Category‐1 caesarean section: when time matters

In skating over thin ice our safety is in our speed – Ralph Waldo Emerson 1803–1882 The global trend in favour of caesarean section has substantially changed health care policies and has left a deep impact on women’s attitudes and perceptions of childbirth. These days, the World Health Organization’s recommendation of limiting the caesarean section rate to 10–15% [1] appears to be a thing of the past, virtually invalidated by both current obstetric practice and maternal requests for abdominal delivery in the absence of a medical indication (caesarean section on request). Actual caesarean section rates have even hit the headlines of prestigious newspapers and are referred to as breaking news by mass media from around the world. They all join in a chorus, the soundtrack of which does not dissimulate overt criticism by pointing out that ‘Caesarean births are at a high in U.S.’ (The New York Times, March 23, 2010), that ‘C-section rates around globe [are] at “epidemic” levels’ (Associated Press, January 12, 2010) and that the ‘C-section epidemic hits China…’ (Shan Juan (China Daily), January 14, 2010); statements that are closely related to the question ‘Are C-sections too common?’ (ABC News, March 10, 2010). According to the NHS Index of National Maternity Statistics, there was an increase in the total caesarean section rate in England from approximately 12% to 25% between 1990 and 2009 [2]. Yet, in some maternity units taking care of high risk pregnancies and operating as referral centres, caesarean section rates exceeded 30%. These figures are comparable with those from the US where the caesarean section rate has risen by 53% since 1996, reaching 32% in 2007, the highest figure ever reported for this country [3]. This surge in caesarean section rates was observed in all US states and included all gestational and maternal age groups as well as all ethnicities. However, caesarean section rates are still higher in China, Vietnam and Thailand, where they account for 46%, 36% and 34% of all deliveries [4]. These numbers clearly indicate that anaesthesia for caesarean section forms an increasingly important part of our practice. They also imply that the number of emergency caesarean sections is steadily increasing, since the split between elective and emergency caesarean section rates has virtually remained unchanged over the last two decades, at least as far as the UK is concerned [5]. Eventually, general anaesthesia may again be gaining some ground in a setting that has seen an apparently unstoppable trend towards regional anaesthesia techniques, a trend supported by recommendations of many professional bodies such as the National Institute for Health and Clinical Excellence (NICE), which has stated that ‘women who are having a caesarean section should be offered regional anaesthesia because it is safer and results in less maternal and neonatal morbidity than general anaesthesia [Grade-A recommendation].’ [6]. All too often, lack of time is the common denominator of non-elective emergency caesarean sections classified as category-1 to category-3 caesarean sections [7]. As a consequence, general anaesthesia may be preferred over regional for these surgical interventions. This has been corroborated by a recent national survey of anaesthetic and perioperative management of category-1 sections in the UK, which showed that the median (IQR [range]) general anaesthetic rate was 51% (29–80% [6–100%]) [8]. Bearing in mind findings published by audits of maternal mortality such as the Confidential Enquiries into Maternal Death (CEMD) [9] and of morbidity such as the American Society of Anesthesiologists’ Closed Claims database [10], the magnitude of the risks and pitfalls associated with general anaesthesia for caesarean section becomes blatantly obvious. In this issue of Anaesthesia, Kinsella et al. [11] present a case series of 25 patients anaesthetised using the previously described technique of ‘rapid sequence spinal’ [12] in category-1 caesarean section. Being aware that the risk of bad outcomes and catastrophic complications is omnipresent when providing general anaesthesia to patients undergoing caesarean section, the rapid sequence spinal approach in this setting is not only promising but may prove to be the safer approach for the mother without unduly jeopardising neonatal outcome. It is quite obvious that the promising results collected in this small case series should be corroborated by further studies that include larger numbers of patients, allowing more conclusive conclusions. The findings of this series does not yet provide sufficient information for a more definitive determination of the benefit-risk balance of a rapid sequence spinal in the case of a category-1 caesarean section. Therefore, this technique should not be propagated without a caveat in clinical practice. This caveat implies, as pointed out by the authors, a number of important provisions that refer to the team caring for the patient, the physician providing anaesthesia, the patient presenting for caesarean section, the fetal condition and the institutional background. For general anaesthesia, rapid sequence induction and intubation is currently being challenged, questioning the balance between the intrinsic hazard of hypoxia due to apnoea and the potential risk of aspiration [13]. In consequence, some authors suggest gentle bag-mask ventilation before intubation in order to avoid significant arterial desaturation [14]. A rapid sequence induction and a rapid sequence spinal have some analogous basic elements in common, in that the rapid sequence of procedural tasks should not distract from the primary goal of providing adequate and safe anaesthesia for caesarean section, irrespective of the technique used. Therefore, the threshold for abandoning intubation attempts during a rapid sequence induction in favour of mask ventilation should be low; analogously, the threshold for abandoning a rapid sequence spinal in case of difficulties should also be low. In our institution, the practice of spinal anaesthesia differs quite a bit from that in St. Michael’s Hospital, Bristol, UK, in as far as some elements of the rapid sequence spinal technique are already common practice. In particular, an alcohol-based rapid disinfectant is used for hand rubbing in order to avoid the time-consuming procedure of handwashing, and improving compliance with basic rules of hygiene. In addition, our practice does not mandate the wearing of a sterile gown for neuraxial anaesthesia, while wearing of a facemask is compulsory. Finally, access to opioids such as fentanyl or sufentanil is facilitated by eliminating the time-consuming prerequisite of signing out medications in the operating theatre. Regional anaesthesia also carries risks in the setting of obstetric anaesthesia. Between 1995 and 2007 the National Health Service Litigation Authority handled 841 anaesthesia-related claims, almost half of which (366/841, 44%) were related to regional anaesthesia [15]. Of these, about half (186/366) were related to obstetric anaesthesia and analgesia. A high proportion of claims also referred to inadequate block and pain during caesarean section or labour (31%), nerve damage (21%) and back pain (10%). Injury related to sensory block (10%) and dural tap (6%) were less common [15]. Therefore, the occurrence of pain during caesarean section in three patients (12%) in the sample presented by Kinsella et al. should not be light-heartedly disregarded when evaluating a rapid sequence spinal for emergency caesarean section. The anaesthetist taking the challenge of this technique should be prepared to assume responsibility for both maternal complaints and critical neonatal outcome. Therefore, excellent communication with the parturients, the obstetricians, the midwives and the neonatologists is of paramount importance when implementing this novel strategy into clinical practice. Recently, high-fidelity simulation has been shown to improve not only procedural, but also non-technical, skills. Performance in weaning patients from cardiopulmonary bypass was significantly better after high-fidelity simulation compared with teaching in interactive seminars [16]. Without any doubt, category-1 caesarean section is as much a ‘high-stakes clinical setting’ as cardiac surgery. Therefore, we believe that rapid sequence spinal anaesthesia should be included in simulation sessions, as recommended in the latest CEMD report [9]. We are grateful to Allison Dwileski for editorial assistance in Basel. No external funding and no competing interests declared.