Ostheimer’s Manual of Obstetric Anesthesia, 3rd Edition. Edited by David J. Birnbach. Philadelphia, Churchill Livingstone, 2000. Pages: 345. Price: $45.00.
Given the recent proliferation of obstetric anesthesia texts, at first glance, this seems to be yet another that may end up incompletely read, next to the other incompletely read texts on the shelf of the harried anesthesia resident. Written by physicians who were all trained by the late Gerald Ostheimer, this text is designed for the anesthesia resident (and although not mentioned, the CRNA student) first entering the realm of obstetric anesthesia. However, looking at the back cover, one might initially be confused because it mentions the skills one should acquire during “obstetric residency rotations,” rather than obstetric anesthesia rotations. As a book designed for a busy resident, it does fit easily into a laboratory coat or the back pocket of scrub pants, and it contains a wealth of information in its pages.
The use of multiple authors in a manual of this size highlights one of its weaknesses: the writing styles vary considerably. A single author would provide a more consistent, better integrated, and more easily read reference. Some of the chapters, particularly those of Drs. Shopper (“General Anesthesia for Cesarean Section”) and Suresh (“Obstetric Hemorrhage”), are particularly well-written. The conversational, authoritative format of these chapters are easily read and comprehended. Others, however, are terse and somewhat dry.
The book has some distinctive features. Dr. Birnbach’s checklist at the beginning of the manual is well-written, providing the resident with a framework for acquiring knowledge during his or her rotations. Although well-discussed in the chapter “Embolic Disease,” no mention of venous air embolus (a complication that could be encountered by the resident) is found in the checklist. Black-boxed “Key Points” are scattered throughout the chapters and serve to focus the reader’s attention on essential issues. Although mentioned in the text, many of these points are not highlighted or weighted in the discussion and thus stand alone. I would suspect that many residents might read only the key points while performing a review. One key point about providing neuraxial analgesia to patients undergoing vaginal birth after cesarean delivery (page 251) does not include the term—the patients are referred to as “. . . women undergoing a trial of labor . . . ,” which covers much broader ground—and could be confusing.
The chapters are logically and traditionally arranged. The initial chapters about maternal physiology and fetal monitoring are well-written and provide the resident with a reasonable background to look intelligently at a fetal heart rate tracing. Perinatal pharmacology is discussed in depth, although the devotion of half a page to an illustration of an instrumented gravid ewe in a “handbook” is baffling. There is one unfortunate error on page 59, stating that only “bound” (vs. unbound) drug can pass the placenta, which may briefly confuse reader. A simple illustration of the sodium channel and the cell wall would readily transmit an understanding of local anesthetic action but is not present in the local anesthetics chapter. Transient radicular irritation and the dilution of 5% lidocaine are mentioned, but recent evidence that lidocaine may be neurotoxic at any concentration is not mentioned.
The explanations of epidural placement, combined spinal epidural placement, and continuous spinal anesthesia are excellent and provide the novice with a real guidebook for successful placement. Unfortunately, some of the illustrations in this section (especially those showing hand position) are not of the quality seen in other parts of the text. In the chapter about regional anesthesia for cesarean delivery, a mention of electrocardiographic changes and myocardial ischemia is inexplicably referred with Joy Hawkins’ 1994 abstract about obstetric anesthesia manpower.
The chapter about general anesthesia for cesarean delivery is the great pearl in this manual and is worth the price of the book. Issues, concerns, and techniques are well–laid out. However, in a book this recently published, an illustration of the LMA-Fastrach™ (The Laryngeal Mask Company, Henley on Thames, Oxon, UK) should have been included. Additionally, when illustrating the use of the fiberoptic scope through a laryngeal mask airway to pass an endotracheal tube, I would have preferred to see an illustration showing the use of the circuit with a side-arm swivel adapter and a gently inflated endotracheal tube in the laryngeal mask airway barrel that allows the provider to maintain continuous ventilation while passing the fiberoptic scope into the trachea.
The management of obstetric complications is again logically arranged. Dr. Suresh’s chapter about hemorrhage stands out for several reasons. This chapter provides the only thorough explanation of a “double setup” in the text. The proper uses and dosages of oxytocin, methylergonovine, and prostaglandin F2α are outlined. A key point about how to use a bedside clot tube is present, as well as cogent tables for transfusion and blood product administration. Interestingly, although placenta accreta, percreta, and increta are illustrated, no definitions are provided.
Considering the depth in which other items were discussed (e.g. , perinatal pharmacology), I found it perplexing that although eclampsia and preeclampsia are defined, no pathophysiology of the disorder is offered. Another concern is a table mentioning the use of sublingual nifedipine for blood pressure control, despite limited experience in this population, and its association with serious complications. 1
Diabetes, asthma, cardiac disease, obesity, and other high-risk conditions are well-outlined and succinctly presented. Rather than mentioning the need for a delivery device for inhaled β agonists for general anesthesia, a picture of a metered dose inhaler in a 60-ml syringe that can be readily attached to the sampling port of a circuit would serve residents with an easily remembered means of administration when treating bronchospasm.
The inclusion of the “Guidelines for Obstetric Anesthesia,” which include not only the practice guidelines but also the standards for basic anesthesia care, provides the reader with a single source for cogent discussions with hospital administrators and obstetric colleagues.
Dr. McDonald’s chapter “Legal and Ethical Issues in Obstetric Issues in Obstetric Anesthesia” is a bonus that should be published as a separate monograph and given to residents and attending staff alike. He clearly outlines the four essential elements of a malpractice action as well as ethical issues regarding consent for labor epidurals, transfusions in Jehovah’s Witness patients, and fetal and neonatal pain. This chapter provides topics not only for departmental discussions, but also for individual soul searching.
Overall, despite some inconsistencies among chapters and authors, this is a good manual for the anesthesia resident or the attending anesthesiologist coming back to obstetric anesthesia after an absence, and I will recommend it to my institution’s residents. The explanations of regional techniques and general anesthesia for cesarean delivery are excellent. The postoperative pain management section could be more current. Is there room for yet another handbook about obstetric anesthesia? I suspect so.
