E EDITORIAL
Excess in Moderation: General Anesthesia for
Cesarean Delivery
Joy L. Hawkins, MD
T
he ultimate goal for anesthesiologists is to provide
the safest and most effective care for their patients.
Parturients on the labor and delivery unit represent a
group with perhaps the highest stakes for achieving excel-
lent patient satisfaction and a safe outcome for mother and
newborn. In this issue of Anesethsia & Analgesia, Stourac
et al.1 report a fascinating national survey of current anes-
thesia practices for cesarean delivery in the Czech Republic
and identify areas for improvement. The survey contains a
wealth of useful and interesting information and begs the
question: how should the authors and readers proceed from
here? As the authors point out, the definition of normal
obstetric anesthesia practice varies widely from country to
country, so how do we identify the optimal way to care for
parturients during cesarean delivery?
A prominent finding in the survey was that general
anesthesia was used in 44.4% of cesarean deliveries. The
authors conclusions imply that the high rate may be a nega-
tive quality indicator. This is certainly a significantly higher
rate of general anesthesia than is seen in the United States or
in many Western European countries, but how much is too
much general anesthesia? What should the rate of general
anesthesia for cesarean delivery be, and what evidence can
we use to determine that threshold? If 44.4% is too much, is
25% a reasonable goal? Does 15% indicate even better qual-
ity care? Is 5%, the often-quoted rate in the United States,
too low? Is the rate of general anesthesia for cesarean deliv-
ery even a valid quality indicator? There is no evidence-
based method to determine the appropriate rate of general
anesthesia for cesarean delivery or even data to provide an
acceptable range.
The strong preference of anesthesiologists for neuraxial
anesthesia for the obstetric patient is unique. In no other
patient group do anesthesiologists strive to avoid general
anesthesia for major abdominal surgery. There certainly
are both real and theoretical reasons to prefer neuraxial
From the Department of Anesthesiology, University of Colorado School of
Medicine, Aurora, Colorado.
Accepted for publication January 11, 2015.
Funding: None.
The author declares no conflicts of interest.
Reprints will not be available from the author.
Address correspondence to Joy L. Hawkins, MD, Department of Anesthesiol-
ogy, University of Colorado School of Medicine, 12631 East 17th Ave., Mail
Stop 8203, Aurora, CO 80045. Address e-mail to Joy.Hawkins@ucdenver.edu.
Copyright 2015 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000000651
June 2015 Volume 120 Number 6 www.anesthesia-analgesia.org 1175
Copyright 2015 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
anesthesia over general anesthesia for cesarean delivery,
such as maternal bonding with the newborn, the potential for
skin-to-skin contact immediately after delivery, less blood
loss, better postoperative pain management with fewer
opioid side effects, and possibly a lower risk of thrombotic
complications. However, in some emergency situations, or
in the presence of specific maternal comorbidities, general
anesthesia may be preferable to a neuraxial technique for
cesarean delivery. These situations might include umbilical
cord prolapse, significant placental abruption, prolonged
fetal bradycardia in the absence of labor neuraxial analgesia,
and maternal cardiac disease, such as critical aortic stenosis
or significant pulmonary hypertension. Thus, the appropri-
ate choice of anesthetic should be decided on a case-by-case
basis depending on maternal and fetal conditions.
The main reason anesthesiologists avoid general anes-
thesia in favor of neuraxial is because of the concern for
difficult airway management. In the 1970s and 1980s, this
was a valid concern when much higher mortality rates
were reported during general than neuraxial anesthesia.2
However, more recent evidence from the Centers for Disease
Control and Prevention,3 the Serious Complication Registry
(SCORE) from the Society for Obstetric Anesthesia and
Perinatology,4 the American Society of Anesthesiologists
(ASA) Closed Claims Project,5 and The Doctors Company,
a medical malpractice insurance company,6 have not found
difficult airway management or pulmonary aspiration
to be major sources of obstetric anesthesia complications.
