Anesth Pain Med.  2022 Jul;17(3):256-261. 10.17085/apm.22196.

General anesthesia for cesarean section: are we doing it well?

• Choi SU

• KMID: 2535317
• DOI: http://doi.org/10.17085/apm.22196

Abstract

Korea has a higher rate of cesarean sections under general anesthesia than in other countries. Neuraxial anesthesia is the gold standard for a cesarean section, but there are some cases in which general anesthesia is inevitable. Therefore, obstetric anesthesiologists should be familiar in performing general anesthesia for cesarean section. Rapid-sequence induction and intubation with cricoid pressure using thiopental-succinylcholine have been the standard for cesarean section under general anesthesia for a long time. Recently, with the introduction of new drugs (propofol, rocuronium, and sugammadex) and equipments (videolaryngoscopy and supraglottic airways), anesthesia methods have also gradually changed. Pursuing the safety of obstetric patients and anesthesiologists at the same time, this review will help update the knowledge or training in performing general anesthesia for cesarean section.

Keyword

Cesarean section; General anesthesia; Obstetric; Rapid sequence induction

Reference

1. Kim AM, Park JH, Kang S, Yoon TH, Kim Y. An ecological study of geographic variation and factors associated with cesarean section rates in South Korea. BMC Pregnancy Childbirth. 2019; 19:162.

2. Chien P. Global rising rates of caesarean sections. BJOG. 2021; 128:781–2.

3. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia and the Society for Obstetric Anesthesia and Perinatology. Anesthesiology. 2016; 124:270–300.

4. Mhyre JM, Sultan P. General anesthesia for cesarean delivery: occasionally essential but best avoided. Anesthesiology. 2019; 130:864–6.

5. Hawkins JL, Koonin LM, Palmer SK, Gibbs CP. Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990. Anesthesiology. 1997; 86:277–84.

6. Ikeda T, Kato A, Bougaki M, Araki Y, Ohata T, Kawashima S, et al. A retrospective review of 10-year trends in general anesthesia for cesarean delivery at a university hospital: the impact of a newly launched team on obstetric anesthesia practice. BMC Health Serv Res. 2020; 20:421.

7. Cobb BT, Lane-Fall MB, Month RC, Onuoha OC, Srinivas SK, Neuman MD. Anesthesiologist specialization and use of general anesthesia for cesarean delivery. Anesthesiology. 2019; 130:237–46.

8. Traynor AJ, Aragon M, Ghosh D, Choi RS, Dingmann C, Vu Tran Z, et al. Obstetric anesthesia workforce survey: a 30-year update. Anesth Analg. 2016; 122:1939–46.

9. Guglielminotti J, Landau R, Li G. Adverse events and factors associated with potentially avoidable use of general anesthesia in cesarean deliveries. Anesthesiology. 2019; 130:912–22.

10. Hawkins JL, Chang J, Palmer SK, Gibbs CP, Callaghan WM. Anesthesia-related maternal mortality in the United States: 1979-2002. Obstet Gynecol. 2011; 117:69–74.

11. Ring L, Landau R, Delgado C. The current role of general anesthesia for cesarean delivery. Curr Anesthesiol Rep. 2021; 11:18–27.

12. Chen Y, Liu W, Gong X, Cheng Q. Comparison of effects of general anesthesia and combined spinal/epidural anesthesia for cesarean delivery on umbilical cord blood gas values: a double-blind, randomized, controlled study. Med Sci Monit. 2019; 25:5272–9.

13. Robbins LS, Blanchard CT, Biasini FJ, Powell MF, Casey BM, Tita AT, et al. General anesthesia for cesarean delivery and childhood neurodevelopmental and perinatal outcomes: a secondary analysis of a randomized controlled trial. Int J Obstet Anesth. 2021; 45:34–40.

14. Park JI, Park SH, Kang MS, Kang GW, Kim ST. Evaluation of changes in anesthetic methods for cesarean delivery: an analysis for 5 years using the big data of the Korean Health Insurance Review and Assessment Service. Anesth Pain Med (Seoul). 2020; 15:305–13.

