When Two Lives Are at Risk
Every decision made during anesthesia for a pregnant patient carries consequences for two people. When anesthesia providers are careless or make the wrong decision for a patient, the results can alter lives forever.
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Article written by Gregory Unatin, Esq. Greg is a managing partner in the law firm of Lupetin & Unatin, a medical malpractice law firm located in Pittsburgh and serving Western Pennsylvania.
Our practice is limited to high-value catastrophic cases because that is where we can do the most for our clients and for patient safety.
Obstetric Anesthesia: A Specialty Within a Specialty
Anesthesiology is a demanding medical specialty, requiring years of training and a precise command of physiology, pharmacology, and medical judgment. Obstetric anesthesia is a subspecialty of anesthesia that requires the physician to have the knowledge of a general anesthesiologist as well as a thorough understanding of how pregnancy affects the human body.
Pregnancy fundamentally alters virtually every physiological system in the body: the cardiovascular system, the respiratory system, the gastrointestinal tract, the blood and its clotting mechanisms, the airway anatomy, and the hormonal environment. Each of those changes has direct implications for how anesthesia must be selected, administered, monitored, and managed. An anesthesiologist or CRNA cannot simply approach a pregnant patient with the same framework they would apply to a healthy non-pregnant adult.
The fetus adds a dimension that does not exist in general anesthesia practice. The fetus cannot be directly monitored during most medical procedures. Its wellbeing is entirely dependent on the pregnant patient’s physiological stability. Anesthetic medications, fluctuations in maternal blood pressure, changes in maternal oxygenation, and the physiological stress of surgery can all directly harm the fetus in ways that may not be immediately apparent — and may not fully manifest until hours, days, or in the case of subtle neurological harm, years later.
Obstetric anesthesia is recognized as a formal subspecialty with its own fellowship training programs, medical research literature, and professional organization — the Society for Obstetric Anesthesia and Perinatology (SOAP) — whose guidelines reflect decades of specialized science. The standard of care in this field is well-defined. When a provider falls short of it, pregnant patients and their babies can pay an irreversible price.
How Pregnancy Changes the Body: What Every Anesthesia Provider Must Know
To understand how anesthesia errors can harm a pregnant patient and her baby, it helps to understand what pregnancy does to the body — and why those changes make anesthesia more complex, more demanding, and less forgiving of error.
Cardiovascular changes and aortocaval compression
By the third trimester, blood volume has increased by roughly 40 to 50 percent, and the heart is pumping significantly more blood per minute than before pregnancy. The most critical cardiovascular consideration in obstetric anesthesia is aortocaval compression: when a pregnant patient beyond approximately 20 weeks lies flat on her back, the weight of the uterus presses on the aorta — the body’s main artery — and the vena cava — the large vein returning blood to the heart. This compression can dramatically reduce blood returning to the heart and simultaneously reduce blood flow through the placenta to the fetus. The fetus has no independent ability to compensate. Positioning the patient in the left lateral position or manually displacing the uterus is the standard remedy. Failure to implement it can cause rapid, severe fetal compromise.
Respiratory changes and the urgency of airway management
Pregnancy reduces the lungs’ reserve air capacity while simultaneously increasing the body’s oxygen consumption to support both pregnant patient and fetus. A pregnant patient will experience a dangerous fall in blood oxygen levels far more quickly than a non-pregnant patient during any period of inadequate breathing — whether from airway difficulty, respiratory depression, or equipment problems. What might be a manageable two-minute interval of airway difficulty in a healthy non-pregnant adult can become a life-threatening emergency in a pregnant woman. Pre-oxygenating the patient with high-flow oxygen before inducing general anesthesia is a mandatory standard precisely because of this compressed margin for error.
Gastrointestinal changes and aspiration risk
Pregnancy slows gastric emptying and increases stomach acid production. Combined with uterine pressure on the stomach, these changes dramatically elevate the risk of vomiting during induction or emergence from general anesthesia. At the same time, these changes increase the risk of aspiration, meaning the inhalation of stomach contents into the lungs. Aspiration in a pregnant patient can cause aspiration pneumonitis, a severe chemical injury to lung tissue caused by stomach acid that can progress rapidly to respiratory failure. The standard of care requires administration of medications to help prevent aspiration before general anesthesia and the use of a rapid-sequence induction technique that minimizes the window during which the airway is unprotected.
Airway changes and the risk of failed intubation
The increased blood volume and hormonal changes of pregnancy cause swelling of the soft tissues throughout the body, including the mouth, throat, and airway. This can make the airway significantly narrower and harder to visualize during intubation- placement of a breathing tube- for anesthesia. Difficult or failed intubation is a leading contributor to anesthesia-related maternal death. A provider preparing to induce general anesthesia in a pregnant patient must anticipate airway difficulty, have a documented backup plan, and have the equipment to manage an airway emergency immediately available before induction begins.
