Episode #292 Forty Years Of Obstetric Anesthesia Progress And The Work Ahead

Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel, and I am your host. Thank you for joining us for another show. The 2025 APSF Stoelting Conference focused on obstetric anesthesia safety and today, we are returning to this topic. There have been many improvements in obstetric anesthesia safety with advances in monitoring, airway management, neuraxial techniques, and multidisciplinary care. But there is still more work to be done to address the very real threats to patient safety from maternal morbidity disparities, hemorrhage, hypertension, and more.

Before we dive further into the episode today, we’d like to recognize Blink Device Company, a major corporate supporter of APSF. Blink Device Company has generously provided unrestricted support to further our vision that “no one shall be harmed by anesthesia care”. Thank you, Blink Device Company – we wouldn’t be able to do all that we do without you!”

Our featured article today is “40 Years of Progress in Obstetric Anesthesia Safety: Milestones, Challenges, and Future Directions” by Zawierucha and colleagues. To follow along with us, head over to APSF.org and click on the Newsletter heading. The first one down is the current newsletter from October 2025. From there, scroll down to our featured article today. I will include a link in the show notes as well.

To help kick off the show today, we are going to hear from one of the authors. Let’s take a listen now.

[Zawierucha] “Hi, my name is Lauren Crosby Zha, and I’m an anesthesiologist at Foothills Medical Center in Calgary, Canada. At the time of writing the article, I was the Obstetric Anesthesia fellow at Massachusetts General Hospital.”

[Bechtel] I asked Lauren why she feels so passionate about this area of anesthesia. Here is what she had to say.

[Zawierucha] “ I am passionate about maternal safety because as an anesthesiologist, my role is to keep patients safe. Every person we look after is somebody, someone, and our job is to make sure we return them safely back to their loved ones. But this goal is even more poignant in childbirth when there’s another little life depending on our patient.

A woman’s experience in childbirth can have a lasting impact on their sense of self, their relationships with their children and partners who depend on them and their long-term physical and emotional wellbeing. And that is why I feel that doing our part to keep them safe in this experience is so important.”

[Bechtel] Thank you so much to Lauren for helping to introduce this important topic. Now, its time to get into the article.

We are seeing an important theme in the October 2025 Newsletter articles with significant patient safety improvements over time and obstetric anesthesia has followed the trend with a significant decrease in obstetric anesthesia mortality and anesthesia-related complications during the latter half of the last century. Guidelines for best practice and standards of excellence in obstetric anesthesia continue to help keep patients safe. Once again, we also see that more work needs to be done since maternal mortality is a leading cause of death in women between the ages of 20-44years old. In the United States, the maternal mortality rate is the highest of any high resource country on this metric. According to the Pregnancy Mortality Surveillance System, anesthesia-related complications are the least common cause of maternal mortality, but there are important threats to anesthesia patient safety that we need to address such as patient complexity, workforce demands, and racial and socioeconomic disparities. Anesthesia professionals can make a real difference with our expertise in acute care medicine, maternal physiology, and patient safety.

Let’s take a look at some of the milestones in the field of obstetric anesthesia. First up, we have advances in neuraxial anesthesia safety. This ushered in a move away from general anesthesia towards neuraxial anesthesia, which led to a significant decrease in anesthesia-related maternal mortality. In addition, labor analgesia became safer with lower-dose local anesthetic concentrations and lower total local anesthesia doses, which decreased the risk for high neuraxial block, local anesthetic toxicity, and operative vaginal delivery. Spinal headaches were much more common in the past, but this has changed with the use of noncutting needles that reduced the risk of post dural puncture headache, failed regional anesthesia, and local anesthetic exposure. Research has helped to guide anesthesia professionals in the operating room when it comes to vasopressor administration to treat spinal-induced hypotension and use of the lowest effective opioid dose to enhance postpartum analgesia while minimizing adverse effects on the mother and baby. Specialized education and training in obstetric anesthesia fellowships have been shown to reduce the use of general anesthesia for cesarean delivery, which may also help to reduce maternal mortality. Keep in mind that there are risks with neuraxial anesthesia and anesthesia professionals need to remain vigilant for high neuraxial block and bradyarrhythmia which may lead to maternal cardiac arrest. Medication safety is a critical component of safe obstetric care. The use of tranexamic acid on labor and delivery floors increased following the Woman Maternal Antifibrinolytic Trial. We have talked about the rare but catastrophic wrong drug, wrong route medication error when tranexamic acid is administered into the intrathecal space in place of local anesthetic. If you haven’t done so already, we hope that you will remove any tranexamic vials or ampules from the operating room and check out episodes #288 and 289 of this podcast for more information about this drug error and what you can do to make sure that it is a never event.

