VOLUME 17, NUMBER 3 SOAPmournsTwo PastPresidents · FALL 1986 VOLUME 17, NUMBER 3 SOAPmournsTwo PastPresidents BOB HODGKINSON President, SOAP1984 ... analgesia on neonatal neurobehavior;

FALL 1986 VOLUME 17, NUMBER 3

SOAP mourns TwoPast Presidents

BOB HODGKINSONPresident, SOAP 1984

Robert "Bob" HodgkinsonRobert "Bob" Hodgkinson, a long-time member and the 1985

President of SOAP, has left us. He collapsed in his office at home andfailed to respond to resuscitative efforts. Our sadness is tempered bythe fact that he did not suffer.I first met Bob in July 1971 when he entered the Anesthesiology

Residency program at the Albert Einstein College of Medicine. Hewas a rather unusual resident, not because he was older than hisclassmates, not because he spoke American English with a charmingBritish inflection, but because he knew more about drugs, theiractions, kinetics and elimination than any other member of ourdepartment. The reason for his wisdom soon became evident: Bobhad been involved in clinical research for international pharmaceuti-cal companies for many years before deciding to become a practisingphysician once again. Followi ng his two years of residency, he serveda one-year fellowship in Obstetric Anesthesia with me, and webecame the best of friends. Bob remained with us for four additionalyears asChief of Obstetric Anesthesia at one of our affiliated hospitalsand then moved to San Antonio where he wasappointed Director ofthe Obstetrical Anesthesia Unit, a post he held until his untimelydeath. Bob was Professor of Anesthesiology, Obstetrics and Gyne-cology at the Medical School, a Diplomate of the American Board ofAnesthesiology, and a Fellow of the American College of Anesthesi-ologists, the New York Academy of Sciences, the Royal Society ofMedicine, and the Royal Society of Tropical Medicine.

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JOHN B. CRAFT, JR.President, SOAP 1985

John CraftSeptember 23, 1986.John Craft has died.On a glorious Saturday afternoon, in October 1985, I hosted a

reception in San Francisco for the members of committees involvedin planning the 9th World Congress of Anesthesiologists -to be heldin Washington, in 1988. John was a member of my Committee forCultural Affairs. As we stood on the deck, and watched the fleet sailinto SanFrancisco Bay,and the Blue Angels fly overhead (by chance itwas the start of Fleet Week in San Francisco), John told me about hismysterious new ailment: a persistent unilateral sore throat, with noobvious inflammatory signs. When he returned home the diagnosisof malignant lymphoma was made, and thus began the agonizingspread throughout his body. Through repeated treatments of che-motherapy and radiation, John maintained faith and optimism thathe would lick this fatal illness. As President of SOAP, he came to SaltLake City in May 1986, to fulfill his duties. So many of his friends andcolleagues were shocked and saddened when they learned of hismalignancy, and we were all very stirred by his unquenchable spirit.I first met John in the early 1970's, at a Frank Moya Anesthesia

Seminar in the Virgin Islands, and we became friends immediately.His passion was Obstetrical anesthesia, and in the late 70's he spentthe first of two sabbaticals with me. His main purpose waseventually todevelop, at George Washington University, the chronic maternal-fetal 'San Francisco smiling sheep' preparation. Judy Johnson, my

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SOAP Newsletter Page 2

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Bob was an excellent clinician and an outstanding researcher. Hislist of publications includes 35 original articles, 12 book chapters, andnine Letters to the Editor of prestigious journals. Two of his originalarticles, both co-authored with F.J.Husain, have made a great impacton the practice of obstetric analgesia/anesthesia. [1. Systemic andpulmonary blood pressure during Caesarean section in parturientswith gestational hypertension (Can Anaesth Soc J 27:389-394,1980); 2.The duration of maternally administered meperidine on neonatalneurobehavior (Anesthesiology 56:611-612, 1982)]In 1983, I realized that I needed help with the Obstetric Anesthesia

Digest. I gingerly approached Bob who immediately and enthusiasti-cally agreed to co-edit the journal. He was most Influentlalm Improv-ing its contents and appearance.Bob's input at SOAP and other Anesthesiology meetings will be

sorely missed. No present member of SOAP will ever forget the tall,urbane gentleman with his scholarly comments.

Gertie F. Marx

Bob Hodgkinson(In his memory)

EL ME)OREver vigilant the manSurrounded by the technical instruments of his skillAnd cognizant of the sounds of life,Sits quietly, aiding his cohorts in their seemingly endless tasks.

An anesthesiologist in nameBut more realistically, an overseer; a guardian,As in his hands lie the destiny of manyWho place infinite faith in his judgements.

For who but he:Is connected to the pulse of existence,Can give the element necessary for breath,Can revitalize the intricate systems that sustain man?

An unassuming administrator in the O.R.Subtle in his mannerism,But always alert, never-the-Iess,To upcoming difficulties and possible solutions.

With quick mind and wit,He calmly adjusts his techniquesTo compensate for the imbalance of the situation,And once again permits tranquility to reign in this sterile

environment.

Proud, determined, and confident,A man among men a step above the rest;Trulya professional with boundless energiesAnd unsurpassed dedication.

Carolyn Bluhm Lopez, C.R.N.A., University of Texas, Health ScienceCenter, San Antonio.

"To have a friend is to have one of the sweetest gifts: to be a friend isto experience asolemn and tender education of soul from day to day.A friend remembers us when we have forgotten ourselves. A friendmay praise us and we are not embarrassed. He takes loving heed ofour work, our health, our aims, our plans. He may rebuke us and weare not angry. If he issilent, we understand. It takes a great soul to be afriend ... One must forgive much, forget much, forbear much. Itcosts time, affection, strength, patience, and love. Sometimes a manmust lay down his life for his friends. There is no true friendshipwithout self-sacrifice.We will be slow to make friends, but having once made them,

neither life nor death, misunderstanding, distance nor doubt mustever come between."

Anonymous

Contributed by Ruth RandUniversity of Texas Health Science Center, San Antonio

Eulogy in Memory of Robert Hodgkinson, MB.,Ch.B., M.D.

(Recited at the funeral service on July 9, 1986 in San Antonio,Texas)

Dear friends,The crucible of medicine purifies its metal through arduous work

and discipline, imagination and reasoning, dedication to standards ofexcellence and, above all, a compassionate dedication to the allevia-tion of pain and suffering. What greater unity of purpose can beachieved than to be concerned with the travails of childbirth, aswellas the protection of the innocent newborn! How fortunate we arethat Robert Hodgkinson flourished in the difficult and mercifulunion of two great specialties, Obstetrics and Anesthesiology! Hisprofessional life exemplified the best in the British and Americantraditions of Medicine, ranging from Sir James Young Simpson, whofirst used chloroform in Obstetrics, to Virginia Apgar, an Anesthesi-ologist who evaluated the condition of the newborn with her nowfamous scoring system.The crucible was charged with his undergraduate and graduate

medical education at Cambridge University in England where, as aPopplewell Scholar, he received his M.B. and Ch.B. degrees in 1946.A Residency in Obstetrics and Gynecology followed and Dr. Hodg-kinson received his diploma from the Royal College of Obstetricsand Gynaecology in 1948, and a Mastership in Midwifery in 1949. Astint in the Royal Army Medical Corps as Obstetrician and Gynecolo-gist at a British Military hospital, then followed. In 1956, Dr. Hodgkin-son received an M. D. degree with Thesis, which is the equivalent tothe Doctorate of Medical Sciences in this country. After 15 years ofpharmaceutical and pharmacological research, Dr. Hodgkinsonmoved to the United States where he completed his AnesthesiaResidency and Fellowship in Obstetrical Anesthesia at Albert EinsteinUniversity College of Medicine in New York. The Director of Obstet-rical Anesthesia at Einstein and mentor of Dr. Hodgkinson was Dr.Gertie Marx, an internationally recognized Anesthesiologist, who hastrained many of the prominent Obstetrical Anesthesiologiststhroughout the world.Dr. Bob Hodgkinson came to us in San Antonio, Texas, in 1977 after

serving on the Obstetrical Anesthesia staff at Einstein, where he hadbegun his work on Neurobehavioral testing in the newborn. Withinan incredibly short period of time, he had published numerousarticles and papers and completed important studies on epiduralanesthesia for Cesarean sections; effects of obstetrical anesthesia-analgesia on neonatal neurobehavior; maternal mortality; placentaltransfer of drugs; and anesthetic care of the obstetrical patient. Hispublications number more than 100 and he has served on Editorialboards and as a Consultant to numerous medical journals. He wasEditor of the Obstetrical Anesthesia Digest, and former President ofthe Society for Obstetrical Anesthesia and Perinatology. Bob Hodg-kinson was a member of many national and international medicalsocieties, including the Royal Society of Medicine. Above all, he hadthe remarkable ability to develop clinical and laboratory investiga-tions, and was the recipient of a great number of research grants.Bob Hodgkinson pioneered the development of Obstetrical Anes-

thesia at the Robert B. Green and Medical Center Hospitals in SanAntonio, Texas, and his service attracted Residents and Fellows frommany parts of the world and from the United States Armed Forces. Hewas a wonderful teacher and enjoyed the respect of his peers, col-leagues, nurses and other professionals. When he passed away, hewas Professor of Anesthesiology, Gynecology and Obstetrics at TheUniversity of Texas Health Science Center at San Antonio.Thus, we see in Bob Hodgkinson the marvelous metal charged

from the fiery crucible and, like the ancient quicksilver, we find thatits presence has been transubstantiated into the permanent quanta ofknowledge that brings progress to humanity. It is transmuted into theResidents and Fellows and colleagues we see here today and isinscribed permanently in the books and articles that Bob haspublished.For all this, we are so grateful and give thanks for the memory and

accomplishments of Robert Hodgkinson, M.B., Ch.B., M.D., Physi-cian, Teacher, Researcher, Husband, Father, and Friend to us all.

