This historical landmark paper demonstrated the terribly-higher maternal mortality during cesarean section performed under general anesthesia vs regional anesthesia in the United States from 1979-1990.

This resulted in the oft-quoted statistic of being '...17 times more likely to die under a GA cesarean section than epidural or spinal.'

It is very important to note that this is a historical article and that the demonstrated very high mortality was greatly contributed to by a culture tolerating inexperienced anesthesia residents performing GA CS after-hours with limited senior support.

Hawkins followed up this study with another in 2011: Anesthesia-related maternal mortality in the United States: 1979-2002. This reassuringly showed a much improved GA CS maternal mortality from 1997-2002 (although still higher than regional CS).

The important take-home from this paper is that a GA cesarean section increases the risk of serious airway events, and if this is not managed by experienced and appropriately trained anaesthetists/anesthesiologists, will result in maternal deaths.

summary

• J L Hawkins, L M Koonin, S K Palmer, and C P Gibbs.
• Department of Anesthesiology, University of Colorado Health Sciences Center, Denver 80262, USA. jlhawkms@ski.uhcolorado.edu
• Anesthesiology. 1997 Feb 1;86(2):277-84.

BackgroundAnesthesia-related complications are the sixth leading cause of pregnancy-related death in the United States. This study reports characteristics of anesthesia-related deaths during obstetric delivery in the United States from 1979-1990.MethodsEach state reports deaths that occur within 1 yr of delivery to the Centers for Disease Control and Prevention as part of the ongoing Pregnancy Mortality Surveillance. Maternal death certificates (with identifiers removed) matched with live birth or fetal death certificates when available from 1979-1990 were reviewed to identify deaths due to anesthesia, the cause of death, the procedure for delivery, and the type of anesthesia provided. Maternal mortality rates per million live births were calculated. Case fatality rates and risk ratios were computed to compare general to regional anesthesia for cesarean section deliveries.ResultsThe anesthesia-related maternal mortality rate decreased from 4.3 per million live births in the first triennium (1979-1981) to 1.7 per million in the last (1988-1990). The number of deaths involving general anesthesia have remained stable, but the number of regional anesthesia-related deaths have decreased since 1984. The case-fatality risk ratio for general anesthesia was 2.3 (95% confidence interval [CI], 1.9-2.9) times that for regional anesthesia before 1985, increasing to 16.7 (95% CI, 12.9-21.8) times that after 1985.ConclusionsMost maternal deaths due to complications of anesthesia occurred during general anesthesia for cesarean section. Regional anesthesia is not without risk, primarily because of the toxicity of local anesthetics and excessively high regional blocks. The incidence of these deaths is decreasing, however, and deaths due to general anesthesia remain stable in number and hence account for an increased proportion of total deaths. Heightened awareness of the toxicity of local anesthetics and related improvements in technique may have contributed to a reduction in complications of regional anesthesia.

This article appears in the collection: Landmark obstetric anesthesia papers.

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