James C. Eisenach, M.D., Editor

Pain Relief and Anesthesia in Obstetrics, edited by Andre Van Zundert and Gerard W. Ostheimer. New York, Churchill Livingstone, 1996. Pages: 1,062. Price: $89.95.

I have to admit, my first thought after receiving this 12-pound, 1,100-page book was "This is the last thing I need further crowding my office!" This initial impression was based, in part, on the plethora of fine obstetric anesthesia texts that have been published recently, including Sol Shnider's Anesthesia for Obstetrics, Mark Norris' Obstetric Anesthesia, and David Chestnut's Obstetric Anesthesia: Principles and Practice, as well as a large assortment of more abridged handbooks and paperbacks.

Among the aforementioned texts, it seems most appropriate to compare Dr. Chestnut's work to Ostheimer and Van Zundert's. Both are of very recent vintage, and aim to be complete and authoritative references. My primary goal in reviewing Pain Relief and Anesthesia in Obstetrics was to try to decide which of these tomes would best fulfill these aims, because it seemed unlikely that many anesthesiologists would need both.

It is apparent, from perusing the contributors of each text, that entirely different approaches were used in selecting the chapter authors. Dr. Chestnut selected an overwhelmingly North American authorship, whereas Ostheimer and Van Zundert chose a strikingly international mix (5 continents are represented). There are risks and benefits to this approach. Chestnut's text reads extremely well to a practitioner most accustomed to North American style prose, and gives an extremely complete view of the art and science of obstetric anesthesia as it is practiced in the best American and Canadian centers. For many North American readers, this may be exactly what they are looking for in a major textbook. In contradistinction, Ostheimer and Van Zundert take aim at a more worldwide audience. Much of their text is devoted to comparing and contrasting the evolution and current practice of obstetric anesthesia among many diverse regions of the world. I found the section on "Organization of an Anesthetic Service for Obstetrics" particularly enjoyable reading, because it compared Australian, South American (Chile and Argentina), British, continental (Swedish, French, Spanish, and Italian), and American author's viewpoints and experiences in this arena. Although this is clearly not the subject area one is likely to explore when trying to develop an anesthetic plan for a complicated parturient, it may be very helpful to innovative anesthesia departments trying to redesign obstetric anesthesia delivery under strong fiscal pressure.

The organization of the text combines traditional and more innovative approaches. After an extremely well written and complete section on the history of pain relief in childbirth, the text is organized into major sections of Maternal-Fetal-Neonatal Considerations, Epidural Anesthesia, Alternatives to Epidural Anesthesia, Anesthesia for Cesarean Section, The High-Risk Parturient, Maternal and Neonatal Outcome, Structure and Function (of Obstetric Anesthesia Services), and finishes with a Controversies section. For the most part, this organizational pattern is well thought out and complete. The High-Risk Parturient and Her Fetus section explores some very interesting coexisting disease in a number of mini-chapters (4-6 pages each). These include carbon monoxide poisoning, venous air embolism, and use of the laryngeal mask airway in obstetric airway emergencies. Other sections seemed a bit loose in their organization, such as the Maternal and Neonatal Outcome section, which contains chapters on parturients with transplanted organs and which seems more appropriately included under the High-Risk Parturient section. Likewise, the Controversies in Obstetric Anesthesia mixes appropriate chapters such as Effects of Epidural Anesthesia on the Progress of Labor with some interesting, but hardly contentious, topics, such as Nutrition During Pregnancy and Computers and Fetal Monitoring. There are also a few chapters that seem as if they overlap excessively with other chapters. An example is Use of Hyperbaric Oxygen, which deals almost exclusively with carbon monoxide poisoning, and might have been combined easily with the Acute Carbon Monoxide Poisoning in Pregnancy chapter.

Although the content of Pain Relief and Anesthesia in Obstetrics is generally complete, one glaring weakness is in the area of intrathecal opioid analgesia for labor. Clearly, this is an immensely popular technique in many obstetric anesthesia centers, and is barely mentioned within this text. This may be due to the logistics of publishing such a major work (most of the references are 1991 and earlier), or related to delays associated with the tragic death of Dr. Ostheimer. Another section of this text that is similarly dated is Effects of Anesthesia on the Progress of Labor, whose most recent reference is from 1990. Clearly, all of the controversy and information generated by the contrasting studies of Thorp and Chestnut are missing. In contrast, Chestnut's Obstetric Anesthesia: Principles and Practice covers intrathecal opioids during labor more completely, and addresses the impact of epidural anesthesia on labor outcome with references through 1993, despite being published more than a year earlier. In this reviewer's opinion, these two topics are the "hottest" issues in obstetric anesthesia today, and the dated coverage detracts from an overall positive review of this text.

In conclusion, Ostheimer and Van Zundert's Pain Relief and Anesthesia in Obstetrics is a generally complete obstetric anesthesia reference text whose major strength is the strikingly international authorship and contrasting of anesthetic approaches in diverse regions of the world. Practitioners less interested in this facet of the text and more interested in the most up-to-date and complete discussions of major obstetric anesthesia issues and controversies might be better served with Dr. Chestnut's text.

Christopher M. Viscomi, M.D., Section of Obstetric Anesthesia, Department of Anesthesiology, University of Utah, 50 N. Medical Dr., Salt Lake City, Utah 84132.