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At time of C section, the kind of anesthetic agent that we use just can't be minimized or trivialized. Everything that we do has some potential impact to the child, whether that's general or regional anesthesia. Each one of them have their potential issues with neonatal physiology. General anesthesia does cross into the placenta, into the fetal bloodstream, of course, and subsequent vasodilation of the fetal vasculature can actually decrease fetal systemic vascular resistance, which can lead to decreased perfusion pressure and oxygenation. So that's one of the concerns there with general anesthesia, in addition to the sedative effects of the anesthetic agent itself on the child and leading to mild and typically transient respiratory depression. But regional anesthesia isn't benign necessarily either, because that sympathetic blockade from a regional block can be associated with maternal hypotension, which of course affects uiplacental blood flow and therefore that can produce fetal hypoxia. Nothing is free. Which brings us into this publication that we're going to highlight, Podcast Family. I am both astounded but not surprised at how fast medical news sites and or social media can pick up on a publication and distribute it like wildfire. And that's good for things that are novel, things that are game changers, things that are either new on the market or off the market, that can either improve patient outcome, the patient experience, reduce risk, whatever, all those things are good. We should do that. We should distribute a good piece of information out to impact care. That's good. However, sometimes things get put out there so fast that really is not all that new information, but more importantly can get misapplied. And that's where things can get hokey. So let me explain. We are recording this on November 19, 2025, but on November 12, 2025, just a week ago in the journal Anesthesiology there was a new publication that took a 30 years of data like guys from 1990 to 2000s. Okay, 30 years of data on general anesthesia and here it is. Don't lose this immediate neonatal issues. In other words, APGAR scores, which we know are already problematic in and of themselves because there's intra observer variability and NICU admissions and it was very favorable towards that which we've actually already known. But wait, there's more. If you're thinking, I wish they would have looked at something more objective than just the apgar, they did. And it again was very reassuring. Quote, we found no difference in mean umbilical arterial or venous pH or the proportion of neonates with umbilical arterial ph less than 7.2. End quote. So they looked at that. That's good news. Again, helpful because it's more objective than something that's a subjective issue. Latken, Apgar. But it's good. It's good to reinforce what we've already is, that in the short term, for anesthesia purposes, at C section, it seems to be fine. That's good. However, when that gets misinterpreted as maybe we should do that for every C section. Now we got to go. Hold on, man. That. That's not what it meant. And we really need to kind of hold on there and pump the brakes a bit. Whoa, whoa, wait a minute. Wait a minute. Hold on. Wait a minute. Just a second. Yeah, because that is exactly the message that I got from a buddy of mine from the West Coast. So just let me set this up. I was on call last night. I'm on night shift this week. And so as I was coming home this morning to go into my hibernation state until I have to go back again, I received a text from a buddy of mine who was also on call, ironically on the west coast, and said, hey, Choppa, real quick, have you heard of some new study out of anesthesia saying that C sections should be done under general anesthesia? Huh? And so I responded, Wait, wait, wait, wait. What's going on here? I know. Whoa, pump the brakes, Bernard. So I said, did you read the study? Or. Or is that your interpretation of what you read? Or how do we get to this point? And very honestly, he said no. And you were going to ask me that. I didn't read it, but somebody told me about it, so I wanted to. To check with you. Well, first of all, yes, there's a study in anesthesiology that looked at general anesthesia and that showed favor favorable short term, short term neonatal issues. Right? So that's good news. However, that does not mean, nor did it imply that general anesthesia should be used for C section. Now, if you're thinking, well, why would somebody even consider that? Why would somebody interpret that in that way? Well, the truth is, there's plenty of data, and it's happened to us recently, where patients can experience discomfort under regional anesthesia at time of C section based on published data. Guys, one in six. One in six say they don't feel pressure. It's actually pain, and it's worse with a topped off epidural rather than a spinal. That's data. We know that. Okay? So in those, the Idea is to quickly convert with patient approval, of course, so that. To general, so that we can, you know, have a safer delivery and she not get PTSD from that. So we've known that. But rather