To the Editor:-We read with interest the case report by Dr Schaut et al., on sevoflurane inhalational induction for emergency cesarean section in a parturient with no intravenous access (Anesthesiology 1997; 86:1392–4). The authors did not address two important concerns in their case report: implications of commencement of surgery in absence of intravenous access, and medicolegal issues.

Cesarean section is not a benign procedure and can be associated with life-threatening complications such as uterine atony hemorrhage, hypotension, amniotic fluid embolism, air embolism, disseminated intravascular coagulation, uterine tears, and so on. These could lead to disastrous consequences in absence of an intravenous access. Baby delivery before intravenous access, therefore, may impose additional risks to risks already associated with mask anesthesia. Although the relative incidence of each of these complications is low, the combined risk of mask anesthesia and surgery without an intravenous access should not be disregarded. This raises an important question of whether the obstetricians were justified to put intense pressure on the anesthesiologists as described by authors. There appeared to be no time to discuss the additional risks involved with a technique deviating from standard of care with the patient or the husband.

During cesarean section, the risk-to-benefit ratio implies risk to the mother versus benefit to the baby. The primary responsibility of the anesthesiologist and the obstetrician is directed toward the safety of the mother. We congratulate the authors for producing a successful outcome. One favorable outcome, however, does not imply that the anesthetic approach is justified, safe, or advisable. If this mother had suffered some sort of catastrophe resulting from lack of intravenous access, it would be hard to defend the technique as performed here. Publication of this case report should not imply advocacy of this technique in similar circumstances, nor set a precedent. Two dictums are relevant here. First, do not allow a fetal disaster deteriorate into a maternal disaster. Second, it is always preferable to give a dead baby to a living mother than to give a dead mother to a living husband.

K. Bhavani-Shankar, M.D.

Clinical Fellow in Obstetric Anesthesia

William R. Camann, M.D.

Assistant Professor; Department of Obstetric Anesthesia; Brigham and Women's Hospital; Harvard Medical School; 75 Francis Street; Boston, Massachusetts 02115

(Accepted for publication September 10, 1997.)