Association between mode of anaesthesia and severe maternal morbidity during admission for scheduled Caesarean delivery: a nationwide population-based study in Japan, 2010-2013

Anaesthesia praCtice for Caesarean dElivery Snapshot Study (ACCESS): Protocol and baseline characteristics of registered centres

BACKGROUND

Specific guidelines to manage caesarean delivery anaesthesia are lacking. A European multicentre study, ACCESS investigates caesarean delivery anaesthesia management in European centres. In order to identify ACCESS participating centres, a registration survey was created.

OBJECTIVE

The aim of the current report is to describe the characteristics of ACCESS study participating centres, the rationale for the ACCESS study and the study methodology.

DESIGN AND SETTING

The ACCESS study is a European multicentre cross-sectional study to describe anaesthesia management for caesarean delivery (CD) using a snapshot (2-week) design. The ACCESS registration survey gathered: contact details for National Coordinators (NC); Lead Investigators (LI) per centre; centre annual CD volume; expected no. of CD during 2-week snapshot window; centre practice information; data collection language. The ACCESS registration survey was launched July 2022 (Google Forms, Google Inc., Mountain View, CA, USA) and distributed through personal connections, national and international societies, social media networks, during Euroanaesthesia 2023, through the European Society of Anaesthesiology and Intensive Care newsletter.

RESULTS

The ACCESS registration survey identified Lead Investigators for 418 centres, in 32 countries, representing an anticipated number of 15,073 CD cases over the planned 12-month study period. A median (range) of 20 (2 to 400) CD cases are anticipated per centre during the 2-week snapshot window. Most 366/418 (87.6%) centres are small, ≤2000 annual CD cases, 42 are medium 2000-5000 cases and 10 are large, ≥5000 annual CD cases. Registered centres reported in 134 (32.0%) centres that anaesthesia for caesarean delivery is performed mostly by a specialist obstetric anaesthesiologist.

CONCLUSION

The ACCESS registration survey revealed variability in volume and CD practice as well as training-levels and staffing among European countries. The ACCESS study (https://www.access-study.org/) aims to generate practice data to guide CD anaesthetic management strategies.

Quantitative and calculated estimated blood loss in cesarean deliveries for twin and singleton pregnancies: a retrospective analysis

PURPOSE

This study retrospectively assessed blood loss during cesarean deliveries for twin and singleton pregnancies using two distinct methods, quantitative estimation measured during cesarean sections and hematocrit-based calculated estimation.

METHODS

We included scheduled cesarean deliveries for twin or singleton pregnancies at ≥ 34 weeks of gestation. Quantitative blood loss was recorded based on the blood volume in the graduated collector bottle and by weighing the blood-soaked textiles during cesarean sections. The blood loss was calculated using the change in hematocrit levels before and after the cesarean delivery.

RESULTS

We evaluated 403 cases including 44 twins and 359 singletons. Quantitative blood loss during cesarean section was significantly higher in twin pregnancies than that in singleton pregnancies (1117 [440] vs 698 [378] mL; p < 0.001). However, no significant differences were observed in the calculated blood loss between the two groups on the day after delivery (487 mL [692 mL] vs 507 mL [522 mL]; p = 0.861). On post-delivery days 4-5, twin pregnancies were associated with a significantly higher calculated blood loss than singleton pregnancies (725 [868] mL vs 444 [565] mL, p = 0.041). Although a significant moderate correlation between quantitative and calculated blood loss was observed in singleton pregnancies (r = 0.473, p < 0.001), no significant correlation was observed between twin pregnancies (r = 0.053, p = 0.735).

CONCLUSION

Quantitative blood loss measurements during cesarean section may be clinically insufficient in twin pregnancies. Incorporating blood tests and continuous assessments are warranted for enhanced blood loss evaluation, especially in twin pregnancies, owing to the risk of persistent bleeding.

Anesthesia practice for Cesarean delivery in Japan: a retrospective cohort study

PURPOSE

General anesthesia for Cesarean delivery affects maternal and neonatal outcomes. We aimed to evaluate temporal trends in anesthesia management for Cesarean deliveries over 16 years and analyze interinstitutional variations in general anesthesia use in Japan.

METHODS

In this retrospective cohort study, we obtained patient data from the nationwide health insurance claims database containing data for ten million individuals. We included patients who underwent Cesarean delivery between 1 January 2005 and 31 August 2021. The primary outcome was the use of general anesthesia. We evaluated institutional variations in general anesthesia use in medical facilities using two-level hierarchical logistic regression analyses with median odds ratios and intraclass correlation coefficients.