Maurice S. Albin,Department of Anesthesiology, The University of Texas Health,Science Center at San Antonio

I~


wonderful research assistant, travelled east and helped John organizehis laboratory, and then he wasoff and running!! He first streamlinedand simplified the data collection with on-line computers. He thenbegan a series of important studies on the impact of various obstetricmedications and anesthetics on the mother and fetus. These placen-tal transfer and pharamacokinetic studies involved intravenous andepi dura I fenta nyl, epi dura I sufenta ni I, intra ve nous da n trole ne,ketamine, and bupivacaine, and he was just about to study a newAstra Pharmaceutica.ls experimental drug for the treatment of AIDS.The growing number of fetuses infected transplacentally with theAIDS virus, from maternal blood, present a problem which is not onlytimely, but has enormous clinical importance. The new Astra drugcrosses the blood-brain barrier, and is being tested clinically by theNational Institutes of Health. The potential fetal toxicity was to be thepurpose of his study, but John was too ill to begin this finalinvestigation.Before coming to San Francisco, John had written important pap-

ers on the effects of epinephrine-containing local anesthetic solu-tions on the progress of labor (small doses don't affect labor), and theprevention of post d ural puncture headaches after" wet taps," by theuse of prophylactic saline injections.John became President of SOAP in 1985, and hosted one of the

most spectacularly successful meetings in our history. His impeccabletaste, graciousness and expertise were apparent in all the importantdetails that make a meeting a memorable experience.John was a young man, at the height of his productivity, and his

tragic death cruelly robs us of a marvelous gentleman, scientist andscholar. His primary non-medical interest was religion. He was abiblical scholar - for years attending weekly classesand planning toobtain a doctorate in Divinity. I believe his faith in God, and theloving care given by his lifelong companion, George Eatman, easedhis horrible sufferi ng and made death not a final event, but a passingto a better time.

Sol M. Shnider

John B. Craft Jr., anesthesiologist

Dr. John Brown Craft Jr., 48, who was Chairman of the Departmentof Obstetrical anesthesia at George Washington University's Medicalschool, died of lymphoma yesterday at his home in Washington.At George Washington University, Dr. Craft developed a research

laboratory in perinatal anesthesia, and he wrote numerous researcharticles for professional journals in the fields of anesthesia andperinatology.From 1985 to 1986 he was president of the Society for Obstetric

Anesthesia and Perinatology, which a colleague described as theforemost organization on Obstetrical anesthesia in the United States.Dr. Burton Epstein, chairman of the Department of Anesthesiology

at the George Washington University Medical Center, said Dr. Craft"dedicated his life to the field of Obstetrical anesthesia when it was, Iwould say, in its infancy.""He not only trained individuals to perform this work in hospitals

throughout the United States, but he also did research that wasrecognized internationally," Dr. Epstein said.He said Dr. Craft served on countless committees that sought to

reduce infant mortality and to improve maternal welfare.Dr. Craft was born in New York. In 1959,after three years in college,

he received a B.A. degree with honors from Johns Hopkins Univer-sity, where he also was elected to Phi Beta Kappa.He was awarded a Winslow full-tuition scholarship at George

Washington University and received his M.D. there in 1963. After aninternship at Walter Reed Army Hospital, he returned to GW tocomplete his residency. For the last 17 years he was a member of theGW medical school staff and on three occasions was presented themedical center's Physicians Recognition Award.In 1977and 1984,while on sabbatical leaves from GW, Dr. Craft was

a Visiting Associate Professor of Anesthesia at the University of Cali-fornia in SanFrancisco. Dr.,Craft arranged the ti ming of his research atthe San Francisco medical school to enable him to attend a season'sperformances of the San Francisco Opera.In 1984, Dr. Craft also did research in Obstetrical anesthesia at

Queen Charlotte's Hospital in London.

Reprinted from the Washington Times, Tuesday, September 23,1986


John B. Craft, Jr., M.D.Obituary

I knew John Craft for 19 years as he progressed from his residency tothe rank ?f full Professor at George Washington University. His mostworthwhile achievement here at G.W. was the establishment of ourO~stetric anesthesia unit, and the directorship of its research andtraining programs..As clinician and teacher he will be missed, but most of all he was a

frrend. Although we "needled" each other unmercifully (he alwayswanted the last word), there was a strong bond of respect andadmiration between us. Sad to say, in recent months, it was I who didthe most "needling" as I started I.V.'s for his chemotherapy. Johnfought his devastating disease in a valiant and graceful manner. Heworked on his research papers up to the last week before his death. Itwas a privilege to have shared his friendship. This time, John, I havethe last word; and it is "good-bye, good friend."

Alice H. Altstatt

RICHARD CLARK, President of SOAP, presents JOHN CRAFT with past-President's plaque, at SOAP '86.

Richard Clark writes:In the space of three months, SOAP has lost two former Presidents

- Bob Hodgkinson and John Craft. While, in our daily round, werejoice and participate in the arrival of new life, we are also con-fronted with our own, and our colleagues,' frailty and mortality. JohnCraft was not yet fifty, and an energetic and active leader in Obstetricanesthesia. He will be greatly missed.John was a native of New York City, who received his medical

education and Anesthesiology training at George Washington Uni-versity in Washington, D.C., later becoming director of ObstetricAnesthesia in that institution. Although we had mutual friends, whoseveral times asked us if we had met, our paths did not cross until thePhiladelphia SOAP meeting in 1975. There we became friends, andmet many times at subsequent SOAP meetings. John rose to the rankof Professor at George Washington, and had an active training pro-gram. He published frequently - perhaps his most quoted articlewas his 1973 paper in Anesthesia and Analgesia on 'Prophylaxis ofDural Puncture Headache with Epidural Saline.' Other studies werein the pregnant ewe, and John spent portions of 1977 and 1984 onsabbatical with Sol Shnider.John hosted and planned SOAP 1985 in Washington, D.C. This

meeting, enjoyed by all, wasa testament to his organizational abilitiesand insights. Although unwell, John was a great help to Bob Hall andme in planning the 1986meeting in Salt Lake City. The lasttime eitherof us saw him was at that meeting. One of the most touchingmoments of my life came when I presented him with a plaque inappreciation for his term as President of SOAP, at the annual ban-quet. He received a standing ovation, which was long, warm andheartfelt. His premature death is a great loss to our small group ofresearchers, and practitioners of the art obstetric anesthesia.

September, 1986

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MINUTES OF THE BOARD OFDIRECTORS' MEETING

The Board of Directors of the Society for Obstetric Anesthesia andPerinatology met at noon on Thursday, May 15, 1986, in the WestinHotel Utah, Salt Lake City. Present were Drs. Richard Clark (PresidentElect) who chaired the meeting, Craft, Hall, Writer, Williams, Datta,and Cotton.

MINUTESMinutes of the previous meeting, have been published in the

Winter 1985-86 SOAP Newsletter, were accepted as printed.

OLD BUSINESSSOAP, 1985 Annual MeetingThe Board considered a number of items submitted by Dr. John

Craft's meeting planner, Martha Morales, relating to this meeting.Martha had suggested that an experienced meeting planner

should be appointed to handle local arrangements of all futuremeetings. Dr. John Craft thought the points in favor were the hosts'inexperience, which resulted in inevitable repetition of the planningprocess, and sometimes costly mistakes. He had been muchimpressed by the planning services provided by Martha, and felt costswere not expensive (approximately $1200.00).Allied to the appointment of a meeting planner, John Craft felt

there was a cogent argument for exploring (at least) the idea of aSOAP national office, with one individual receiving all queries andhandling Society printing. Robert Hall thought we should examineour objectives in relation to SOAP, and he questioned whether wewere interested in actively building the Society. If this were the case,acentral office would be worthwhile, but not otherwise. John Craftbelieved creation of a national office would require the Society toincorporate and seek tax-free status. (Where have I heard that onebefore?-Ed.) One requirement of such status would be the need forcareful bookkeeping.David Cotton asked John Craft for more information about the

expensive mistakes meeting planners might make. It appears theserelated to negotiations with hotels, and the possibility of seekingdiscounts for rooms and other services. In this area, the advice of anexperienced planner could be very important. Arrangements sur-rounding a SOAP meeting included negotiated contracts and verbalagreement, and each time we changed to a new individual the sameproblems were likely to recur. Des Writer, about to assume the'burden' of organizing SOAP 1987, felt the election of local hosts,who planned their own meetings, added to SOAP's informality. Localhosts were always appreciated, and the varying character of meetingswas enjoyed by members. Robert Hall, speaking from the experienceof organizing SOAP 1986, thought local convention bureaus couldhandle much of the planning, and replace the need for a permanentmeeting planner.On a voice vote members of the Board declared themselves against

the need for a meeting planner, and generously agreed to leave suchdetails to the local hosts!Dr. Craft then referred to the cost of 'no-shows' at meeting func-

tions. Mrs. Morales had suggested separate fees for each food func-tion, as,here had been 50wasted mealsat the SOAP banquet in 1985.Drs. Hall and Clark had already adopted this arrangement, in theirplanning for SOAP, 1986.John Craft suggested hosts consider reducing the registration fee

by $25-30, for those pre-registering one or more weeks prior to themeeting. Robert Hall noted that, in large centers particularly, manypeople find themselves unable to plan ahead and expect to appear atthe last minute. A reduction for pre-registration could be unfair tothese people. The Board was unable to come to any clear consensuson this proposal.Martha Morales had suggested SOAP should consider the possibil-

ity of special regional conferences, and the publication of a SOAPjournal. Board members believed there were enough meetingsalready, and Drs. Hodgkinson and Marx were doing an excellent jobwith the Obstetric Anesthesia Digest. In addition, members couldlook forward to the occasional publication of a SOAP Newsletter!DesWriter pointed out there was no international journal in Obstetric

SOAP BOARD OF DIRECTORS: (L to R Front Row) Richard Clark,John Craft, Bob Hall. (Back Row) Sanjay Datta, Des Writer, VirginiaWilliams, David Cotton.

anesthesia, but if SOAP were to become involved in such a publica-tion it would raise us to another league. Sanjay Datta emphasized thealready significant publication of Obstetric anesthesia material in'Anesthesiology' and' Anesthesia and Analgesia,' and SOAPmembers in addition receive Obstetric Anesthesia Digest. The Boardof Directors concluded they did not wish to move towards thepublication of a journal at this time.

