Journal of Anesthesia

, Volume 32, Issue 6, pp 901–907 | Cite as

Challenges and hurdles for patient safety in obstetric anesthesia in Japan

  • Nobuko Fujita
  • Naida M. Cole
  • Yasuko Nagasaka
Invited Review Article


The use of pain relief for labor has gained popularity in Japan. However, its acceptance is still low among laboring women: only 6.1% of Japanese parturients receive labor analgesia, in contrast with the United States, where approximately 70% receive labor analgesia. Unfortunately, several maternal deaths associated with labor analgesia have been reported in recent years in Japan and how to achieve safer obstetric care is a pressing concern. In this review, we focus on current approaches to labor analgesia in the United States as they compare to existing practices in Japan. We discuss challenges for the introduction and implementation of standard anesthesia practice into the Labor and Delivery Room (LDR; i.e., labor and delivery ward), aiming to secure safety for both mothers and fetus in every part of Japan in the near future.


Obstetric anesthesia Labor analgesia Neuraxial analgesia 



The authors thank Dr. William Camann, M.D., Associate Professor at Harvard Medical School and former Director of Obstetric Anesthesiology at Brigham and Women’s Hospital for his insightful comments. This article has been presented in part at the 120th Annual Meeting of the Japan Society of Obstetric Anesthesia and Perinatology, and was partially published in Japanese (Bunben to Masui, 2017 Nov; 99:19–25).


