Stemming the Tide of Obstetric Morbidity: An Opportunity for the Anesthesiologist to Embrace the Role of Peridelivery Physician

Racial and Ethnic Disparities in Receipt of General Anesthesia for Cesarean Delivery

Importance

General anesthesia for cesarean delivery is associated with increased maternal morbidity, and Black and Hispanic pregnant patients have higher rates of general anesthesia use compared with their non-Hispanic White counterparts. It is unknown whether risk factors and indications for general anesthesia differ among patients of differing race and ethnicity.

Objective

To evaluate differences in general anesthesia use for cesarean delivery and the indication for the general anesthetic by race and ethnicity.

Design, Setting, and Participants

In this retrospective, cross-sectional, single-center study, electronic medical records for all 35 117 patients who underwent cesarean delivery at Northwestern Medicine's Prentice Women's Hospital from January 1, 2007, to March 2, 2018, were queried for maternal demographics, clinical characteristics, obstetric and anesthetic data, the indication for cesarean delivery, and the indication for general anesthesia when used. Data analysis occurred in August 2023.

Exposure

Cesarean delivery.

Main Outcomes and Measures

The rate of general anesthesia for cesarean delivery by race and ethnicity.

Results

Of the 35 117 patients (median age, 33 years [IQR, 30-36 years]) who underwent cesarean delivery, 1147 (3.3%) received general anesthesia; the rates of general anesthesia were 2.5% for Asian patients (61 of 2422), 5.0% for Black patients (194 of 3895), 3.7% for Hispanic patients (197 of 5305), 2.8% for non-Hispanic White patients (542 of 19 479), and 3.8% (153 of 4016) for all other groups (including those who declined to provide race and ethnicity information) (P < .001). A total of 19 933 pregnant patients (56.8%) were in labor at the time of their cesarean delivery. Of those, 16 363 (82.1%) had neuraxial labor analgesia in situ. Among those who had an epidural catheter in situ, there were no racial or ethnic differences in the rates of general anesthesia use vs neuraxial analgesia use (Asian patients, 34 of 503 [6.8%] vs 1289 of 15 860 [8.1%]; Black patients, 78 of 503 [15.5%] vs 1925 of 15 860 [12.1%]; Hispanic patients, 80 of 503 [15.9%] vs 2415 of 15 860 [15.2%]; non-Hispanic White patients, 255 of 503 [50.7%] vs 8285 of 15 860 [52.2%]; and patients of other race or ethnicity, 56 of 503 [11.1%] vs 1946 of 15 860 [12.3%]; P = .16). Indications for cesarean delivery and for general anesthesia were not different when stratified by race and ethnicity.

Conclusions and Relevance

Racial disparities in rates of general anesthesia continue to exist; however, this study suggests that, for laboring patients who had labor epidural catheters in situ, no disparity by race or ethnicity existed. Future studies should address whether disparities in care that occur prior to neuraxial catheter placement are associated with higher rates of general anesthesia among patients from ethnic and racial minority groups.

Obstetric Anesthesia and Heart Disease: Practical Clinical Considerations

Maternal morbidity and mortality as a result of cardiac disease is increasing in the United States. Safe management of pregnancy in women with heart disease requires appropriate anesthetic, cardiac, and obstetric care. The anesthesiologist should risk stratify pregnant patients based upon cardiac disease etiology and severity in order to determine the appropriate type of hospital and location within the hospital for delivery and anesthetic management. Increased intrapartum hemodynamic monitoring may be necessary and neuraxial analgesia and anesthesia is typically appropriate. The anesthesiologist should anticipate obstetric and cardiac emergencies such as emergency cesarean delivery, postpartum hemorrhage, and peripartum arrhythmias. This clinical review answers practical questions for the obstetric anesthesiologist and the nonsubspecialist anesthesiologist who regularly practices obstetric anesthesiology.

Peripartum optimization and coordination of collaborative care practice: a critical role for the obstetric anesthesiologist in combating maternal morbidity and mortality

PURPOSE OF REVIEW

Antenatal anesthesia clinics remain uncommon despite the rising incidence of maternal morbidity and mortality in the United States. The purpose of the present review is to outline the major considerations and challenges surrounding antenatal anesthetic evaluation.

RECENT FINDINGS

Data from the general surgical population would suggest a mortality benefit associated with preoperative anesthesia evaluation, although no such data exists in the obstetric population.Robust systems for case ascertainment and referral are needed. Recent publications on obstetric comorbidity indices may provide useful tools to ascertain high-risk parturients for a referral to antenatal obstetric anesthesiology clinics and higher levels of maternal care. Major obstetric organizations have identified and laid out criteria for maternal level of care. Anesthesiology resources also play a role in these designations and can help triage patients to facilities with appropriate resources.

