A Review of the Impact of Obstetric Anesthesia on Maternal and Neonatal Outcomes

Abstract

Obstetric anesthesia has evolved over the course of its history to encompass comprehensive aspects of maternal care, ranging from cesarean delivery anesthesia and labor analgesia to maternal resuscitation and patient safety. Anesthesiologists are concerned with maternal and neonatal outcomes, and with preventing and managing complications that may present during childbirth. The current review will focus on recent advances in obstetric anesthesia, including labor anesthesia and analgesia, cesarean delivery anesthesia and analgesia, the effects of maternal anesthesia on breastfeeding and fever, and maternal safety. The impact of these advances on maternal and neonatal outcomes is discussed. Past and future progress in this field will continue to have significant implications on the health of women and children.

Figure 1

Subject areas of obstetric anesthesiology research advancements on maternal and neonatal outcomes over the last decade. Bubble size indicates relative impact of each topic.

Figure 2

Epidural analgesia technique (A) vs. combined spinal epidural technique (B). In epidural analgesia, the epidural space is located using an epidural needle, by a loss-of-resistance technique. A 19–20 gauge epidural catheter is threaded into the space and used to dose medications. In combined spinal-epidural analgesia, the epidural space is located in the same fashion, and prior to threading the epidural catheter, a small 25–27 gauge spinal needle is introduced through the epidural needle to puncture the dura and to bolus a single dose of local anesthetic with or without opioid. The spinal needle is removed and a 19–20 gauge epidural catheter is threaded for subsequent dosing. Figure from Eltzschig HK, Lieberman ES, Camann WR. Regional anesthesia and analgesia for labor and delivery. N Engl J Med. 2003 23;348:319–32.

Figure 3

Maintenance of epidural analgesia by continuous epidural infusion vs. programmed intermittent epidural bolus. Differences in spread (blue pigment) of equivalent doses of local anesthetic over course of 1 hour in (A) continuous epidural infusion and in (B) programmed intermittent epidural bolus are depicted.

Figure 4

Post-cesarean delivery pain management options and anatomical locations of peripheral nerve blocks.

Figure 5

Maternal Early Warning Criteria. The presence of any of these abnormal “triggers” should activate an immediate bedside evaluation by a physician or qualified clinician who can accelerate care toward prompt diagnosis and treatment of the underlying condition. Considerations for potential differential diagnoses are noted. Any nurse or clinician who is concerned about maternal status should feel empowered to raise concerns up the chain of command to achieve an appropriate response. Mechanisms for escalating notifications should be established. The triggers listed are not comprehensive for all possible obstetrical scenarios and are not intended to replace clinical judgement. Adapted from Mhyre JM, D’Oria R, Hameed AB, Lappen JR, Holley SL, Hunter SK, Jones RL, King JC, D’Alton ME: The maternal early warning criteria: a proposal from the national partnership for maternal safety. Obstet Gynecol 2014 124: 782–6.