The American Society of Anesthesiologists (ASA) and the Society for Obstetric Anesthesia and Perinatology (SOAP) should consider creating a consensus statement for peri-anesthesia management during out-of-hospital cesarean sections (OHCS) unless they intend to release an update on practice guidelines for obstetric anesthesia. Florida has become the first state to allow OHCS, potentially leading to other states following suit.
It remains to be seen whether the outcomes of pregnant patients, mothers, and their newborns in Florida will encourage or discourage the adoption of OHCS nationwide.
Florida anesthesiologists could use a timely anesthesia advisory from ASA/SOAP to help them give general and conduction anesthesia-analgesia in advanced birth centers (ABCs) for labor epidurals, OHCS for pregnant patients, postpartum sterilization for mothers, and maybe even circumcision for newborns. This would benefit not only in-state but also out-of-state anesthesiologists.
SAMBA’s anesthesia advisory may be necessary despite new mothers staying at ABCs for up to 72 hours after giving birth, whether vaginally or through surgery. Obstetric anesthesiologists managing obstetric patients and their newborns at newly established ABCs could benefit from the insights of ambulatory anesthesiologists at already established ambulatory surgery centers (ASCs).
While ABCs aim to provide accessible care to pregnant patients, mothers, and newborn infants while containing healthcare costs, they must attain non-inferior healthcare outcomes compared to hospitals. However, with at least one obstetrician and anesthesiologist per ABC mandated by Florida law, it’s crucial to provide preemptive anesthesia advisory to ensure that pregnant patients, mothers, and newborn infants do not fall through the cracks.
The new Florida law does not clearly state whether at least one pediatrician should be present per ABC, and as a result, it is likely that obstetric anesthesiologists would be responsible for neonatal resuscitation. To act as neonatal anesthesiologists, these professionals may need to fulfill the requirements of the Neonatal Resuscitation Program (NRP) of the American Academy of Pediatrics (AAP).
When it comes to performing OHCS at ABCs, there may be a natural selection for obstetricians and anesthesiologists based on their competence in time efficiency. However, there are concerns about potential increases in mean-median indemnity payments to injured parties and legal expenses for injured parties due to OHCS at ABCs, unless ASCs have historical non-obstetric data to prove otherwise. This may be a major factor in overcoming the resistance among obstetricians and anesthesiologists to perform OHCS at ABCs.
Obstetric anesthesiologists may need to take on the responsibility of advocating for the use of tranexamic acid in low-resource settings to prevent high-risk peripartum hemorrhage when ABCs fail to effectively screen and refer their patients to hospitals.
This approach could complement the practice of using intrauterine balloons during OHCS at ABCs. However, it raises the question of whether all pregnant patients who are typed and crossmatched for blood transfusion should be referred to hospitals instead of staying at ABCs, especially those who may be at a higher risk for peripartum hemorrhage compared to those who are only screened for blood group and antibodies.
It would be intriguing to see what an anesthesia advisory would recommend regarding the restriction of management at ABCs based on ASA-approved adult examples such as body mass index and ASA-approved obstetric examples like complicated pregnancy. These factors could potentially elevate a patient’s ASA physical status classification and increase their peri-anesthesia risks.
It remains to be seen whether OHCS at ABCs will remain limited to elective and planned procedures. Obstetric anesthesiologists must be prepared for emergent and unplanned OHCS, regardless of whether their labor epidurals are deemed to increase the prevalence of such situations. If ABCs have the necessary infrastructure to support OHCS, obstetricians may defer timely referrals of their patients to hospitals for CS.
Obstetric anesthesiologists may face additional challenges when deciding between opioids and non-opioids as neuraxial adjuvants for pain management during and after childbirth. Similarly, they must also consider the use of opioids versus non-opioids when administering postoperative pain management, with or without regional nerve blocks.
Drawing inspiration from the critical role trauma anesthesiologists play in transporting hemorrhaging trauma patients, the role of obstetric anesthesiologists in transporting intraoperative and postoperative obstetric patients who may be actively hemorrhaging must be clearly defined.
To avoid transporting hemorrhaging obstetric patients to collaborating hospitals, mobile operating suites could be transported instead. This would be a feasible alternative if ABCs choose to have mobile operating suites available for use.
Anesthesiologists must refrain from exploring how rising healthcare costs could contribute to the development of healthcare deserts, whether due to reimbursement challenges or potential legal liabilities.
The vast and varied geography, as well as the dispersed population, makes it difficult to prevent the emergence of these healthcare deserts. Nevertheless, it seems that OHCS (out-of-hospital cardiac arrest) is becoming increasingly common, and anesthesiologists should not long for the days when OHCS was only a rare occurrence, referred to as resuscitative hysterotomy.