New standards for anesthesia in out-of-hospital Cesarean sections

Unless planning to issue an update on practice guidelines for obstetric anesthesia, the American Society of Anesthesiologists (ASA), along with its subspecialty organization, the Society for Obstetric Anesthesia and Perinatology (SOAP), should formulate a consensus statement for peri-anesthesia management during out-of-hospital cesarean sections (OHCS). Florida has become the first state to allow OHCS, an infrastructural relaxation for obstetric care that other states may follow. Whether the ensuing outcomes among pregnant patients, mothers, and their newborn infants in Florida will accentuate or attenuate the spread of OHCS nationwide, a timely anesthesia advisory by ASA/SOAP for anesthesiologists practicing in Florida would be beneficial. Not only in-state but also out-of-state anesthesiologists could be providing general and conduction anesthesia-analgesia in Florida’s advanced birth centers (ABCs) during labor epidurals and OHCS among pregnant patients, postpartum sterilization among mothers, and potentially during circumcision among their newborn infants.

Although mothers may stay at ABCs for 48-72 hours after delivering their newborns vaginally or surgically, input from the Society for Ambulatory Anesthesia (SAMBA) in anesthesia advisory could be warranted. The historical experiences of ambulatory anesthesiologists at already-established ambulatory surgery centers (ASCs) could guide future outcomes among obstetric anesthesiologists managing obstetric patients and their newborns at the newly-invented ABCs. The health care cost-containment with ABCs delivering accessible care to pregnant patients, mothers, and their newborn infants would require ABCs to achieve non-inferior health care outcomes compared to hospitals. However, neither the pregnant patients, mothers, nor newborn infants can be allowed to fall through the cracks in the absence of preemptive anesthesia advisory, considering that along with at least one obstetrician per ABC, at least one anesthesiologist per ABC is mandated per the new Florida law.

Since it is not clearly stipulated in the new Florida law whether the ABCs must have at least one pediatrician per ABC, it may be assumed that the responsibility for neonatal resuscitation would fall on obstetric anesthesiologists. These professionals may need to meet the requirements of the Neonatal Resuscitation Program (NRP) of the American Academy of Pediatrics (AAP) before acting as neonatal anesthesiologists. There could be a natural selection for obstetricians and anesthesiologists based on their competence in time efficiency when performing OHCS at ABCs. There are concerns about whether mean-median indemnity payments to injured parties and legal expenses for all parties will escalate due to OHCS at ABCs unless ASCs have historical non-obstetric data to prove otherwise, thus potentially overcoming the resistance among obstetricians and anesthesiologists to perform OHCS at ABCs.

Until ABCs evolve to effectively screen their patients for high-risk peripartum hemorrhage and preemptively refer them to hospitals for peripartum management, it may fall to obstetric anesthesiologists to advocate for the prophylactic use of tranexamic acid in low-resource settings. This could supplement the strategy for liberal use of intrauterine balloons during OHCS at ABCs, with the question always lingering whether all pregnant patients who have been typed and crossmatched for blood transfusion should go to hospitals rather than staying at ABCs. These patients might be at high risk for peripartum hemorrhage compared to those only typed and screened for blood group and antibodies.

As society has finally arrived at this point, anesthesiologists should not delve into how escalating health care costs might be evolving health care deserts, either due to reimbursement difficulties or medicolegal liabilities. Neither the diverse geography nor the dispersed demography helps contain health care deserts. Anyhow, OHCS might be here to stay, and anesthesiologists should not reminisce the time when OHCS was only limited to the rarest of rare perimortem CS, now more appropriately termed resuscitative hysterotomy.