Obstetrical anesthesia presents unique challenges. Labor begins without warning, and anesthesia may be required within minutes of a full meal. Vomiting with aspiration of gastric contents is a constant threat. The usual physiological adaptations of pregnancy require special consideration, especially with disorders such as preeclampsia, placental abruption, or sepsis syndrome.
Of all anesthesia-related deaths in the U.S. from 1995 to 2005, 3.6 percent were in pregnant women (Li and co-workers, 2009). Anesthesia complications caused 1.6 percent of pregnancy-related maternal deaths in the United States from 1991 through 1997 (Berg and co-workers, 2003). Of the 855 pregnancy-associated deaths described by Mhyre and colleagues (2007), anesthesia was related to 2.3 percent. Data from the Pregnancy Mortality Surveillance Program of the Centers for Disease Control and Prevention indicate that anesthesia-related maternal mortality rates have declined significantly (Chang and colleagues, 2003). Supportive of this, Deneux-Tharaux and colleagues (2005) reported that there were no maternal deaths from anesthetic complications in Massachusetts and North Carolina during 1999 and 2000. Finally, Kuklina and co-workers (2009) reviewed obstetrical morbidity in the U.S. and reported a decrease in severe anesthesia complications—2 per 1000 in 1999 compared with 1.1 per 1000 in 2005.
Several factors have contributed to improved safety of obstetrical anesthesia. Hawkins and colleagues (1997b) and D'Angelo (2007) concluded that the most significant factor is the increased use of regional analgesia. Increased availability of in-house anesthesia coverage almost certainly is another important reason (Hawkins and associates, 1997a, b; Nagaya and associates, 2000).
Obstetrical Anesthesia Services
The American College of Obstetricians and Gynecologists (2002) reaffirmed its joint position with the American Society of Anesthesiologists that a woman's request for labor pain relief is sufficient medical indication for its provision. The American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (2007) have specified that it is the responsibility of the obstetrician or certified nurse-midwife, in consultation with an anesthesiologist, if appropriate, to formulate a suitable plan for pain relief. Identification of any of the risk factors shown in Table 19-1 should prompt consultation with anesthesia personnel to permit a joint management plan. This plan should include strategies to minimize the need for emergency anesthesia in women for whom such anesthesia would be especially hazardous. To help guide these decisions, the American Society of Anesthesiologists Task Force on Obstetrical Anesthesia (2007) has recently updated its Practice Guidelines.
Table 19-1. Maternal Risk Factors That Should Prompt Anesthesia Consultation |Favorite Table|Download (.pdf)
Table 19-1. Maternal Risk Factors That Should Prompt Anesthesia Consultation
- Marked obesity
- Severe edema or anatomical abnormalities of the face, neck, or spine, including trauma or surgery
- Abnormal dentition, small mandible, or difficulty opening the mouth
- Extremely short stature, short neck, or arthritis of the neck
- Serious maternal ...