ANESTHESIA IN OBSTETRICS


ANESTHESIA IN OBSTETRICS. The question of curare has been raised a number of times. It is most effective in certain cases. Intocostrin, tubo-curarine, and syncurine are all drugs that act upon the myoneural junction, paralyzing the extrinsic muscles. I have found it most useful in breech and posterior presentations.


For centuries, the ideal method of anesthesia during childbirth has been of great concern. Many people believe that anesthesia in such a “normal” physiological procedure is not necessary and in fact, undesirable. In the covered wagon day, the mother would turn over the reins of the horse to someone else while she went in the back of the wagon to have her baby. That evening she would be outside getting dinner and doing the daily wash. The women of today are not pioneers, however, and desire some relief for their pain-some wanting it with the very first uterine contraction.

We are attempting to find the best procedure for all concerned-the mother, the baby, the hospital staff and other patients and by no means least, the attending physician and obstetrician.

I shall attempt to describe the various methods that are available.

There are numerous drugs used during the first stage of labor, mostly the barbiturates-nembutal, second, pentothal sodium by rectum and pento-barbital sodium intravenously. Paraldehyde is still used a great deal. These may be given any time after labor is definitely established. This is not anesthesia but analgesia- the patient having no remembrance of labor or delivery; however, she is most uncooperative and has to be watched continually to prevent her from injuring herself and the baby. Also she is quite likely to precipitate the baby in bed with resulting third degree laceration of the perineum.

Another undesirable result from excessive “pre-medication” is the effect on the infant. All of these drugs pass through the placenta with the fetal circulation with resulting narcosis of the infant remaining after after delivery. This may be to a harmful degree, or may not; but resuscitation must be restored to in a very large majority of cases.

There are several procedures available which may be used when labor is well established and the cervix definitely dilating. They are caudal, saddle-block spinal, epidural, local and general anesthesia. I will not attempt, in this paper, to give the techniques or procedures as they should be attempted only by those most competent and well trained. They are not difficult or laborious, but a deviation of one or two centimeters with a needle can make considerable difference in the welfare of a mother and her baby. The purpose of this paper is to refresh the memories of all of us as to the various procedures that may be available, if desired, or requested, by the patient.

Caudal may be “one shot” or continuous. If the patient is a multipara who usually moves rapidly, a single injection, which is effective for 2-3 hours, may be sufficient. This consists of passing a large gauge needle into the caudal canal and injecting 30-40 c.c depending upon the size and build of the patient, into this area. There are definite precautions which must be adhered to.

The continuous procedure is more desirable, is no more difficult and may be maintained for hours. After the needle has been inserted into the caudal canal, a small ureteral catheter is passed through the needle and the latter removed. The catheter is secured to the skin with adhesive. Subsequent injections of the local agent may be introduced from time to time as needed. With this procedure, the patient is free to move around in bed, is cooperative and not irrational. The older method of continuous caudal consisted of inserting a malleable needle into the caudal canal. With this procedure, the patient had to remain on her side.

The final result was the same, but the comfort of the patient has been greatly increased with the use of the catheter. The labor may be slightly prolonged, and the patient must be watched as she has no pain with her contractions and no sensation as to the stretching of the perineum. The infant is in no way affected by this procedure and cries spontaneously. No, or little, “pre-medication” is necessary with this method, so we do not have the patient “climbing the wall” as with the oral or intravenous pentobarbital, nembutal or seconal.

The saddle-block spinal, or just the “saddle-block,” if you do not wish to use the term spinal when talking to the patient, has greatly replaced the continuous caudal. This consists of a single, low shot” spinal. The injection is made between the third and fourth lumbar vertebrae using nupercaine and glucose, which is a much heavier solution than the spinal fluid. This is given with the patient in a sitting position. The solution descends to the dural sac, and only the lower pelvic nerves are involved.

The area of anesthesia usually extends from the knees to the umbilicus. The patient can move freely in bed and has no sensation of pain. The secret of success in the saddle-block spinal lies in the length of time the patient remains in the sitting position after the injection, before the supine position is maintained. The drug action lasts from four to five hours, and the procedure may be repeated as often as necessary when the pains return.

Epidural anesthesia has been introduced recently. I have never tried this procedure, as it is most intricate with a small margin of error. When doing a spinal tap, just before “hitting” the dura, an area of negative pressure is encountered. This is the epidural space. This space is continuous with the area injected during a caudal. The caudal canal is very easily entered by those trained, and I can see no reason for attempting a difficult procedure higher up the epidural space. If you can “hit” the caudal canal, you can inject enough fluid to extend up the epidural space very simply and as far as you desire.