Much has changed in obstetric anesthetic practice since the
1970s and 1980s that make general anesthesia safer, at least
in the United States and other high-income countries. We
have better equipment to manage the unexpected difficult
airway, including supraglottic airway devices, video laryn-
goscopes, promulgation of difficult airway algorithms, and
multidisciplinary simulations and team training to improve
performance when a crisis occurs. For the subset of patients
for whom general anesthesia really might be riskier because
of a suspected difficult airway or significant obesity, or who
might be at increased risk for emergency cesarean delivery,
an epidural catheter can be placed early in labor for use in
the event of intrapartum cesarean delivery. Documentation
of a preanesthetic airway examination might be a more rel-
evant quality indicator than the rate of general anesthesia.
The SCORE project described anesthetic practice and
outcomes by reviewing 307,000 deliveries from 30 centers
in the United States between 2004 and 2009.4 There were
no cases of pulmonary aspiration, and although the rate
of failed intubation was 1 in 533, there were no hypoxic
 E Editorial
cardiac arrests secondary to a lost airway although these
low rates could be explained by selection bias. Instead, the
most common serious complications in the SCORE project
were related to neuraxial anesthetics. High neuraxial block
attributable to unrecognized spinal catheters or spinal anes-
thesia induced after a failed epidural block occurred with
an incidence of 1 in 4336.
In the most recent ASA Closed Claims database report
on obstetric anesthesia claims, maternal injuries related to
neuraxial anesthesia, such as nerve injury, headache, pain
during surgery, and emotional distress, make up the major-
ity of cases.5 Many of the claims for pain and emotional dis-
tress were related to inadequate neuraxial blocks that were
used for surgical procedures, perhaps because the anesthe-
sia provider was reluctant to convert to general anesthesia.
When a neuraxial anesthetic does not provide an adequate
surgical block, failure to induce general anesthesia will lead
to physical pain and emotional distress for the mother, and
may increase the risk of aspiration if deep sedation is used
with an unsecured airway. There is potential morbidity for
the mother and liability for the anesthesiologist. In these cir-
cumstances, failure to convert to general anesthesia can be
considered poor quality care. Other claims against the anes-
thesiologist for adverse neonatal outcomes were often related
to delay of delivery when excessive time was taken to initi-
ate neuraxial anesthesia rather than proceeding with induc-
tion of general anesthesia.5 Anesthesiologists should move
beyond the single issue of airway management as the entire
basis for our anesthetic choices for cesarean delivery. General
anesthesia should not be perceived as poor quality care. In
some circumstances, it might be the best choice and may be
just as safe as neuraxial anesthesia in modern practice.3
Even though there are appropriate indications for gen-
eral anesthesia, and I do not believe the general anesthe-
sia rate should be used as a quality indicator, I agree with
the authors of the Czech survey that a general anesthesia
rate of 44% is high, if only because these women are not
benefiting from the real advantages of neuraxial compared
with general anesthesia. How might anesthesiologists in
the Czech Republic lower the rate of general anesthesia?
In the survey, the indication for general anesthesia differed
depending on whether the cesarean delivery was urgent or
elective. In emergency cases, urgency was the indication in
67%, patient refusal in 15%, and failure of neuraxial anes-
thesia in 4%. In elective cases, patient refusal occurred in
64%, and failure of neuraxial anesthesia was the indication
in another 9%. Emergency and some urgent situations may
be indications for general anesthesia for cesarean delivery.
Expeditious initiation of neuraxial anesthesia may also be
appropriate even when there is compromise to the mother
or fetus, but excessive delay if the procedure is technically
difficult or prolonged may harm the mother or newborn.
However, the most common reasons for general anesthesia
in elective cases were patient refusal and failure of neuraxial
anesthesia. Why were patients refusing neuraxial anesthe-
sia for elective cesarean delivery?