RESULTS

The cohort included 86,793 patients who underwent 102,617 Cesarean deliveries at 2,496 institutions. General anesthesia was used in 3.7% (95% confidence interval [CI], 3.6 to 3.9) of all Cesarean deliveries. The temporal trend in the use of general anesthesia decreased gradually from 10.8% in 2005 to 2.9% in 2021 (P for trend < 0.001). The adjusted median odds ratio for medical facilities was 6.1 (95% CI, 5.9 to 6.7), and the intraclass correlation coefficient was 0.52 (95% CI, 0.51 to 0.55).

CONCLUSION

Although the rate of general anesthesia use for Cesarean delivery in Japan decreased gradually from 2005 to 2021, general anesthesia was used in 3.7% of all Cesarean deliveries. The use of general anesthesia varied significantly across institutions, and 52% of the overall variations in general anesthesia practice can be explained by differences between facilities.

Investigating Racial and Ethnic Disparities in Maternal Care at the System Level Using Patient Safety Incident Reports

BACKGROUND

Maternal mortality in the United States is high, and women and birthing people of color experience higher rates of mortality and severe maternal morbidity (SMM). More than half of maternal deaths and cases of SMM are considered preventable. The research presented here investigated systems issues contributing to adverse outcomes and racial/ethnic disparities in maternal care using patient safety incident reports.

METHODS

The authors reviewed incidents reported in the labor and delivery unit (L&D) and the antepartum and postpartum unit (A&P) of a large academic hospital in 2019 and 2020. Deliveries associated with a reported incident were described by race/ethnicity, age group, method of delivery, and several other process variables. Differences across racial/ethnic group were statistically evaluated.

RESULTS

Almost two thirds (64.8%) of the 528 reports analyzed were reported in L&D, and 35.2% were reported in A&P. Non-Hispanic white (NHW) patients accounted for 43.9% of reported incidents, non-Hispanic Black (NHB) patients accounted for 43.2%, Hispanic patients accounted for 8.9%, and patients categorized as "other" accounted for 4.0%. NHB patients were disproportionally represented in the incident reports, as they accounted for only 36.5% of the underlying birthing population. The odds ratio (OR) demonstrated a higher risk of a reported adverse incident for NHB patients; however, adjustment for cesarean section attenuated the association (OR 1.25, 95% confidence interval 1.01-1.54).

CONCLUSION

Greater integration of patient safety and health equity efforts in hospitals are needed to promptly identify and alleviate racial and ethnic disparities in maternal health outcomes. Although additional systems analysis is necessary, the authors offer recommendations to support safer, more equitable maternal care.

Trend in neuraxial morphine use and postoperative analgesia after cesarean delivery in Japan from 2005 to 2020

The increasing rate of cesarean deliveries warrants obstetric anesthesiologists to deliver high-quality post-cesarean delivery analgesia. The aim of this study was to evaluate the temporal trends in the use of neuraxial morphine for cesarean deliveries and to describe the current postoperative analgesia practices. A retrospective cohort study using nationwide health insurance claims databases was conducted from 2005 to 2020 in Japan. Pregnant women who had undergone cesarean deliveries were included. The annual rate of neuraxial morphine use was extracted and analyzed. Additionally, we explored the patient- and facility-level factors associated with neuraxial morphine use through a multilevel logistic regression analysis. The cohort included 65,208 cesarean delivery cases from 2275 institutions. The prevalence of neuraxial morphine use was 16.0% (95% confidence interval [CI], 15.8-16.3) in the overall cohort. Intrathecal morphine was used in 20.6% (95% CI, 20.2-21.0) of spinal anesthesia cases. The trend in neuraxial morphine use steadily increased from 2005 to 2020. The significant predictors of neuraxial morphine use included spinal anesthesia, recent surgery, large medical facilities, and academic hospitals. Variations in the utilization of postoperative analgesia were observed. Our study described the current trend of neuraxial morphine use and the variation in postoperative analgesia practice in Japan.

Current Epidemiology of the General Anesthesia Practice for Cesarean Delivery Using a Nationwide Claims Database in Japan: A Descriptive Study

The current status of general anesthesia practice for cesarean delivery in Japan remains unknown. Therefore, using a nationwide claims database, we aimed to investigate general anesthesia use for cesarean delivery over a period of 15 years, and to analyze the general anesthesia practice in Japan. Patients who claimed the Japanese general anesthesia claim code (L008) for cesarean delivery between 1 January 2005, and 31 March 2020, were analyzed. Primary endpoint was the prevalence of general anesthesia use. We used two definitions of general anesthesia: L008 code only (insurance definition) and combination of the L008 code with muscle relaxant use (clinical definition). The general anesthesia claim cohort (L008) included 10,972 cesarean deliveries at 1111 institutions from 2005 to 2020. Muscle relaxants were used in 27.3% of L008 claims cases. The rate of general anesthesia use for cesarean delivery ranged from 3.9% in clinical definition to 14.4% in insurance definition of all cesarean deliveries. We observed a temporal trend of gradual decrease in general anesthesia use, regardless of its definition (p for trend < 0.001). We recommend the clinical definition of general anesthesia as the combination of L008 code and muscle relaxant use in a claims-based approach.