Coagulation changes and implications for neuraxial anesthesia
Pregnancy induces a hypercoagulable state — meaning the blood clots more readily than normal. A hypercoagulable state during pregnancy elevates the risk of dangerous blood clots, including deep vein thrombosis (clots in the leg veins) and pulmonary embolism (a clot traveling to the lungs and blocking blood flow, potentially causing sudden death). This state also has direct implications for neuraxial anesthesia — spinal and epidural anesthesia, which involve placing needles and catheters near the spinal canal. During neuraxial anesthesia, abnormal clotting function can increase the risk of spinal hematoma, a bleeding complication capable of causing permanent paralysis if not recognized and treated rapidly.
Placental transfer of medications
The placenta does not fully shield the fetus from substances in the pregnant patient’s bloodstream. Most general anesthetic agents, sedatives, and opioid pain medications cross the placenta and reach the fetal circulation, where they can cause respiratory depression, cardiovascular depression, and altered neurological function. When a fetus is delivered while anesthetic agents remain active in the pregnant patient’s bloodstream, the newborn may be unable to breathe independently and may require immediate resuscitation. The anesthesia provider must account for this in the selection and timing of medications, and the obstetric team must ensure that neonatal resuscitation personnel are present and prepared before delivery when this risk exists.
Anesthesia for Non-Obstetric Procedures During Pregnancy
Many people assume that pregnant patients only encounter anesthesia during labor, delivery, or cesarean section. In reality, many pregnant patients require surgical or procedural anesthesia for conditions entirely unrelated to their pregnancy.
Examples of conditions that may require surgery during pregnancy include:
- Appendicitis (Appendectomy)
- Gallstone Disease (Cholecystectomy)
- Kidney stones and ureteral obstruction (ureteroscopy, stent placement, etc.)
- Ovarian Cysts (Laparoscopic Cyst Removal)
- Cervical Insufficiency (Cervical Cerclage)
- Cardiac Disease
- Neurologic Emergencies
- Cancer
In every one of these situations, the anesthesia provider must protect maternal blood pressure and oxygenation, minimize fetal exposure to potentially harmful agents, maintain uterine blood flow, coordinate post-operative obstetric monitoring, and prepare for the possibility of emergency delivery. The fact that the surgery has nothing to do with the pregnancy does not reduce these obligations. An anesthesia provider who treats a pregnant surgical patient as simply a non-pregnant adult who is carrying a child has fundamentally misunderstood the nature of their responsibility.
How the Fetus Can Be Harmed: The Pathophysiology of Fetal Injury During Anesthesia
Uteroplacental insufficiency from maternal hypotension
The blood supply to the uterus and placenta flows in direct proportion to the pregnant patient’s blood pressure. When anesthesia causes maternal hypotension, uterine blood flow falls immediately and proportionally. The fetus receives less oxygen and fewer nutrients. Brief, mild hypotension may be tolerated without harm. Severe or prolonged hypotension that remains unrecognized or inadequately treated can deprive the fetus of oxygen and, if unaddressed, progress to fetal distress. In the most serious cases, fetal hypoxia can lead to irreversible neurological injury or fetal death. Preventing maternal hypotension, detecting it immediately, and treating it promptly and aggressively are among the most fundamental obligations in obstetric anesthesia.
Fetal hypoxia from maternal hypoxia or hyperventilation
The fetus receives all its oxygen from the pregnant patient’s blood through the placenta. When the pregnant patient’s oxygen level falls — from airway difficulty, respiratory depression, or inadequate ventilation — fetal oxygenation falls as well, often more sharply than the maternal decline alone would predict. Equally serious is the risk of hyperventilation: when a patient under general anesthesia is ventilated too aggressively, the carbon dioxide level in her blood falls, triggering constriction of the blood vessels supplying the uterus and reducing delivery of oxygen to the fetus. Paradoxically, the fetus may be deprived of oxygen even though the pregnant patient’s own oxygen saturation appears normal on the monitor.
Direct fetal effects of anesthetic agents crossing the placenta
For some pregnant patients, general anesthesia is administered near the time of delivery—whether necessitated by extreme obstetric emergencies (such as umbilical cord prolapse, placental abruption, or acute fetal distress) or maternal contraindications to regional anesthesia (such as coagulopathy, active hemorrhage, or failed spinal blockade). The fetus is exposed to anesthetic agents and volatile gases through the placenta and may be born in a state of respiratory depression. Predictably, the newborn may be unable to initiate or sustain adequate breathing independently. The obstetric and anesthesia teams must anticipate this outcome and ensure that a dedicated neonatal resuscitation team is present in the delivery room before the patient is induced. A medical team that fails to arrange for this specialized coverage in the setting of general anesthesia has failed to prepare for a foreseeable emergency.
