Neuraxial Anesthesia For Cesarean Delivery Research Articles

Impact of an interdisciplinary process to increase utilization of neuraxial anesthesia for cesarean delivery: A retrospective database analysis

BackgroundNeuraxial anesthesia is the preferred anesthesia mode for cesarean delivery (CD). The primary study aim was to study the rate of neuraxial anesthesia for cesarean delivery before and after educational strategies were implemented, focusing on neuraxial anesthesia use for CD. MethodsWe performed a retrospective analysis of the mode of anesthesia for CD. Educational strategies to inform about neuraxial anesthesia for CD included interdisciplinary daily handovers and ward rounds, and interdisciplinary academic meetings and simulation sessions. We retrieved data from the hospital electronic record for mode of anesthesia for CD, intravenous supplementation, to assess the impact of our strategies on neuraxial anesthesia use for CD (2014–2023). ResultsThe rate of neuraxial anesthesia increased from 89.8% in 2014 to 96.3% in 2023, with corresponding decrease in general anesthesia from 10.2 to 4.5% for all CD. The use of labor epidural augmentation for unplanned CD increased from 31.9 to 55.1%. IV supplementation with spinal anesthesia for unplanned CD increased from 18.1 to 32.1%. ConclusionsThis study demonstrates the utility of educational strategies to increase neuraxial anesthesia use and highlights the importance of proactive interdisciplinary labor management.

Anesthesiologists' Attitudes Toward Randomization to General versus Neuraxial Anesthesia for Cesarean Delivery.

Anesthesiologists' Attitudes Toward Randomization to General versus Neuraxial Anesthesia for Cesarean Delivery.

Anesthesia Management in Patient with Uncorrected Double Outlet Right Ventricle Underwent Cesarean Section: Serial Case Report

Background: Double outlet right ventricle (DORV) is a rare cardiac condition in which the heart demonstrates single ventricle physiology. Pregnancy complicates cyanotic heart disease as the decrease in systemic vascular resistance (SVR) worsens the right-to-left shunt. The effect worsens by neuraxial anesthesia for cesarean delivery. Anesthesia for these patients needs understanding for the physiology of DORV in order to maintain stable hemodynamics. Heart defect still become non obstetric main factor causing morbidity and mortality in pregnant woman. Case: We present three case of parturients with DORV scheduled for cesarean section. Elective caesarean section was scheduled using spinal anesthesia hyperbaric bupivacain combined with fentanyl. Hemodynamic during operation was stable. Conclusion: Low dose spinal anesthesia performed in this patient did not cause hypotension and minimal hemodynamic changes because the intensity of the sympathetic block was lower.

A national Israeli survey of neuraxial anesthesia for cesarean delivery: pre-operative block assessment and intra-operative pain management

BackgroundNeuraxial protocols for cesarean delivery differ among institutions, with various means of assessing the block prior to incision and managing breakthrough intra-operative pain. The different approaches used to deal with these issues in Israel have not been assessed. MethodsQuestionnaires were distributed to all anesthesiologists working in obstetric units in Israeli hospitals. The survey included several non-identifying respondent details intended to allow a description of the study population as a whole and multiple-choice questions addressing neuraxial techniques, method of pre-operative block assessment and medications used to treat intra-operative pain. ResultsThree hundred and sixty-one doctors completed the survey in 24 medical centers, an 81.1% response rate. Thirteen different protocols for spinal anesthesia and 20 different protocols for epidural anesthesia were described. Nine different protocols for assessment of the block prior to incision were identified, with significant inter-institutional differences (P <0.001). For treatment of intra-operative pain prior to delivery, 35.7% of spinals given and 40% of epidurals given were converted to general anesthesia whereas, after delivery, conversion of spinal to general anesthesia was 18% and epidural to general anesthesia was 18.6%. ConclusionsThere were a variety of spinal and epidural regimens used as well as different methods for assessing the block and managing intra-operative pain. Further studies should be performed to identify optimal techniques for neuraxial anesthesia for pre-operative block assessment and for management of intra-operative pain.

