To the Editor:—
In their recent obstetric anesthesia workforce survey, Bucklin et al. 1observed that anesthesiologists provided regional analgesia for labor more often in 2001 than in 1992 or 1981. Obstetricians provided correspondingly less, with the main decrease occurring between 1981 and 1992. In 1981, obstetricians provided 26, 31, and 46% of regional analgesia in the three sizes of institutions surveyed, whereas in 1992, they provided 0, 5, and 3%. Similarly obstetricians administered 3, 4, and 9% of anesthetics for cesarean deliveries in 1981 but none in 1992.2Hawkins et al. 2and Lagasse and Santos3previously noted these dramatic decreases between 1981 and 1992, relating them in part to concerns about medicolegal liability by obstetricians.
The source of these liability concerns was the publication in 1982 of revised professional standards by the American College of Obstetricians and Gynecologists (ACOG). For the first time, ACOG discouraged the concurrent provision of both an anesthetic and a procedure by an obstetrician, a previously common occurrence, and required the inclusion of anesthesia departments in privileging practitioners for obstetric anesthesia. The fifth edition of the Standards for Obstetric-Gynecologic Services , published in 1982, states,4
An obstetrician trained in the appropriate methods of anesthesia administration may provide the anesthesia if privileges for these procedures have been granted by the obstetric and anesthesia departments. However, it is more desirable for an anesthesiologist or anesthetist to provide this care so the obstetrician may devote undivided attention to the delivery …
Any ambulatory surgical unit that utilizes general, epidural, or spinal anesthesia should do so under the direction of an anesthesiologist.
The fourth edition of the Standards for Obstetric-Gynecologic Services , published in 1974,5contains no warning about divided attention or inclusion of anesthesiologists in privileging and qualifies anesthesiologist care with the terms “whenever possible.” The 1982 explanation that obstetricians should concentrate on obstetrics while anesthesiologists concentrate on anesthesia appeared in the official ACOG Standards that sought “a high standard of quality care” and were designed “to set forth recommendations and suggested guidelines for agencies, hospitals and individuals to follow.”4
This philosophy of care seems obvious today but was controversial in the 1970s. In 1981, 46% of obstetricians agreed with the statement that anesthesiologists are not sufficiently trained in obstetric anesthesia.6Some insurance plans paid obstetricians for labor anesthesia. Therefore, the outcome of any deliberations by ACOG members in 1981 over obstetric anesthesia care was uncertain. The philosophic shift represented in the 1982 Standards is an obstetric anesthesia milestone.
The obstetrician chairing the ACOG Professional Standards Committee between 1978 and 1981, which developed the fifth edition Standards, was Robert E. Johnstone, M.D. (fig. 1). He was a Professor of Obstetrics and Gynecology at the University of Cincinnati, Ohio, who had organized a group of obstetricians, midwives, and administrators to improve obstetric care within the city. Coleading this group was Richard Schmidt, M.D. (Director, Department of Obstetrics and Gynecology, Good Samaritan Hospital, Cincinnati, Ohio; President, ACOG, 1977–78; retired), Chair of the ACOG committee that published the 1974 standards, who involved Johnstone nationally. Together, they had worked on practices to improve the care of patients with toxemia of pregnancy, using professional education, written policies, and quality assurance programs. They then recognized that the second greatest cause of obstetric mortality in Cincinnati was related to anesthesia care. This was a concern and focus as Johnstone assumed the chair position of the national ACOG committee.
Johnstone had learned to perform regional anesthetics during his obstetric residency training at the Lying-In Hospital in Boston, Massachusetts. When he started his practice in Cincinnati in 1954, he sometimes administered saddle-block anesthetics himself to patients for difficult deliveries. He soon became busy and recruited a nurse anesthetist to anesthetize patients with open-drop ether, paying her salary out of his income. There were few anesthesiologists in Cincinnati during the 1950s and 1960s, and they spent their time in the surgical operating rooms. Women in labor received subcutaneous doses of narcotics, primarily meperidine, and sedatives until the time of delivery, when they would receive either the saddle block or ether anesthesia. Johnstone recognized that having an anesthesia practitioner in the delivery room allowed him to focus on the delivery. In 1970, Johnstone supported the founding of an anesthesiology residency at the University of Cincinnati School of Medicine. As this program grew during the 1970s, he observed lumbar epidural analgesia and other regional techniques that anesthesiologists could provide. He encouraged the participation of anesthesiologists in obstetric care and supported insurance payments for their services. Johnstone recognized improvements in patient outcomes as anesthesiologists provided more care.
The personal experiences by Johnstone with anesthesiology influenced him to advocate obstetric anesthesia care by anesthesiologists. During the 1970s, his son became an anesthesiologist, training in Philadelphia, Pennsylvania, and practicing in Alabama, and provided additional information about what anesthesiologists could do. They once discussed an unfortunate case in Alabama where an obstetrician administered a saddle-block anesthetic to a woman, delivered a baby with forceps, and then looked up to discover that the patient had arrested. Reinforced with such anecdotes and relying on personal observations, Johnstone was able in 1981 to lead a committee of obstetricians to a new standard: anesthesia by anesthesiologists.
Johnstone retired in 1988 but remains proud of his contribution to improving obstetric care (personal verbal communications from Robert E. Johnstone, M.D., Professor, Obstetrics and Gynecology, University of Cincinnati, Cincinnati, Ohio; Director, Department of Obstetrics and Gynecology, Christ Hospital, Cincinnati, Ohio; retired). His contribution is reported as an explanation for some changes noted in the obstetric anesthesia workforce surveys and an important step in the development of anesthesiology.
West Virginia University, Morgantown, West Virginia. firstname.lastname@example.org