General anesthesia is unacceptable for elective cesarean section

Association between anesthetic method and postpartum hemorrhage in Korea based on National Health Insurance Service data

Background

Postpartum hemorrhage (PPH) is a major cause of maternal mortality and the risk factors for PPH differ among studies. In this large-scale study, we investigated whether the anesthetic method used was associated with PPH after cesarean section.

Methods

We extracted data on cesarean sections performed between January 2008 and June 2013 from the National Health Insurance Service database. The anesthetic methods were categorized into general, spinal and epidural anesthesia. To compare the likelihood of PPH among deliveries using different anesthetic methods, crude and adjusted odds ratios (ORs) and 95% confidence intervals were calculated using logistic regression analysis.

Results

Data from 330,324 cesarean sections were analyzed, and 21,636 cases of PPH were identified. Univariate analysis showed that general and epidural anesthesia increased the risk of PPH compared to spinal anesthesia. The OR for PPH was highest for morbidly adherent placenta, followed by placenta previa, placental abruption, and hypertension. When other clinical covariates were controlled for, general and epidural anesthesia still remained significant risk factors for PPH compared to spinal anesthesia.

Conclusions

This study showed that general and epidural anesthesia elevated the risk of PPH compared to spinal anesthesia during cesarean section. Since we could not consider the potential bias of group differences in indications, more in-depth clinical trials are needed to validate our findings. Obstetric factors such as placental abnormalities had high odds ratios and thus are more important than the choice of anesthetic method, which should be based on the patient's clinical condition and institutional resources.

The Current Role of General Anesthesia for Cesarean Delivery

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.

Comparison of the effect of general and spinal anesthesia for elective cesarean section on maternal and fetal outcomes: a retrospective cohort study

Background

Anesthesia is needed to ensure both maternal and fetal safety during cesarean sections. This retrospective cohort study compared maternal and fetal outcomes between general and spinal anesthesia for cesarean section based on perioperative hemodynamic parameters (pre- and postoperative systolic blood pressure, heart rate), mean difference of hematocrit and estimated blood loss, and neonatal Apgar scores at 1 and 5 min.

Methods

Data from electronic medical records of 331 singleton pregnancies between January 2016 and December 2018 were analyzed retrospectively; 44 cases were excluded, and 287 cases were assigned to the general group (n = 141) or spinal group (n = 146).

Results

Postoperative hemodynamic parameters were significantly higher in the general group than the spinal group (systolic blood pressure: 136.8 ± 16.7 vs. 119.3 ± 12.7 mmHg, heart rate: 93.2 ± 16.8 vs. 71.0 ± 12.7 beats/min, respectively, P < 0.001). The mean difference between the pre- and postoperative hematocrit was also significantly greater in the general than spinal group (4.8 ± 3.4% vs. 2.3 ± 3.9%, respectively, P < 0.001). The estimated blood loss was significantly lower in the spinal than general group (819.9 ± 81.9 vs. 856.7 ± 117.9 ml, P < 0.001). There was a significantly larger proportion of newborns with 5-min Apgar scores < 7 in the general than spinal group (6/141 [4.3%] vs. 0/146 [0%], respectively, P = 0.012).

Conclusions

General group is associated with more maternal blood loss and a larger proportion of newborns with 5-min Apgar scores < 7 than spinal group during cesarean sections.

The Effect of Fluid Therapy Before Spinal Anesthesia on Prevention of Headache After Cesarean Section: A Clinical Trial

BACKGROUND

Despite numerous studies on postdural puncture headache (PDPH) and the factors affecting it, issues such as prevention methods and techniques that are associated with a lower prevalence of this complication are still under discussion and research. The aim of this study was to evaluate the effect of increasing fluid therapy of patients before surgery on the incidence of postoperative headache.