An Update on Racial and Ethnic Differences in Neuraxial Anesthesia for Cesarean Delivery.

BackgroundRacial and ethnic differences in the use of neuraxial anesthesia compared with general anesthesia are less studied, particularly in obstetrical anesthesia. Here, we aimed to provide an update on the association between race and ethnicity, and the use of neuraxial anesthesia for cesarean delivery in the United States (US).MethodsWe used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Participant Use Data File 2019. We extracted cases that had a primary surgery defined with Current Procedural Terminology (CPT) code for cesarean delivery (59510, 59514, and 59515) and cesarean after attempted vaginal delivery in parturients with a prior history of cesarean (59618, 59620, and 59622). Multivariable logistic regression was used to report the association of race and ethnicity with primary anesthetic technique.ResultsThere were 12,876 parturients included in the study. Compared with White parturients, Black (adjusted odds ratio (aOR) = 0.71, 95% confidence interval (CI): 0.57-0.88, p = 0.001) and American Indian or Alaska Native (aOR = 0.22, 95% CI: 0.12-0.40, p < 0.001) parturients had lower odds of receiving neuraxial compared with general anesthesia. There were no significant differences in the odds of neuraxial anesthesia between non-Hispanic and Hispanic cohorts.ConclusionsWhile we do observe racial differences in anesthetic technique, Hispanic patients did not have significantly lower odds of neuraxial anesthesia. This study highlights the importance of an update to prior studies, as the current study suggests a lack of disparity between non-Hispanic and Hispanic parturients. While the results here are encouraging, a multidisciplinary approach is necessary to further address racial disparities.

To Study the Role of Perfusion Index as a Predictor of Hypotension during Spinal Anesthesia in Lower Segment Cesarean Section - A Prospective Observational Study.

Background and Aims:Spinal anesthesia has become the choice of neuraxial anesthesia for cesarean delivery. Hypotension, the most common side effect of spinal anesthesia is more in parturients. Perfusion index (PI) is one of the newest methods, used noninvasively for the prediction of hypotension postspinal anesthesia, evaluation of regional block success, and a tool for pain assessment. In our study, we have used PI for predicting the occurrence of hypotension postsubarachnoid block in elective lower segment cesarean section (LSCS).Methods:In this prospective observational study, parturients posted for elective LSCS under spinal anesthesia were included. Spinal anesthesia was performed at L3-L4 interspace using 25G (gauge) Quincke needle, with 1.8 mL of 0.5% hyperbaric bupivacaine plus 20 μg fentanyl. Hypotension was defined as a decrease in systolic blood pressure >25% from the baseline.Statistical Analysis Used:Statistical analysis was performed using the paired sample t-test, Chi-square test, and independent t-test.Results:From our study, we had found that a positive correlation exists between the baseline PI of the patient and the occurrence of hypotension intraoperatively. A cutoff value of 1.75 (with P < 0.001) was found to be significant; above which the occurrence of hypotension was definite. The sensitivity of this cutoff value was 75% and specificity was 71% for this value.Conclusion:Baseline perfusion of >1.75 can predict hypotension postspinal anesthesia in LSCS. The incidence of hypotension was about 93% in parturients whose baseline was above the cutoff value.

Pragmatic approach to neuraxial anesthesia in obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system

Neuraxial anesthesia provides optimal labor analgesia and cesarean delivery anesthesia. Obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system present unique challenges to the anesthesiologist. Potential...

Adaptation of an Obstetric Anesthesia Service for the Severe Acute Respiratory Syndrome Coronavirus-2 Pandemic: Description of Checklists, Workflows, and Development Tools.

