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In 1947 John Bonica as new Chief of Anesthesiology at Tacoma General Hospital organized one of the first around-the-clock labor anesthesia services and when became the first chairman of the new Department of Anesthesiology at the University of Washington (1960), caudal anesthesia was the primary technique used for providing labor analgesia. In 1967 the first volume of Bonicas classic textbook Principles and practice of obstetric analgesia and anesthesia was published. The text was a comprehensive treatise that pulled together virtually everything that was known in that field. Perhaps the most significant development in obstetric anesthesia in the past 20 years has been the introduction of spinal opioid analgesia.. Bonica predicted the probable success of these techniques in the last edition of his Obstetric analgesia and anesthesia handbook published in 1980. Current obstetric anesthetic practice, though quite different from what it was 30 or 40 years ago, has its roots in the priorities, techniques and teachings of Dr. John J. Bonica. Key words: John J Bonica life - Caudal Anaesthesia - Obstetric Anaesthesia - Opioid Analgesia.

Obstetric anesthesia - Then and now

H.S. CHADWICK

Department of Anesthesiology University of Washington, Seattle, WA, USA

n this talk I would like to compare and contrast the practice of obstetrical anesthesia during the Bonica years (1960-1978) at the University of Washington with the curAddress reprint requests to: H.S. Chadwick, M.D. Associate Professor, Department of Anesthesiology, Box 356540, University of Washington, Seattle, WA 98195, USA. Email: chadwick@u.washington.edu.

rent state of the art at the same institution. In many ways this comparison reflects the changes that have occurred in modern obstetric anesthesia in the United States and in other parts of the world. According to Dr. Bonica his interest in obstetric anesthesia started with the delivery of his first daughter. His wife Emma had a near fatal complication during open drop ether anesthesia. Though it was considered inappropriate to provide medical care for ones own family member, John Bonica physically took over managing her anesthetic and may well have saved her life. From that time forward he devoted his life not only to the advancement of anesthesiology and pain medicine but also to advancing the anesthetic care of mother and fetus. A major milestone in the history of obstetric anesthesia occurred on January 19, 1847 when James Young Simpson gave the first ether anesthetic for a complicated obstetric delivery. He was severely criticized by his peers for such a dangerous and unnecessary action. The clergy thought that such action was going against the natural order and Gods will. Many women, however, embraced his innovation. Most notably Queen Victoria requested anesthesia for the delivery of her

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8th child. This was administered by John Snow in 1853 analgesie a la reine. For the next several decades not much new happened in the field of obstetric anesthesia. In the early 1900s in Germany scopolamine-morphine sedation or Dammerschlaf (twilight sleep) became popular. Bonica has called the period from 1860-1940 the dark ages of obstetric analgesia and anesthesia.1 The next major innovation in obstetric anesthesia was the introduction of regional anesthesia. John Cleland in 1933, based on his work at the University of Oregon in animals and clinical studies accurately described the pain pathways involved in labor and delivery.2 This was the anatomic foundation that we still accept today. He demonstrated that paravertebral blocks at T11 and T12 could block the pain of the first stage of labor. The pain of second stage labor could be blocked by caudal injections. In 1943 Hingson et al. published their large series advocating the use of continuous caudal analgesia (using a malleable needle) in obstetrics.3 This was the same year that Bonica as chief resident in anesthesiology took over the management of his wifes ether anesthetic. Two years later Tuohy described the first continuous subarachnoid anesthetic using a ureteral catheter placed through the needle.4 In 1947 Bonica as new Chief of Anesthesiology at Tacoma General Hospital organized one of the first around-the-clock labor anesthesia services. Flowers et al. in 1949 reported the first continuous lumbar epidural for labor and cesarean section using a plastic tube inserted into the epidural space.5 When John Bonica became the first chairman of the new Department of Anesthesiology at the University of Washington (1960) caudal anesthesia was the primary technique used for providing labor analgesia. Other more esoteric blocks were also done such as lumbar sympathetic blocks and paravertebral block. Only when commercially available catheters came into widespread use in the 1970s did epidural analgesia begin to become more popular. Single shot techniques or the use of malleable caudal needles were replaced by caudal or epidural catheters that could be placed for prolonged periods and

