Choice of Anesthesia for Cesarean Delivery

Neuraxial anesthesia use in cesarean deliveries (CDs) has been rising since the 1980s, whereas general anesthesia (GA) use has been declining | Anesthesia & Analgesia

In this brief report we analyzed recent obstetric anesthesia practice patterns using National Anesthesiology Clinical Outcomes Registry data. Approximately 218,285 CD cases were identified between 2010 and 2015. GA was used in 5.8% of all CDs and 14.6% of emergent CDs. Higher rates of GA use were observed in CDs performed in university hospitals, after hours and on weekends, and on patients who were American Society of Anesthesiologists class III or higher and 18 years of age or younger.

Full reference: Juang, J. et al. (2017) Choice of Anesthesia for Cesarean Delivery: An Analysis of the National Anesthesia Clinical Outcomes Registry. Anesthesia & Analgesia. 124 (6) pp. 1914–1917

Airway management for Cesarean delivery performed under general anesthesia

Rajagopalan S, et al. (2017) International Journal of Obstetric Anesthesia. 29(3) pp. 64-9

Introduction: With the increasing popularity of neuraxial anaesthesia, there has been a decline in the use of general anaesthesia for Caesarean delivery. These authors sought to examine the incidence, outcome and characteristics associated with a failed airway in patients undergoing Caesarean delivery under general anaesthesia.

Conclusions: The authors conclude that advances in adjunct airway equipment, availability of an experienced anaesthetist and simulation-based teaching of failed airway management in obstetrics may have contributed to their improved maternal outcomes in patients undergoing Caesarean delivery under general anaesthesia.

Read the full abstract here

Choice of Anesthesia for Cesarean Delivery

Juang, J. et al. Anesthesia & Analgesia. Published online: January 16 2017

L0028350 An anaesthetist standing, his equipment behind him. Colour l

Image source: Virginia Powell – Wellcome Images // CC BY-NC-ND 4.0

Neuraxial anesthesia use in cesarean deliveries (CDs) has been rising since the 1980s, whereas general anesthesia (GA) use has been declining.

In this brief report we analyzed recent obstetric anesthesia practice patterns using National Anesthesiology Clinical Outcomes Registry data. Approximately 218,285 CD cases were identified between 2010 and 2015. GA was used in 5.8% of all CDs and 14.6% of emergent CDs.

Higher rates of GA use were observed in CDs performed in university hospitals, after hours and on weekends, and on patients who were American Society of Anesthesiologists class III or higher and 18 years of age or younger.

Read the abstract here

No Benefit To Tilting Women During Cesarean Delivery

O’Rourke, K. Clinical Anesthesiology.  Published online: 5 August 2016

Is there any benefit to the common practice of tilting women during cesarean delivery? A randomized clinical trial suggests maybe not.

“Not tilting the surgical table does not impair neonatal acid–base status compared to the tilt position when baseline systolic blood pressure is maintained with phenylephrine infusion,” said Allison Lee, MD, assistant professor of anesthesiology at NewYork-Presbyterian Hospital/Columbia University Medical Center, in New York City. She presented the study at the 2016 annual meeting of the Society for Obstetric Anesthesia and Perinatology (abstracts 01-04 and 01-05).

Dogma Debunked

For the last 50 years, it has been obstetric anesthesia dogma that clinicians should provide left uterine displacement during cesarean delivery. When pregnant women near term lie in the supine position, the uterus can compress the inferior vena cava causing hypotension, reduced placental perfusion and decreased fetal oxygenation. Most women at term have a completely obstructed inferior vena cava, yet very few have significant hemodynamic consequences. The reason is because of the development of compensatory mechanisms, such as venous constriction in the lower extremities, which promotes flow through collateral venous channels, Dr. Lee explained.

Clinicians have worried, however, that these compensatory mechanisms may disappear under anesthesia.

In the 1970s, a number of studies supported tilting women during cesarean delivery because of improved outcomes in the neonate (e.g., Brit J Anaesth1972;44:477-484). The 15-degree tilt used in most studies is arbitrary, a compromise that still provides access for a surgeon to operate. These older studies are limited because the anesthetic technique used bears little resemblance to what is done in contemporary practice; the studies were not randomized, and it is questionable whether the outcome differences were clinically significant.

Dr. Lee pointed out that a recent study comparing the effect of lateral tilt on the volume of abdominal aorta and inferior vena cava in pregnant and nonpregnant women showed that in parturients, the aorta was not compressed and a 15-degree left-lateral tilt position did not effectively reduce inferior cava compression (Anesthesiology 2015;122:286-293).

Read the full article here

Regional anaesthesia for caesarean section and what to do if it fails

Kimber Craig, S.A. Anaesthesia & Intensive Care Medicine. 17(8).pp. 365-368

N0036280 Labour and birth

Image source: Heather Spears – Wellcome Images // CC BY-NC-ND 4.0

Regional anaesthetic techniques are now the most frequently used type of anaesthetic used for caesarean deliveries. They have a better safety profile than general anaesthesia in the pregnant woman. The choice of whether to use a spinal, epidural or combined spinal-epidural technique will depend on patient and surgical factors. Particular care should be taken to those receiving therapeutic anticoagulation or with clotting abnormalities. Women should be provided with appropriate information to make an informed choice, including details of the intended risks and benefits of the technique. All women having caesarean deliveries must have vital sign monitoring, antacid prophylaxis and intraoperative venous thromboembolic prophylaxis. A left lateral tilt must be maintained until delivery of the baby. Breakthrough pain during caesarean delivery is a distressing complication and must be treated immediately. General anaesthesia should be offered and if declined, the woman’s pain must be adequately managed with alternative analgesic methods. These include nitrous oxide, opioids and local anaesthetic infiltration.

Read the abstract here