Safety stands paramount
The hospital has performed epidurals since 2016, a service that requires an anesthesiologist to be available on site 24 hours a day. During fiscal 2022, 386 women opted for the pain-relief method during childbirth.
It is performed by inserting a thin tube into the epidural space of the spine and injecting a local anesthetic. In rare cases, complications associated with the process can be fatal.
The hospital has a policy of not inducing labor, which means that they have little control over the timing of births. This, in turns, meant that the timing of any epidurals that might have been required was not known in advance. That forced the hospital to keep anesthesiologists on hand round the clock to administer epidurals and respond in the unlikely event of a complication.
Kimura Tadashi, professor and head of the obstetric department at Osaka University Hospital, wants to ensure all epidurals are performed by trained anesthesiologists familiar with obstetrics.
Kimura outlines the risks: "When anesthesia is given, the surrounding motor nerves also rest. So when we try to relieve pain in the upper body, the muscles for breathing also rest, and in rare cases, expectant mothers may not be able to breathe.
"This is a most frightening situation, and advanced techniques such as intubation of a ventilator may be required. Only anesthesiologists familiar with obstetric anesthesia should do it."
A difficult decision
In February this year, hospital management decided it needed to suspend epidurals for women during childbirth, with some exceptions. Its limited roster of anesthesiologists were being called upon for an increasing number of surgeries in other departments.
The decision was made with safety top of mind. While Kimura hopes to offer all pregnant women the choice of an epidural, just like at university hospitals in Europe and the United States, staffing pressures mean it is no longer possible.
"I am truly sorry to all the mothers-to-be who expected and hoped for painless delivery at our hospital," he says.
A day in the life for an anesthesiology team
The shortage of anesthesiologists at Osaka University Hospital affects the services it can offer patients. A diary rundown for one day in June shows the pressure they are under:
▼7:00 a.m.
Anesthesiologists arrive at work and prepare equipment in all the operating theaters.
▼7:45 a.m.
Each team member checks the day's schedule, with 42 surgeries on the list. They then scrub down and take up positions in theater.
Yoshida Takeshi is the coordinator today. There are 30 anesthesiologists on duty, but there are times when that's inadequate. "Staffing is always tight and worrying. In addition to scheduled surgeries, we also have emergency surgeries, so it's hard to manage who to put where," says Yoshida.
▼8:30 a.m.
Two heart surgeries, one for an adult, and one for a child, are performed at the same time. Both cases require advanced anesthetics.
Including organ transplants and cancer procedures, the number of surgeries performed at the hospital is increasing yearly. During fiscal 2022, there were 12,000, an increase of nearly 1,000 from the previous year. This is one of the highest case numbers among Japan's university hospitals. As the roster of surgeries increases, so does the workload of anesthesiologists, leading to a labor shortage.
The specialized doctors are not only required during surgical operations. They also support patients in the intensive care unit.
▼0:15 p.m.
Yoshida takes a short break after checking on a patient in the intensive care unit. He takes just ten minutes to eat lunch. At the same time, he checks the schedule for the next surgery and personnel placement. "This is the end of my fun time today. It's all work now," says Yoshida, who has three emergency surgeries during the afternoon.
▼1:00 a.m.
Yoshida wraps up his day after 1:00 am.
Reflecting on women's pain-relief choices
Anesthesiologists at the hospital support advanced medical care, including epidurals during childbirth. They hope the service can resume.
"We have to think about where to allocate our limited personnel," notes Yoshida. "It is a common understanding among all medical staff that painless delivery is one of the jobs for anesthesiologists. As a doctor in the field, I want to resume that as soon as possible."
Low epidural rate nationwide
It's not just Osaka University Hospital that is struggling with a shortage of anesthesiologists. The problem exists nationwide and that is reflected in Japan's low take-up rate for epidurals.
According to a fiscal 2020 survey, 8.6 percent of births in Japan involve epidural pain relief. Some hospitals limit the practice to the daytime, and in some cases epidurals are performed by an obstetrician or gynecologist.
Elsewhere in the world, women can choose epidurals as a standard pain-relief method. The Japan Society of Obstetric Anesthesia and Perinatology reports an average rate of about 70 percent in the US and more than 80 percent in France.
A woman's "natural right"
Obstetrician and gynecologist Tachibana Daisuke, a professor at Osaka Metropolitan University, says, "It is natural for pregnant women to want to alleviate the intense pain that accompanies childbirth, just as anesthesia is used to relieve pain during dental treatment or surgery.
"We should change the notion that 'labor pains are a matter of course.' At the same time, it is essential to build a system that can respond to emergencies and deal with any complications."
Solving the anesthesiologist shortage is no easy task. Many women in Japan give birth at small local clinics rather than large maternity hospitals favored overseas.
Tachibana says it may be necessary to consider ways to consolidate medical institutions that handle childbirth. But gathering specialists at a few dedicated locations would come with its own set of challenges and could make it harder for mothers to give birth where they choose.
In the meantime, what he describes as a woman's "natural right" to pain relief is not part of most childbirth experiences in Japan.
