Obstetric Anesthesia, 2nd Edition.Edited by Mark C. Norris.Philadelphia, Lippincott Williams & Williams, 1999. Pages: 864. Price: $125.00.

Markus C. Schneider, M.D., Kantonsspital/University Women’s Hospital, Basel, Switzerland. Markus.Schneider@unibas.ch

In the Preface to this textbook, the editor emphasizes his aim to provide useful information about obstetric anesthesia practice, both for the residents in training and for practitioners involved in the management of normal and high-risk pregnancies, whether in the community or in university hospital settings. Therefore, the book “is organized the way an anesthesiologist approaches a patient: preoperative evaluation, intraoperative management, and postoperative care.” This format is in accordance with the concept of the anesthesiologist as a perioperative physician. The subject index also encompasses a variety of peripartum conditions that necessitate anesthetic interventions that are not related strictly to a surgical procedure, such as labor analgesia, resuscitation of the mother in response to amniotic fluid embolism, or neonatal resuscitation. In addition, the book addresses pertinent organizational and economic aspects of obstetric anesthesia services and examines legal and ethical issues surrounding this field of practice notoriously fraught with the inherent quandary as to what to do in the case of divergent maternal and fetal therapeutic priorities.

The editor, Mark C. Norris, Professor of Anesthesiology and Obstetrics and Gynecology at the Washington University School of Medicine, St. Louis, Missouri, is to be commended for engaging 52 experts from the United States, 3 from South Africa, and 1 from Canada as contributing authors, some of whom are among the most prominent representatives of specific areas of obstetric and anesthetic care, thus conferring on the book the prestige of accounts of the current opinion leaders.

The book is divided into four parts: (1) preoperative assessment; (2) intraoperative management, including a section about neuraxial analgesia for labor and delivery, anesthesia for cesarean section, and anesthetic management of complications in the parturient; (3) postdelivery; and (4) organizing an obstetric anesthesia service. The book includes a number of appendices that refer to standards, guidelines, and recommendations relevant for obstetric anesthesia as approved by the American Society of Anesthesiologists and the American College of Obstetricians and Gynecologists. Chapters are far from being uniform, ranging in length from 8 to 33 pages, including reference sections with 50–312 references per chapter that are reasonably comprehensive and up-to-date (through 1998). The vast majority of chapters contain an appropriate number of clear tables (ranging from 1 to 19) and figures (from 1 to 25) for illustration. These illustrations are of special interest for busy practitioners taking a quick look in search of some condensed information or specific recommendation because there are neither introductory outlines for quick orientation nor a conclusion or summary in many of the chapters. A series of colored pictures of the epidural space, the vertebral column, and the adjacent tissue structures are particularly beautiful, as are the photomicrographs of dural defects produced by different needles and the reproductions of fetal and uterine ultrasound findings. However, coming across a series of anatomic drawings showing how to perform an ilioinguinal nerve block in a subject with all the attributes of a male was somewhat of a surprise in an otherwise clearly female context.

The subject index of 39 pages is logical in format, easy to use, and a reliable source of most key words. However, because of the editor’s organizational concept of discussing major topics in different parts of the book, some information may be difficult to locate quickly in the index. I could not find information about the current practice of assessing coagulation in healthy parturients before providing neuraxial anesthesia or about the lack of evidence that determination of prothrombin time or platelet count should be implemented as a routine in this situation. Although blood donation is referenced under the heading of transfusion, the issues of intraoperative autologous blood transfusion and blood salvage are absent. Similarly, the use of thrombelastography and the limitations of testing bleeding time in assessing platelet function are indexed and presented thoroughly in the book, but the care of parturients at increased risk for thrombosis related to protein C or protein S deficiency is not included in the corresponding chapter. Although quality assurance constitutes an integral part of postoperative care and, as such, is emphasized throughout a number of the chapters, the appropriate key word is missing in the index section.

It is not a surprise that this book displays a variety of writing styles, some unevenness in depth and extent of coverage, and some redundancies, which are the labels and hallmarks of many textbooks produced by a multitude of authors. Thus, there are algorithms for failed intubation in two places, in the chapters “Anesthesia and the Compromised Fetus” and “Intraoperative Anesthetic Complications.” Because these algorithms are congruent, they are acceptable, but another repetition found in this book is contradictory and refers to trimethaphan as causing (p. 99) and not causing (p. 510) reflex tachycardia.