Honorarium for SOAP PhotographerThe question of a more suitable honorarium for Dr. Alex Pue,

SOAP's unofficial photographer, was then discussed by the Board.Des Writer proposed, and David Cotton seconded, that when AlexPue attends future Annual meetings, as SOAP's unofficial photo-grapher, he be accorded the following benefits: complimentaryregistration, tickets to all social functions, and a free hotel room.Agreed unanimously.

Videotaping SOAP ProceedingsRichard Clark then introduced the matter of audio and/or video

taping of SOAP proceedings. This wasdiscussed at the host dinner onthe previous evening and, whilst there had been initial enthusiasm, itwas ultimately discarded because of concerns raised by members,primarily relating to medico-legal issues. After little discussion, theBoard declared themselves opposed at present to the video-taping ofpanel discussions.

SOAP Annual Meeting, 1988Dr. Gertie Marx had written to Robert Hall, expressing concern

about the combined OAA-SOAP meeting planned for Oxford, Sep-tember, 1988. She doubted if many SOAP members would have thetime or money to attend SOAP 1988 (in San Francisco), the ASAmeeting (also in San Francisco), and the combined meeting with theOAA. She therefore suggested the 1988San Francisco SOAP meetingbe postponed until 1989,and that SOAP 1988be held in Oxford, UK.Dr. Craft saw two problems concerning Dr. Marx's proposal: firstly,SOAP members, in agreeing to the 1988joint meeting, had acceptedthe idea of two meetings in SanFrancisco during 1988,and he foresawthere could be a big 'no show' in Oxford. Therefore, he thought itsensible to stick to the decision of SOAP 1985Annual Business Meet-ing, when 56 members had expressed an interest in attending SOAP1988,but made no clear commitment. He thought it would be impos-sible to change things in midstream and to accept Dr. Gertie Marx'sproposal. Sanjay Datta said some residents and fellows, who antici-pated presenting papers, might not receive adequate travel expensesfor the Oxford meeting.The Board agreed to encourage SOAP members, once again, to

attend the proposed joint meeting in 1988, and would ask membersto sign up for Oxford on a sheet of paper to be made available at thedaily registration desk. It was also suggested there be more informa-tion in the SOAP Newsletter concerning this joint meeting. TheBoard stated we should continue with our present plans to holdSOAP 1988 in San Francisco.

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Ex-treasurer's ReportDr. John Craft then presented his account of the expenses for the

1985 Washington SOAP Meeting.

Registration FundsAfter SOAP 1985, Dr. John Craft had recommended there be a

cutoff date for registration refunds, and he reported the loss of some$4,000.00 on late refunds. Dr. Hall, in contrast, thought this had notbeen a significant problem for the current meeting, but felt weshould not offer refunds at a late stage, even for social functions. TheBoard therefore recommended there be no return of the registrationfee for cancellations made within two weeks of the date of theAnnual Meeting. There would be a host option on refunds for socialfunctions, according to local requirements.

UPDATE 1 APRIL - 9 MAY 1986

SOAP subscriptions 1,424.00(U.S. funds)

TOTAL INCOME $12,921.14 TOTAL INCOME

1,099.74

$16.22

9.2328.50

56.00

2,690.83Can

1,021.15150.004.00

$2,312.6216.22

$2,763.05

$,2,328.24

Accrued from SOAP5.00 Subscriptions

(Cdn Funds)$11,251.29 TOTAL INCOME

EXPENSESN.5.F. ChequeDr. A. Pue (SOAPPhotos)

Total transferredto Cdn. Acct.

EXPENSES$41.00 Postage

Courier Service262.91 Graphics & Printing

of Newsletter1,607.94 Newleaf Enterprises to

stuff & mail SOAPNewsletterChristmas BonusesBank Service Charges

TOTAL EXPENSES $1,911.85 TOTAL EXPENSESBALANCE Mar 31/86 $11,009.29 BALANCE Mar 31/86

U.S. Account Canadian AccountINCOME INCOMEBALANCE Mar 31/86 $11,009.29 BALANCE Mar 31/86Accrued from SOAP TransferredSubscriptions from Cl Acct-(U.S. Funds) 237.00 $1,960.53 (U.S.)

Accrued providinglit. search

TOTAL INCOME

EXPENSESRegistration refunds $,2,157.00Kennedy Center 10,658.42Tours 1,091.00Exhibitor Refunds 486.60Hotel Charges 41,451.02Honoraria/expenses 1,095.00Secretarial and Meeting PlannerCosts 2,667.86

Printing/Art Work 5,060.41Banquet Entertainment 1,250.00Telephone/Postage 640.57Awards 60.13Miscellaneous 49.83

18,316.90

$83,653.15

$47,795.,008,550.001,597.006,446.25648.00

INCOMERegistrationKennedy CenterToursExhibitorsSale of BooksTransfer from SOAP1984

TOTAL

Transferred to SOAP 1986 - $16,985.31

Members congratulated Dr. Craft on the success of the Washing-ton meeting, and his careful presentation of these accounts. Therewere no matters arising.

Secretary-Editor's ReportDr. Writer presented the Secretary-Editor's report of his second

year in office. He noted the production of the SOAP Newslettercontinues to be financially solvent, using the services of DalhousieUniversity Graphics Department, and the University Printing Center.A local organization, 'Newleaf Enterprises: which employs disabledpersons, handles the mailing of each Newsletter issue, approximately1,100 being distributed. Dr. Writer again expressed some disap-pointment that only two newsletters had been published since theprevious annual meeting, and regretted the lack of suitable copywhich, with the generally enlarged format of each issue, largelyaccounted for the dearth of newsletters. He presented his statementof income and expenses to the Board, and noted that we had yet toreceive our expected contribution from SOAP 1985, which wouldfurther swell the funds in the Newsletter account. The amount ofinterest earned does not make the Society liable to tax in Canada. Inconcluding his report, Dr. Writer, ever optimistic, hoped for betterthings in the coming year and offered his services to the Board ofDirectors if they so wished. In addition, he acknowledged the con-siderable support of his hard working secretaries, Lorna Beeler andJanet Dorey.

The Board asked Dr. Writer to continue as Secretary-Editor, butrecognized in the coming year his significant responsibility for organ-ization of SOAP 1987. Des stated he would, therefore, welcomehearing from any individuals interested in assisting with the Newslet-ter editorship, or acting as contributing editors.The Board agreed that $4,250.00be sent to the Secretary-Editor for

Newsletter costs.

SOAP Newsletter AccountAPRIL 1985 - MARCH 1986

$58.471,387.00

1,190.4654.90

$2,690.83

$72.22

EXPENSESPostage

$1,960.53 Graphics & Printing ofNewsletter

Newleaf Enterprises tostuff & mail SOAPNewsletterSOAP Photos

$1,960.53 TOTAL EXPENSES

$9,290.76 BALANCE 9 May/86

EXPENSESTotal transferredto Cdn Acct

TOTAL EXPENSES

BALANCE 9 May/86

NEW BUSINESSGertie F. Marx SymposiumDr. Joffre Robbalino then attended the meeting to speak to the

topic of the Gertie F.Marx Symposium, which he had organized andrun forthe previous two years on the eve of the New York Postgradu-ate meeting in December. Dr. Frank James had written to President-elect, Richard Clark, because he felt Dr. Phil Sechzer, Director,Department of Anesthesiology, Maimonides Medical Center, Brook-lyn, would be unable to continue sponsoring the symposium formuch longer. Frank and Dr. Robbalino had suggested this sympo-sium be incorporated into the SOAP program.Dr. Robbalino then reviewed the history of the Gertie Marx Sym-

posium, established in 1984 in association with the New York PGAcourse. Despite the location of the meeting in Brooklyn, there hadbeen an attenda nee of approxi mately 200 in the first year. In 1985theattendance declined to approximately 160, and no meeting wasplanned for 1986. The symposium had taken a clinical approach, withcase presentations on Obstetric anesthesia, and a competition for thebest abstract submitted. Unless something was done, he felt thesymposium would fade out, and had accordingly explored the possi-bility of having it attached to SOAP. Dr. Robbalino suggested amorning at the beginning or end of the meeting, and he emphasizedthe symposium's success had been the clinical case presentations,and 'how to do it' talks. Dr. Richard Clark wondered if Dr. Robbalinowas proposing a symposium under the direction of the SOAP host, ororganized independently. Certainly, he felt the Society should con-sider its active involvement, for example with a Gertie Marx clinicalsession. Dr. Sanjay Datta suggested assessorscould identify the threebest abstracts submitted, and these might, perhaps, qualify for aGertie Marx award. For example, we could designate one of thebreakfast panels in the name of Dr. Gertie Marx, and follow this witha presentation of the three best abstracts. Afterfurther discussion, theBoard of Directors agreed there be one breakfast panel dedicated toclinical presentations, followed by the presentation of the three

continued on page 6

2,241.55(Cdn)

$87.29

$66,667.84TOTAL

Canadian AccountINCOME

$10,703.10 BALANCE Apr 24/85714.04 Transferred from U.S.