SUMMARY

Obstetric anesthesiologists have a critical role not only in preoperative patient optimization but also in coordinating multidisciplinary care for optimal patient outcomes.

Delivery Hospital Characteristics and Postpartum Maternal Mortality: A National Case-Control Study in France

BACKGROUND

The variability in resources for managing critical events among maternity hospitals may impact maternal safety. Our main objective was to assess the risk of postpartum maternal death according to hospitals' organizational characteristics. A secondary objective aimed to assess the specific risk of death due to postpartum hemorrhage (PPH).

METHODS

This national population-based case-control study included all 2007-2009 postpartum maternal deaths from the national confidential enquiry (n = 147 cases) and a 2010 national representative sample of parturients (n = 14,639 controls). To adjust for referral bias, cases were classified by time when the condition/complication responsible for the death occurred: postpartum maternal deaths due to conditions present before delivery (n = 66) or during or after delivery (n = 81). Characteristics of delivery hospitals included 24/7 on-site availability of an anesthesiologist and an obstetrician, level of perinatal care, number of deliveries annually, and their teaching and profit status. In teaching and other nonprofit hospitals in France, obstetric care is organized on the principle of collective team-based management, while in for-profit hospitals, this organization is based mostly on that of "one woman-one doctor." Logistic regression models were used to estimate adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for postpartum maternal death.

RESULTS

The risk of maternal death from prepartum conditions was lower for women who gave birth in for-profit compared with teaching hospitals (aOR, 0.3; 95% CI, 0.1-0.8; P = .02) and in hospitals with <1500 vs ≥1500 annual deliveries (aOR, 0.4; 95% CI, 0.1-0.9; P = .02). Conversely, the risk of postpartum maternal death from complications occurring during or after delivery was higher for women who delivered in for-profit compared with teaching hospitals (aOR, 2.8; 95% CI, 1.3-6.0; P = .009), as was the risk of death from PPH in for-profit versus nonprofit hospitals (aOR, 2.8; 95% CI, 1.2-6.5; P = .019).

CONCLUSIONS

After adjustment for the referral bias related to prepartum morbidity, the risk of postpartum maternal mortality in France differs according to the hospital's organizational characteristics.

Obstetric Anesthesia: Leading the Way in Patient Safety

The subspecialty of obstetric anesthesiology has embraced patient safety research, which has led to a reduction in obstetric anesthesia-related morbidity and mortality. Although there are innumerable individual improvements, this article highlights the following innovations: safer and more effective labor analgesia, safer treatments for hypotension associated with neuraxial blockade, advances in spinal and epidural techniques for operative deliveries, lower incidence of postdural puncture headache through improved technology, safer parental agents for labor analgesia, improved safety of general anesthesia in obstetrics, improved education and the use of simulation including team training, and reductions in operating room-related infections.

Uterine hypertonus and fetal bradycardia occurred after combined spinal-epidural analgesia during induction of labor with oxytocin infusion: A case report

RATIONALE

Pain management is an essential part of good obstetrical care. The rapid onset of pain relief after combined spinal-epidural (CSE) analgesia may cause a transient imbalance in maternal catecholamine level, leading to uterine hyperactivity and fetal heart rate (FHR) abnormalities. How to manage the uterine basal tone and FHR abnormalities after labor analgesia still remains controversial.

PATIENT CONCERNS

A 33-year-old nulliparous woman at 40 weeks' gestation underwent induction of labor after premature rupture of membranes. CSE analgesia was provided when the patient described her pain as the top on a scale of 10 during induction of labor with oxytocin infusion.

DIAGNOSES

Uterine hypertonus and fetal bradycardia were diagnosed within 10 minutes after CSE analgesia.

INTERVENTIONS

Oxytocin infusion and CSE analgesia were immediately suspended, and measures of staying in left lateral decubitus position and giving supplemental oxygen were attempted to resuscitating the baby. Because of suspicious fetal distress, the baby was rapidly delivered by emergency cesarean section.

OUTCOMES

The Apgar score of the baby was 8 and 10 at 1 and 5 minutes after birth. Subsequent follow-up confirmed that both mother and baby were in good condition.