Association of General Anesthesia and Neuraxial Anesthesia in Caesarean Section with Maternal Postpartum Depression: A Retrospective Nationwide Population-Based Cohort Study

Although cesarean section (CS) has become a common method of child delivery in recent decades, the choice between general anesthesia (GA) and neuraxial anesthesia (NA) for CS must be carefully considered. Depending on the type of anesthesia used in CS, a major outcome observed is the occurrence of postpartum depression (PPD). This study investigated the association between PPD risk and the anesthesia method used in CS by using data from three linked nationwide databases in Taiwan, namely, the National Health Insurance Research Database, the National Birth Reporting Database, and the National Death Index Database. After propensity score matching by baseline depressive disorders, maternal demographics, status at delivery, infant’s health, maternal diseases during pregnancy, and age of partner, we included women who had natural births (n = 15,706), cesarean sections with GA (n = 15,706), and cesarean sections with NA (n = 15,706). A conditional logistic regression was used to estimate the odds ratios and 95% confidence intervals (CIs) of PPDs, including depression, sleep disorder, and medication with hypnotics or antidepressants, under anesthesia during CS. The prevalence rates of combined PPDs were 26.66%, 43.87%, and 36.30% in natural births, CS with GA, and CS with NA, respectively. In particular, the proportions of postpartum use of hypnotic drugs or antidepressants were 21.70%, 39.77%, and 31.84%, which were significantly different. The aORs (95% CIs) were 2.15 (2.05–2.25) for the included depressive disorders, 1.10 (1.00–1.21) for depression, 1.03 (0.96–1.11) for sleep disorder, and 2.38 (2.27–2.50) for medication with hypnotics or antidepressants in CS with GA compared with natural births. Women who underwent CS with GA had a significantly higher risk of depressive disorders and a higher need for antidepressants for sleep problems than those who underwent CS with NA. The risks of PPD were significantly associated with the anesthesia method, especially GA. Our results can assist physicians in carefully considering the appropriate anesthesia method for CS delivery, particularly with regard to postpartum drug abuse and drug safety.

Post cesarean section surgical site infection and associated factors among women who delivered in public hospitals in Harar city, Eastern Ethiopia: A hospital-based analytic cross-sectional study

Background

Cesarean section (CS) is often complicated by surgical site infection (SSI) that may happen to a woman within 30 days after the operation. This study was conducted to estimate the prevalence of SSI and identify the factors associated with SSI.

Methods

A hospital-based analytic cross-sectional study was conducted based on the review of medical records of 1069 women who underwent CS in two public hospitals in Harar city. The post-CS SSI is defined when it occurred within 30 days after the CS procedure. Factors associated with SSI were identified using a multivariable binary logistic regression analysis. The analysis outputs are presented using an adjusted odds ratio (aOR) with a corresponding 95% confidence interval (CI). All statistical tests are defined as statistically significant at P-values<0.05.

Results

The prevalence of SSI was 12.3% (95% confidence interval (CI): 10.4, 14.4). Emergency-CS was conducted for 75.9% (95% CI: 73.2, 78.3) of the women and 13.2% (95% CI: 11.3, 15.4) had at least one co-morbid condition. On presentation, 21.7% (95% CI: 19.3, 24.3) of women had rupture of membrane (ROM). Factors significantly and positively associated with post-CS SSI include general anesthesia (aOR = 2.0, 95%CI: 1.10, 2.90), ROM (aOR = 2.27, 95%CI: 1.02, 3.52), hospital stay for over 7 days after operation (aOR = 3.57, 95%CI: 1.91, 5.21), and blood transfusion (aOR = 4.2, 95%CI: 2.35, 6.08).

Conclusion

The prevalence of post-CS SSI was relatively high in the study settings. Screening for preoperative anemia and appropriate correction before surgery, selection of the type of anesthesia, close follow-up to avoid unnecessary prolonged hospitalization, and careful assessment of membrane status should be considered to avoid preventable SSI and maternal morbidity.

