Editor—Caesarean section is the most commonly performed surgical procedure in obstetrics. Evidence from the Hospital Episode Statistics and anaesthetic survey of the National Health Service activity collected as part of the accidental awareness during general anaesthesia (5th National Audit Project [NAP5]) suggests that 8–10% of all Caesarean sections performed in UK utilise a general anaesthetic.1 , 2 The WHO declared a global pandemic of coronavirus disease 2019 (COVID-19) in March 2020.3 Since the onset of COVID-19, recommendations suggest the use of neuraxial anaesthesia if possible over general anaesthesia for Caesarean section to avoid the risks of aerosolisation associated with tracheal intubation and extubation.4 , 5 General anaesthesia for Caesarean section in the current pandemic poses risks for all healthcare staff and can impact utilisation of personal protective equipment for the hospital. We investigated whether general anaesthesia rates at our tertiary obstetric unit (10 000 deliveries and 2600 Caesarean sections annually) had changed since March 2020 with the emergence of COVID-19.
Anaesthetic information for all Caesarean sections undertaken at our unit between April 1, 2020 and May 31, 2020 was reviewed from electronic records. We specifically looked to determine the general anaesthesia rate for different categories of Caesarean section (proposed by the Royal College of Obstetricians and Gynaecologists) within that period.6 We then compared the general anaesthesia rates with the similar period in the preceding 2 yr (2018 and 2019). No ethical approval was needed as the review was classed as an audit as per the Royal College of Anaesthetists (RCoA) standards.7 Data are presented as frequency (%) and analysed using χ2 independence, Fisher's expanded exact P-values, percentage difference, and 95% confidence interval (CI) with P<0.05 (two sided) as significant.
The number of Caesarean sections increased by 4.3% (95% CI: 1.3–7.4; P=0.015) during the 2020 period (Table 1 ). There was a change in rates of general anaesthesia (P=0.0042). The rate for the previous 2 yr was 7.5%, and this decreased significantly to 3.3% in 2020, representing a reduction of 4.2% (95% CI: 1.7–6.6; P=0.0016) during the pandemic. There was a change in the distribution of general anaesthesia rates in categories with respect to the total number of Caesarean sections (P=0.022). There was also a change in the distribution of categories for Caesarean section with respect to delivery rates (P=0.037). General anaesthesia rates stratified by category suggest reductions for Categories 2 and 3 Caesarean sections (P<0.05). Nine of the 459 Caesarean sections tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (1.96%), and all of them had neuraxial anaesthesia. Our hospital met all the RCoA suggested standards for general anaesthesia rates, both before (2018–9) and during the SARS-CoV-2 pandemic.
Table 1.
Rates of deliveries, general anaesthesia, and categories of Caesarean sections from April 1 to May 31, 2020. Data presented as n (%). *†Fisher's expanded P-values are presented. ‡Categories of Caesarean section 1–4 are percentages of total number deliveries per year (n=4300; χ2: 16.04; degrees of freedom: 8). ¶General anaesthesia rates in Categories 1–4 are based on the total Caesarean sections per year (n=1329; Fisher's expanded exact). §General anaesthesia rates are percentages stratified in each category (Fisher's expanded exact test).
| Year | 2018 | 2019 | 2020 | P-value |
|---|---|---|---|---|
| Deliveries total, n | 1484 | 1461 | 1355 | |
| Caesarean section total | 431 (29.0) | 439 (30.1) | 459 (33.9) | 0.015* |
| General anaesthesia total | 29 (6.7) | 36 (8.2) | 15 (3.3) | 0.0042† |
| Categories 1–4 Caesarean section | 0.037‡ | |||
| General anaesthesia in Categories 1–4 Caesarean section | 0.022¶ | |||
| Category 1 | ||||
| Caesarean section | 116 (7.7) | 126 (8.6) | 105 (7.7) | |
| General anaesthesia | 15 (12.9) | 22 (17.5) | 12 (11.4) | 0.41§ |
| Category 2 | ||||
| Caesarean section | 81 (5.5) | 77 (5.2) | 103 (7.6) | |
| General anaesthesia | 4 (4.9) | 8 (10.4) | 2 (1.9) | 0.044§ |
| Category 3 | ||||
| Caesarean section | 30 (2.0) | 26 (1.8) | 37 (2.7) | |
| General anaesthesia | 4 (13.3) | 1 (3.8) | 0 (0.0) | 0.045§ |
| Category 4 | ||||
| Caesarean section | 204 (13.7) | 210 (14.4) | 214 (15.8) | |
| General anaesthesia | 6 (2.9) | 5 (2.4) | 1 (0.5) | 0.12§ |
Our single-centre audit is one of the first to highlight a reduction in the frequency of administration of general anaesthesia for all categories of Caesarean section during the pandemic. The significant change in distribution of general anaesthesia rates for Caesarean section possibly suggests greater awareness of risks posed by an aerosol-generating procedure amongst multidisciplinary obstetric team members, thereby influencing obstetric and anaesthetic decision-making for Caesarean section.
The reduction in general anaesthesia for Caesarean section during the pandemic could also be attributed to staffing changes introduced in our tertiary unit. Since the pandemic began, a 24/7 on-site anaesthetic consultant was established to support on-site anaesthetic trainees. A previous national survey of anaesthetic activity in obstetrics (NAP5) revealed that anaesthesia for 23% of Category 1 Caesarean sections in the UK was delivered by trainees out of hours with distant supervision possibly contributing to the high ‘avoidable’ general anaesthesia rates.2 We feel that the staffing changes introduced have led to: (i) enhanced situational awareness, team working, and communication with obstetricians, leading to appropriate and timely decision-making for Caesarean section; and (ii) improved direct and indirect supervision of anaesthetic trainees providing them with more educational and training opportunities to improve both their general anaesthesia and neuraxial anaesthesia techniques and decreased failure rates.
General anaesthesia rates for Caesarean section have declined markedly in the developed world over the last two decades. We feel COVID-19 has given obstetric anaesthetists in our tertiary unit an opportunity to drive down general anaesthesia rates for Caesarean section further, as is evident from our audit. Previous studies have highlighted that general anaesthesia for Caesarean section, with known risks of difficult or failed intubation, aspiration, and accidental awareness, is associated with a higher maternal mortality and morbidity (increased blood transfusion, surgical site infection, pain, venous thromboembolism, and length of stay) especially when undertaken in an emergency setting.8 , 9 Thus, a safe reduction in general anaesthesia rate for Caesarean section (partly caused by COVID-19) is desirable, is in the ‘best interests of mothers’, and is a welcome sign for all personnel in the operating theatre environment who may feel vulnerable during an aerosol-generating procedure. Whether anaesthetists can sustain this reduction in general anaesthesia rates, and translate this reduction into improving maternal outcomes and morbidity needs to be researched further.
We recommend that all obstetric units monitor their general anaesthesia rates for Caesarean section as part of quality improvement programmes. Changes in rate can then lead to analysis of contributory factors and quantification of changes in maternal morbidity and mortality associated with the general anaesthesia rates.
Declarations of interest
MC has editorial board roles with the European Journal of Anaesthesiology, British Journal of Anaesthesia, and International Journal of Obstetric Anesthesia. No other conflicts of interest exist.
References
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