Central neuraxial blockade is the most commonly used anesthetic technique for elective cesarean delivery.¹ A decided delivery time of 30 minutes after diagnosis has been accepted as a standard for emergency cesarean delivery in cases where there is an imminent threat to fetal life.² This has forced anesthesiologists to administer general anesthesia under severe time constraints so as to enable obstetricians to deliver the baby at the earliest.³ Unfortunately, handling the obstetric airway has its own potential hazards and failure to take control of the airway has been recognized worldwide as one of the common causes for maternal morbidity and mortality.¹ Given this background, several studies have evaluated the potential benefits of delivering the fetus within 30 minutes of diagnosing fetal distress. Presumably, a delayed delivery could result in deleterious effects on the fetus. Such effects on the newborn can be assessed using APGAR scores at 1 minute and 5 minutes, umbilical cord pH at birth, and rates of admission to special care units or neonatal intensive care units.

Although many studies have shown that a decision to have the delivery time less than 30 minutes is not always achievable, they have also shown that a relative delay in delivering the baby did not result in increased neonatal morbidity.2, 4 Literature evidence, in fact, suggests that delivering the baby within 30 minutes of making a diagnosis of fetal distress and deciding that an emergent operative delivery is essential can actually be harmful to the fetus.4, 5 Their argument is that the ensuing atmosphere of panic inadvertently created by professional caregivers can result in a catecholamine rush in the mother, which can compromise fetal circulation. Limitation of time may result in minimal possible time being spent with the mother by both obstetricians and anesthesiologists. This haste may lead to suboptimal care toward improving the mother’s condition and fetal environment by the obstetrician. From the anesthesiologist’s perspective, making hasty decision may result in inadequate evaluation and improper patient preparation, which may result in unanticipated or unexpected problems contributing to maternal morbidity or mortality, which might influence the fetal outcome also.⁶ Literature evidence further suggests a decision to have the delivery time 75–90 minutes can result in adverse fetal outcome.2, 5

In my experience, of the 384 patients who underwent emergency cesarean section in view of significant fetal distress, I have provided spinal anesthesia for 367 patients. Of these 367 patients, there were two patients requiring general anesthesia in view of failed spinal anesthesia. None had any adverse fetal outcome. Two babies were electively intubated immediately after birth as they had been diagnosed to have congenital diaphragmatic hernia. Two babies needed tracheal intubation for suction of meconium; however, neither needed prolonged intubation/oxygen therapy in the postoperative period. Regarding maternal problems, one mother had transient asystole after spinal anesthesia that was reverted to sinus tachycardia with atropine. Nine mothers had transient postdural puncture headache that was self-limiting. Of the 17 patients who received general anesthesia as first technique of choice, 9 had maternal problems indicative of general anesthesia, such as acute respiratory distress syndrome, altered coagulation parameters, spinal deformity, and severe preeclampsia with unknown coagulation status. In one patient with severe preeclampsia, although the quick preoperative airway evaluation was not suggestive of any anticipated difficult airway, we had problems in intubating resulting in a near cardiac arrest situation before securing the airway with the aid of intubating laryngeal mask airway. Of the 8 patients who received general anesthesia despite no maternal indication (obstetrician distress was the main reason for proceeding with general anesthesia), one patient had undiagnosed subglottic stenosis who was completely asymptomatic preoperatively that resulted in significant maternal morbidity and prolonged intensive care unit stay (article in consideration for publication in another journal). Therefore, based on the existing evidence and my own personal experience, I propose a three-pronged approach to tackle fetal distress. First, extension of the “decision to delivery time to less than 60 minutes.” This would be feasible in most obstetric setups and provide sufficient time to optimize the maternal condition and possibly the fetal environment as well. Second, anesthesiologists should follow the dictum of “mother first, regional fast” where emphasis is laid on ensuring the safety of the mother, while an experienced anesthesiologist is scrubbed up and waiting to provide spinal anesthesia as soon as the patient arrives to the operating room. Needless to say, this would be influenced by avoiding general anesthesia wherever possible and rapidly establishing regional anesthesia (spinal anesthesia/activating a preexisting working epidural catheter).⁷ Third, measures to improve the fetal environment and optimizing the mother’s condition (improving the hemodynamics with fluids and drugs, administering oxygen, preventing aortocaval compression, tocolysis, and so on) should be instituted in the time available. I am confident that this strategy would be beneficial for both the mother and the fetus in most cases other than exceptional cases where an immediate general anesthesia may be warranted. In our institution, we have been practicing spinal anesthesia for all fetal distress cases (along with institution of other measures mentioned above) unless the mother’s condition warrants general anesthesia.

To conclude, I wish to draw attention of both anesthesiologists and obstetricians to the fact that better fetal outcome does not depend on how fast the baby is delivered but on how well the baby is delivered.

†There are no conflicts of interest for this article.

‡There was no source of funding for this work.