  1. 1.
    Terui K. Comparison of the obstetric anesthesia practice between Japan and USA. Masui. 2009;58:1473–5.PubMedGoogle Scholar
  2. 2.
  3. 3.
    Traynor AJ, Aragon M, Ghosh D, Choi RS, Dingmann C, Vu Tran Z, et al. Obstetric anesthesia workforce survey: a 30-year update. Anesth Analg. 2016;122(6):1939–46.CrossRefGoogle Scholar
  4. 4.
    Gibbs CP, Krischer J, Peckham BM, Sharp H, Kirschbaum TH. Obstetric anesthesia: a national survey. Anesthesiology. 1986;65(3):298–306.PubMedGoogle Scholar
  5. 5.
    Bucklin BA, Hawkins JL, Anderson JR, Ullrich FA. Obstetric anesthesia workforce survey: twenty-year update. Anesthesiology. 2005;103(3):645–53.CrossRefGoogle Scholar
  6. 6.
    Yeo S, Fetters M, Maeda Y. Japanese couples’ childbirth experiences in Michigan: implications for care. Birth. 2000;27(3):191–8.CrossRefGoogle Scholar
  7. 7.
    Committee on Practice B-O. Practice bulletin No. 177: obstetric analgesia and anesthesia. Obstet Gynecol. 2017;129(4):e73–89.CrossRefGoogle Scholar
  8. 8.
    Wang TT, Sun S, Huang SQ. Effects of epidural labor analgesia with low concentrations of local anesthetics on obstetric outcomes: a systematic review and meta-analysis of randomized controlled trials. Anesth Analg. 2017;124(5):1571–80.CrossRefGoogle Scholar
  9. 9.
    Richards W, Parbrook GD, Wilson J (1976) Stanislav Klikovich (1853–1910). Pioneer of nitrous oxide and oxygen analgesia. Anaesthesia. 31(7):933–40.CrossRefGoogle Scholar
  10. 10.
    O’Sullivan EP. Dr Robert James Minnitt 1889–1974: a pioneer of inhalational analgesia. J R Soc Med. 1989;82(4):221–2.CrossRefGoogle Scholar
  11. 11.
    Rosen MA. Nitrous oxide for relief of labor pain: a systematic review. Am J Obstet Gynecol. 2002;186(5 Suppl Nature):110–26.Google Scholar
  12. 12.
    Collins MR, Starr SA, Bishop JT, Baysinger CL. Nitrous oxide for labor analgesia: expanding analgesic options for women in the United States. Rev Obstet Gynecol. 2012;5(3–4):e126–31.Google Scholar
  13. 13.
    Likis FE, Andrews JC, Collins MR, Lewis RM, Seroogy JJ, Starr SA, et al. Nitrous oxide for the management of labor pain: a systematic review. Anesth Analg. 2014;118(1):153–67.CrossRefGoogle Scholar
  14. 14.
    Richardson MG, Lopez BM, Baysinger CL, Shotwell MS, Chestnut DH. Nitrous oxide during labor: maternal satisfaction does not depend exclusively on analgesic effectiveness. Anesth Analg. 2017;124(2):548–53.CrossRefGoogle Scholar
  15. 15.
    Robert L, Barbieri WC. Catherine McGovern. Nitrous oxide for labor pain. OBG Manag. 2014;26(12):10–14.Google Scholar
  16. 16.
    Volikas I, Butwick A, Wilkinson C, Pleming A, Nicholson G. Maternal and neonatal side-effects of remifentanil patient-controlled analgesia in labour. Br J Anaesth. 2005;95(4):504–9.CrossRefGoogle Scholar
  17. 17.
    Weibel S, Jelting Y, Afshari A, Pace NL, Eberhart LH, Jokinen J, et al. Patient-controlled analgesia with remifentanil versus alternative parenteral methods for pain management in labour. Cochrane Database Syst Rev. 2017;4:CD011989.PubMedGoogle Scholar
  18. 18.
    Kan RE, Hughes SC, Rosen MA, Kessin C, Preston PG, Lobo EP. Intravenous remifentanil: placental transfer, maternal and neonatal effects. Anesthesiology. 1998;88(6):1467–74.CrossRefGoogle Scholar
  19. 19.
    Van de Velde M, Carvalho B. Remifentanil for labor analgesia: an evidence-based narrative review. Int J Obstet Anesth. 2016;25:66–74.CrossRefGoogle Scholar
  20. 20.
    Bonner JC, McClymont W. Respiratory arrest in an obstetric patient using remifentanil patient-controlled analgesia. Anaesthesia. 2012;67(5):538–40.CrossRefGoogle Scholar
  21. 21.
    Muchatuta NA, Kinsella SM. Remifentanil for labour analgesia: time to draw breath? Anaesthesia. 2013;68(3):231–5.CrossRefGoogle Scholar
  22. 22.
    Freeman LM, Bloemenkamp KW, Franssen MT, Papatsonis DN, Hajenius PJ, Hollmann MW, et al. Patient controlled analgesia with remifentanil versus epidural analgesia in labour: randomised multicentre equivalence trial. BMJ. 2015;350:h846.CrossRefGoogle Scholar
  23. 23.
    Ohashi Y, Baghirzada L, Sumikura H, Balki M. Remifentanil for labor analgesia: a comprehensive review. J Anesth. 2016;30(6):1020–30.CrossRefGoogle Scholar
  24. 24.
    Hantoushzadeh S, Alhusseini N, Lebaschi AH. The effects of acupuncture during labour on nulliparous women: a randomised controlled trial. Aust N Z J Obstet Gynaecol. 2007;47(1):26–30.CrossRefGoogle Scholar
  25. 25.
    Skilnand E, Fossen D, Heiberg E. Acupuncture in the management of pain in labor. Acta Obstet Gynecol Scand. 2002;81(10):943–8.CrossRefGoogle Scholar
  26. 26.
    Borup L, Wurlitzer W, Hedegaard M, Kesmodel US, Hvidman L. Acupuncture as pain relief during delivery: a randomized controlled trial. Birth. 2009;36(1):5–12.CrossRefGoogle Scholar
  27. 27.
    Chuntharapat S, Petpichetchian W, Hatthakit U. Yoga during pregnancy: effects on maternal comfort, labor pain and birth outcomes. Complement Ther Clin Pract. 2008;14(2):105–15.CrossRefGoogle Scholar
  28. 28.
    Nagaya K, Fetters MD, Ishikawa M, Kubo T, Koyanagi T, Saito Y, et al. Causes of maternal mortality in Japan. JAMA. 2000;283(20):2661–7.CrossRefGoogle Scholar
  29. 29.
    Guidelines for neuraxial anesthesia in obstetrics, Committee of Origin. Obstetric anesthesia (Approved by the American Society of Anesthesiologists, House of Delegates on October 12, 1988, and last amended on October 16, 2013).Google Scholar
  30. 30.
    Statement for Safety of Parturients 2016 from The Maternal Death Exploratory Committee (MDEC). Accessed 26 Oct 2018.
  31. 31.
    A Statement for the provision of safe labor analgesia practice reported by the Ministry of Health, Labor and Welfare in Japan, 2018. Accessed 26 Oct 2018.
  32. 32.
    Collaborators GBDMM. Global, regional, and national levels of maternal mortality, 1990–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016;388(10053):1775–812.CrossRefGoogle Scholar
  33. 33.
    Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9947):980–1004.CrossRefGoogle Scholar
  34. 34.
    Horon IL, Cheng D. Effectiveness of pregnancy check boxes on death certificates in identifying pregnancy-associated mortality. Public Health Rep. 2011;126(2):195–200.CrossRefGoogle Scholar
  35. 35.
  36. 36.
    Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006–2010. Obstet Gynecol. 2015;125(1):5–12.CrossRefGoogle Scholar
  37. 37.
    Zaremba S, Mueller N, Heisig AM, Shin CH, Jung S, Leffert LR, et al. Elevated upper body position improves pregnancy-related OSA without impairing sleep quality or sleep architecture early after delivery. Chest. 2015;148(4):936–44.CrossRefGoogle Scholar
  38. 38.
    Matsuda Y, Kawamichi Y, Hayashi K, Shiozaki A, Satoh S, Saito S. Impact of maternal age on the incidence of obstetrical complications in Japan. J Obstet Gynaecol Res. 2011;37(10):1409–14.CrossRefGoogle Scholar
  39. 39.
    Vital. Health and Social Statistics Division, Statistics and Information Department, Minister’s Secretariat, Ministry of Health, Labour and Welfare. Summary of static/dynamic surveys of medical institutions and hospital report 2017 (in Japanese). Accessed 26 Oct 2018.
  40. 40.

Copyright information

© Japanese Society of Anesthesiologists 2018

Authors and Affiliations

  1. 1.Department of AnesthesiaSt. Luke’s International HospitalTokyoJapan
  2. 2.Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA

Personalised recommendations