Preterm labor triggered by surgery
Surgical procedures during pregnancy — particularly abdominal operations — carry a real risk of triggering uterine contractions and preterm labor, especially in the second trimester. The physiological stress of surgery, the inflammatory response it generates, and the handling of tissues near the uterus can initiate contractions. The standard of care requires involving the obstetric team in pre-operative planning, arranging post-operative monitoring for signs of preterm labor, and considering tocolytic medications — drugs that suppress uterine contractions — when appropriate.
Teratogenicity and fetal neurodevelopmental risk
During the first trimester — when the fetus’s major organ systems are forming — certain anesthetic agents raise concerns about potential teratogenicity, meaning the ability to cause fetal developmental abnormalities. The standard of care is clear: elective procedures should be deferred until after the first trimester whenever medically possible, and selection of anesthetic agents in early pregnancy must be made with these concerns in mind. More recently, research has raised concerns about the potential effects of prolonged or repeated anesthetic exposure on fetal brain development in the third trimester. A careful anesthesia provider must be aware of this risk, factor it into discussions about timing and necessity of procedures, and document that these considerations were addressed.
What Obstetric Anesthesia Malpractice Looks Like: Illustrative Scenarios
The following scenarios are entirely hypothetical and are provided for illustrative purposes only. They are not descriptions of actual cases handled by Lupetin & Unatin. They are intended to help readers understand how the categories of error discussed in this article can arise in real clinical situations.
A 28-year-old woman at 28 weeks of gestation is brought to the operating room for an emergency appendectomy. General anesthesia is induced and the patient is positioned flat on her back. Uterine displacement is not implemented. Within minutes her blood pressure falls significantly. The anesthesia provider, focused on the surgical site, does not respond with urgency. Several minutes pass before vasopressors — blood pressure-raising medications — are given. The surgery proceeds. Post-operatively, fetal heart rate monitoring reveals a pattern consistent with fetal distress. Emergency cesarean section is performed. The infant survives but is subsequently diagnosed with a hypoxic brain injury — damage caused by a period of inadequate oxygen delivery during the untreated hypotensive episode. The family is told the child will face lifelong cognitive and developmental challenges.
What went wrong: Failure to implement aortocaval decompression is the failure of a basic, mandatory precaution. A competent provider ensures left lateral displacement from the moment the patient is positioned, has vasopressors immediately available, and treats any blood pressure decline as an emergency from the first sign of deterioration — not after several minutes have elapsed.
A 32-year-old woman at 32 weeks of gestation requires a urological procedure under general anesthesia. The pre-operative airway assessment notes no significant concerns. Pre-oxygenation is abbreviated. On induction, the provider encounters unexpectedly difficult airway anatomy — the edematous tissues of late pregnancy have significantly worsened visualization of the patient’s airway. Multiple attempts to intubate are required. During these attempts, the patient’s oxygen level falls rapidly — much faster than would occur in a non-pregnant patient given her reduced respiratory reserve. By the time the airway is secured, both pregnant patient and fetus have experienced a significant period of hypoxia. Emergency cesarean section is performed. The infant survives but is subsequently diagnosed with cerebral palsy — a permanent movement and developmental disorder attributable to the episode of oxygen deprivation.
What went wrong: Failure to anticipate and prepare for the airway challenges specific to late pregnancy — combined with inadequate pre-oxygenation and the absence of a documented failed-intubation plan — converted a manageable complication into a catastrophic one. A reasonably careful provider would have conducted a pregnancy-specific airway assessment, pre-oxygenated fully, and had a complete difficult airway plan in place before induction.
A 24-year-old woman presents for an elective orthopedic procedure. Neither the pre-operative nursing assessment nor the anesthesia provider’s evaluation includes a pregnancy test or a specific inquiry about the possibility of pregnancy. The patient, approximately 10 weeks pregnant and unaware of it, is induced under general anesthesia without aspiration prophylaxis and without any pregnancy-specific precautions. On emergence from anesthesia, she vomits and aspirates. She develops severe aspiration pneumonitis requiring intubation, mechanical ventilation, and a prolonged ICU admission. The pregnancy is lost in the setting of the aspiration event and the physiological crisis it generates.
What went wrong: Screening for pregnancy before elective surgery under general anesthesia in any woman of reproductive age is a basic pre-operative standard. Had the pregnancy been identified, aspiration prophylaxis would have been administered, appropriate precautions implemented, and — given the elective nature of the procedure — surgery deferred to a safer gestational window.