U.S. Acct. -80.00 $1,607.94 U.S.

U.S. AccountINCOMEBALANCE Apr 24/85Accrued interestSale of SOAPMailing Labels



abstracts chosen asbest by the assessors,in honor of the contributionto obstetric anesthesia made by Dr. Gertie Marx. This arrangementwould apply from SOAP 1987 onwards. Agreed unanimously.

Registration for OAA Attendees at SOAPAnnual Meetings.

In response to a request from the OAA, the Board of Directorsagreed to waive the registration fee for OAA attendees at our Annualmeetings.

Honoraria for Speakers at SOAP MeetingsThe Board of Directors unanimously agreed on the following

guidelines:Fred Hehre Lecturer: Return airfare, cost of hotel room for theduration of the meeting, ticket to planned social events and$500.00 honorarium.'What's New' Speakers: Complimentary registration and $250.00honorarium.Panelists and Moderators: No compensation.

SOAP DirectoryAs previously instructed by the Board of Directors, Des Writer had

included a flyer concerning a proposed SOAP directory in theNovember 1985 issue of the SOAP Newsletter. Some 1100 question-

naires were distributed, and approximately 330 SOAP members rep-lied. After some discussion, the Board instructed the Secretary-Editorto prepare a directory of SOAP members, who agreed to their namesbeing circulated, to include the following information:

Name, address, telephone numbers, affiliation and main area ofspecialty interest.

Such a directory would be for circulation only to members, and theBoard suggested 1st September, 1986 as a publication date.

OFFICERS 1986/87The Board agreed on the following nominations: President -

Richard Clark; Treasurer - Des Writer; Secretary-Editor -Des Wri-ter; Vice-President - Sam Hughes. Des Writer proposed, and DavidCotton seconded that, when a co-host is involved in the organizationof an Annual meeting, he/she be designated Associate President forthe forthcoming year. The Board of Directors unanimously agreed.

OB ANESTHESIA FELLOWSHIPSDr. John Craft transmitted a request from the past Presidents and

Directors of OB Anesthesia training programs, who would like theFall SOAP Newsletter to include a list of available Ob Anesthesiatraining fellowships, and names of the present holders. Des Writeragreed to collate this information.

There being no further business, and lunch having been welldigested, the Board adjourned to the afternoon scientific session.

•REPORT OF THE ANNUAL

BUSINESS MEETING SOAP 1986The Annual Business Meeting of the Society for Obstetric Anaes-

thesia and Perinatology was held at 1600 hrs on May 15, 1986, in theWestin Hotel Utah, with Dr. Richard Clark presiding.

MinutesMinutes of the previous meeting were accepted as published in

the Winter 1985/86 Newsletter.

Board of Directors' ReportDr. Writer read the recommendations of the Board of Directors'

lunchtime meeting. Enthusiastic applause indicated SOAP members'hearty support of the proposed Gertie Marx Symposium. Dr. RichardClark thought this show of support confirmed SOAP's continuinggood health.

Recommendation Concerning AssociatePresidentThe Meeting accepted the Board of Directors' recommendation,

with a near unanimous vote.

Officers 1986/7Dr. Clark presented the slate of officers for the forthcoming year:

President Dr. Richard ClarkAssociate President Dr. Robert HallTreasurer, Host SOAP 1987 Dr. Des WriterSecretary-Editor Dr. Des WriterVice-President Dr. Sam HughesDirector Obstetrics Dr. David CottonDirector Neonatology Dr. Virginia WilliamsChairman, ASA Committee onObstetric Anesthesia Dr. Gersh Levinson

Nominations were taken from the floorfor the election of a Direc-tor at large to replace Dr. Sanjay Datta on the expiration of his twoyear term. Dr. Betty Kuhnert was declared elected.

Nominations for Host SOAP '89

Dr. Richard Clark then braced members for the record list ofnominations to come, and said he understood nine members werevying with one another to secure nomination as host of SOAp 1989.

First at the podium was Dr. Monica Jones, introduced by TomJoyce. So members could have the delights of Houston firmlyimplanted in their minds, Monica provided a dazzling display of thevirtues and vices of this southern city (Houston A). She praised theeasy access by two airports, the many luxury hotels, the heritage ofTexas and its beautiful homes, the delights of its upcoming sesqui-centennial Year and the opportunities for jogging and hiking in itsbeautiful parks. Temperatures in April and May would be pleasantlywarm, and there was a multitude of opportunities for those with orwithout families. Among these Monica listed the Astros and theRockets, the Johnson Space Centre, the Galleria - for the best inshopping, year-round ice skating, nightclubs, discos and the manyworld class restaurants. For those more culturally inclined, there wasthe Center for the Performing Arts. Finally, Monica bemused thebusiness meeting with a 16 mm. movie recounting the culinary,recreational, entertainment, cultural, sporti ng and pyrogenic distrac-tions to waylay SOAPers.

Following Monica's up-market presentation, Dr. Sanjay Dattamade no apology for presenting lowly Boston asthe proposed site ofthe 1989meeting. He did not intend to dazzle members with slides ora 16mm. film, but wanted them to come to Boston and take their ownpictures. He reminded us of the success of SOAP 1980, which hadbeen held in Boston, and pleaded for a 1989 repeat.Dr. Ezzat Abouleish then regaled members with the Houston B

presentation. He was prepared to act ashost orco-host to SOAP 1989,in this pleasant city. He declared himself to be a man of experience,who had worked hard for SOAP for many years. He started the firstTexas Anesthesia Conference for Obstetric Anesthesia. To imprintHouston indelibly in the memory of SOAPers, he reiterated theglamorous city's many attractions: its cleanliness, beauty, magnifi-cence, generous landscape, Fine Arts Center, Space Center, Galleria(including the famous K-Mart), horses, nightlife, Seaworld, Rodeo,and Seaport. Displaying a rare picture of himself moonlighting in agas station, he instructed members how he would obtain regular gasat 63.9 cents/gallon. t

;;

I

Apologizing fortaking members away from these sensuous oppor-tunities in her native state, Virginia Williams elegantly presented themarine attractions of Seattle and the Pacific Northwest, where shenow resides. Recently rated as the best vacation place in the U.S.A.,the city boasts beautiful vistas of ocean and mountains, beneath itsoccasionally clear skies. Virginia displayed the photogenic delights ofPuget Sound, the restored downtown, the harbourside (with moreboats per capita than any other US city), and the mountains, whichprovide opportunities for spring skiing. In late May, members cantake boat trips to San Juan, or even 'overseas' to Vancouver andVancouver Island. Hearty mountaineers can climb Mount Rainier(weather permitting) in two (or more) days.David Dewan then gave us a picture of the Piedmont, and the

University town of Winston-Salem. The city hosted SOAPin 1979, andhas excellent convention facilities, including some first class hotels.There isample recreation with fine golf courses,and great opportuni-ties for tennis. SOAPers can visit Old Salem, or several stately Caroli-nian homes. There is also ample cultural opportunity, and the pro-ductions of the North Carolina School of the Arts.Ralph Milliken spoke up for Westchester County and nearby New

York. Proposing Dr. Gertie Marx asthe principal host, and President-Elect for 1989, Ralph contrasted the quiet pastures of WestchesterCounty with the bustle of neighboring New York City. EchOing withmemories of the Revolution, Westchester County has museums,such as the famous Barnham and Bailey Museum, parkland,waterline-like long Island Sound, and the corporate headquarters ofmany companies, notably Pepsi-Cola. A great place for a meeting andeasily accessible from New York City's three major airports, or West-chester Airport.Stuart Bramwell encouraged us to come to the city of the other

cola. He, supported by Jim Evans,felt it was time for SOAPto meet inAtlanta, with its fine architecture, culture, spring flowers and Dog-wood Festival. The city prides itself on its sophistication, and oldhistoric buildings and, of course, on the new Hartsfield Airport, fromwhich one may travel to almost anywhere (even Canada.!). Atlantahas many parks, four miles of riverbank, the Woodruff Arts Center,and Art Museum, and an enormous variety of entertainment fromthe "folksy" to the "fluffy."Not wishing to bore us with further slides, JayDevore once again

mooned over Madison, Wisconsin. The most logical choice for aSOAP Meeting, he declared, is this central location easily accessiblefor all SOAPers. With its beautiful countryside, four lakes, inexpen-sive living, and crime-free streets, Wisconsin offers SOAP unbeatabledelights.Finally, tempting SOAPers with a guarantee of warm weather,

unspoiled by ocean, John Curtis spoke of rapidly growing Phoenix.This five-star resort city offers golf, tennis, and horseback riding, plusa rapidly growing group of obstetric anesthetists dedicated to pro-ducing a high-quality meeting.After the first vote Seattle (33), Houston (20) and Boston (18)

emerged as the leading contenders. With the remaining aspirantsexcluded, members then cast their final votes. Seattle (52) emergedvictorious over Boston (38) and Houston (united) 29, and VirginiaWilliams was nominated as host for SOAP 1989 and, (when sheassumes office), our first lady President.Dr. Sheila Cohen then proposed 'That the Business Meeting

reconsider the previous decision of the Board of Directors to asso-ciate the Presidency of SOAP with the meeting site.' Having clarifiedthat the effect of agreeing to this motion would be to dissociate theoffice of President from the site of the Annual Business Meeting,Richard Clark invited discussion from the audience. Brett Gutscheemphasized that a prospective host could organize a meeting inotherthan his or her home city (prompting reminiscences of the easilyaccessible Jackson Hole.) Frank James pointed out that the real workis in organizing the meeting, and Tom Joyce thought of the Presidentas an honorary figure, who simply hosted the Board of Directors'meeting. Sol Shnider thought the incoming President had an enor-mous job, and it would be a mistake to divorce the office of Presidentfrom that of meeting host. Richard Clark, President-Elect, declaredhimself one example of a President hosting the meeting in an alter-nate city. George Albright spoke against the motion because hebelieved the system was working "amazingly well."On a vote, the motion was defeated -12 for, 107 (approximately)

against.There being no further business, Richard declared the meeting

closed, with an invocation to SOAPers to enjoy the delights of Saltlake City.

