A retrospective review of 10-year trends in general anesthesia for cesarean delivery at a university hospital: the impact of a newly launched team on obstetric anesthesia practice

Abstract

Background: The indications for general anesthesia (GA) in obstetric settings, which are determined in consideration of maternal and fetal outcome, could be affected by local patterns of clinical practice grounded in unique situations and circumstances that vary among medical institutions. Although the use of GA for cesarean delivery has become less common with more frequent adoption of neuraxial anesthesia, GA was previously chosen for pregnancy with placenta previa at our institution in case of unexpected massive hemorrhage. However, the situation has been gradually changing since formation of a team dedicated to obstetric anesthesia practice. Here, we report the results of a review of all cesarean deliveries performed under GA, and assess the impact of our newly launched team on trends in clinical obstetric anesthesia practice at our institution.

Methods: Our original database for obstetric GA during the period of 2010 to 2019 was analyzed. The medical records of all parturients who received GA for cesarean delivery were reviewed to collect detailed information. Interrupted time series analysis was used to evaluate the impact of the launch of our obstetric anesthesia team.

Results: As recently as 2014, more than 10% of cesarean deliveries were performed under GA, with placenta previa accounting for the main indication in elective and emergent cases. Our obstetric anesthesia team was formed in 2015 to serve as a communication bridge between the department of anesthesiology and the department of obstetrics. Since then, there has been a steady decline in the percentage of cesarean deliveries performed under GA, decreasing to a low of less than 5% in the latest 2 years. Interrupted time series analysis revealed a significant reduction in obstetric GA after 2015 (P = 0.04), which was associated with decreased use of GA for pregnancy with placenta previa. On the other hand, every year has seen a number of urgent cesarean deliveries requiring GA.

Conclusions: There has been a trend towards fewer obstetric GA since 2015. The optimized use of GA for cesarean delivery was made possible mainly through strengthened partnerships between anesthesiologists and obstetricians with the support of our obstetric anesthesia team.

Keywords: Cesarean delivery; General anesthesia; Multi-disciplinary collaboration; Obstetric anesthesia; Placenta previa.

Fig. 1

Yearly change in the total number of all deliveries and cesarean deliveries (%) in the years from 2010 to 2019. The annual number of cesarean deliveries has been increasing in concert with an increasing number of total deliveries. In the latest 7 years, approximately one-third of parturients underwent cesarean delivery at our institution

Fig. 2

Yearly change in the number and percentage of cesarean deliveries that required general anesthesia. Previously, cases requiring general anesthesia (GA) accounted for more than 10% of the annual number of cesarean deliveries, peaking at 14.5% in 2012. Since then, we have seen a declining trend in the percentage of cesarean deliveries requiring GA, decreasing to a low of less than 5% in 2018 and 2019

Fig. 3

Interrupted time series with comparison between pre- and post-intervention period. The time series of quarterly changes in the percent of cases using general anesthesia (GA) from January 2010 to December 2019 were generated to provide a compassion before and after the intervention. The data show a level change in the proportion of GA cases following the launch of our obstetric anesthesia team in 2015. The blue dots in the post-intervention period 2015–2019 are all positioned below the line (red dashed line) representing the pre-existing trend seen during the pre-intervention period 2010–2014. Interrupted time series analysis revealed that the percent of GA cases was significantly decreased in the post-intervention period (P = 0.04). No significant change in slope was found between pre- and post-intervention (P = 0.74)

Fig. 4

The number and percentage of parturients with placenta previa who received general anesthesia for elective or emergent cesarean delivery in 2010–2019. Before 2015, the annual number of parturients with placenta previa (PP) who underwent elective or emergent cesarean delivery under general anesthesia (GA) exceeded 15, accounting for more than 40% of total GA cases. However, there has been a marked decline since 2015 both in the number and proportion of cesarean deliveries for parturients with placenta previa that were conducted under GA

Fig. 5

Blood loss during cesarean delivery under general anesthesia in parturients with placenta previa. Each red circle represents a case of placenta previa (PP) conducted under general anesthesia (GA). During the study period, 9 cases with an intraoperative blood loss of more than 4000 mL were recorded

Fig. 6

The number and percentage of urgent cesarean deliveries that required general anesthesia in 2010–2019. The annual number of cesarean deliveries that required urgent administration of general anesthesia (GA) remained rather small before 2013. Although varying from year to year, there were annually about 7 urgent cases in the past 7 years

Fig. 7

The relationship between decision to delivery interval and neonatal umbilical arterial pH. There were 59 urgent cesarean cases in the study years 2010 to 2019, including two cases of twin deliveries. Decision to delivery interval (DDI) was not determined in two cases, and neonatal umbilical arterial pH (UApH) was not recorded in four cases. Analysis of a total of 55 cases suggested a slight inverse correlation between DDI and UApH