Anesthesia, sex and miscarriage history may influence the association between cesarean delivery and autism spectrum disorder

BACKGROUND

To explore the association between cesarean section (CS) and risk of autism spectrum disorder (ASD), and evaluate the possible factors influencing this association.

METHODS

In total, 950 patients diagnosed with ASD and 764 healthy controls were recruited in this study. Socio-demographic characteristics and prenatal, perinatal, and neonatal characteristics were compared between the two groups. Univariate and multivariable conditional logistic regression analyses were applied to adjust for confounders. Further stratified analyses based on sex and miscarriage history were similarly performed to explore the factors influencing the association between CS and ASD.

RESULTS

CS was evidently associated with an elevated risk of ASD (adjusted odds ratio [aOR] = 1.606, 95% confidence interval (CI) = 1.311-1.969). Unlike regional anesthesia (RA), only CS performed under general anesthesia (GA) consistently elevated the risk of ASD (aOR = 1.887, 95% CI = 1.273-2.798) in females and males in further stratified analysis. The risk of children suffering from ASD following emergency CS was apparently increased in males (aOR = 2.390, 95% CI = 1.392-5.207), whereas a higher risk of ASD was observed among voluntary CS and indicated CS subgroups (aOR = 2.167, 95% CI = 1.094-4.291; aOR = 2.919, 95% CI = 1.789-4.765, respectively) in females. Moreover, the interaction term of CS and past miscarriage history (β = - 0.68, Wald χ2 = 7.5, df = 1, p = 0.006)) was similarly defined as influencing ASD.

CONCLUSIONS

The exposure of children to GA during CS may explain the possible/emerging association between CS and ASD. In addition, sex and miscarriage history could equally be factors influencing the association between CS and ASD.

Moderate rate of implementation of spinal anesthesia for cesarean section: does it improve neonatal well-being? A case-control study

Before 2013, almost none of the cesarean section (CS) deliveries at our institution were performed with spinal anesthesia (SA), but after 2013 SA became the first-choice anesthesia for CS because it achieved better neonatal outcomes. However, the current rate of SA implementation at our institution was estimated to be approx. 60-70%, which is intermediate between these at other institutions in Japan or in other countries. This raises a question: What rate of SA use among CS cases achieves the best neonatal outcomes? To answer this question, we conducted this single-center case-control study with 1326 CS cases between 1994 and 2017 and compared the neonatal outcomes before to those after 2013. The logistic regression models were prepared to estimate the risk of birth asphyxia defined as a 5-min Apgar of < 7, associated with eight potential confounders, including the modified anesthetic protocol. The modified protocol was not a significant independent factor for neonatal asphyxia, indicating that our moderate SA priority protocol did not improve the neonatal outcomes even when compared to the outcomes at a 0% SA rate. A > 70% rate of SA implementation may be needed to provide better neonatal outcomes.

A scoping review of severe maternal morbidity: describing risk factors and methodological approaches to inform population-based surveillance

Background

Current interest in using severe maternal morbidity (SMM) as a quality indicator for maternal healthcare will require the development of a standardized method for estimating hospital or regional SMM rates that includes adjustment and/or stratification for risk factors.

Objective

To perform a scoping review to identify methodological considerations and potential covariates for risk adjustment for delivery-associated SMM.

Search methods

Following the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews, systematic searches were conducted with the entire PubMed and EMBASE electronic databases to identify publications using the key term “severe maternal morbidity.”

Selection criteria

Included studies required population-based cohort data and testing or adjustment of risk factors for SMM occurring during the delivery admission. Descriptive studies and those using surveillance-based data collection methods were excluded.

Data collection and analysis

Information was extracted into a pre-defined database. Study design and eligibility, overall quality and results, SMM definitions, and patient-, hospital-, and community-level risk factors and their definitions were assessed.

Main results

Eligibility criteria were met by 81 studies. Methodological approaches were heterogeneous and study results could not be combined quantitatively because of wide variability in data sources, study designs, eligibility criteria, definitions of SMM, and risk-factor selection and definitions. Of the 180 potential risk factors identified, 41 were categorized as pre-existing conditions (e.g., chronic hypertension), 22 as obstetrical conditions (e.g., multiple gestation), 22 as intrapartum conditions (e.g., delivery route), 15 as non-clinical variables (e.g., insurance type), 58 as hospital-level variables (e.g., delivery volume), and 22 as community-level variables (e.g., neighborhood poverty).

Conclusions

The development of a risk adjustment strategy that will allow for SMM comparisons across hospitals or regions will require harmonization regarding: a) the standardization of the SMM definition; b) the data sources and population used; and c) the selection and definition of risk factors of interest.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40748-020-00123-1.