•


SOAP '86The tragic passing of Bob Hodgkinson, and John Craft,

has pre-empted much of the information about SOAP1986. Minutes of the Annual Meeting, and of the Board ofDirectors' Meeting, together with the Fred Hehre lecture,will serve to recall some of the flavor of Salt lake City. Ournext issue will contain summaries of scientific presenta-tions, and much much more. Stick around!

*IPRESIDENT'SCOWMN , *"Reflections onSalt Lake City"

Richard B. Clark, M.D.President. SOAPAugust, 1986

SOAP '86 has come and gone and, despite my bias, I think thismeeting compared very favorably with others. There was probablymore interchange of information than previously; the facilities wereexcellent, as was the ambience. Person after person commented onthe warmth and friendliness they felt in Salt lake City; a 'warm fuzzy,'I'm sure, due mainly to Bob Hall's Personal Airport Pick Up Service. Itwas a lot of trouble for Bob, but he earned the undying gratitude ofmany people. .We were all terribly shocked and saddened, in early July, to hear of

the passing of our 1984 Host, Bob Hodgkinson. My last memory ofhim was seeing him packing up his ingenious display of ObstetricAnesthesia Digest in the exhibit area. Bob was noted for his acerbicwit, precision, practicality, quiet insight and jaunty manner. He willbe very much missed. I have written a letter of condolence to hiswidow, Ottillia, and other SOAP members may wish to do the same.Some of Bob's colleagues have donated to the American CancerSociety, and SOAP's Board of Directors will consider establishing anendowment fund for the memory of departed members, when theymeet in October.SOAP remains a small, informal organization, but some of the

problems of growth and maturation are (I think) beginning to arise.There was considerable discussion at the last business meeting (per-haps more than we had time for) about the issue of separating thehost and the meeting site. Of course, more than one person statedour present system worked "amazingly well". Although a motion toseparate the two was overwhelmingly defeated (12 for, 107 against) Idon't think the issue will die. I urge members to contribute theirviews to SOAP Box. We need more time for discussion - one hour ayear isn't enough!, and, I have asked Des to schedule a longerbusiness meeting in Halifax if possible. Pleasewrite with your furtherthoughts - the debate can continue in the SOAP Newsletter.Another example of growing pains is the selection process we

employ for the Annual Meeting site. All of you noticed the largenu mber of nominations (9) for the meeting site for 1989. That, proba-bly, is healthy, butthe discussion about meeting sites, their merits anddemerits, and the almost rancorous tone that developed, distressedme. I think our elegant Society should be above that (I'm serious!).How should we approach this? Should we let the chips fall wherethey may? Several suggestions were made - persons wishing to hostthe meeting should apply in advance, and send their CurriculumVitae to the Board. (I would like to point out that the Articles ofOrganization state "It [the meeting site) shall be chosen approxi-mately two years in advance from a list of alternative sites and hosts

continued on page 12


DR. FRANK GRE/SS, Chairman of theDepartment of Obstetrics and Gynecol-ogy, Bowman Gray School of Medicine ofWake Forest University, Winston-Salem,North Carolina, gave the 1986 Fred Hehrelecture, here edited and revised forpublication.

Fred HehreLecture,Soap 1986

I really did n't know Fred Heh re at all, just asa casual acquai ntance. Iwish I had known him more at the time. What I propose to do for youin this tribute is take you through the last 25 years, possibly a littlemore, to look at the development of our knowledge concerning theevolution of the placental circulation. Some things I shall say reflectmy own bias, but have served as effective ways for me to try andunderstand how this circulation works.

In his first few slides Dr. Greiss elaborated on the uterine circula-tion of the non-pregnant uterus. "The sheep estrous cycle isabout 17to 19 days, and uterine blood flow is very low during the progesta-tional phase, for about 2 or 3days, before some 'action' begins. Thenfollows a marked increase in uterine blood flow (UBF), which peaksjust about the time the ewe begins to stand for the ram, over a 24-36hour period surrounding ovulation. In both right and left uterinearteries, the same type of thing happens, and the changes are notspecific to the side of the corpus luteum.ln relating the UBF curve tothe changes in estrogen and progesterone levels which occur, thereis a coincidence between the estrogen spike and the UBF spike.Similarly, when estrogen is given to a castrated ewe there is a periodof about 30 minutes, following which one sees this same remarkablerise in UBF, in some casesa fifty to hundredfold increase. I believe theincreased blood flow at estrous is, essentially, an obligatory changeinduced by the estrogen rise."

"In conceptual estrous, UBFappears little different for 17 days fromthe non-conceptual cycle. However, a progressive increase thenoccurs, the changes usually being slightly earlier on the side of thecorpus luteum and pregnancy."

"When looking at the overall changes throughout pregnancy, thisincreased blood flow doesn't look much, compared with whathappens at term. In conceptual estrous, after approximately 17 to 19days, UBF starts to increase; then fetal size begins to take off, about athird of the way through pregnancy, and UBF follows it. If we expressblood flow as flow per unit weight of fetus and uterus, it's quite highat the time of estrous, then low, then increases markedly in earlypregnancy. Then a progressive decrease occurs until flow stabilizesapproximately halfway through gestation, subsequently remainingconstant. If we study the fraction of total UBF going to the caruncles(the areas of the uterus destined to develop into the definitive pla-centa), between days 40 and 60 to 70, there is a shift from about 25percent to, approximately, 60 to 65 percent of total flow. Then, afurther slow progressive increase in this fraction occurs to term, whenthis fraction approxi mates 85 percent. Simultaneously, A- V O2 extrac-tion gradually increases, and the O2 consumption of the conceptusalso progressively increases, until approximately halfway throughpregnancy, when O2 delivery becomes more or less constant."

Dr. Greiss went on to examine some of the other changes whichoccur in the uterus during this time of increased blood flow and O2

consumption."Let's look first at the non-pregna nt sheep uterus. Here the carun-

c1es- the small nipples where definitive placentation will occur -are arranged in row-like columns. When pregnancy occurs thecaruncles begin to look different. They turn from nipple-like struc-tures into a mesa-like structure, and then gradually come to theirdefinitive development, like mushroom caps. Development is muchmore advanced around the fetus than in other areas of the uterus. Aspregnancy progresses this development continues. In microscopicclose-up of the region of these mesa like structures, one can begin tosee development of the fetal vasculature, the individual portions ofthe umbilical cord branching to each of these developing placentae.As this remarkable change occurs, between approximately 30 to 70days, one observes the shift of UBF earlier discussed - from the 25%level to 60 to 70 percent. Distributional studies with microspheresshow that the larger flow fraction was, initially, going to non-

placental tissues and then the shift to the conceptus gradually occurs.Why does this happen?"I remember one day looking through Barcroft and Barrons' book,

which most of us who work in the area of UBF think of as the Bible.Barcroft described, within the cotyledons, great shafts of Wharton'sjelly-like material, which infiltrate the caruncles and graduallychange them into the definitive mushroom caps. He measured gluc-osamine levels in the 1940's, when this was the measure of hyaluronicacid, the major constituent of Wharton's jelly. He found the gluco-samine concentration to be quite significant in the cotyledons, and itremained so throughout pregnancy. Barcroft's studies were all from,approximately, 60 days of gestation on."

"I got to thinking about this glucosamine-like substance, andplayed some 'games' with it, injecting it in very high doses into abranch of the uterine artery. As one progressively increases thedosage, one observes an almost immediate flow increase, a markedvasodilatation which approximates the type of change that occurswith estrogens. In an effort to determine if there is any relationshipbetween glucosamine and the 'shunting' of blood from the uterus tothe placenta itself, we studied a number of sheep from non-pregnant, through early pregnant, until SOdays of gestation, andmeasured the hyaluronic acid content, expressed asthe glucosaminecontaining fraction. And, interestingly, this fraction starts to increaseabout 18 days to 20days, exactly the same ti me asUBFstarts to take offfrom its very low levels. Although this is correlative data, and does notprove this to be the reason the shift occurs, I think it is a ratherprovocative and interesting observation.""What are the implications of these changes with respect to the

circulation? To explore this, I would like to review pressure/flowrelationships. As most of you know, there are two possibilities:(i) A passive vascular bed, in which a curvilinear relationship

exists between pressure and flow, with the curvilinearity to thepressure axis. This is typified by skin, and the slope of the linereflects the degree of basal vascular tonus. When a fair amountof basal tonus exists the slope of the line is low, whereas whentonus is very Iowa much steeper slope occurs.