Care of the pregnant patient during the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic presents many challenges, including creating parallel workflows for infected and noninfected patients, minimizing waste of materials, and ensuring that clinicians can seamlessly transition between types of anesthesia. The exponential community spread of disease limited the time for development and training. The goals of our workflow and process development were to maximize safety for staff and patients, minimize the risk of contamination, and reduce the waste of unused supplies and materials. We used a cyclical improvement system and the plus/delta debriefing method to rapidly develop workflows consisting of sequential checklists and procedure-specific packs. We designed independent workflows for labor analgesia, neuraxial anesthesia for cesarean delivery, conversion of labor analgesia to cesarean anesthesia, and general anesthesia. In addition, we created procedure-specific material packs to optimize supplies and prevent wastage. Finally, we generated sequential checklists to allow staff to perform standard operating procedures without extensive training. Collectively, these workflows and tools allowed our staff to urgently care for patients in high-risk situations without prior experience. Over time, we refined the workflows using a cyclical improvement system. We present our checklists and workflows as well as the system we used for their development, so that others may use them to their benefit.

Exposure to General Anesthesia for Cesarean Delivery and Odds of Severe Postpartum Depression Requiring Hospitalization.

Previous research suggests that, compared with regional anesthesia, general anesthesia is associated with increased odds of postoperative depressive disorders. No study has specifically evaluated the possible protective effect of neuraxial anesthesia for cesarean delivery on maternal mental health compared with general anesthesia. This exploratory study was designed to test the hypothesis that general anesthesia for cesarean delivery is associated with increased odds of severe postpartum depression (PPD) requiring hospitalization compared with neuraxial anesthesia. This retrospective cohort study included cesarean delivery cases performed in New York State hospitals between January 2006 and December 2013. Exclusion criteria were as follows: (1) having >1 cesarean delivery during the study period; (2) residing outside of New York State; (3) having a general anesthetic for other surgery or delivery in the previous year or in the year after the index case. The primary outcome was the occurrence of PPD, and the secondary outcomes were: (1) the composite of suicidal ideation or self-inflicted injury (ie, suicidality); (2) anxiety disorders; and (3) posttraumatic stress disorders (PTSD). Primary and secondary outcomes were identified during the delivery hospitalization and up to 1 year after delivery. Adjusted odds ratios (aORs) and 95% confidence interval (CI) of adverse psychiatric outcomes associated with general anesthesia were estimated using propensity score matching. Of the 428,204 cesarean delivery cases included, 34,356 had general anesthesia (8.0%). Severe PPD requiring hospitalization was recorded in 1158 women (2.7/1000; 95% CI, 2.5-2.9); of them, 60% were identified during readmission, with a median of 164 days after discharge. Relative to neuraxial anesthesia, general anesthesia in cesarean delivery was associated with a 54% increased odds of PPD (aOR, 1.54; 95% CI, 1.21-1.95) and a 91% increased odds of suicidal ideation or self-inflicted injury (aOR, 1.91; 95% CI, 1.12-3.25). There was insufficient evidence in these data that general anesthesia was associated with anxiety disorders (aOR, 1.37; 95% CI, 0.97-1.95) or PTSD (aOR, 1.50; 95% CI, 0.50-4.47). General anesthesia for cesarean delivery is associated with increased odds of severe PPD requiring hospitalization, suicidal ideation, and self-inflicted injury. If confirmed, these preliminary findings underscore the need to avoid the use of general anesthesia for cesarean delivery whenever possible, and to provide mental health screening, counseling, and other follow-up services to obstetric patients exposed to general anesthesia.

Refractory hypotension under neuraxial anesthesia for cesarean delivery.

Refractory hypotension under neuraxial anesthesia for cesarean delivery.

Learning From the Law: A Review of 21 Years of Litigation for Pain During Cesarean Section

(Anaesthesia. 2018;73:223–230) In the United Kingdom, the majority of cesarean deliveries are now performed under neuraxial anesthesia instead of general anesthesia, thereby mitigating the increased anesthetic risks associated with general anesthesia in pregnant women. However, as the use of neuraxial anesthesia for cesarean delivery has increased so has the risk of patients experiencing pain during surgery. As a result, pain during cesarean delivery has now become the most common reason for negligence claims relating to regional anesthesia against obstetric anesthesiologists in the UK. This article examined common themes (relating to consent, checking the block, managing intraoperative pain, and professionalism) that emerged from an analysis of these claims and highlighted the lessons to be learned for practicing anesthesiologists.

