Unless planning to issue an update on practice guidelines for obstetric anesthesia, the American Society of Anesthesiologists (ASA), along with its subspecialty organization, the Society for Obstetric Anesthesia and Perinatology (SOAP), should formulate a consensus statement for peri-anesthesia management during out-of-hospital cesarean sections (OHCS). Florida has become the first state to allow OHCS, an infrastructural relaxation for obstetric care that other states may follow. Whether the ensuing outcomes among pregnant patients, mothers, and their newborn infants in Florida will accentuate or attenuate the spread of OHCS nationwide, a timely anesthesia advisory by ASA/SOAP for anesthesiologists practicing in Florida would be beneficial. Not only in-state but also out-of-state anesthesiologists could be providing general and conduction anesthesia-analgesia in Florida’s advanced birth centers (ABCs) during labor epidurals and OHCS among pregnant patients, postpartum sterilization among mothers, and potentially during circumcision among their newborn infants.
Although mothers may stay at ABCs for 48-72 hours after delivering their newborns vaginally or surgically, input from the Society for Ambulatory Anesthesia (SAMBA) in anesthesia advisory could be warranted. The historical experiences of ambulatory anesthesiologists at already-established ambulatory surgery centers (ASCs) could guide future outcomes among obstetric anesthesiologists managing obstetric patients and their newborns at the newly-invented ABCs. The health care cost-containment with ABCs delivering accessible care to pregnant patients, mothers, and their newborn infants would require ABCs to achieve non-inferior health care outcomes compared to hospitals. However, neither the pregnant patients, mothers, nor newborn infants can be allowed to fall through the cracks in the absence of preemptive anesthesia advisory, considering that along with at least one obstetrician per ABC, at least one anesthesiologist per ABC is mandated per the new Florida law.
Since it is not clearly stipulated in the new Florida law whether the ABCs must have at least one pediatrician per ABC, it may be assumed that the responsibility for neonatal resuscitation would fall on obstetric anesthesiologists. These professionals may need to meet the requirements of the Neonatal Resuscitation Program (NRP) of the American Academy of Pediatrics (AAP) before acting as neonatal anesthesiologists. There could be a natural selection for obstetricians and anesthesiologists based on their competence in time efficiency when performing OHCS at ABCs. There are concerns about whether mean-median indemnity payments to injured parties and legal expenses for injured parties will escalate due to OHCS at ABCs unless ASCs have historical non-obstetric data to prove otherwise, thus potentially overcoming the resistance among obstetricians and anesthesiologists to perform OHCS at ABCs.
Until ABCs evolve to effectively screen their patients for high-risk peripartum hemorrhage and preemptively refer them to hospitals for peripartum management, it may fall to obstetric anesthesiologists to advocate for the prophylactic use of tranexamic acid in low-resource settings. This could supplement the strategy for liberal use of intrauterine balloons during OHCS at ABCs, with the question always lingering whether all pregnant patients who have been typed and crossmatched for blood transfusion should go to hospitals rather than staying at ABCs. These patients might be at high risk for peripartum hemorrhage compared to those only typed and screened for blood group and antibodies.
It would be interesting to see what an anesthesia advisory might say about restricting management at ABCs based on ASA-approved adult examples like body mass index and ASA-approved obstetric examples like complicated pregnancy, which could upgrade patients’ ASA physical status classification and thus their peri-anesthesia risks. Only time will tell whether OHCS at ABCs will remain limited to elective and planned OHCS. Obstetric anesthesiologists must be well-prepared for emergent and unplanned OHCS, whether or not their labor epidurals could be deemed to risk an increased prevalence of such emergent and unplanned OHCS. Obstetricians at ABCs might defer timely referrals of their patients to hospitals for CS when ABCs have the infrastructure to support OHCS.
There could be additional challenges for obstetric anesthesiologists regarding the use of opioids vs. non-opioids as neuraxial adjuvants at ABCs and postoperative pain management with opioids vs. non-opioids with and without regional nerve blocks. Inspired by trauma anesthesiologists’ perioperative roles in transporting hemorrhaging trauma patients, the role of obstetric anesthesiologists must be clearly defined when transporting intraoperative and postoperative obstetric patients who could be actively hemorrhaging. Unless ABCs choose to have mobile operating suites, it might be feasible to transport the mobile operating suites themselves to collaborating hospitals rather than transporting hemorrhaging obstetric patients to those hospitals.
As society has finally arrived at this point, anesthesiologists should not delve into how escalating health care costs might be evolving health care deserts, either due to reimbursement difficulties or medicolegal liabilities. Neither the diverse geography nor the dispersed demography helps contain health care deserts. Anyhow, OHCS might be here to stay, and anesthesiologists should not reminisce the time when OHCS was only limited to the rarest of rare perimortem CS, now more appropriately termed resuscitative hysterotomy.
Deepak Gupta is an anesthesiologist.