than a conversion to that, there are patients who perhaps may want general anesthesia because of a bad experience in the past. They've felt pain in the past, they've got hardware in their spine, they've got spinal fusion from whatever condition, whatever. So in those cases, this study helps open up that conversation, although there's big gaps that remain. Now, let me just set this up, then we're done here with the intro. This new study from anesthesiology, from anesthesiology, again, short term neonatal issues at time of birth has big gaps, all right? And the gaps are things that we cannot miss. And there's three big issues here that we're going to talk about after the intro. Three big issues here. However, if a patient asks you, what about general anesthesia? Absolutely, guys, we've done this. We've gone elective general anesthesia for those issues that we've just discussed. We've had it both on patient who had a traumatic previous regional anesthetic experience. We've had those who've had hardware in their back. So we've done it even before this study came out because that's what this study says you can do. So all to say, if you haven't read the study itself, be careful what you hear by word on the street, because this is not saying that general anesthesia should be used over regional, simply that it can be a discussion when necessary. But gaps remain. Now, even though this study. Guys, we're going to be done here in just a minute. Even though this study was favorable, there are other studies on general anesthesia that are not so favorable also from this year. Now, these are kind of scary because one of them said that those patients who have a C section under general anesthesia have an increased risk of postpartum depression and or suicidality. And you're like, what? Guys, this just came out in September 2025, just two months ago. But that study has a lot of issues and that scares people who don't understand statistics. I'm going to tell you about that in just a minute because the confidence intervals and the odds ratios were not good. But yeah, that's the title of that publication. Oh, an association with general anesthesia at C section and postpartum depression and suicidality. It scares people. And that's wrong. There's another publication that came out earlier in this year in February 2025. And I'm going to give you that reference and it'll be in our show notes as well. That said. Oh, is general anesthesia at C section possibly linked to. To poorer developmental progress in the child? Guys, again, if you don't know statistics, that's going to scare you. That is not the case. I'll be very clear. General anesthesia has not been linked at time of C section to neurodevelopmental issues or postpartum depression or suicidality in all the other data. But this one piece From September of 2025 and this other piece from February 2025 confuse things if you don't understand statistics. So briefly, we're going to talk about those as the. Maybe. Hold on. Not so good. Or the questions that remain regarding general anesthesia at C section. I know. Whoa. Pump the brakes, Bernard. So, again, thank you to my buddy on the west coast who apparently was up at the same time I was during the night for that message. So to be clear, yes, there is a publication that was conducted by a great group of researchers. Guys, this is Penn Medicines, a great research group that took a look at anesthesia for C section in the journal Anesthesiology. We're going to tell you what it did say, what it didn't say, and what patients need to be aware about. The three big issues. Guys, three big issues. Should they go under general anesthesia that they need to be aware of. That's not in this publication. Three issues not in this publication that we need to address. All right, I think I've set it up enough. Man, that's a lot of stuff. I. I actually wasn't. I didn't think it was gonna go that far, but it did. But it had to be said, because general anesthesia as primary mode of pain control for C section. Hold on a minute. Whoa, whoa. Wait a minute. Wait a minute. Hold on. Wait a minute. Just a second. Yep. I think I've set it up enough. We will be right. This is Dr. Chapa's ob gyn no spin podcast. I know. Whoa. Pump the brakes, Bernard. All right, so first of all, why is this even a thing? Well, as we recently covered in an episode. Didn't we do that? I think we talked. We did because we had the C section. We were right before hysterotomy. She started complaining of pain. Traumatic for everybody. So it does happen. Based on the data, Guys. Not my opinion. Not in my anecdotal issue. Based on published evidence, it shows that up to one in six patients. Up to one in six women who are having a regional anesthetic, okay. Whether that's a spinal or a topped off epidural, one in six will experience some kind of pain. Okay, that's too high for me. Way too high for me. So this is a real issue now. Having pain and then converting to general, that's a no brainer. I mean, you got to do something. So I get that the bigger question is, should general be offered right off the chute at the beginning, at the start of a case for those patients who have high anxiety