15. Park SH, Kim DJ, Kim WY, Kim JH, Lee YS, Park YC. Clinical evaluation of anesthesia for cesarean section at tertiary medical center: retrospective study for 5 years (2009-2013). Anesth Pain Med. 2016; 11:49–54.

16. Johnson RV, Lyons GR, Wilson RC, Robinson AP. Training in obstetric general anaesthesia: a vanishing art? Anaesthesia. 2000; 55:179–83.

17. Searle RD, Lyons G. Vanishing experience in training for obstetric general anaesthesia: an observational study. Int J Obstet Anesth. 2008; 17:233–7.

18. Palanisamy A, Mitani AA, Tsen LC. General anesthesia for cesarean delivery at a tertiary care hospital from 2000 to 2005: a retrospective analysis and 10-year update. Int J Obstet Anesth. 2011; 20:10–6.

19. Odor PM, Bampoe S, Moonesinghe SR, Andrade J, Pandit JJ, Lucas DN; Pan-London Perioperative Audit and Research Network (PLAN), for the DREAMY Investigators Group. General anaesthetic and airway management practice for obstetric surgery in England: a prospective, multicentre observational study. Anaesthesia. 2021; 76:460–71.

20. Desai N, Wicker J, Sajayan A, Mendonca C. A survey of practice of rapid sequence induction for caesarean section in England. Int J Obstet Anesth. 2018; 36:3–10.

21. Sumikura H, Niwa H, Sato M, Nakamoto T, Asai T, Hagihira S. Rethinking general anesthesia for cesarean section. J Anesth. 2016; 30:268–73.

22. Kosaka Y, Takahashi T, Mark LC. Intravenous thiobarbiturate anesthesia for cesarean section. Anesthesiology. 1969; 31:489–506.

23. Abouleish E, Abboud T, Lechevalier T, Zhu J, Chalian A, Alford K. Rocuronium (Org 9426) for caesarean section. Br J Anaesth. 1994; 73:336–41.

24. Sabetian G, Zand F, Mirhadi F, Hadavi MR, Asadpour E, Dehghanpisheh L, et al. Adequacy of maternal anesthesia depth with two sodium thiopental doses in elective caesarean section: a randomized clinical trial. BMC Anesthesiol. 2021; 21:201.

25. Odor PM, Bampoe S, Lucas DN, Moonesinghe SR, Andrade J, Pandit JJ; Pan-London Peri-operative Audit and Research Network (PLAN), for the DREAMY Investigators Group. Incidence of accidental awareness during general anaesthesia in obstetrics: a multicentre, prospective cohort study. Anaesthesia. 2021; 76:759–76.

26. Park HS, Kim YS, Kim SH, Jeon AR, Kim SE, Choi WJ. Comparison of electroencephalogram between propofol- and thiopental-induced anesthesia for awareness risk in pregnant women. Sci Rep. 2020; 10:6192.

27. Duggal K. Propofol should be the induction agent of choice for caesarean section under general anaesthesia. Int J Obstet Anesth. 2003; 12:275–6.

28. Russell R. Propofol should be the agent of choice for caesarean section under general anaesthesia. Int J Obstet Anesth. 2003; 12:276–9.

29. Tumukunde J, Lomangisi DD, Davidson O, Kintu A, Joseph E, Kwizera A. Effects of propofol versus thiopental on Apgar scores in newborns and peri-operative outcomes of women undergoing emergency cesarean section: a randomized clinical trial. BMC Anesthesiol. 2015; 15:63.

30. Nayar R, Sahajanand H. Does anesthetic induction for cesarean section with a combination of ketamine and thiopentone confer any benefits over thiopentone or ketamine alone? A prospective randomized study. Minerva Anestesiol. 2009; 75:185–90.

31. Moradkhani M, Hejri P, Nadri S, Beiranvand S. Effects of ADJUVANT ketamine on induction of anesthesia for the cesarean section. Curr Rev Clin Exp Pharmacol. 2021; 16:197–200.