A 35-year-old woman at 36 weeks of gestation undergoes a procedure under spinal anesthesia — a type of anesthesia injected into the fluid surrounding the spinal cord that numbs the lower body. Post-spinal hypotension is a predictable, well-recognized complication in pregnant patients. In this case, hypotension is identified but the provider’s response is slow and inadequate. Blood pressure remains below an acceptable threshold for an extended period. Post-operative fetal heart rate monitoring reveals deep, prolonged decelerations indicating fetal distress. Emergency cesarean section is performed. The infant is born with evidence of hypoxic-ischemic encephalopathy, a form of brain injury caused by inadequate oxygen and blood flow, and faces a lifetime of neurological impairment.
What went wrong: Post-spinal hypotension in a pregnant patient is not a surprise — it is an anticipated, preventable complication. The standard of care requires prophylactic safety measures before or immediately after spinal placement and prompt, aggressive treatment at the first sign of a clinically significant drop in blood pressure. Delayed or inadequate treatment of a known, foreseeable complication is a failure of the standard of care.
A 29-year-old woman at 22 weeks of gestation undergoes abdominal surgery for a large symptomatic ovarian cyst. A general anesthesiologist without specific obstetric training provides the anesthetic. The patient’s obstetrician is not notified. No discussion takes place about post-operative monitoring for uterine contractions, and no tocolytic medications are prescribed or available. The patient recovers from anesthesia and is discharged from the recovery room with routine post-operative instructions. No fetal monitoring is performed before discharge. Within 48 hours, she presents to the emergency room in active preterm labor and delivers at 22 weeks and 2 days — at the very edge of viability. The infant survives but suffers serious complications of extreme prematurity, including chronic lung disease, intraventricular hemorrhage (bleeding within the brain), and significant developmental delay.
What went wrong: The risk of preterm labor following abdominal surgery during the second trimester is well-recognized and must be anticipated. Involving the obstetric team in pre-operative planning, arranging post-operative uterine monitoring, and ensuring the patient has a clear post-discharge obstetric follow-up plan are standard requirements.
This is where the Pennsylvania “Loss of Chance” doctrine is vital. We don’t have to prove that you would have been 100% cured with a faster diagnosis. We only need to prove that the doctor’s negligence took away a meaningful opportunity for a better outcome or made your treatment significantly more painful, invasive, or expensive.
Yes. Pennsylvania follows a “Modified Comparative Negligence” rule. This means that as long as you were not more than 50% responsible for the delay, you can still recover damages. Even if you missed an appointment, if the doctor failed to properly warn you of the urgency or misread a previous test that should have triggered an immediate call, the primary liability often still rests with the provider.
When Obstetric Anesthesia Errors Become Medical Malpractice
When an anesthesia provider fails to apply the specialized knowledge and defined standards of care that obstetric anesthesia demands — and that failure causes injury to the pregnant patient, the fetus, or both — the injured patient and her family may have a claim for medical malpractice. These are among the most complex cases in medical negligence litigation. They require expert knowledge not just in anesthesiology, but in obstetrics, neonatology, and in many cases pediatric neurology or other specialties depending on the nature and extent of the injuries. And the injuries themselves — a child with a permanent brain injury, a pregnant patient who lost her pregnancy, a family forever changed by a complication the medical evidence shows should never have occurred — are among the most devastating that any medical error can cause.
These cases are built on a careful investigation of the complete medical record: the pre-anesthesia evaluation, the intraoperative anesthesia record, the fetal monitoring strips, the nursing documentation, the post-operative records, and the neonatal records when a child was harmed. The gaps in that record — blood pressure values never documented during a critical window, monitoring strips not run or not preserved, communications with the obstetric team that never occurred — can be as significant as the documentation that exists.
At Lupetin & Unatin, we have spent decades representing patients and families in complex medical malpractice cases, including cases involving obstetric anesthesia. For example, we recently secured at $13.5 million settlement in a case involving obstetrical anesthesia provided to patient undergoing a non-obstetric medical procedure. The fetus developed severe distress and hypoxia due to aortocaval compression. Regrettably, due to delayed recognition of the signs of fetal distress, the child suffered catastrophic brain injury before he could be delivered by emergency cesarean section.
We understand the physiology of pregnancy, the standards of obstetric anesthesia, and the mechanisms by which the errors described in this article translate into the injuries that families carry for a lifetime. We work with leading experts in obstetric anesthesia, maternal-fetal medicine, and neonatology to build cases that explain clearly what the standard of care required and exactly how it was not met. We fight for the full measure of accountability and compensation that injured patients and their families deserve — and we have the experience and the resources to pursue it.
If you or your child were harmed by an anesthesia error during pregnancy, we are here
Whether the error occurred during labor and delivery, during a procedure for an unrelated medical condition, or anywhere along the course of your obstetric care, you deserve to know what happened and why. These cases are complex, but getting to the truth — and holding the responsible parties accountable — is what we do.
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