Anesthesia for Cesarean Delivery—Regional or General?

INTRODUCTION

The 2018 cesarean delivery rate in the United States was 31.9%, down slightly from its peak in 2009 of 32.9%. The most common indications for cesarean delivery include prior cesarean delivery, labor dystocia, abnormal/indeterminate fetal heart rate tracings, fetal malpresentation, multiple gestation, and fetal macrosomia. The cesarean delivery rate is likely to increase further because women are requesting an elective cesarean delivery even for their first delivery (also known as “cesarean delivery on maternal request”). Currently, this incidence is quoted at 2.5% of all US births. The American College of Obstetricians and Gynecologists (ACOG) has opined that it is acceptable for an obstetrician to perform an elective cesarean delivery if the patient understands the risks and benefits of performing the elective cesarean delivery vs. attempting a vaginal delivery. In the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended. Additionally, the number of women attempting a trial of labor after cesarean (TOLAC) has also decreased. The selection of regional anesthesia or general anesthesia (GA) for cesarean delivery depends on the experience of the anesthesiologist, past medical history of the patient, and the indication for and urgency of the cesarean delivery. The anesthetic considerations will be discussed separately for the elective case, where there is little controversy that regional anesthesia is the preferred technique, and the emergent case, where controversy exists.

OPTIONS/THERAPIES

When choosing regional anesthesia or GA for cesarean delivery, one must consider both maternal and neonatal outcomes. Maternal outcome studies have primarily focused on maternal mortality, and neonatal outcome studies have focused on umbilical cord pH, Apgar score, the need for ventilatory assistance at birth, and neurobehavior scores.

EVIDENCE