LESSONS

The loss of the tocolytic effect of epinephrine after CSE analgesia and continuous oxytocin infusion may work together to form a totally synergistic function, finally leading to inevitable uterine hypertonus and fetal bradycardia. Both the obstetrical provider and anesthesiologist should carefully monitor all patients in the first 15 minutes after CES analgesia induction. Oxytocin administration in this critical period deserves attention. Additionally, intraprofessional collaboration is also necessary to ensure high quality and safe delivery for all childbearing women.

United States State-Level Variation in the Use of Neuraxial Analgesia During Labor for Pregnant Women

IMPORTANCE

Neuraxial labor analgesia is recognized as the most effective method of providing pain relief during labor. Little is known about variation in the rates of neuraxial analgesia across US states. Identifying the presence and extent of variation may provide insights into practice variation and may indicate where access to neuraxial analgesia is inadequate.

OBJECTIVE

To test the hypothesis that variation exists in neuraxial labor analgesia use among US states.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective, population-based, cross-sectional analysis using US birth certificate data. Participants were 2 625 950 women who underwent labor in 2015.

MAIN OUTCOMES AND MEASURES

State-specific prevalence of neuraxial analgesia per 100 women who underwent labor and variability in neuraxial analgesia use among states, assessed using multilevel multivariable regression modeling with the median odds ratio and the intraclass correlation coefficient to evaluate variation by state.

RESULTS

In the study population of 2 625 950 women, 0.1% (n = 2010) were younger than 15 years, 7.0% (n = 183 546) were between the ages of 15 and 19 years, 23.6% (n = 620 118) were between the ages of 20 and 24 years, 29.6% (n = 777 957) were between the ages of 25 and 29 years, 26.0% (n = 683 656) were between the ages of 30 and 34 years, 11.4% (n = 298 237) were between the ages of 35 and 39 years, 2.2% (n = 57 130) were between the ages of 40 and 44 years, and 0.1% (n = 3296) were between the ages of 45 and 54 years. More than 90% were privately insured or insured with Medicaid. Neuraxial analgesia was used by 73.1% (n = 1 920 368) of women. After adjustment for antepartum, obstetric, and intrapartum factors, Maine had the lowest neuraxial analgesia prevalence (36.6%; 95% CI, 33.2%-40.1%) and Nevada the highest (80.1%; 95% CI, 78.3%-81.7%). The adjusted median odds ratio was 1.5 (95% CI, 1.4-1.6), and the intraclass correlation coefficient was 5.4% (95% CI, 4.0%-7.9%).

CONCLUSIONS AND RELEVANCE

Results of this study suggest that a small portion of the overall variation in neuraxial analgesia use is explained by US states. Unmeasured patient-level and hospital-level factors likely account for a large portion of the variation between states. Efforts should be made to understand what the main reasons are for this variation and whether the variation influences maternal or perinatal outcomes.

What's New in Obstetric Anesthesia: a focus on maternal morbidity and mortality

The Ostheimer lecture is given each year at the annual meeting of the Society for Obstetric Anesthesia and Perinatology. It summarizes "What's New in Obstetric Anesthesia" based on a systematic evaluation of the relevant literature published in the previous calendar year. In this review I consider studies published in 2016 focused on the prevalence of, and risk factors for, maternal morbidity and mortality. I also discuss novel therapeutic approaches to the prevention and treatment of major sources of maternal morbidity and mortality.

What's New in Obstetric Anesthesia: The 2016 Gerard W. Ostheimer Lecture

This special article presents potentially important trends and issues affecting the field of obstetric anesthesia drawn from publications in 2015. Both maternal mortality and morbidity in the United States have increased in recent years because, in part, of the changing demographics of the childbearing population. Pregnant women are older and have more pre-existing conditions and complex medical histories. Cardiovascular and noncardiovascular medical diseases now account for half of maternal deaths in the United States. Several national and international organizations have developed initiatives promoting optimal obstetric and anesthetic care, including guidelines on the obstetric airway, obstetric cardiac arrest protocols, and obstetric hemorrhage bundles. To deal with the increasing burden of high-risk parturients, the national obstetric organizations have proposed a risk-based classification of delivery centers, termed as Levels of Maternal Care. The goal of this initiative is to funnel more complex obstetric patients toward high-acuity centers where they can receive more effective care. Despite the increasing obstetric complexity, anesthesia-related adverse events and morbidity are decreasing, possibly reflecting an ongoing focus on safe systems of anesthetic care. It is critical that the practice of obstetric anesthesia expand beyond the mere provision of safe analgesia and anesthesia to lead in developing and promoting comprehensive safety systems for obstetrics and team-based coordinated care.