about it, those patients who've had previous poor experience, who have had PTSD from that, who have had that hardware in their back, as we've already said in the intro. Sure. And this new study says that at least in the immediate short term interval, spending 30 years of data, hey, babies did okay. And we've known that now patients who have repetitive exposure to general anesthesia during surgery, even that is a bigger unknown because that just doesn't happen that frequently. But maybe that potentially could lead to other issues. But that's not what we're talking about here. And even in that case, you gotta do what you gotta do. And if there's a maternal condition that needs general anesthesia, antepartum, I mean, please do that. But there's much less data there. Repetitive anesthesia exposure, antepartum, we're talking about briefly at time of C section. Okay, so one in six patients will experience some kind of pain with regional. And it seems to be worse with an epidural versus a one shot spinal. Okay, so be aware of that. So if they had an epidural and they're like, oh, we've topped it off, they'll be fine. Okay, well that, that should be good. But sometimes that's, that's not always effective. So just be aware of that. And those patients who have top off epidural, they tend to have a little bit more pain than those who have a spinal. That publication came out in April. Guys, this is April as an epub of 2025 officially out this summer. July of 2025 again in, in the journal Anesthesiology. The same journal, different article, right. The title of this was Intraoperative pain during Cesarean delivery under Neuroaxial Anesthesia. A systematic review and meta analysis. Of course. I'll put this link in our show notes. But it did show, it's very, it's very clear. The highest pool incidence of pain at about 33% was the topped off epidural. Okay, so it does happen. Spinal actually had the lowest pool incidence of pain at about 14%, but still that's 14%. So general anesthesia as a conversion, that's a no brainer. And those who may ask for that, we've got to stop saying, well, that's just crazy talk. I mean, you want to go under elective general anesthesia for your C section. I mean, typically we do regional. And that is true. That is the standard and the customer. But some of that also was birthed, no pun intended, was birthed out of societal pressures that. Well, don't you want to see your baby? I mean, surely you don't want to be asleep for that. Hey, I don't judge. Everybody's different. So if a patient says they want primary general anesthesia, this study, at least in the short term for neonatal wellness, is reassuring. Okay, now again, we didn't get into the two other publications just briefly knowing that they're jacked in the data because the numbers are really not that impressive for postpartum depression or suicidality, as well as the other publication that we talked about in February. That has to be explained by the numbers. Okay. What has to do with children's neurodevelopmental issues? Because both of those were kind of alarmist. But if you take a look at the odds ratio and the confidence intervals, you're like, dude, what? That's. That's not correct. And again, not only should you not misinterpret a. A well done study, you shouldn't misinterpret stats that really aren't that impressive to begin with. I know. Whoa, pump the brakes, Bernard. So we're going to get into those two other publications after we talk about this main publication from November of 2025. So November, move it back, go back a little bit to September, go back a little bit more to February. So three publications from this year talking about general anesthesia at C section. How about that? Well, where am. What? I've totally lost. None of that was planned. What am I doing now? Give me a second. Oh, yes. Okay, so let's do this. This current publication. So this study again, it's good, it's helpful. I'm glad we did this, but we kind of knew this already. I've chosen general anesthesia primarily when it's necessary in the past because we know that it's okay as short term exposure. Again, November 12, 2025, out of the journal Anesthesiology, the title was Neonatal Outcome with Regional versus general Anesthesia for Cesarean Delivery. This is a meta analysis of randomized controlled trials. Great. RCTs check. Meta analysis. Check. Spanned 30 years of data. Check how many studies. So 36 studies were included. And the total number of neonates that made up the pool was over 3,400. All right. To be exact, 3,456. 