Obstetric Anesthesia: Leading the Way in Patient Safety

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Key points

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    The field of anesthesiology has been a leader in patient safety.

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    Obstetric anesthesia has a long history of advancing patient safety and continues to lead in this area.

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    Team training is a major advance in patient safety for the labor and delivery suite.

Although anesthesiologists comprise only approximately 5% of physicians practicing in the United States, the specialty is acknowledged as a leader in patient safety.1 The practice of anesthesia is far safer today than it was just a few decades ago.

Safer and more effective labor analgesia

In the 1970s and 1980s neuraxial analgesia for labor was typically provided with a labor epidural, which was dosed every few hours when the desired anesthetic effect wore off. The local anesthetic of choice was often concentrated enough to cause a solid sensory block, but also caused a significant degree of motor blockade and marked hypotension. The methods for administering labor analgesia have changed numerous times in the ensuing 40 years. Now continuous infusions of dilute local anesthetics

Safer treatments for hypotension associated with neuraxial blockade

Hypotension is much less commonly associated with the provision of neuraxial analgesia for labor as compared with spinal anesthesia for cesarean delivery. Treatment, however, is still necessary especially when dense neuraxial blocks to provide anesthesia for cesarean deliveries reach higher dermatomal levels and are associated with sympathetic blockade. Beginning in the 1970s, ephedrine became the predominantly used pressor agent to treat neuraxial technique-related hypotension. This preference

Advances in spinal and epidural techniques for operative deliveries

The 1980s saw a dramatic increase in the use of neuraxial blockade for cesarean delivery. At first, the use of neuraxial anesthesia was not nearly as safe as it is today. During this period, bupivacaine was introduced into obstetric practice with the promise of better sensory blockade and less motor block. Unfortunately, several cases of maternal mortality occurred when large bolus doses of 0.75% epidural bupivacaine administered through an unrecognized intravascular catheter caused a cardiac

Decreasing the incidence of postdural puncture headache through improved technology

The anesthesia community has also been at the forefront of developing and using spinal needles that are associated with dramatically lower incidences of postdural puncture headache. Postdural puncture headaches, which have been called “the worst common complication in obstetric anesthesia,”16 have almost disappeared following spinal anesthesia because of the use of these new spinal needles. These needles, commonly termed “pencil point,” spread rather than cut dural fibers.17 In addition, a

Safer parental agents for labor analgesia

Although the safest and most effective method for providing labor pain relief is a neuraxial block,19 not every parturient can receive one. This is related to staffing issues,20 patient refusal, or contraindications to these blocks (eg, the parturient with a coagulopathy). If analgesia is requested in such a patient, the current choices for parenteral medications are far superior compared with those that were offered in the past. Whereas pethidine (Demerol) given intramuscularly was the gold

Improved safety of general anesthesia in obstetrics

General anesthesia has long been feared as a leading cause of maternal mortality. Ongoing morbidity and mortality studies identify cases of failed intubation and aspiration associated with general anesthesia.25 General anesthesia increases the risk for death at the time of cesarean delivery. Before the availability of modern tools that increase the safety of airway management, general anesthesia was associated with 16.7 times the mortality of neuraxial anesthesia.6 These tools include better

Improved education and the use of simulation including team training

Simulation-based education has improved the safety of obstetric anesthesia practice.30 The use of general anesthetics for cesarean delivery has significantly decreased.31 As a result, there is less opportunity for tomorrow’s practitioners to learn how to manage difficult airways and failed intubations. Simulation-based training is perhaps the only way to prepare them to deal with these rare, life-threatening emergencies.26 The effectiveness of this training is demonstrated by Goodwin and French,

Reduction of operating room–related infections

Health care–associated infection affects approximately 10% of patients admitted to acute care facilities, accounting for approximately 500,000 infections annually.41 Labor and delivery suites and ORs are no exception. There are numerous studies that show that ORs are not sterile environments and that some postoperative infections are traced to contamination in the OR.42 Anesthesiologists’ inadequate hand hygiene has been shown to play a role in the transmission of infection.43 Studies have now

Future directions

The practice of obstetric anesthesia is now remarkably safe in the United States and other high-income countries. Anesthesia-related mortality is now exceedingly rare. Unfortunately, data suggest that the gains in safety that have occurred over the past half century in high-income countries have not been realized in low- and middle-income countries. A recent meta-analysis by Sobhy and colleagues45 estimated that in these countries the risk of death from anesthesia is 1.2 per 1000. Anesthesia

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    Disclosure Statement: No conflicts.

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