The effect of COVID-19 on general anaesthesia rates for caesarean section. A cross-sectional analysis of six hospitals in the north-west of England

At the onset of the global pandemic of COVID-19 (SARS-CoV-2), guidelines recommended using regional anaesthesia for caesarean section in preference to general anaesthesia. National figures from the UK suggest that 8.75% of over 170,000 caesarean sections are performed under general anaesthetic. We explored whether general anaesthesia rates for caesarean section changed during the peak of the pandemic across six maternity units in the north-west of England. We analysed anaesthetic information for 2480 caesarean sections across six maternity units from 1 April to 1 July 2020 (during the pandemic) and compared this information with data from 2555 caesarean sections performed at the same hospitals over a similar period in 2019. Primary outcome was change in general anaesthesia rate for caesarean section. Secondary outcomes included overall caesarean section rates, obstetric indications for caesarean section and regional to general anaesthesia conversion rates. A significant reduction (7.7 to 3.7%, p < 0.0001) in general anaesthetic rates, risk ratio (95%CI) 0.50 (0.39-0.93), was noted across hospitals during the pandemic. Regional to general anaesthesia conversion rates reduced (1.7 to 0.8%, p = 0.012), risk ratio (95%CI) 0.50 (0.29-0.86). Obstetric indications for caesarean sections did not change (p = 0.17) while the overall caesarean section rate increased (28.3 to 29.7%), risk ratio (95%CI) 1.02 (1.00-1.04), p = 0.052. Our analysis shows that general anaesthesia rates for caesarean section declined during the peak of the pandemic. Anaesthetic decision-making, recommendations from anaesthetic guidelines and presence of an on-site anaesthetic consultant in the delivery suite seem to be the key factors that influenced this decline.

Outcomes associated with anaesthetic techniques for caesarean section in low- and middle-income countries: a secondary analysis of WHO surveys

Associations between anaesthetic techniques and pregnancy outcomes were assessed among 129,742 pregnancies delivered by caesarean section (CS) in low- and middle-income countries (LMICs) using two WHO databases. Anaesthesia was categorized as general anaesthesia (GA) and neuraxial anaesthesia (NA). Outcomes included maternal death (MD), maternal near miss (MNM), severe maternal outcome (SMO), intensive care unit (ICU) admission, early neonatal death (END), neonatal near miss (NNM), severe neonatal outcome (SNO), Apgar score <7 at 5 minutes, and neonatal ICU (NICU) admission. A two‐stage approach of individual participant data meta‐analysis was used to combine the results. Adjusted odds ratio (OR) with 95% confidence intervals (CIs) were presented. Compared to GA, NA were associated with decreased odds of MD (pooled OR 0.28; 95% CI 0.10, 0.78), MNM (pooled OR 0.25; 95% CI 0.21, 0.31), SMO (pooled OR 0.24; 95% CI 0.20,0.28), ICU admission (pooled OR 0.17; 95% CI 0.13, 0.22), NNM (pooled OR 0.63; 95% CI 0.55, 0.73), SNO (pooled OR 0.55; 95% CI 0.48, 0.63), Apgar score <7 at 5 minutes (pooled OR 0.35; 95% CI 0.29, 0.43), and NICU admission (pooled OR 0.53; 95% CI 0.45, 0.62). NA therefore was associated with decreased odds of adverse pregnancy outcomes in LMICs.

Epidemiology of obstetric critical illness

Obstetric intensive care unit (ICU) admissions comprise only a small part of severe maternal morbidity. The incidence rate of both remains relatively unclear due to inconsistent definitions across publications, although this has begun to be addressed. There is a relative paucity of information regarding disease-specific survival following obstetric ICU admission, but outcomes are clearly related to the cause of admission and the quality of care. The ratio between maternal near-miss cases (many of whom are admitted to ICUs) and maternal death may provide insight into the preventability of death. Hemorrhage and pre-eclampsia constitute the leading causes of ICU admission and have relatively low mortality rates, perhaps demonstrating the impact of informed care in managing obstetric critical illness. Obstetric sepsis, heart disease and anesthesia complications should be the focus of future research. The incidence of obstetric sepsis has been increasing in the last decade, with mortality rates remaining relatively high. The incidence of obstetric heart disease is increasing and maternal complications have been attributed to fractionated care of mothers within this category. Anesthesia complications remain a predominant cause of maternal death and likely intensive care admission. Data are lacking regarding the relative proportion of cases per disease that remain treated outside the ICU; and the outcomes of various management strategies. The only study of the health status of survivors of obstetric ICU admission revealed that six months after hospital discharge, one in five women still had a poorer health-related quality of life than those of a reference age- and sex-matched cohort.