(ii) An autoregulated vascular bed, as in the cerebral circulation.Here, when pressure is decreased, flow tends to maintain itselfconstant, primarily by vasodilatation, until vasodilatation canno longer occur. Then a steep drop in flow results."

"With this as background, we began to look at pressure/flowrelationships, in the uterine circulation. When we look at total UBF,we see a straight line - a physical impossibility! It certainly lookssomething like a curvili near, passive vascular bed, but the curve has aslope of one. What we presumed from this was that, under restingcircumstances, uterine vessels (mainly in the placental circulation)are widely dilated, so widely dilated they can dilate no more, explain-ing the one-to-one relationship. These findings bothered us, and Iremember spending a number of evenings talking with Dr. HaroldGreen, a mentor to me in this area. (Harold was a professor ofPhysiology, who did a lot of work in the cardiovascular system, and hecouldn't come up with any answers either!) However, we then beganwork with the non-pregnant sheep and found we didn't get the samekind of curve; in fact one sees an autoregulatory curve. A little lightthen began to dawn, and we started to look at some differentialpressure-flow studies through the developmental period, fromapproximately 20 to 70 days of gestation in the ewe."

"In the early part of pregnancy, 29 to 40 days the pressure-flowrelationship is more consistent with the non-pregnant sheep. Then,from 42 to 50 days, the flow pattern to the placenta migrates towardsthe line of linearity, while the autoregulatory component persists inthe 'non-pregnant' circulation to the myoendometrium. Later, in thedefinitive situation, the placental circulation has a curvilinear rela-

jI1j

JI

tionship, as opposed to the autoregulatory changes which persist inthe myoendometrial circuit. I believe these changes reflect the pro-gressive vasodilatation occurring in the vessels which supply thecaruncle (becoming cotyledon) - a dilatation, and shunting of bloodto this area. Thus, the initial enigma, the straight line, is explained bythe fact that we're looking at two different pressure-flow curves -the myoendometrial curve, and a curve for the placental circulation.The composite curve, by virtue of the proportionate distribution,winds up as the original straight line. To test our hypothesis further,we calculated flow percentages, gave an isolated bolus of micros-pheres, then determined their distribution. This confirmed our sus-picion that we were looking at two beds each behaving slightlydifferently but, by '/irtue of the proportionate change during preg-nancy, producing a composite straight line. This hassome very perti-nent, practical applications which I shall shortly discuss."

"So much for sheep. What about the human female, whom most ofus deal with?" Dr. Greiss then showed slides from Elizabeth Ramseyand Martin Donner's book 'The development of the placenta,' whichincludes many drawings from photomicrographs, showing phases ofthe early development. "In the early weeks of development there isaprogressive invasion of the uterus by trophoblast, which makes smalllakes in the endometrium. Then one sees progressive invasion ofmaternal capillaries, and destruction of the spiral arterioles. These, inturn, dilate and switch over to spiral arteries, rather than arterioles.Then, there is engulfment of the maternal capillaries, and furtherdevelopment of villi. Then a very remarkable thing occurs - thetrophoblast, which has now eaten away the capillary, begins to rundown into the lumen of the remaining spiral arteriole, like candlewax going down the side of the candle as Elizabeth Ramsey describesit. As it goes down, it completely invades and replaces the wall of thespiral arteriole. So, at the end, one sees destruction of smooth mus-cle, and of the elastica, and replacement of this by trophoblast. Thenendothelium grows over. This appears, for the human female, to bethe mechanism whereby the vessels destined to supply placentaachieve their dilatation, and approxi mate the type of change I'vedescribed in the sheep. The changes progress throughout pregnancyuntil, asfull term, dilatation reaches down into the radial arteries, andinvasion of the trophoblast occurs to that level. This results in dis-placement of the site of active resistance from a small vessel to arather large vessel - in effect an approximately ten-fold increase indiameter of the vessel."

"Finally, of course, we come to definitive placentation - a singlecotyledon, as we think of it, now supplied by a single spiral artery,perfusing the surface of the fetal villi under a head of pressure, andthen percolating back into the systemic circulation. It's an amazingthing that, grafted on to the inside of the uterus, for the duration ofpregnancy, is a new place where blood comes outside the normalchannels, and enters the intervillous space, then to return. It hasinteresting implications as it relates to uterine contractions."

"What do we know about absolute flow to the uterus? In the earlydays of abortions, Assali took advantage of the opportunity to mea-sure UBF in the human, using both flowmeters and the N,O diffusionequilibrium technique. He found, from 8 weeks until about 28 weeks,a progressive increase in flow which we all expected. However, whenhe expressed this as flow per unit weight of uterus and its contents,even as early as about 10 weeks - a quarter of the way throughpregnancy - he observed relatively constant flow, at a level whichapproximates about 100-125 ml.kg-1.min-1 (approximately a third ofthat in the sheep). Work undertaken at term, at the time of cesareansection, both by the Boston group and Assali's group, shows similarlyconsistent data. Oxygen supply is very consta nt during this period, at10 ml.kg-1.min-1 - the same amount as delivered in the sheep, butwith one third the blood flow. Indeed, there are great similaritiesbetween the sheep uterine circulation, and how it evolves, and thehuman circulation as it evolves. All of the data certainly suggests thatthe human placental circulation is the same widely dilated, passivebed, we can clearly demonstrate in the sheep."

"Now, let me switch over to some practical applications. Onerecognises there must be a built-in safety factor to protect the fetusfrom the various stresses which beset it, throughout pregnancy,pathology, and the things you and I do to it. And many compensatorymechanisms underlie this safety factor. I want to examine just one-0, delivery. 0, delivery is flow-limited and, in the latter part ofpregnancy aswe have seen, flow rates per kg. of uterus and contents,A-V 0, extraction, and therefore 0, delivery, are constant. Whathappens if we reduce UBF? Obviously, the fetus must extract more0,. And, for as long as the fetus can extract 0, as flow decreases, 0,


delivery can remain constant. Most of the data I've been able to findin the literature suggests the limit of this is 2x, at least in sheep. So,from just this mechanism alone, UBF can fall by 50 percent, and byreleasing twice as much 0, maintain the same amount of 0, delivery.It's when flow falls below this point that 0, delivery decreases. I thinkof this as when baby begins to die. We can use the same thoughtprocess to construct a hypothetical relationship, a background uponwhich acute stimuli occur. There must be an area throughout normalpregnancy, with normal development of the intervillous circulation,where everything is optimal- oxygenation, foodstuffs, fetal growth.There must also be an area where things are suboptimal -foodstuffsmay be inadequate, for example - and this is probably the area ofIUGR. Then, when we exceed the limits of the system, the infant hasto fall back on anaerobic respiration, producing fetal acidosis. I seethis astne area of late decelerations in fetal heart rate. Obviously thisbaby can only continue for a certain period of time before it dies.Finally, there may be an area where we totally exceed the safetyfactor, and we might address our attention to toxemia of pregnancyto illustrate this."

"Brosens, of Leeuwen, working with Robinson in England, studiedplacental biopsies in normal, and in toxemic patients, to examine thespiral arteries, and their degree of infiltration by trophoblast. The firstwave of trophoblastic invasion occurs at approximately 8 -10 weeksof gestation; a second wave, which extends down into the radialarteries below the myoendometrial junction, occurs at approxi-mately 14 weeks. It appears, from their very elegant studies, that thesecond wave doesn't occur in toxemia. Therefore, we're not dealingwith as much vasodilatation as when the second wave occurs. IfBrosen's theory is correct -that the toxemic never does develop 100percent vasodilatation -there may only be 75 percent the normalflow. One cannot then reduce flow by 50 percent and still have thesame degree of safety; flow can only reduce by 25 percent. Casereports published some years ago, from Durban, S. Africa, illustratedthis point in a very toxemic patient given their equivalent of apreso-line. Too much was given, and maternal blood pressure fell from160/110 torr to very low levels. If we presu me the mother started, notat 100 percent vasodilation, but at only 75 percent, asthe pressure fellthe flow followed and the hypoperfusion exceeded the safety of thesystem. The baby developed bradycardia, so severe they had todeliver the infant by cesarean section. A second case they presentedalso proved illustrative. In this mother, although they didn't pushapresoline quite so hard, and didn't drop the flow or pressure quiteso much, there was labor in addition. Now the problem of uterinecontractions complicates the picture, and fetal diStressoccurs, whichisa function not only of the hypotension, but also of changes inducedby uterine contractions. Even with less hypotensive stress, theincreased labor stress was enough to compromise mean uterine flowand get the baby into difficulty. The practical application of thiscomes with respect to spinal anesthesia. In work with ewes, which weundertook, we used subarachnoid tetracaine, deliberately to causehypotension. As expected, as the pressure fell flow followed rightalong with it. Although we gave phenylephrine at the end of thehypotensive period to restore maternal BP, we were really no betteroff. However, if we gave fluid replacement, for example dextran, arather remarkable increase in flow occurred, simply from infusingenough volume into the expanded vascular capacity. You're all, ofcourse, familiar with the fact that, when hypotension occurs, you can'talways correct it with fluid replacement, and you must decide whichdrug to give. Work which Frank Jamesand I undertook compared theresponses with ephedrine and aramine (mataraminol).It's easy to seewhy the adverse effects of metaraminol were never recognized ear-lier than 20 years ago, because in the usual hypotensive range babiesdidn't get into trouble. Only when flow falls into the 'jeopardy' range,does the proper selection of vasopressor agent make the differencebetween a dead baby, a depressed baby and a live baby."

