Obstetrical epidural anaesthesia in remote hospitals.

In this issue of the Journal, Dr. Orser describes the experience with obstetricaL epidural anaesthesia in a smalL (40 beds), remote Canadian Hospital staffed by family practitioners. ~ Over a ten year period, seven per cent of obstetric patients received an epidural anaesthetic administered by one of nine different anaesthetists who had six months or less of formal anaesthesia training. Dr. Orser is to be commended for a thorough review of the experience and for addressing the issues surrounding the use of epiduraL anaesthesia within small obstetric units. The hospital which formed the basis of this report is in Newfoundland, but the problem of providing medical care in remote communities is common to all Canadian Provinces and Territories. In the Province of Manitoba, for example, rural medical services are provided in 70 hospitals, 50 of which have less thart 30 beds. Many of these hospitals are inaccessible by road for all or part of the year. Fully 15 per cent of all obstetrical deliveries in the province are performed at hospitals with less than 50 beds and where centralization of care is impossible except at prohibitive cost. Our task is to ensure that the best obstetric anaesthesia care is made available at these hospitals. The two main issues arising from Orser's report and general consideration of the geographical distribution of obstetric care in Canada are: I Should epidural anaesthesia be provided in low volume obstetric units with neither specialist anaesthetists or specialist obstetricians? and 2 What standards should be applied with respect to obstetrical epidural anaesthesia in those institutions? The first question is more difficult to answer than the second. Orser reports complication rates which compare favourably with those published from a much larger teaching unit. 2 The failure rate of epidural anaesthesia for