3,456. Very quickly, as you would expect, regional anesthesia tended to have a little bit higher apgars, but they weren't clinically significant. I mean, they were marginal. Plus, we already know that apgars don't really mean much because they're a little bit of intra observer variability. But more importantly, here's a big one, and this is really it. Quote, need for neonatal intensive care did not differ across anesthesia techniques. End quote. In other words, hey, APGAR score is not that big of a deal. Need for NICU wasn't difference between the two. Okay, great. That's it. That. That's all. That's, that's the result. And it's picked up like wildfire, guys. I read six different medical press sites that had, oh my God, no, no difference in neonatal outcome. And that's good. That's great. That is reassuring. But you know what would have been nice? It would have been nice to stratify length of anesthesia exposure. How long was a C section? Remember, these are all RCTs. All right? So regional versus general, and that's good. So overall, no increase in NICU admissions. Obviously, those that had general required a little bit more respiratory support as you brave off that gas in the child. But overall, no increase needed for NICU admission. But again, that's the question. Does it matter how long the kid is under general anesthesia for the section? Maybe that would have been nicer to take a look at that. But here's the important thing that that was kind of missed. I'm reading directly from the results here, guys, right? This is not my interpretation. My point is this. First point. Number one, general anesthesia. If you got to, then do it, it's going to be fine. All right? For C section, it's going to be fine. Although there is a higher need for respiratory support in the child, at least in the immediate birth interval, neonatal interval, but no NICU admission differences. So if you got to do it, do it. But here's the second take home message. Quote, according to this meta analysis, right, in their results section, all studies had high or unclear risk of bias, end quote. Huh? Yeah. So it was like, oh, we found no differences. But yeah, well, the studies all had a high risk of Bias or it was an unclear risk of bias. That's something that you can't discard. In short, the conclusion was regional anesthesia for cesarean delivery is associated with slightly higher APGAR scores and less frequent need for a neonatal respiratory support than general anesthesia. Additional studies are required to determine associations of anesthesia technique with need for intensive care and longer term outcomes. End quote. Yeah, totally true. That's right. That's the conclusion. That's it. Nowhere in there does it say, oh, this potentially should serve as a primary over regional because one out of six is going to feel some pain that's not in there. That was taken out of some commentaries for this where one of the authors correctly stated, hey, we're just opening up the doors, just opening up patience to having conversations for those who may be asking about general anesthesia to go if, hey, let's talk about it. It shouldn't be a taboo, it should be open for discussion. Knowing that we have more data that's necessary, especially for longer term issues, even though we have now, is extremely reassuring. Excluding the publication from September and and February of 2025 that we're about to get into, let me read you this quote from one of the authors associated with this in a commentary quote. For patients who are open to regional anesthesia, spinal or regional block remains great as first choice options. Yeah, totally true, he goes on to say, but having conversations with patients about general anesthesia doesn't need to be taboo. Patients deserve to know that they have options and our study helps provide the evidence to support those discussions. End quote. That's it. That's all it. That's all it said? That's all it was getting at. It didn't say we should do primary or repeat C sections under general electively for everybody. It just opened up the conversation. So once again, notice what this study did have and what it did. It didn't have any long term issues. I would have liked to see a little bit of stratification for time under general anesthesia, but nonetheless it is what it is. But knowing again that one out of six will have some kind of pain at C section, this is welcome news that at least in the short term APGAR scores, not that much of a difference. And while respiratory support is necessary a little bit more frequently, as expected with general, it didn't change NICU admissions, although the studies had a high risk bias. All right, so I tell you what, let's stop there for a minute. When I come back, we're going to get into the publication first. From September as we walk down the timeline, go backwards in time, showing a possible association with general anesthesia with postpartum depression and suicidality. That was in September 2025 in anesthesia and analgesia. And then we'll end this episode with February 2025 about a potential negative impact on neurodevelopmental progress in children exposed to general anesthesia. And while these sound alarming, if you understand statistics, they are not be very clear. This is not the universal thought on general anesthesia for cesarean delivery. We have no good quality studies that show that they are harmful either for postpartum depression or for suicidality or for neurodevelopmental delays. And these two publications, if you look at the odds ratio and confidence intervals, will explain just that. Let's take a little break and we'll come back and we'll wrap this up. You're listening to the ob gyn. No spin podcast. Whoa, whoa. Wait a minute. Wait a minute. Hold on. Wait a minute. Just a sec. All right, so now let's tackle September of 