Another major improvement is the decline in fatalities from aspiration and failed airway management. Video-laryngoscopy, aspiration prophylaxis, difficult airway algorithms, and obstetric-specific guidelines for airway management have helped to improve the safety of general anesthesia for pregnant patients. As you can see, anesthesia and analgesia for childbirth whether with neuraxial or general anesthesia has become quite safe.

What about non-anesthesia causes of maternal morbidity and mortality? We talked about this quite a bit in our 5-part Stoelting Conference podcast series starting with episode #276 and we hope that you will check it out if you haven’t done so already. Anesthesia professionals have played an important role in this area as well by championing implementation of maternal early warning systems and recognition and management of the main contributors to maternal morbidity and mortality including hemorrhage, hypertensive crisis, sepsis, venous thromboembolism, and heart failure. Are you using the care bundles that have been developed by the Alliance for Innovation on Maternal Health and the California Maternal Quality Care Collaborative? These have been shown to be cost effective in reducing severe maternal morbidity. Protocols for postpartum hemorrhage have widespread application since even in low resource settings, they have been shown to improve outcomes. Anesthesia professionals must be active participants in the care bundles for hemorrhage and hypertensive disorders to help keep patients safe and improve outcomes.

Multidisciplinary teamwork is needed to implement these maternal care bundles. Teamwork, effective communication, and coordination are also necessary on labor and delivery units when it comes to preoperative and pre-procedural checklists and huddles as well as debriefings following critical events. Reporting and reviewing patient safety concerns on a peer-protected Quality Assurance committee provides mutual learning, opportunities to address systems-level challenges, and support to the potential “second victims” following critical events.

Finally, just like in other areas of anesthesia care, the use of simulation to practice recognizing and managing peripartum emergencies is vital to improve the performance of the multidisciplinary team and support a culture of safety. Are you doing simulation training with your colleagues on the labor and delivery units at your institution? If not, this may be a good goal for the new year.

Now, it’s time to review the challenges to safe obstetric anesthesia care. Current challenges include increasing patient complexity, maternal mental health conditions, racial disparities in outcomes, and geographic and socioeconomic barriers to care. You may have been thinking that patients have more significant comorbidities when they present to the maternity unit and the literature supports this. There is a increasing prevalence of chronic diseases in obstetric patients. Risk stratification may be helpful here. The Obstetric Comorbidity Index or OB-CMI, is a validated, numerical scoring system that uses maternal comorbidities to assess and predict the risk of severe maternal morbidity and mortality. Anesthesia professionals are called upon to be perinatal consultants for risk stratification, antenatal planning, and optimization to help determine the level of maternal care and improve maternal outcomes. We also need to pay close attention to the postpartum time period since over 50% of maternal deaths occur between 7 and 365 days postpartum. There is an opportunity here for anesthesia professionals to make a big difference by recognizing patients at high risk for postpartum decompensation and escalate care accordingly.

Another threat to safe obstetric care is maternal mental health conditions including suicide and overdose or poisoning related to substance use disorder, which has moved up to become one of the leading causes of maternal mortality, right up there with hemorrhage, cardiac conditions, infection, and thrombotic embolism. Anesthesia professionals can make a difference by recognizing high-risk patients, implementing trauma-informed care, and addressing pain management.