The local injection procedure is very desirable if the general practitioner or obstetrician desires to familiarize himself with the technique. It is the most useful if an anesthesiologist is at hand when a mother decides to have her baby. The stretching of the perineum is accompanied with great pain which can be somewhat relieved by local injection of procaine in the area of the main nerve branches. Episiotomy and repair are accomplished painlessly.

Lastly, we have general anesthesia. Our routine procedure at The National homoeopathic Hospital in Washington, D.C., has been very successful, and very little “pre-medication” is used. If the first stage of labor is unduly prolonged, 5 percent glucose in saline or distilled water, intravenously, 1000 cc. at a treatment, is instituted. This has seemed to be very good sedative in the prolonged cases-much better than morphine sulphate, demerol, seconal, etc.

Morphine sulphate in small doses (gr. 1/8) and occasionally a barbiturate, seconal (gr. 1 1/2), have been used. Usually the patient receives nothing until time of delivery. In Washington we use Ethylene and Oxygen at the “last minute.” The Richmond Washington-Baltimore area uses more Ethylene, so I have been told, than the remainder of the United States combined.

When the patient is ready to deliver, we block out those last minutes with gas. Occasionally we have to run in a little ether (10 to 20 cc. or a tea- to a tablespoonful) during a delivery to keep the patient from moving at the time of suturing. The patient is awake and asking how much her baby weighs about two minutes after the mask is removed.

The question of curare has been raised a number of times. It is most effective in certain cases. Intocostrin, tubo-curarine, and syncurine are all drugs that act upon the myoneural junction, paralyzing the extrinsic muscles. I have found it most useful in breech and posterior presentations. It definitely relaxes the perineal muscles to enable an after-coming head to deliver without Pipers forceps and a posterior occiput sometimes to be manually rotated and spontaneously delivered.

In conclusion, I have attempted to present the various anesthetic procedures that are available at the time of parturition which give the patient the opportunity to decide which type of anesthesia she desires for herself.

WASHINGTON, D.C.

DISCUSSION.

DR. ALLAN D. SUTHERLAND [Brattleboro, Vt.]: I was interested in the part of the paper that I heard; I didnt hear it all, but I think the ideal to be sought with regard to obstetrical anesthesia is the choice of an anesthetic method which is least likely to produce harm either to mother or to child, and for this reason I would be inclined toward either general anesthesia at the last moment or a caudal or saddle or nerve blocking anesthesia.

I think that the use of analgesia in the first stage of labor has in the past been much overdone, and I think there has been a great deal of harm developed from it.

In my own practice I try to use Dr. Grantley Dick Reads method of childbirth, “Childbirth Without Fear,” and it works very well in a number of cases. That doesnt require an anesthesia unless the patient wants it, and then I think the anesthetic of choice is gas-oxygen, which the patient can manipulate for herself, with a special type of machine that automatically shuts off when she relaxes. That may not be an ideal way of giving a general anesthesia, but it sometimes works out very well, and many of the patients need none. (Applause).

DR. A.H. GRIMMER [Chicago, III.]: From a scientific point of view, this is a fine paper, but it is a far cry from the old days. of course, we are not in the old days, I realize, when we used to go to the houses and deliver them, and we didnt have anesthesia or anything else, but we did get some marvelous results with our homoeopathic remedies, almost painless cases, so little they didnt give any trouble, but, as the doctor remarked, it is sometimes a very difficult thing to get the homoeopathic remedy, and then there are cases where there are mechanical reasons, where even the homoeopathic remedy cannot do anything for them. Then the choice of a good anesthesia is certainly a boon to the woman, and it is a good thing to know. I guess nowadays we dont deliver any more at the houses, and only certain men go to the hospitals to take these cases, so they are out of the hands of the general practitioner.

It is a very interesting paper. (Applause).

DR. HARVEY FARRINGTON [Chicago, III.]: It was a very neat and well-written paper and exceedingly interesting to me. The doctor takes the conservative viewpoint, of course, being a homoeopath.

Referring to what Dr. Grimmer has just said, I have been told that there is a tendency to take the case back to the home, and that some obstetricians have found they do better there than in the hospital.

Now, I hesitate to speak of my own experience, because in upwards of 650 or 700 cases, hardly 50 were in the hospital. The others were delivered at the house, with the exception of one little baby who was born in a little old Ford on the way to the hospital. There, there was no attention, no anesthetic. The mother, however, had already borne three. This was her fourth child and her births were easy and expeditious.

