fetal status necessitating prompt delivery. The obstetric ward then converts to a critical care unit with American Society of Anesthesiologists physical status class 3 and 4 parturients about to undergo major metabolic stresses and hemodynamic shifts in labor, which may worsen their peripartum morbidity. Intensive attention by the anesthesiologist, communication with the obstetric team to weigh the risks and benefits of a management plan, and quick implementation of this plan are crucial in the care and safety of this patient population.Controversies in Obstetric Anesthesia and Analgesia is planned perfectly for its target audience. It is a teaching text for trainees and a quick refresher for experienced practitioners. In the Preface, a concise synopsis of the goals are identified, which are consistently met in each chapter. To evaluate the usefulness of its content, we consulted the book when different situations arose in our high-risk labor and delivery suite. Common controversies addressed were how to manage a parturient with substance abuse, how to minimize risk for a patient undergoing cesarean delivery who has not fasted beforehand, and how to treat hypotension after a neuraxial block. The pros and cons of routine administration of oxygen during cesarean delivery were considered, as was an evaluation of the benefits of regional anesthesia in patients with a coagulopathy. More interesting, however, this book addressed critical care topics in pregnancy. For example, in the case of a patient with severe mitral stenosis presenting in labor, the book provided quick solutions for the optimal management, along with a digestible explanation of the interaction of this valvular pathology and labor. Similarly, when a patient with an ejection fraction of 28% was admitted for induction of labor, the peripartum cardiomyopathy section contained suggestions for management with a quick, yet thorough, explanation of the reason for each recommendation. For the reader who seeks more information, references are cited at the end of each chapter.We highly recommend this book. It has a permanent home in our hospital’s obstetric anesthesia workroom, accessible both to residents and attendings. In short, this book is current, concise, and well-organized, and is a welcome addition to our practice.Jennifer Hofer, M.D.*and Barbara Scavone, M.D.*The University of Chicago Medical Center, Chicago, Illinois. jhofer@dacc.uchicago.edu