General anesthesia for Cesarean delivery: can interinstitutional variation in practice offer deeper insights into our choice of anesthetic modality?

Excerpt

In modern anesthesia practice, neuraxial anesthesia is considered the gold standard to facilitate Cesarean deliveries (CDs).¹ Experts suggest that, with the known morbidity of general anesthesia (GA) coupled with the acknowledged challenges of the obstetric airway, all possible alternatives should be considered before choosing GA for CD.² What is the basis for such strong wording? A study of anesthesia-related deaths during obstetric delivery in the USA from 1979 to 1990 indicated that most maternal deaths were due to complications of GA.³ These stark results prompted decades-long efforts to improve the safety and decrease the use of GA for CD in favour of neuraxial techniques. Corroborating the practice change, a subsequent analysis showed anesthesia-related case-fatality rates during CD decreased from 2.9 per million in 1979–1990 to 1.2 per million in 1991–2002.⁴ In fact, the rates of GA for CD at a tertiary care hospital from 2000 to 2005 became as low as 0.5–1%; so low, that there was an observed lack of exposure of trainees to obstetric GA.⁵ Approximately ten years later, large retrospective database studies in the USA reported a slight rise in GA use for CD to approximately 5.8%.⁶ Evidently, circumstances where GA is necessary for CD, for maternal or obstetrical indications, will continue to exist. …