2025, because this was a little weird. Out of anesthesia and analgesia. The title is association of General Anesthesia for Cesarean Delivery with Postpartum Depression and Suicidality. Like, ooh, well, that's not good. No, it's not. But first of all, this is retrospective cohorts. Of course, retrospective. Gotta put it in perspective. There's some issue there. They looked at patients who had a C section. This is out of New York, under general anesthesia, and then looked at repeat admission within that postpartum year and. And. Or E.D. visits and. Or outpatient clinic visits for postpartum depression requiring medical therapy or readmission, and that included issues like suicidality. Okay, now, and those are big issues. The concern here is that if you just read the conclusion, which is, quote, use of general anesthesia for cesarean delivery is independently associated with a significantly increased risk of postpartum depression, requiring hospitalization and suicidality. It underscores. This is the conclusion, not me. It underscores the need to avoid using general anesthesia whenever possible and to address the potential mental health issues of patients after general anesthesia use. End quote. Wow. Okay, so, guys, I'm telling you, do you see the balance here? Now put this into perspective. The one that showed general anesthesia from a neonatal aspect, nothing bad. That was in November 2025, two months previous. We have authors saying, quote, it underscores a need to avoid using general anesthesia whenever possible. End quote. This is why. This is why research and physicians and Clinicians. Why we get frustrated. Okay, so you're like, well, that's terrible. I got this as issues. Wait a minute, wait a minute. Because you got to understand what the numbers look like. Nes. Obstetrical complications like blood transfusion, maternal morbidity, postpartum hemorrhage, preterm birth, stillbirth. All of those were included in the secondary review. Okay, so, yes, because that makes sense, right? What if it was a traumatic issue and they required general. That's obviously going to increase the risk of post trauma depression and suicidality. And that's true. But according to this calculation, general anesthesia was a independent risk factor for postpartum depression and suicidality. That's concerning. I'm not minimizing this, guys. This is a big deal. My point is, though, you gotta look at the numbers like, well, what are we talking about here? Well, let me, Let me give this to you just quickly, because I don't want to belabor this. The short of it is, stats matter here. Okay? So stats matter here. First of all, after matching and controlling for other issues, the incidence rate for Postpartum depression was 15.5 per 1000 person years for women who received regional anesthesia, and it was 17.5 per 1000 person years for those who received general anesthesia. That's a hazard ratio, adjusted of 1.12, y', all, 1.12. So you gotta remember this 2%, a odds ratio of 2 is a doubling, right? That's a double. That's a 100% increase. 1.12. As an adjusted ratio, it's 12%. Like, whoa. Well, that is big. Yes, it is big. But the confidence interval. Meaning, Remember, any confidence interval that crosses one means, yeah, maybe it's a chance issue. It's not real clear. And. Or if it's very broad, confidence intervals that also decrease accuracy. Okay, so the confidence interval of that was 0.97 up to 1.3. So it hovered all around 1. Confidence interval crossed 1. So again, just put it into perspective. I'm not minimizing that. Maybe there's some kind of association there with mental health, but not according to these stats. In terms of admission for postpartum depression, these authors found an adjusted hazard ratio of 1.38. 1.38. Again, that's a 38% increase. You're like, oh, well, that's a big deal. It is until you figure out that the confidence interval was 1.07 to 1.77. Again, hovers around one and pretty tight. Which means I don't Know what to do with that. The issue with suicidality, that was 1.45. Confidence interval again crossed 1 at 1.02 to 2.05. So both of those included 1. My point is, look how in one month, general anesthesia, I get in the limelight. Oh, this is great. No increase in NICU admissions. Two months ago you had these authors out of New York going, hey, what about our stuff? What about the potential for mental health issues after general anesthesia, even after adjusting for some bad issues? So I'm not minimizing what they found. They found true odds ratios above 1, but they were barely above 1. And the confidence interval crossed 1. But the conclusion says, oh, it underscores the need to avoid using general whenever appropriate. I think both of those publications send wrong interpretations. The general anesthesia is like, woo hoo, general anesthesia for everybody. It's Oprah. You get general anesthesia and you get general anesthesia, and you get general anesthesia. Wait a minute. It's a good alternative, but doesn't replace the first line as regional at all. The second thing is, yes, this is concerning, but those statistics, those numbers aren't all that impressive. Very similar to the publication in February 2025 