32. McGuigan PJ, Shields MO, McCourt KC. Role of rocuronium and sugammadex in rapid sequence induction in pregnancy. Br J Anaesth. 2011; 106:418–9; author reply 419-20.

33. Pühringer FK, Kristen P, Rex C. Sugammadex reversal of rocuronium-induced neuromuscular block in caesarean section patients: a series of seven cases. Br J Anaesth. 2010; 105:657–60.

34. Moya F, Kvisselgaard N. The placental transmission of succinylcholine. Anesthesiology. 1961; 22:1–6.

35. Vanner R. Cricoid pressure. Int J Obstet Anesth. 2009; 18:103–5.

36. Tsen LC, Bateman BT. Anesthesia for cesarean delivery. In: Chestnut's obstetric anesthesia: principles and practice. 6th ed. Edited by Chestnut DH, Wong CA, Tsen LC, Ngan Kee WD, Beilin Y, Mhyre JM, et al.: Amsterdam, Elsevier. 2019, pp 568-626.

37. Morgan M. The confidential enquiry into maternal deaths. Anaesthesia. 1986; 41:689–91.

38. Priebe HJ. Cricoid pressure: an expert's opinion. Minerva Anestesiol. 2009; 75:710–4.

39. Hansel J, Rogers AM, Lewis SR, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adults undergoing tracheal intubation. Cochrane Database Syst Rev. 2022; 4:CD011136.

40. Browning RM, Rucklidge MW. Tracheal intubation using the Pentax Airway Scope videolaryngoscope following failed direct laryngoscopy in a morbidly obese parturient. Int J Obstet Anesth. 2011; 20:200–1.

41. Howle R, Onwochei D, Harrison SL, Desai N. Comparison of videolaryngoscopy and direct laryngoscopy for tracheal intubation in obstetrics: a mixed-methods systematic review and meta-analysis. Can J Anaesth. 2021; 68:546–65.

42. Timmermann A. Supraglottic airways in difficult airway management: successes, failures, use and misuse. Anaesthesia. 2011; 66 Suppl 2:45–56.

43. Frerk C, Mitchell VS, McNarry AF, Mendonca C, Bhagrath R, Patel A, et al. Difficult Airway Society Intubation Guidelines Working Group. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015; 115:827–48.

44. Apfelbaum JL, Hagberg CA, Connis RT, Abdelmalak BB, Agarkar M, Dutton RP, et al. 2022 American Society of Anesthesiologists practice guidelines for management of the difficult airway. Anesthesiology. 2022; 136:31–81.

45. Mushambi MC, Kinsella SM, Popat M, Swales H, Ramaswamy KK, Winton AL, et al. Obstetric Anaesthetists' Association; Difficult Airway Society. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics. Anaesthesia. 2015; 70:1286–306.

46. Delgado C, Ring L, Mushambi MC. General anaesthesia in obstetrics. BJA Educ. 2020; 20:201–7.

47. Lyons G, Macdonald R. Awareness during caesarean section. Anaesthesia. 1991; 46:62–4.

48. Bogod D, Plaat F. Be wary of awareness--lessons from NAP5 for obstetric anaesthetists. Int J Obstet Anesth. 2015; 24:1–4.

49. Mankowitz E, Brock-Utne JG, Downing JW. Nitrous oxide elimination by the newborn. Anaesthesia. 1981; 36:1014–6.

50. Yoo KY, Lee JC, Yoon MH, Shin MH, Kim SJ, Kim YH, et al. The effects of volatile anesthetics on spontaneous contractility of isolated human pregnant uterine muscle: a comparison among sevoflurane, desflurane, isoflurane, and halothane. Anesth Analg. 2006; 103:443–7.

51. Kimizuka M, Tokinaga Y, Azumaguchi R, Hamada K, Kazuma S, Yamakage M. Effects of anesthetic agents on contractions of the pregnant rat myometrium in vivo and in vitro. J Anesth. 2021; 35:68–80.

52. Mhyre JM, Riesner MN, Polley LS, Naughton NN. A series of anesthesia-related maternal deaths in Michigan, 1985-2003. Anesthesiology. 2007; 106:1096–104.