We know that maternal mortality remains unacceptably high among racial and ethnic minority groups. Black women in the United States have a significantly higher rate of severe maternal morbidity and are overrepresented among maternal deaths. It is alarming that black women are more likely to die from cardiac and coronary conditions, are less likely to receive appropriate care escalation for postpartum hemorrhage, and are less likely to receive an epidural blood patch for post dural puncture headache.

There is also the threat that social determinants of health continuing to negatively impact maternal morbidity and mortality. In low and middle-income countries, geographic and socioeconomic barriers to care leader to higher rates of preventable deaths. In high-income countries, there are also barriers to accessing safe maternal healthcare from legislative barriers including bans or restrictions on abortion care. Commitment to advocacy, workforce planning, and anesthesia training is necessary to help address these inequities in global health care settings.

Going forward, obstetric anaesthesia professionals will need new tools in their safety toolkit to address healthcare inequity and increasing patient complexity. These tools may include point of care ultrasound to help reduce procedural complications related to neuraxial anaesthesia, assess aspiration risk, and help with the management of cardiopulmonary complications in unstable patients. New risk predictive tools driven by AI, big data models, and biologic markers may help to personalize risk stratification, coordinate early intervention, and manage scarce resources. We may also be reaching into our toolkits and pulling out wearable technology for our patients to help provide close post-partum care and even home monitoring to help tackle the problem of postpartum morbidity and mortality. Finally, using consensus based standardized care like enhanced recovery after caesarean delivery may help to address racial disparities and continue to drive safer and effective care going forward.

The authors leave us with this alarming statistic that for every maternal death, there are 70-80 cases of severe morbidity at the time of hospitalization and this definition does not include morbidity in the prenatal or postpartum period. There has been significant improvement in anaesthesia-related complications, but there is still more work to be done to advance maternal care of all women. The authors leave us with this call to action: “Adhering to standards of best practice, leveraging new technologies in obstetrics and anaesthesia, and continuing to foster a culture of safety can help to ensure continued forward progress.”

We made it to the end of the article, but before we wrap up for today, we are going to hear from Lauren again. I also asked her what she hopes to see going forward. Let’s take a listen to what she had to say.

[Zawierucha] “ Maternal mortality and preventable deaths remain unacceptably high among racial minority groups, and I hope to see anesthesiologists leveraging their experience in critical care and patient safety to make strides towards closing these gaps in outcomes.

We can do this in clinical settings with championing protocolized care, like the AIM safety bundles and at the system level through maternal mortality review committees and other initiatives.”

[Bechtel] Thank you so much to Lauren for contributing to the show today. We are looking forward to the future with improved implementation of patient safety initiatives to help move the needle on maternal outcomes and improve obstetric anesthesia safety.

If you have any questions or comments from today’s show, please email us at [email protected]. Please keep in mind that the information in this show is provided for informational purposes only and does not constitute medical or legal advice. We hope that you will visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today.

We are excited to announce the 2026 APSF Trainee Quality Improvement Patient Safety Recognition Program. This program hosts tracks for physician anesthesiology residents nurse anesthesia students, and student anesthesiology assistants. Eligible participants include current trainees and those who graduated in the immediately prior academic year. This is your chance to demonstrate your program’s work in patient safety and QI initiatives. The winner in each track will be notified around August 1, 2026 and the APSF will sponsor the winners to attend the 2026 Stoelting Conference in National Harbor Maryland to share your work and network with attendees. Here’s how to submit your work. You may independently determine he best media for submitting your project summary. Acceptable formats include a document or an audio or video recording. The submission deadline is June 1, 2026 so you have some time to get organized and excited to submit your best work and support he APSF vision. Check out the show notes for more information about the submission process. You can also email [email protected] with any questions.

Thanks for listening to the Anesthesia Patient Safety Podcast. If today’s discussion sparked a thought, reinforced a practice, or helps you care for your next patient on labor and delivery a little more safely, we’d love for you to stay connected. Subscribe wherever you get your podcasts, share this episode with a colleague, and join us as we keep learning from each other—because patient safety doesn’t end when the case does.

Until next time, stay vigilant so that no one shall be harmed by anesthesia care.

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