Cesarean delivery under general anesthesia: Continuing Professional Development

Abstract

Purpose: Whenever possible, neuraxial anesthesia is the preferred technique for Cesarean delivery; however, under certain circumstances, general anesthesia remains the most appropriate choice. The purpose of this Continuing Professional Development module is to review the key issues regarding general anesthesia for Cesarean delivery.

Principal findings: In developed countries, anesthesia-related maternal mortality and morbidity are both low. Mortality following Cesarean delivery under general anesthesia is attributable chiefly to failed intubation or other induction-related issues. Extubation can also be a danger period. The various methods of preventing difficult intubation and the associated consequences include airway assessment, fasting during obstetric labour, and pharmacological prophylaxis for aspiration. The traditional rapid sequence induction has been slightly modified because of the increased use of propofol and remifentanil. Difficult airway management algorithms specific to the pregnant woman are being developed and tend to recommend the use of supraglottic devices for unanticipated difficult intubation. The prevention of intraoperative awareness is another major consideration. Maintenance with halogenated agents at > 0.7 minimum alveolar concentration (MAC) is recommended; however, propofol maintenance can be an interesting option when uterine atony is present. Multimodal postoperative analgesia is recommended.

Conclusion: A general anesthetic for Cesarean delivery should be based on the following principles: preventing aspiration, anticipating a difficult intubation, maintaining oxygenation, insuring materno-feto-placental perfusion and maintaining a deep level of anesthesia to avoid intraoperative awareness while minimizing neonatal effects.