The Current Role of General Anesthesia for Cesarean Delivery

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Abstract

Purpose of the Review

The use of general anesthesia for cesarean delivery has declined in the last decades due to the widespread utilization of neuraxial techniques and the understanding that neuraxial anesthesia can be provided even in urgent circumstances. In fact, the role of general anesthesia for cesarean delivery has been revisited, because despite recent devices facilitating endotracheal intubation and clinical algorithms, guiding anesthesiologists facing challenging scenarios, risks, and complications of general anesthesia at the time of delivery for both mother and neonate(s) remain significant. In this review, we will discuss clinical scenarios and risk factors associated with general anesthesia for cesarean delivery and address reasons why anesthesiologists should apply strategies to minimize its use.

Recent Findings

Unnecessary general anesthesia for cesarean delivery is associated with maternal complications, including serious anesthesia-related complications, surgical site infection, and venous thromboembolic events. Racial and socioeconomic disparities and low-resource settings are major contributing factors in the use of general anesthesia for cesarean delivery, with both maternal and perinatal mortality increasing when general anesthesia is provided. In addition, more significant maternal pain and higher rates of postpartum depression requiring hospitalization are associated with general anesthesia for cesarean delivery.

Summary

Rates of general anesthesia for cesarean delivery have overall decreased, and while general anesthesia no longer is a contributing factor to anesthesia-related maternal deaths, further opportunities to reduce its use should be emphasized. Raising awareness in identifying situations and patients at risk to help avoid unnecessary general anesthesia remains crucial.

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Most cited references 99

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Universal Screening for SARS-CoV-2 in Women Admitted for Delivery

Desmond Sutton, Karin Fuchs, Mary E. D’Alton … (2020)

To the Editor: In recent weeks, Covid-19 has rapidly spread throughout New York City. The obstetrical population presents a unique challenge during this pandemic, since these patients have multiple interactions with the health care system and eventually most are admitted to the hospital for delivery. We first diagnosed a case of Covid-19 in an obstetrical patient on March 13, 2020, and we previously reported our early experience with Covid-19 in pregnant women, including two initially asymptomatic women in whom symptoms developed and who tested positive for SARS-CoV-2, the virus that causes Covid-19, after delivery. 1,2 After these two cases were identified, we implemented universal testing with nasopharyngeal swabs and a quantitative polymerase-chain-reaction test to detect SARS-CoV-2 infection in women who were admitted for delivery. Between March 22 and April 4, 2020, a total of 215 pregnant women delivered infants at the New York–Presbyterian Allen Hospital and Columbia University Irving Medical Center . All the women were screened on admission for symptoms of Covid-19. Four women (1.9%) had fever or other symptoms of Covid-19 on admission, and all 4 women tested positive for SARS-CoV-2 (Figure 1). Of the 211 women without symptoms, all were afebrile on admission. Nasopharyngeal swabs were obtained from 210 of the 211 women (99.5%) who did not have symptoms of Covid-19; of these women, 29 (13.7%) were positive for SARS-CoV-2. Thus, 29 of the 33 patients who were positive for SARS-CoV-2 at admission (87.9%) had no symptoms of Covid-19 at presentation. Of the 29 women who had been asymptomatic but who were positive for SARS-CoV-2 on admission, fever developed in 3 (10%) before postpartum discharge (median length of stay, 2 days). Two of these patients received antibiotics for presumed endomyometritis (although 1 patient did not have localizing symptoms), and 1 patient was presumed to be febrile due to Covid-19 and received supportive care. One patient with a swab that was negative for SARS-CoV-2 on admission became symptomatic postpartum; repeat SARS-CoV-2 testing 3 days after the initial test was positive. Our use of universal SARS-CoV-2 testing in all pregnant patients presenting for delivery revealed that at this point in the pandemic in New York City, most of the patients who were positive for SARS-CoV-2 at delivery were asymptomatic, and more than one of eight asymptomatic patients who were admitted to the labor and delivery unit were positive for SARS-CoV-2. Although this prevalence has limited generalizability to geographic regions with lower rates of infection, it underscores the risk of Covid-19 among asymptomatic obstetrical patients. Moreover, the true prevalence of infection may be underreported because of false negative results of tests to detect SARS-CoV-2. 3 The potential benefits of a universal testing approach include the ability to use Covid-19 status to determine hospital isolation practices and bed assignments, inform neonatal care, and guide the use of personal protective equipment. Access to such clinical data provides an important opportunity to protect mothers, babies, and health care teams during these challenging times.