The high rate of patient refusal of neuraxial anesthesia
and the relatively high failure rate of epidural anesthesia
may be more concerning than the common use of general
anesthesia. Anesthesiologists and obstetricians perceive
many benefits to neuraxial anesthesia for cesarean delivery,
1176
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and it is up to physicians to communicate these benefits to
their patients. However, neuraxial anesthesia does have a
quantifiable failure rate, whereas general anesthesia is vir-
tually 100% reliable. This survey found an 8% failure rate
for epidural anesthetics. A failed block and intraoperative
conversion to general anesthesia is discouraging for the
patient, the obstetrician, and the anesthesiologist, especially
if preceded by the patient experiencing pain. Neuraxial
anesthetic techniques require extensive training, can be
technically challenging, and once chosen for cesarean deliv-
ery, require a great deal of interpersonal interaction with the
patient and her support person in the operating room. This
can be mentally taxing compared with the general operat-
ing room, where there is only 1 person requiring attention,
and an unconscious patient at that. One might say that gen-
eral anesthesia is easier for the anesthesiologist, especially if
there is little opportunity to maintain neuraxial anesthesia
skills in ones practice.
To increase the use of neuraxial anesthesia in any prac-
tice, and to take advantage of all its benefits, a number of
obstacles can be reduced or removed.
1. Antepartum patient education efforts should begin
in the obstetricians office. Anesthesiologists can
develop a simple 1-page explanation of neuraxial pro-
cedures, their benefits, and their rare complications.
2. Ongoing education must be pursued so that anes-
thesiologists stay current with neuraxial techniques,
medications, and troubleshooting when neuraxial
blockade is less than perfect. Task trainers and simu-
lation allow providers to practice their techniques in a
safe, nonpatient-care environment.
3. Repetition increases comfort with any procedure. In
this survey, only 40.5% of deliveries included anesthe-
sia services, mainly for cesarean delivery rather than
labor analgesia. As neuraxial labor analgesia becomes
more common, anesthesiologists will be more com-
fortable with block initiation and management and
more likely to consider using epidural anesthesia
for cesarean delivery when the epidural catheter is
already in place and working well.
4. Access to adjuvants that improve the quality of neur-
axial blocks can be increased. Anesthesiologists should
recognize that neuraxial fentanyl and sufentanil have
been widely used for decades despite lack of official
approval by national agencies such as the Food and
Drug Administration in the United States. National
anesthesiology organizations should explore the rea-
son for the high cost of preservative-free morphine.
Despite higher costs, its superior postoperative pain
control may offset its initial cost by reducing the use
of parenteral opioids, decreasing the need for nursing
interventions, and improving patient mobilization.
5. Although epidural bupivacaine and ropivacaine can
be effective surgical anesthetics, their long onset time
and duration are rarely optimal for cesarean delivery,
and their systemic toxicity is more serious than other
local anesthetics. Using 2% lidocaine for elective or
urgent surgeries (and if it can be made available, 3%
2-chloroprocaine for truly emergent cases) should
improve throughput and efficiency in the obstetric
operating rooms.
anesthesia & analgesia
 Excess in Moderation
With an understanding of current practice in the Czech
Republic, the authors are in an excellent position to lead
development of evidence-based guidelines for obstetric
anesthesia practice, ideally produced jointly with their
national organization of obstetricians. Practices such as pre-
operative airway evaluation and documented Mallampati
score (documented in only 37.5% of cases), timely admin-
istration of antibiotic prophylaxis (used in only 86% of
cesarean deliveries) before skin incision (done in only 11%),
reversal of nondepolarizing muscle relaxants (55% did not
reverse), and use of pencil-point needles for spinal anes-
thesia (used in only 60%) would quickly lead to improved
patient outcomes.
The authors are to be commended for their dedication
to improving anesthetic care for parturients in the Czech
Republic. Although attention will likely be focused on the
high use of general anesthesia for cesarean delivery, there
are other more important goals for obstetric anesthesiolo-
gists to strive for than just increased use of neuraxial anes-
thesia. The perioperative surgical home is a popular concept
being developed in the United States; perhaps anesthesiolo-
gists can work toward developing the peripartum obstetric
home.7 Coexisting medical conditions are the most common
cause of maternal mortality in the United States,8 and anes-
thesiologists are adept at optimizing medical comorbidities
in the perioperative period. Techniques are just techniques;
anesthesiologists practice medicine and have the ability to
impact the entire continuum of care. E
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DISCLOSURES
Name: Joy L. Hawkins, MD.
Contribution: This author helped write the manuscript.
Attestation: Joy L. Hawkins approved the final manuscript.
This manuscript was handled by: Cynthia A. Wong, MD.
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