injected as needed. Analgesia could now be tailored to provide T10-L1 segmental hypalgesia for labor and then injected with larger volumes of more concentrated local anesthetic to produce denser blocks in the sacral segments for delivery. For cesarean section epidural blocks could be brought up more easily using less volume of local anesthetic than with caudal anesthetics. Dr. Bonica was particularly enthusiastic about the so-called double catheter technique (combined lumbar and caudal technique) that allowed the ultimate in delivering local anesthetic drugs to where they were needed. Today the double catheter technique is only rarely used in our practice. In 1967 the first volume of Bonicas classic textbook Principles and practice of obstetric analgesia and anesthesia was published.6 The text was a comprehensive treatise that pulled together virtually everything that was known in that field. It delved deeply into the anatomy and physiology of pain during labor and delivery and the inhalational and regional anesthetic techniques for managing the parturient. Since the Bonica years continuous epidural infusions have become the norm. With the popularity of continuous epidural infusions the caudal approach has virtually disappeared. A major advantage of the continuous epidural infusion is time efficiency. It is much easier to manage a number of patients with this technique than with intermittent injection techniques. The patient also does not have to endure the roller coaster effect of having good analgesia that then wears off and having to wait until it can be re-injected by the anesthesia provider. With a continuous infusion a segmental block tends to gradually spread to involve the perineal region (sacral segments). In our experience if a patient has been on an infusion for 3 or 4 h, it is likely that she will not need a delivery dose. A typical solution for epidural infusion is 0.125% bupivacaine at 10-14 ml/h. With the addition of 2 g/ml fentanyl the local anesthetic can be reduced to 0.0625% and still retain equal analgesic potency but with less motor block.7 A further modificationof this technique that has become popu-

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lar in some practices is the patient controlled epidural analgesia (PCEA). This has the advantage of giving the patient more control over her analgesia but does not work well for all patients. Perhaps the most significant development in obstetric anesthesia in the past 20 years has been the introduction of spinal opioid analgesia. The use of neuraxial opioid has specific and important advantages in obstetric anesthesia. Opioids produce selective analgesia with a minimum of sensory and motor changes. Additionally, these agents cause very little hemodynamic instability. Bonica predicted the probable success of these techniques in the last edition of his Obstetric analgesia and anesthesia handbook published in 1980.8 The current popularity of the walking epidural is largely possible because of the properties of spinal opioids. A variety of neuraxial opioid techniques are used today in which opioid alone or in combination with local anesthetics are used for labor analgesia or to supplement local anesthetics for cesarean section. Another technique that has gained popularity in our practice is the combined subarachnoid and epidural (CSE) anesthesia. This can be used to advantage in labor or for cesarean section. The chief advantage of the CSE for labor is very rapid onset of analgesia. This can be particularly desirable for patients who are very uncomfortable in advanced labor. A subarachnoid injection of fentanyl 5-25 mg with or without bupivacaine 2.5 mg is very effective. Others prefer to use sufentanil 2.5-5 mg instead of the fentanyl. In some practices this is given in early labor and patients are allowed to get out of bed and ambulate walking epidural. Some authors have found that these techniques can shorten the duration of labor or reduce the need for instrumented delivery.9, 10 Others have not found any differences in this regard.11 At the University of Washington we also use a walking epidural technique, however we do not use CSE for that purpose. Our mobile epidural analgesia consists of meperidine 25 mg diluted to a 5 mL volume with saline. This is injected through the epidural catheter following a standard epidural test dose. The

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technique is very effective and provides rapid analgesia for patients in early labor. Analgesia lasts about 2 h or until the patient progresses to more active labor. Side effects are generally rare and patients can ambulate if they wish. A major advantage of this technique is that it does not require a dural puncture. Since the Bonica years there have been other changes in obstetric anesthesia practice. The epinephrine containing test dose to rule out both intravascular as well as subarachnoid catheter placement has become the standard of care at the University of Washington. This test dose was popularized by the work of Moore et al. who spent a number of years in the early 1980s at our institution prior to his retirement.12 There are other practices that are closely identified with the Bonica years that have continued to this day. One of these is the popularity of using low dose ketamine for analgesia when regional techniques are not possible. The use of ketamine in this way was popularized by Akamatsu et al.13 To this day, we use low dose ketamine e.g. 10 mg every 5-10 min up to 50 mg over a 30 minute period for selected indications. In his later years Dr. Bonica devoted much of his time to writing and his work with the World Federation of Societies of Anaesthesiologists. Shortly before his death in 1994 he and Dr. John McDonald completed work on the completely revised and updated second edition of Bonicas classic obstetric anesthesia textbook.14 Current obstetric anesthetic practice, though quite different from what it was 30 or 40 years ago, has its roots in the priorities, techniques and teachings of Dr. John J. Bonica. His legacy is alive and well in our department.