In his last series of slides Dr. Greiss showed some preliminary workundertaken by Dick Stanger, Cincinnati, in the early days of isoxu-prine. "I want you to imagine a multipara, who is about 7 centimetersdilated, who has been having good regular contractions, prior to theadministration of isoxuprine. When started, isoxuprine predictablycaused vasodilatation and a decrease in systemic blood pressure. Inthis case, Stanger and co-workers stopped the uterine contractionseffectively, and an expected maternal tachycardia ensued. They thengot 'itchy' and decided to stop this drug. With the blood pressure stillfluctuating something happened - a contraction occurred. Now,when the contraction comes along, coupled with the vasodilatation,

continued on page 10


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theSOAPbox

Dr. ]. Bruce Laubach, Obstetrical Anesthesia Associates of Dallas,Inc., felt dismayed at comments made by Gersh Levinson, when hespoke on 'How I manage a routine vaginal delivery: at SOAP, 1986.The Editor 'dropped in' on their exchange.

Dear Dr. Levinson:Dismay may be too mild to describe my feelings when you made

your presentation at the recent SOAP meeting. The recommenda-tion, coming from an internationally recognized expert, that anotherAnesthesiologist be called in whenever a cesarean section is per-formed, is part of a prescription for destruction of existing Obstetricanesthesia programs in private, non-teaching hospitals. Coming onthe heels of Dr. Gibbs' survey of Obstetric anesthesia in the country, itis especially distressing. He pointed out the difficulty of getting evenone Anesthesiologist in the labor and delivery area. If two becomesthe standard, we can expect even less participation. It may work foryou, with a small service, but on a service such as ours, with 4500deliveries and a section rate of over 30%,the reality is overwhelming.It occurs to me that all of us, in the real (non-academic) world, have

devised our own systems. You have developed yours and we haveours. We have conducted over 25,000major Obstetric anesthetics inthe past 6 years, with four to six Anesthesiologists, and no house staff.On less than five occasions, we have found it necessary to call in asecond physician. We have had no anesthetic complications relatedto the manner of coverage.Would it be of interest to have, at the next SOAP meeting, a panel

of non-academic obstetric Anesthesiologists, to discuss this? Thereare, now, a number of us out here. Many of us have systems thatwork, providing high quality care to large numbers of patients.


the baby shows fetal bradycardia. Stanger's reaction to this was tosweat ... "let's get this baby out of here." So he started oxytocin and,as you all know, one must start slowly because of possible tetaniccontractions. In this case, a tetanic contraction occurred, about th reetimes the length of normal contractions. During that time the fetalbradycardia worsened. As time progressed, after stopping the isoxu-prine, the mother's blood pressure climbed. Classic late decelera-tions occurred, but the bradycardia was lesssevere. Finally, pressurereturned to normal, good regular contractions occurred, and thebaby improved. What was happening to UBFat this time? I suggest, asperipheral vasodilatation and a decrease in pressure occurred, UBFfell correspondingly and, when they started to worry, they had goodreason! Flow was dipping down to jeopardy range. Rememberingthe inverse relationship between uterine contractions and UBF, it'sthe combination of hypotension's effect on decreased flow, and thefurther reduction of blood flow induced by the contractions, whichgets baby into difficulty. This explained why baby deteriorated duringthe tetanic contraction.I tend to think of impaired UBFasa baby a little 'out of breath,' a lot

'out of breath' or, 'right out of breath.' Contractions are fetal breath-holding. This baby was somewhat out of breath, and had to hold itsbreath when a contraction occurred, explaining the late decelera-tions. Finally, when things returned to normal again, (good pressure,good basal flow) baby was no longer 'out of breath.' In this situation,when it must hold its breath during contractions it really doesn'tbother the baby much.""I have taken you through my views of how the placenta develops,

and the impact this has upon its circulation and our clinical manage-ment. I have given you a few illustrations, and taken some liberties. Ishall not answer any questions!""I thank you very, very much for the honor of being your Fred

Hehre lecturer."

•

Standards of care should be developed, for sure. Perhaps thoseactually providing that care, should have some input into thatprocess.

,. Bruce Laubach, M.D.

Dear Dr. Laubach:I regret your dismay over my presentation at the recent SOAP

meeting. Unfortunately you missed certain points which I thought Ihad clearly made.The topic assigned to me was "How I Manage a Routine Vaginal

Delivery." I have spoken often on how obstetric anesthesia should bedelivered and on "standards" in obstetric anesthesia, but the meetingorganizers specifically required that this talk be limited to how Iactually practice. I never stated, implied or intended that my practiceshould be taken asa standard.I am currently in private practice and work without house staff. The

group I joined had adopted the practice of calling in a secondAnesthesiologist for cesarean sections several years ago. With 3500deliveries per year they believed there should be someone availableto manage the not infrequent obstetric emergencies and the partur-ients with ongoing epidural anesthetics. They would be insulted, as Iam, to learn that you don't consider them to be in the "real (non-academic) world." I assure you that we are "actually providing thatcare."I am glad you have devised a satisfactory system of providing

obstetric anesthesia coverage and I am sorry you interpreted myremarks as a recommendation that you change your practice.

Gershon Levinson, M.D.

(We have taken note of Dr. Laubach's suggestion that a non-academic obstetric Anesthesiologist, from the 'real' world, be invitedto participate in a panel at SOAP, 1987. Our program plans do notallow for a whole panel of 'non-academics,' but we strongly encour-age them to attend SOAP, 1987, and be heard!

Des Writer, Host, SOAP '87)

MeetingsWe've Heard About

November 3-9, 1986. 2nd International Course on "Recent Advanceson Perinatal Medicine," Erice-Sicily, Italy. Contact: Prof. E.V. Cosmi,via Monte Madonna, 23 00060 Formello (Rome), Italy

November 19-21, 1986. Institute of Obstetrics & Gynaecology (Uni-versity of London), Teach-In on Obstetric Anaesthesia & Analgesia,Queen Charlotte's Maternity Hospital, London, England. Contact:Symposium Secretary, Institute of Obstetrics & Gynaecology, QueenCharlotte's Maternity Hospital, Goldhawk Road, Lndon W60XG (Tel:01 - 740 3904).

December 7-9,1986. Three More Hot Topics in Neonatology, RossSpecial Conference, Hotell'Enfant Plaza,Washington, D.C. Contact:J. F. Lucey, M.D., Medical Center Hospital of Vermont, Burlington,Vermont 05401.

March 5-8, 1987. TACO III: Third Texas Anesthesia Conference forObstetrics, Houston, Texas, Inter-Continental Hotel. Contact: PatJoynton or Alice Reardon 713-792-5346Outside TX 1-800-231-9481

March 20-22, 1987.Obstetrical Anesthesia: 1987,Hotel Meridien, SanFrancisco, California. Contact: Anesthesia Research Foundation Reg-istration Office, Attention: Mark A. Rosen, M.D., University of Cali-fornia San Francisco, C-450, San Francisco, CA 94143-0648, Tele-phone: (415) 476-2273.

April4,J987. Sixth Annual Symposium, "The High Risk Mother andFetus - Anesthetic and Obstetric Management," Women & InfantsHospital, 101 Dudley Street, Providence, R. I.

May 21-24,1987. SOAP 19th Annual Meeting in Halifax, Nova Scotia,Canada. Halifax Sheraton Hotel. Host Des Writer •

March 3-6, 1988. SOAP 20th Annual Meeting, Meridien Hotel, SanFrancisco. Host Sam Hughes.

April, 1988. 11th European Congress of Perinatal Medicine, Rome,Italy. Contact: Organising Secretariat, c/o 2a, C1inica Obstetrica eGinecologica, Policlinico Monteluce, 06100, Perugia, Italy.


FELLOWSHIPSFellowshipsin 08 Anesthesia: The PastPresidents and Directors of

OB Anesthesia training programs asked the SOAP newsletter toinclude a list of all available OB anesthesia training fellowships, withnames of present holders, in the Fall issue. To date we have receivedthe following replies, and a complete list will be published in the nextissue.

BAYLOR COLLEGE OF MEDICINE1986-87 Six Month FellowshipWilliam Grimes, M.D.Jon Botts, M.D.Jonathan Gallen, M.D.Charles Freeman, M.D.Valerie Robinson, M.D.

1986-87 Twelve Month FellowshipPhillip Greider, M.D.DIRECTOR: Thomas H. joyce, III, M.D., Vice Chairman, Departmentof Anesthesiology, Professor of Anesthesiology, Professor of Obstet-rics and Gynecology, Jefferson Davis Hospital, 1801 Allen Parkway,Houston, Texas 77019.

UNIVERSITY OF IOWA1986-87 FellowshipPontus Ostman, M.D.Cindy Owen, M.D.DIRECTOR: Won w. Choi, M.D. CO-DIRECTOR: David H. Chest-nut, M.D., The University of Iowa Hospitals and Clinics, Departmentof Anesthesia, Iowa City, Iowa S2242

lOPPORTUN ITIESlAs a serv(ce to SOAP members, advertisements for available positions will be printed free of chargeas space permits. Ads will be deleted after they have been published in four consecutive issues (oneyear). Advertisers are requested to notify us as soon as positions are filled. Address all correspon-dence about ads to the Editor. Chief of Anaesthesia, Grace Maternity Hospital, 5821 University Ave.,Halifax, Nova Scotia, Canada 83H 1\V3.