METHODS

This single-blind clinical trial study was performed on 60 patients undergoing elective surgery with spinal anesthesia based on the inclusion criteria in 2017 in Neyshabur. After obtaining the consent of the patients, the participants were randomly divided into two groups of intervention (A) and test (B) (30 people in each group). Data were created by self-checklist and visual analog scale (VAS) pain measurement criteria were recorded by phone during 4, 7, 24, 48, 72 hours, and 7 days after surgery.

RESULTS

In the study, the average headache increased up to 72 hours after surgery in the experimental group and in the intervention group up to 48 hours after surgery and then decreased.

CONCLUSION

The results of our study generally showed that fluid therapy did not reduce headache, but showed decreasing trend of headache. According to the research results, more research is needed on the causes of headache after spinal anesthesia.

Effect of Spinal Anesthesia versus General Anesthesia on Blood Glucose Concentration in Patients Undergoing Elective Cesarean Section Surgery: A Prospective Comparative Study

Background

This prospective study compared the blood glucose concentration with spinal anesthesia or general anesthesia in patients undergoing elective cesarean section surgery.

Methods

In total, 58 pregnant women who underwent elective cesarean section surgery were included in this prospective comparative study. Group S (n = 35) included patients who chose spinal anesthesia, and group G (n = 23) included patients who chose general anesthesia. The patients were allocated to the groups upon patients' preference. For the group G, the blood glucose concentration (BGC) was obtained 5 minutes before induction, T1, and 5 minutes after induction T2. For the group S, the BGC was obtained immediately before the injection of the local anesthetic agent T1 and 5 minutes after the complete block T2. For both groups, BGC was measured 5 minutes before the end of surgery T3 and 30 minutes after the end of surgery T4. For BGC measurements, we used a blood glucose monitoring system with a lancet device to prick the finger.

Results

There was no statistically significant difference in the mean blood glucose concentration between the groups S and G in T1 (78.3 ± 18.2 vs. 74.3 ± 14.7, p > 0.05) and T2 (79.2 ± 18.3 vs. 84.9 ± 23.7, p > 0.05). The mean BGC was statistically significantly higher in group G in comparison to group S in the times 5 minutes before (80.2 ± 18.1 vs. 108.4 ± 16.7, p < 0.05) and 30 minutes after the end of surgery (80.9 ± 17.7 vs. 121.1 ± 17.4, p < 0.05).

Conclusion

There is a much lower increase in blood glucose concentration under spinal anesthesia than under general anesthesia. It is reasonable to suggest that the blood sugar concentration must be intraoperatively monitored in patients undergoing general anesthesia.

Comparison of maternal and fetal outcomes among patients undergoing cesarean section under general and spinal anesthesia: a randomized clinical trial

CONTEXT AND OBJECTIVE

As the rates of cesarean births have increased, the type of cesarean anesthesia has gained importance. Here, we aimed to compare the effects of general and spinal anesthesia on maternal and fetal outcomes in term singleton cases undergoing elective cesarean section.

DESIGN AND SETTING

Prospective randomized controlled clinical trial in a tertiary-level public hospital.

METHODS

Our study was conducted on 100 patients who underwent cesarean section due to elective indications. The patients were randomly divided into general anesthesia (n = 50) and spinal anesthesia (n = 50) groups. The maternal pre and postoperative hematological results, intra and postoperative hemodynamic parameters and perinatal results were compared between the groups.

RESULTS

Mean bowel sounds (P = 0.036) and gas discharge time (P = 0.049) were significantly greater and 24th hour hemoglobin difference values (P = 0.001) were higher in the general anesthesia group. The mean hematocrit and hemoglobin values at the 24th hour (P = 0.004 and P < 0.001, respectively), urine volume at the first postoperative hour (P < 0.001) and median Apgar score at the first minute (P < 0.0005) were significantly higher, and the time that elapsed until the first requirement for analgesia was significantly longer (P = 0.042), in the spinal anesthesia group.

CONCLUSION

In elective cases, spinal anesthesia is superior to general anesthesia in terms of postoperative comfort. In pregnancies with a risk of fetal distress, it would be appropriate to prefer spinal anesthesia by taking the first minute Apgar score into account.