PRO & CON.

Dr. Brett B. Gutsche is a professor emeritus of anesthesiology and of obstetrics and gynecology at the University of Pennsylvania, Philadelphia.

Should an anesthesia provider be present for vaginal delivery in all patients receiving neuraxial analgesia?

YEWS Not only should a member of the anesthesiology team be present throughout delivery, but one should see that patient at regular intervals during labor.

Often we hear that it will be a routine vaginal delivery and an anesthesiologist doesn't need to be there, but we can't predict what's going to be a routine vaginal delivery. The mobile epidurals used for labor analgesia today often do not provide adequate anesthesia for the vaginal delivery. We anesthesia providers need to be there to judge the necessity of supplementing that block, whether for a simple, straightforward, spontaneous vaginal delivery or because the ob.gyn. needs to do an operative vaginal delivery, such as forceps or vacuum extraction.

Anesthesia does away with protective reflexes. Even light blocks take them away, and we are responsible for monitoring and proper care of mothers with the loss of these reflexes. Improper positioning of the patient after epidural block can lead to perineal nerve damage. Quality assurance and medical legal considerations demand our presence at vaginal delivery

Financial and reimbursement issues dictate our presence at routine vaginal delivery as well. We talk about how poorly we are reimbursed for a labor epidural, but if all we're going to do is put an epidural in the patient and hook her up to a pump, have we earned what we're getting? We are not just a technical service, we are part of the team. And we're not part of the team if we just see the patient once and start the epidural.

In terms of maternal satisfaction, we contract with the patient when we give neuraxial anesthesia. That's not just her analgesia at the time we place it, but her analgesia throughout her labor and vaginal delivery