Now, I think the important thing regarding this is homoeopathic treatment before the delivery, and so far as possible before pregnancy, and especially during pregnancy. I have had many varied cases and some of them were really very difficult ones and also serious. I have seen a hemorrhage so profuse that the blood squirted on the wall, and the trained nurse got sick; however, we came out without any serious after effects.

We all know that our Materia Medica is rich in remedies that will relieve the pains and hasten the labor, and in my own case, with some knowledge of the Materia Medica and Yinglings Manual, I got along very well; in fact, I have seen at least seven absolutely painless births, and three of them were under my own care, because the young man, the husband, had moved to some other city. In one instance the doctor accused the mother of lying because she had no pain.

“No,” she said, “it is just a bearing down”.

One of my cases of painless labor was twins. This woman had a backache. She felt as though there were part of the vertebrae breaking in her back. That is a symptom of Psorinum, which not only removed that symptom but caused the easy and practically painless labor. Two boys were born. One came head first in the normal way; the other one turned in the uterus and followed a few minutes later, head first.

I remember once being called by Dr. Sayer, who was one of the finest surgeons. I ever knew, and he also knew quite a bit about homoeopathy. His patient was in the hall of the hospital on a cot and she had been in labor a number of hours, and he said she was not progressing at all, and he wondered what could be done. She had considerable irritability, and he said, “Dont you think it is Nux?” As I watched her he said, ” I cannot stop these pains,” but after some Asagraea she began to have normal pains and they had to hurry her to the operating room, and I said, “I have never lost a mother.” Naturally, somebody asked, “Did you ever lose a father?”.

I said, “Almost,” because when he found it was twins, he threatened to commit suicide!.

DR. DONALD G. GLADISH [Glenview, III.]: Referring to the matter that Dr. Sutherland brought up, the matter of Grantley Dick Read and his “Childbirth Without Fear” is interesting. It is a tendency which we could well support individually because anything that gets away from a lot of premedication and a lot of anesthesia is quite in our line, and it is working out quite well, I think, in many places throughout the country, where hospitals have taken it up, and there is quite an interest among the pregnant mothers to try it out if they have heard anything about it. It certainly does cut down on the need for analgesia and anesthesia, both.

DR. H.A. NEISWANDER [Pandora, Ohio]: Obstetrics, of course, is a thing that belongs to the man in general practice, all through his experience, and, of course, that is something that we in our territory have to deal with regularly. As the doctors have said, previously these deliveries were all done in the home. Now they are all done at the hospital.

Our hospital has a special routine that they follow. My patients have their homoeopathic remedy before they are sent to the hospital, and the routine in our hospital is that they are given demerol, one or two, or three doses, whatever is necessary, and then at the time of the delivery they go in for chloroform or a little ether, just enough to take off the sharp edge of the pain.

One of the things particularly interesting to me -I am the only homoeopath in our section working in out hospital, and the nurses will tell me every once in a while, “Why do your patients act so-and-so? The others dont Why do they respond so-and-so? The others dont,” and every once in a while they will say, “Why dont you give her some of Dr. Neiswanders white pills?” After all, they dont know anything about homoeopathic medicine, but even so they do know and see the effect of the indicated remedy and drug, and the more I watch it and the more I see, the more I am sold on what our homoeopathic remedies can do. (Applause).

DR. SWARTWOUT [closing]: Dr. Sutherland spoke about a patient giving herself the anesthetic, putting the mask on the face, and the thing goes this way (indicating). That is the McKesson machine, which is a very good machine in this type of thing, if you want the patient to do it.

Dr. Grimmer said some patients dont want an anesthetic. Since this book was written about “Childbirth Without Fear,” we have had several who have come to the delivery room wanting to have their baby without any anesthetic, but we are always there and we have had several who at the last minute said, “Well, I cant take it. Give me some gas”.

Dr. Farrington spoke about the mothers. Our present-day mothers read so much in The Readers Digest, Mc Calls and so forth. All I was trying to do was to call to mind to all of us the procedures that are available, and I think I definitely stated my feeling on the matter. I didnt say anything about the homoeopathic remedies, but I just pointed out those procedures that are available.

I go along with Dr. Neiswander, and all we do is just at the last minute give them enough to put them to sleep so they just do not know what is happening at that time.

Thank you very much for the discussion. (Applause).

John A. Swartwout