Knowledge of the major developments in obstetric anaesthesia and analgesia helps to put modern obstetric practice into context. The following brief summary outlines some of these developments, and also those in general anaesthetic practice that have had profound effects on the subspecialty.
General
• Ancient methods of pain relief included various plant-derived sedatives, acupuncture and physical methods such as binding.
• 1881: Matrons’ Aid Society founded (becoming the Midwives’ Institute and later the College of Midwives).
• 1929: British College of Obstetricians and Gynaecologists founded (granted a Royal Charter in 1947).
• 1932: Association of Anaesthetists of Great Britain and Ireland founded.
• 1933: Grantly Dick-Read, English obstetrician, published his book Natural Childbirth, followed in 1944 by Childbirth Without Fear. He proposed a link between fear, tension and pain, suggesting that the cycle could be broken by abolishing fear.
• 1941: College of Midwives founded (granted a Royal Charter in 1947).
• 1948: Faculty of Anaesthetists of the Royal College of Surgeons of England founded.
• 1952-54: the period covered by the first report of the Confidential Enquiries into Maternal Deaths, published by the Department of Health.
• 1953: Virginia Apgar, anaesthesiologist at Columbia University, described her scoring system for assessing neonates.
• 1956: Fernand Lamaze, French obstetrician, published his book Painless Childbirth, in which he suggested that pain was a conditioned reflex triggered by uterine contractions, and that a period of unconditioning followed by reconditioning (psychoprophylaxis) could reduce pain.
• 1969: Obstetric Anaesthetists’ Association founded.
• 1975: Frederick Leboyer, French obstetrician, published Birth Without Violence, in which he advocated delivery in a quiet, darkened room, with minimal stimulation.
• 1988: College of Anaesthetists founded (granted a Royal Charter in 1992).
• 1993: the Department of Health’s Expert Maternity Group published its report Changing Childbirth (the Cumberlege Report), which placed the expectant mother at the centre of care, emphasising her right to choose and signalling a formal move away from the traditional paternalistic ‘medical’ approach.
Systemic analgesia
• 1902: morphine and hyoscine first used in labour.
• 1940: pethidine first used in labour.
• 1950: pethidine approved by the Central Midwives Board.
• 1970: pethidine patient-controlled analgesia (PCA) described.
• 1999: remifentanil PCA described.
Inhalational analgesia
• 1847: James Young Simpson, Professor of Midwifery at Edinburgh University, administered the first obstetric general anaesthetic using ether. Considerable opposition came from religious leaders for going against the Bible, and from medical authorities for compromising safety. Simpson went on to advocate chloroform in preference to ether, having used it the same year. He was a major influence in British obstetrics and also designed obstetric forceps, which bear his name.
• 1853: John Snow, London physician, generally considered the father of British anaesthesia, delivered Queen Victoria’s eighth child (Prince Leopold) under chloroform, putting an end to the above objections. Snow is also famous for his part in ending the London cholera epidemic of 1854.
• 1881: Stanislav Klikovitch, Russian physician working in St Petersburg, described the use of nitrous oxide (80% with 20% oxygen) for labour, noting its lack of effect on the uterus and the requirement for inhalation before each contraction started.
• 1936: Robert James Minnitt’s nitrous oxide/air apparatus approved by the Central Midwives Board.
• 1961: Michael Tunstall, Aberdeen anaesthetist, described the use of premixed nitrous oxide and oxygen in labour. The mixture was marketed 2 years later in the UK as Entonox. Tunstall also described the isolated forearm technique for detecting awareness, developed the Entonox demand valve (from diving equipment) and advocated the ‘failed intubation drill’ in obstetrics.
Regional analgesia
• 1884: Carl Koller, German ophthalmologist, used cocaine for eye surgery.
• 1885: James Leonard Corning, New York neurologist, produced spinal and epidural blockade in dogs.
• 1899: August Bier, German surgeon, used spinal anaesthesia for surgery. Bier described postdural puncture headache for the first time.
• 1901: Jean-Athanase Sicard and Fernand Cathelin, French neurologist and urologist respectively, introduced caudal analgesia.
• 1921: Fidel Pages, Spanish surgeon, used lumbar epidural blockade for surgery.
• 1931: Eugen Bogdan Aburel, Romanian obstetrician, described continuous caudal plus lumboaortic plexus blocks in labour.
• 1933: John Cleland, American obstetrician, described paravertebral block in labour.
• 1942: Robert Hingson, American obstetrician, described continuous caudals in labour.
• 1949: Cleland described continuous lumbar epidural block in labour.
• 1960s to 1990s: British pioneers included Andrew Doughty (Kingston, 1960s-70s); J. Selwyn Crawford (Birmingham, 1960s-80s); Donald Moir (Glasgow, 1960s-80s); Barbara Morgan (Queen Charlotte’s, London, 1980s-90s).
• 1980s: pencil-point spinal needles were first described in 1920s, but advances in their manufacture resulted in their wide availability in the late 1980s/early 1990s.
• 1981-82: combined spinal-epidural technique first described in the UK; popularised in obstetrics in the 1990s; ‘mobile epidural’ combined spinal-epidural technique popularised at Queen Charlotte’s Hospital by Barbara Morgan.
• Late 1980s: microfine spinal catheters used in the late 1980s/early 1990s; withdrawn in the USA by the Food and Drug Administration in 1992.
• 1990s: patient-controlled epidural analgesia (PCEA) introduced.
• 2000s: more sophisticated methods of epidural analgesia (e.g. programmed intermittent bolus, computer-integrated PCEA) described in the mid- to late 2000s.
General anaesthesia for caesarean section
• 1945: Curtis Mendelson, American obstetrician, described the syndrome of acid aspiration both clinically and experimentally, distinguishing it from upper airway obstruction caused by inhalation of large pieces of food.
• 1961: Brian Sellick, London anaesthetist, described cricoid pressure as a means of preventing aspiration of gastric contents.
• 1960s: the problem of intraoperative awareness became topical, with up to 9% of mothers who received thiopental, nitrous oxide and neuromuscular blockade remembering intraoperative events. Donald Moir, Glasgow anaesthetist, described a technique of halothane 0.5% with 50:50 nitrous oxide:oxygen in 1970, with no recall. Tunstall described the isolated forearm technique as a means of monitoring consciousness during general anaesthesia in 1979.
• 2014: the 5th National Audit Project (Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland) implicated obstetric anaesthesia as a risk factor in accidental awareness under general anaesthesia.