Establishing Obstetric Anesthesiology Practice Guidelines in the Republic of Armenia: A Global Health Collaboration.

Disparity exists in anesthesia practices between high- and low-to-middle income countries, and awareness has been raised within the global health community to improve the standards of anesthesia care and patient safety. The establishment of international collaborations and appropriate practice guidelines may help address clinical care deficiencies. This report's aim was to assess the impact of a multiyear collaboration on obstetric anesthesia practices in the Republic of Armenia. An invited multinational team of physicians conducted six visits to Armenia between 2006 and 2015 to observe current practice and establish standards of obstetric anesthesia care. The Armenian Society of Anaesthesiologists and Intensive Care specialists collected data on the numbers of vaginal delivery, cesarean delivery, and neuraxial anesthesia use in maternity units during the period. Data were analyzed with the Fisher exact or chi-square test, as appropriate. Neuraxial anesthesia use for cesarean delivery increased significantly (P < 0.0001) in all 10 maternity hospitals within the capital city of Yerevan. For epidural labor analgesia, there was sustained or increased use in only two hospitals. For hospitals located outside the capital city, there was a similar increase in the use of neuraxial anesthesia for cesarean delivery that was greater in hospitals that were visited by an external team (P < 0.0001); however, use of epidural labor analgesia was not increased significantly. Over the course of the collaboration, guidelines for obstetric anesthesia were drafted and approved by the Armenian Ministry of Health. Collaboration between Armenian anesthesiologists and dedicated visiting physicians to update and standardize obstetric anesthesia practices led to national practice guidelines and sustained improvements in clinical care in the Republic of Armenia.

Anesthesia for cesarean delivery in the Czech Republic: a 2011 national survey.

The purpose of this national survey was to determine current anesthesia practices for cesarean delivery in the Czech Republic. In November 2011, we invited all departments of obstetric anesthesia in the Czech Republic to participate in a prospective study to monitor consecutive peripartum obstetric anesthesia procedures. Data were recorded online in the TrialDB database (Yale University, New Haven, CT). The response rate was 51% (49 of 97 departments); participating centers represented 60% of all births in the country during the study period. There were 1943 cases of peripartum anesthesia care, of which 1166 cases (60%) were anesthesia for cesarean delivery. Estimates were weighted based on population distribution of cesarean delivery among types of participating centers. Neuraxial anesthesia was used in 55.6% (95% confidence interval [CI], 52.8%-58.5%); the distribution of anesthesia techniques differed among type of participating center. The rate of neuraxial anesthesia in university hospitals was 55.6% (95% CI, 51.5%-59.6%), 32.4% (95% CI, 26.4%-39.0%) in regional hospitals, and 60.7% (95% CI, 55.2%-66.0%) in local hospitals. The reasons for cesarean delivery under general anesthesia were emergency procedure (67%), refusal of neuraxial blockade by parturient (30%), failure of neuraxial anesthesia (6%), and preoperative administration of low-molecular-weight heparin (3%). Postcesarean analgesia was primarily provided by systemic opioid (66%) and nonopioid analgesics (61%), solely or in combination. Epidural postoperative analgesia was used in 14% of cases. Compared with national neuraxial anesthesia rate data published in the 1990s (6.7% in 1993), there has been an upward trend in the use of neuraxial anesthesia for cesarean delivery during the 21st century (40.5% in 2000) in the Czech Republic. The rate of neuraxial anesthesia use for cesarean delivery has increased in the Czech Republic in the last 2 decades. However, the current rate of general anesthesia is high compared with other Western countries.

