We are pleased (and not surprised) that single-dose spinal anesthesia during labour would stimulate debate. We agree with all of the technical points Dr Dopp brings forth, in fact they were well described in our first draft, but the review needed to be shortened for publication.
Delivery of safe obstetric service in our location includes general practitioners providing anesthesia, cesarean sections, external versions, and bedside ultrasounds. Clearly, varying levels of expertise and training are required.
Settings without epidural services are left with limited options for analgesia, including repeat doses of intravenous or intramuscular narcotics. These also impose the risk of respiratory depression and the need for adequate protocols for monitoring. In our situation the nursing staff was familiar with the use of intrathecal morphine as a common analgesic after cesarean section. It was an easy leap for them to modify their post-operative intrathecal narcotics (ITN) protocols. In our institution, intrathecal morphine patients are monitored with this protocol for 18 hours.
Dr Dopp identifies fetal bradycardia as a potential problem with this technique, and we referenced the study by Mardirosoff and colleagues (level I evidence), in which ITN did not have any effect on Apgar scores.
We are respectful of the opinion that Dr Dopp expresses about the suitability of this procedure’s being disseminated through Canada’s rural hospitals, but we don’t share it. Nor is it consistent with the feedback we have received from family doctors. We have had inquiries since this article was published from doctors wanting to improve analgesia in their obstetric practices, including GP-anesthetists hoping to provide a service that is less labour intensive than an epidural service. I note that many communities our size and larger provide no obstetric analgesia service of any kind because of the onerous time commitments that the epidural service entails. In our experience this time-efficient procedure has allowed us to provide a comprehensive obstetric analgesia service, including ITN and occasional epidurals.
If this article has piqued the interest of any family doctors to consider providing ITN during labour, we are confident they will be able to perform the due diligence to safely implement the program. We believe that family medicine training in Canada is specifically designed to give our doctors the skills to start providing new services as they evolve. This is not to dismiss the complex infrastructure set up in all of our hospitals that supports and ensures the provision of safe services. These include, but are not limited to our hospital boards, medical advisory committees, risk management departments, obstetric service departments, capable nursing staff and mangers, and hospital pharmacists.
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