It would have been interesting to highlight the problems associated with adult respiratory distress syndrome in the context of “Intraoperative Anesthetic Complications” or in the chapter “Anesthesia and Preeclampsia/Eclampsia” and to refer to specific findings published in the triennial “Report on Confidential Enquiries into Maternal Deaths in the United Kingdom.”1In the last volume of these audits, covering 1994–1996, adult respiratory distress syndrome was found to be much more likely a complication of overtransfusion, fluid overload, and pulmonary edema after disseminated intravascular coagulation than a consequence of aspiration of gastric contents and to be a major factor contributing to maternal mortality. 1 

A brief summary of the chapters may help in portraying the scope, strengths, and shortcomings of the book. The first part contains chapters typically found in obstetric anesthesia textbooks that deal with preoperative assessment of the following: physiologic adaptation to pregnancy; preoperative examination of the parturient with coexisting disease; pathophysiology and obstetric management of preeclampsia; diabetes mellitus; perinatal physiology and pharmacology; fetal examination; and fetal complications. The second part includes the core chapters related to the intraoperative management of anesthesia and more information regarding the basic principles dealing with the following: surgery during pregnancy; anesthesia for fetal surgery; obstetric management of labor; mechanisms of labor pain; alternatives to conduction analgesia; anatomy of the epidural space; techniques of neuraxial analgesia for labor; intrathecal drugs; epidural drugs; effects on progress and outcome of labor; indications for cesarean delivery; general, epidural, and spinal anesthesia for cesarean delivery; anesthesia and cardiac disease, hematologic disease, diabetes, obesity, pulmonary, and neurologic disease, maternal substance abuse, preeclampsia and eclampsia; vaginal birth after cesarean section; intraamniotic infection; peripartum hemorrhage and maternal resuscitation; amniotic fluid embolism; intraoperative anesthetic complications; anesthesia and the compromised fetus; the premature fetus; fetal malpresentation and multiple birth; and neonatal resuscitation. The third part discusses anesthetic care after delivery for such issues as postpartum sterilization; postoperative analgesia; and postoperative complications associated with regional anesthesia. The fourth and final part contributes two fascinating chapters to guide the reader in the new millennium with a guide to managing a state-of-the-art obstetric analgesia–anesthesia service and legal and ethical issues for obstetric anesthesia.

Despite the risk of reflecting personal preferences and biases, some chapters deserve being referred to for their content and the amount of information provided. Too much information risks doing a disservice to trainees and busy readers who are looking for broad outlines and quick take-home messages. This may be the case in a number of chapters in the first part of the book. However, such a criticism does not apply to the excellent chapters about preeclampsia, perinatal physiology and pharmacology, or fetal examination and complications. The chapters about fetal surgery and surgery during pregnancy are easy to read and include a large number of illustrations. Because active management of labor has completely changed childbirth, a chapter about obstetric management has also been included. This is followed by an outstanding chapter about the mechanism of labor pain. In the chapter about alternatives to conduction analgesia, the concise description of how to perform a lumbar sympathetic block can benefit those not familiar with that alternative approach. The practical value of a textbook also relies on the provision of tips and tricks as in the chapter of neuraxial techniques. The chapters about intrathecal and epidural drugs are both up-to-date, include the various anesthetic compounds that are used in daily clinical practice, and refer to ambulation during neuraxial labor analgesia. The debate about their influence on labor progress and outcome is featured in a separate chapter, and most of these conclusions have been confirmed by a recently published meta-analysis. 2The indications for cesarean section, some economic implications, and different anesthetic management options are discussed thoroughly. Although accurate information is provided for the different anesthetic techniques for a combined spinal–epidural anesthetic, the option of a spinal–epidural anesthetic in preeclamptic parturients is not mentioned. The chapters about anesthetic management of complications in the parturient did not attract my attention as much as some other chapters. Nevertheless, I very much appreciated the review of vaginal birth after cesarean section and that of intraamniotic infection. As already mentioned, there is also quite a bit of overlap with other chapters in the book. The chapter about anesthesia in the presence of fetal compromise offers important insights into the specific dilemma in which both the mother and the fetus often are at risk. Anesthetic considerations in the case of a premature delivery are presented in the following chapter. After consecutive chapters that discuss important aspects of management of fetal malpresentation, multiple births, and neonatal resuscitation, a series of three chapters focuses on specific aspects of postpartum care, including anesthesia for tubal ligation, postoperative analgesia, and diagnosis and management of complications related to regional anesthesia.

The book presentation is excellent; the paper quality and the typeface allow for easy readability. There are only a few typographic errors, some of which were in the last edition (for instance, the doula; fasciculation and defasciculation). In summary, despite these few minor reservations, this publication accomplishes its mission as a detailed reference book for those in training and a review book for those in practice.

Department of Health: Report on Confidential Enquiries into Maternal Deaths in the United Kingdom 1994–1996. DOH, London, 1998,
Halpern SH, Leighton BL, Ohlsson A, Barrett JF, Rice A: Effect of epidural vs parenteral opioid analgesia on the progress of labor: A meta-analysis. JAMA 1998; 280: 2105–10