How UK Obstetric Anesthetists Assess Neuraxial Anesthesia for Cesarean Delivery

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Anesthetic and obstetric outcomes in morbidly obese parturients: a 20-year follow-up retrospective cohort study

BackgroundIn 1993, Hood and Dewan published the results of a trial comparing obstetric and anesthetic outcomes of 117 morbidly obese parturients with matched controls. The authors demonstrated a higher initial epidural anesthesia failure rate, a higher cesarean delivery rate and an increased risk of obstetric complications. We replicated the previous study to provide updated information on outcomes in the morbidly obese pregnant population. We hypothesized that morbidly obese women would still have higher complication and failure rates compared to matched controls and that general anesthesia would be less commonly used than in the previous study. MethodsThe medical records of 230 patients weighing >136kg (300pounds) were compared to matched controls: the next patient delivered by the same obstetrician with a weight <113kg (250pounds). ResultsThe mean weight of the morbidly obese group was 53.4±6.6kg/m2 compared to 31.1±5.4kg/m2 in the control group. Fifty percent of morbidly obese women required cesarean delivery compared to 32% of controls (P <0.01). Morbidly obese patients had a longer first stage of labor (P <0.01), larger neonates (P <0.01), and were more likely to have a failed initial neuraxial technique for labor analgesia (P <0.01). The need for a replacement procedure for labor was 17%, significantly less than 20years ago when 42% of catheters in morbidly obese women failed (P <0.01). Failure rates of neuraxial anesthesia for cesarean delivery were similar between groups. Neuraxial procedure times were greater in morbidly obese parturients (P <0.01). Morbidly obese women were less likely to receive general anesthesia compared to 20years ago (3% vs. 24%, P <0.01). ConclusionsMorbidly obese parturients are still at increased risk for antenatal comorbidities, failed labor analgesia, longer first stage of labor and operative delivery. Replacement labor epidural catheters and general anesthesia for cesarean delivery are less commonly required anesthetic techniques compared to the original study.

Serum uric acid as a novel marker for uterine atony and post-spinal vasopressor use during cesarean delivery

IntroductionSerum uric acid is a marker for oxidative stress in preeclampsia. Because oxidative stress can result in diminished uterine contractility and impaired vascular relaxation, we hypothesized that an elevated serum uric acid level in women undergoing neuraxial anesthesia for cesarean delivery would be associated with greater uterine atony, as measured by supplemental uterotonic agent use and blood loss, and less hypotension, as measured by total vasopressor use. MethodsAll records of patients (n=2527) undergoing cesarean delivery in 2009 were reviewed. Serum uric acid was measured within 24h of delivery in 509 patients; data from 345 patients with singleton pregnancies undergoing neuraxial anesthesia were analyzed. Demographic data, medical and obstetric history, anesthetic management and peripartum course were evaluated. ANOVA, Chi-square, and multivariate logistic and linear regression analyses were performed. ResultsIncreased serum uric acid correlated positively with preeclampsia and the need for supplemental uterotonic agents (odds ratio 1.53, 95%CI 1.2–2.0, P=0.002), but not blood loss. The presence of preeclampsia also correlated with greater supplemental uterotonic agent use (P=0.01). The correlation between serum uric acid and post-spinal vasopressor use (i.e., none, moderate, and high) was of borderline significance (P=0.05). In patients without diabetes, serum uric acid levels correlated inversely with post-spinal vasopressor use (P=0.04). ConclusionsElevated serum uric acid in parturients undergoing cesarean delivery with neuraxial anesthesia correlated with increased use of supplemental uterotonic agents and decreased use of post-spinal vasopressors. Further validation of this study is required to determine if serum uric acid in parturients can serve as a reliable predictor for higher and lower occurrences of uterine atony and spinal-induced hypotension, respectively.

Failed epidural top-up for cesarean delivery for failure to progress in labor: the case against single-shot spinal anesthesia