Anestesia in ostetricia - Passato e presente Nel 1947 John Bonica, quale direttore del Dipartimento di Anestesia del Tacoma Hospital organizz uno dei primi servizi attivi 24/h per lanestesia ostetrica e nel 1960, quando and a dirigere il nuovo Dipartimento di Anestesia dellUnivesit di Washington, lanestesia caudale era la tecnica pi utilizzata per lanalgesia nel parto. Nel 1967 pub-

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blic la prima edizione del suo famoso testo Principles and practice of obstetric analgesia and anesthesia, che raccoglieva tutto lo scibile allora conosciuto sullargomento. Lo sviluppo maggiore in anestesia ostetrica degli ultimi 20 anni stato determinato, probabilmente, dallintroduzione dellanalgesia con oppioidi per via spinale. Bonica predisse questo successo nellultima edizione, nel 1980, del suo testo Obstetric analgesia and anesthesia. Gli insegnamenti di John J. Bonica hanno cambiato lanestesia in ostetricia. Parole Chiave: John J Bonica, vita - Anestesia caudale - Anestesia ostetrica - Analgesia oppioide

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References

1. Bonica JJ. Evolution and current status. In: Bonica JJ, McDonald JS, editors. Principles and practice of obstetric analgesia and anesthesia (second edition). Malvern: Williams & Wilkins; 1995. p. 11-3. 2. Cleland JGP. Paravertebral anaesthesia in obstetrics: experimental and clinical bases. Surg Gynecol Obstet 1933;57:51-62. 3. Hingson RA, Edwards WB. Comprehensive review of continuous caudal analgesia for anesthetists. Anesthesiology 1943;4:181-96. 4. Tuohy EB. Continuous spinal anesthesia: a new method using a ureteral catheter. Surg Clin North Am 1945;25:834-40. 5. Flowers CE, Hellman LM, Hingson RA. Continuous

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peridural anesthesia and analgesia for labor, deliver and cesarean section. Anesth Analg 1949;28:181-9. Bonica JJ. Principles and practice of obstetric analgesia and anaesthesia. Philadelphia: F.A. Davis Company; 1967. Chestnut DH, Owen CL, Bates JN, Ostman LG, Choi WW, Geiger MW. Continuous infusion epidural analgesia during labor: a randomized, double-blind comparison of 0.0625% bupivacaine/0.0002% fentanyl versus 0.125% bupivacaine. Anesthesiology 1988;68:754-9. Bonica JJ. Obstetric analgesia and anesthesia (second edition). Amsterdam: World Federation of Societies of Anaesthesiologists; 1980. Comparative Obstetric Mobile Epidural Trial (COMET) Study Group UK. Effect of low-dose mobile versus traditional epidural techniques on mode of delivery. A randomized controlled trial. Lancet 2001;358:19-23. Tsen LC, Thue B, Datta S, Segal S. Is combined spinalepidural analgesia associated with more rapid cervical dilation in nulliparous patients when compared with conventional epidural analgesia? Anesthesiology 1999;91:920-5. Norris MC, Fogel ST, Conway-Long C. Combined spinalepidural versus epidural labor analgesia. Anesthesiology 2001;95:913-20. Moore DC, Batra MS. The components of an effective test dose prior to epidural block. Anesthesiology 1981;55:693-6. Akamatsu TJ, Bonica JJ, Rehmet R, Eng M, Ueland K. Experiences with the use of ketamine for parturition. I. Primary anesthetic for vaginal delivery. Anesth Analg 1974;53:284-7. Bonica JJ, McDonald JS. Principles and practice of obstetric analgesia and anesthesia (2*edition). Malvern: Williams & Wilkins; 1995.

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