PENNSYLVANIA: The Department of Anesthesiology at PennsylvaniaHospital, a major affiliate of the University of Pennsylvania School ofMedicine, has an immediate opening for an individual with primaryinterest in obstetrical anesthesia. Applicants must be eligible for fullor part-time faculty appointment at the University of PennsylvaniaSchool of Medicine. Minimum requirements include board certifica-tion or board eligibility (recent graduate); completion of an OBanesthesia fellowship, Pennsylvania state licensure or eligibility. Thisis a very active patient care and teaching service with 3900deliveries ayear. Research is encouraged. Send CV or contact: Melville Q.Wyche, jr., M.D., Director, Department of Anesthesiology, Pennsyl-vania Hospital, 8th and Spruce Streets, Philadelphia, Pennsylvania19107. The University of Pennsylvania is an EO/ AA employer. 10/86

NEW YORK: OB Anesthesiologists: Fellowship trained to work forP.c. at busy University affiliated hospital. Home of regional Perinatalcenter. 4,000+ deliveries/year. Excellent cultural, educational andrecreational resources. liberal salary and fringe benefits. Send CVwith application to CNY Anesthesia Group, P.c., 736 Irving Avenue,Syracuse, New York 13210. 10/86

CALIFORNIA Stanford University School of Medicine Department ofAnesthesia is seeking applicants, with a special interest in ObstetricAnesthesia, for a faculty position at the Assistant or Associate Profes-sor level. In addition to board certification, additional clinical andresearch training or experience in the field is required, and candi-dates must be eligible for or possess a California licence. Women andmembers of minority groups are encouraged to apply. H. BarrieFairley M.B. B.S., Chairman, Department of Anesthesia, StanfordUniversity School of Medicine, Stanford, California 94305. 4/86

WASHINGTON, D.C. Director, Obstetric Anesthesia. Must be boardcertified or eligible anesthesiologist with a specialized year in OBanesthesia or equivalent experience. To work in a 550 bed university

UNIVERSITY OF MARYLAND1986-87 Six Month FellowshipDouglas Marz, M.D.William j. McGuinn, M.D.DIRECTOR: Andrew M. Malinow, M.D., Chief, Section of ObstetricAnesthesiology, Assistant Professor of Anesthesiology, University ofMaryland Hospital, 22 South Greene Street, Baltimore, Maryland21201

STATE UNIVERSITY OF NEW YORK1986-87 Twelve-month Fellowshiplawrence Epstein, M.D.Harvey Nitzky, M.D.

1986-87 Six Month FellowshipHoward Buchbinder, M.D.William Smookler, M.D.

DIRECTOR: Terry Whetstone Harmon, M.D. Director/OB Anesthe-sia, Assistant Professor of Anesthesia, Obstetrics and Gynecology,Downstate Medical Center, State University of New York, 450 Clark-son Avenue, Box 6, Brooklyn, NY 11203.

hospital with an active obstetric service (1,400 deliveries per year)especially directed toward epidural anesthesia. Forty-eight percentof our patients are considered to be in a high risk category. Activeresident teaching service. Clinical and animal research experiencepreferred. District of Columbia medical licensure is required, aca-demic and research opportunities are available, salary and benefitsare excellent including the cosmopolitan advantages of the nation'scapital. The George Washington University Medical Center is anequal opportunity/affirmative action employer. Send C.V. and 2letters of reference to Burton S. Epstein, M.D., Department of Anes-thesiology,901 Twenty-third Street, N.W., Washington, D.C. 20037,(202) 676-3134. 4/86

MASSACHUSETIS Chief of Anesthesia/Staff Anesthesiologist, St.Margaret's Hospital for Women, Boston, Massachusetts. St. Mar-garet's Hospital has 152 beds, 3 OR's, 41abor and delivery suites and isthe largest Catholic OB Hospital in the country, also the majorteaching affiliate of Tuft's University for OB/GYN residents and fel-lows. Major tertiary referral center for high risk pregnancy. Approxi-mately 3,500 OB deliveries and 1,700 general cases annually. Expan-sion plans include increasing OB cases, general cases with surgicalcare type patients and introduction of adult oncology. Require-ments: Chief of Anesthesia - Board Certified by the American Boardof Anesthesiology. Staff Anesthesiologist - Completion of Fellowshipin Obstetric anesthesia and/or in active process of Board Certifica-tion. Qualified candidates will have excellent interpersonal commun-ication skills, be diplomatic and affable. Chief must demonstrateleadership skills. Apply to: Darlene J. Calcagno Director of HumanResources, Metropolitan Anesthesia Associates, P.c., 400 Washing-ton Street, Braintree, Massachusetts 02184, (617) 849-0055. 4/86

ONTARIO One year fellowship in Obstetrical Anesthesia availablebeginning january 1986 or July 1986. High risk University center withapproximately 3,000deliveries per year. Opportunities to gain clinicalexperience in all forms of Obstetrical Anaesthesia. Active NeonatalIntensive Care Unit. Responsibilities include resident teaching andclinical research. Applicants should be eligible to receive a CanadianFellowship in Anesthesiology or equivalent. Please send a letter ofapplication and curriculum vitae to: Dr. S. Halpern, Department ofAnesthesia, Women's College Hospital, 76 Grenville Street, TorontoM5S 1B2, Tel. (416) 966-7113. 11/85



submitted by the Board of Directors"). (See the late, late, lateSummer Newsletter 1985). Of course, this isn't the first time we'veignored the Constitution! Please write the Editor, and he will be gladto publish your opinions. We need a better idea of what people wantbefore next year's business meeting.

SOAP, originally, was a small group founded to promote informaldiscussion about the peripartum period. The idea was not to have arigid format, or formal presentations, and not to be structured. Thisgradually changed, and I think we now all benefit from the orderlyexchange of information that is SOAP's most attractive attribute.

Recently (I believe) we have shifted to too much science - onebecomes numbed by the plethora of rat, sheep and monkey studies.However, we had several clinical presentations in Salt lake City, andthe trend will continue, I hope, in Halifax. I think most people likedthe poster sessions, and Des plans to retain this part of the program inHalifax.

SOAP is now truly international. When founded, it comprised,mostly, practitioners from the Midwest and South. Shortly thereafterthere was strong involvement from the Eastand West coasts. What istruly remarkable is the enthusiasm and participation of our Canadiancolleagues. (realfy?-Ed.) The 1983 meeting was north of the 49thparallel, as will be our 1987 meeting. Merci, Canada! We havemembers from South America, and strong ties to the OAA (ObstetricAnaesthetists Association) of Great Britain.

As at previous SOAP meetings, there was a dearth of Obstetriciansand Neonatologists in 1986. Previous writers have lamented this (seeTom Benedetti's letter in the Summer 1984Newsletter). Obstetriciansand Neonatologists are certainly welcome, but we may have tocondition ourselves to their non participation. There were few neo-natal abstracts submitted for SOAP 1986, and even fewer obstetricpapers. Bob Hodgkinson believed we should reappraise the future ofSOAP and encourage the attendance of Neonatologists. Re-read hiscolumn in the Summer 1984 Newsletter, and reflect on it, comparing

the directions for growth he predicted with what has actually trans-pired. For better or for worse, we are attractive mostly to obstetricAnesthesiologists.

The 1990 meeting certainly should be held in the Midwest, orSouth. Since 1984 we have been to the East coast, and the RockyMountains, and we will soon travel to the Maritimes and to the farWest (twice). It is time for a central location again!

Each SOAP meeting builds on preceeding ones; each has its dis-tinctive flavor" thanks to the Host's ability to infuse his/her localresources and color into the event. Ilook forward very much to thescience and learned opinions in Halifax, the city's historic surround-ings, the succulent seafood and, above all (!) Nova Scotianentertainment.

SAIL INTO SOAP '87 in Halifax, Nova Scotia. Get to work on thoseAbstracts!

EDITOR: Desmond Writer, M.B., Ch.B.EDITORIAL ASSISTANTS: Lorna Beeler, Janet DoreyTYPESETTING AND LAYOUT:Dalhousie Uni-ersity Graphics

The SOAP Newsletter is published quarterly in Halifax, Nova Scotia, by the Society for Obstetric Anesthesia andPerinatology. Unless otherwise indicated, opinions expressed are those of the Editor and do not necessarilyrepresent the consensus of the Society. Address correspondence to the Editor, Chief of Anaesthesia, GraceMaternity Hospital, S821 University Avenue, Halifax, Nova Scotia, Canada B3H 1W3.

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SECRETARY/EDITORDesmond Writer, M.B., Ch.B.Halifax, Nova Scotia

DIRECTOR-AT-LARGEBetty Kuhnert, M.D.Cleveland, Ohio

PRESIDENTRichard Clark, M.D.Salt Lake City, Utah

ASSOC. PRESIDENTRobert Hall, M.D.Salt Lake City, Utah

VICE-PRESIDENTDr. Sam HughesSan Francisco, Calif.

TREASURERDesmond Writer, M.B., Ch.B.Halifax, Nova Scotia

SOAP 1986-87BOARD OF DIRECTORS

DIRECTOR: OBSTETRICSDavid B. CottonHouston, Texas

DIRECTOR: NEONATOLOGYVirginia WilliamsSeattle, Washington

EHAIRMAN, ASA COMMITTEEON OBSTETRICAL ANESTHESIA

Gersh LevinsonSan Francisco, California

Documents

VOLUME 17, NUMBER 3 SOAPmournsTwo PastPresidents · FALL 1986 VOLUME 17, NUMBER 3 SOAPmournsTwo PastPresidents BOB HODGKINSON President, SOAP1984 ... analgesia on neonatal neurobehavior;