As a consequence of increasing use of epidurals for labor analgesia, 1 Bucklin B.A. Hawkins J.L. Anderson J.R. Ullrich F.A. Obstetric anesthesia workforce survey: twenty-year update. Anesthesiology. 2005; 103: 645-653 Crossref PubMed Scopus (242) Google Scholar the majority of women in the United States presenting for cesarean delivery during labor will have an epidural in-situ. Most clinicians in this setting elect to use the existing epidural to provide cesarean delivery anesthesia. 2 Aiono-Le Tagaloa L. Butwick A.J. Carvalho B. A survey of perioperative and postoperative anesthetic practices for cesarean delivery. Anesthesiol Res Pract. 2009; 2009: 510642 PubMed Google Scholar A failed epidural top-up for cesarean delivery in labor is a potentially serious clinical problem that has gained increasing attention recently. The Royal College of Anaesthetists developed guidelines for acceptable rates for failed neuraxial anesthesia for cesarean delivery. 3 Russell IF. Technique of anaesthesia for caesarean section. In: Royal College of Anaesthetists raising the standard: a compendium of audit recipes. 2nd ed.; 2006. http://www.rcoa.ac.uk/docs/ARB-section8.pdf [accessed June 2011]. Google Scholar The guidelines state that the conversion rate from neuraxial to general anesthesia should be <1% for elective and <3% for non-elective cesarean delivery.

Neuraxial Anesthesia for Cesarean Delivery

*Département ď Anesthésie-Réanimation, AP-HP, Hôpital Bicêtre, Le Kremlin-Bicêtre, France †Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, IL

Neuraxial Labor Analgesia for Vaginal Delivery and Its Effects on Childhood Learning Disabilities

In prior work, children born to mothers who received neuraxial anesthesia for cesarean delivery had a lower incidence of subsequent learning disabilities compared with vaginal delivery. The authors speculated that neuraxial anesthesia may reduce stress responses to delivery, which could affect subsequent neurodevelopmental outcomes. To further explore this possibility, we examined the association between the use of neuraxial labor analgesia and development of childhood learning disabilities in a population-based birth cohort of children delivered vaginally. The educational and medical records of all children born to mothers residing in the area of 5 townships of Olmsted County, Minnesota from 1976 to 1982 and remaining in the community at age 5 years were reviewed to identify those with learning disabilities. Cox proportional hazards regression was used to compare the incidence of learning disabilities between children delivered vaginally with and without neuraxial labor analgesia, including analyses adjusted for factors of either potential clinical relevance or that differed between the 2 groups in univariate analysis. Of the study cohort, 4684 mothers delivered children vaginally, with 1495 receiving neuraxial labor analgesia. The presence of childhood learning disabilities in the cohort was not associated with use of labor neuraxial analgesia (adjusted hazard ratio, 1.05; 95%confidence interval, 0.85-1.31; P = 0.63). The use of neuraxial analgesia during labor and vaginal delivery was not independently associated with learning disabilities diagnosed before age 19 years. Future studies are needed to evaluate potential mechanisms of the previous finding indicating that the incidence of learning disabilities is lower in children born to mothers via cesarean delivery under neuraxial anesthesia compared with vaginal delivery.

A randomized controlled study of whether the partner’s presence in the operating room during neuraxial anesthesia for cesarean delivery reduces patient anxiety

Background This study compared anxiety in two groups of women undergoing elective cesarean delivery to ascertain if their partner’s presence during neuraxial anesthesia placement affected patients’ overall anxiety levels. Methods Three hundred fifteen patient-partner dyads were randomized to two groups: group 1 partners were present in the operating room during neuraxial anesthesia placement while group 2 partners remained outside the operating room during placement. Before surgery, all patient-partner dyads completed a survey of demographics, anesthetic experiences and baseline anxiety. Anxiety levels were rated using a visual analogue scale (VAS) and the state portion of the Spielberger State-Trait Anxiety Inventory. Results The mean change in anxiety as measured by VAS among patients whose partners were present in the operating room for neuraxial anesthetic placement decreased from before to after the procedure (-4.5 ± 25.8; P=0.03; 95% CI -8.55, -0.45); the mean change in anxiety in patients whose partners were not present did not alter significantly (+1.9 ± 25.3; P=0.34; 95% CI 6.68, 12.12). Anxiety was increased among partners who were not present (+9.4, P<0.001). Conclusion Although patients whose partners were present in the operating room at the time of neuraxial anesthesia placement reported less anxiety over the time of the study than did patients whose partners were not present, these differences were small and are not considered to be clinically important. Increased anxiety among partners who were not present at neuraxial placements warrants further study.