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COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of New York City hospitals

Noelle Breslin, Caitlin Baptiste, Cynthia Gyamfi-Bannerman … (2020)

The novel coronavirus 2019, or COVID-19, infection has rapidly spread through the New York metropolitan area since the first reported case in the state on March 1, 2020. New York currently represents an epicenter for COVID-19 infection in the United States, with 84,735 cases reported as of April 2, 2020. We previously presented an early experience with seven COVID-positive patients in pregnancy, including two women who were diagnosed with COVID-19 following an asymptomatic initial presentation. We now describe a series of 43 test-confirmed cases of COVID-19 presenting to a pair of affiliated New York City hospitals over two weeks from March 13 to 27, 2020. Fourteen (32.6%) patients presented without any COVID-associated viral symptoms, and were identified either after developing symptoms during admission or following the implementation of universal testing for all obstetrical admissions on March 22. Of these, 10/14 (71.4%) developed symptoms or signs of COVID-19 infection over the course of their delivery admission or early after postpartum discharge. Of the other 29 (67.4%) patients who presented with symptomatic COVID-19 infection, three women ultimately required antenatal admission for viral symptoms, and an additional patient represented six days postpartum after a successful labor induction with worsening respiratory status that required oxygen supplementation. There were no confirmed cases of COVID-19 detected in neonates upon initial testing on the first day of life. Applying COVID-19 disease severity characteristics as described by Wu et al, 37 (86%) women possessed mild disease, four (9.3%) exhibited severe disease, and two (4.7%) developed critical disease; these percentages are similar to those described for non-pregnant adults with COVID-19 infections (about 80% mild, 15% severe, and 5% critical disease).

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Pregnancy-Related Mortality in the United States, 2011–2013

Andreea A. Creanga, Carla Syverson, Kristi Seed … (2017)

To update national population-level pregnancy-related mortality estimates and examine characteristics and causes of pregnancy-related deaths in the United States during 2011-2013.

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Author and article information

Contributors

Ruth Landau:

ORCID: http://orcid.org/0000-0002-3737-7536

rl262@cumc.columbia.edu

Journal

Journal ID (nlm-ta): Curr Anesthesiol Rep

Journal ID (iso-abbrev): Curr Anesthesiol Rep

Title: Current Anesthesiology Reports

Publisher: Springer US (New York )

ISSN (Print): 1523-3855

ISSN (Electronic): 2167-6275

Publication date (Electronic): 24 February 2021

Pages: 1-10

Affiliations

[1 ]GRID grid.21729.3f, ISNI 0000000419368729, Department of Anesthesiology, , Columbia University Irving Medical Center, ; New York, NY USA

[2 ]GRID grid.34477.33, ISNI 0000000122986657, Department of Anesthesiology and Pain Medicine, , University of Washington, ; Seattle, WA USA

Author information

Ruth Landau http://orcid.org/0000-0002-3737-7536

Article

Publisher ID: 437

DOI: 10.1007/s40140-021-00437-6

PMC ID: 7902754

PubMed ID: 33642943

SO-VID: 02c3b36d-dc42-483a-87ad-b0c59d25f737

License:

This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

The Current Role of General Anesthesia for Cesarean Delivery

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Abstract

Purpose of the Review

Recent Findings

Summary

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RNA drug delivery

Most cited references 99

Universal Screening for SARS-CoV-2 in Women Admitted for Delivery

COVID-19 infection among asymptomatic and symptomatic pregnant women: Two weeks of confirmed presentations to an affiliated pair of New York City hospitals

Pregnancy-Related Mortality in the United States, 2011–2013

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