that looked at the association of GA General Anesthesia for C section and subsequent developmental issues. Because if you just read the conclusion, it's a little scary. General anesthesia for cesarean delivery may be associated with with developmental disorders diagnosed within two to four years after birth. End quote. You're like, whoa, whoa, again, wait a minute. And you wanted me to use general anesthesia. Whoa, whoa, wait a minute, wait a minute, hold on, wait a minute, just a second again, statistics matter. So if you take a look at these stats here and you actually stratify that for how the kid did based on APGAR score. And again, we know APGAR scores got some issues. Quote, this association. Guys, I'm reading directly from this February publication of this year, this association was no longer present when the confounding effects of APGAR scores were included in the propensity score model. In other words, if you put it through a little wash of statistics, throw in some things called propensity scores, kind of match you with another cohort. Nah, maybe not so much. So again, great limelight on general anesthesia this month. But one from September saying, I don't know, even though the numbers aren't good, something to be aware of. And this one in February going, well, maybe it might could be linked to poor neurodevelopmental outcomes. But yeah, once you actually Take a look at some real accounting and stratification and match with controls. Yeah, probably not so much confusing. So here's the take home message and I'm gonna give you the three things that we need to keep in mind about general anesthesia and then we're done. So the take home message is general anesthesia as a one time exposure at C section. You gotta do what you gotta do safe, doesn't increase NICU admission, even though there's a high risk of bias, does not for the vast majority of the data, excluding this February publication, have anything to do with altered neurodevelopmental outcomes, and nor has it been shown to have a persistent negative effect on mental health. Because these numbers here aren't all that impressive. Okay, so based both guys, based both on retrospective studies and case cohorts, single short exposure of general anesthesia during C section have been reassuring. Okay, so to be very clear, these quick exposures have not consistently been linked to any clinically meaningful neurodevelopmental issues or mental health outcomes in a negative way in the mother. Okay, I just wanted to give you three different perspectives here, guys. From November, September and then February, all of this year on general anesthesia, do what you got to do. And I agree with one of those affiliated authors in that commentary that it just opens up the discussion if you really have to, and maybe pay attention to these things. If a patient had general anesthesia, make sure you have contact with her afterwards, make sure there's not a mental health issue, make sure that there isn't a pre existing mental health issue, which is what those authors recommended. Maybe ask for them, ask for that history beforehand, which we should do anyway and be prepared for that postpartum. But just things to be aware of. Three things that we need to keep in mind for general anesthesia at C section, then we're done. Number one, support person can't be there. So that's something the patient needs to know. Number two, unlike with a spinal or a whatever kind of regional block, or you can give a longer acting opioid analgesic that gives them some post op pain relief, that's not the case with general anesthesia. Okay? They wake up and they're awake. And unless you've given them some local or they've got a pain pump at the incision, you know, the pain control postpartum is a little bit different under general than if they had a block with a long acting opioid agent. And then the third, of course, which is the biggest issue is yeah, they can't see the child immediately at delivery. You go through all the pregnancy and then you can't see the child at birth. Those are the three big issues. A poor person post op pain control may be different than with a long acting agent in the epidural or subarachnoid space and then three is that they obviously can't see the child at time of delivery. Just wanted to clarify all because a buddy of mine out on the west coast said should we be doing general anesthesia as primary no, homie, no. The answer is no. But even though this new publication from November does have its limitations, it does allow, as that affiliated author stated, to have the discussion with the patient when necessary. Podcast Family I think we've done what we're supposed to do. We've covered three pivotal pieces of information regarding general anesthesia at time of C section from 2025, with the most recent being just last week on 12 November 2025. Podcast Family as always, we're thankful for you. Thanks for being part of our podcast community. Now that we've done all that, let's take. This has been Dr. Chapa Zobey Gyn no Spin podcast Podcast Family thank you for your support. Thank you for listening listening. And as always, we'll see you on another episode of the no Spin Podcast.