Cesarian Sections: Anesthesia and Outcomes

A cesarian section is the most common surgery performed worldwide, and yet there is no standardized anesthetic technique². Older studies looking at general anesthesia vs. local anesthesia for cesarian sections (C-sections) have found that in aggregate, general anesthesia is associated with higher morbidity and mortality, but this data has been called into question by obstetric anesthesia research done in this decade².   

There are three types of regional anesthesia currently performed for a cesarian section: single-shot spinal, epidural, and combined epidural spinal anesthesia³. The most commonly administered is the single-shot spinal anesthesia approach, and this typically entails heavy bupivacaine with fentanyl or morphine used for post-operative analgesia³. Epidural anesthesia is associated with better hemodynamic and cardiovascular stability but has fallen out of favor because of higher post-operative pain and higher risk of intraoperative conversion to general anesthesia³. Finally, combined epidural spinal anesthesia has a faster onset and better nerve block than epidural anesthesia, while retaining good cardiovascular stability and low conversion to general anesthesia, especially for patients with higher BMI³.  However, it is technically difficult to administer and so it is not used as commonly as the single-shot spinal³.  

A 2012 non-systematic review looked at outcomes for maternal morbidity and mortality when comparing regional and general anesthesia for a cesarian section². Most C-sections in the United States are done under subarachnoid neuraxial anesthesia, and this percentage is increasing with time, even in cases where general anesthesia was previously indicated². In terms of mortality, this review found that while papers from the 80s reported increased mortality in association with general anesthesia, papers from 2012 onward showed a significant improvement in relative risk of maternal mortality from general anesthesia in C-sections². This may be due to an improvement in general anesthesia techniques, as well as advancements in airway protection and preventing aspiration pneumonia². Similarly, there was a statistically significant decrease in maternal morbidity due to bleeding with epidural and spinal anesthesia, although it is important to note that there is typically little blood loss associated with C-sections, and thus this decrease is not as clinically significant². Other measures of morbidity such as pain, nausea, vomiting, surgical wound infections, time to ambulation, and neurological adaptations show similarly statistically decreased morbidity with epidural and spinal anesthesia compared with general anesthesia, but the clinical significance of this data needs to be further elucidated². In conclusion, this review found no true anesthesia-related difference in maternal morbidity and mortality in C-sections, but neuraxial anesthesia remains preferred due to better pain management, surgical wound infection incidence and patient satisfaction².  

A more recent study compared health-related quality of life in patients undergoing general anesthesia vs. spinal anesthesia for requested/elective Cesarian sections without maternal or obstetric complications¹. This 2018 paper makes note that even though general anesthesia is associated with a higher risk of poorer post-C-section outcomes such as failed intubation, aspiration, and estimated blood loss, pregnant patients continue to request general anesthesia for their deliveries at high rates¹. This study compared 80 patients who chose spinal anesthesia with 80 who chose general anesthesia and found significant benefits to health-related quality of life scores for spinal anesthesia¹. Much like the 2012 review, spinal anesthesia was associated with better pain control post-C-section, less estimated blood loss, and faster return to activities of daily living, which now include caring for a child¹.  

Because C-sections are so increasingly and commonly performed, their outcomes have an important public health implication. It is thus important to have strong data supporting clear anesthesia recommendations for Cesarian sections, not only in the US but also worldwide.  

References 

1. Ghaffari S, Dehghanpisheh L, Tavakkoli F, et al. The Effect of Spinal versus General Anesthesia on Quality of Life in Women Undergoing Cesarean Delivery on Maternal Request. Cureus. 2018; 10(12): e3715. doi:10.7759/cureus.3715 

1. Páez L. JJ, Navarro V. JR. Anestesia regional versus general para parto por cesárea. Rev Colomb Anestesiol. 2012;40:203–6. doi:10.1016/j.rcae.2012.06.001 

1. Wiggans S, Ekambaram R and Cross R. Regional anesthesia for caesarian section (and what to do when it fails). Obstetric Anesthesia, 2013; 14(8): 328-330. doi:10.1016/j.mpaic.2013.05.006