Socioeconomic Deprivation and Utilization of Anesthetic Care During Pregnancy and Delivery

Socioeconomic deprivation is associated with reduced use of antenatal resources and poor maternal outcomes with pregnancy | Anesthesia & Analgesia

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Background: Research examining the association between socioeconomic deprivation and use of obstetric anesthesia care in a country providing universal health coverage is scarce. We hypothesized that in a country providing universal health coverage, France, socioeconomic deprivation is not associated with reduced use of anesthetic care during pregnancy and delivery. This study aimed to examine the association between socioeconomic deprivation and (1) completion of a mandatory preanesthetic evaluation during pregnancy and (2) use of neuraxial analgesia during labor.

Conclusions: In a country providing universal health care coverage, women who were socioeconomically deprived showed reduced completion of preanesthetic evaluation during pregnancy but not reduced use of neuraxial labor analgesia. Interventions should be targeted to socioeconomically deprived women to increase the completion of the preanesthetic evaluation.

Full reference: Kantor, E. et al. (2017) Socioeconomic Deprivation and Utilization of Anesthetic Care During Pregnancy and Delivery: A French Retrospective, Multicenter, Cohort Study. Anesthesia & Analgesia. Post Author Corrections: 13 July 2017

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.

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Whats New in Obstetric Anesthesia: The 2016 Gerard W. Ostheimer Lecture

Hess, P.E. (2017) Anesthesia & Analgesia. 124(3) pp. 863–871

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This special article presents potentially important trends and issues affecting the field of obstetric anesthesia drawn from publications in 2015. Both maternal mortality and morbidity in the United States have increased in recent years because, in part, of the changing demographics of the childbearing population. Pregnant women are older and have more pre-existing conditions and complex medical histories. Cardiovascular and noncardiovascular medical diseases now account for half of maternal deaths in the United States.

Several national and international organizations have developed initiatives promoting optimal obstetric and anesthetic care, including guidelines on the obstetric airway, obstetric cardiac arrest protocols, and obstetric hemorrhage bundles. To deal with the increasing burden of high-risk parturients, the national obstetric organizations have proposed a risk-based classification of delivery centers, termed as Levels of Maternal Care. The goal of this initiative is to funnel more complex obstetric patients toward high-acuity centers where they can receive more effective care.

Despite the increasing obstetric complexity, anesthesia-related adverse events and morbidity are decreasing, possibly reflecting an ongoing focus on safe systems of anesthetic care. It is critical that the practice of obstetric anesthesia expand beyond the mere provision of safe analgesia and anesthesia to lead in developing and promoting comprehensive safety systems for obstetrics and team-based coordinated care.

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Labor or Cesarean for Superobese Women?

Rates of severe maternal and neonatal morbidity were similar among superobese women undergoing primary cesarean delivery versus a trial of labor, most often ending in vaginal delivery | Clinical Anesthesiology

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Researchers say a prospective clinical trial is needed to determine whether one method of birth is superior to the other in mothers who are superobese.

According to Alexander Butwick, MBBS, FRCA, MS, among women who are superobese, rates of cesarean delivery are particularly high (≥50%), but little has been known about how delivery mode affects perinatal and neonatal outcomes. Dr. Butwick, who presented the findings at the 2016 annual meeting of the Society for Obstetric Anesthesia and Perinatology (abstract 01-02), is associate professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine, in California.

Over the years, clinicians have observed that obesity is associated with an increased risk for obstetric, perinatal and anesthetic morbidities. Obese pregnant women are at an increased risk for gestational diabetes, preeclampsia, operative delivery, postpartum infection and venous thromboembolism.

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Choice of Anesthesia for Cesarean Delivery

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

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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.

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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).

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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

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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.

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