By: 12 August 2013

There is an increasing need for safe emergency anaesthesia as cases of emergency caesarean section (CS) continue to rise, say experts speaking at Euroanaesthesia, the ESA’s annual congress.

Dr Geraldine O’Sullivan, a clinician for obstetric anaesthesia at Guy’s and St Thomas’ NHS Foundation Trust in London, discussed how in the UK between 25-30 percent of deliveries are by CS, well above the WHO recommended rate of 15 percent (England 25 percent, Scotland/Wales 26 percent, Northern Ireland 30 percent, UK overall 25 percent). The 25 percent overall rate in the UK is made up of approximately 15 percent emergency CS, and 10 percent elective CS. Back in 1990, just 11 percent of UK births were CS, made up of five percent elective and six percent emergency.

“Other countries in Europe are experiencing similar issues to varying degrees and we need to ask why this is happening,” says O’Sullivan, who is also on the Board of the ESA. “Reasons could include better intra-partum foetal monitoring, fears of medico-legal claims, and, maternal demand. Whatever the cause for the rise in the CS rate, it is likely that in the near future, performance indicators will be devised for hospitals to help explain and evaluate that hospital’s CS rate.”

Maternal demand is perhaps the most controversial aspect of increasing rates of CS. The private sector has a higher rate than the public health system (in the region of 50 percent for private UK hospitals, and even higher in countries such as Brazil where the private sector CS rate is 70 percent). “There is also a knock-on effect for future pregnancies, since once a woman has undergone one CS, she is then at greater risk of having an emergency CS in the next pregnancy, though in most cases she would demand another elective CS anyway,” says O’Sullivan. “Even for those women who have chosen vaginal birth following a previous CS, around half will end up having a CS.

“The increased CS rate is putting anaesthesia, obstetric, and midwife teams under much greater strain at a time when there are increasingly reduced resources across healthcare systems in Europe.” The UK experiences 700,000 births per year, so O’Sullivan said even a small reduction in the UK-wide CS rate of 25 percent would cause large reductions in costs, since each CS costs the UK National Health Service (NHS) approximately £500 to £1000 extra compared with a vaginal delivery.

Emergency (unplanned) cases of CS, which account for 66 percent of all caesareans in the UK, are associated with a higher morbidity and mortality than a planned CS. This mortality has been shown to be higher if a woman has a general as opposed to an epidural or a spinal anaesthetic for her CS. “Women who require an emergency CS during labour, but who have already had an epidural catheter sited during the labour, are in a good position to receive emergency anaesthesia for CS, since stronger drugs can be injected down the epidural,” says O’Sullivan. “The use of these drugs, which are essentially stronger solutions of the drugs used for pain relief in labour, means that the mother can be ready for her emergency surgery within 10-12 minutes of the anaesthetist being informed that emergency delivery is required.”

Dr Matt Wilson from the National Institute for Health Research (NIHR) clinician scientist and senior Llecturer in anaesthesia at the University of Birmingham, also spoke at the event, naming advancing maternal age and improved obstetric monitoring as reasons for this trend.

“Crucially, since women who have previously delivered by CS are more likely to do so for further pregnancies, the trend becomes self-sustaining. There is good evidence to suggest that vaginal birth after CS is declining,” said Wilson.

“Maternal cardiac disease is itself more likely to result in delivery by CS, and is now a primary cause of maternal mortality, reflecting this population shift,” he added.

“There is compelling evidence that maternal obesity creates an additional risk of unplanned intervention.” He refers to a recent report by the UK Royal College of Obstetricians and Gynaecologists (RCOG) that cited an observational study demonstrating a linear relationship between body-mass index and CS rate.

Wilson also says that substantial advances have been made in the effectiveness and provision of epidural analgesia have been made over the past few decades. Large, well-conducted clinical trials have confirmed that epidural pain relief does not increase the likelihood of CS. Whilst providing better pain relief, Wilson will say there is no evidence that refinements of epidural technique such as ‘patient-controlled epidural analgesia’ have had an impact on delivery mode.

The UK’s National Health Service (NHS) has adopted a categorisation system of urgency of unplanned CS to systemise the response of care teams and facilitate audit. Wilson says this has proven a mixed blessing, with the potential for ‘category creep’ and as yet, little evidence that achieving ‘decision-to-delivery’ time targets influence neonatal outcomes, even in the most urgent CS.

“Haemorrhage remains the principle cause for maternal admission to intensive care and there are several new interventions, including targeted coagulation therapy and intra-operative red cell salvage which, whilst promising, are yet to be proven by randomised trials,” concludes Wilson.