Epidural, spinal anesthesia safe for cesarean deliveries, study finds

"Cesarean delivery is the most commonly performed inpatient surgical procedure in the United States, with 1.3 million cesareans being performed under epidural, spinal or general anesthesia each year," said Jean Guglielminotti, M.D., Ph.D., lead study author and postdoctoral research fellow, Department of Anesthesiology, Columbia University Medical Center, New York. "Women giving birth by cesarean delivery are generally at an increased risk for experiencing complications from anesthesia compared to women who deliver vaginally. However, our research shows anesthesia-related outcomes in cesarean deliveries have significantly improved."

According to ASA practice guidelines, spinal or epidural anesthesia is preferred for most cesarean deliveries. However, general anesthesia may be administered in some cases, such as an emergency cesarean delivery.

In the study, Dr. Guglielminotti and co-authors Guohua Li, M.D., Dr PH, and Ruth Landau, M.D., at Columbia University Medical Center and Cynthia A. Wong, M.D., at Northwestern University Feinberg School of Medicine, Chicago, examined trends in major (e.g. death, cardiac arrest) and minor (e.g. headache, back pain, pain during surgery, emotional distress) anesthesia-related complications, perioperative complications unrelated to anesthesia (e.g. acute heart failure, acute respiratory failure, stroke), and overall mortality in 785,854 cesarean deliveries in New York state hospitals between 2003 and 2012. Patients' maternal age, type of anesthesia, and outcome characteristics were reviewed.

Of the 785,854 cesarean deliveries studied, 5,715 had at least one anesthesia-related complication. The overall rate of major and minor anesthesia-related complications for those who received spinal or epidural anesthesia during cesarean delivery decreased 25 percent, from 8.9 per 1,000 in 2003 to 6.6 per 1,000 in 2012. No decrease in complications was observed in cesareans performed under general anesthesia.

In contrast, the rate of perioperative complications unrelated to anesthesia increased 47 percent over the last decade, with at least one non-anesthetic perioperative complication occurring in 7,040 cesarean deliveries. The increase may be due to more women having serious preexisting medical conditions before undergoing cesarean delivery, the authors note.

Interestingly, the authors observed the number of cesarean deliveries performed significantly increased from 29 percent in 2003 to 35 percent in 2012, the proportion of women over age 40 having cesareans increased, as well as, women with preexisting medical conditions. Nonetheless, the overall in-hospital mortality rate after cesarean delivery significantly decreased.

"Over the last two decades, obstetric anesthesia providers have focused on improving the quality and safety of care provided to expectant mothers while providing pain relief during labor and safe anesthesia for cesarean delivery," said Dr. Guglielminotti. "Our research highlights the importance and success of intervention programs to improve obstetric anesthesia care. This is all the more important with the high cesarean delivery rate in the U.S. and the increase in maternal age, chronic maternal diseases and high-risk pregnancies."

An accompanying editorial commented favorably on the study and suggested physician anesthesiologists maintain their excellent safety record for anesthesia-related complications, but work with obstetricians and others to further reduce complications by participating as "peri-delivery" physicians.

"Anesthesia and analgesia for childbirth have become remarkably safe and the magnitude of the observed reduction in anesthesia-related complications by Guglielminotti et al. likely reflects gains in the safety of anesthetic management," wrote editorial authors Jill M. Mhyre, M.D., associate professor of anesthesiology at the University of Arkansas for Medical Sciences in Little Rock and Brian T. Bateman, M.D., M.Sc., assistant professor of anesthesia at Harvard Medical School in Boston. "However, the observation that anesthesia-related complications are declining, while non-anesthetic perioperative complications are increasing suggests the need for physician anesthesiologists to look beyond the delivery of safe anesthesia and to embrace the role of the 'peri-delivery' physician."